Fifty percent of infertility involves a male factor. The evaluation begins with a history, physical exam and semen analysis x 2. The history should include questions about exposure to gonad toxins. The differential diagnosis of no ejaculate includes; retrograde ejaculation, failure of ejaculation (rare), failure of emission and psychogenic. Evaluation of absence of the vas deferens which occurs in 2% of infertile men includes; genetic testing for CFTR mutations of the female partner. If the female is negative testing of the male is optional. Male fertility slowly declines with age and the incidence of miscarriage increases. The physical exam should include; check for gynecomastia, visual fields, varicocele, and evaluation of the genitalia and virtualization. Normal testis size is =/> than 4 Cm x 2 Cm or 20 ml. Endocrine evaluation should be done if there is evidence in the history or physical exam of endocrine disease, decreased libido or a sperm count of <5-10 million. It should not be done routinely. If AM total testosterone (T) level is low check free or bioavailable testosterone. Prolactin should be check only if T is low and if it is low consider pituitary MRI. Treat hypogonadotropic hypogonadism with GNRH or HCG and FSH. Clinical infections should be treated. A positive semen culture is very difficult to interpret because there are bacteria in the normal distal urethra. Men with clumping of sperm or unexplained poor motility should have an immunologic evaluation. This is a very rare cause of male infertility. It is best treated with ICSI. Testis Biopsy is usually only indicated in men with azoospermia, normal size testis without evidence of obstruction and several oligospermia in men with one small and one normal sized testis. Azoospermia should be diagnosed only after there are no sperm on 2 centrifuged samples. Semen analysis does not determine fertility unless there are no sperm. However it does provide the ability to estimate the likelihood of spontaneous pregnancy. WHO standards and interpretation will be discussed. Reactive oxygen testing is of little clinical value. DNA fragmentation testing should not be done routinely since it does not change clinical care except in candidates for ICSI. Strict criteria morphology is difficult to interpret since it does not predict pregnancy after sexual intercourse. It does correlate with IVF fertilization. Additional tests of sperm function are of little clinical value except for a post coital test for men who for religious reasons cannot provide a semen specimen. Retrograde ejaculation should be treated with alkalization and retrieval of a post void ejaculate. There are many options to retrieve sperm from men with obstructive azoospermia. We use testis biopsy either open or percutaneous. Retrieval for non-obstructive azoospermia should be done with micro dissection after checking for chromosomal abnormalities and micro gene deletions on the Y chromosome. Ejaculatory duct obstruction will be discussed. Varicocele should be repaired (we do a microscopic repair) if the semen quality is subpar and the female partner has been evaluated. Sub clinical varicocele should not be fixed. Men with a low T and a normal E-2 should be treated with Clomid and if this fails HCG. If the E2 is high or the T/E-2 ratio is less than 10 they need an aromatase inhibitor. Failure of ejaculation usually can be treated with two headed vibratory stimulus. If this fails try electro-ejaculation. Microscopic vasovasostomy and vaso-epididymostomy have a good success rate in experienced hands for the treatment of obstructive azoospermia. Surgical techniques will be discussed Future:Preliminary data is available for; molecular agents to treat low T production by stimulating the Leydig cells, technology to allow less expensive IVF, improved education for patients and clinicians to increase the percent of patients who would benefit from sperm banking achieve this goal, retrieval of spermatogenic stem cells from pre pubertal patients who face future infertility because of radiation, chemotherapy, Klinefelter’s syndrome etc., better diagnosis and treatment because of increased knowledge of the genetic origins of male infertility, better methods to select sperm for IVF and ICSI that do not have DNA fragmentation; improve the predict of which adolescent with varicocele will benefit from surgical repair. Speculative future developments; more insight in to unexplained infertility, better antioxidant Rx, better understanding of the male contribution to recurrent pregnancy loss, ICSI with male DNA obtained from circulating leukocytes, in vitro generation of sperm cells.
Materials and methods