Date Published: December 1, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Hideyuki Kobayashi, Koichi Nagao, Koichi Nakajima.
Male infertility problems can occur when sperms are limited in number or function. In this paper, we describe the clinical evaluation of male infertility. A detailed history, physical examination, and basic semen analysis are required. In addition, ultrasound, karyotyping, and hormonal studies are needed to determine specific causes of infertility. In addition, the World Health Organization (WHO, 2009) has developed a manual to provide guidance in performing a comprehensive semen analysis. Among the possible reasons for male infertility, nonobstructive azoospermia is the least treatable, because few or no mature sperm may be produced. In many cases, men with nonobstructive azoospermia typically have small-volume testes and elevated FSH. Although treatment may not completely restore the quality of semen from men with subnormal fertility, in some cases a successful pregnancy can still be achieved through assisted reproductive technology.
About 1 in 7 couples have problems conceiving, with a similar incidence worldwide. Over 80% of couples who have regular sexual intercourse and do not use contraception will achieve a pregnancy within one year, and approximately 92% can achieve a pregnancy within 2 years . Infertility affects males and females equally, although many people believe that infertility is a female problem. In Japan, especially, couples oppose insemination or adoption as an alternative to having a child carrying both parents’ genes, which means that males are likely to seek infertility evaluations when a couple has difficulty conceiving.
The infertility history should include a detailed account of the patient’s reproductive and sexual history, developmental, family, medical, and surgical history. The information to be included in each portion of the history is detailed below.
The physical examination for male infertility should focus on identifying abnormalities that could affect fertility. Endocrine disorders should be suspected in cases of abnormal androgenization. Gynecomastia can result from excessive estrogens, an improper estrogen-to-androgen ratio, or elevated prolactin levels. Penile curvature, angulation, and the location of the urethral meatus should be assessed. The scrotum should be carefully palpated with the patient standing, noting the size and consistency of the testicles; the room should be kept warm for this exam.
After the above exams have been completed, appropriate laboratory tests should be performed. The first step in laboratory testing is to identify patients who are likely to be infertile, subfertile, and fertile, for which only semen analysis is required. Since most infertile men have some motile sperm in the semen, threshold values are used to indicate whether fertility is more or less likely. Azoospermic patients, however, are sterile. Importantly, although the number of motile sperm is suggestive of fertility, there can be considerable variation in the fertility of men with equal motile sperm counts.
While many assays can be used in the diagnosis of male infertility, the foundation of any workup should be obtaining a detailed history, thorough physical examination, and a basic semen analysis. Additional tests, including an antisperm antibody assay and hormonal, karyotype, and ultrasound studies are needed only to investigate specific causes of infertility. In addition, there are some significant health issues which are diagnosed only with presentation of male infertility, testis tumor and significant endocrinopathies amongst them. A careful evaluation that considers all of the possible explanations for a man’s infertility is not only critical for a good diagnosis, it is an ethical imperative for the reproductive specialist.