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Male Infertility

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Topic updated on 02/20/17 8:12pm

Snapshot
  • A 41-year-old man presents with his 25-year-old wife to a fertility specialist. They have been trying to conceive for about one and a half years now. A few months ago, his wife was evaluated thoroughly for causes of female infertility, which all returned normal. Based on her physician’s recommendations, they are now concerned about his fertility.
Introduction
  • Definition of infertility
    • inability to conceive
      • after 1 year of unprotected sex in the absence of any known causes of infertility
      • after 6 months if the woman is > 35 years old or in couples with known risk factors for infertility
  • Terms related to sperm cells
    • oligozoospermia
      • decrease in number of sperm cells in ejaculate
    • azoospermia
      • no sperm cells in ejaculate
    • asthenozoospermia
      • decrease in sperm motility
    • teratozoospermia
      • abnormal morphology
  • Epidemiology
    • 10-15% of reproductive-aged couples in the US
    • 12% of men are infertile
      • 80% of men with infertility have oligozoospermia with asthenozoospermia, but with normal morphology of sperm
      • more common in those over 40-years-old
      • often unable to determine etiology
    • more common in developing countries
Endocrine and Systemic Disorders Genetic Disorders of Spermatogenesis Acquired Disorders of Spermatogenesis Post-testicular Defects and Disorders of Sperm Transport
  • Kallmann syndrome
  • Hemochromatosis
    • increased deposition of iron in pituitary gland
  • Pituitary disorders
  • Post-irradiation
  • Exogenous androgen use
  • Obesity
  • Klinefelter's syndrome (XXY)
  • Androgen insensitivity syndromes
  • 5-alpha-reductase deficiency
  • Myotonic dystrophy
  • Infection causing orchitis (e.g., mumps, tuberculosis, and leprosy)
  • Epididymo-orchitis (often due to gonorrhea and chlamydia)
  • Cryptorchidism
  • Testicular torsion
  • Varicocele
  • Vas deferens abnormalities
  • Cystic fibrosis
  • Ejaculatory duct obstruction
  • Retrograde ejaculation
 
Presentation
  • Symptoms
    • inability to conceive
    • history of undescended testicle
    • history of orchitis
    • history of surgical procedure in the area
      • vasectomy
    • absence of sense of smell
      • Kallmann syndrome
  • Physical exam
    • hypogonadism
    • body habitus
      • decreased muscle mass and increased body fat may indicate androgen deficiency
      • obesity
    • abnormal scrotum
      • varicocele
    • gynecomastia
Evaluation
  • Standard semen analysis
    • semen volume and pH
    • sperm concentration, motility, and morphology
    • sperm leukocyte count
    • microscopy for debris, agglutination, and immature germ cells
    • tested for hyperviscosity
  • Specialized semen analysis
    • sperm autoantibodies
    • semen culture
    • sperm-cervical mucus interaction
  • Over the counter at-home test
    • limited reliability of test
    • does not assess sperm motility or morphology
  • Endocrine tests
    • testosterone, lutenizing hormone, and follicle-stimulating hormone
  • Genetic testing if suspicious for cystic fibrosis or other genetic disorder
Differential
  • Female infertility
  • Insufficient time to conceive
  • Past vasectomy
Treatment
  • Limited treatment available
  • Lifestyle modifications
    • smoking cessation
    • reduce alcohol intake
    • exercise and weight loss
    • avoid lubricants
  • Treat underlying condition if possible
    • varicocele ligation
    • dopamine agonist for hyperprolactinemia
    • gonadotropin therapy or pulsatile GnRH for hypogonadotropic hypogonadism
    • testosterone supplementation if deficient
  • Assisted reproductive techniques
    • manual extraction of mature spermatozoa or spermatids in testicular biopsy
    • in vitro fertilization
    • intrauterine insemination
    • artificial insemination with donor semen
Prognosis, Prevention, and Complications
  • Prognosis
    • depends on etiology of infertility
    • factors associated with better prognosis
      • younger age of female partner
      • shorter duration of infertility
      • higher percent of sperm concentration
      • good sperm motility
      • normal sperm morphology
  • Complications
    • psychiatric complications
      • depression
      • anxiety
      • low self-esteem
      • sexual dysfunction

 



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