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Diagnosis of male infertility

There are several steps in evaluating male infertility:

Medical history- Physical examination

A  detailed medical history and physical examination are essential in evaluating male infertility. Several areas should be stressed and specific questions should be asked.

Family history is of great importance regarding inherited disease. One should take into consideration past medical history, previous pregnancies, duration of unprotected intercourse, previous urogenital and childhood diseases.

Occupational history often gives information regarding environmental factors that may affect testicular function. High temperature environment (boiler makers, steam fitters, bakers, laundry worker’s etc), electromagnetic waves, exposure to x- rays, radiation or chemical products may affect sperm quality.

Severe childhood diseases, partial descent of the testes, operations (hernia repair) or testical trauma may lead to inflammation or atrophy of the testes.

Tobacco undoubtly reduces sperm quality and increases abnormal sperm forms. Marijuana causes testical reduction and teratospermia. Also, coccaine and  drugs affecting the nervous system, may reduce spermatogenesis.

Laboratory evaluation

The basic semen analysis must be considered the mainstay in evaluating male infertility. A carefully performed semen analysis is a highly predictive indication of the functional status of the male reproductive hormonal cycle, spermatogenesis and the patency of the reproductive tract. The parameters that are taken into consideration are sperm count, volume of ejaculate, motility and morphology of sperm.

Since some variation occurs normally, at least two specimens 4-6 months apart should be examined before any judgment of impaired fertility is made.

If abnormalities persist, endocrine evaluation in the form of  serum follicle-stimulating hormone (FSH), luteinizing hormone (LH),  testosterone (T), prolactin (PRL) and Estradiol (E2) is carried out.

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The evaluation of the male patient with  abnormal semen analyses are divided into  two groups:

  • Those with complete absence of sperm (azoospermia).
  • Those with other semen abnormalities i.e. low sperm count, low sperm motility, increased morphological abnormalities, or alterations in semen volume. (oligozoospermia).

A clear distinction should be made between obstructive and nonobstructive azoospermia. Further tests and testicular biopsy provide diagnosis. In case of obstructive azoospermia, there is an indication for surgical treatment (e.g varicocele, obstructed vas deferens).

In patients with abnormal semen parameters approximately 37% will be diagnosed of having a condition called varicocele.

Varicocele refers to the presence of varicose veins in the testicles. This occurs when blood in the testicles does not circulate out properly and as a result local temperature  increases, which in turn prevents proper production and maturation of sperm. Varicocele is diagnosed with clinical examination and ultrasound scan of the testes. Surgical management can result in subsequent pregnancy rates of 40-50%.

In patients with oligospermia medical therapy for up to three months may help. Another approach is through intrauterine insemination which could be an effective solution.

In patients with severe oligospermia unresponsive to medical therapy, IVF can play an important role.

Generally speaking, recent advances in assisted reproduction (ICSI, MESA-TESE) have made treatment of most cases of male infertility, possible.