Infertility is defined as the inability to conceive after one year of unprotected, adequately timed intercourse, although depending on age and previous history, couples often seek evaluation sooner. Approximately 15 to 20 percent of all couples are infertile. The difficulties are attributable to a significant male factor alone—around 30 percent of couples—and to a combination of male and female factors in an additional 20 percent. Therefore, in over 50 percent of all infertile couples, an abnormal male factor contributes to reproductive difficulties. This means that well over 2.5 million men could potentially benefit from a fertility evaluation. Men with infertility, and especially with abnormal semen parameters, are at increased risk for multiple medical conditions. These include testicular cancer, endocrine (hormonal) conditions including diabetes and pituitary / thyroid disorders, and conditions associated with low testosterone production such as osteoporosis, metabolic syndrome, and heart disease. Thus it is crucial for men with infertility to be evaluated and appropriately counseled. The Center for Disease Control and Prevention (CDC) has recently labeled male infertility a "disease" in order to emphasize that infertile men should be evaluated and associated medical conditions addressed.
There are a vast number of etiologies of male infertility, therefore we advocate a systematic approach which begins with a detailed history and physical examination, followed by a targeted laboratory evaluation. The initial evaluation includes one to two semen analyses and hormonal (blood) testing. Depending upon these results, a more detailed evaluation with repeat semen analyses, more specific sperm function tests, additional hormonal or genetic studies, radiologic studies, and/or other procedures including a testicular biopsy may be performed. In modern practice, however, testicular biopsy is typically performed only at the time of sperm retrieval procedures.
Based on the findings, an individualized assessment and treatment approach is made for each couple. Most commonly, evaluation is done in parallel with reproductive endocrinologists and gynecologists, and ultimate management decisions are made with a team approach based on factors such as the couple's age, family goals, and priorities.
History and Physical Examination
You will be asked to complete a detailed questionnaire of your medical, social, surgical and paternity history. Questions include not only your general medical health, but your family history, and history of exposure to various toxins, illnesses, or medications that can affect fertility. A detailed sexual history including questions on sex drive, erections, ejaculations and orgasm will be obtained. Information about your partner’s fertility and workup and evaluation will be asked. Download a questionnaire that you can fill out before your visit.
During your new patient consultation, a detailed physical examination will also be performed. This typically includes a head-to toe examination of characteristics that could give insight into your reproductive function. Secondary sexual characteristics, abdomen, groin, penis and scrotal contents will be examined for any abnormalities pertinent to fertility and other related medical conditions.
In addition to obtaining at least two semen analyses with 2-3 days of ejaculatory abstinence, bloodwork will likely be obtained. Your hormonal evaluation will include tests of pituitary function and testicular function. Genetic testing may also be obtained. It may be necessary to obtain further testing on your semen, blood or perform an office or operative procedure to evaluate your infertility. An ultrasound of the testes is also sometimes obtained to evaluate for abnormalities such as varicocele, infection, or tumor.
The testes perform two functions. The first is to produce the male hormone testosterone which is secreted into the blood stream and has wide-ranging effects upon the body. The other role of the testis is to produce sperm. Either one or both functions may go astray during a man's lifetime. Since the testis has an absolute requirement for testosterone in order to make sperm, it is possible to have abnormalities in spermatogenesis with normal testosterone but not vice versa. It is extremely rare for men of reproductive age to have abnormal testosterone levels and much more common for them to have abnormalities in sperm production associated with normal testosterone levels.
Genetic tests can be useful in various ways in male infertility. For example, a karyotype (chromosome evaluation) can help us find if a patient is at risk for other medical conditions. Y-chromosome microdeletion testing can sometimes help predict our chances of obtaining sperm for a patient.
Finally, all genetic tests can reveal valuable information to be able to counsel the future children of infertile couples about their own health and fertility. Oftentimes, when genetic tests show abnormalities, it is best to see a genetic counselor to help learn more about the implications of the test results.
The Jargon: Azoospermia, Aspermia, Oligospermia, Asthenospermia and Teratospermia
Clearly these words were not made by people having a hard time building a family — sorry about that. They have Greek and Latin roots, and doctors use them to try to tease out different semen characteristics or "semen parameters".
Most importantly, here's what they mean:
- Azoospermia - absence of sperm in the ejaculate.
- Aspermia - zero volume ejaculate.
- Oligospermia - low numbers of sperm.
- Asthenospermia - poor sperm motility.
- Teratospermia - abnormal morphology (shape) of sperm.