The Fertility Evaluation

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% - 20% of all couples are infertile.  The difficulties are attributable to a significant male factor alone in 30% of couples and to a combination of male and female factors in an additional 20%. Therefore, in >50% of all infertile couples, an abnormal male factor contributes to reproductive failure.   This means that well over 2.5 million men would benefit from a fertility evaluation.
 
Traditionally, the initial evaluation of the male was performed only when the couple had been unable to conceive after 1 year of unprotected intercourse.  However, because many couples are now postponing parenthood, and because the risk of a female’s infertility increases as she passes the age of 35, male infertility evaluations should be performed upon initial presentation.  

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 thorough laboratory evaluation.  The initial evaluation includes a semen analysis and hormonal testing.  Depending upon these results, a more detailed evaluation with a repeat semen analyses, sperm function tests, additional hormonal studies, radiologic studies, genetic evaluation, and other procedures including a testicular biopsy may be performed.

History and Physical Examination

You will be asked to complete a detailed questionnaire of your medical, social, surgical and pregnancy history.  Questions include not only your general medical health, but your family history, exposure history, use of tobacco, alcohol and drugs, exposure to toxins, radiation and chemotherapy, as well as problems with infection.  A detailed sexual history including questions on sex drive, erections, ejaculations and orgasm will be obtained.  A history of your partner’s fertility and workup and evaluation will be asked.

During your new patient consultation, a detailed physical examination will be performed.  Your height, weight, secondary sexual characteristics, abdomen, groin, penis and scrotum will be examined.  Your testicular volume will be assessed and a rectal examination performed.

Laboratory Testing

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.

Testicular Function 

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.

What is a Diagnostic Testis Biopsy?

The most common finding amongst infertile men is abnormal sperm production in terms of numbers and quality. However, a small percentage of men have a zero sperm count known as azoospermia. There are three causes for azoospermia:

1. Insufficient hormones and this is easily established by blood tests.
2. Problem in the testis producing sperm
3. Blockage preventing sperm from getting out similar to a vasectomy.

The last two can sometimes be differentiated by findings in the history, physical examination or on blood tests, however, there are a significant number of times when it is still uncertain. In that case, a diagnostic testicular biopsy is performed to differentiate between obstruction and a problem inside the testis.

A diagnostic testicular biopsy consists of taking a small pea sized amount of tissue out of both testes and sending them to the pathology laboratory for examination. The tissue must be handled properly in a special way for the biopsy to be worthwhile. Thus, even though the procedure is quite simple, it is best performed at a center that has a great deal of experience with male infertility.

Treatment Options

The management options for couples in whom the husband has a zero sperm count depend upon the exact cause. Adoption and donor insemination are always an alternative option to fixing the husband’s problem or using sperm harvested from him in combination with in vitro fertilization (IVF), test tube baby technology. Hormonal therapy is highly effective in men who have insufficient hormones. For those men who have a problem in the testis, therapies aimed at improving testicular function may be employed such as varicocele repair. The alternative is to harvest sperm from the testes (see sperm retrieval procedures).

About 50% of men with a zero sperm count have sufficient sperm production within the testes to allow fertilization of the wife’s eggs using intracytoplasmic sperm injection (ICSI) a form of IVF. The options for couples where the man has a zero sperm count due to a blockage are to repair the blockage or harvest sperm to be used in IVF.