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Evaluation of the Male - Overview

 

Overview

 

It takes two people to conceive, and therefore both the male and female should ALWAYS be evaluated if there is a problem conceiving. The goal of evaluation of men having difficulty conceiving is two-fold.

  1. Identify and treat any problems related to fertility
  2. Identify and treat serious conditions which have implications for the general health of a male beyond inability to conceive.

 

The approach to evaluation is to try and localize the site of the problem. There may be more than one site which is contributing to infertility.

 

 

The general approach requires an interview and exam which is followed by further testing and treatment if necessary.

 

You can expedite your visit by filling out the pre-visit infertility questionnaire.

 

 

 

Physical Examination

Physical examination will often times identify a cause for infertility if one is present, or at least point the physician in the right direction in terms of localizing the problem. Here are some things that are checked:

  1. General body habitus and virilization: low testosterone level may present with diminshed hair growth, especially on the face and chest. Breast enlargement can be a sign of elevated estrogen levels.
  2. Penis: problems with erectile dysfunction or with the urethra such as hypospadias are sometimes found.
  3. Testes: size, lie and consistency are the main features assessed. Since the majority of the testicular volume is for sperm production, small testes can indicated that dimished sperm production. Varicoceles and congenital absence of the vas deferens are best detected with physical examination.

 

Semen Analysis

Information can be found here.

 

Hormones Measured in the Evaluation of Male Infertiliy and Their Interpretation

 

Hormones play a critical role in spermatogenesis. The testis has 2 primary functions:

  1. Testosterone production
  2. Sperm production

 

Both of these are under hormonal control by the brain and there is an expected relationship between the hormone levels secreted by the brain and those secreted by the testis.. Problems with either of these functions can sometimes be detected by blood tests which can help localize if the brain, the testis and/or the reproductive tract (the pipes which carry sperm from testis to penis) is the problem.

 

The basic hormone evaluation includes:

  1. Testosterone
  2. Follicle stimulating hormone (FSH)
  3. Prolactin (PRL)
  4. Optional: Estradiol, Thyroid Stimulating Hormone (FSH), Estradiol

 

Figure: Negative feedback loop between the brain and testis. The testis produces (1) testosterone and (2) sperm. The brain has 'sensors' for testosterone and sperm production (the latter is indirectly reflected in levels of inhibin B - a hormone which is decreased if sperm production is diminished, that is, Inhibin B 'inhibits secretion of FSH'). The brain attempts to maintain constant levels of testosterone and sperm produced by the testis by adjusting the levels of 2 hormones which affect testicular function in response to the levels of testosterone and inhibin B in the blood.

  • If testosterone is lower than desired, the brain increases secretion of luteinizing hormone; conversely, if testosterone levels are too high, it decreases LH secretion. The testis usually responds to increased LH levels by increasing testosterone and to low LH levels by decreasing testosterone. 
  • In the same way, the brain will increase FSH levels if inhibin B levels are decreased in response to decreased sperm production or increase them if inhibin B levels are low.

 

The 3 common patterns of hormonal abnormalities.

Site of Problem Testosterone LH FSH Comment
Pre-Testicular Low Low Low  
Testicular Low High High Examples include varicocele or Klinefelter's syndrome
Post-Testicular Normal Normal Normal Obstruction, e.g. vasectomy

Pre-testicular problems are those associated with impaired hormone secretion by the brain. The expected response of the brain to low testosterone or sperm production is missing.

Testicular problems are those which originate within the testis themselves. The brain responds appropriately by increasing LH, FSH or both in reponse to low testosterone or decreased sperm production, respectively.

Post-testicular problems are those in which the brain and testis OK (sperm and testosterone are being produced normally), but the pipes blocked and sperm are absent from the ejaculate.

 

One important thing to note about measurements of LH and FSH is that increased levels are very specific for testicular dysfunction, but relatively insensitive. A lack of sensitivity means that normal levels of LH and FSH do not exclude the presence of a testicular problem. High specificity means that if LH and FSH are elevated it means that a problem is definitely present.

 

Click here for detailed information on Hormones and Infertility in Males

 

Routine Infectious Disease Testing

By law, men in whom sperm may used for ART must be tested for transmissible infections. This includes:

  1. Syphillis serology (RPR) and T. palladium Antibody (Syphilis Screen)
  2. Heaptitis B surface Antigen (BBsAg)
  3. Hepatitis C Virus Antibody (Hep C Ab)
  4. HIV 1+2 Ab and HIV p24 Ag (Screen)