Evaluation of the Male

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. 

Approach to Management of Male Infertility

The approach to evaluation and management of male infertility always occurs within the context of the couple. Having said that, the job of the urologist is to evaluate the male problem. There are several questions that we attempt to answer during evaluation and treatment.

1. Is there a problem with male infertility? This requires a basic evaluation including a history, physical exam and some foundational testing (semen analysis, hormone profile).

2. If there is a problem, where is the problem? The goal is to localize the problem (see below). The results of initial testing will usually point us in the right direction. In some cases, there may be more than site that is problematic (e.g. vasectomy plus low testosterone production) and in other cases we may have a good idea of where the problem is likely to be but are not certain. Additional testing may be necessary.

3. If there is a problem, can it be ‘categorized’ into a ‘type or pattern’? This approach can help streamline the investigations. A couple of common categories include ‘azoospermia’ or ‘primary testicular failure’. Sometimes the category is quite specific such as ‘non-obstructive azoospermia (NOA)’. In each instance, additional testing can further refine the cause.

4. What is the cause of the problem? Being able to identify where the problem resides is helpful but it may not lead to a treatment. Ideally, we want to identify and treat the underlying cause (with, for example, medication, surgery or lifestyle change). Unfortunately, it is very common that while the problem can be localized, we can’t put our finger on what caused the problem in the first place. Failure to identify an underlying cause after completing the necessary investigations is known as idiopathic infertility.

5. What can be done to treat or address the problem? This is the last and most important question - but it can only be posed once the other questions have been answered. Most patients ask this first and don’t appreciate that some diagnostic testing is usually required. There are many different treatments for the many different causes and your urologist will be able to provide you advice after you’ve done the recommended testing.

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 Infertility 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.

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)