A fertility evaluation is often pursued in couples who have not been able to conceive for a period of 6-12 months of unprotected intercourse. A fertility evaluation may be appropriate sooner than this when the couple is considered to be at higher risk for subfertility or infertility: when the female partner is over age 35; when there has been a history of infertility in a prior relationship; or when there are other risk factors which may cause fertility problems (e.g. cryptorchidism, testicular neoplasm, chemotherapy, radiation therapy).
A proper fertility history begins with an assessment of the couple's prior and current fertility status. The age of the partners and the duration of unprotected intercourse is established. It should be ascertained as to whether the infertility is primary or secondary for each partner. If secondary, the nature and outcome of prior pregnancies with the same or any previous partner is necessary. Any previous infertility evaluation or treatment for either partner should be noted as well.
In approximately 5% of couples presenting for infertility evaluation, sexual dysfunction is causative. Is the semen ejaculated into the vagina? Does the couple use lubricants, jellies, oils, or saliva, most of which are known to be spermicidal? Given an approximate 48-hour viability of sperm within the female reproductive tract, timing of intercourse is important. The sexual history should also include an assessment of male libido, which crudely reflects serum testosterone levels.
The man should be questioned regarding the nature and volume of a typical ejaculate. A markedly diminished semen volume and clear, waterlike fluid may suggest absence of the seminal vesicle component associated with either ejaculatory duct obstruction or congenital bilateral absence of the vas deferens (CBAVD). Normal orgasm with low or absent semen volume could also lead one to suspect retrograde ejaculation. Semen that fails to liquefy suggests prostatic dysfunction.
Cryptorchidism means an undescended (hidden) testis. It is present in about 0.8% of newborn males and is an important risk factor for infertility. Hernia repair in infancy or childhood is associated with a 3–17% risk of injury to the inguinal or retroperitoneal vas deferens. Post-pubescent mumps is associated with a 30% risk of unilateral orchitis and a 10% risk of bilateral orchitis, which may result in severe abnormalities in spermatogenesis.
The approximate age of onset of puberty is important. Men will usually remember pubertal landmarks only if they were very early or very late. Precocious puberty suggests an adrenal abnormality such as congenital adrenal hyperplasia. Very delayed or incomplete sexual maturation suggests hypogonadotropic hypogonadism, such as Kallmann's syndrome, or pan-testicular failure, such as Klinefelter syndrome.
Any and all conditions or illnesses for which the patient has been or is currently being treated, including all medications currently or previously taken, are documented. Many prescription drugs interfere with spermatogenesis. Drugs of abuse such as alcohol, marijuana, and cocaine may directly interfere with testosterone and sperm production. A detailed occupational history is directed toward identifying exposure to gonadotoxic agents such as heat, ionizing radiation, heavy metals, and pesticides. A family history directed at fertility problems in parents and siblings may be important. Intrauterine exposure to diethylstilbestrol (DES) is also associated with male genitourinary tract anomalies and dysfunction.
A thorough physical examination can provide insight into the cause of impaired sperm production as well as the overall state of sperm production, and into potential causes of reproductive tract obstruction. The exam is preferably performed in a warm room. The patient's general body habitus and hair distribution are examined.
The breasts are observed and palpated for gynecomastia, which can be associated with an imbalance of testosterone and estrogens, including estrogen secreting testicular neoplasms, adrenal tumors, and liver disease. Nipple discharge or tenderness may be seen with prolactin-secreting pituitary adenomas.
The penis and urethral meatus are also closely examined. The urethra can be milked for discharge. The location of the meatus is noted. Severe hypospadias may result in inadequate delivery of semen into the vagina.
Scrotal examination is first performed with the patient supine. This allows a varicocele, if present, to collapse. Testis size and consistency can then be properly assessed. Normal testicular volume ranges from 15 to 30 cc. The testes should be firm in consistency. A change in testicular consistency is indicative of an abnormality within the testes. In most cases, testes that are normal in size and consistency usually have normal sperm production.
The normal epididymis, which sits behind and to the side of the testis, is normally soft and barely palpable. Hardening, nodularity, or irregularities are suggestive of epididymal pathology, such as obstruction of the reproductive tract beyond the epdidymis.
The vas deferens should be palpated on both sides. The vas is the diameter and consistency of a venetian blind cord, and is usually behind and separate from the internal spermatic cord structures.
With the patient standing, large varicoceles are readily seen through the relaxed scrotal skin in a warm room. Small varicoceles may be appreciated as a distinct impulse and palpable dilation of the internal spermatic veins during the Valsalva maneuver.
If indicated, a digital rectal examination is performed. The size and consistency of the prostate is noted. Masses, cysts, irregularities, tenderness, and whether or not the seminal vesicles are palpable are noted.
A semen analysis is an imperative part of any fertility evaluation.
Semen specimens are obtained by masturbation into a sterile wide-mouth container after 2-5 days of abstinence and analyzed within 2 hours of collection. Two to three analyses, separated by at least 1-2 weeks, are required for a meaningful evaluation.
|Semen Characteristics||Units||WHO V (2010)|
|Volume||ml||1.5 or more|
|pH||pH units||(7.2 - 8.0)|
|Sperm Concentration||x 106 / ml||> 15|
|Total Sperm Count||x 106 / ejaculate||> 39|
|Motility (within 60 minutes of ejaculation)||% Motile||> 40%|
|Progression at 370°C||Scale 0-4||3 - 4|
|Morphology (Strict)||% Normal sperm||> 4%|
|Vitality||% Live sperm||>= 75|
|White Blood Cells||x 106/ml||< 1.0|
Basic endocrine evaluation includes measurement of serum total testosterone (TT) and follicle-stimulating hormone (FSH). Testosterone is necessary for the development and maintenance of secondary sexual characteristics and libido as well as initiation and maintenance of spermatogenesis. Elevated serum FSH suggests abnormalities in spermatogenesis.
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