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The Fertility Evaluation

Infertility is defined as a couple's inability to achieve pregnancy following one year of appropriately timed and unprotected intercourse. This suggests that in more than 50% of couples presenting for infertility evaluation, a male factor is contributory.
This means that 2.5 million American men would potentially benefit from fertility evaluation. It makes more sense, however, to start with the male partner, whose initial evaluation may be performed rapidly and noninvasively.
This specific treatment of the "male problem" is often more successful, less expensive and possibly less invasive than ICSI or other assisted reproductive treatments. In addition, about 1% of men who present with the symptom of "infertility" will actually have a serious medical problem.
Fertility History
Prior to arrival at the office, the patient is asked to fill out, at home with the partner, a detailed fertility questionnaire The 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.
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 somewhat spermicidal?

Ejaculate History
The man should be questioned regarding the nature and volume of a typical ejaculate. A markedly diminished semen volume and clear.waterlike fluid suggests. absence of the seminal vesicle component associated with either ejaculatory duct obstruction or congenital absence of the vas deferens (CAV). Normal orgasm with low or absent semen volume should lead one to suspect retrograde ejaculation and warrant examination of a postejaculatory urine specimen for the presence of sperm. Semen that fails to liquefy suggests prostatic dysfunction.
Cryptorchidism means a hidden testis is an important risk factor for infertility. Fifty percent of men with a history of unilateral cryptorchidism and 90% of men with a history of bilateral cryptorchidism are subfertile. 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 may result in severe ipsilateral abnormalities in spermatogenesis. Precocious puberty suggests an adrenal abnormality such as congenital adrenal hyperplasia. Very delayed or incomplete sexual maturation suggests hypogonadotropic hypogonadism (Kallmann's syndrome when associated with anosmia) or pantesticular failure, such as Kleinfelter's syndrome.
Many prescription drugs interfere with spermatogenesis, including cimetidine, sulfasalazine, nitrofurantoin, and anabolic steroids. Drugs of abuse such as alcohol,

marijuana, and cocaine are directly gonadotoxic. A detailed occupational history is directed toward identifying exposure to gonadotoxic agents such as heat, ionizing radiation, heavy metals, and pesticides. Family history may be important. Intrauterine exposure to diethylstilbestrol (DES) is also associated with male genitourinary tract anomalies and dysfunction.
Evaluation of body habitus, thyroid is palpated, heart and lungs auscultated. Situs inversus with associated immotile sperm is seen in immotile cilia (Kartagener's) syndrome. The breasts are observed and palpated for gynecomastia, nipple discharge or tenderness may be seen with prolactin-secreting pituitary adenomas. A large varicocele that does not collapse in the supine position warrants a search for an abdominal mass. An enlarged liver suggests hepatic dysfunction, associated with infertility due to altered sex steroid metabolism.
Scrotal examination, use an orchidometer to measure testicular size. The testes should be firm in consistency. In general, testes that are normal in size and-consistency usually have normal sperm production, whereas small-volume, soft testes are associated with impaired spermatogenesis. Bilateral congenital absence of the vas deferens (CAV) in 1.3% of patients presenting for infertility evaluation. These men will have azoospermia associated with low seminal volumes and nonclotting clear ejaculate.

Testes biopsy and scrotal exploration are not necessary, CAV is associated with. an 11% incidence of renal agenesis and abnormalities. Most men with CAV test positive for cystic fibrosis gene mutations.
If a varicocele is detected, the patient should be placed supine. A varicocele should completely collapse when the patient is supine. A large varicocele, which does not collapse in the supine position, leads to suspicion of a retroperitoneal mass and an abdominal sonogram is indicated. Our data has clearly shown that response to varicoceletomy is related to varicocele size. Digital rectal examination is always 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. Stool should be tested for occult blood.
Semen specimens are obtained by masturbation into a sterile wide-mouth container after 2-5 days of abstinence and analyzed within 2 hr of collection . Two to three analyses, separated by at least a month, are required for a meaningful evaluation. In the setting of a recent febrile illness or exposure to gonadotoxic agents we would repeat the semen analysis no sooner than 3 months later. Failure of liquefaction is due to abnormalities of the prostate. Sixty-five percent of the volume is from the seminal vesicles, 30-35% from the prostate, and 3-5% from the vasa. Seminal fructose derives from the seminal vesicles. A postejaculatory urine specimen is obtained by first having

the patient empty his bladder prior to ejaculation and then voiding following ejaculation into a separate container.
Manual light microscopic evaluation of sperm concentration, motility, and morphology is still the gold standard. Specimens with head-to-head or tail-to-tail agglutination are evaluated for antisperm antibodies or infection. Men with agglutination or leukospermia should have their semen cultured for aerobic and anaerobic organisms.
Profound abnormalities in morphology are associated with poor fertilizing capacity. Large numbers of tapered sperm are seen in testes with elevated temperatures, such as varicocele, cryptorchid, or retractile testes, or in the testes of men who take saunas or hot baths. Antisperrn antibodies bound to sperm are associated with lower pregnancy rates. All conditions associated with impairment of the blood-testis barrier that usually prevents sperm antigens from being exposed to the general circulation. A postcoital test is useful for evaluating sperm-cervical mucus interaction.
Endocrine Evaluation includes measurement of serum testosterone (T) and follicle-stimulating hormone (FSH). Serum FSH crudely reflects the status of the serniniferous epithelium. An FSH level greater than two to three times the upper limits of normal suggests severely impaired seminiferous tubule , but may still be treatable. LH levels need be obtained only in men with abnormal T levels.