This article aims to walk you through the systematic process of male partner evaluation. It will discuss every aspect of the process of evaluation of an Infertile Male, why it is done and how it helps the specialist in making informed decisions.
History and physical examination together with the semen analysis provide the basic information for the initial evaluation of most men.
In addition to a normal general medical history, particular attention should be paid to history of undescended testes, pubertal development, genital surgery or infection, fertility in the current or previous relationships and coital frequency, erection or ejaculation problems.
Examination of the male is important to identify any general health issues associated with infertility such as obesity, proper positioning of testes, consistency and size of testes, abnormalities in the ducts arising from testes or adjoining veins. Penile abnormalities may result in inadequate delivery of semen to the upper vagina. Rectal examination may reveal prostate abnormalities.
What investigations are usually recommended for evaluation of a male partner? they can be divided into the following broads heads:
It is the most important investigation of male subfertility.
One sample will suffice if normal. However, a man’s sperm count can vary considerably over time and therefore, if an abnormality is detected a repeat semen analysis should be performed after 3 months, or sooner if the initial test shows nil sperms. This reduces the likelihood of a transient illness causing misleading results.
Normal semen analysis -
FSH, LH, testosterone should be measured in men with sperm counts of less than 5 million/ml.Testosterone: levels undergo diurnal variation; they are highest in the morning, and therefore random measurements should be interpreted with caution if the result is borderline. Normal range is 270-1000ng/dl.
Other indications for serum hormonal testing include evidence of impaired sexual function (e.g. impotence, reduced libido) and clinical symptoms of endocrine disease (e.g. hypothyroidism).
Subtle genetic abnormalities can manifest as male infertility.
A karyotype that is a Chromosomal analysis looks for the number of chromosomes present in an individual; is indicated in cases of severely low sperm counts because these men are at increased risk of structural and sex-chromosomal anomalies. For instance, Klinefelter syndrome (47, XXY) is the most frequently detected sex chromosomal abnormality. As many as 10–15% of men with azoospermia have underlying micro-deletions in one or more gene regions implicated in spermatogenesis, on the long arm of the Y chromosome (Yq).
Bilateral absence of specialised ducts called vas deferens carrying sperms from testes to male urethra can be associated with cystic fibrosis carrier status and therefore men with non-palpable vas deferens should be tested for mutations in the cystic fibrosis gene, as indeed should all men with obstructive azoospermia where no cause has been identified.
Scrotal ultrasound should be performed if an abnormality such as a testicular tumour is detected on physical examination.
Ultrasound can also be useful in the clinical diagnosis of varicocele, especially with the use of Colour flow Doppler.
If an absent vas is detected on examination, a renal ultrasound scan is recommended, as up to 30% of such men may have a renal abnormality.
Testicular biopsy can aid the diagnosis of severely low sperm counts and facilitate sperm recovery for intracytoplasmic sperm injection (ICSI). Biopsy can be done by an open(that is through small 0.5-1cm cuts) or needle approach and is used to obtain a small piece of testicular tissue for histological examination. Testicular biopsy specimens can be classified as normal (appropriate number of cells with complete spermatogenesis) or hypospermatogenesis (all cell types present and in correct ratio but at reduced cell numbers) or maturation arrest (failure of spermatogenesis beyond a certain stage; can be ‘early’ or ‘late’).
Routine semen analysis provides information about sperm synthesis and sperm delivery, but gives little information about the functional ability of sperm.
One such test is the Sperm DNA fragmentation tests which assess sperm DNA integrity can be used as both diagnostic and prognostic tests for the outcome of assisted reproductive technologies. To read more about dna fragmentation, click here.