When an abnormality in the sperm is demonstrated (and confirmed
with appropriate follow up semen analyses), a cost considerate
and organized approach to the evaluation and treatment should
be initiated. The evaluation is based on consideration of the
causes for abnormal sperm production.
* (1) a detailed fertility history should be taken, including
Prior pregnancies achieved with the current or any prior partners,
regardless of outcome (such as spontaneous abortion or miscarriage,
term delivery, or termination).
Prior infertility treatments attempted and their outcome, including
infertility care for the partner (if any)
Any noted abnormalities in completing intercourse or ejaculation
* (2) a detailed medical history, including
Surgery involving the region of the scrotal sac or an inguinal
hernia repair
Known exposure to increased heat, such as hot baths, tight underwear,
truck driving
Varicocele detection on exam
Radiation or chemotherapy (the testes are very sensitive to radiation
with as little as 15 rads associated with decreased spermatogenesis,
50 rads associated with transient azoospermia, 600 rads associated
with permanent azoospermia)
Cancer of the testicle(s) as well as surgical or medical treatment
Infections involving the reproductive tract, including venereal
diseases or prior prostatitis (which is not caused by a venereal
disease) and their treatment
Serious systemic viral or other disorder that is associated with
a fever within the prior 3-5 months
Trauma to the testes (even if several years prior)
Substance abuse, including cigarettes, alcohol, cocaine, narcotics,
and marijuana
Toxin exposure, including pesticides or industrial chemicals in
poorly ventilated conditions
Medications taken in the past 3-6 months
Prior chromosome testing results
DES exposure in utero
Known history of congenital absence of the vas deferens
Known history of retrograde ejaculation or history of low ejaculatory
volume
Neurologic symptoms, including headaches, blurry vision, dizziness,
vomiting without known cause
Ongoing medical conditions requiring follow-up with a physician
Ability to smell (tested with substances like coffee, not harsh
odors)
* (3) an expert physical exam should be performed (ideally
by a urologist with a special interest in male infertility), including
Overall appearance for adequacy of virilization (hair growth and
pattern, breast development which is referred to as gynecomastia
if present in the male, eunuchoid dimensions with long extremities
and tall stature)
Size and consistency of the testes (with either the calipers of
an orchidometer that measures testicular diameters or oval shape
"ovoids" that are calibrated by volume for comparison)
with a normal adult testicle being greater than 4 ml in length
and 20 ml in volume. Since 85-90% of testicular volume consists
of seminiferous tubules (involved in sperm production), a serious
insult to spermatogenesis is often reflected by a decrease in
testicular volume
Presence of the epididymis (and any induration, irregularity or
cystic changes) and vas deferens (with any nodularity noted)
Detection, location, and size of a varicocele
* (4) an initial laboratory evaluation might include
(A) FSH (and ideally LH and total testosterone) concentration
in the blood
These tests are especially important if man is azoospermic, looking
to identify an endocrinologic basis.
The most common treatable finding is an insufficient amount of
pituitary gonadotropins (FSH and LH). This might reflect a pituitary
or CNS-hypothalamic dysfunction and a structural lesion should
be ruled out as well as insufficiency of the other pituitary hormones.
An elevated LH and testosterone concentration with a low to normal
FSH concentration suggests "partial androgen resistance"
syndrome which results from a deficiency in the intracellular
androgen receptor number or function. There is a wide spectrum
of pathology associated with this syndrome and it is now thought
that a large number of previously diagnosed "idiopathic oligospermia"
patients may really have "partial androgen resistance"
syndrome as the underlying cause.
An elevated FSH that is 2-3 fold greater than normal reflects
a poor prognosis and likely testicular spermatogenic (seminiferous
tubule and Sertoli cell) compartment failure (with no Sertoli
cell inhibin production to suppress the FSH).
If there is an elevated FSH and elevated LH concentration with
low testosterone then there is most likely "panhypogonadism"
(complete testicular failure).
If all three hormone concentrations are normal then there is most
likely a nonhormonal cause for the abnormal sperm concentration
(such as a varicocele) and there is no basis for hormonal treatment.
(B) Prolactin concentration
If the FSH and LH concentrations are suppressed then the prolactin
concentration should be checked since treatment of hyperprolactinemia
will often correct the gonadotropin abnormality. Structural lesions
(including a prolactinoma) must be ruled out if repeated hyperprolactinemia
is demonstrated.
(C) Free (bioactive fraction of the total) testosterone
concentration
This is important if there is a low total testosterone concentration
with a normal FSH and LH concentration, especially if the man
is obese, since the supressed total testosterone concentration
may only reflect a decrease in the sex hormone binding globulin
(the liver protein that bindings sex hormones such as testosterone
resulting in decreased bioactivity). If the free testosterone
concentration is normal, no further followup for these findings
is required.
(D) Anti sperm antibodies
If the abnormality is predominantly a motility or progression
problem then many infertility specialists suggest highly specific
antisperm antibody testing. The results of this specific testing
does not change my treatment plan so I only check for antibodies
with the nonspecific postcoital test. Treatment is based on the
results of the postcoital test, endocrine evaluation, physical
exam (for varicocele) and presence of elevated numbers of round
cells on semen analysis.
(E) centrifugation of the semen sample
If the semen is initially considered devoid of sperm (azoospermia),
one should perform a microscopic examination of the centrifuged
sperm pellet. This can often identify at least a few sperm to
rule out complete ductal obstruction
(F) examination of a postejaculate urine specimen
If there is both a low volume (less than 1cc) and low density
of sperm (or azoospermia) the postejaculate
urine should be examined to rule out retrograde ejaculation
(G) transrectal ultrasound, vasography or seminal fructose
level
If azoospermia with a low ejaculatory volume and reasonable (less
than 2 fold normal) FSH concentration then these tests can rule
out an ejaculatory duct obstruction
(H) testicular biopsy
If azoospermia with no ejaculatory duct obstruction, low volume
and reasonable (less than 2 fold normal) FSH concentration then
a testicular biopsy to assess testicular sperm production is important.
If the testicular biopsy is normal in this situation, vasography
can confirm an obstruction (which can then be treated surgically)
or an emission failure if no obstruction is present (which can
be treated with medications or electroejaculation). If the testicular
biopsy shows no sperm or germ cells then consideration of adoption
and donor sperm is appropriate. If the testicular biopsy shows
a maturational arrest in the sperm, then a large varicocele (if
present) can reasonably be repaired (otherwise consideration of
adoption or donor sperm is appropriate).
From this initial evaluation the physician can pull together a
tremendous amount of information and usually direct management
quite specifically.
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