Male infertility is directly or indirectly responsible for roughly 50% of cases involving reproductive-age couples with fertility-related issues. Unfortunately, the evaluation of male infertility is often underestimated or postponed. An evaluation of the infertile male using standardised procedures improves both diagnostic precision and the results of subsequent management in terms of treatment effectiveness, risk and costs.
A medical history and physical examination are standard assessments in all men, including semen analysis.
A detailed medical history should be obtained for any factor that may impact fertility potential. Information regarding the following areas should be collected: prior fertility, previous diseases during childhood and puberty, surgeries performed (especially those involving the pelvic regions and genitalia), genital traumas, infections, physical and sexual development, social and sexual habits, exposure to radiotherapy or chemotherapy, current or recent medications and a family history of birth defects, mental retardation, reproductive failure or cystic fibrosis.
Prognostic factors for male infertility are:
- Duration of infertility
- Primary or secondary infertility
- Results of semen analysis
- A history of urogenital surgery
- Cancer treatments
- Age and fertility status of female partner
Male fertility can be reduced as a result of:
- Congenital or acquired urogenital abnormalities
- Urogenital tract infections
- Increased scrotal temperature (e.g. as a consequence of varicocele)
- Endocrine disturbances
- Genetic abnormalities
- Immunological factors
A semen analysis measures the amount of semen a man produces and determines the number and quality of sperm in the semen sample. A semen analysis is usually one of the first tests done to help determine whether a man has infertility problems. Problems with the semen or sperm affects more than one-third of infertile couples. If the results of semen analysis are normal, one test should be sufficient. If the results are abnormal in at least two tests, further andrological investigation is indicated.
Tests that may be done during a semen analysis include:
- Volume. This is a measure of how much semen is present in one ejaculation.
- Liquefaction time. Semen is a thick gel at the time of ejaculation and normally becomes liquid within 20 minutes after ejaculation. Liquefaction time is a measure of the time it takes for the semen to liquefy.
- Sperm count. This is a count of the number of sperm present per millilitre of semen in one ejaculation.
- Sperm morphology. This is a measure of the percentage of sperm that have a normal shape.
- Sperm motility. This is a measure of the percentage of sperm that can move forward normally. The number of sperm that show normal forward movement in a certain amount of semen can also be measured (motile density).
- pH. This is a measure of the acidity (low pH) or alkalinity (high pH) of the semen.
- White blood cell count. White blood cells are not normally present in semen.
- Fructose level. This is a measure of the amount of a sugar called fructose in the semen. The fructose provides energy for the sperm.
Hormonal Determinations (Endocrine evaluation)
In men with testicular deficiency hypergonadotrophic hypogonadism is usually present, with high levels of follicle stimulating hormone [FSH] and luteinising hormone [LH], and sometimes low levels of testosterone. Generally, the levels of FSH correlate with the number of spermatogonia; when spermatogonia are absent or markedly diminished, FSH values are usually elevated. It is important to assess if the male patient is suffering from hormonal problems. A routine part of the initial evaluation is testing of specific serum hormone levels, which usually includes FSH, LH, testosterone, and prolactin.
Male tests to be conducted include:
- Insulin – Fasting
- Glucose – Fasting
- Growth Hormone
- HIV – Screening Test
- Hep B – Antibodies
- Hep C – Antibodies
- Semen Analysis