Comprehensive office evaluation in the new millennium

Comprehensive office evaluationin the new millennium

Peter J. Burrows, MD, Christopher G. Schrepferman, MD,Larry I. Lipshultz, MD*

Division of Male Reproductive Medicine and Surgery, Scott Department of Urology, Baylor College of Medicine,

6560 Fannin, Houston, Texas 77030, USA

History and physical examination

Treatment of the infertile male is difficult at

best. Productive therapy can be instituted only

after completion of a thorough evaluation that

beginswith a detailed, directed history and physical

examination. The clinician first needs a thorough

understanding of male reproductive physiology

and reproductive anatomy. The ability to obtain

a comprehensive reproductive history and to per-

form a directed physical is one of the greatest tools

available to the clinician. Ideally, the initial evalua-

tion should include both partners. The goal of this

article is to provide the readerwith a foundation for

a comprehensive evaluation of the male partner.

History

By the classically accepted definition, an infer-

tile couple is one that has failed to conceive after

1 year of unprotected intercourse. This paradigm

results in discouraging numerous, extensive pre-

mature laboratory tests and doctor visits until an

appropriate attempt at natural conception has

been completed. The authors do believe, however,

that a cursory, goal-directed, cost-effective initial

evaluation should begin at the couple’s discretion.

It is now common to see couples that, for reasons

such as remarriage or busy careers, have post-

poned family building. This delay may have com-

promised the fertility potentials of both male and

female. In addition, once couples have decided to

start a family, they often become extremely anx-

ious after only a few months of failure to conceive.

The history (outlined in Table 1) begins with a

discussion of the duration of the couple’s infertil-

ity, previous fertility treatments, previous preg-

nancies, and a detailed sexual history. The longer

the duration of the infertility, the worse the chan-

ces are for a cure.

Sexual history

Five percent of couples seeking treatment for

infertility will describe a counterproductive sexual

behavior [1,2]. Themost commonfindings are a his-

tory of coital habits not conducive to conception.

The most frequently reported misconception con-

cerns the frequency of intercourse [3]. The optimal

timing for intercourse is 24 hours before ovulation

and then every 24 hours after ovulation. Sperm

have been shown to remain viable for 2 days in cer-

vical mucus and in the cervical crypts. For couples

following this suggested pattern, viable sperm are

more likely to be present during the 12- to 24-hour

period in which the egg is in the fallopian tube and

capable of being fertilized [4].

The couple’s coital habits are also an important

topic for discussion. The use of many common

lubricants, or even saliva, results in impaired

sperm motility. In vitro studies have shown that

frequently used substances such as K-Y jelly,

Lubifax, Surgilube, hand lotions, petroleum jelly,

and saliva to impede motility. Raw egg white,

vegetable oil, and the Replen douche do not impair

in vitro motility. Astroglide a water-soluble inert

* Corresponding author.

Scott Department of Urology, Baylor College

of Medicine, 6560 Fannin, Suite 2100 Houston, Texas

77030.

E-mail address: [email protected]

(L.I. Lipshultz).

0094-0143/02/$ - see front matter � 2002, Elsevier Science (USA). All rights reserved.

PII: S 0 0 9 4 - 0 1 4 3 ( 0 2 ) 0 0 0 9 1 - 5

Urol Clin N Am 29 (2002) 873–894

lubricant, contains no spermatotoxic ingredients;

however, with increasing concentration, sperm

motility is impaired to the same degree as with

petroleum-based lubricants such as K-Y jelly [5].

It is also important to explain the concept of the

‘‘sperm reserve’’ and to point out that frequent

masturbation or intercourse can deplete this

reserve, especially in oligospermic men, and result

in semen with markedly decreased sperm density.

Childhood history

The physician should next address the patient’s

childhood medical and surgical history. A history

of genitourinary congenital anomalies may lead

to further questioning regarding reconstruc-

tive surgery that may impair fertility or make the

clinician suspicious of an underlying genetic

problem. Pediatric illness associated with pro-

longed high fevers may injure quiescent germ cells

[6]. Pubertal mumps orchitis occurs unilaterally in

67% of patients and bilaterally in 33%. Testicular

atrophy occurs in 36% of those affected bilaterally,

and infertility occurs in 13% [7]. Prepubertal

mumps orchitis has little effect on future fertility.

Childhood or fetal exposure to chemotherapy,

radiation, or hormones can result in later sperm-

atogenic defects [8].

Undescended testes, regardless of timing of

orchiopexy, have been shown to reduce fertility

dramatically. Following treatment for unde-

scended testes, men have an associated incidence

of azoospermia of 13.3% in unilateral and 34% in

Table 1

Infertility history

History of infertility

Duration

Prior pregnancies

Present partner

Another partner

Previous treatments (varicocele, IUI, IVF)

Evaluation and treatments of wife

Infections

Viral, febrile

Mumps orchitis

Venereal

Tuberculosis

Sexual history

Potency

Lubricants

Timing of intercourse

Frequency of intercourse

Frequency of masturbation

Gonadotoxins and medications

Chemicals (pesticides)

Drugs (chemotherapeutic, cimetidine, sulfasalazine,

nitrofurantoin, alcohol, marijuana, androgenic

steroids, narcotics)

Thermal exposure

RadiationSmoking

Childhood and development

Genitourinary congenital anomalies

Undescended testes, orchiopexy

Herniorrhaphy

Y-V plasty of bladder

Testicular torsion

Testicular trauma

Onset of puberty

Family history

Cystic fibrosis

Androgen receptor deficiency

Infertile first-degree relatives

Medical history

Systemic illness (ie, diabetes mellitus, multiple

sclerosis)

Previous and current therapy

Review of systems

Respiratory infections

Anosmia

Galactorrhea

Impaired visual fields

Surgical history

Orchiectomy (testis cancer, torsion)

Retroperitoneal injuryPelvic injury

Pelvic, inguinal, or scrotal surgery

Herniorrhaphy

Y-V plasty, transurethral resection of the prostate

Occupational history

Heat

Vibration

Stress

Abbreviations: IUI, intrauterine insemination; IVF, in vitro fertilization; Y-V, plasty treatment for bladder neck

contracture.

874 P.J. Burrows et al / Urol Clin N Am 29 (2002) 873–894

bilateral cryptorchidism. Eighty-one percent of

men with a history of unilateral undescended testes

are capable of paternity, however. Moreover, un-

treated unilateral undescended testes result in a

30% incidence of azoospermia; with bilateral unde-

scended testes the incidence is 80% [9]. Adjuvant

gonadotropin therapy initiated following early

orchiopexy may improve future fertility [10]. Fur-

thermore, orchiopexy, whether for cryptorchidism

or testicular torsion, has occasionally resulted in

iatrogenic vasal or epididymal obstruction.

A review of childhood surgical procedures may

reveal important details that could impair subse-

quent fertility. Pediatric hernia repair may have a

26.7% incidence of vasal obstruction [11]. Bladder

neck surgery was routinely performed during ure-

teral reimplant surgery 30 years ago. This type of

surgery causes infertility through retrograde ejacu-

lation. Children born with congenital anomalies

involving the genitourinary system, such as epispa-

dias/bladder exstrophy, can exhibit difficulties with

both ejaculation and emission, despite spermato-

genesis that may be normal. Low-volume (\1.0

mL) azoospermia or severe oligospermia requires

a postejaculate urine analysis. A history of testicu-

lar torsion and orchiopexy can have a profound

effect on later sperm production.

Medical history

The patient’s medical history should then be

addressed. The clinician should note any systemic

disease process, in addition to current or previous

pharmacotherapy, chemotherapy, and ingestants.

The most common medical processes that interfere

with male fecundity are diabetes mellitus, pulmo-

nary disorders (sleep apnea, chronic obstructive

pulmonary disease [COPD]), infectious diseases

(HIV, gonorrhea, syphilis, tuberculosis), neuro-

logic disorders (multiple sclerosis), and, finally,

renal and hepatic insufficiencies. A history of spi-

nal cord or pelvic trauma should be identified. This

type of trauma is common with falls and car acci-

dents and can lead to disruption of innervation for

emission and ejaculation or to injury and subse-

quent obstruction to the male ductal system (eg,

vas deferens or epididymis) [12]. A history of tes-

ticular or groin trauma should be noted, because

these injuries may be possible sources of obstruc-

tion or atrophy.

Environmental exposure. The history should also

include a detailed inquiry into exposure to envi-

ronmental toxins shown to have deleterious effects

on spermatogenesis. Environmental toxin expo-

sure can affect the hormonal regulation of sper-

matogenesis as well as be directly gonadotoxic.

Elevated scrotal temperature caused by heat in

the work environment has the same effect of inhib-

iting maturation beyond the primary spermatocyte

as seen in varicocele and cryptorchidism [13,14].

Because noise and whole-body vibration induce a

stress response and release of adrenal hormones,

decreased sperm quality has also been seen in

men exposed to mechanical vibration (Table 2)

[15,16].

Exposures to organic solvents in the form

of glycol ethers, paints, and inks have all been

implicated as potential toxins at the primary

Table 2

Environmental factors that can affect fertility

Exposure

Occupations and sources

of exposure Effect on Fertility

Heat Welders, ceramics fl motility, fl density [197]; low birth

weight, › spontaneous abortion [198]

Ionizing radiation Nuclear power plant workers › offspring leukemia [199–201]

Electromagnetic fields Workers in rubber and plastic

manufacturing plants

fl density, fl motility, normal

morphology [202]

Whole-body vibration

or noise

Tractor drivers, helicopter pilots,

subway drivers

fl density, flmotility [15,16]

Heavy metals Lead in paint, battery manufacture,

printing, manufacture

fl density, hypothalamic-pituitary

injury [203,204]

Organic solvents Glycol ethers–painting, printing inks fl density [205]

Benzene Petroleum manufacture fl density, fl morphology [201]

Synthetic estrogens Pesticides (DDT, PCBs) fl morphology, fl density, pituitary-

hypothalamic suppression [206]

Dietary estrogens Fungal contaminated grains Unknown [207]

Abbreviations: PCB, polychlorinated biphenyl.

875P.J. Burrows et al / Urol Clin N Am 29 (2002) 873–894

spermatocyte level. Benzene used in petroleum re-

fineries can also cause oligoteratospermia in mice

[17]. Pesticides can induce an endocrinopathy by

increasing serum estradiol and thus lowering the

testosterone/estradiol (T/E2) ratio [18].

Exposure to environmental toxins is an area of

growing concern and litigation. Exposure to lead

affects the hypothalamic-pituitary-gonadal (HPG)

axis, resulting in testosterone suppression, and is

also a direct spermatotoxin [19]. Tobacco smoke

can cause sperm DNA damage and impair sperm

density, motility, and morphology [6,20]. Agents

such as organic solvents and heavy metals have

been reported in many studies to have a gonado-

toxic effect [21–23].Certainpesticides suchasdibro-

mochloropropane are strong testicular toxins.

Medications and other ingestants. Prescription

and recreational drugs should be evaluated with

regard to their dose and duration of use. Antimi-

crobial agents, such as erythromycin, tetracycline,

nitrofurantoin, gentamicin, and ciprofloxacin,

may impair spermatozoal function temporarily

[24–26]. Other common medications such as sulfa-

salazine and cimetidine have been implicated as

spermatotoxic agents [27]. Normal spermatogene-

sis should return after discontinuation of these

medications, although the significance of their

gonadotoxicity is still somewhat speculative. Nar-

cotic abuse has been shown to inhibit gonado-

tropin secretion and to lower testosterone levels

[28,29]. In addition, caffeine, nicotine, alcohol,

and marijuana have been implicated as reversible

gonadotoxic agents [30–32].

Anabolic steroids. The rate of anabolic steroid

abuse has been reported to be as high as 30% to

75% among professional bodybuilders [33]. Exog-

enous androgenic steroids exert their deleterious

effects by feedback effect at the level of the pitui-

tary and hypothalamus by inhibiting gonadotro-

pin release. The Leydig’s cells of the testes are

thus not stimulated to produce testosterone, and

spermatogenesis is greatly impaired. Cessation of

anabolic steroids should reverse spermatogenic

arrest; however, depending on the quantity of

exogenous steroids taken and the duration of their

use, return, if it occurs, may take up to 2 years [34].

Infectious history. Inquiry into specific infections

of the reproductive tract in addition to generalized

febrile illnesses is part of the routine history,

because these infections can lead to obstructive

infertility. Antibiotic treatment can decrease the

obstructive complications [35]. Pubertal mumps

orchitis is bilateral in 16% of cases and may cause

severe edema within the testes resulting in pressure

necrosis. Conservative treatment results in a steri-

lity incidence of 30% to 87% [36]. Treatment with

interferon 2-beta has been reported to preserve

spermatogenesis [37].

Cancer, chemotherapy, and radiation. Testes can-

cer and Hodgkin’s lymphoma (HL) are the two

most common malignancies of fertile males. Both

diseases have excellent long-term survival rates

when treated with chemotherapy with or without

radiation therapy [38]. Patients with either HL or

testes cancer may have decreased spermatogenesis

before any treatment. This testicular impairment is

not caused by direct invasion of the testes. Disse-

minated testes cancer, independent of histologic

type, is associated with pretreatment oligospermia

in 72% of patients, whereas HL is associated

with pretreatment azoospermia in 70% to 100% of

patients [39–42]. The recovery of spermatogenesis

following chemotherapy is unpredictable. Gandini

et al [43] showed that 55% of men treated with

chemotherapy with or without radiotherapy have

semen parameters better than or equal to their pre-

treatment parameters. Only 7.5% (4/53) of the men

treated with chemotherapy became azoospermic in

this study.

Sperm banking before initiating anticancer

treatment is strongly suggested. Banking not only

preserves viable healthy gametes but also has a

psychologically boosting effect by giving the

patients a sense of control and hope. In addition,

with the advent of intracytoplasmic sperm injec-

tion (ICSI), the minimal requirement for banking

is only one motile sperm!

Tumor type does not affect postthaw quality of

sperm. Furthermore, studies have shown that

before treatment, this patient population shows

no increase in teratogenic or cancer risk in the off-

spring conceived naturally or with assisted fertility

techniques [44]. Offspring of pretreatment testes

cancer patients have nomore chromosomal abnor-

malities than offspring in the normal population

[45].

The testicular germinal epithelium, compared

with other organs, is especially sensitive to the

toxic effects of chemotherapy and radiation

(XRT) [46,47]. Although recovery of spermato-

genesis is unpredictable, chemotherapy is gonado-

toxic and potentially permanent. In patients with

HL, the occurrence of azoospermia depends on

chemotherapy dose, duration of treatment, type

of drugs used, and number of drugs used, as well


as on pretreatment fertility. Treatment of HL

with mechlorethamine, vincristine (Oncovin, Lilly,

France), procarbazine, and prednisone (MOPP

protocol) results in a 70% to 100% incidence of

acute azoospermia that persists at 12 years in

90% of these patients [48]. High-dose chemother-

apy associated with bone marrow stem cell trans-

plant causes uniform and permanent sterility. The

mechanism is through nondiscriminate DNA dis-

ruption. Posttreatment HL patients have increased

chromosomal hyperploids and five times the oc-

currence of increased disomies. Changes in DNA

integrity can be seen at 11 months after treatment

[38]. Bleomycin, etoposide, and cisplatin (BEP) are

used routinely in testes cancer and cause short-

term azoospermia. Shortly after treatment, a high

incidence of morphologically abnormal sperm can

be seen. Long-term follow up of these patients,

however, shows a 25% natural conception rate,

even with reduced reproductive capacity. Two

months after chemotherapy, 96% of post-BEP

patients have azoospermia; however, 3 months

after treatment, 46% have a normal semen analy-

sis, with only 17% remaining azoospermic [49].

Radiation treatment affects postmeiotic sper-

matogenesis. DNA damage after one treatment

persists for 3 months. The effect of radiation ther-

apy on fertility depends on the dose and the time

after treatment that the patient is evaluated. Sper-

matogenesis recovery following less than 100 rads,

200 to 300 rads, 400 to 600 rads, and more than

600 rads is 9 to 12 months, 30 months, 5 years,

and never, respectively (Table 3) [46,50]. In conclu-

sion, most studies show that cancer treatment with

chemotherapy with or without radiation increases

the rate of structural and numerical chromosomal

abnormalities that may persist indefinitely [38].

Surgical history

Operations on any retroperitoneal organs can

lead to loss of male fecundity. Retroperitoneal

lymph node dissection for testicular cancer can

result in a sympathectomy with resultant retro-

grade ejaculation. Some men will retain seminal

emission, but many will have retrograde ejacula-

tion or lose the ability to emit semen altogether.

Overall, however, 75% of all testis cancer patients

will retain fertility potential [38].

Forty percent to 90% of men following trans-

urethral resection of the prostate (TURP) have in-

fertility secondary to retrograde ejaculation [51].

Adult hernia repair using synthetic mesh can

obstruct the vas deferens in up to 20% of patients

because of an internal inflammatory response [52].

Physical examination

The physical examination may reveal critical

information pertaining to the cause of infertility

and should be thorough yet focused on the body

habitus and genital area. Secondly, infertility

may be a symptom of significant yet unsuspected

medical pathologic conditions [53]. Thirteen of

1200 (1.08%) patients presenting for fertility evalu-

ation were found to have a serious underlying

medical problem. The incidence of testicular and

brain tumors discovered during male fertility eval-

uation was greater than in the general population.

Body habitus

The clinician needs to assess the patient for

signs of androgen deficiency. Because androgen

deficiency results in inadequate virilization, the

physical examination could reveal eunuchoid pro-

portions, gynecoid distribution of pubic hair, or

gynecomastia–all signs of an endocrine disorder.

Visual field defects, galactorrhea, and a history

of headaches may indicate a hypothalamic or

pituitary tumor. Hypogonadism may be associ-

ated with midline brain and skull defects, including

anosmia, color blindness, cleft palate, and cerebel-

lar ataxia. The diagnosis of delayed maturation

caused by an endocrine abnormality should be

investigated.

Phallus. Penile curvature should be assessed,

as should the location of the urethral meatus.

Hypospadias and chordee both can result in im-

proper placement of the ejaculate in the vaginal

vault. Hypospadias, when accompanied with other

genitourinary congenital abnormalities, often indi-

cates an underlying chromosomal defect [54].

Scrotum and inguinal area. Careful examinationof

the inguinal region, spermatic cord, and testes is a

routine part of this initial examination. The ingui-

nal area should be examined for scars, including

Table 3

Recovery of spermatogenesis after radiation exposure

Radiation dose (rads)

Time until recovery of

spermatogenesis

[100 9–12 months

200–300 30 months

400–600 [5 years

[600 Permanent sterility

From Bahadur G, Ralph D. Gonadal tissue cryopre-

servation in boys with paediatric cancers. Hum Reprod

1999;14:11–17; with permission.


those from a hernia repair or correction of cryp-

torchidism. The scrotal contents should be exam-

ined with the patient standing. Both testes are

examined for size and consistency. The normal

adult testis averages 4.6 cm in length, 2.6 cm in

width, and 18 to 20 cm3 in volume. The authors rec-

ommend using either an orchidometer or calipers

for accuracy. Small testes should alert the examiner

to the possibility of impaired spermatogenesis,

because the sperm-producing seminiferous tubules

make up 85% of the testes [55].

The epididymides and vasa are palpated for

anatomic integrity and consistency. Epididymal

cysts may be obstructive. An indurated vas defer-

ens may be the sequela of an infection or obstruc-

tion. Complete or partial absence of the vas

deferens is seen in 2% of male infertility patients

and is highly associated with a cystic fibrosis

(CF) gene mutation [56].

The spermatic cords should be palpated for the

presence of a varicocele. Varicocele is still the most

commonly identified and correctable anatomic ab-

normality in the subfertile man. The patient should

be standing and asked to take a deep breath and

bear down (ie, perform aValsalva’smaneuver) [57].

Digital rectal examination. A digital rectal exami-

nation (DRE) is necessary to assess prostatic en-

largement, size, midline cysts, and seminal vesicle

presence or induration. The prostate is often small

in androgen-deficient states and boggy in men with

prostatitis. A significant finding on DRE may re-

quire a transrectal ultrasound (TRUS) scan for

further confirmation.

Endocrine evaluation

Evaluation of patients suspected of having

male-factor infertility should include assessment

of the HPG axis. Measurements of the serum

gonadotropin hormones (follicle-stimulating hor-

mone [FSH] and luteinizing hormone [LH]), tes-

tosterone, prolactin, and estradiol are indicated

contingent on the findings during the history and

physical examination. A detailed overview of the

complicated physiology and feedback control of

the HPG axis is provided elsewhere. In one large

retrospective study [58], 20% of infertile men were

found to have endocrine disorders. In infertile

men with soft testes and sperm densities less than

1 million/cm3, FSH and testosterone levels alone

will detect 99% of all endocrine abnormalities.

With a normal semen analysis, there is no indica-

tion for measuring gonadotropins (Table 4) [59]. Table

4

Horm

onalsyndromeandtreatm

entin

male

infertility

Condition

Defect

Diagnosis

GnRH

FSH

LH

Testosterone

Treatm

ent

Hypogonadotropic

hypogonadism

Pituitary

lesion

MR

imaging/CTofhead,horm

one

testing

flfl

flfl

hCG

andFSH

Primary

testicularfailure

Klinefelter’ssyndrome,

cryptorchidism,

chem

otherapy,gonadotoxins

History

andphysicalexamination,

laboratory

studies,

karyotype,

testes

biopsy

››

›flfl

TESE

andIC

SI

Hyperprolactinem

iaPituitary

tumors

MR

imaging/CTofhead,horm

one

testing

flfl

flfl

Dopamineagonists,surgery

Androgen

resistance

Mutationofandrogen

receptor?

DAZ

mutation

Genitalskin,fibroblast

culture,Y

chromosomemicrodeletion

›fl›fl

›fl›fl

None

Abbreviations:

DAZ,deleted

inazoospermia;GnRH,gonadotropin-releasinghorm

one;

FSH,follicle-stimulatinghorm

one;

LH,luteinizinghorm

one;

hCG,human

chorionic

gonadotropin;TESE,testicularsperm

extraction;IC

SI,intracytoplasm

icsperm

injection.


The current indications to perform initial

serum hormone measurements include: (1) sperm

density less than 1 million/cm3, (2) impaired sex-

ual function, and (3) clinical findings suggestive

of an endocrinopathy or severe testicular failure.

Although these hormones are secreted in a pul-

satile manner, studies have shown that a single spe-

cimen is usually adequate [60]. Dynamic testing

(eg, gonadotropin-releasing hormone [GnRH] or

human chorionic gonadotropin [hCG] stimulation

tests) may uncover a lack of endocrine reserve that

would not be revealed through standard testing.

Dynamic testing is not performed routinely and,

for the most part, is limited to a research setting.

With the results of serum hormone assays,

problems usually can be categorized in one of

four groups: testicular failure (hypergonadotropic

hypogonadism), hypogonadotrophic hypogonad-

ism (HGH), hyperprolactinemia, or androgen

resistance. With categorization of patients into

definable groups, treatment can be better directed,

andamoreaccurateprognosis canbediscussed [61].

Primary testicular failure

(hypergonadotropic hypogonadism)

Primary testicular failure is found in approxi-

mately 10% of men presenting with infertility

[62]. Common causes include Klinefelter’s syn-

drome (47,XXY), cryptorchidism, or a history of

chemotherapy and radiation. Gonadotoxins such

as alcohol and marijuana are commonly acquired

causes of testicular failure and prevent the syn-

thesis of testosterone as well as increasing sex

hormone–binding globulin [20,63–68]. Physical ex-

amination often reveals small, soft testes with

characteristic laboratory findings of a low testo-

sterone, an elevated FSH level, and a normal pro-

lactin level. Follicle-stimulating hormone level is

elevated because of a lack of feedback inhibition

of inhibin from the Sertoli’s cells in concert with

severe failure of spermatogenesis. Luteinizing hor-

mone elevation is variable, because the Leydig’s

cells are more resistant to injury. Although an

FSH level greater than three times normal is patho-

gnomonic for primary testicular failure, a testis

biopsy is the only technique that can qualify the

abnormality [69].

Recently, Pavlovich et al [70] described an

endocrinopathy in men with severe male-factor

infertility characterized by a decreased T/E2 ratio.

After treatment with the aromatase inhibitor testo-

lactone, some ratios normalized, and some associ-

ated oligospermia improved. The concept of a T/

E2 abnormality and the data remain to be studied

further, however.

Hypogonadotropic hypogonadism

Common causes for HGH include Kallmann’s

syndrome, pituitary tumors, pituitary trauma, and

anabolic steroiduse.Kallmann’s syndrome is a con-

genital malformation of midline cranial structures.

Pituitary tumors can cause local destruction of the

anterior pituitary. Diagnosis of tumors and hemor-

rhage is established by CT scan or MR imaging of

the sella turcica. Laboratory findings ofHGHshow

decreased testosterone, decreased gonadotropins,

and a variable prolactin. Dynamic testing with

GnRH stimulation can differentiate between a

hypothalamic and pituitary origin. Hypogonado-

tropic hypogonadism has an excellent prognosis,

and spermatogenesis can often be returned with

hCG and FSH replacement therapy [71].

Hyperprolactinemia

Hyperprolactinemia is a form of HGH caused

by excessive prolactin secretion. The most

common cause for hyperprolactinemia is a prolac-

tin-secreting microadenoma (\10 mm); a less com-

mon cause is a prolactin-secreting macroadenoma

([10 mm) [72]. The degree of elevation of prolac-

tin provides insight into the type of pathology.

Prolactin levels greater than 250 ng/mL, between

25 and 250 ng/mL, between 25 and 100 ng/mL,

and from 0 to 25 ng/mL probably represent macro-

adenoma, microadenoma, pituitary stalk compres-

sion, and normal levels, respectively. Imaging with

CT scanning or MR imaging is required for diag-

nosis. An elevation in peripheral prolactin should

be followed with repeat testing, because prolactin

has a wide variation throughout the day and

should not be measured within 2 hours of waking.

Treatment depends on clinical findings and size of

tumor. Treatment ranges from transsphenoidal

surgery to medical suppression with dopamine

agonists such as bromocriptine [72–74].

Androgen resistance

Androgen resistance is a rare condition caused

either by a defect in the androgen receptor or by

defects in the enzymes responsible for peripheral

androgen conversion. It should be suspected when

testosterone conversions are significantly elevated

without an associated rise in LH. Genes coding

for the androgen receptor have been mapped to

theY chromosome andmaybe linked to the deleted

in azoospermia (DAZ) gene [75]. Testosterone is


overproduced and is converted peripherally by

aromatase to estradiol. Estradiol has a feedback

inhibitory effect on testosterone secretion. Thus,

LH and testosterone are not consistent indicators

for androgen resistance. Diagnosis is made by a

genital skin fibroblast culture and measurement of

androgen receptor function. There is no effective

treatment for this condition. 5a-Reductase muta-

tion prevents the peripheral conversion of testoster-

one to the more active form dihydrotestosterone.

Serum testosterone levels are usually mildly

elevated. Patients may present with ambiguous

genitalia.

Additional endocrine testing

Hypothyroidism and congenital adrenal hyper-

plasia are two rare causes for male infertility that

have an excellent prognosis when treated appro-

priately. Thyroid dysfunction, either elevated or

suppressed, accounts for less than 0.5% of male

infertility. Treatment can completely reverse the

deleterious effects on spermatogenesis. Thyroid

screening is not recommended for infertility

patients unless clinically indicated, however [59].

Congenital adrenal hyperplasia (CAH) is

caused by one of many enzymatic defects in the

production of cortisol. The enzymatic defect that

most commonly accounts for CAH is 21-hydroxy-

lase deficiency. With this deficiency, the adrenal

produces excessive androgens and suppresses tes-

ticular development. Diagnosis is made by blood

and urine assays. Precocious puberty is the classic

presentation. Spermatogenesis can be restored

with corticosteroid treatment [58].

Genetic testing

Men with azoospermia and oligospermia repre-

sent 40% to 50% of all infertile men [76]. Research

from the 1990s suggests, furthermore, that much

of what has been termed idiopathic male infertility

may really have a genetic basis. A complete discus-

sion of all mutations known to affect male fecund-

ity is beyond the scope of this article. Nakamura

et al [77] found the frequency of karyotype ab-

normalities to be 12.67% in 1791 oligospermic

infertile men and to be 4.6% in azoospermics.

Genetic testing should be implemented when the

following conditions exist: (1) sperm density is less

than 5 million/cm3; (2) there is nonobstructive

azoospermia; and (3) there are clinical suggestions

for a chromosomal evaluation. Depending on

the indications, currently available genetics tests in-

clude a karyotype, Y chromosome microdeletion

analysis, and a CF genetic screening panel.

Karyotype evaluation

Karyotype evaluation is obtained when the

sperm concentration is less than 1 million/cm3 or

when clinical evidence for a chromosomal syn-

drome is detected. A study of 170 men with nonob-

structive azoospermia revealed that 17% had either

a Y chromosome microdeletion or a karyotype

abnormality [78–80]. Klinefelter’s syndrome is 45

times more common in infertile men than in the

general population [81]. Klinefelter’s syndrome

affects 7% to 13% of men with azoospermia and

occurs in 1 of 500 live births. Ninety-five percent

of affected males present in adulthood with infer-

tility, but only 25% have the classic characteristics

of gynecomastia, tall stature, and small, firm

testes. Among infertile men with Klinefelter’s syn-

drome, the classic findings are small, firm testes, an

elevated FSH level, a low testosterone level, and an

elevated estradiol level. Some seemingly azoosper-

mic men with Klinefelter’s syndrome have sperm

that are retrievable by testicular sperm extraction

(TESE), and normal pregnancies achieved with

sperm from infertile men with Klinefelter’s syn-

drome have been reported [82].

Chromosomal defects found less frequently in

infertile men include the 47,XXY syndrome, Noo-

nan’s syndrome (45,YO), and mixed gonadal dys-

genesis (45,XO/46,XY) [83–85]. Thus far, offspring

born to fathers with 47,XXY karyotype have been

chromosomally normal. Structural abnormalities,

despite a lack of detectable aneuploidy, can be

observed in 2% to 4% of men with very low sperm

counts [79]. Approximately half of these defects

are Robertsonian translocations between chromo-

somes 13 and 14, a translocation that is considered

balanced. These men typically have severe sperma-

togenic defects but have been able to produce

embryos through ICSI [81].

Y chromosome microdeletions

The reported frequency of Y chromosome

microdeletions varies from 1% to 55% in infertile

men, depending on inclusion criteria [86–105].

Cystic fibrosis transmembrane gene mutations

Men found on physical examination to have

partial or total absence of the vas deferens, epidi-

dymis, or seminal vesicles or an unexplained con-

genital epididymal obstruction should be tested


for CF gene mutations. Mesonephric duct anoma-

lies are commonly associated with mutations in the

cystic fibrosis transmembrane conductance regula-

tor gene (CFTR). More than 800 mutations have

been discovered; however, 70% to 90% of patients

carrying a CF mutation have a defect of one or

more of the 32 mutations included in a routine

CF screening. A three base pair deletion in exon

10 (delta 508) accounts for 70% of the CFTR

mutations found in the white population [84].

Ninety-five percent of men with CF have congeni-

tal bilateral absence of the vas deferens (CBAVD).

Fifty percent to 80% of men with CBAVD, how-

ever, will have CFTRmutations but no pulmonary

sequelae. Forty-three percent of men with congen-

ital unilateral absence of the vas deferens will have

a CFTR mutation [106]. Forty-seven percent of

men with congenital epididymal obstruction will

have CFTR mutations [84,107,108].

Secondary generalized mesonephric duct

anomalies can occur in patients with CBAVD.

All men with CBAVD should be evaluated for

renal anomalies, because unilateral renal agenesis

occurs in 11% of patients with CBAVD and in

26% of patients with unilateral vassal absence

[106].

The carrier frequency of CF is 1 in 25 men of

Northern European descent, and pulmonary CF

is the most common fatal autosomal recessive

disorder of the white population. Because sper-

matogenesis is usually unaffected by a CFTR

mutation, sperm can be harvested from the epidi-

dymal remnant or from the testis by one of several

techniques [109]. It is imperative that the female

partners of men suspected of being CFTR carriers

should likewise be tested before any assisted repro-

ductive techniques are used.

Laboratory evaluation

Routine semen analysis

Following a thorough history and physical

examination, laboratory testing should be per-

formed. The endocrine evaluation has already

been discussed, but certainly, the cornerstone of

the laboratory evaluation is the routine semen

analysis. This test cannot of itself determine male

fertility, however. Attempts to accurately define

male fertility by semen analysis parameters alone

have been largely unsuccessful [110–114], primar-

ily because fertility is a couple-related rather than

an individually determined phenomenon. A com-

plete female fertility evaluation should be per-

formed concurrently with that of the male to

achieve successful and cost-effective outcomes.

Accurate semen testing must include proper

collection and analysis. Semen ideally should be

collected after a 2- to 3-day sexual abstinence. A

shorter abstinence period results in a lower sperm

density, whereas a longer period may result in

lower motility. If possible, the sample should be

obtained by masturbation, avoiding the use of

spermatotoxic lubricants. When interpreting

results, it is important for the clinician to recognize

the difference between normal and adequate semen

quality. The World Health Organization (WHO)

has published reference values below which preg-

nancy becomes less likely, but these values should

not be considered to represent what is normal or

representative of the mean, or average values for

a nonselected male cohort (Table 5) [115].

Sperm density is defined as the number of

sperm per milliliter of ejaculate. A normal germi-

nal epithelium produces 100 to 300 million sperm

per day. Approximately 3 months are required

for the production and maturation of sperm within

the seminiferous tubules, and another 3 to 10 days

are needed for transport through the male repro-

ductive tract [116]. Attempts to define normal or

mean sperm density have resulted in inconsistent

findings [117–121]. In general, a sperm density of

between 60 and 80 million/mL is reported as

average, although striking geographic variation

has also been reported [119]. Most of the samples

in these studies were taken from men before

vasectomy, a setting in which the average age

is somewhat higher than in a typical infertility

population and in which the abstinence period is

not well controlled. Men with high-quality sper-

matozoa may be fertile even when sperm density

is low. The best example of this phenomenon is

Table 5

World Health Organization criteria for normal semen

values

Parameter Normal Values

Volume �2.0 mL or greater

pH 7.2–7.8

Sperm concentration �20 million/mL

Total sperm count �40 million

Motility �50% with normal morphology

Morphology [30% normal forms

From Kim ED, Lipshultz LI. Evaluation and

imaging of the infertile male. Infertility and Reproduc-

tive Medicine Clinics of North America 1999;10(3):377–

409; with permission.


seen in men treated for hypogonadotrophic hypo-

gonadism, who are often fertile with sperm con-

centrations below 5 million/mL, emphasizing that

routine semen analysis alone is an inadequate

measure of male fertility potential.

Azoospermia (the complete absence of sperm in

the ejaculate) occurs in 8% of men seeking care in

an infertility clinic. True azoospermia can be con-

firmed only after a centrifuged pellet is examined.

Once azoospermia is diagnosed, it is imperative

to differentiate obstructive from nonobstructive

azoospermia. Typically, obstructed patients have

normal testicular size and no detectable endocrin-

opathy. Obstruction may occur in the seminiferous

tubule or rete testis, in the epididymis, anywhere

along the vas deferens (including vasal agenesis),

or at the ejaculatory duct. Nonobstructive azoo-

spermia is typified by small or soft testicles, ele-

vated FSH levels, and abnormal biopsy findings,

including maturation arrest, severe hypospermato-

genesis, or germ cell aplasia.

Sperm motility is defined by both the percent-

age of motile sperm and the quality of movement,

called forward progression. Normal sperm motil-

ity should be at least 50%, with a forward prog-

ression of 2.0 or higher (where 0 is no movement,

and 4.0 is excellent qualitative motion). Isolated

asthenospermia, particularly if severe, suggests

immunologic infertility, infection, inflammation,

partial genital duct obstruction, varicocele, or

ultrastructural defects of the sperm motility mech-

anism (eg, immotile cilia syndrome).

Ejaculate volume can vary significantly de-

pending on abstinence period and magnitude of

sexual stimulation. Most of the ejaculate is

derived from the seminal vesicles, and a mark-

edly reduced volume should arouse suspicion of

an incomplete collection, ejaculatory duct ob-

struction (complete or partial), seminal vesicle

agenesis, androgen deficiency, or retrograde ejac-

ulation. Complete ejaculatory duct obstruction

can be ruled out by the finding of fructose (a

seminal vesicle product) in the semen or with

TRUS combined with seminal vesicle aspiration.

A postejaculate urine sample should be obtained

in all patients with semen volumes less than 1.0

mL to rule out retrograde ejaculation. The pres-

ence of more than 5 to 10 sperm per high-power

field in the urine confirms the diagnosis. Seminal

vesicle agenesis is often associated with ipsilat-

eral vasal agenesis, prompting a careful repeat

physical examination. Androgen deficiency, if

present, can be diagnosed with routine hormonal

screening.

Advanced semen testing

Following the initial evaluation and semen

analysis, advanced testing is indicated to identify

defects potentially contributing further to male-

factor infertility. As listed in Table 6, these tests

include tests for abnormalities of both seminal

fluid and sperm function [122]. The decision about

which tests are required depends on the history,

physical examination, and initial semen analysis.

Abnormalities of seminal fluid

Semen leukocytes. An excessive number of white

cells in the semen (leukocytospermia) is associated

with deficiencies of motility and sperm function.

Leukocytes are difficult to distinguish from im-

mature germ cells without the use of immuno-

histochemical staining or monoclonal antibody

technology. Leukocytospermia is defined by the

WHO as the presence of greater than 1 · 106 white

blood cells per milliliter, although recent research

suggests that much lower levels may increase semi-

nal oxidative stress, hindering sperm function and

motility [123]. As discussed later, cytokines and

reactive oxygen species are secreted by seminal

inflammatory cells, further harming sperm motil-

ity and viability [117,124,125]. Empiric antibiotic

therapy generally provides no benefit and may

be harmful, because many commonly prescribed

antibiotics, including sulfa drugs, tetracyclines,

macrolides, and nitrofurantoin, may have sperma-

totoxic effects [25,126,127]. Therefore, all men with

elevated seminal white blood cell levels should

Table 6

Tests for abnormalities of seminal fluid and sperm

function

Tests for abnormalities of the seminal fluid

Quantitation of leukocytes in semen

Reactive oxygen species

Antisperm antibody testing

Tests for abnormalities of sperm function

Strict morphology

Computer-assisted semen analysis

Hypo-osmotic swelling test

Viability stain assays

Cervical mucus-sperm interaction assays

Sperm capacitation assays or mannose ligand receptor

assays

Acrosome reaction assays

Sperm penetration assay

Data from Spitz A, Kim ED, Lipshultz LI. Con-

temporary approach to the male infertility evaluation.

Obstet Gynecol Clin North Am 2000;27(3):487–516;

with permission [184].


have a semen culture performed, even thoughmost

will be negative [128]. In culture-positive patients,

antibiotic therapy is warranted. Culture-negative

leukocytospermia is more common, however,

and is best treated with anti-inflammatory therapy

and frequent ejaculation. For refractory cases of

leukocytospermia, sperm washing to remove the

white cells, followed by intrauterine insemination

(IUI), can be offered.

Reactive oxygen species. Reactive oxygen species

(ROS), primarily the superoxide anion, the

hydroxyl radical, and the hypochlorite radical,

are a group of free radicals that possess the ability

to damage aerobic cellular systems. They are a

normal by-product of sperm physiology and are

important mediators of normal sperm function

and the acrosome reaction [129]. Normally, anti-

oxidant scavengers, including superoxide dismu-

tase and catalase, serve to neutralize free radical

activity in the semen. In pathologic states, how-

ever, immature or abnormal spermatozoa in asso-

ciation with seminal leukocytes can generate high

ROS levels that overwhelm seminal anti-oxidant

mechanisms. Damage to spermatozoa occurs by

lipid peroxidation of the sperm membrane.

High levels of ROS have been identified in the

semen of up to 40% of infertile patients [130],

implicating oxidative stress as a potential cause

in idiopathic infertility [124], but only rarely are

ROS detectable in healthy volunteers and azoo-

spermic men. Elevated levels have been correlated

with abnormal sperm density, motility, and mor-

phology [117,129,131,132] and have been linked

to reduced fertility in men with varicoceles [133–

135], spinal cord injury [136], and immunologic

infertility [137]. Reactive oxygen species may cause

DNA damage in spermatozoa, raising theoretic

concerns that offspring conceived through ICSI

could potentially inherit abnormal DNA [138].

Therapy for men with high seminal levels

of ROS consists of antioxidant therapy (despite

a lack of controlled trials demonstrating effi-

cacy) and the elimination of leukocytospermia.

Recently, Mostafa and colleagues [139] demon-

strated a reduction in ROS levels and increased

anti-oxidant activity in the semen of men following

varicocelectomy, suggesting a causal relationship.

Antisperm antibodies. In the late 1950s, antisperm

antibodies (ASA) were identified in a significant

number of infertile men, suggesting that these anti-

bodies may interfere with fertilization [140]. Typi-

cal effects of ASA autoimmunity include disorders

of sperm movement (clumping or necrospermia),

impaired cervical mucus-sperm interaction,

impaired sperm-ovum penetration, and perhaps

interference in the first stage of embryo develop-

ment [141–143]. Risk factors for the development

of ASA include prior genital infections, testicular

trauma [144,145], thermal injury, genital tract

obstruction, and testicular biopsy [146], although

more recent studies indicate that ASA resulting

from testicular biopsy is exceedingly rare [147,

148]. Not all men with ASA are infertile [149]; in

fact, the significance of ASA in men with infertility

is controversial, and no uniform treatment strat-

egies currently exist [150,151]. Typically, cortico-

steroids have been used in an attempt to suppress

antibody production, but to date no double-blind,

randomized trial has convincingly demonstrated

efficacy. Published studies, using variable dosing

regimens and control groups, report pregnancy

rates from 0% to 50% [152–155]. Assisted re-

production remains an excellent therapeutic

option for patients with ASA, because fertiliza-

tion rates with ICSI are not reduced when com-

pared to those in patients with nonimmunologic

infertility [156,157].

Abnormalities of sperm or sperm function

Strict morphology. Historically, sperm morphol-

ogy was assessed and reported with the routine

semen analysis. In 1986, Kruger and colleagues

introduced strict criteria for the evaluation of mor-

phology based on measurements taken from sper-

matozoa that successfully migrated to the cervix.

These criteria include the following: a smooth oval

head measuring 3 to 5 mm in length and 2 to 3 mm

in width; a well-defined acrosome, comprising 40%

to 70% of the head; an absence of defects of the

neck, midpiece, or tail; and an absence of cytoplas-

mic droplets larger than half the size of the head

(Fig. 1) [158]. All sperm with tapered, pyriform,

duplicated, or amorphous heads and all borderline

sperm are classified as abnormal. Morphologically

normal sperm are not necessarily genetically

normal. In 2001, Ryu et al [159] demonstrated

increased sex chromosome aneuploidy in morpho-

logically normal sperm from infertile men under-

going in vitro fertilization (IVF) with ICSI,

exposing a potential deficiency of using strict mor-

phology (SM) to choose sperm for ICSI.

Strict morphology, however, has been shown to

be an effective predictor of IVF success rates.

Grow and colleagues [160] demonstrated IVF

fertilization rates of 94% when SM was normal

([14%) and 88% with intermediate SM levels


(4% to 14%), but when SM fell below 4%, fertiliza-

tion rates dropped to 15%. Although most studies

have confirmed a predictive role for SM with

regard to both IVF fertilization rates [161–163]

and IUI pregnancy rates [164,165], others have

not confirmed these findings [166,167]. Currently,

most investigators recognize and use strict mor-

phology as only one valuable component of a com-

plete male fertility examination.

Computer-assisted semen analysis. Computer-

assisted semen analysis (CASA) was introduced

in the 1980s to provide an automated, objective,

and standardized routine semen analysis. Most

CASA systems measure sperm density, motility,

straight-line and curvilinear velocity, linearity,

average path velocity, amplitude of lateral head

displacement, flagellar beat frequency, and hyper-

activation. Although CASA may be more precise

and reproducible than visual analysis of motility

parameters in most cases, its cost and potential

lack of reliability at very high or very low sperm

densities suggest that it offers little clinical advant-

age over routine visual analysis [168].

Hypo-osmotic swelling test. In 1984, Jeyendran

et al [169] reported that under hypo-osmotic condi-

tions (150 mOsm/L), a normal spermatozoon will

absorbfluid,resultinginbulgingoftheplasmamem-

brane and curling of the tail. Curling of the tail can

easilybevisualizedwithphase-contrastmicroscopy.

This simple test measures the physical and func-

tional integrity of the plasma membrane and there-

fore spermatozoon viability, because dead cells

cannot maintain an osmotic gradient. The hypo-

osmotic swelling test (HOS) is commonly used to

assess the viability of frozen sperm and to select live

testicular sperm for ICSI when no motility is

observed [170–172]. A practical protocol for per-

formingthetesthasbeendescribedintheWHOLab-

oratory Manual for the Examination of Human

Semen [115] and by Jeyendran and colleagues [173].

Viability stain assays. Similar to HOS, viability

stain assays are used to determine whether a sper-

matozoon is alive and whether the plasma mem-

brane is intact. The test is based on the principle

that only live sperm can exclude dye, namely eosin

Y and trypan blue [174,175]. Unfortunately, once

sperm have been stained, they are no longer viable

and therefore cannot be used for IVF/ICSI.

Cervical mucus and sperm interaction assays. In-

ability of the spermatozoon to pass through cervi-

cal mucus is a contributing cause of infertility in up

to 10% of couples. Mucus quality varies through-

out the menstrual cycle. Midcycle cervical mucus

functions mainly as (1) a biologic filter that allows

passage of motile spermatozoa and impedes dead

or abnormal spermatozoa, (2) a reservoir supply-

ing spermatozoa to the uterus for days after coitus,

and (3) an initiator of capacitation.

The postcoital test (PCT) is the most commonly

used method of evaluating cervical mucus-sperm

interaction. An aspirate of midcycle cervical

mucus is obtained following intercourse, and

sperm concentration and motility are examined.

A finding of 20 or more spermatozoa per high-

power field is considered normal. Abnormal find-

ings are most commonly related to inappropriate

timing of coitus. Other causes include ASA, anov-

ulation, abnormal hormonal milieu, genital tract

infection, poor semen quality, and male sexual

dysfunction.

Because the PCT depends heavily on clinical

factors that cannot be carefully controlled, its util-

ity is questionable, particularly when no motile

spermatozoa are found. Other tests designed to

investigate cervical mucus-sperm interaction in-

clude the Penetrak (Freiburg, Germany) test using

bovine mucus and the Tru-Trax assay using

human mucus (Humagen, Charlottesville, VA).

Both tests produce reliable and reproducible

results, but currently there is no general consensus

about their clinical utility [176].

Sperm capacitation assays or mannose ligand

receptor assays. Spermatozoa are unable to fertil-

ize ova until they undergo capacitation, a series of

membranous and metabolic changes that allow the

acrosome reaction to occur. Capacitation is char-

acterized by hyperactivated motility and multiple

ultrastructural and biochemical changes. The

Fig. 1. Kruger strict morphology.


process can be evaluated visually using computer-

ized sperm tracking or assessed biochemically by

measuring mannose ligand receptors. Human

sperm surface receptors involved in zona pellucida

recognition and binding are mannose-specific

[177]. In vitro fertilization success rates have been

correlated with the appearance of mannose ligand

receptor expression on sperm heads [178]. More

recently, a prospective study demonstrated the

ability of a mannose ligand receptor assay to iden-

tify spermatozoon populations at risk for poor

fertilization with conventional IVF, particularly

when other commonly measured sperm parame-

ters are normal [179].

Acrosome reaction assays. The acrosome is a

membrane-bound organelle found within the

plasma membrane of the head of the spermato-

zoon and appears during spermatogenesis as a

product of the Golgi’s apparatus. The acrosome

is covered externally by the plasma membrane

and overlies the nuclear membrane. The acrosome

contains acrosin and hyaluronidase and covers

roughly the anterior two thirds of the sperm head.

The acrosome reaction occurs when the inner

plasma membrane fuses with the outer acrosomal

membrane, causing release of the acrosomal con-

tents [180].

In a fertile male, less than 10% of spermato-

zoa will undergo the acrosome reaction spontane-

ously; most still undergo capacitation and zona

pellucida binding. Once bound, acrosomal hydro-

lases (primarily acrosin) are released, which subse-

quently degrade the zona pellucida and facilitate

fertilization.

The acrosome reaction can be monitored by

several laboratory techniques, including a triple-

stain technique, which is the most frequently used

method; the use of monoclonal antibodies to acro-

somal components; the use of fluorescent lectins,

such as peanut agglutinin, which label the outer

acrosome membrane; and the use of Pisum sativum

agglutinin, which labels the acrosome matrix [118].

Unfortunately, these assays are labor-intensive

and evaluate a limited number of spermatozoa

that do not necessarily represent the fraction of

spermatozoa responsible for fertilization. Cur-

rently, there are no widely accepted standards for

evaluation and interpretation for these acrosome

assays, and no correlation with IVF outcomes

has been convincingly demonstrated. Despite their

limited clinical use, assays of the acrosome reac-

tion are important in studying this fundamental

step in fertilization and its role in infertility.

Sperm penetration assay. The sperm penetration

assay (SPA) was first reported over 25 years ago

as a potential quantitative measure of fertilizing

capacity [181]. The test was developed following

the observation that when the zona pellucida of

the hamster ova is removed, the species specificity

of fertilization and the block to polyspermyare lost.

Ideally, the test would be performed using human

ova, but they are not widely available, and there

are ethical considerations associated with their

use. Hamster ova have provided a useful model

for the measurement of human sperm function.

For in vivo fertilization to occur, the sperm

must undergo capacitation and the acrosome re-

action [182]. Currently it is not known whether

capacitated sperm that have gained the ability to

penetrate human ova have undergone the acro-

some reaction or whether this reaction occurs as

a local event at the time of gamete fusion. In any

event, the SPA, which requires the occurrence of

both capacitation and the acrosome reaction, has

proven to be a reliable technique for the evaluation

of sperm fertilizing capacity.

Several laboratories have reported their experi-

ence with the SPA and a wide range of modifi-

cations [182,183]. Currently, the absence of any

widely accepted standardized protocol for per-

forming the SPA has resulted in high interlabora-

tory variability and widely disparate reports of

utility. Nevertheless, laboratories that use opti-

mized protocols have reported a strong correlation

with fertilizing capability [184,185]. Many labora-

tories report the percentage of ova penetrated,

with a score of less than 10% to 15% considered

abnormal. Using an optimized SPA, however,

sperm from normal fertile donors penetrate 100%

of the hamster ova with extensive polyspermy.

The results are therefore expressed as the mean

number of penetrations per ovum, which has been

termed the sperm capacitation index (SCI).

Patients with an SCI of less than five have a lower

probability of achieving penetration in conven-

tional IVF than do patients with a normal SCI.

At the Baylor College of Medicine, patients with

an abnormal SCI are advised to use ICSI during

IVF cycles to maximize oocyte fertilization rates.

Recently, Romano et al [186] demonstrated the

utility of an optimized SPA to predict spontaneous

pregnancy rates with high positive and negative

predictive value.

Hemizona assay. The hemizona assay uses nonfer-

tilized human oocytes to measure the ability of

sperm to bind to the zona pellucida. The zona is


microscopically divided, and the two halves are

separately analyzed using capacitated donor or

patient (test) sperm. Hemizona assay results have

been shown to correlate with IVF fertilization

rates, but ethical concerns and the scarcity of

intact human ova prevent its widespread use [187].

Radiologic imaging

Transrectal ultrasound scanning

Diagnostic imaging techniques may be indi-

cated as part of the complete male fertility eval-

uation. Transrectal ultrasound scanning is the

first-line diagnostic modality that is used to rule

out ejaculatory duct obstruction (EJDO) in men

with low-volume or fructose-negative azoosper-

mia, severe unexplained oligoasthenospermia, or

palpable abnormalities detected on digital rectal

examination. The TRUS is commonly performed

with the patient in the lateral decubitus, knee-

to-chest position using a high-resolution 6.5- to

7.5-MHz probe. The bladder ideally should be

partially filled to improve the delineation of the

bladder, perivesical fat, and seminal vesicles.

The ejaculatory duct, formed by the confluence

of the seminal vesicles and the ampullae of the vasa

deferentia, measures 4 to 8 mm in diameter and

is often difficult to image in its nondilated state

[188]. The obstructed lumen is best appreciated

using sagittal images as a hypoechoic tubular

structure entering the urethra at the level of the

verumontanum.

The common causes of EJDO are listed in

Table 7. Mullerian duct cysts cause obstruction

of the ejaculatory duct by external compression,

whereas wolffian duct cysts contain sperm and

are likely to result from distal duct stenosis. Pro-

static retention cysts are peripherally located and

do not contain sperm [189]. Fig. 2 demonstrates

a TRUS image of an ejaculatory duct cyst. Trans-

rectal ultrasound scanning is also useful to identify

seminal vesicle dilation, a common finding in

EJDO. Although marked seminal vesicle dilation

is not always present, particularly in association

with a secondary epididymal obstruction, EJDO

should be suspected in all patients with a transaxial

seminal vesicle width greater than 1.2 to 1.5 cm

[172,188]. In men with azoospermia and suspected

EJDO, the finding of dilated seminal vesicles

should be followed by ultrasound-guided seminal

vesicle aspiration. Preprocedure preparation is

identical to that for transrectal prostate biopsy,

namely a cleansing enema and broad-spectrum

antibiotic coverage with a fluoroquinolone. The

finding of sperm in the seminal vesicle confirms

the diagnosis of EJDO, although the absence of

sperm does not rule out EJDO, because a secon-

dary epididymal obstruction may also be present.

A typical ultrasonographic image of dilated semi-

nal vesicles is shown in Fig. 3.

Seminal vesiculography and vasography

Seminal vesiculography is performed at the

time of seminal vesicle aspiration to confirm distal

obstruction. Injection with nonionic contrast will

demonstrate no evidence of bladder filling in cases

of EJDO; in addition, the proximal vas can be

imaged in some instances [190]. The seminal vesicle

can also be injected with methylene blue, typically

at the time of planned transurethral resection of a

suspected EJDO, to rule out complete EJDO or to

assist the resectionist.

Table 7

Causes of ejaculatory duct obstruction in subfertile

males

Cause No.

Mullerian duct cyst 17

Wolffian duct malformation 19

Previous surgical trauma 15

Transabdominal excision of seminal vesicle cyst

Rectal surgery in childhood

Bullet wound

Bladder exstrophy repair

Previous genital infection 19

Tuberculosis 8

Megavesicles 8

Carcinoma of the prostate 1

Total 87

From Pryor JP, Hendry WF. Ejaculatory duct

obstruction in subfertile males: analysis of 87 patients.

Fertil Steril 1991;56:725–730; with permission.

Fig. 2. Transrectal ultrasonographic image of an ejac-

ulatory duct cyst.


Formal vasography is primarily used to assess

vasal patency within the inguinal canal. Inguinal

vasal obstruction should be suspected in men with

normal volume obstructive azoospermia and a his-

tory of inguinal or scrotal surgery. Vasography

can be performed using an open or transcutaneous

puncture technique [191,192]. The authors prefer

to use an open hemivasotomy at the junction of

the convoluted and straight vas deferens. Initially

saline solution is injected distally; if no resistance

is met, no additional imaging is needed. Alterna-

tively, methylene blue may be injected, and a small

catheter passed into the bladder. If blue discolora-

tion of the urine is noted, a complete obstruction is

ruled out. If resistance is met, the passage of a large

monofilament suture helps to estimate the location

of the obstruction, which is then confirmed by for-

mal vasography. A 25-gauge, 0.5-inch Angiocath

sheath is gently placed into the lumen of the vas

deferens, and a dilute nonionic contrast agent is

injected distally. The contrast agent should never

be injected proximally because of the potential

danger of damaging the delicate epididymal

tubules. Placing the table in 15� of reverse Tren-

delenburg and creating a pneumocystogram im-

proves the quality of the plain radiograph. A

normal vasogram must demonstrate both filling of

the seminal vesicle and contrast in the bladder.

Because vasography can cause secondary scarring

and occlusion of the vas deferens, any required

microsurgical reconstruction should be performed

at the timeof the study, including repairof thehemi-

vasotomyusing standardmicrosurgical techniques.

Ultrasonography

Scrotal ultrasonography is indicated in select

patients to assist in the diagnosis of varicocele,

evaluate testicular size, and rule out associated tes-

ticular or paratesticular abnormalities, including

germ cell tumors, epididymal inflammation or

cystic disease, and potentially obstructive parates-

ticular tumors. Varicoceles are the most common

reversible cause of male infertility, noted in as

many as 40% of infertile men [193]. The diagnosis

is made in most patients using physical examina-

tion alone, but color flow Doppler ultrasonogra-

phy is useful in obese patients, in those with a

suspected spermatic cord lipoma, and in those with

a difficult physical examination. With a 7- to

10-MHz probe, a varicocele appears as a hollow

tubular structure that increases in size during the

Valsalva’s maneuver. In addition, reversal of flow

can be documented by employing real-time ultra-

sonography and power Doppler in the same scan.

The ultrasonographic definition of varicocele is

variable. McClure and co-workers [194] define a

varicocele as the presence of three or more veins

with one having a minimum resting diameter of

3 mm or an increase in venous diameter with the

Valsalva’s maneuver. Other investigators have

used 2 to 3 mm as a cutoff point, making meaning-

ful comparisons of the results of ultrasound-based

varicocelectomy studies difficult [195,196]. The

authors use size (3 mm) and reversal-of-flow char-

acteristics with the Valsalva’s maneuver to define

an ultrasonographic varicocele.

Scrotal ultrasonography is not indicated to

confirm the diagnosis of vasal agenesis, which is

made on the basis of physical examination alone.

In men with unilateral vasal agenesis, however,

there is a strong association with ipsilateral renal

agenesis, and a renal ultrasound should therefore

be performed [106].

Testis biopsy

Testicular biopsy is an essential part of the eval-

uation of patients with azoospermia. Previously,

the testis biopsy was performed solely as a diag-

nostic measure to rule out obstruction as the cause

of azoospermia. With the advent of ICSI, testis

biopsy is also a therapeutic intervention, because

tissue obtained at biopsy can and should be cryo-

preserved for later use in the appropriate patient.

Summary

The success of a comprehensive office-based

evaluation of male-factor infertility depends on

the physician’s thorough understanding of risk as-

sessment in the history, identification of pertinent

Fig. 3. Typical ultrasonographic image of dilated

animal vesicles.


physical examination findings, and correct assess-

ment of laboratory data. Office-based ultrasono-

graphic techniques have already increased the

urologist’s ability to visualize suspected anatomic

abnormalities, and the use of functional tests of

sperm has given greater depth to the limited, but

essential, prognostic capabilities of the routine

semen analysis.

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