Male Factor Infertility

Abstract

Of the 10–20 % of infertile couples, 20 % are purely male factor and 30 % are combined male and female factors. Risk factors include trauma or torsion of the testes, erectile dysfunction, low testosterone, varicocele, and exposure to toxins including chemotherapy, tobacco, and alcohol abuse. Couples should be evaluated after 9–12 months if unprotected intercourse has failed to result in conception.

Evaluation includes two semen analyses each after 72 h of abstention from ejaculation. Semen parameters evaluated include volume, sperm count, motility, and agglutination. Additional studies should include serum testosterone, FSH and LH, and prolactin if testosterone is low. Special studies may include transrectal ultrasound to identify ejaculatory duct obstruction. In special instances, testicular biopsy and vasography may be indicated. All patients should have a basic physical examination to include genital examination with special attention to the testes and penis. A rectal examination to assess the prostate is also important.

Treatment options include hormonal replacement in patients with deficient testosterone. Exogenous testosterone alone may reduce the sperm count. Clomiphene 25–50 mg/day for 6 months may be helpful. For men with a diagnosed varicocele, varicocelectomy may be helpful. For men with ductal obstruction, microsurgical repair may result in improved sperm quality. Ejaculatory dysfunction may be treated medically, or sperm retrieval with artificial insemination may be necessary for severe retrograde ejaculation that does not respond to medication. Retrieval of sperm through vibratory stimulation may also be useful for assisted reproductive techniques (ART).

In refractory patients, donor insemination or advanced ART may be necessary.