Last reviewed:December 2019
Last updated:March  2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • inability of a couple to conceive
  • vasectomy
  • palpable and dilated testicular veins
  • erectile dysfunction and decreased libido
  • testis atrophy (testis smaller than 20 cm^3)
  • body habitus, abnormal hair distribution, and gynaecomastia
  • absent vasa or epididymis

Other diagnostic factors

  • headaches, galactorrhoea, and visual disturbance
  • anosmia
  • frequent respiratory infections
  • pain, blood, or pus with ejaculation

Risk factors

  • varicocele
  • cryptorchidism
  • prior chemotherapy or radiotherapy
  • current medications
  • cystic fibrosis and congenital bilateral absence of vas deferens (CBAVD)
  • Y chromosome abnormalities
  • Klinefelter's syndrome (47,XXY)
  • endocrinopathy
  • genital tract infection
  • erectile dysfunction
  • previous infertility
  • retrograde ejaculation
  • obesity
  • testicular torsion or trauma
  • lifestyle including smoking and alcohol consumption
  • exposure to androgen
  • age >55 years
  • environmental toxin exposure
  • history of CAD or diabetes
  • history of STD
  • hot tub use

Diagnostic investigations

Treatment algorithm


Director of Male Reproductive Medicine and Sexual Medicine

Henry Ford Health System

K9 Urology Clinic




AAD declares that he has no competing interests.

Medical Director

IVF Michigan Fertility Center

Bloomfield Hills



AOH declares that he has no competing interests.

Dr Ali A. Dabaja and Dr Ahmad O. Hammoud would like to gratefully acknowledge Dr Benjamin Emery, the previous contributor to this monograph. BE declares that he has no competing interests.

Peer reviewersVIEW ALL

Associate Professor

Division of Urology

University of Alabama at Birmingham




PNK declares that he has no competing interests.

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