Male factor infertility

Last reviewed: 23 Apr 2022
Last updated: 03 Mar 2022

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • inability of an opposite-sex couple to conceive
  • vasectomy
  • palpable and dilated testicular veins
  • erectile dysfunction and decreased libido
  • testis atrophy (testis smaller than 20 cm³)
  • body habitus, abnormal hair distribution, and gynaecomastia
  • absent vasa or epididymis
More key diagnostic factors

Other diagnostic factors

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

Risk factors

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

Diagnostic investigations

1st investigations to order

  • sperm concentration
  • sperm motility
  • sperm morphology
  • seminal fluid parameters
More 1st investigations to order

Investigations to consider

  • sperm viability
  • sperm membrane function
  • hormonal assays
  • MRI of the pituitary and hypothalamus
  • colour flow Doppler imaging
  • post-ejaculation urine testing for retrograde ejaculation
  • genetic analysis
  • sperm DNA assays
  • anti-sperm antibody (ASA) serology
  • acrosome reaction test
  • sperm penetration assay (hamster egg penetration test)
  • sperm longevity test
  • electron microscopy
  • testicular biopsy
More investigations to consider

Treatment algorithm

ACUTE

obstructive azoospermia

gonadotrophin or gonadotrophin-releasing hormone deficiencies

primary hypogonadism

high oestrogen levels in combination with low testosterone

hyperprolactinaemia due to pituitary adenoma

presence of anti-sperm antibodies

presence of varicocele and no other cause of infertility detected

idiopathic male infertility

ONGOING

medical/surgical intervention ineffective, contraindicated, or unlikely to succeed

Contributors

Authors

Samuel Ohlander, MD

Assistant Professor

Co-Head of the Division of Andrology

University of Illinois

Chicago

IL

Disclosures

SO declares that he has no competing interests.

Mahmoud Mima, MD

Assistant Professor

Department of Urology

University of Illinois

Chicago

IL

Disclosures

MM declares that he has no competing interests.

Rodrigo Pagani, MD

Assistant Professor

Co-Head of the Division of Andrology

University of Illinois

Chicago

IL

Disclosures

RP declares that he has no competing interests.

Acknowledgements

Dr Samuel Ohlander, Dr Mahmoud Mima, and Dr Rodrigo Pagani would like to gratefully acknowledge Dr Ali A. Dabaja, Dr Ahmad O. Hammoud, and Dr Benjamin Emery, previous contributors to this topic.

Disclosures

AAD, AOH, and BE declare that they have no competing interests.

Peer reviewers

Peter N. Kolettis, MD

Associate Professor

Division of Urology

University of Alabama at Birmingham

Birmingham

AL

Disclosures

PNK declares that he has no competing interests.

  • Differentials

    • Cystic fibrosis (CF)
    • Primary hypogonadism
    • Hypopituitarism
    More Differentials
  • Guidelines

    • Testosterone deficiency in men: evidence-based Q&A
    • World Health Organization laboratory manual for the examination and processing of human semen
    More Guidelines
  • Patient leaflets

    Erection problems

    Erection problems: questions to ask your doctor

    More Patient leaflets
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