Summary
Definition
History and exam
Key diagnostic 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 gynecomastia
- absent vasa or epididymis
Other diagnostic factors
- headaches, galactorrhea, and visual disturbance
- anosmia
- frequent respiratory infections
- pain, blood, or pus with ejaculation
Risk factors
- varicocele
- cryptorchidism
- prior chemotherapy or radiation therapy
- 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, alcohol, and cannabis use
- exposure to androgen
- age >55 years
- environmental toxin exposure
- history of coronary artery disease or diabetes mellitus
- history of STI
- hot tub use
Diagnostic tests
1st tests to order
- sperm concentration
- sperm motility
- sperm morphology
- seminal fluid parameters
Tests to avoid
- antisperm antibody (ASA) serology
- sperm function testing
Tests to consider
- sperm viability
- sperm membrane function
- hormonal assays
- MRI of the pituitary and hypothalamus
- color flow Doppler imaging
- post-ejaculation urine testing for retrograde ejaculation
- genetic analysis
- sperm DNA assays
- acrosome reaction test
- sperm longevity test
- electron microscopy
- testicular biopsy
Treatment algorithm
obstructive azoospermia
gonadotropin or gonadotropin-releasing hormone deficiencies
primary hypogonadism
high estrogen levels in combination with low testosterone
hyperprolactinemia due to pituitary adenoma
presence of antisperm antibodies
presence of varicocele and no other cause of infertility detected
idiopathic male infertility
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.
References
Key articles
Salonia A, Bettocchi C, Boeri L, et al; EAU Working Group on Male Sexual and Reproductive Health. European Association of Urology guidelines on sexual and reproductive health - 2021 update: male sexual dysfunction. Eur Urol. 2021 Sep;80(3):333-57.Full text Abstract
Practice Committee of the American Society for Reproductive Medicine in Collaboration with the Society for Male Reproduction and Urology. Electronic address: asrm@asrm.org. Diagnostic evaluation of sexual dysfunction in the male partner in the setting of infertility: a committee opinion. Fertil Steril. 2023 Nov;120(5):967-72.Full text Abstract
Brannigan RE, Hermanson L, Kaczmarek J, et al. Updates to male infertility: AUA/ASRM guideline (2024). J Urol. 2024 Dec;212(6):789-99. Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Cystic fibrosis (CF)
- Primary hypogonadism
- Hypopituitarism
More DifferentialsGuidelines
- Updates to male infertility: AUA/ASRM guideline (2024)
- Diagnostic evaluation of sexual dysfunction in the male partner in the setting of infertility
More GuidelinesPatient information
Erection problems
Erection problems: questions to ask your doctor
More Patient information
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