From the Guidelines
A male infertility workup should begin with a comprehensive medical history and physical examination, followed by semen analysis as the cornerstone diagnostic test, as recommended by the most recent guidelines 1. The initial semen analysis should evaluate volume, pH, sperm concentration, motility, and morphology, with abnormal results confirmed by a second analysis after 2-3 weeks.
- Key parameters to assess include:
- Semen volume: low volume (<1.4 mL) may indicate distal obstruction
- pH: acidic pH (<7.0) may indicate ejaculatory duct obstruction
- Sperm concentration: <5 million/mL may indicate severe oligospermia
- Motility and morphology: abnormal results may indicate impaired sperm production or function Laboratory testing should include hormonal assessment with follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone levels to evaluate for hypogonadism or other endocrine disorders, as suggested by recent guidelines 1.
- Additional testing may include:
- Prolactin and thyroid function tests if clinically indicated
- Genetic testing for men with severe oligospermia or azoospermia, including karyotype analysis, Y-chromosome microdeletion testing, and cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation screening
- Scrotal ultrasound to evaluate for obstruction in cases of azoospermia or physical examination abnormalities
- Post-ejaculatory urinalysis to rule out retrograde ejaculation in men with low ejaculate volume (<1.5 mL) Specialized tests like sperm DNA fragmentation may be considered in cases of recurrent pregnancy loss or failed assisted reproductive technology cycles, as recommended by recent guidelines 1. This systematic approach helps identify the underlying cause of infertility, whether it be varicocele, obstruction, genetic factors, or idiopathic, allowing for appropriate treatment planning and counseling regarding fertility potential.
From the Research
Male Infertility Workup
- The evaluation of male infertility includes detailed history taking, focused physical examination, and selective laboratory testing, including semen analysis 2.
- A comprehensive physical examination is essential for every male partner, with adequate assessment of the development of secondary sexual characteristics 3.
- Semen analysis, according to World Health Organization recommendations, is the cornerstone of male partner evaluation 3.
Laboratory Testing
- Hormonal evaluation, including at least total testosterone, follicle stimulating hormone, and luteinising hormone, should be performed for men with oligozoospermia or azoospermia 3.
- Genetic testing should be offered to azoospermic men and those with severe oligozoospermia 3.
- Ultrasound of the genitourinary tract can provide additional information in select cases 3.
Treatment Options
- Clomiphene citrate, a selective estrogen receptor modulator, may improve semen quality by stimulating hormone synthesis and spermatogenesis 4.
- Varicocelectomy has been shown to improve semen parameters in men with a clinical varicocele 5.
- Advanced sperm function tests, such as oxidative stress assays, can be utilised in the diagnosis and treatment of infertile men with a clinical varicocele 5.