What history, physical examination, laboratory workup, and referral recommendations are appropriate for a 36-year-old man with difficulty conceiving?

Evaluation of a 36-Year-Old Male with Difficulty Conceiving

Begin with a focused reproductive history, genital-focused physical examination, and at least two semen analyses one month apart—these three components form the essential foundation of male infertility evaluation and must be performed simultaneously with female partner assessment. 1, 2, 3

Medical and Reproductive History

Core Reproductive Questions

• Duration of infertility: Document how long the couple has been attempting pregnancy with regular unprotected intercourse 1, 2
• Coital frequency and timing: Assess whether intercourse occurs every 1-2 days after menstruation ends 2
• Previous fertility: Any prior pregnancies with current or previous partners 1, 3
• Female partner history: Age, menstrual regularity, history of pelvic inflammatory disease or sexually transmitted infections 1, 2

Male-Specific Medical History

• Sexual function: Presence of erectile or ejaculatory dysfunction 1, 2
• Testicular history: Prior infections (mumps orchitis), trauma, tumors, undescended testes, or orchidopexy 1, 2
• Systemic illnesses: Diabetes mellitus, thyroid disorders, chronic kidney disease 1, 3
• Prior surgeries: Hernia repairs, scrotal or inguinal surgeries, vasectomy 1, 3
• Medications: Current prescription drugs, anabolic steroids, testosterone products, chemotherapy 1, 2, 3
• Gonadotoxin exposures: Occupational heat exposure, radiation, heavy metals, pesticides 1, 2
• Lifestyle factors: Smoking, alcohol consumption, recreational drug use (especially cannabis), caffeine intake >5 cups/day 2, 4

Physical Examination

Genital Examination (Essential Components)

• Penile examination: Location of urethral meatus, presence of hypospadias 1
• Testicular palpation: Measure testicular volume (normal >15 mL or length >4 cm); assess consistency (firm vs. soft suggests impaired spermatogenesis) 1, 3
• Vas deferens: Palpate bilaterally for presence and consistency—absence suggests congenital bilateral absence of vas deferens 1
• Epididymis: Assess for fullness, induration, or tenderness 1
• Varicocele detection: Examine standing with and without Valsalva maneuver (feels like "bag of worms") 1
• Digital rectal examination: Assess prostate size and consistency 1

General Examination

• Body mass index: Calculate BMI; obesity (>30 kg/m²) or underweight (<18.5 kg/m²) impairs fertility 2
• Secondary sexual characteristics: Assess body hair distribution, gynecomastia, eunuchoid proportions (may indicate hypogonadism) 1, 3

Laboratory Workup

Semen Analysis (Mandatory First-Line Test)

• Obtain at least two samples collected one month apart after 2-3 days of sexual abstinence 2, 3, 5
• Key parameters to assess: Volume, pH, sperm concentration, total motile sperm count (TMSC), progressive motility, and morphology 1, 3, 4
• Critical threshold: TMSC <10 million suggests need for assisted reproductive technology 2

Hormonal Evaluation (Indicated for Oligozoospermia or Azoospermia)

• Total testosterone: Measure morning fasting level 3, 5
• Follicle-stimulating hormone (FSH): Elevated FSH with small testes suggests primary testicular failure 3, 5
• Luteinizing hormone (LH): Helps differentiate primary vs. secondary hypogonadism 3, 5

Additional Testing (Selected Cases)

• Infectious disease screening: Hepatitis B surface antigen, hepatitis C antibodies, HIV, syphilis—required before assisted reproduction 2
• Genetic testing: Karyotype and Y-chromosome microdeletion analysis for men with sperm concentration <5 million/mL or azoospermia 3, 5
• Thyroid function tests: Only if clinical features suggest thyroid disease 2

Referral Recommendations

Immediate Referral to Urology/Andrology Specialist

• Azoospermia (no sperm in ejaculate) 2, 3
• Severe oligozoospermia (sperm concentration <5 million/mL) 3, 5
• Abnormal physical examination: Absent vas deferens, small firm testes (<15 mL), large varicocele 1, 3
• Abnormal hormonal profile: Low testosterone with low/normal FSH and LH (hypogonadotropic hypogonadism) 3, 4
• Sexual dysfunction: Erectile or ejaculatory problems requiring specialized management 1, 2

Referral to Reproductive Endocrinology/Fertility Specialist

• After 12 months of documented infertility in couples where basic evaluation is normal or shows mild abnormalities 2, 3
• TMSC 3-10 million: Consider intrauterine insemination with ovarian stimulation (non-inferior to IVF for mild male factor) 2
• TMSC <3 million: Likely requires in vitro fertilization with intracytoplasmic sperm injection 2
• Unexplained infertility: After completing basic workup of both partners 2, 4

Critical Pitfalls to Avoid

• Never evaluate only the male partner—simultaneous female partner assessment is mandatory, as 50% of infertility involves both partners 2, 3
• Do not rely on a single semen analysis—at least two samples one month apart are required for accurate assessment 2, 3, 5
• Do not prescribe testosterone or anabolic steroids—these suppress spermatogenesis and worsen infertility 2, 3
• Do not delay evaluation—at age 36, the female partner's age becomes increasingly critical; if she is ≥35 years, evaluation should begin after only 6 months of trying 2, 4

Immediate Lifestyle Modifications

While awaiting specialist evaluation, counsel the couple on:

• Intercourse timing: Every 1-2 days beginning after menstruation ends 2
• Smoking cessation: Both partners 2
• Eliminate alcohol and recreational drugs 2
• Limit caffeine to <5 cups/day 2
• Avoid commercial vaginal lubricants (impair sperm motility) 2
• Optimize body weight: Target BMI 19.8-26.0 kg/m² 2
• Female partner supplementation: Folic acid and iodine 2