Male Infertility Evaluation
Introduction
Infertility is defined as the inability to conceive after one year of unprotected, adequately timed intercourse, although depending on age and previous history, couples often seek evaluation sooner. Approximately 15% - 20% of all couples are infertile. The difficulties are attributable to a significant male factor alone in 30% of couples and to a combination of male and female factors in an additional 20%. Therefore, in >50% of all infertile couples, an abnormal male factor contributes to reproductive failure. This means that well over 2.5 million men would benefit from a fertility evaluation.
Traditionally, the initial evaluation of the male was performed only when the couple had been unable to conceive after 1 year of unprotected intercourse. However, because many couples are now postponing parenthood, and because the risk of a female’s infertility increases as she passes the age of 35, male infertility evaluations should be performed upon initial presentation.
There are a vast number of etiologies of male infertility, therefore we advocate a systematic approach which begins with a detailed history and physical examination, followed by a thorough laboratory evaluation. The initial evaluation includes a semen analysis and hormonal testing. Depending upon these results, a more detailed evaluation with a repeat semen analyses, sperm function tests, additional hormonal studies, radiologic studies, genetic evaluation, and other procedures including a testicular biopsy may be performed.
History and Physical Examination
You will be asked to complete a detailed questionnaire of your medical, social, surgical and pregnancy history. Questions include not only your general medical health, but your family history, exposure history, use of tobacco, alcohol and drugs, exposure to toxins, radiation and chemotherapy, as well as problems with infection. A detailed sexual history including questions on sex drive, erections, ejaculations and orgasm will be obtained. A history of your partner’s fertility and workup and evaluation will be asked.
During your new patient consultation, a detailed physical examination will be performed. Your height, weight, secondary sexual characteristics, abdomen, groin, penis and scrotum will be examined. Your testicular volume will be assessed and a rectal examination performed.
Laboratory Testing
In addition to obtaining at least two semen analyses with 2-3 days of ejaculatory abstinence, bloodwork will likely be obtained. Your hormonal evaluation will include tests of pituitary function and testicular function. Genetic testing may also be obtained. It may be necessary to obtain further testing on your semen, blood or perform an office or operative procedure to evaluate your infertility. An ultrasound of the testes is also sometimes obtained to evaluate for abnormalities such as varicocele, infection, or tumor.
Testicular Function
The testes perform two functions. The first is to produce the male hormone testosterone which is secreted into the blood stream and has wide ranging effects upon the body. The other role of the testis is to produce sperm. Either one or both functions may go astray during a man’s lifetime. Since the testis has an absolute requirement for testosterone in order to make sperm, it is possible to have abnormalities in spermatogenesis with normal testosterone but not vice versa. It is extremely rare for men of reproductive age to have abnormal testosterone levels and much more common for them to have abnormalities in sperm production associated with normal testosterone levels.
What is a Diagnostic Testis Biopsy?
The most common finding amongst infertile men is abnormal sperm production in terms of numbers and quality. However, a small percentage of men have a zero sperm count known as azoospermia. There are three causes for azoospermia:
1.Insufficient hormones and this is easily established by blood tests.
2.Problem in the testis producing sperm
3.Blockage preventing sperm from getting out similar to a vasectomy.
The last two can sometimes be differentiated by findings in the history, physical examination or on blood tests, however, there are a significant number of times when it is still uncertain. In that case, a diagnostic testicular biopsy is performed to differentiate between obstruction and a problem inside the testis.
A diagnostic testicular biopsy consists of taking a small pea sized amount of tissue out of both testes and sending them to the pathology laboratory for examination. The tissue must be handled properly in a special way for the biopsy to be worthwhile. Thus, even though the procedure is quite simple, it is best performed at a center that has a great deal of experience with male infertility.
Treatment Options
The management options for couples in whom the husband has a zero sperm count depend upon the exact cause. Adoption and donor insemination are always an alternative option to fixing the husband’s problem or using sperm harvested from him in combination with in vitro fertilization (IVF), test tube baby technology. Hormonal therapy is highly effective in men who have insufficient hormones. For those men who have a problem in the testis, therapies aimed at improving testicular function may be employed such as varicocele repair. The alternative is to harvest sperm from the testes (see sperm retrieval procedures).
About 50% of men with a zero sperm count have sufficient sperm production within the testes to allow fertilization of the wife’s eggs using intracytoplasmic sperm injection (ICSI) a form of IVF. The options for couples where the man has a zero sperm count due to a blockage are to repair the blockage or harvest sperm to be used in IVF.
Microdissection TESE
Explanation of Procedure
Microscopic or Microdissection Testicular Sperm Extraction (TESE) is a surgical procedure performed in the operating room under general anesthesia to retrieve sperm for IVF/ICSI. Microdissection TESE can improve sperm retrieval for men with non-obstructive azoospermia (a sperm production problem) over those achieved previously with standard testis biopsy techniques.
As with the standard multi-biopsy approach, optical magnification via an operating microscope is used to visualize blood vessels under the surface of the tunica albuginea, the outside layer of the testis, allowing placement of the dissection to occur in bloodless regions of the testis. Instead of planning for multiple biopsies, a large incision is made in the midportion of the tunica albuginea to optimize visualization of the testicular parenchyma without affecting testicular blood supply. The testicular tissue is then directly examined with high-powered microscopy in an attempt to identify individual seminiferous tubules that are larger than other tubules in the testicular tissue. Small samples are sharply excised from these areas when the tubules appear larger and whiter. Each excised testicular tissue specimen is then dissected into smaller pieces and then examined for sperm. Additional dissections are made when sperm are retrieved or further sampling was thought likely to impair the testicular blood supply.
Microdissection is particularly useful to apply in men with smaller testes, as for example in men with Klinefelter’s syndrome. Microdissection is also easier to apply in cases of Sertoli-cell only pattern as there is a greater difference between tubular diameter size. In cases of maturation arrest, microdissection assists in identifying the limited regions of sperm production.
Outcomes
Schegel et al has reported for men with at least one area of hypospermatogenesis, 81% of men had sperm retrieval, whereas when the most advanced spermatogenesis form was maturation arrest, 42% of men has sperm retrieved. When the most advanced spermtogenic pattern was that Sertoli Cell-only, 24% of men have sperm retrieved. Microdissection TESE improves these sperm retrieval outcomes, and allows retrieval of sperm in men whom sperm retrieval was unsuccessful with standard TESE approaches Schlegel reports that sperm retrieval success increased from 45% to 63% after introduction of the microdissection technique.
Microdissection TESE is performed “fresh” at the time of egg retrieval, either the day before or day of. Cryopreservation of additional tissue is performed. Donor sperm backup is recommended to be used if no sperm are found on microdissection TESE.
Microdissection techniques make it feasible to retrieve sperm in men who would otherwise be unable to proceed with IVF/ICSI. Retrieval rates are improved, less testicular tissue is extracted and fertility is optimized for the infertile male. Careful coordination with the female partner’s reproductive endocrinologist is essential.
Schlegel PN: Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod 1999, 14:131-135
Schlegel PN and Li, PS: Microdissection TESE: Testicular sperm retrieval in non-obstructive azoospermia. Video and abstract ( V-16) presented at the 94th annual meeting of American Urologic Association, May 1-6, 1999, Dallas, TX
The comprehensive infertility evaluation includes a detailed reproductive and sexual history for both partners, past medical history, surgical history, medication use, allergies, family history, social history and review of symptoms. Identification of possible reversible causes such a improper timing, use of lubricants, use of medications, drug use, tobacco use, hot tub use, recent fevers are elicitied. Identification of contributing problems such as female factor infertility, exposure to chemotherapy, radiation, toxins, presence of a varicoceles, testicular torsion, undescended testicles, trauma, infection of the testes, epididymis or prostate,
Karen Elizabeth Boyle, M.D.
Reproductive Medicine & Surgery, Sexuality and Aesthetics
Contact Us
Karen E. Boyle, M.D.
Phone: 877-290-5055
Fax: 410-825-5811
Chesapeake Urology Associates at Greater Baltimore Medical Center (GBMC)
Physicians Pavilion North
6535 North Charles Street, Suite 625
Baltimore, MD 21204
