The evaluation of the infertile couple includes examination of the male, looking for abnormality in the sperm or its delivery.
Initial Evaluation:
(1) history and physical examination: A reduced testicular size (< 4 cm in long axis or < 15 cc volume) indicates:
(1a) primary testicular failure, or
(1b) hypothalamic-pituitary insufficiency
(2) semen analysis
Semen analysis:
(1) The sample needs to be delivered promptly (false positive abnormal motility if delayed).
(2) If the first sample abnormal, then a repeat test should be performed.
(2a) if both samples abnormal, continue workup
(2b) if second sample normal, repeat semen analysis in 3-6 months
Semen analysis
Sperm Count |
Sperm Motility or Morphology |
Additional Finding |
Action |
---|---|---|---|
absent (azoospermia) |
|
|
serum testosterone, LH, FSH |
low (< 20 Million per mL, oligospermia) |
often abnormal (< 50% motility, increased abnormal forms) |
|
serum testosterone, LH, FSH |
normal (>= 20 Million per mL) |
abnormal (< 50% motility, increased abnormal forms) |
|
workup abnormal motility or morphology with normal count |
normal (>= 20 Million per mL) |
normal |
woman normal, or postcoital test abnormal despite good mucus |
repeat semen analysis |
normal (>= 20 Million per mL) |
normal |
woman abnormal, or postcoital test normal |
none, patient probably normal |
Normal serum ranges in adult males (Tietz, 1995)
|
Low end of reference range |
High end of reference range |
---|---|---|
serum testosterone, in ng/dL |
280 |
1100 |
LH, in mIU/mL |
1.24 |
7.8 |
FSH, in mIU/mL |
1.42 |
15.4 |
Patterns of Testosterone, LH and FSH
Test |
LH |
FSH |
Sperm Count |
Action |
---|---|---|---|---|
N |
N |
N |
normal |
normal, or partial androgen resistance (unlikely) |
N |
N |
N |
oligospermia |
nonendocrine problem with oligospermia |
N |
N |
N |
azoospermia |
nonendocrine problem with azoospermia |
N |
N |
I |
|
isolated germinal compartment failure |
N |
N |
D |
|
partial androgen resistance (possible) |
N |
I |
N |
|
partial androgen resistance (possible) |
N |
I |
I |
|
|
N |
I |
D |
|
partial androgen resistance (possible) |
N |
D |
N |
|
|
N |
D |
I |
|
|
N |
D |
D |
|
|
I |
N |
N |
|
partial androgen resistance (possible) |
I |
N |
I |
|
|
I |
N |
D |
|
partial androgen resistance (possible) |
I |
I |
N |
|
partial androgen resistance |
I |
I |
I |
|
|
I |
I |
D |
|
partial androgen resistance |
I |
D |
N |
|
|
I |
D |
I |
|
|
I |
D |
D |
|
|
D |
N |
N |
|
hypogonadotrophic hypogonadism (possible) |
D |
N |
I |
|
|
D |
N |
D |
|
hypogonadotrophic hypogonadism (possible) |
D |
I |
N |
|
|
D |
I |
I |
|
primary panhypogonadism |
D |
I |
D |
|
|
D |
D |
N |
|
hypogonadotrophic hypogonadism (possible) |
D |
D |
I |
|
|
D |
D |
D |
|
hypogonadotrophic hypogonadism |
Workup for nonendocrine problem with azoospermia:
(1) seminal fructose positive - postejaculation urine examination:
(1a) sperm present: retrograde ejaculation
(1b) sperm absent
(1b1) obstruction
(1b2) germinal compartment failure
(2) seminal fructose negative
(2a) obstruction
(2b) germinal compartment failure
Workup for nonendocrine problem with oligospermia:
(1) varicocele present: varicocele
(2) varicocele absent: idiopathic oligospermia
Workup for abnormal sperm motility or morphology with normal sperm count:
(1) supravital stain for dead sperm (necrospermia)
(2) serum sperm agglutination antibodies
(3) presence of white cells
(4) culture for bacteria and chlamydia
Specialty: Urology, Clinical Laboratory
ICD-10: ,