Evaluation of the Male Partner in an Infertile Couple

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)

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

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