Male Factor Infertility - Podcast Version TeachMeObGyn 0:00 / 0:00 1x 0.25x 0.5x 0.75x 1x 1.25x 1.5x 1.75x 2x The British Fertility Society defines infertility as ‘a disease of the reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sex (without contraception) between a man and a woman”. In this article, we will review male factor infertility. Causes of male factor infertility 1 Primary spermatogenic failure This is defined by NICE as any spermatogenic abnormality caused by a condition other than hypothalamic pituitary disease. Congenital: absence of testes, cryptorchidism, genetic abnormalities Acquired: testicular trauma/torsion, mumps orchitis, testicular tumour, systemic disease (e.g. liver cirrhosis), varicocele, cytotoxic agents Idiopathic 2 Genetics Klinefelter’s syndrome: 47 XXY karyotype Kallmann syndrome leading to a hypogonadotropic hypogonadism Androgen insensitivity syndrome (karyotype of XY, phenotypically female) 3 Obstructive Azoospermia Bilateral obstruction of the seminal ducts leading to a total absence of sperm in semen Causes include absent vas deferens, post-infection, post-surgery 4 Varicocele Found in 25% men with abnormal semen analysis (Pathophysiology linking a varicocele with infertility is unclear, potentially due to increased scrotal temperature) 5 Hypogonadism Primary: hypergonadotropic hypogonadism due to testicular failure Secondary: hypogonadotropic hypogonadism due to reduced gonadotrophin-releasing hormone (GnRH) and/or FSH/LH secretion Androgenic insensitivity: end organ resistance to gonadotrophins 6 Other Medications: chemotherapy and cytotoxic agents, sulfasalazine, anabolic steroids Psychological factors leading to ejaculation disorders or erectile dysfunction Lifestyle factors: smoking, obesity, excessive alcohol, illicit drug use History and Examination History Examination Full medical, sexual and social history, including: Length of time trying to conceive Frequency and type of sexual intercourse Children born to the man Ejaculatory or erectile dysfunction Medications e.g. sulfasalazine, anabolic steroids, cytotoxic chemotherapy drugs Past medical history: mumps, STIs, testicular trauma, undescended testes, systemic disease (diabetes, liver cirrhosis), prior surgery e.g. orchidopexy Family history including genetic disorders such as cystic fibrosis Social and occupational history e.g. smoking, alcohol intake, exercise, diet Physical examination may include: Calculation of BMI Genital examination: Position of urethral meatus, structural abnormalities of the peniis Testicular volume and consistency, varicocele, hernia, undescended testes Check for signs of hypogonadism: gynaecomastia, lack of body hair growth and a reduction in muscle mass Look for signs of anabolic steroid use Primary Care Investigations Semen analysis is the first line investigation for male factor infertility in primary care. The results should be compared to the WHO reference values: Semen volume 1.5ml or more pH 7.2 or more Sperm concentration 15 million spermatozoa per ml or more Total sperm number 39 million spermatozoa per ejaculate or more Total motility (percentage of progressive motility and non-progressive motility) 40% or more motile or 32% or more with progressive motility Vitality 58% or more live spermatozoa Sperm morphology (percentage of normal forms) 4% or more If the results of the first semen analysis are abnormal, then repeat testing is offered ideally 3 months after the initial test – this is to allow time for the spermatozoa cycle to be completed. Repeat testing may be required sooner than 3 months if a severe deficiency is detected on the initial analysis e.g. azoospermia If initial semen analysis normal, there is no need for further testing. Referral to secondary care is required following 2 abnormal semen analysis results Chlamydia testing Referral to Secondary Care Referral is required following two abnormal semen analysis results According to NICE, an earlier referral may be warranted if the following are present: Previous genital pathology Previous urogenital surgery Previous STI Varicocele Significant systemic illness Abnormal genital examination Known reason for infertility e.g. previous cancer treatment Secondary Care Investigations Following a detailed review of the initial investigations undertaken in primary care, the following tests may also be considered in secondary care: Genetic testing Sperm culture Endocrine tests e.g. FSH and testosterone Imaging of the urogenital tract Testicular biopsy Management of Male Factor Infertility Lifestyle management Weight management Psychological stress management Lifestyle advice including smoking and alcohol cessation Medical management Hypogonadotropic hypogonadism – gonadotrophin drugs should be offered NICE state that men with idiopathic semen abnormalities should not be offered medications such as anti-oestrogens or gonadotrophins as no benefit has been shown Surgical management If obstructive azoospermia Surgical correction can be offered NICE state that surgery for varicoceles should not be offered as part of infertility treatment as it has not been shown to improve pregnancy rates References nice.org.uk. 2018.Scenario: Initial assessment | Management | Infertility | CKS | NICE. [online] Available at: <https://cks.nice.org.uk/topics/infertility/management/initial-assessment/> [Accessed 9 August 2022] nice.org.uk. 2018.Causes of infertility | Background information | Infertility | CKS | NICE. [online] Available at: <https://cks.nice.org.uk/topics/infertility/background-information/causes-of-infertility/> [Accessed 9 August 2022]. nice.org.uk. 2018.Scenario: Management | Management | Infertility | CKS | NICE. [online] Available at: <https://cks.nice.org.uk/topics/infertility/management/management/> [Accessed 9 August 2022]. NICE Guideline CG156, 2013. Fertility problems: assessment and treatment. [online] Available at: <https://www.nice.org.uk/guidance/cg156/resources/fertility-problems-assessment-and-treatment-pdf-35109634660549> [Accessed 9 August 2022] Harding, M., 2016. Infertility – Male. [online] Patient.info. Available at: <https://patient.info/doctor/infertility-male> [Accessed 9 August 2022]. Frequent questions What is male factor infertility? Male factor infertility refers to the inability of a male to achieve a pregnancy with a female partner after 12 months of regular unprotected intercourse. This condition can arise from various causes, including spermatogenic failure, obstructive azoospermia, and hormonal imbalances. What are the common causes of male factor infertility? The primary causes of male factor infertility include primary spermatogenic failure, obstructive azoospermia, varicocele, and hypogonadism. Additional factors may include genetic disorders, testicular trauma, and lifestyle choices such as smoking and excessive alcohol consumption. How is male factor infertility diagnosed? Diagnosis of male factor infertility typically begins with a semen analysis, assessing parameters like sperm concentration, motility, and morphology against WHO reference values. If abnormalities are found, further testing may be warranted, including genetic evaluations and hormonal assessments. What lifestyle changes can improve male fertility? Improving male fertility can often be achieved through lifestyle modifications such as maintaining a healthy weight, quitting smoking, reducing alcohol intake, and managing psychological stress. These changes can enhance overall reproductive health and potentially improve semen quality. What treatment options are available for male factor infertility? Treatment for male factor infertility may include lifestyle management, medical interventions for hormonal imbalances, and surgical options for obstructive conditions. However, treatments like surgery for varicoceles are not recommended as they have not been shown to significantly improve pregnancy rates. Rate This Article