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SHOULD I BE EVALUATED?In the past, couples were instructed to initiate an infertility workup only after at least one year of unsuccessful attempts. Often, the evaluation was limited to the female partner alone. This view has subsequently changed, and couples are now encouraged to proceed with an evaluation when they first suspect a problem with their reproductive function. Issues such as patient anxiety and advanced maternal age are among the factors that have led to this new approach. For the male patient, the workup should generally begin when the female partner's evaluation is initiated. A male fertility specialist, usually a urologist who has a focus in his practice on male fertility problems as well as some postgraduate training in this area, should perform this workup. The important point, as mentioned earlier, is that a male factor is involved in as many as 50% of infertile couples, and thus a delay in diagnosis may ultimately impair chances for the couple's success.EVALUATION OF THE MALE PATIENTHISTORY The evaluation of the male patient begins with a thorough history. The physician will ask about a number of items, including duration of the problem, sexual habits, prior pregnancies and previous treatment, as well as the general health of the patient. A childhood or developmental history, including questions regarding a history of testicular torsion or postpubertal mumps, is included. The patient's medical and surgical history should be discussed, including items such as a history of diabetes, prostate surgery, or hernia repairs. A discussion of exposure to possible toxic agents such as radiation, heavy metals, and organic solvents should be included.PHYSICAL EXAMINATION The physical examination should be thorough and complete. The physician will likely pay close attention to the penis and scrotal contents. Testicular size and consistency, as well as the presence or absence of the vas deferens and swelling or tenderness of the epididymides, are noted. For this portion of the examination, the physician may ask you to stand, take a deep breath, and "bear down" (the Valsalva maneuver) as he examines you for the presence of enlarged veins around the testicle (varicoceles). Additionally, a prostate examination is a key aspect of a thorough evaluation. ROUTINE LABORATORY TESTINGSEMEN ANALYSIS A central component of laboratory testing is the semen analysis. To perform this, a man is generally asked to obtain a specimen through masturbation. Special containers are also available for home collection, but prompt return of the specimen to the laboratory (within one hour) is mandatory. Collection of the entire specimen is important for accurate diagnosis. A period of 48-72 hours of abstinence should precede the collection. Table 1 lists minimal standards for adequate semen parameters. It is important to note that these values are not the absolute values needed to achieve a pregnancy, but rather statistical limits below which male infertility is more likely to be a problem. Furthermore, significant variation in one or several semen parameters from one specimen to another may be present and is not uncommon. It is for these reasons that at least two semen specimens should be analyzed. Adherence to strict collection techniques and abstinence periods is therefore crucial to minimize variation.Table 1: Semen Analysis: Minimal Standards of Adequacy On at least two occasions: (Adapted from Sigman, M., Lipshultz, L.I., and Howards, S.S.: Evaluation of the subfertile male. In: Infertility in the Male, 3rd Edition. Edited by L.I. Lipshultz and S.S. Howards. St. Louis: Mosby-Year Book, 1997, p. 177.) SERUM HORMONE LEVELS A routine part of the initial evaluation is a determination of specific hormones in the blood, which usually include FSH, LH, testosterone, and prolactin levels. The interrelationship of these four hormones is closely tied to normal sperm production. Abnormalities may be a sign of a primary hormone problem in the hypothalamus, pituitary, or testis. ADDITIONAL LABORATORY TESTINGSemen Leukocytes: Increased numbers of white blood cells (WBC) in the semen have been associated with deficiencies in sperm function and motility. Recently, the development of specialized staining techniques for WBC has allowed their definitive identification within the semen. Semen WBC have been associated with genitourinary infections and/or inflammation. WBC have also been implicated in the release of harmful substances called reactive oxygen species (ROS). ROS will be discussed at length below. Evidence of elevated levels of WBC in the semen should lead to a semen culture, which is used to identify the presence of infection.Antisperm Antibod Testing: Antisperm antibodies (ASA) in the semen are associated with lower pregnancy rates. Conditions associated with the presence of seminal ASA include genitourinary infections, testicular trauma, thermal injury, and genital tract obstruction. The most accurate means of detecting ASA is through the use of the Immunobead® test. Microscopic beads are used to detect the presence of spermbound antibodies. Greater than 20% of sperm with ASA binding is usually clinically significant and possibly associated with functional sperm deficits. Under the microscope, the semen of a man with positive ASA may frequently be noted to have excessive clumping and decreased sperm motility. Reactive Oxygen Species (ROS): ROS are molecules with an extra electron that can be easily passed on to another molecule. When present in excessively high levels, ROS can cause injury to sperm and other genital tract cells. Specifically, this damage can involve the sperm membrane and DNA and may lead to overall ire paired sperm function. Morphology: Morphology assays are descriptive analyses of sperm shape. Several studies have suggested a correlation between sperm morphology and function. Two types of morphology tests used include the "standard" morphology assay and Kruger's strict morphology assay. In the latter, sperm are actually measured in multiple areas to identify "perfect sperm shape," which should be greater than 4% of the cells examined. Sperm Penetration Assay (SPA): This is a functional test which evaluates the sperm's ability to penetrate hamster ova. The result of a normal SPA is correlated with a greater incidence of positive in vitro fertilization (IVF) outcomes. Abnormal results may steer a couple towards assisted reproductive techniques using specific sperm separation procedures prior to intrauterine insemination (IUI) or even to intracytoplasmic sperm injection (ICSI) with IVF. |
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