Evaluation of the Subfertile Man


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Evaluation of the Subfertile Man

  1. 1. Evaluation of theEvaluation of the Subfertile ManSubfertile Man Dr .Ashraf Fouda Ob/Gyn. Consultant Damietta General Hospital E. mail : ashraffoda@hotmail.com
  2. 2. Infertility affectsInfertility affects 15 % of couples15 % of couples,, andand 50 % of male infertility50 % of male infertility is potentiallyis potentially correctable.correctable.
  3. 3.  Evaluation of theEvaluation of the subfertile man requires:subfertile man requires: 1.1. A complete medicalA complete medical historyhistory,, 2.2. Physical examinationPhysical examination, and, and 3.3. LaboratoryLaboratory studies.studies.
  4. 4. The main purpose ofThe main purpose of the male evaluationthe male evaluation is tois to identifyidentify and treat correctableand treat correctable causescauses ofof subfertility.subfertility.
  5. 5. In addition,In addition, many men seek anmany men seek an explanationexplanation for theirfor their condition, which can becondition, which can be discovered during theirdiscovered during their evaluation.evaluation.
  6. 6. The male fertilityThe male fertility evaluation canevaluation can uncover significant medicaluncover significant medical and genetic pathologyand genetic pathology that could affect thethat could affect the patient's health or thatpatient's health or that of his offspring.of his offspring.
  7. 7. Although pregnancies canAlthough pregnancies can be achieved without anybe achieved without any evaluation other than aevaluation other than a semen analysissemen analysis,, This testThis test alone is insufficientalone is insufficient to adequately evaluateto adequately evaluate the male patient.the male patient.
  8. 8.  Treatment of correctableTreatment of correctable male-factor pathology is :male-factor pathology is : 1.1. Cost effectiveCost effective,, 2.2. Does not increase the risk ofDoes not increase the risk of multiple birthsmultiple births, and, and 3.3. Can spare the womanCan spare the woman invasive procedures and potentialinvasive procedures and potential complicationscomplications associated with assistedassociated with assisted reproductive technologies.reproductive technologies.
  9. 9. Appropriate evaluationAppropriate evaluation and treatmentand treatment of the subfertileof the subfertile man are critical inman are critical in delivering suitable caredelivering suitable care to theto the infertile couple.infertile couple.
  10. 10. IInfertility,nfertility, defined as the inabilitydefined as the inability to conceive afterto conceive after one year ofone year of unprotected intercourseunprotected intercourse,, affectsaffects 15 % of15 % of couplescouples..
  11. 11. Male subfertilityMale subfertility is one of theis one of the mostmost rapidly growing fields inrapidly growing fields in medicinemedicine,, with dramatic advanceswith dramatic advances in diagnosis andin diagnosis and treatment.treatment.
  12. 12. Although infertilityAlthough infertility (or subfertility)(or subfertility) is oftenis often attributed toattributed to female causes,female causes, fertilityfertility is a two-personis a two-person phenomenonphenomenon..
  13. 13.  Successful conception depends onSuccessful conception depends on many complicated events,many complicated events, includingincluding :: 1.1. SSatisfactory sexual and ejaculatoryatisfactory sexual and ejaculatory function,function, 2.2. AAppropriate timing, and appropriate timing, and a 3.3. CComplex set of interactionsomplex set of interactions between the male and the femalebetween the male and the female reproductive tracts.reproductive tracts.
  14. 14. Male and female factorsMale and female factors coexist in aboutcoexist in about one thirdone third of cases,of cases, whilewhile one thirdone third of cases areof cases are secondary tosecondary to male factors onlymale factors only.. Therefore, evaluation ofTherefore, evaluation of both partners is criticalboth partners is critical,, and the woman's gynecologicand the woman's gynecologic evaluation should proceedevaluation should proceed simultaneously with the man's.simultaneously with the man's.
  15. 15. Causes of Male SubfertilityCauses of Male Subfertility The most common identifiableThe most common identifiable cause of male subfertility is acause of male subfertility is a varicocelevaricocele,, a condition ofa condition of palpably distended veinspalpably distended veins of the pampiniform plexus of theof the pampiniform plexus of the spermatic cordspermatic cord..
  16. 16. The termThe term "subclinical varicocele""subclinical varicocele" refers to a lesionrefers to a lesion too small to betoo small to be detected by physicaldetected by physical examination.examination. Causes of MaleCauses of Male SubfertilitySubfertility
  17. 17. The concept of aThe concept of a subclinical varicocelesubclinical varicocele arosearose from the observation in early reportsfrom the observation in early reports that the detrimental effect ofthat the detrimental effect of small varicoceles equaled thatsmall varicoceles equaled that of larger varicoceles.of larger varicoceles. However,However, more recent studiesmore recent studies suggest that larger varicoceles havesuggest that larger varicoceles have aa greater impactgreater impact on fertility.on fertility. Causes of Male SubfertilityCauses of Male Subfertility
  18. 18. As a result,As a result, most subspecialistsmost subspecialists who deal withwho deal with male subfertilitymale subfertility do not regarddo not regard subclinical varicocelessubclinical varicoceles as clinicallyas clinically significant.significant.
  19. 19.  Another commonAnother common correctable cause of malecorrectable cause of male subfertility issubfertility is obstructionobstruction,, which may occurwhich may occur after a vasectomyafter a vasectomy.. Causes of Male SubfertilityCauses of Male Subfertility
  20. 20. Less common correctable causesLess common correctable causes include :include : 1.1.EEjaculatory dysfunctionjaculatory dysfunction,, 2.2.IInfectionnfection,, 3.3.MMedicationsedications, and, and 4.4.HHormonal deficiencyormonal deficiency Causes of Male SubfertilityCauses of Male Subfertility
  21. 21. When the sum of theseWhen the sum of these correctable causescorrectable causes is calculated,is calculated, it becomes apparent thatit becomes apparent that more than one half of casesmore than one half of cases of male subfertilityof male subfertility are potentially correctableare potentially correctable.. Causes of Male SubfertilityCauses of Male Subfertility
  22. 22. The specific correctiveThe specific corrective treatments such astreatments such as vasectomy reversal andvasectomy reversal and varicocele ligationvaricocele ligation are more cost effective thanare more cost effective than empiric treatment withempiric treatment with assisted reproductiveassisted reproductive technologies.technologies. Causes of Male SubfertilityCauses of Male Subfertility
  23. 23.  Furthermore, correction ofFurthermore, correction of underlying male factors canunderlying male factors can:: 1.1. Allow forAllow for natural conceptionnatural conception,, 2.2. Does not carry an increased risk ofDoes not carry an increased risk of multiple birthsmultiple births, and, and 3.3. Spares the womanSpares the woman invasiveinvasive proceduresprocedures and the potentialand the potential complicationscomplications of these therapies.of these therapies. Causes of Male SubfertilityCauses of Male Subfertility
  24. 24. Recent advances, particularlyRecent advances, particularly inin molecular geneticsmolecular genetics, have, have improved our understanding ofimproved our understanding of some forms of male subfertility.some forms of male subfertility. A significant proportion ofA significant proportion of male subfertility currently ismale subfertility currently is unexplainedunexplained.. Causes of Male SubfertilityCauses of Male Subfertility
  25. 25. AboutAbout 13 %13 % of men withof men with nonobstructive azoospermianonobstructive azoospermia (i.e., no sperm in the semen(i.e., no sperm in the semen because of low or absent spermbecause of low or absent sperm production)production) have been shown to havehave been shown to have Y-Y- Causes of Male SubfertilityCauses of Male Subfertility
  26. 26. AboutAbout 70 %70 % of men withof men with congenitalcongenital bilateralbilateral absence of the vas deferensabsence of the vas deferens are carriers ofare carriers of cystic fibrosis mutations.cystic fibrosis mutations. Causes of MaleCauses of Male SubfertilitySubfertility
  27. 27. ))ICSIICSI(( The most significant advance in theThe most significant advance in the treatment of severe male infertility istreatment of severe male infertility is in vitro fertilizationin vitro fertilization with intracytoplasmic sperm injectionwith intracytoplasmic sperm injection (ICSI).(ICSI). With this technique, aWith this technique, a single spermsingle sperm isis injected directly into the oocyte.injected directly into the oocyte. Only one viable sperm per eggOnly one viable sperm per egg is required for ICSI, and a preciseis required for ICSI, and a precise diagnosis is not required to achievediagnosis is not required to achieve
  28. 28. ))ICSIICSI(( When using sperm from menWhen using sperm from men with known or presumedwith known or presumed genetic infertilitygenetic infertility, it must be, it must be assumed thatassumed that any male offspringany male offspring also will be infertilealso will be infertile.. Y-chromosome microdeletionsY-chromosome microdeletions from the father are inheritedfrom the father are inherited by the sons when ICSI is used.by the sons when ICSI is used.
  29. 29. ThereThere does not appeardoes not appear to be anto be an increased riskincreased risk ofof major malformationsmajor malformations in children born fromin children born from ICSI compared withICSI compared with the generalthe general population.population.
  30. 30. CounselingCounseling about these potentialabout these potential genetic issuesgenetic issues is a critical partis a critical part of the male fertilityof the male fertility evaluation.evaluation.
  31. 31. EvaluationEvaluation The main goals of evaluatingThe main goals of evaluating the subfertile man are tothe subfertile man are to identify correctable causesidentify correctable causes of infertilityof infertility and to help him and his partnerand to help him and his partner to conceive by theto conceive by the most natural, least invasivemost natural, least invasive means possible.means possible.
  32. 32. In addition,In addition, the evaluationthe evaluation may uncovermay uncover significant underlyingsignificant underlying medical ormedical or genetic pathologygenetic pathology.. EvaluationEvaluation
  33. 33. Subfertility may be relatedSubfertility may be related to an underlyingto an underlying malignancymalignancy,, such as asuch as a testicular or pituitarytesticular or pituitary tumortumor.. EvaluationEvaluation
  34. 34. If the only evaluationIf the only evaluation is ais a semen analysissemen analysis,, underlying pathologyunderlying pathology can becan be missedmissed.. EvaluationEvaluation
  35. 35. History and PhysicalHistory and Physical ExaminationExamination  A carefulA careful historyhistory can :can : 1.1. Offer clues to theOffer clues to the underlyingunderlying causecause of infertility andof infertility and 2.2. Provide anProvide an assessment ofassessment of the man'sthe man's fertility potentialfertility potential..
  36. 36.  These data should be documented:These data should be documented: 1.1. TThe duration of the infertility,he duration of the infertility, 2.2. PPrevious evaluation and treatment,revious evaluation and treatment, 3.3. PPrevious pregnanciesrevious pregnancies (for either partner),(for either partner), andand 4.4. AAny difficulty establishing theseny difficulty establishing these pregnanciespregnancies History and PhysicalHistory and Physical ExaminationExamination
  37. 37. 1.1. IInadequate frequency or timingnadequate frequency or timing of intercourse,of intercourse, 2.2. SSexual dysfunction, andexual dysfunction, and 3.3. LLubricant useubricant use can impede pregnancy.can impede pregnancy. History and PhysicalHistory and Physical ExaminationExamination Evidence level BEvidence level B
  38. 38. The optimal frequencyThe optimal frequency of intercourse isof intercourse is every day or every other dayevery day or every other day around the expected timearound the expected time of ovulation.of ovulation. History and PhysicalHistory and Physical ExaminationExamination Evidence level BEvidence level B
  39. 39. Because nearlyBecause nearly all commerciallyall commercially available lubricantsavailable lubricants areare spermatotoxicspermatotoxic,, their use is discouraged.their use is discouraged. History and PhysicalHistory and Physical ExaminationExamination
  40. 40. Most menMost men of reproductive ageof reproductive age do not have a significant medicaldo not have a significant medical historyhistory, but some specific, but some specific risk factors may be identified.risk factors may be identified. For example,For example, diabetes mellitusdiabetes mellitus can causecan cause erectile and ejaculatory dysfunction.erectile and ejaculatory dysfunction. History and PhysicalHistory and Physical ExaminationExamination
  41. 41.  Previous disorders of the testes,Previous disorders of the testes, such as :such as : 1.1. Cryptorchidism orCryptorchidism or 2.2. Spermatic cord torsion, orSpermatic cord torsion, or 3.3. A history of inguinal, scrotal, orA history of inguinal, scrotal, or retroperitoneal surgery,retroperitoneal surgery, are associated with subfertility.are associated with subfertility. History and PhysicalHistory and Physical ExaminationExamination
  42. 42.  Use of:Use of: 1.1. PrescriptionPrescription oror 2.2. DrugsDrugs andand 3.3. Exposure toExposure to environmental toxinsenvironmental toxins also canalso can impair fertilityimpair fertility History and PhysicalHistory and Physical ExaminationExamination
  43. 43. AnosmiaAnosmia may suggest an underlyingmay suggest an underlying hypothalamic etiologyhypothalamic etiology (such as Kallmann's(such as Kallmann's syndrome) or a pituitarysyndrome) or a pituitary etiology,etiology, History and PhysicalHistory and Physical ExaminationExamination
  44. 44.  Frequent respiratory infectionsFrequent respiratory infections are a feature of :are a feature of : 1.1. Young's syndrome:Young's syndrome: (e.g., chronic sinusitis, bronchiectasis,(e.g., chronic sinusitis, bronchiectasis, obstructive azoospermia) andobstructive azoospermia) and 2.2. Kartagener's syndrome:Kartagener's syndrome: (e.g., primary ciliary(e.g., primary ciliary dyskinesia/immotile cilia, chronicdyskinesia/immotile cilia, chronic sinusitis, bronchiectasis, situs inversus).sinusitis, bronchiectasis, situs inversus). History and PhysicalHistory and Physical ExaminationExamination
  45. 45. 1.1. HHeadaches,eadaches, 2.2. VVisual field disturbances, orisual field disturbances, or 3.3. GGalactorrheaalactorrhea should prompt an investigationshould prompt an investigation for a tumor of the centralfor a tumor of the central nervous systemnervous system.. History and PhysicalHistory and Physical ExaminationExamination
  46. 46. Clues to the Diagnosis of MaleClues to the Diagnosis of Male InfertilityInfertility
  47. 47. Clinical clue PossibleClinical clue Possible diagnosisdiagnosis
  48. 48. Clinical clue PossibleClinical clue Possible diagnosisdiagnosis
  49. 49. AA thorough examinationthorough examination can identify underlying causescan identify underlying causes of subfertility.of subfertility. Abnormal distribution of hairAbnormal distribution of hair and fatand fat can suggest ancan suggest an underlying endocrinopathy,underlying endocrinopathy, such assuch as hypogonadotropic hypogonadism.hypogonadotropic hypogonadism. History and PhysicalHistory and Physical ExaminationExamination
  50. 50. TheThe position and sizeposition and size of the urethral meatusof the urethral meatus should be noted becauseshould be noted because severe hypospadiassevere hypospadias can impaircan impair sperm depositionsperm deposition near the cervix.near the cervix. History and PhysicalHistory and Physical ExaminationExamination
  51. 51. Normal testes areNormal testes are 20 cm320 cm3 oror more or at leastmore or at least 4 cm4 cm in greatestin greatest dimension.dimension. Those smaller thanThose smaller than 20 cm320 cm3 areare suggestive of decreased spermsuggestive of decreased sperm production and may occur inproduction and may occur in hypogonadal menhypogonadal men as well.as well. History and Physical ExaminationHistory and Physical Examination
  52. 52. The presence of theThe presence of the vasa deferentiavasa deferentia andand epididymidesepididymides as well asas well as anyany indurationinduration oror engorgementengorgement suggestive ofsuggestive of obstructionobstruction should be noted.should be noted. History and PhysicalHistory and Physical ExaminationExamination
  53. 53. VaricocelesVaricoceles are found mostare found most commonly on thecommonly on the left sideleft side,, but up tobut up to 20 %20 % may bemay be bilateralbilateral.. Diagnosis should be madeDiagnosis should be made in ain a warm roomwarm room by palpationby palpation of the spermatic cord withof the spermatic cord with the patient in thethe patient in the standing positionstanding position.. History and PhysicalHistory and Physical ExaminationExamination
  54. 54. VaricocelesVaricoceles are graded:are graded: 1+1+ :: (palpable with Valsalva's maneuver only),(palpable with Valsalva's maneuver only), 2+2+ :: (palpable), and(palpable), and 3+3+ :: (visible through the scrotal(visible through the scrotal skin).skin). History and PhysicalHistory and Physical ExaminationExamination
  55. 55. 1.1. An isolatedAn isolated right-sided varicoceleright-sided varicocele oror 2.2. A lesion on either side thatA lesion on either side that does not disappear when thedoes not disappear when the patient assumes the supinepatient assumes the supine positionposition::  Should prompt imaging of theShould prompt imaging of the retroperitoneum to evaluate forretroperitoneum to evaluate for inferior vena caval orinferior vena caval or renal vein obstructionrenal vein obstruction.. History and Physical ExaminationHistory and Physical Examination
  56. 56.  Digital rectal examinationDigital rectal examination is performed to examine:is performed to examine: 1.1. TheThe prostateprostate gland,gland, 2.2. Seminal vesiclesSeminal vesicles, and, and 3.3. Possible cystsPossible cysts that can causethat can cause ejaculatory duct obstruction.ejaculatory duct obstruction. History and PhysicalHistory and Physical ExaminationExamination
  57. 57. Laboratory EvaluationLaboratory Evaluation TheThe semen analysissemen analysis is the foundationis the foundation of the laboratory evaluation.of the laboratory evaluation. At leastAt least two samplestwo samples,, preferably taken atpreferably taken at least two or three weeksleast two or three weeks apartapart,, should be analyzed aftershould be analyzed after two to three days oftwo to three days of sexual abstinencesexual abstinence..
  58. 58. The sample should be collected byThe sample should be collected by masturbationmasturbation in a clean containerin a clean container and analyzedand analyzed within one hourwithin one hour ofof collection.collection. The sample can beThe sample can be collected at homecollected at home if it is kept at body temperature andif it is kept at body temperature and brought to the laboratory inbrought to the laboratory in sufficient time.sufficient time. Laboratory EvaluationLaboratory Evaluation
  59. 59. In addition to theIn addition to the numbernumber of sperm per mLof sperm per mL (concentration),(concentration), other parameters, such asother parameters, such as motilitymotility, are important in, are important in assessing a man's fertilityassessing a man's fertility potential.potential. Laboratory EvaluationLaboratory Evaluation
  60. 60. Reference Values of SemenReference Values of Semen VariablesVariables
  61. 61. LeukocytospermiaLeukocytospermia, which is, which is defined asdefined as more than 1 millionmore than 1 million white blood cells per mL ofwhite blood cells per mL of semensemen, requires specific testing., requires specific testing. It isIt is not possiblenot possible to definitivelyto definitively identify these cells byidentify these cells by microscopic appearance alone.microscopic appearance alone. Laboratory EvaluationLaboratory Evaluation
  62. 62. In the presence of significantIn the presence of significant leukocytospermialeukocytospermia, empiric antibiotic, empiric antibiotic therapy is reasonable.therapy is reasonable. DoxycyclineDoxycycline (Vibramycin), in a dosage of(Vibramycin), in a dosage of 100 mg twice a day for two weeks,100 mg twice a day for two weeks, is an effective regimen.is an effective regimen. AA repeat semen analysisrepeat semen analysis should beshould be performed at the completion of therapy.performed at the completion of therapy. Laboratory EvaluationLaboratory Evaluation
  63. 63. The semen analysisThe semen analysis does not test fertilitydoes not test fertility,, but ratherbut rather fertilityfertility potentialpotential.. The chance of initiating aThe chance of initiating a pregnancy correlates withpregnancy correlates with the total number ofthe total number of Laboratory EvaluationLaboratory Evaluation
  64. 64. Pregnancies can be established withPregnancies can be established with subnormal parameterssubnormal parameters,, illustrating the importance of theillustrating the importance of the femalefemale partner's fertility potentialpartner's fertility potential and theand the fact that anfact that an abnormalabnormal semen analysis cannot besemen analysis cannot be Laboratory EvaluationLaboratory Evaluation
  65. 65. TheThe morphologymorphology is a measurementis a measurement of the percentageof the percentage of the normal-shapedof the normal-shaped sperm.sperm. TheThe Kruger or strict morphologyKruger or strict morphology scorescore has been correlated withhas been correlated with decreased success with in vitrodecreased success with in vitro fertilization.fertilization. Laboratory EvaluationLaboratory Evaluation
  66. 66. TheThe significancesignificance ofof morphologymorphology in estimating the chance forin estimating the chance for natural conceptionnatural conception is less clear.is less clear. As with any other single semenAs with any other single semen parameter,parameter, it cannot be usedit cannot be used in an absolute way toin an absolute way to predict fertility.predict fertility. Laboratory EvaluationLaboratory Evaluation
  67. 67. A semen analysis does not assessA semen analysis does not assess sperm functionsperm function.. Specialized testing is availableSpecialized testing is available to evaluate this factor.to evaluate this factor. Most tests attempt to examineMost tests attempt to examine some component ofsome component of sperm-oocytesperm-oocyte interaction or fertilization.interaction or fertilization. Laboratory EvaluationLaboratory Evaluation
  68. 68. Hormone testingHormone testing forfor allall subfertilesubfertile men ismen is not necessarynot necessary.. When sperm concentration isWhen sperm concentration is less than 10 million per mLless than 10 million per mL,, measurement of themeasurement of the serum testosterone andserum testosterone and follicle-stimulating hormonefollicle-stimulating hormone (FSH)(FSH) levels is indicated.levels is indicated. Laboratory EvaluationLaboratory Evaluation
  69. 69. The levels ofThe levels of serum testosterone andserum testosterone and FSHFSH are adequate to assessare adequate to assess thethe pituitary-testicular axispituitary-testicular axis in the majority ofin the majority of cases.cases. Laboratory EvaluationLaboratory Evaluation
  70. 70. If theIf the total testosterone level istotal testosterone level is normalnormal,, no further endocrine testing is needed.no further endocrine testing is needed. If theIf the total testosterone level is lowtotal testosterone level is low,, thethe serumserum luteinizing hormone andluteinizing hormone and prolactinprolactin levelslevels can be checked to evaluate forcan be checked to evaluate for Laboratory EvaluationLaboratory Evaluation
  71. 71. WhenWhen testosterone is merelytestosterone is merely borderline or only slightly lowborderline or only slightly low,, supplementation should be avoidedsupplementation should be avoided unless the man isunless the man is significantly symptomaticsignificantly symptomatic (i.e., erectile dysfunction,(i.e., erectile dysfunction, markedly decreased energy level,markedly decreased energy level, lack of libido).lack of libido). Laboratory EvaluationLaboratory Evaluation
  72. 72. Testosterone supplementationTestosterone supplementation will actuallywill actually lower the sperm concentrationlower the sperm concentration in such men because it canin such men because it can causecause pituitary suppressionpituitary suppression of gonadotropinsof gonadotropins.. Laboratory EvaluationLaboratory Evaluation
  73. 73. If theIf the FSH level is elevatedFSH level is elevated,, it suggest end-organit suggest end-organ (testicular) failure(testicular) failure.. AA low levellow level may indicate anmay indicate an underlying FSH deficiency,underlying FSH deficiency, such as occurs withsuch as occurs with hypogonadotropic hypogonadismhypogonadotropic hypogonadism.. Laboratory EvaluationLaboratory Evaluation
  74. 74. Evaluation of the SubfertileEvaluation of the Subfertile ManMan
  75. 75. More specialized testingMore specialized testing may be required based on themay be required based on the outcome of this initial evaluationoutcome of this initial evaluation .. These tests requireThese tests require referralreferral to a center withto a center with clinical and laboratory expertiseclinical and laboratory expertise in the field ofin the field of reproductive medicine.reproductive medicine. Laboratory EvaluationLaboratory Evaluation
  76. 76. For example, men withFor example, men with low ejaculate volumelow ejaculate volume (less than 1 mL) should(less than 1 mL) should have ahave a post-ejaculatory urinepost-ejaculatory urine samplesample analysis to rule outanalysis to rule out retrograde ejaculationretrograde ejaculation.. Laboratory EvaluationLaboratory Evaluation
  77. 77. Azoospermic men can undergoAzoospermic men can undergo testicular biopsytesticular biopsy to evaluateto evaluate the level of sperm productionthe level of sperm production andand differentiate betweendifferentiate between testicular failure andtesticular failure and obstructionobstruction (i.e.,(i.e., AzoospermiaAzoospermia
  78. 78. AzoospermiaAzoospermia  In patients with azoospermia:In patients with azoospermia: 1.1. Low semen volumeLow semen volume (less than 1 mL), and(less than 1 mL), and 2.2. A normal FSH level,A normal FSH level,  Transrectal ultrasonographyTransrectal ultrasonography is indicated to evaluate foris indicated to evaluate for possiblepossible ejaculatory duct obstructionejaculatory duct obstruction..
  79. 79. AzoospermiaAzoospermia
  80. 80. Genetic testing and counselingGenetic testing and counseling are indicated in specific instances.are indicated in specific instances. In patients withIn patients with azoospermia or severe oligospermiaazoospermia or severe oligospermia,, thethe karyotypekaryotype should be determinedshould be determined because of thebecause of the increased incidenceincreased incidence of karyotypic abnormalitiesof karyotypic abnormalities in this population.in this population. AzoospermiaAzoospermia
  81. 81. Men withMen with congenital absencecongenital absence of the vas deferens,of the vas deferens, either unilateral oreither unilateral or bilateralbilateral,, may bemay be carriers of cystic fibrosiscarriers of cystic fibrosis.. These men should haveThese men should have abdominal ultrasonographyabdominal ultrasonography to check forto check for renal agenesis.renal agenesis. AzoospermiaAzoospermia
  82. 82. The outcome of the initial evaluation canThe outcome of the initial evaluation can help guide treatment.help guide treatment. IfIf correctable causes are foundcorrectable causes are found,, specific corrective treatment is offered.specific corrective treatment is offered. IfIf no correctable problem existsno correctable problem exists,, the couple may wish to pursue treatmentthe couple may wish to pursue treatment withwith assisted reproductive technologiesassisted reproductive technologies (ART)(ART) such as intrauterine inseminationsuch as intrauterine insemination and (ICSI) .and (ICSI) . AzoospermiaAzoospermia
  83. 83. AnAn alternativealternative toto (ART)(ART) is empiric treatment withis empiric treatment with clomiphene citrateclomiphene citrate ,, althoughalthough few convincing datafew convincing data show benefit.show benefit. AzoospermiaAzoospermia
  84. 84. Some reproductiveSome reproductive subspecialists advocatesubspecialists advocate abandoningabandoning the male evaluationthe male evaluation,, with the exception ofwith the exception of thethe semen analysissemen analysis..
  85. 85. Whether this is an efficient approachWhether this is an efficient approach to conception,to conception, is debatableis debatable,, But denying the man an evaluation,But denying the man an evaluation, including an opportunityincluding an opportunity to learn the cause of his problemto learn the cause of his problem and theand the chance for specific corrective therapy,chance for specific corrective therapy, seemsseems inappropriateinappropriate