This document provides an overview of the evaluation and investigations for male infertility. It discusses the key components of the medical history and physical exam, including reproductive, sexual, childhood, medical, and family histories. Initial laboratory assessments include semen analysis according to WHO standards and endocrine evaluation if indicated. Imaging tools like ultrasound, Doppler ultrasound, and MRI can identify conditions affecting fertility. Traditional and modern methods are described to further evaluate couples where initial testing is normal but functional defects may still impair fertilization. A postcoital or Sims test examines sperm-mucus interaction ability.

1. Evaluation & investigations
for
Male infertility
Dr. Somendra Bansal
SMS Medical College, Jaipur

2. • Infertility is defined as 1 year of unprotected
intercourse without a conception (inability to
conceive naturally within 12 months)
approx. 15%-20% of couples presenting to their
physician with such a complaint
• Of these, 30-40% - male factor
• 30-40% - female factors
• 20% - both male and female factors
Urol Clin N Am 41 (2014) 163-167

3. • Couples with normal fertility may be
counselled that pregnancy rates by
intercourse are approximately 20% to 25% per
month, 75% by 6 months and 90% by 1 year

4. Key components of the history and
physical examination
History
• Reproductive History
• Sexual History
• Childhood Conditions
• Systemic Illnesses
• Cancer Treatment
• Surgical History
• Family History
• Medication and Drug Use
• Occupational and Lifestyle
Exposures
Physical examination
• Review of Systems
• Physical Examination
General
Genitalia

5. • Because spermatogenesis lasts, on average, 64
days, careful attention to the patient’s history
over the previous 2 to 3 months, especially
recent fevers, other illnesses, substance
abuse, and gonadotoxin exposures
• Evaluation should be repeated in 3 months, if
necessary

6. Reproductive History
• Past and current attempts at pregnancy
• Methods of birth control
• Sexual technique
• Timing of intercourse (ovulatory prediction)
• Use of lubricants
• Menstrual history
• Prior female evaluation

7. • Infertility attributable to sexual behavior may
be present in up to 5% of couples
• MC misconceptions- frequency and timing of
intercourse around ovulation
• Intercourse should be performed every other
day beginning 5 days before expected
ovulation until 5 days after

8. Sexual History
• Erectile and ejaculatory dysfunction
• Hypogonadal symptoms
• Sexually transmitted infections

9. Childhood Conditions
• Cryptorchidism
• Hypospadias
• Congenital anomalies
• Age at puberty
• Pubertal mumps orchitis result in subfertility
in 13% of men
• In utero or childhood exposure to
chemotherapy, radiation, or hormones may
result in defects in spermatogenesis

10. • Despite treatment, 13% and 34% of men
with U/L and B/L cryptorchidism
respectively, will demonstrate
azoospermia. If left untreated, these
rates are much higher.
• Surgery for testicular torsion or pediatric
hernia repair affect future paternity
• Childhood hernia repairs associated with
26.7% incidence of vasal obstruction.

11. Systemic Illnesses
• Fevers or recent illness
• Diabetes
• Spinal cord injury
• Infectious or inflammatory (eg, epididymitis)
• These illnesses may have implications for
fertility and affect emission, ejaculation, or
potentially result in obstruction of male
reproductive system

12. Cancer Treatment
• Chemotherapy
• Radiation
(In men presenting with infertility, testis
cancer and Hodgkin lymphoma are the two
most common malignancies encountered.
Both are associated with impairment of
spermatogenesis)

13. Surgical History
• Hernia repair or other inguinal surgery
• Scrotal trauma
• Testicular torsion
• Retroperitoneal, pelvic, prostatic or bladder
(sympathetic chain injury and retrograde
ejaculation or anejaculation)
• Orchiopexy
• TURP
(Vasal occlusion rates in adult patients undergoing
hernia surgery with mesh approach 20%)

14. Family History
• Infertility
• Genetic disorders (eg, cystic fibrosis)
• Consanguinity

15. Medication and Drug Use
• Testosterone, anabolic steroids
(suppression of serum Gn and intratesticular Testo)
• Recreational drugs (eg, marijuana, narcotics)
• Alcohol and tobacco
(impair sperm concentration, motility, morphology
and increase DNA fragmentation rates)
• Antibiotics
• Immunosuppressants
(Cessation of steroid use can result in a reversal of
spermatogenic arrest and recovery can take up to 2
years, if it occurs at all)

16. Occupational and Lifestyle Exposures
• Chronic heat (eg, laptops)
• Benzene-based solvents
• Pesticides and herbicides
• Heavy metals
(These agents may result in disruption of
hormonal regulation or have direct toxic
effects on spermatogenesis)

17. History from the female partner
• Age
• H/O of pelvic surgery or infections
• Uterine or tubal abnormalities
• Exposure to gonadotoxins
• H/O of endometriosis or ovulatory irregularity
• Cycle length and characteristics
• Coital frequency
• Sexual dysfunction
• Pelvic infections or surgery
• Use of prescription or recreational drugs
• Pelvic pain, dyspareunia
• Thyroid dysfunction, hirsutism

18. Review of Systems
• Respiratory and sinus infections
• Anosmia
• Galactorrhea
• Visual field deficits

19. Physical Examination (General)
• Body habitus (eg, obesity, Klinefelter)
(indicator of underlying endocrine or genetic
abnormalities)
• Gynecomastia
• Secondary sexual characteristics
(Gynecomastia and Gynecoid distribution of
pubic hair may reveal androgen deficiency)

20. Physical Examination (Genitalia)
• Penis: hypospadias, chordee, venereal lesions
• Testis: size, consistency, contours, masses
• Epididymis: induration, cysts or spermatoceles
• Vas deferens: agenesis, atresia, granuloma
• Spermatic cord: asymmetry, varicocele
• DRE: midline cyst, dilated seminal vesicles
• Inguinal examination: surgical scars

21. • Average testicular size measured via
orchidometer or calipers, is 4.6 cm in length,
2.6 cm in width, and 18 to 20 cm3 in volume
• Diminishment of testicular size may be an
indication of impaired spermatogenesis or
androgen deficiency

22. • Hypospadias can result in improper placement
of semen within vaginal vault and, when
accompanied with other congenital defects,
may represent an underlying chromosomal
abnormality
• Varicoceles represent most common anatomic
abnormality identified in infertile men

23. INITIAL LABORATORY ASSESSMENT
• Semen Analysis
• Endocrine Evaluation
IMAGING
• Ultrasound
• Color doppler scrotal ultrasound
• TRUS
• MRI

24. Semen Analysis
• Minimum of two semen analyses
• Ideal abstinence period of 2 to 3 days
• A shorter abstinence affect concentration and
prolonged abstinence affect motility
• Collection should be done via masturbation or
with special seminal collection condoms lacking
spermicidal agents
• Transportation of specimen should be at body
temp. with arrival at laboratory within 1 hour of
collection

25. 2010 WHO references for semen analyses
Parameter Lower Reference Limit
Semen volume (mL) 1.5 (1.4-1.7)
pH >7.2
Total sperm number
(million/ejaculate)
39 (33-46)
Sperm concentration (million/ml) 15 (12-16)
Total motility (%) 40 (38-42)
Progressive motility (%) 32 (31-34)
Strict morphology (normal forms, %) 4 (3.0-4.0)
Vitality (Live spermatozoa, %) 58 (55-63)

26. Endocrine Evaluation
Indications:
• Men with oligospermia, azoospermia
• History & physical examination findings
suggestive of hormonal abnormalities (sexual
dysfunction, delayed puberty, or diminished
libido, decreased androgenization such as
gynecomastia)
• Men with a normal semen analysis do not
routinely require assessment of gonadotropins

27. • Endocrine causes of male infertility present in
<3% of cases
• Most endocrinopathies are found in men with
sperm conc. of <10 million sperm/mL
• Initial hormone assessment should include a
serum FSH and testosterone
• Morning determinations of testosterone are
preferred given its well-described diurnal
variation

28. • A more comprehensive evaluation should
obtained when abnormalities are present on
the initial evaluation
LH, prolactin, estradiol, free testosterone, and
sex hormone binding globulin (SHBG)
• Men with profound hypogonadism
(testosterone <150 ng/dL) or
hyperprolactinemia require a pituitary MRI to
evaluate for pituitary adenoma

29. Pattern of endocrine testing by diagnosis
Campbell 10 ed/ 627

30. Imaging
• Ultrasound- MC used in evaluation of male
infertility
• USG identify conditions affecting fertility,
including testicular tumors, spermatoceles,
seminal vesicle atresia, ejaculatory cysts, and
renal disorders associated with CBAVD
• Scrotal color Doppler USG used to confirm a
suspicious diagnosis of a varicocele

31. • Use of ultrasound required in varicocele in
whom the physical examination is limited
Ex. obesity, tight or small scrotums, previous
surgery, altered anatomy, or inability to
tolerate examination
• USG criteria for diagnosis of varicocele-
1-Reversal of blood flow with a Valsalva
2-Presence of spermatic veins >3mm

32. TRUS
Indications
• Low-volume azoospermia
• Severe unexplained oligoasthenospermia
• Palpable abnormalities on DRE
• Suspected ejaculatory duct obstruction (EDO)
(EDO can be due to infection or inflammation,
compression from median cysts, atonic SV in
diabetes & enlarged SV in adult polycystic
kidney disease)

33. • TRUS reveal absence of ampullae of vas
deferens or seminal vesicle abnormalities in
men with CBAVD
• Visualization of seminal vesicles >1.5 cm in AP
diameter is considered suggestive of EDO
& seminal vesicle aspiration may be
performed concurrently to confirm diagnosis

34. MRI
• Used selectively in evaluation of male infertility
• Valuable in patients with renal, seminal vesicle,
vasal, urethral, or other pelvic abnormalities
not fully visualized with USG
• MRI is more commonly used in workup of
profound hypogonadism (testosterone <150
ng/dL) and hyperprolactinemia to rule out
pituitary adenoma

35. • Of men presenting for an initial infertility
evaluation,30% will demonstrate normal
semen parameters
• Further testing may consider in these men
because some will show functional defects,
which can impair fertilization
• Additional assessments
-Reactive oxygen species (ROS)
-DNA fragmentation

36. Traditional Methods
• Routine semen analysis
• Light microscopy
• ASAs
• Postcoital test
• Sperm penetration assay
• Hemizona assay
• Sperm acrosome reaction
Modern Methods
• Strict morphology
• DNA fragmentation
• Fluorescent in situ
hybridization testing (FISH)
• Y-chromosome
microdeletion assay
• ROS
• Genomic microarrays

37. Sperm-Mucus Interaction/Postcoital
Test/ Sims test
• The cervical mucus is shown to demonstrate cyclical
changes in consistency and to be highly receptive
around the time of ovulation.
• Increase in penetrability is often observed one day
before the LH surge.
• Cervical mucus protect spermatozoa from the hostile
environment of the vagina
• The penetrability of the spermatozoa through the
cervical mucus can be detected by the cervical mucus
migration assay
• Assess cervical environment as a cause of infertility

38. • Accurate timing is crucial because it must be
conducted when the cervical mucus is thin and
clear just before ovulation. In this test, cervical
mucus is examined 2 to 8 hours after normal
intercourse
• Progressively motile sperm >10 to 20 per HPF is
designated as normal
• Practical guidelines of the American Society of
Reproductive Medicine recommend PCT in the
setting of hyperviscous semen, unexplained
infertility, or low-volume semen with normal
sperm count

39. ADDITIONAL SEMEN TESTS
ROS
• When seminal antioxidants (superoxide
dismutase and catalase) are depleted, excess
ROS levels adversely affect spermatogenesis
• These oxidants impair sperm function and
motility via peroxidation of sperm lipid
membranes and creation of toxic fatty acid
peroxides

40. • Elevated ROS levels present in up to 40% of
infertile patient
• High ROS conc. cause impairment of sperm
conc., motility, morphology and elevated levels
of DNA fragmentation
• Elevated ROS levels identified in men with
impaired fertility and associated varicoceles,
spinal cord injury, and immunologic infertility

41. DNA Fragmentation
• Stability and integrity of sperm DNA is
important for fertilization and embryo
development
• DNA fragmentation refers to denatured and
damaged DNA, which is not able to be
repaired and can result abnormal
protamination, mutations altering DNA
compaction, presence of a varicocele, and
environmental exposures

42. • Quantify sperm DNA fragmentation rates by-
• Direct assay
- Single-cell gel electrophoresis (comet)
- TUNEL (Terminal deoxynucleotidyl transferase-
mediated deoxyuridine triphosphate nick-end
labeling)
• Indirect assays
- Sperm chromatin structure assay (SCSA)
• Generally accepted abnormal threshold values for
SCSA are ≥25% to 27% in comparison to ≥36% for
TUNEL assays

43. • Sperm DNA damage associated with recurrent
miscarriage and elevated rates of numerical
chromosome abnormalities
• Although routine use of DNA fragmentation
assays in male-infertility evaluation is
debated, it may be clinically useful for most
patients, especially those couples ultimately
pursuing ART

44. Fluorescent in situ Hybridization (FISH)
• FISH used to assess sperm aneuploidy
• Up to 6% of men with infertility and a normal
karyotype have increased frequency of meiotic
abnormalities in their sperm
• Indications for FISH testing - couples with recurrent
pregnancy loss and unexplained, persistent IVF failure
• Rates of sperm aneuploidy are highest in men with
NOA, significantly abnormal sperm morphology,
ultrastructural sperm defects, chromosomal
translocations, and karyotypic abnormalities
• Limitations of FISH -cost and lack of testing on actual
sperm used for ICSI

45. GENETIC EVALUATION
• Men with oligospermia and azoospermia
represent 40% to 50% of all infertile men and
have a known increase in genetic abnormalities
• Genetic testing is indicated when the sperm
density is <5 million/mL, NOA is present, or there
are clinical suggestions of an abnormality
• MC used tests -karyotype, Y chromosome
microdeletion analysis, and cystic fibrosis testing

46. CBAVD and
Cystic Fibrosis Gene Mutations
• CBAVD is diagnosed on physical examination and
is usually due to a mutation in the CFTR gene
located on chromosome 7
• Almost all men with clinically detected cystic
fibrosis demonstrate CBAVD
• 80% of azoospermic men with CBAVD and 1/3 of
men with unexplained obstruction will have CFTR
mutations
• In patients found to have an abnormality on CFTR
testing, the partner should be screened

47. • Vasal agenesis may be due to a non-cystic
fibrosis–mediated embryologic defect, which
is associated with U/L absence of kidney
• A renal ultrasound is indicated when vasal
abnormalities present on examination
• Patients demonstrating CFTR mutations
should be referred for genetic counseling
before IVF

48. Karyotype-Associated Abnormalities
• Prevalence of chromosomal abnormalities
- Azoospermia- 10% to 15%
- Severe oligospermia (<5 million sperm/mL)- 5%
- Normal sperm concentrations - <1%
• In azoospermia, sex chromosome abnormalities
predominate, whereas in oligospermia,
autosomal anomalies
• Men with azoospermia, severe oligospermia, or
clinical evidence of a chromosomal syndrome
should undergo karyotype testing before ART.

49. Klinefelter syndrome (KS)
• MC karyotypic abnormality in infertile men
(47, XXY)
• Present in 11% of men with azoospermia and
occurs in 1 of 500 live births
• 95% of affected men present in adulthood
with infertility, but only 25% demonstrate the
characteristic gynecomastia, tall stature, and
small firm testes

50. Y-chromosome Microdeletions
• 2% normal men exhibit deletions of clinically
relevant regions of the Y chromosome
• Microdeletions present in 7% of men with
impaired spermatogenesis
• Incidence of these microdeletions increases to
16% in men with severe oligospermia or
azoospermia.
• These microdeletions are not detectable with
standard karyotype testing. Instead, they require
polymerase chain reaction techniques to analyze
sequence tagged sites along the Y chromosome

51. • Within the long arm of the Y chromosome
(Yq11) are three important regions that
influence spermatogenesis
• These are the azoospermia factor (AZF)
regions, including AZFa, (proximal), AZFb
(central), and AZFc (distal)
• Of the three regions, AZFc deletions are the
most common

52. DEFECTS IN ISOLATED SEMEN
PARAMETERS
• Seminal Volume Abnormalities
• Abnormalities in Sperm Concentration
- Oligospermia
- Azoospermia
• Abnormalities in motility (Asthenospermia)
• Abnormalities in morphology (Teratospermia)
• Multiple semen abnormalities
(Oligoasthenoteratozoospermia / OAT)
• Leukocytospermia

53. Seminal Volume Abnormalities
• Lower limit of adequacy for semen volume- 1.5 ml
• Aspermia- Complete absence of the ejaculate / semen
1) When no antegrade fluid is produced during male orgasm
2) Retrograde ejaculation
3) Failure of emission occurs when no semen transits through
vas deferens and ejaculatory ducts into the posterior urethra
4) Ejaculation may be impaired by
-Neurologic disorders, such as spinal cord injury and DM
-Use of a-blockers for BPH
-Retroperitoneal and colonic surgery (injury to sympath. N.)

54. Causes of low-volume ejaculates
• Incomplete collection
• Short abstinence periods
• Lack of emission
• EDO
• Hypogonadism
• CBAVD
• Partial retrograde ejaculation

55. • In patients at risk for retrograde ejaculation
and those with ejaculate volumes of < 1 mL, a
postejaculate urinalysis should be performed
• Any sperm in the postejaculatory urinalysis is
also useful in ruling out complete EDO
• In absence of sperm in postejaculatory urine,
EDO should be suspected

56. • Semen analysis in complete EDO
Azoospermic, acidic, low volume and
fructose-negative
• TRUS can rule out EDO through visualization
of seminal vesicles <1.5 cm in AP diameter
• The diagnosis of partial EDO may be
considered in the setting of low volume,
oligoasthenospermia with normal testis size
and hormones

57. Oligospermia
• Oligospermia - < 15 million/mL sperm
• In men with <10 million/ml sperm, serum FSH
and testosterone is advised b/c this will detect
most clinically significant endocrinopathies
• Severe oligospermia- <5 million/Ml are at
increased risk of genetic abnormalities
• A karyotype and Y-chromosome microdeletion
analysis should be performed in these patients

58. Azoospermia
• 4% of men presenting for an infertility
evaluation will demonstrate azoospermia
• Diagnosis of azoospermia can only be
established after specimen is centrifuged at
3000 g for 15 minutes and the pellet examined
• D/D b/w NOA v/s OA
• Require testing for endocrinopathy, karyotype
and Y-chromosome microdeletion analysis

59. Nonobstructive azoospermia
(NOA)
• Defined by a deficiency of
spermatogenesis
• Atrophic testes &
Elevated FSH
Obstructive azoospermia
(OA)
• Represents adequate sperm
production in setting of ductal
obstruction
• Normal testis size &
Normal FSH
• Causes
-CBAVD
-Vasectomy
-EDO
-Vasal or epididymal
obstruction secondary to
injury or infection
Men with CBAVD require testing for CFTR gene mutations

60. • Testicular biopsy, performed as testicular sperm
aspiration (TESA) d/d b/w NOA & OA
• In patients with NOA, role of testicular biopsy is
most often limited to microsurgical testicular
sperm extraction (micro-TESE) in conjunction with
IVF and ICSI
• Testicular biopsy as a diagnostic tool to d/d NOA
from OA was recently questioned in men with an
FSH ≥7.6 mIU/mL and a testicular long axis ≤4.6
cm because these men are statistically most likely
to have NOA

61. • Location of the obstruction delineated intraop
via scrotal exploration and vasal fluid
aspiration in conjunction with vasal irrigation
or contrast vasography

62. Abnormalities in motility
• Sperm motility - % of motile sperm and quality
of movement of forward progression
• WHO criteria-normal % of motile sperm 40%,
with 32% demonstrating progressive motility
• Isolated asthenospermia typically denotes a
low % of sperm demonstrating any movement
or sperm that have poor forward progression
• Hormonal testing not indicated in setting of
isolated asthenospermia

63. Isolated asthenospermia causes
• Prolonged abstinence
• Partial EDO
• Genital tract infections
• Pyospermia
• ASAs
• Ultrastructural sperm defects
• Varicoceles
Asthenospermia associated with agglutination
• Presence of ASAs
• Leukocytospermia (ie, excessive WBC in ejaculate)

64. • Nonmotile sperm are typically nonviable
• Necrospermia- when all sperm are nonviable
• Men with absent or low (5%–10%) motility
and normal-to high viability will have
ultrastructural defects (primary ciliary
dyskinesia / immotile cilia syndrome)
• These sperm should be examined with
electron microscopy

65. Abnormalities in morphology
Teratospermia – defects in morphology
• may be due to the presence of varicoceles, but
more commonly are idiopathic
Globozoospermia- absence of the acrosome

66. Strict morphology
• smooth oval head 3 to 5 mm in length and 2 to 3
mm in width
• a well-defined acrosome, comprising 40% to 70%
of the head
• an absence of defects of the neck, midpiece or tail
• an absence of cytoplasmic droplets larger than half
size of head
• In 2010, the WHO established Kruger strict
morphology as the new standard reference for
sperm morphology. This new threshold established
4% as lower reference limit of strictly normal forms

67. Multiple semen abnormalities
• Oligoasthenoteratozoospermia (OAT) reflects
semen analysis abnormalities in sperm density,
motility, and morphology
• 37% of men presenting for infertility will have
defects in ≥2 semen parameters
• MC cause of OAT – Varicocele
• Other causes- fever, gonadotoxin exposure,
medications, cryptorchidism, and partial EDO
• Subclinical varicoceles not considered clinically
significant and do not warrant correction

68. • Leukocytospermia - large numbers of WBC in
semen, associated with abnormalities in
sperm motility and function
• Using traditional light microscopy,
distinguishing between round cells, which can
represent leukocytes or immature germ cells,
can be difficult
• IHC staining or monoclonal antibodies is
required to differentiate

69. • Pyospermia - >1 million leukocytes per mL and
it requires evaluation for genital tract infection
or inflammation
• Cytokines and ROS released by inflammatory
cells can impair sperm motility and viability
• Men with elevated leukocytes should have a
semen culture performed, although this test is
infrequently positive for significant
noncommensal organisms

70. • Empiric antibiotic therapy is not warranted
• In culture-positive - antibiotic therapy
• In culture-negative - NSAIDs and frequent
ejaculation are more appropriate
• In refractory cases, sperm washing to remove
white cells followed by IUI can be successful

71. Thank
You