Male Infertility Evaluation

A history of specific childhood illnesses and disorders may be an important finding in the evaluation of the infertile male. For example, it has been shown that in the male born with an undescended testis on one side, regardless of the time of surgery to correct this, semen quality is considerably less than that found in normal men.

Approximately 30% of men with unilateral undescended testicles and 50% with bilateral undescended testicles have sperm counts below 10 million/mL. Despite this impairment in semen, the majority of men with a history of one undescended testis are able to initiate a pregnancy without difficulty.

A history of postpubertal mumps infection of the testicle is also important. Mumps does not appear to affect the testes when experienced prepubertally. However after the age of 11 or 12, unilateral mumps orchitis is seen in 30% of males affected and bilateral orchitis in approximately 10%. Furthermore, the testicular damage can be quite severe and should be readily appreciated on physical examination, since the involved testis will be markedly small and soft.

Patients who have had operative correction of bladder conditions during childhood often suffer from retrograde ejaculation due to ablation of the internal sphincter at the bladder opening. Bladder neck reconstruction at the time of ureteral reimplantation surgery was common in the early 1960s. Retrograde ejaculation should be suspected in men who give a history of bladder surgery and whose ejaculate volume is less than 1 cc. The correct diagnosis can be made by finding large numbers of sperm in the postejaculate urine. Children born with congenital anomalies involving the male reproductive system, such as bladder exstrophy/epispadias, can also exhibit abnormalities of ejaculation. Sperm production in the testis is usually normal; however, the ejaculatory ducts may be obstructed or retrograde ejaculation may occur.

The history should also include a detailed inquiry into exposure to environmental toxins and medications that may interfere with spermatogenesis, either directly or through alterations in the endocrine system. For agents such as heat, ionizing radiation, heavy metals, and some organic solvents, there are many studies that support these associations. Recent publications have also reported the effect of specific pesticides (i.e. dibromochloropropane) on gonadal function. Furthermore, reversibility has been substantiated when the infertile patient has been removed from this toxic environment. However, once azoospermia (no sperm at all in the ejaculation) has occurred, return to a normal pre-exposure state is highly unlikely.

Medications, such as sulfasalazine and cimetidine, or ingestants, such nicotine, alcohol, or marijuana, have also been shown to be gonadotoxic agents. Withdrawal from these substances should enable return of normal spermatogenesis if they are acting adversely.

The use of anabolic steroids is a potentially significant cause of infertility in both adults and adolescents, and the problem is becoming more common. The incidence of steroid abuse has been reported to be as high as 30%-75% among professional athletes or body builders. Androgenic steroids exert their deleterious effect by depressing hormone secretion from the pituitary gland and interfering with normal spermatogenesis. Consequently, if a person is taking any of these medications at the time of initial interview, the medication should be stopped and the patient’s semen reevaluated at a later date.

Retroperitoneal Lymph Node Dissection. Approximately 75% of all testicular cancer patients will retain the potential for fertility. Retroperitoneal lymph node dissection can involve excision of portions of the sympathetic chain necessary for ejaculation. Some patients will retain seminal emission, but many will have retrograde ejaculation or lose the ability to emit semen altogether.

Prostatectomy.Patients who have had transurethral or open prostatectomy also have a high incidence of retrograde ejaculation. This incidence is reported to range from 40%-90%.

One of the most common problems encountered in this patient population is either too-frequent or too-infrequent sexual intercourse. Often, neither the husband nor the wife understands the menstrual cycle. The optimal time for intercourse is midcycle with a frequency of intercourse every 48 hours. This is based on the fact that sperm survival in normal cervical mucus is approximately 2 days. Thus, this frequency will assure viable sperm concurrently in the 24-hour period during which the egg will be within the fallopian tube and capable of being fertilized. Most studies have revealed that the highest likelihood of conception occurs when intercourse is performed within the 48-hour period preceding ovulation.

It is also important to discuss coital techniques with the husband, e.g., the use of lubricants or the frequency of masturbation that can deplete the sperm “reserve.” Many lubricants have been tested for in vitro effects on sperm motility. Commonly used substances, such as K-Y Jelly, Lubifax, Surgilube, Keri Lotion, petroleum jelly, and saliva result in a deterioration of motility. Others, such as raw egg white, vegetable oil, and the Replens douche, have not impaired in vitro motility. Astroglide, a water-soluble, inert vaginal lubricant, contains no petroleum ingredients or detergents that may be toxic to sperm; however, with increasing concentration, there is impairment of sperm motility equivalent to that found with K-Y jelly.