Editing Infertility: Diagnosis and Evaluation (section)

== Imaging ==

=== Renal ultrasound ===
*'''Goal is to identify potential associated renal abnormalities.'''
**'''The male genital tract is derived from the Wolffian or mesonephric tract.''' It is a paired organ, which forms the epididymis, vas deferens, and seminal vesicles during embryogenesis. '''As it connects to the primitive kidney, abnormalities in the Wolffian duct can lead to renal anomalies.'''
*'''<span style="color:#ff0000">Indications (1):</span>'''
*#'''<span style="color:#ff0000">Congenital absence of the vas(a) (regardless of the CFTR status)</span>'''
*#*≈26-75% of males with unilateral absence of the vas deferens will have ipsilateral renal anomalies including agenesis.
*#*≈10% of males with bilateral vasal agenesis will have ipsilateral renal anomalies including agenesis.

=== Trans-rectal Ultrasound (TRUS) ===
*Used to 
**Assess the anatomy of the primary organs/structures involved in ejaculation including the prostate, seminal vesicles, vasal ampulla, and ejaculatory ducts
**Rule out ejaculatory duct obstruction
*'''Should not be performed as part of the initial evaluation'''
*'''<span style="color:#ff0000">Indications</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
*#'''<span style="color:#ff0000">Semen analysis suggestive of ejaculatory dust obstruction (2):</span>'''
*#*'''<span style="color:#ff0000">Low semen volume with azoospermia and palpable vasa</span>'''
*#*'''<span style="color:#ff0000">Low semen volume and significant asthenospermia (total motility <40% or progressive motility <32%)</span>'''
*#**'''<span style="color:#ff0000">Normal semen is derived from testicular (~10%), prostatic (~20%), and seminal vesicle (~70%) fluid.'''
*#***All components are androgen sensitive so that men with testosterone deficiency may have low semen volume and the utility of TRUS in such circumstances may be low.
*#***'''<span style="color:#ff0000">Seminal vesicle fluid is alkaline. Obstruction that limits or prevents the seminal vesicle contribution will lead to acidic semen (pH <7.0)'''.
*#****Men with a normal semen pH are unlikely to have a complete distal genital tract obstruction.
*#'''<span style="color:#ff0000">Symptoms (e.g., painful ejaculation)</span>''' 
*In men with CBAVD, TRUS does not contribute to the diagnosis or treatment, so it should not be done for evaluation of such infertile men.
*'''<span style="color:#ff0000">Findings associated with ejaculatory duct obstruction (4):</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
*#'''<span style="color:#ff0000">AP diameter of seminal vesicle >1.5cm</span>'''
*#'''<span style="color:#ff0000">Ejaculatory duct caliber (>2.3mm)</span>'''
*#'''<span style="color:#ff0000">Dilated vasal ampulla (>6mm)</span>'''
*#'''<span style="color:#ff0000">Prostatic cysts (midline or paramedian (ejaculatory duct)</span>'''

=== Scrotal Ultrasound ===
*'''Used to assess testicular size, varicoceles'''
**Ultrasound definition of varicocele: presence of multiple large veins greater than 3 mm in diameter and reversal of blood flow with the Valsalva maneuver.
*'''<span style="color:#ff0000">Indications</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**'''<span style="color:#ff0000">Should not be routinely performed in the initial evaluation of the infertile male.</span>'''
***'''<span style="color:#ff0000">Routine use of ultrasonography to investigate presumed varicocele is to be discouraged</span>''', as treatment of non-palpable varicoceles is not associated with improved semen parameters and fertility rates as has been shown for treatment of clinical varicoceles.
**'''<span style="color:#ff0000">May be used if difficult to examine scrotum (obese patient or when the dartos muscle remains highly contracted during the physical exam)</span>'''

=== Abdominal imaging for isolated right varicocele ===
*'''Routine imaging based solely on the presence of a right varicocele is unnecessary'''
**A retrospective study of over 4060 men with varicoceles reported no difference in cancer diagnoses in these men based on varicocele laterality[https://pubmed.ncbi.nlm.nih.gov/29649544/]
*'''Abdominal imaging should be considered for men with a new onset or non-reducible varicocele, especially if varicocele is large'''

=== Vasography ===
*Assess patency of vas.

=== MRI brain ===
*'''Evaluate for functioning and non-functioning pituitary tumors in secondary hypogonadotropic hypogonadism with a elevated or normal serum prolactin level'''
** '''2018 AUA Testosterone Deficiency Guidelines: total testosterone <150 ng/dL in combination with a low or low/normal LH should undergo a pituitary MRI regardless of prolactin levels, as non-secreting adenomas may be identified.'''