Infertility: Diagnosis and Evaluation

Includes 2020 AUA/ASRM Guidelines on Infertility

• See Algorithm from Original Guidelines
• See Video Reviewing Guidelines (Dr. Joshua Helpern)

See 2015 CUA Azoospermia Guideline Notes

General principles

• For initial infertility evaluation, both male and female partners should undergo concurrent assessment.
  • Maternal age is the strongest predictor of fertility outcome in couples undergoing therapy.
  • Many couples have more than one fertility issue present.
    • For the female partner, tests are indicated to evaluate ovarian reserve, ovulatory function, tubal structures as well as assessment of the uterine cavity.
    • For the male partner, good clinical practice is to
      • Obtain a reproductive history
      • Perform a physical examination
      • Basic diagnostic tests of reproductive function
• Males with abnormal SAs and/or abnormal reproductive history, including physical examination and selected laboratory and radiologic assessment should be evaluated by specialists in male reproduction
• Goals of evaluation are to identify (5):★
  1. Potentially correctable conditions for treatment to allow for conception through intercourse or through techniques, such as IUI or IVF, when those approaches would otherwise not be possible
  2. Irreversible conditions that are amenable to ART using the sperm of the male partner
  3. irreversible conditions that are not amenable to the above, and for which donor insemination or adoption are possible options
  4. Life- or health-threatening conditions (e.g. testicular cancer or pituitary tumours) that may underlie the infertility or associated medical comorbidities that require medical attention
  5. Genetic abnormalities or lifestyle and age factors that may affect the health of the male patient or of offspring particularly if ART are to be employed
• In couples with failed assisted reproductive technology cycles or recurrent pregnancy losses (RPL) (two or more losses), evaluation of the male should be considered.
  • In this clinical setting, the male partner should be evaluated by a male reproductive expert and consideration given to evaluation of sperm DNA fragmentation and karyotype testing of the male.
    • Even with a "normal" SA, a sperm that appears morphologically and functionally normal may not be chromosomally normal or may have a high level of DNA fragmentation.
  • Some experts would also consider sperm aneuploidy testing
    • This test is not universally available for all centers.
• Timing
  • Infertility should be evaluated after 6 months of attempted conception when the female partner is over 35 years of age★
• Patient Counselling
  • Counsel infertile men or men with abnormal semen parameters of the health risks associated with abnormal sperm production.
    • 1-6% of men have undiagnosed medical diseases at the time of an infertility evaluation
    • Abnormal semen parameters associated with increased risk of
      • Testicular cancer
      • Mortality
• Advise couples with advanced paternal age (≥40) that there is an increased risk of adverse health outcomes for their offspring.
  • Effects of male age on reproductive function
    • Reproductive function
    • Sexual function
    • Testicular morphology
    • Semen parameters (except sperm concentration, semen parameters decrease as age increases)
    • Infections of the accessory glands
    • Vascular disease
    • Genetics (sperm aneuploidies, aneuploidies in off-spring, sperm DNA integrity, telomeres, epigenetics)
    • Fertility
    • Miscarriage
    • C-section
    • Pre-eclampsia
    • Trophobalst disease
    • Preterm birth
    • Adverse outcome in offspring
  • Genetic counseling may be appropriate for couples with advanced paternal age to discuss the magnitude of these risks

UrologySchool.com Summary

2020 AUA Guidelines★

• History and physical exam
• Labs
  • Semen analysis
    • At least two SAs obtained a month apart are important to consider, especially if the first SA has abnormal parameters★
      • Semen parameters are highly variable biological measures and may vary substantially from test to test
      • Up to 35% of men with non-obstructive azoospermia will have sperm detected on subsequent SA without medical intervention[1]
  • Serum
    • FSH and morning total testosterone, if (6):
      1. Azoospermia
      2. Oligozoospermic (particularly if sperm concentration) <10 million/mL)
      3. Impaired libido
      4. Erectile dysfunction
      5. Atrophic testes
      6. Evidence of hormonal abnormality on physical evaluation
      • If testosterone low (<300ng/mL), get (5)
        1. Repeat measurement of total testosterone (or bioavailable testosterone)
        2. Free (or bioavailable) testosterone
        3. LH
        4. Estradiol
        5. Prolactin levels
  • Genetic testing, if indicated (see below)
    • Karyotype and Y-microsome deletion, if
      • Primary infertility and (3):
        1. Azoospermia or severe oligozoospermia (<5 million sperm/mL) with elevated FSH OR
        2. Testicular atrophy OR
        3. Presumed diagnosis of impaired sperm production as the cause of azoospermia
    • Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) mutation carrier testing (including assessment of the 5T allele), if (3):
      1. Vasal agenesis (unilateral or bilateral)
      2. Idiopathic obstructive azoospermia
      3. If the female partner is a carrier (to consider for preimplantation diagnosis)
• Imaging
  • Renal ultrasound, if (1):
    1. Vasal agenesis
  • Trans-rectal ultrasound, if (3):
    1. Low semen volume with azoospermia and palpable vasa OR
    2. Low semen volume and significant asthenospermia (total motility <40% or progressive motility <32%) OR
    3. Symptoms (e.g. painful ejaculation)

History and Physical exam

History

• Infertility history
  • Duration of infertility
  • Whether the infertility is primary or secondary
    • Evaluation of men with secondary infertility should include a focus on conditions or exposures that have developed or occurred after initiation of the earlier pregnancy(ies).
  • Any treatments to date
• Risk factors
  • See Epidemiology and Risk Factors for Infertility Chapter Notes
    • Classification
      • Pre-testicular
      • Testicular (TIC)
        • Toxins (medications, chemotherapy, radiation, social habits)
          • If there has been exposure to any gonadotoxic agents, these medications should be stopped and semen should be retested in 3-6 months
          • Environmental exposures (pesticides, excessive heat on the testicles)
          • Lifestyle (cigarette smoking, recreational drugs, alcohol use, stress, anabolic steroid usel)
        • Infections/inflammation of the GU tract (sexually transmitted infections, epididymo-orchitis, mumps orchitis)
        • Childhood (congenital causes (recall DUNKY-XX), hydrocele or hernia surgery, torsion, cryptorchidism)
      • Post-testicular
        • Sexual history
          • Libido, sexual function, sexual activity
          • Use of lubricants
• General health
  • Medical comorbidities (e.g., hypertension, hyperlipidemia, obesity, diabetes) can contribute to infertility.
  • If there has been a recent serious medical illness or injury or evidence of a recent reproductive tract infection, semen testing should be repeated at least 3 months following recovery from the illness
• Previous surgery of the reproductive tract
  • For testis cancer, undescended testis, hydrocelectomies, spermatocelectomies, varicocelectomies, vasectomies
  • Vasectomy reversal may represent a more cost-effective option compared to IVF in couples with adequate ovarian function§
• History of any genetic abnormalities in the patient or the family

Physical exam

• General (3)
  1. Body habitus
     • Obese men have
       • Elevated estradiol
         • Mechanism: adipose cells have aromatase which metabolizes testosterone to estradiol
       • Reduced serum testosterone and reduced SHBG (therefore, more bioavailable testosterone component of total testosterone)
  2. State of virilization
  3. Gynecomastia, may be a marker for endocrine disorders
• Abdomen
  • Scars suggest previous procedures that may have involved the pelvis or impacted the urogenital system (inguinal surgery or treatment of undescended testis)
• Genitals
  • Phallus
    • Meatal displacement may make it difficult for semen deposition in the vagina
    • Penile plaque as in Peyronie’s disease may make it difficult for vaginal intercourse
    • Penile lesions/ulcers/discharge may be a sign of sexually transmitted infection
  • Scrotum (5)
    1. Scars suggest previous scrotal surgery/trauma
    2. Testis
       • Size and consistency of the testis; size correlates well with sperm production
         • Long axis length <4.6cm associated with impaired spermatogenesis
         • Volume <20mL considered low
         • Obstructive azoospermia is suspected if the physical examination reveals testes of normal size, fully descended into the scrotum and bilaterally indurated epididymides with or without absence of the vas deferens
         • When the testes are atrophied and soft, especially in the presence of FSH greater than 7.6 IU/L, the results are suggestive of spermatogenic failure rather than obstructive azoospermia.
       • Location as scrotal position of the testes is important for normal function
       • Exam may also reveal masses consistent with a testicular cancer
    3. Vas deferens
       • Shape/consistency as normal development and contour should be confirmed to rule out agenesis as may be seen in the presence of a CFTR mutation or aberrant Wolffian duct embryogenesis
         • Unilateral absence
           • Suggests complete lack of Wolffian duct development on that side, including renal agenesis
             • The absent vas should raise a red flag for possible ipsilateral renal agenesis because the ureteral bud and vas are both derived from the wolffian duct
             • Recall, male structures derived from Wolffian ducts:
               1. Body and tail of epididymis (note efferent ductules and head of epididymis from mesonephric tubules)
               2. Vas deferens
               3. Seminal vesicles
                  • Distally, the wolffian ducts join the urogenital sinus by about 30 days gestation, where they develop into the seminal vesicles
               4. Ejaculatory duct
               5. Appendix epididymis
             • Male structures derived from Müllerian duct (2):
               1. Appendix testis
               2. Prostatic utricle
             • Male structures derived from urogenital sinus:
               1. Prostate
               2. Bulbourethral glands
         • Bilateral absence
           • Consider investigation for CF gene mutation
             • Mutations in the CFTR gene are present in up to 80% of men with congenital bilateral absence of the vas deferens (CBAVD), 20% of men with congenital unilateral absence of the vas deferens and 21% of men with idiopathic epididymal obstruction★
               • Most common CFTR mutation is ΔF508, which is severe
               • ≈7% of brothers of patients with CBAVD will have also vasal agenesis
               • No association between CBAVD and Y microdeletions.
             • If the male partner is being tested for CFTR, such is in CBAVD, both patient and female partner should be tested for CFTR to determine risk of cystic fibrosis in offspring (CUA Azoospermia Guidelines).
               • Only a portion of CFTR mutations are detected by routine testing.
                 • A male with CBAVD should be assumed to be a CFTR carrier despite a negative CFTR gene test and the female partner still needs to be tested prior to any assisted reproductive techniques.
           • Semen is almost always of low volume and acidic in patients with CBAVD due to hypoplasia or absence of the seminal vesicles, which provide alkalinity
         • In men with congenital bilateral or unilateral absence of the vas deferens who are not carriers of cystic fibrosis mutations, abdominal US to assess for renal agenesis is indicated since these men have a higher chance of having absence of one of their kidneys
           • 26% of males with unilateral congenital absence of the vas deferens and 11% of males with CBAVD had an absent ipsilateral kidney;
             • Most of the bilateral CAVD patients with an absent ipsilateral kidney are in patients with no identifiable CF gene mutation.
       • Presence/location of any vasectomy defect or granuloma should also be assessed
    4. Epididymides
       • Shape/consistency as normal development should be identified to determine atresia that could be identified by the presence of a CFTR mutation.
       • Induration/dilation could suggest obstruction.
       • Epididymal cysts or spermatoceles may also lead to obstruction.
    5. Varicoceles
       • Potential mechanisms of varicocele contributing to infertility
         • Hyperthermia
         • Testicular hormonal imbalance
         • Increased reactive oxygen species
         • Hypoperfusion leading to hypoxia
       • Large varicoceles are associated with greater preoperative impairment in semen quality than small varicoceles
       • Varicocele treatment may be more cost effective than assisted-reproductive therapy or can lower the intensity of treatment§
       • See Varicocele Chapter Notes
  • Digital rectal exam
    • Midline prostatic cysts or dilated seminal vesicles may assist in the diagnosis of ejaculatory duct obstruction

Laboratory

Semen analysis

• Generally, results cannot precisely distinguish fertile from infertile men except
  • Individual sperm parameters diagnostic of infertility (4):
    1. Azoospermia
    2. Necrozoospermia
    3. Complete asthenozoospermia
    4. Some types of teratozoospermia (e.g., complete globozoospermia)
• Should be examined under the microscope within one hour of collection
• Should be given after 2-3 days of abstinence
• Number of samples
  • At least two semen analyses obtained a month apart are important to consider, especially if the first SA has abnormal parameters★
    • If azoospermia, a second SA should be performed at least one to two weeks later.

WHO semen parameter percentiles

• Derived from men whose partners became pregnant (fertile population) within 1 year of discontinuation of contraceptives.
• The 5th percentile is used to describe infertility cut-offs for 7 semen parameters
  • Values falling above or below the lower limit do not by themselves predict either fertility or infertility; males with abnormal semen parameters have contributed to a prior successful pregnancy through natural conception
    • The odd ratio for infertility increases as the number of abnormal parameters increases.

1. Volume <1.5mL
   • See 2015 CUA Azooospermia Guideline Notes
   • Causes (6)
     • Obstruction or hypoplasia (severe androgen deficiency, CBAVD) of the prostate and seminal vesicles
     • Alpha blockers
     • Retrograde ejaculation
       • Definition: semen with sperm are released into the prostatic urethra but travel backward (retrograde) into the bladder
         • Distinguished from aspermia (absence of antegrade ejaculate; dry ejaculate)
       • Causes
         • Diabetes
         • RPLND
         • Spinal cord injury
     • Multiple sclerosis
   • Hypervolemia (>5 mL), dilutes sperm therefore interferes with reproduction.
     • IUI can be used to concentrate sperm
2. Total number <39 million/ejaculate
   • Most important semen analysis parameter
   • Definition of azoospermia: no sperm in the ejaculate
   • If semen analysis shows azoospermia, laboratory should then centrifuge the ejaculate and re-suspend the pellet in a small volume of seminal plasma and examine under wet mount microscopy for the presence of rare sperm.
     • If no sperm are present, a second semen analysis should be performed at least one to two weeks later. If the sample is azoospermic, then another pellet analysis should be performed.★
     • Further investigations for azoospermia depend on if it is associated with low-volume (obstructive) azoospermia or normal-volume azoospermia
   • Azoospermic patients with§
     • Normal ejaculate volume may have either obstruction of the reproductive system or abnormalities of spermatogenesis
     • Low semen volume and normal sized testes may have ejaculatory dysfunction or ejaculatory duct obstruction
3. Concentration <15 million/mL
   • Visual assessment under microscopy
   • Definition of oligospermia: <15 million/mL
4. Total motility <40%
   • Visual assessment under microscopy
   • Asthenospermia is when total motility <40% or progressive motility <32%
     • Causes of asthenospermia§
       1. Sperm structural defects
       2. Prolonged abstinence periods
       3. Genital tract infection
       4. Anti-sperm antibodies
       5. Partial ductal obstruction
       6. Varicocele
5. Progressive motility <32%
   • Progressive motility: moving actively, linearly or in large circle, regardless of speed
   • Nonprogressive motility: all other patterns with absence of progression
6. Normal forms <4%
   • Teratozoospermia: normal forms <4%
   • Globospermia: failure of acrosomal head to form small, round heads.
     • Without the acrosome, fertilization with sperm in the natural setting or with incubational in vitro fertilization will not be successful. Intracytoplasmic sperm injection is required.
       • Ejaculated sperm is available in this patient, and therefore surgical sperm extraction is unnecessary.
   • Higher rates of aneuploidy with many abnormal forms.
     • Conditions associated with aneuploidy:
       • Aging
       • Cytotoxic agents
       • Environmental exposures (smoking)
     • Consider aneuploidy in patients with recurrent pregnancy losses
     • intracytoplasmic sperm injection with biological gametes is not recommended with sperm associated with macrocephaly and multiple tails due to the high rate of aneuploidy
   • Strict morphology is not a consistent predictor of fertility, and for this reason, the AUA states that strict morphology “should not be used in isolation to make prognostic or therapeutic decisions"
7. Vitality <58%
   • Metabolically active living cells
   • Necrospermia: reduced vitality
     • Cannot evaluate in complete asthenospermia since assay relies on association of moving particles proximal to motile sperm
       • To rule out necrospermia when motility is 0%, consider vital stain
     • In the complete absence of motility and necrospermia has been ruled out, electron microscopy can identify if ultrastructural tail defects are present in the immotile cilia syndrome
       • In immotile cilia syndrome is confirmed, patients can subsequently be counselled to undergo IVF
8. Viscosity, coloration, pH
   • In spinal cord injury, a brown hue can be noted in the semen
   • pH should be 7.2-7.8 (alkaline due to seminal vesicle contribution)
     • If low volume with
       • Acidic pH, azoospermic ejaculate can be indicative of obstruction in the genital tract
       • Normal pH (>7.2), azoospermic ejaculate can be indicative of incomplete collection, retrograde ejaculation, or partial obstruction

• The presence of abnormal semen parameters suggests the presence of a male factor in an infertile couple which should prompt further evaluation of the male

Secondary Semen Analyses

DNA fragmentation

• Negatively associated with pregnancy rates and positively associated with miscarriages
  • Patients with high sperm DNA fragmentation can be counseled that there is a possible association with infertility and compromised outcome after ART
• Direct measures of sperm DNA fragmentation include (2):
  • Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay
  • Comet assay
• Indications
  • Not recommended in the initial evaluation of the infertile couple★
  • May be useful in couples undergoing IVF with repeated IVF failure
• Management
  • Currently no effective therapy to correct an abnormal DNA fragmentation result
  • If high sperm DNA fragmentation, consider★
    • Using surgically obtained sperm in addition to ICSI
      • In a prospective cohort study of over 100 couples with high DNA fragmentation, testicular sperm yielded substantially higher live birth rates than ejaculated sperm.[2]
    • Antioxidant administration
    • Varicocele repair
    • Frequent ejaculation
      • Decreased abstinence may be an intervention to limit sperm DNA damage.[3]
    • Donor sperm

Semen WBC staining

• Increased levels of round cells in the semen may result from
  1. Presence of elevated levels of white blood cells in the semen (pyospermia)
     • White blood cells in the semen may result from infection or inflammation in the proximal or distal male genital tract.
  2. Spermatogenic problem where immature germ cells (spermatocytes and/or round spermatids) are present in the ejaculate
     • No evidence that elevated levels of immature sperm in the semen is deleterious to fertility, and they may be present in semen of infertile men and fertile men with high sperm counts.
  3. Idiopathic
     • Most common cause
• Important to know whether men with elevated levels of round cells in the semen have immature germ cells or an infectious or inflammatory etiology for subsequent management (see below)
• Leukocytes and immature germ cells are not differentiable with light microscopy
  • Papanicolaou staining may be used
    • Immunocytochemical staining provides more information to aid in distinguishing between inflammation and those subtypes involved in fighting off infection
• Indications★
  • Increased round cells on semen analysis (>1million/mL)
    • Upper limit of normal as <1 million white blood cells/mL of semen
• Management
  • If staining suggestive of
    • Pyospermia, evaluate for the presence of infection★
      • Sexual transmitted infections can also lead to leukocytes in semen and this needs to be ruled-out
      • Chronic prostatitis due to bacterial infection may require long courses of antibiotic treatment, and some cases of elevated levels of white blood cells may result from chronic nonbacterial prostatitis.
      • Leukocytes can occur with UTIs, but unless urine is in the semen, this is an unlikely source.
      • Inflammation may be medically treated with anti-inflammatory drugs.
    • Immature germ cells is a condition that cannot be treated

Anti-sperm antibodies

• Can result in sperm agglutination in the semen
  • Anti-sperm antibodies may be present without sperm agglutination and, conversely, agglutination may be present due to other factors, such as the presence of E.coli in the semen
• Can impair sperm-ova penetration
• Associated with events such as trauma, mumps orchitis, testis malignancy, vasal obstruction, vasectomy that disrupts the blood-testis barrier, or the patency of the male genital tract allowing sperm antigens or genital tract infections to generate anti-sperm antibodies.
  • Vasectomy disrupts the blood-testis barrier, resulting in detectable levels of serum antisperm antibodies in 60% to 80% of men.
• IgA and IgG antibodies are the predominant antibodies found in semen, while IgM is rarely found[4]
• Tests used (2):
  • Mixed antiglobulin reaction test
  • Immunobead (IB) test
    • Gives information about the type and presence of the immunoglobulins and their localization specifically on the sperm head, midpiece or tail or covering the entire sperm
• Indications
  • Should not be done in the initial evaluation of male infertility
  • Should only be considered if it will affect management of the patient.
    • For couples planning on ICSI, ASA testing should not be performed since it will not change management.
• Management
  • IUI after specific semen processing or ICSI
    • Some have reported improved IUI pregnancy rates with specific semen processing protocols for couples with anti-sperm antibodies compared to standard sperm washing, although the data are limited
    • In those with anti-sperm antibodies, ICSI yields higher pregnancy rates per cycle than IUI with semen processing designed to disrupt the bound antibodies.

Sperm aneuploidy testing

• Involves the use of fluorescent molecular probes for chromosomes 13, 18, 21, X, Y because the presence of an extra chromosome for these specific chromosomes is consistent with a potentially viable but affected offspring. Aneuploidy of all other human chromosomes is not consistent with a viable offspring.[5]
• Indications
  • Recurrent pregnancy loss

Sperm penetration assay

• Most closely models incubational in vitro fertilization

Sperm culture

• Limited seminal concentrations of the majority of bacteria including E. Coli have minimal or no effects on sperm motility in vivo

Fructose

• Produced in the male reproductive tract by the seminal vesicles and is released into the semen during ejaculation
• Energy source for spermatozoa§
• Mean concentration of fructose in human semen is 2–3 mg/mL (11–16 μmol/mL)§
  • Low semen fructose may suggest ejaculatory duct obstruction

Serum

FSH and Morning Total Testosterone

• Not recommended as a primary first-line test in the evaluation of male infertility★
• Indications (6):★
  1. Azoospermia
  2. Oligozoospermic (particularly if sperm concentration <10 million/mL)
  3. Impaired libido
  4. Erectile dysfunction
  5. Atrophic testes
  6. Evidence of hormonal abnormality on physical evaluation

FSH

• Indirect assessment of germ cell mass
  • If testicle long axis < 4.6 cm and FSH >7.6 IU/L --> consider spermatogenic dysfunction
  • If testicle long axis > 4.6 cm and FSH < 7.6 IU/L --> consider obstructive azoospermia

Morning Total Testosterone

• Should be defined based upon a morning blood sample, since levels drop during the day
• ≥300 ng/dL considered adequate (164 ng/dL bioavailable)
• If fasting morning total testosterone level is low (<300 ng/dL), obtain
  1. Repeat measurement of total testosterone (or bioavailable testosterone)
  2. Free (or bioavailable) testosterone
  3. LH
  4. Estradiol
  5. Prolactin
     • The relationship of testosterone, LH, FSH, and prolactin helps to identify the clinical condition.

Other

• LH
  • Determine if hypoandrogenism testicular (primary) or pituitary (secondary) in nature
• Estradiol
  • Ratio of total T:E < 10:1 indicates reproductive dysfunction
• Prolactin
  • Abolishes GnRH pulsatility, suppresses testosterone production
  • Pituitary disease (hyperplasia, adenoma, tumours), including prolactinoma, is associated with visual field changes, headache, and erectile dysfunction
  • Obtain prolactin if clinically indicated. Consider MRI if very elevated.
    • Prolactin is a labile assay. Before continuing with further diagnostic assessment or therapy, moderately elevated assay results should first be confirmed with a second test.

	Severely impaired spermatogenesis	Obstructive azoospermia	Hypogonadotropic hypogonadism
LH	Increased or no change	No change	Decreased
FSH	Increased	No change	Decreased
Testosterone	Decreased or no change	No change	Decreased

Post-ejaculate Urine Analysis

• Used to diagnose retrograde ejaculation
• Viable sperm from urine or any location within the male reproductive tract can be used with ART to achieve a pregnancy.

Genetic Testing

Options

1. Karyotype
2. Y Chromosome Microdeletion
3. Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) mutation carrier testing

Indications

• Karyotype and Y chromosome microdeletion
  • Primary infertility and (3):
    1. Azoospermia or severe oligozoospermia (<5 million sperm/mL) with elevated FSH OR
    2. Testicular atrophy OR
    3. Presumed diagnosis of impaired sperm production as the cause of azoospermia
• Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) mutation carrier testing (3):
  1. Vasal agenesis/abnormalities OR
  2. Idiopathic obstructive azoospermia OR
  3. If the female partner is a carrier (to consider for preimplantation diagnosis)

Karyotype

• Evaluates the number and structure of chromosomes in order to detect abnormalities
• Karyotype abnormalities (e.g. Klinefelter syndrome) are the most common known genetic abnormalities that cause male infertility.
  • An abnormal karyotype is present in about 6% of all infertile men[6]

Y Chromosome Microdeletion Analysis

• Y chromosome microdeletions are the second most common known genetic cause of infertility in the male
• Should be done in azoospermia before surgical sperm extraction to counsel likelihood of retrieval
  • Men with complete deletions of AZFa and/or AZFb should not undergo TESE for ART. ★
  • Men with deletions of AZFc and smaller partial deletions of AZFa and/or AZFb should be counseled that sperm may or may not be found with TESE.★

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) mutation carrier testing

• Including assessment of the 5T allele
  • In addition to classic mutations, the 5-thymidine (5T) variant of the polythymidine tract in the splice site of intron 8 (which regulates exon 9 splicing efficiency) is also commonly found in men with obstructive azoospermia due to CFTR abnormalities.
• For men who harbor a CFTR mutation, genetic evaluation of the female partner should be recommended.
  • In cases where the male patient has a mutation in the CFTR gene and the partner is also a carrier, then there is a risk of an affected offspring (25% if both partners are carriers, and up to 50% if the male has mutations in both alleles with a female partner who is a carrier)

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.
• Indications (1):
  1. Congenital absence of the vas(a) (regardless of the CFTR status)
     • ≈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
• Indications★
  1. Semen analysis suggestive of ejaculatory dust obstruction (2):
     • Low semen volume with azoospermia and palpable vasa
     • Low semen volume and significant asthenospermia (total motility <40% or progressive motility <32%)
       • 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.
         • 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.
  2. Symptoms (e.g., painful ejaculation)
• 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.
• Findings associated with ejaculatory duct obstruction (4):★
  1. AP diameter of seminal vesicle >1.5cm
  2. Ejaculatory duct caliber (>2.3mm)
  3. Dilated vasal ampulla (>6mm)
  4. Prostatic cysts (midline or paramedian (ejaculatory duct)

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.
• Indications★
  • Should not be routinely performed in the initial evaluation of the infertile male.
    • Routine use of ultrasonography to investigate presumed varicocele is to be discouraged, 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.
  • May be used if difficult to examine scrotum (obese patient or when the dartos muscle remains highly contracted during the physical exam)

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[7]
• 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.

Testicular biopsy

• Should not routinely be performed to differentiate between obstructive azoospermia and non-obstructive azoospermia★
  • Differentiation of obstructive azoospermia from non-obstructive azoospermia may most frequently be predicted from clinical and laboratory results without the need for surgical diagnostic biopsy.
    • FSH > 7.6 IU/L and testis longitudinal axis < 4.6 cm indicate an 89% likelihood of spermatogenic dysfunction as the etiology
    • FSH < 7.6 IU/L and testis longitudinal axes > 4.6 cm indicate 96% likelihood of obstruction as the etiology
  • In the infrequent cases with intermediate values, testis biopsy may be performed
    • Consider diagnostic and therapeutic biopsy if FSH and testicular volume normal but no clinical evidence of obstruction
      • May identify germ cell maturation arrest
    • In the rare cases where testis biopsy is done primarily for diagnostic purposes, sperm cryopreservation from the sample should be attempted if ART is an option.
• Spermatogenesis may be highly focal in men with azoospermia so a random biopsy may miss areas of sperm production

Special Scenarios

Recurrent pregnancy loss

• Defined as ≥2 failed pregnancies
  • Distinct from infertility
• Most miscarriages are related to abnormalities within the fetus itself★
• Causes of recurrent miscarriages (6)
  1. Genetic causes (e.g., chromosomal translocations)
  2. Anatomic abnormalities of the female uterus (e.g., septum, submucosal fibroids, adhesions)
  3. Infections
  4. Hematologic and immunologic disorders of the female partner
  5. Female partner endocrine issues (e.g., thyroid and diabetes)
  6. Male factor issues
     • Most common identified etiologic issues in males: karyotypic abnormalities and sperm DNA fragmentation.
• Diagnosis and Evaluation (3):
  1. Karyotype
     • Paternal structural chromosomal defects are associated with miscarriage and RPL
  2. Sperm DNA fragmentation
     • High levels of sperm DNA fragmentation are positively associated with miscarriage
  3. Sperm aneuploidy testing

Gonadotoxic Therapies and Fertility Preservation

• Prior to commencement of gonadotoxic therapies and other cancer treatments, discuss the effects of therapy on sperm production with patients★
  • Radiotherapy and chemotherapy used for cancer and other medical conditions can lead to temporary or long-term gonadal injury.
    • The recovery of sperm production following radiotherapy and/or chemotherapy depends on the survival of spermatogonial stem cells in the testis.
      • Radiation
        • The recovery of sperm in the ejaculate may take months to years when radiation dose > 1 Gy; dose > 10 Gy will often result in permanent azoospermia
        • Fractionated radiation (given over the course of weeks) may have a more detrimental effect on spermatogenesis than a single radiation dose
      • Chemotherapy
        • Alkylating agents (e.g., procarbazine, cyclophosphamide, ifosfamide) and cisplatin target spermatogonial stem cells, and these drugs are the most likely to lead to permanent azoospermia at high doses
        • Most other chemotherapeutic agents (e.g., anthracyclines, microtubule inhibitors, antimetabolites, topoisomerase inhibitors) target differentiating germ cells in the testis (e.g., spermatids, spermatocytes, differentiating spermatogonia) and cause a transient reduction in sperm parameters with gradual recovery of sperm count observed three to six months after cessation of therapy.
          • Topoisomerase II inhibitors (e.g., etoposide) are most toxic to spermatocytes with little to no toxicity to stem cells
          • Doxorobucin targets differentiating spermatogonia and spermatocytes
• Encourage sperm banking, preferably multiple specimens when possible, prior to commencement of gonadotoxic therapy or other cancer treatment that may affect fertility★
  • Couple may need to undergo several cycles of IVF treatment in order to achieve a pregnancy
  • Malespresenting with cancer will generally have poorer semen parameters than normal donors, and their sperm respond less favorably to freeze-thawing (with poorer post-thaw motility) than donor sperm
• For azoospermic men with an intratesticular lesion, cryopreservation of testicular tissue should be considered during orchiectomy or excisional biopsy of the testicular lesion (an Onco-TESE approach)
• Inform patients undergoing a retroperitoneal lymph node dissection (RPLND) of the risk of aspermia and the availability of sperm banking prior to surgery.★
  • Obtain a post-orgasmic urinalysis for men with aspermia after RPLND who are interested in fertility.★
    • Given the distribution of the nodes involved in drainage of the testes, the lumbar sympathetic nerve fibers responsible for ejaculation (T10-L2) are in close proximity to the node dissection templates.
    • Sympathetic nerve fiber damage, such as that which can occur during a RPLND, can result in failure of the bladder neck to contract effectively allowing semen deposited into the prostatic urethra to pass in a retrograde fashion into the bladder (i.e., RE).§
    • As with any neural trauma, maximum recovery can take 12 to 24 months and thus, patients who have had nerve sparing RPLND should be told that return of antegrade ejaculation may take a protracted period of time.
      • If aspermia remains 24 months after RPLND, then the patient should be informed that this is likely to be permanent.
• Inform patients undergoing chemotherapy and/or radiation therapy to avoid pregnancy for a period of at least 12 months after completion of treatment.★
  • One of the major concerns regarding the effects of gonadotoxic therapies in males wishing to father children is the induction of mutations in developing testicular germ cells.
    • Studies have clearly demonstrated that radiation and chemotherapy can alter the genomic integrity of testicular germ cells.
      • The genomic damage induced by these treatments is germ cell stage specific.
      • This implies that during and for a defined period of time after exposure to radiation and/or chemotherapy (depending on the susceptible germ cell) a male can produce an increased proportion of genetically abnormal spermatozoa. Conceiving a child during this period can substantially increase the risk of genetic mutations in the offspring.
• Consider informing patients that a SA performed after gonadotoxic therapies, should be done at least 12 months (and preferably 24 months) after treatment completion.★
  • Studies demonstrate lowest sperm concentration by 12 months and maximization of recovery in the majority of studies between 2 to 3 years after the completion of treatment[8]
• Inform men seeking paternity who are persistently azoospermic after gonadotoxic therapies that Testicular Sperm Extraction (TESE) is a treatment option.★

Questions

1. List the WHO sperm parameters and their cut-offs.
2. List 6 causes of low-volume semen.
3. What are the genetic tests in infertility? When are they indicated?

Answers

1. List the WHO sperm parameters and their cut-offs.
2. List 6 causes of low-volume semen.
3. What are the genetic tests in infertility? When are they indicated?

Mock Oral Exam

• Azoozpermia (Master the Medicine)
• Ejaculatory Duct Obstruction (Master the Medicine)
• Vasectomy (Master the Medicine)
• Vasectomy Reversal and ART (Master the Medicine)
• Infertility (Master the Medicine)

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 24
• Schlegel, Peter N., et al. "Diagnosis and treatment of infertility in men: AUA/ASRM guideline part I." The Journal of urology 205.1 (2021): 36-43.