Friday 2 November 2007
Investigating The Infertile Male
It is natural for the attention of the gynecologist and family practitioner to initially turn toward the female in cases of infertility. Although infertility is generally viewed a ‘female problem’, fully 45% of infertile couples have male infertility as a contributing cause. It makes sense then to begin the fertility evaluation with a basic evaluation of the male partner. Because significant male factor infertility is generally treated with in vitro fertilization, needless hysterosalpingograms, laparoscopies and clomiphene cycles can be avoided by early detection of significant dysfunction in the male partner. The savings of time and money can be tremendous. IVF with intracytoplasmic sperm injection (IVF/ICSI) has made it possible to successfully treat virtually all cases of male infertility, even with only a few moving sperm in the entire ejaculate.
The evaluation of the male partner starts with a competent semen analysis. Non-specialized laboratories, such as Ranbaxy and Metropolis, perform a World Health Organization (WHO) semen analysis. This is a crude screening test and should be replaced by the strict semen analysis (Kruger) that is done by most fertility centers. The difference between the WHO and the Kruger test is that, with the Kruger test, sperm morphology is evaluated in a very stringent manner. The results of the Kruger test predict fertilization rates in vitro and presumably in vivo as well. The WHO does not predict outcome and will frequently miss subtle but clinically significant sperm abnormalities. The cost of the Kruger test is the same or less than a WHO analysis at our center.
When male infertility is suspected and tests reveal abnormal semen parameters, the couple should be referred to a fertility physician and/or urologist for further evaluation. Conditions warranting referral for male infertility are: a sperm concentration of less than 20 million per mL, motility less than 35%, and morphology less than 5% (Kruger) or 30% (WHO).
A direct antisperm antibody test should be done in cases where the male has a history of genital trauma, genital surgery or has never initiated a pregnancy. The direct antibody test is done on a semen sample and detects whether antibodies are attached to the sperm themselves. The cutoff for a positive test varies between labs but is usually considered positive when greater than 10%-20% of sperm are bound. Couples with antisperm antibodies should be referred to a fertility physician for further evaluation and treatment.
Genetic evaluation of male infertility is indicated when there is a sperm concentration less that 5 million per milliliter. This male infertility evaluation should consist of a karyotype and a study to look for microdeletions on the long arm of the Y chromosome (Yq deletion study). An assay for DNA fragmentation in the sperm cells may also be helpful in select patients. If azoospermia is present, carrier status for one of the cystic fibrosis mutations should be ruled out. These men should, of course, be referred for a urological evaluation. If surgical treatment of the infertile male is not indicated, a fertility physician can then complete treatment.
Hormonal evaluation of the infertile male is indicated when there is a history of sexual dysfunction, azoospermia or abnormal physical findings. This workup, which consists of testosterone, FSH, LH and prolactin levels, should be accompanied by urological consultation.