Evaluation of Male Infertility

Infertility is on the rise and the male component seems to be paralleling the female counterpart. Accurate prediction of fertility status of male partner needs a standardized evaluation with the latest and precise methods of reference values.
Semen analysis still remains THE test which defines the fertility status of a male and parameters include sperm concentration, motility and morphology, and should be done if pregnancy has not occurred within one year of unprotected intercourse.
An earlier evaluation may be warranted if a known male or female infertility risk factor exists or if a man questions his fertility potential or if the female age is more than 35 years.

Goals of optimal evaluation of an infertile male

To identify a potential condition for an early referral to a fertility specialist

For irreversible conditions that are amenable to assisted reproduction using male gametes

To help you decide about those irreversible conditions where only donor insemination and adoption are possible

To diagnose certain medical conditions like diabetes, hypertension

To know about genetic abnormalities that you may pass on to the offspring

Initial evaluation

Complete reproductive / medical history and physical examination.
Two semen analyses.

SEMEN ANALYSIS

Semen sample collected by any method in a wide mouthed container, after an abstinence period of 2 – 7 days, kept between 20 °C and 37 °C, and liquefying the sample for 30 to 60 minutes, it is reported according to WHO 2010 criteria*.

OTHER TESTS

• Computer-aided semen analysis (CASA) – is a special test which provides us special information on your sperm density, motility, straight-line and curvi-linear velocity of sperm, average path velocity, amplitude of lateral head displacement, flagellar beat frequency, hyper activation of sperm but the test requires an expensive equipment and some trained personnel.
• Biochemical Tests - The only biochemical test of clinical importance is fructose estimation. Absence of fructose in your semen sample may indicate some kind of blockage either due to genetic reasons such as bilateral congenital absence of the vas deferens or due to ejaculatory duct obstruction. It is usually done in men with low semen volumes or aspermia.
• Hypo-osmotic swelling test (HOST) - this test is done to detect the viability of sperms in a sample with all immotile sperms. It helps to select viable sperm from testis and is a predictor of IVF outcome in such cases.
• Semen Culture - indicated in semen samples containing inflammatory cells. Persistent semen infection needs to be treated prior to taking up such a patient for treatment.
• DNA Fragmentation Index – It is a marker of male fertility potential and helps us decide our treatment modality, who is to be offered IUI versus higher modality of assisted reproduction like ICSI. This test is done in men with normal or abnormal semen parameters but who have had repeated failures when no other female factor is found (conditions where one is suspecting DNA damage). DNA Fragmentation Index (DFI) <30 can be offered IUI. DFI >30 are offered ICSI.
• Post ejaculatory urine assessment – sometimes semen goes to your urinary bladder after ejaculation (retrograde ejaculation). This is suspected in diabetics, men with low semen volumes and counts, patients with history of pelvic, bladder, prostatic or retroperitoneal surgeries.
• Hormonal evaluation–is indicated in men where history and examination is suggestive of hormonal disturbance. Also, in men with counts <10 million/ml. Most common is elevated
  Serum FSH and an abnormal Thyroid profile. If the initial FSH is abnormal, repeat FSH along with serum testosterone, LH, and Prolactin. An elevated serum FSH is indicative of failure in spermatogenesis, however, a normal FSH does not guarantee an intact spermatogenesis.
• Diagnostic Imaging –
• Scrotal ultrasound – done in cases of varicocele, epididymitis, epididymal cysts,spermatocoeles, testicular tumors. Color Doppler images especially help in detecting varicoceles.
• TRUS – a special ultrasound used to examine patients with ejaculatory duct obstruction which may occur due to prostatic cysts or stones obstructing the ejaculatory ducts. USG-guided seminal vesicle aspiration – presence of 3 or more sperm per high power field is suggestive of ejaculatory duct obstruction.
• Abdominal Ultrasonography – To rule out associated renal (kidney) abnormalities in patients with vassal agenesis which may be there in up to 20% men who are suffering from  some genetic diseases like CFTR mutation-negative gene.
• MRI Brain – in cases of hyperprolactinemia to distinguish between micro adenomas and macro adenomas.
• Genetic screening – Genetic evaluation is done in all infertile men with severe abnormal semen parameters as there is a risk of transmission of the gene to the offspring. 3 – 5% men have abnormal karyotype.7–10% of infertile men and nearly 2% of fertile men have Y chromosome micro deletions. Cystic fibrosis gene mutations are seen in nearly 30% of infertile males and 4% of fertile males with 80% of such infertile men have congenital bilateral absence of vas deferens (CBAVD).
• Testicular Biopsy–A diagnostic testicular biopsy is done to differentiate between obstruction versus testicular failure in azoospermic men.

*WHO 2010 Criteria