The
Male Infertility Evaluation
Daniel
A. Potter, MD, FACOG
Board
Certified, Reproductive Endocrinologist
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 LabCorp and Unilab, 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 reproductive endocrinologist
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 reproductive
endocrinologist 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 reproductive endocrinologist 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.
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