Evaluation of Male Infertility

Educational Objectives

The goal of this program is to improve evaluation of male infertility. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize limitations of semen analysis in the evaluation of male infertility.

2. Identify infertile men for whom urologic consultation is indicated.

Summary

Infertility: fertile couples — pregnancy rates 20% to 25%/mo with unprotected intercourse (85%/yr); infertile couples — 15% unable to conceive after 1 yr of unprotected intercourse (definition of infertility); pregnancy rates 2% to 3%/mo; 25% to 30% of couples eventually conceive without assistance

Evaluation: 4% to 17% of couples seek medical treatment for infertility; male factor implicated in 50% of infertile couples but only 20% to 40% of men referred to urologist; rationale for urology referral — significant pathology identified in 6% of infertile men (eg, incidence of testicular cancer 3- to 10-fold higher); incidence of genetic abnormalities 30- to 100-fold higher; other medical conditions diagnosed on evaluation; chromosomal abnormalities detected in 6% (vs 1% in general population), including Klinefelter syndrome (most common), balanced translocations, and Y-chromosome microdeletions; indications for male screen — no pregnancy within 1 yr of unprotected intercourse; known male risk factor (eg, undescended testicle); known female risk factor (eg, advanced maternal age); initial screening — detailed reproductive history and 2 semen analyses (some studies suggest one analysis adequate); goals of male evaluation — identification of correctable conditions, irreversible conditions amenable to assisted reproductive technology (ART; eg, in vitro fertilization), irreversible conditions not amenable ART, and provision of counseling about donor sperm or adoption; identification of underlying health conditions that affect fertility and genetic abnormalities that affect progeny

Interpretation of semen analysis: limitations — variability in method and collection; lack of standardization; narrow scope of test; does not identify underlying pathology; low prognostic power; history — adapted for humans in 20th century; primate sperm highly heterogeneous in motility and morphology; World Health Organization manual accepted as standard version; fifth manual reports fifth percentile as lower reference limit; factors in biological variability — sample collection (ie, first part of sample sperm-rich; latter part diluted by seminal vesicle fluid); age; testicular size; duration of abstinence; method of collection (intercourse vs masturbation)

Results: not prescriptive or prognostic; extensive overlap in distribution of semen parameters seen between fertile and infertile men; cutoff point for fertility difficult to establish; false-positive and -negative results possible; scientific representation suggests results in fifth percentile indicate <5% chance semen originated from fertile man; issues not addressed by semen analysis — parameters can fluctuate; results can vary by laboratory; does not reveal underlying pathology or other factors affecting fertility; clinical use — assess total motile sperm count (TMSC, ie, total number of sperm in ejaculate multiplied by percent motility); Hamilton et al (2015) reported TMSC <5 million associated with significantly lower spontaneous conception rate than with higher TMSC; Guzick et al (2001) reported risk for infertility higher with multiple abnormal semen parameters than with one abnormal parameter; new test — sperm DNA integrity test; may be more predictive of fertility

Readings

Check JH: The infertile male — diagnosis. Clin Exp Obstet Gynecol, 2006;33(3):133-9; Guzick DS et al: Sperm morphology, motility, and concentration in fertile and infertile men. N Engl J Med, 2001 Nov 8;345(19):1388-93; Hajder M et al: The effects of total motile sperm count on spontaneous pregnancy rate and pregnancy after IUI treatment in couples with male factor and unexplained infertility. Med Arch, 2016 Feb;70(1):39-43; Hamilton JA et al: Total motile sperm count: a better indicator for the severity of male factor infertility than the WHO sperm classification system. Human Reprod, 2015 May;30(5):1110-21; Kuriya A et al: Do pregnancy rates differ with intra-uterine insemination when different combinations of semen analysis parameters are abnormal? J Turk Ger Gynecol Assoc, 2018 Jun 4;19(2):57-64; Madbouly K et al: Postwash total motile sperm count: Should it be included as a standard male infertility work up. Can J Urol, 2017 Jun;24(3):8847-52.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Kim was recorded at What’s New in Urology: A Primer for the Primary Care Provider, held April 13, 2019, in Los Angeles, CA, and presented by Cedars-Sinai Medical Center. For information about upcoming CME activities presented by Cedars-Sinai Medical Center, please visit: cedars-sinai.edu/education/continuing-medical-education. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP672802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.