Male factor infertility: Initial workup and diagnosis in primary care

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madman

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Abstract

Objective
To present a case-based discussion on the workup of male factor infertility and review currently available treatments.

Sources of information This discussion is based on the current Canadian Urological Association and American Urological Association guidelines, with reference to landmark papers as appropriate from 2010 onward. All articles were retrieved through PubMed.

Main message Approximately 15% of Canadian couples experience infertility, making it a commonly encountered condition in the primary care setting. Among couples suffering from infertility, male factors can be identified as the sole cause in 30% of cases and as a contributing issue in 20% of cases. Although many of the treatments described aim to improve a couple’s chances of naturally conceiving a child via intercourse, many patients ultimately require medical or surgical intervention to achieve pregnancy. This can be a long, protracted course for patients, with important roles for primary care providers and fertility specialists alike.

Conclusion Male fertility assessment and treatment has historically been left in the hands of fertility specialists, creating a bottleneck for patients to receive fertility care. However, with an increased understanding of the underlying causes of male factor infertility, the workup and initial management can occur in the primary care setting, helping to streamline care.





Infertility affects 15% of couples in Canada and is defined as the failure of a couple to become pregnant within 1 year of regular unprotected intercourse.1 Regular intercourse is defined as intercourse every 2 to 3 days. Male factors are identified as the sole cause in 30% of cases, female factors are identified as the sole factor in 35% of cases, 20% of cases have a combination of female and male factors, and 15% have no identifiable cause.2

Despite this being a relatively common problem, training on male fertility is largely limited to urologists, often those who have undergone subspecialty fellowship training in this domain. However, the initial workup and diagnosis of men with fertility issues can be completed by primary care physicians, helping to streamline care and alleviate the accompanying stress and anxiety among couples struggling to conceive.

This review presents the foundational definitions of male factor infertility, the initial workup of this condition, and the medical and surgical options currently at urologists’ disposal for the treatment of common conditions affecting male fertility.





Case description

A 35-year-old man, whose partner is a 32-year-old woman presents with difficulty to conceive for 1 year. What is the diagnostic workup?


Main message
Definitions of abnormal semen analysis findings


Case update

The history of our patient is noncontributory, although he is noted to have small testicles bilaterally. He has no risk factors on review of history, and his partner has no fertility concerns. Findings of his semen analyses reveal normal-volume azoospermia. His FSH and LH levels are high, with a borderline low testosterone level. For now, you give him a presumptive diagnosis of nonobstructive azoospermia due to testicular failure. He requests information about possible treatments to achieve fertility and his chances of having a pregnancy with his partner.


What are the treatment options?

*Conservative treatment

*Medical treatment

-Selective estrogen receptor modulators (SERMs)
-Aromatase inhibitors
-Human chorionic gonadotropin
-Testosterone
-Treatment of retrograde ejaculation


*Surgical treatment
-Varicoceles
-Obstructive azoospermia
-Nonobstructive azoospermia



Case resolution

The patient is ultimately referred to a fertility specialist who suggests that he most likely requires surgical exploration to find sperm. The couple is counseled at the time of diagnosis that despite having nonobstructive azoospermia, their chance of mTESE sperm retrieval is nearly 50%, and their chance of live birth is variable but can be approximated at 25%.27,28 They are also counseled that alternative options include sperm donation and adoption. The patient ultimately undergoes mTESE, and fortunately, a small number of sperm are found; his partner undergoes egg retrieval and ICSI is carried out to achieve pregnancy.




Conclusion

This review highlights the initial evaluation of male factor infertility, which can often be performed in the primary care setting. With a careful history and judicious use of investigations, many causes of male infertility can be uncovered. Although treatment of most conditions must be done by fertility specialists, improved time to diagnosis can only benefit patients.

With currently available medical and surgical treatments, couples presenting with male factor infertility have several options to improve their chances of having a child. Although many of the treatments described above aim to improve a couple’s chances of naturally conceiving a child via intercourse, many patients ultimately require medical or surgical intervention to achieve pregnancy. This can be a long, protracted course for our patients, with important roles for primary care providers and fertility specialists alike.
 

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madman

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Table 1. Definitions of common abnormalities noted on semen analysis
Screenshot (4143).png
 
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