Snapshot A 35-year-old man presents to the physicians office with concerns about his fertility. He has a history of cryptorchidism. Though he had been counseled on the possibilities of infertility, he had not given it much thought until he became engaged. He wishes to furtively evaluate his sperm before approaching the topic with his fiancée. Introduction Definition of infertility inability to conceive after 1 year of unprotected sex in the absence of any known causes of infertility after 6 months if the woman is > 35 years old or in couples with known risk factors for infertility Terms related to sperm cells oligozoospermia decrease in number of sperm cells in ejaculate azoospermia no sperm cells in ejaculate asthenozoospermia decrease in sperm motility teratozoospermia abnormal morphology Epidemiology 10-15% of reproductive-aged couples in the US 12% of men are infertile 80% of men with infertility have oligozoospermia with asthenozoospermia, but with normal morphology of sperm more common in those over 40-years-old often unable to determine etiology Types of Male Infertility Endocrine and Systemic Disorders Genetic Disorders of Spermatogenesis Acquired Disorders of Spermatogenesis Post-testicular Defects and Disorders of Sperm Transport Kallmann syndrome Hemochromatosis Pituitary disorders Post-irradiation Exogenous androgen use Obesity Klinefelter's syndrome (XXY) Androgen insensitivity syndromes 5-alpha-reductase deficiency Myotonic dystrophy Infection causing orchitis (e.g.,mumps, tuberculosis, and leprosy) Epididymo-orchitis (often due to gonorrhea and chlamydia) Cryptorchidism Testicular torsion Varicocele Vas deferens abnormalities Cystic fibrosis Ejaculatory duct obstruction Retrograde ejaculation Presentation Symptoms inability to conceive history of undescended testical history of orchitis history of surgical procedure in the area absence of sense of smell Kallmann syndrome Physical exam hypogonadism body habitus decreased muscle mass and increased body fat may indicate androgen deficiency obesity abnormal scrotum varicocele gynecomastia Evaluation Standard semen analysis measure semen volume and pH assess sperm concentration, motility, and morphology sperm leukocyte count microscopy for debris, agglutination, and immature germ cells tested for hyperviscosity Specialized semen analysis sperm autoantibodies semen culture sperm-cervical mucus interaction Endocrine tests testosterone, lutenizing hormone, and follicle-stimulating hormone Genetic testing if suspicious for cystic fibrosis or other genetic disorder Differential Diagnosis Female infertility Insufficient time to conceive Past vasectomy Treatment Limited treatment available Lifestyle modification smoking cessation reduce alcohol intake exercise and weight loss Treat underlying condition if possible varicocele ligation dopamine agonist for hyperprolactinemia testosterone supplementation if deficient Assisted reproductive techniques manual extraction of mature spermatozoa or spermatids in testicular biopsy in vitro fertilization intrauterine insemination artificial insemination with donor semen Prognosis, Prevention, and Complications Prognosis depends on etiology of infertility factors associated with better prognosis younger age of female partner shorter duration of infertility higher percent of sperm concentration good sperm motility normal sperm morphology Complications psychiatric complications