HISTORY AND PHYSICAL EXAMINATION

TABLE 1.
History of the Infertile Male

The initial history should ascertain:

The duration of the couple's infertility and whether or not other treatment has been attempted. In the past, the fertility evaluations were delayed until a couple had been unable to achieve a pregnancy during 1 year of unprotected intercourse. It is the current philosophy that the evaluation of one's fertility may properly begin at whatever time patients express concern, and both the male and female portions of a fertility workup can be undertaken simultaneously in an efficient, cost-effective, and timely fashion.

Occurrence of pregnancies with either past or present partners and the age of the male partner when they occurred. Difficulties achieving these pregnancies and any previous evaluations or treatments should be noted.

History of bladder, pelvic, or retroperitoneal surgery suggesting the possibility of ejaculatory dysfunction with associated incomplete or retrograde ejaculation.

Sexual habits.

Timing: The optimal timing for intercourse is every 48 hours (i.e., every other day) during the time when ovulation is most likely (usually at the female's midcycle).

Coital habits: Couples must be cautioned to use lubricants only if necessary, and then only in limited amounts. Spermatotoxic lubricants (such as K-Y Jelly, Lubifax, Surgilube, Keri Lotion) and even saliva can impair sperm motility. Other lubricants, such as raw egg white, vegetable oil, safflower oil, peanut oil, and petroleum jelly, do not impair in vivo sperm motility.

Childhood illnesses and disorders.

Cryptorchidism: Cryptorchidism, both unilateral and bilateral, frequently is associated with oligospermia. Although approximately 30% of men with unilateral cryptorchidism and 50% of men with bilateral cryptorchidism have sperm densities below 20 million/mL, approximately 80% of men with a history of unilateral cryptorchidism are fertile. In contrast, the fertility rate is only 50% for couples in whom the male has a history of bilateral cryptorchidism. The data concerning the timing of repair of undescended testes are inconclusive, but it is known that testes remaining undescended until after puberty do not function well and that fertility rates are not improved with postpubertal orchidopexy.

Testicular trauma or a history of unilateral testicular torsion also may adversely affect the testes. Approximately 30% to 40% of men with a history of unilateral testicular torsion have an abnormal semen analysis for reasons that remain unclear. A breakdown in the blood-testis barrier may be the cause, or the testis susceptible to torsion may have had a preexisting spermatogenic defect (as evidenced by a high incidence of impaired spermatogenesis in the biopsied contralateral testis). When trauma or torsion occurs after puberty, there is speculation that resultant infertility may be immunologically mediated.

Delayed or incomplete puberty may reveal an endocrinologic etiology (such as Klinefelter's syndrome or idiopathic hypogonadism). Similarly, gynecomastia may also suggest an underlying endocrine problem.

Bilateral mumps orchitis experienced prepubertally seems to have no effect, but mumps orchitis experienced postpubertally is associated with severe testicular damage in 10% of patients.

Diabetes mellitus or multiple sclerosis can impair potency as well as ejaculation.

Treatment for cancer affects fertility. Any patient who has been treated with radiation or chemotherapy for testis or any other cancer is at risk of impaired spermatogenesis. Patients with testicular cancer are particularly affected.

Past history of a herniorrhaphy suggests the possibility of an iatrogenic vasal injury.

Any inflammatory process that involves the lower urinary tract may lead to adverse scarring of the ductal system, e.g., ejaculatory duct stenosis or obstruction, that may affect fertility. Furthermore, any generalized febrile episode may transiently impair spermatogenesis.

Immotile cilia syndrome (nonmotile sperm secondary to an ultrastructural defect in the sperm tail) may be the cause of infertility in the male with recurrent respiratory infections (Kartagener's syndrome or Young's syndrome).

A gene for cystic fibrosis is carried without their knowledge by a number of men who may also have congenital absence of the vasa and seminal vesicles and, consequently, a low ejaculate volume and azoospermia.

History of exposure to certain medications, drugs, or environmental toxins that may affect testicular function must be determined (see Table 2).

Exposure to elements increasing the overall scrotal temperature. The elevated testicular temperature observed with cryptorchidism and in association with scrotal varicoceles may explain the impaired spermatogenesis associated with these disorders. To optimize their sperm production, men are encouraged to avoid the use of saunas and hot tubs.

TABLE 2.
Medications, Toxins, and Drugs Associated with Male Infertility

PHYSICAL EXAMINATION

The initial physical examination performed by the primary care practitioner may reveal critical information pertaining to the etiology of a man's infertility. Special care should be taken by the physician to note any evidence of hypogonadism or a hypothalamic or pituitary tumor. Gynecomastia may indicate primary testicular failure or a secondary hypothalamic-pituitary axis abnormality.

Because the seminiferous tubules account for 85% of the testicular volume, a careful examination of the testicles may help identify the cause of the infertility as testicular or post-testicular (obstructive). The normal adult testicle averages 4.6 cm in length, 2.6 cm in width, and 18.6 mL in volume. These parameters can be easily measured using a ruler, caliper, or orchidometer. If testicular insult has occurred before puberty, the testes most likely will be small and firm, whereas postpubertal damage usually renders the testicles small and soft.

The prostate should be carefully examined for size (often small in men with androgen deficiency) and consistency (tender and boggy with prostatitis). The penis should be examined for any abnormalities (hypospadias, abnormal curvature, phimosis) that may interfere with the proper deposition of sperm deep within the vagina. The epididymis and vas should be carefully palpated. An irregular epididymis may indicate infection or obstruction. Finally, the vas should be palpated because approximately 2% of infertile men have congenital absence of the vasa and seminal vesicles. Since these men are also at risk for carrying one of more of the genes for cystic fibrosis, they should have a genetic evaluation.

Next, the testicular cords should be carefully palpated for the presence of a varicocele. With the patient standing in a warm examination room, the testicular (spermatic) cord should be palpated between the thumb and index finger while the patient performs the Valsalva maneuver, i.e., takes a deep breath and "bears down." An increase in the thickness of the cord or the presence of a discrete pulse (the venous reflux) suggests the possibility of a varicocele. In addition, a small left testicle with a boggy, "bag-of-worms"-like mass surrounding the testicle is very characteristic of a large varicocele. When any abnormalities are noted on the genital examination, prompt referral to the urologist is indicated for further noninvasive examinations (including ultrasound) or possible surgical considerations.

Finally, a full physical examination is performed to rule out any chronic or unsuspected systemic diseases that may impair testicular function.