An update on the clinical assessment of the infertile male. [corrected]

Abstract

Male infertility is directly or indirectly responsible for 60% of cases involving reproductive-age couples with fertility-related issues. Nevertheless, the evaluation of male infertility is often underestimated or postponed. A coordinated evaluation of the infertile male using standardized procedures improves both diagnostic precision and the results of subsequent management in terms of effectiveness, risk and costs. Recent advances in assisted reproductive techniques (ART) have made it possible to identify and overcome previously untreatable causes of male infertility. To properly utilize the available techniques and improve clinical results, it is of the utmost importance that patients are adequately diagnosed and evaluated. Ideally, this initial assessment should also be affordable and accessible. We describe the main aspects of male infertility evaluation in a practical manner to provide information on the judicious use of available diagnostic tools and to better determine the etiology of the most adequate treatment for the existing condition.

Figure 1

Tools commonly used during the physical examination of subfertile males. A) Photograph of the Prader orchidometer. It is used to measure the volume of the testicles and consists of a chain of 12 numbered beads of increasing size from 1 to 25 mL. The beads are compared with the testicles of the patient and the volume is read off the bead that most closely matches the size of the testicle. Pre-pubertal sizes are 1 to 3 mL, pubertal sizes are 4 to 12 mL and adult sizes are 15 to 25 mL. B) Schematic illustration depicting the use of the 9 Mhz pencil-probe Doppler stethoscope for varicocele examination. The patient is examined in the upright position and the conducting gel is applied to the upper aspect of the scrotum. A venous “rush” may be heard during the Valsalva maneuver, indicating blood reflux.

Figure 2

Photograph of a large left grade III varicocele that can be seen through the scrotal skin.

Figure 3

Magnetic resonance imaging showing enlarged seminal vesicles with lithiasis.

Figure 4

Algorithms for the workup of the infertile male. Algorithm to be considered on initial assessment (top). Algorithm for the management of the patient presenting with azoospermia (bottom).