Diagnosis of Infertility in Men
During the initial consultation, both partners will be evaluated for fertility problems. Your healthcare provider will ask about any symptoms, and your family and medical history will be reviewed. This will include any serious medical conditions or treatments, history of previous sexually transmitted diseases, history of trauma and your lifestyle, including use of tobacco and alcohol.
Male infertility is not the same as impotence, which is the inability to have an erection.
Your healthcare provider will also perform a physical exam. During the physical exam, he or she will look for varicoceles (a dilation or swelling of the veins that drain the testicle) and any other physical problems, such as undescended testicles, that might cause infertility. In addition, the pattern of hair growth in the genital area will be assessed. The prostate gland will be examined also. You will probably be asked to produce a semen sample for analysis and a blood sample to assess levels of reproductive hormones. Other tests will depend on the healthcare providers evaluation of your physical, medical and family history.
This is usually the first part of any evaluation for male infertility. The semen analysis is performed in a laboratory or your doctor’s office. The semen sample needs to be examined soon after it is produced (within a few hours). You should abstain from ejaculating for at least 48 hours but not more than five days before the semen analysis.
Several aspects of the semen will be assessed:
The normal volume of semen is 2 to 5 milliliters (about a teaspoon). If the volume is low, it could indicate that the seminal vesicles are not making enough fluid or that the tubes are blocked. The prostate gland also contributes fluid to semen, and low total volume could indicate a problem with the prostate.
Sperm Number (Count)
The normal number of sperm in a sample is 40 million to 300 million per milliliter. Sperm counts below 10 million per milliliter are considered poor. A sperm count is considered adequate if it is over 20 million, and the movement and shape of the sperm are normal.
Motility and Velocity
This refers to the sperm’s ability to move. The percentage of sperm that are active will be rated (from 0% to 100%), with normal considered at least 50% active. In addition, the quality of sperm movement (forward progression) will be assessed and rated on a 0 to 4 scale, with a score of 2 or more considered adequate.
To be considered normal, a sperm must have an oval head, a normal mid-piece, and a tail. An abnormal sperm could have a tapered head, or two tails. The sperm head contains enzymes that break down the egg's protective coating and allow the sperm to penetrate the egg. High numbers of abnormally shaped sperm can reduce the ability of the sperm to fertilize an egg. The normal value for sperm morphology is reported in two ways. The World Health Organization reports the percent of normal-shaped sperm as greater than 60%. Another method is the Kruger classification (strict criteria), which more selectively evaluates sperm shape. The percentage of normally shaped sperm by the strict criteria is greater than 14%. The Kruger classification is used by some fertility clinics because it can more accurately predict the level of sperm fertilization.
Other Semen Tests
The semen analysis also reports the presence or absence of the sugar fructose, which is normally present in semen. If fructose is absent, it suggests a congenital absence of the vas deferens or seminal vesicles or an obstruction in the ducts.
Normal fresh semen immediately coagulates into a gel that liquefies within 20 minutes or so. If semen does not gel and then liquefy again, it could suggest a problem in the seminal vesicles.
If the sperm do not move well and clump, the doctor may look for antibodies in the blood and on the sperm’s surface. Antibodies that attach to the head of the sperm can affect its ability to penetrate the egg, and antibodies on the tail can alter motility.
This test checks for bacterial infections that may contribute to infertility.
In this test, sperm is mixed with hamster eggs to assess the sperm’s ability to break through the outer membrane of the egg and fuse with the egg’s cytoplasm. This test is commonly called the hamster egg test or sperm penetration assay (SPA).
Cervical Mucus Penetration Test
This test assesses how well the sperm can move through mucus, which is normally present in the woman’s cervix. For this test, cervical mucus is simulated with cow mucus.
A blood test may be performed to determine your levels of important reproductive hormones, including follicle-stimulating hormone (FSH), androgens (testosterone), luteinizing hormone (LH), and prolactin.
If your sperm count is very low, you may have a chromosomal abnormality that is affecting your ability to produce sperm. The presence of this type of abnormality can be determined through a blood test that is sent to a special lab that will prepare a karyotype to look at the chromosomes.
In addition there are more specific genetic tests that may be performed depending on your history and examination.
Other Possible Tests
In some circumstances, your doctor may request additional tests. These may include:
- Ultrasound —a test that uses sound waves to examine structures inside the body
- X-ray —a test that uses radiation to take a picture of structures inside the body
- Testicular Biopsy —removal of a small sample of testicle tissue for testing
- Post-coital Test —to determine if your sperm is compatible with the mucus in your partner’s cervix
American College of Obstetricians and Gynecologists website. Available at: http://www.acog.org/ .
American College of Obstetricians and Gynecologists. Guideline: management of infertility caused by ovulatory dysfunction. Obstet Gynecol. 2002;99:247-258.
American Society for Reproductive Medicine website. Available at: http://www.asrm.org/.
American Society for Reproductive Medicine. Guideline: optimal evaluation of the infertile female. Fertil and Steril. 2004;82:S169-S172.
International Council on Infertility Information Dissemination website. Available at: http://www.inciid.org/.
Jose-Miller AB, Boyden JW, Frey KA. Infertility. Am Fam Physician. 2007;75:849-856.
RESOLVE. The National Infertility Association website. Available at: http://www.resolve.org/.
Sharlip ID, Jarrow J, Beiiker AM, et al. Report on optimal evaluation of the infertile male. J Urol. 2002;167:2138-2144.
Shefi S, Turek PJP. Definition and current evaluation of subfertile men. Internat Braz J Urol. 2006;32:385-397.
Last reviewed November 2008 by ]]>Adrienne Carmack, MD]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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