HISTORY AND PHYSICAL EXAMINATION
Evaluation of the infertile man should include complete history, detailed physical examination and pertinent laboratory tests. Specialized questionnairefacilitates the accumulation of the necessary information. The male reproductive history often helps to explain abnormal semen analysis and direct further treatment.
I. Fertility history. Proper evaluation begins with a comprehensive fertility questionnaire. The age of the partners, detailed history of the couple's length of infertility, prior pregnancies, miscarriages and abortions must be ascertained. Any previous evaluation or treatment should be noted.
II. Sexual history. Too frequent intercourse or compulsive masturbation depletes sperm reserve. Most effective frequency of intercourse is every 48 hours and the optimal time is midcycle. Semen has to be ejaculated into the vagina. If lubrication is necessary, egg white or milk may be recommended since other lubricants, jellies, oils or saliva are somewhat spermicidal.
III. Ejaculate history. Markedly diminished semen volume and thin clear fluid suggests the absence of the seminal vesicles of congenital absence of the vas deferens. Low or absent semen volume with normal orgasm may be associated with retrograde ejaculation (sperm are ejaculated into the bladder).
IV. Male reproductive history
Cryptorchidism (9% of men attending an infertility clinic): progressive and irreversible loss of germ cells. 50% of men with a history of unilateral and 90% of men with bilateral cryptorchidism are subfertile. However, paternity was documented in 80% of men with a history of unilateral and 35% with a history of bilateral cryptorchidism. The effect of early (before 1 year of life) corrective surgery is not clear and may not preserve spermatogenic epithelium.
Prepubertal mumps does not affect testes while postpubertal mumps orchitis may cause severe spermatogenic disorders and testicular atrophy.
Hernia/hydrocele repair: 7.2% of men with obstructive azoospermia attending an infertility clinic was found to have iatrogenic injuries to the vas deferens.
Testicular torsion/trauma: Patients with unilateral torsion may be at risk for contralateral testicular damage. The etiology of the contralateral damage is thought to be immunologically mediated.
Many systemic diseases directly or indirectly affect fertility. Ejaculatory disorders are common in patients with diabetes mellitus, multiple sclerosis, and transverse myelitis and spinal cord injuries. Patients with testicular cancer have impaired pretreatment testicular function and also are at risk of infertility secondary to various surgical, chemotherapeutic and radiation treatment strategies due to destruction of spermatogonia. Men who underwent retroperitoneal lymph nodes dissection are at risk of ejaculatory failure due to damage of sympathetic chain overlying aortic bifurcation.
Any recent febrile illness may cause significant, but usually transient, damage to spermatozoa. Therefore semen analysis should be repeated in at least 3 months.
The history should include detailed review of medications and exposure to environmental gonadotoxins. Medications that affect spermatogenesis include cimetidine, ketoconazole, spironolactone, Dilantin, caffeine, sulfasalazine, colchicine, allopurinol, and calcium channel blockers. Marijuana, heroin, cocaine, alcohol, nicotine showed spermatotoxic effect.
The use of anabolic steroids by athletes suppresses gonadal function by depressing pituitary output of LH and FSH through feedback inhibition. The usual results are severe oligospermia or azoospermia, which is usually, but not always, reversible after discontinuation of steroids.
Physical examination is performed in a warm room(20-24 C) by an examiner with warm-gloved hands, since contraction of dartos muscle induced by low temperature makes examination of scrotal contents difficult. The patient is asked to disrobe completely and stand with his arms outstretched. Physical examination begins with thorough observation of the general status and body habitues of the patient as well as secondary sex characteristics. Incomplete masculinization with disproportional long extremities due to deficient androgen stimulation required for epiphyseal closure at the time of puberty often indicates Klinefelter's syndrome.
The thyroid is palpated and the heart and lungs auscultated. The breasts are observed and palpated for gynecomastia (it may be associated with estrogen secreting testicular tumors, adrenal tumor and liver disease). Galactorrhea may be associated with prolactin-secreting pituitary adenoma. Auscultation of heart and lungs is performed. Chronic bronchitis may be associated with congenital epididymal dysplasia seen in Young's syndrome. Situs inversus is seen in immotile cilia syndrome Palpation and percussion of abdomen then performed.
Penis and urethral meatus are examined for condylomata, discharge, and position of the meatus (hypospadia)
Scrotal examination is first performed with the patient in a supine position.
Normal testes are rubbery, about 4.6 cm long and 2.6 cm wide with average volume 18-30ml. The volume of each testis is compared with the corresponding ovoid of the Prader orchidometer. The seminiferous tubules with germinal cells account for 90% of testicular volume, therefore smaller and softer testes indicate the lower sperm production. A change is testicular volume and consistency is indicative of testicular pathology. Testicular consistency should be estimated by gentle pressure. Small firm testes usually no more than 3 ml in volume are found in men with Klinefelter's syndrome. Small soft testes indicate poor spermatogenesis. Focal irregularities in consistency may represent testicular tumor.
Normal epididymis is located posterolateral to the testis, generally smooth, nondilated and soft, running in a superior to inferior direction. A full firm easily outlined epididymis that is nontender suggests epididymal obstruction. Spermatocele is dilated cystic extension of the efferent ducts and may act as obstructive lesion. Cystic epididymis may occur in patients with Von Hippel-Lindau disease
The vas deferens is palpable from convoluted portion to the external inguinal ring, usually posteromedial and separate from internal spermatic cord structure. If vas is present, note should be made of whether or not it is normal, thickened, nodular,or painful. Normal vas is thin, firm tubular structure.is the diameter and consistency of a venetian blind cord and should be palpated bilaterally. Congenital bilateral absence of the vas deferens was observed in 1.3% of men presenting for infertility evaluation. This condition is associated with renal agenesis and abnormalities in 20% of patients, therefore, renal sonogram should be obtained. Most men with this condition test positive for cystic fibrosis gene mutation. Unilateral absence of the vas deferens is much rarer. Palpation is the best way to diagnose absent vas. In patients with absence of the vas epididymis may be of any length and consistency, but usually only the caput portion is present. Atretic vas may be confused with spermatic cord vessels
Evaluation of varicocele should be performed in an upright position. Varicocele can be categorized into:
Subclinical: abnormality is present only upon scrotal thermography or Doppler ultrasonography
Grade I: No visible or palpable venous distension except when Valsalva maneuver is performed. The best method to elicit a strong and sustained Valsalva is to tell the patient to bear down as if having a bowel movement. It may reveal "impulse" if varicocele is present
Grade II: venous distension is easily palpable but not visible.
Grade III: venous plexus is visible through scrotal skin ("bag of worms").
A large varicocele that does not collapse in the supine position warrants a search for abdominal or retroperitoneal mass.
Inguinal examination has to be performed to examine for inguinal scars, hernias
Digital rectal examination is always performed to evaluate prostate. Occasionally large midline cystic structure may be palpable. Seminal vesicles are not normally palpable. If they are palpable and/or painful, this usually indicates obstruction or inflammation. Stool should be tested for occult blood.
- Goldstein M., Matthews GJ. What's Important and What's New in the Management of Male Infertility. In: Stephen N Rous, editor. Urology Annual, 1995; 253-283
- Sandlow JI, Sparks AET. Evaluation of the male in couples seeking reproductive assistance: Going beyond the seminal fluid analysis. Assisted reprduction reviews 1998; 8(1): 36-39