Infertility
Page updated Winter 2023.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to take or administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.
Evaluation
Step 1
History: Improperly timed intercourse, spermicidal lubricant, heat exposure, recent febrile illness, exogenous testosterone, chemo, radiation, others
Physical Exam: Testicles, epididymis, and vas deferens
Semen Analysis: X 2 SA References
Testosterone: Normal: >300 ng/dL
FSH
Obstructive: FSH <7.6 IU/L and testis > 4.6 cm
Non-obstructive: FSH >7.6 IU/L and testis < 4.6 cm
Abnormal Hormones
Correct it and check semen analysis in 2-3 months. Hormones Normal Values
Pyospermia
Infectious symptoms: Doxycycline 100 mg bid for 4 weeks.
No infectious symptoms: Antinflammatory medications for 2 weeks. Ask the patient to have 2-3 ejaculates per day. Repeat SA. If there is pyospermia, treat with Doxycyline.
Vasal agenesis
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Gene
CFTR mutation: mTESE
Renal Ultrasonography
Step 2 Scenario 1: Low Volume Semen
Postejaculate Urinalysis
Positive for sperm:
Pseudoephedrine
Natural means, IUI, IVF
Negative for sperm: Rule out ejaculatory duct obstruction if semen is acidic and there is azoospermia
Transrectal Ultrasonography (TRUS)
SV> 1.5 cm: Ejaculatory duct obstruction
Step 2 Scenario 2 :Azoospermia, Sperm Count <5 million sperm/mL
Karyotype and Y-chromosome
Microdeletion Analysis
Klinefelter syndrome (47,XXY) is the most common genetic cause of male infertility.
AZFc deletion, XXY: mTESE
AZFa or AZFb deletion: Donor sperm, adoption
Step 2 Scenario 3: Normal SA or Isolated or globally reduced parameters
Semen volume is not < 1.5 ml
Sperm count is not < 5 million/ mL
Management Options: Natural means, IUI, IVF
Low Testosterone
Do not use testosterone replacement for the treatment of male infertility or for males who are interested in future fertility.
Hypogonadotropic Hypogonadism
Etiology of the disorder should be determined and treated accordingly.
Hyperprolactinemia
Etiology of the disorder should be determined and treated accordingly.
Treatment options for infertile patients are:
HCG Injection: 1,500-5,000 IU two to three times weekly (M/W/F) to a maximum of 10,000 IU/week administered intramuscularly or subcutaneously.
Anastrozole (Arimidex): 0.5- 1 mg PO, 3/week (M/W/F)
Clomiphene (Clomid):Start with 25 mg PO, 3 times per week (M/W/F) and slowly titrate up to 50 mg once a day as needed.
Low FSH
FSH Injection :75–150 IU, SC injection, 2–3 times per week
hMG Injection:75 IU , SC injection, 2–3 times per week
Idiopathic Infertility
Therapeutic options are:
FSH analogue: 150 IU three times weekly- IM or SC
ART
Gonadotoxic Exposure
Includes chemotherapy and/or radiation therapy.
Bank sperm, preferably multiple specimens prior to gonadotoxic therapy.
Avoid pregnancy for at least 12 months after completion of treatment.
Semen Analysis should be performed at least 12 months (preferably 24 months) after treatment completion.
TESE might be needed.
RPLND and Neurogenic Aspermia
There is risk of aspermia after RPLND, due to retrograde ejaculation.
Sperm retrieval options:
Sympathomimetics
From urine after alkalization of urine. Post-orgasmic urinalysis is useful for sperm retrieval.
Vibratory stimulation
Electroejaculation
Surgical sperm retrieval
Varicocele
Varicocelectomy is recommended in infertile men, if there is palpable varicocele(s),and abnormal semen analysis.
Varicocelectomy is not recommended for men with non-palpable varicoceles detected only by imaging.
We do not recommend varicocelectomy for azoospermic men.
History of Vasectomy
Therapeutic options are:
Microsurgical reconstruction
Sperm retrieval
Ejaculatory duct obstruction
Therapeutic options are:
Transurethral resection of ejaculatory ducts (TURED)
Sperm retrieval
Sperm Retrieval- Non-obstructive Azoospermia
Options are:
Testicular sperm extraction (TESE)
Sperm Retrieval- Obstructive Azoospermia
Therapeutic options are:
Microsurgical epididymal sperm aspiration
Percutaneous epididymal sperm aspiration
Testicular sperm extraction
Cryopreserved sperm
Either fresh or cryopreserved sperm may be used for ICSI.
Intrauterine Insemination (IUI)
Clomid or hMG may be used to improve success rate.
It is associated with lower pregnancy rates in men with low total motile sperm count (<5 million motile sperm).
Assisted Reproductive Technology (ART)
IVF/ICSI: In vitro fertilization/ intracytoplasmic sperm injection
Inform men with Yq microdeletion who would like to proceed with ICSI that microdeletions will be passed to sons, but not to daughters.
Recurrent pregnancy losses
Sperm DNA Fragmentation
Karyotype