Infertility

Page updated Winter 2021.
DisclaimerMedicine 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 resources. 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 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 resources. 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.

Diagnosis
Semen Analysis

 Parameter Lower reference limit (range)
 Semen volume (mL) 1.5 (1.4-1.7)
 Sperm concentration (millions/mL) 15 (12-16)
 Total sperm number (millions/ejaculate) 39 (33-46)
 Total motility  40 (38-42)
 Progressive motility (%) 32 (31-34)
 Vitality (%) 58 (55-63)
 Sperm morphology (normal forms, %) 4 (3.0-4.0)
 pH > 7.2
 Peroxidase-positive leukocytes (millions/mL) < 1.0
 
FSH

Helps with diagnosis of azoospermia without biopsy.
Obstructive: FSH <7.6 IU/L and testis > 4.6 cm
Non-obstructive: FSH >7.6 IU/L and testis < 4.6 cm

Testosterone

Normal: >300 ng/dL

Karyotype and Y-chromosome Microdeletion Analysis

Non-obstructive azoospermia
Sperm count <5 million sperm/mL
Klinefelter syndrome (47,XXY) is the most common genetic cause of male infertility.

Sperm DNA Fragmentation

For couples with recurrent pregnancy losses. Also perform karyotype in this setting.

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Gene

For vasal agenesis.

Infection Evaluation

For pyospermia.

Transrectal Ultrasonography (TRUS)

If ejaculatory duct obstruction is suspected.

Renal Ultrasonography

For patients with vasal agenesis.

Treatment

Low Testosterone

Treatment options for infertile patients are:

Aromatase inhibitors: Anastrozole or letrozole

Selective estrogen receptor modulators (SERMs)

Clomiphene, Tamoxifen

hCG

Combination therapy

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.


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.

Post-orgasmic urinalysis is useful for sperm retrieval. 

Therapeutic options include:

Sympathomimetics 

Sperm retrieval for IVF:

From urine after alkalization of urine

Vibratory stimulation 

Electroejaculation

Surgical sperm retrieval


Treatment

Varicocele

Varicocelectomy is recommended 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.

Vasectomy 

Therapeutic options are:

Microsurgical reconstruction

Sperm retrieval


Ejaculatory duct obstruction

Therapeutic options are:

Transurethral resection of ejaculatory ducts (TURED) 

Sperm retrieval


Sperm RetrievalNon-obstructive Azoospermia

Therapeutic 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.