The first visit is geared to understanding each individual couples' problems, goals and timeline for treatment. I spend a lot of time educating patients on fertility issues that may pertain specifically to them as there are a lot of terms and phrases used and understanding these is critical.
The medical evaluation of men having difficulty with fertility includes four major components:
A history of specific childhood illnesses and disorders may be an important finding in the evaluation of the infertile male. For example, it has been shown that in the male born with an undescended testis on one side, regardless of the time of surgery to correct this, semen quality is considerably less than that found in normal men.
Approximately 30% of men with unilateral undescended testicles and 50% with bilateral undescended testicles have sperm counts below 10 million/mL. Despite this impairment in semen, the majority of men with a history of one undescended testis are able to initiate a pregnancy without difficulty.
A history of postpubertal mumps infection of the testicle is also important. Mumps does not appear to affect the testes when experienced prepubertally. However after the age of 11 or 12, unilateral mumps orchitis is seen in 30% of males affected and bilateral orchitis in approximately 10%. Furthermore, the testicular damage can be quite severe and should be readily appreciated on physical examination, since the involved testis will be markedly small and soft.
Patients who have had operative correction of bladder conditions during childhood often suffer from retrograde ejaculation due to ablation of the internal sphincter at the bladder opening. Bladder neck reconstruction at the time of ureteral reimplantation surgery was common in the early 1960s. Retrograde ejaculation should be suspected in men who give a history of bladder surgery and whose ejaculate volume is less than 1 cc. The correct diagnosis can be made by finding large numbers of sperm in the postejaculate urine. Children born with congenital anomalies involving the male reproductive system, such as bladder exstrophy/epispadias, can also exhibit abnormalities of ejaculation. Sperm production in the testis is usually normal; however, the ejaculatory ducts may be obstructed or retrograde ejaculation may occur.
The history should also include a detailed inquiry into exposure to environmental toxins and medications that may interfere with spermatogenesis, either directly or through alterations in the endocrine system. For agents such as heat, ionizing radiation, heavy metals, and some organic solvents, there are many studies that support these associations. Recent publications have also reported the effect of specific pesticides (i.e. dibromochloropropane) on gonadal function. Furthermore, reversibility has been substantiated when the infertile patient has been removed from this toxic environment. However, once azoospermia (no sperm at all in the ejaculation) has occurred, return to a normal pre-exposure state is highly unlikely.
Medications, such as sulfasalazine and cimetidine, or ingestants, such nicotine, alcohol, or marijuana, have also been shown to be gonadotoxic agents. Withdrawal from these substances should enable return of normal spermatogenesis if they are acting adversely.
The use of anabolic steroids is a potentially significant cause of infertility in both adults and adolescents, and the problem is becoming more common. The incidence of steroid abuse has been reported to be as high as 30%-75% among professional athletes or body builders. Androgenic steroids exert their deleterious effect by depressing hormone secretion from the pituitary gland and interfering with normal spermatogenesis. Consequently, if a person is taking any of these medications at the time of initial interview, the medication should be stopped and the patient's semen reevaluated at a later date.
Retroperitoneal Lymph Node Dissection. Approximately 75% of all testicular cancer patients will retain the potential for fertility. Retroperitoneal lymph node dissection can involve excision of portions of the sympathetic chain necessary for ejaculation. Some patients will retain seminal emission, but many will have retrograde ejaculation or lose the ability to emit semen altogether.
Prostatectomy. Patients who have had transurethral or open prostatectomy also have a high incidence of retrograde ejaculation. This incidence is reported to range from 40%-90%.
One of the most common problems encountered in this patient population is either too-frequent or too-infrequent sexual intercourse. Often, neither the husband nor the wife understands the menstrual cycle. The optimal time for intercourse is midcycle with a frequency of intercourse every 48 hours. This is based on the fact that sperm survival in normal cervical mucus is approximately 2 days. Thus, this frequency will assure viable sperm concurrently in the 24-hour period during which the egg will be within the fallopian tube and capable of being fertilized. A recent study in the New England Journal of Medicine revealed that the highest likelihood of conception occurs when intercourse is performed within the 48-hour period preceding ovulation.
It is also important to discuss coital techniques with the husband, e.g., the use of lubricants or the frequency of masturbation that can deplete the sperm "reserve." Many lubricants have been tested for in vitro effects on sperm motility. Commonly used substances, such as K-Y Jelly, Lubifax, Surgilube, Keri Lotion, petroleum jelly, and saliva result in a deterioration of motility. Others, such as raw egg white, vegetable oil, and the Replens douche, have not impaired in vitro motility. Astroglide, a water-soluble, inert vaginal lubricant, contains no petroleum ingredients or detergents that may be toxic to sperm; however, with increasing concentration, there is impairment of sperm motility equivalent to that found with K-Y jelly.
Physical examination of the infertile man is brief and focused on the testicles and adjacent structures in the scrotum. Any factor that affects overall health can theoretically be responsible for abnormalities in sperm production.
Decreased body hair Gynecomastia Eunuchoid proportions
Peyronie's disease (acquired curvature) Congenital curvature Hypospadias
Testicular volume Epididymal induration Presence/absence of vas deferens Varicocele
|Digital Rectal Examination||
Prostatic size Prostatic/seminal vesicular mass/induration/cysts
If the patient appears to be inadequately virilized (androgen-deficient), as evidenced by decreased body hair, gynecomastia (breast enlargement), eunuchoid proportions (tall/thin appearance) the diagnosis of delayed maturation due to an endocrine abnormality should be considered and evaluated.
Penile curvature or angulation should be assessed, as should the location of the urethral meatus (opening). Some anatomic abnormalities can result in improper placement of the ejaculate within the vaginal vault.
The bulk of the physical exam should be focused on the scrotum. Testicular size and consistency should be noted. Decreased testicular size is often associated with impaired sperm production. The length of the testis should be greater than 4 cm and the volume greater than 20 mL. Examination of the tissue adjacent to the testis is also essential. Epididymal induration, irregularity, and cystic changes should be noted, as should the presence of absence of the vas deferens and any nodularity along its course.
Finally, engorgement of the veins around the testis should be identified. This is called a varicocele and is the most common cause of abnormalities in testis function found in men. Varicoceles are essentially varicose veins of the scrotum. They are more common on the left than the right, but can occur on both sides as well (Fig. 1). The deleterious effect of varicoceles on testis function is most likely due to heat transmitted from the dilated veins to the testis. The testes hang outside the body proper so that they can be 2-3 degrees cooler than core body temperature. Sperm production and function is very sensitively linked to temperature. Most varicoceles are readily detected on physical exam. However, if thick spermatic cords are palpated, but these do not get larger with straining, a scrotal ultrasound should be performed to confirm whether a varicocele is present.
DRE is sometimes necessary to assess prostatic size as well as to rule out prostatic and/or seminal vesicular firmness, masses, or cysts.
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