Subfertility in Men
🔎 Initial Assessment
- ⏳ Duration of Infertility: Subfertility = no conception after 12 months of regular, unprotected intercourse.
- ❤️ Sexual History: Frequency & timing of intercourse, erectile/ejaculatory dysfunction.
- 🤰 Pregnancy History: Previous successful or unsuccessful conceptions give insight into fertility potential.
- 🩺 Medical History: Thyroid disease, diabetes, mumps orchitis, undescended testes.
- 👨👩👦 Family History: Genetic or inherited fertility problems (e.g., CF, Klinefelter’s).
- 🚬🍺 Lifestyle: Smoking, alcohol, drugs, obesity, heat exposure, stress → impair sperm quality.
👨 Examination
- 🧍 General: Look for hypogonadism (gynecomastia, small testes, low muscle mass).
- ⚕️ Genital Exam: Testicular size, varicocele (“bag of worms”), absence of vas deferens.
- 💇 Secondary Sexual Features: Body hair, fat distribution, signs of androgen deficiency.
🧪 Basic Investigations
- 💧 Semen Analysis: WHO criteria → sperm count, motility, morphology (key first-line test).
- 🧬 Hormonal Profile: FSH, LH, testosterone, prolactin → distinguish testicular vs pituitary causes.
- 🦋 Thyroid Function: Hypo/hyperthyroidism can reduce fertility.
- 🖥️ Scrotal Ultrasound: Detect varicocele, duct obstruction, congenital absence of vas deferens.
🔬 Further Investigations
- 🧾 Genetic Testing: Karyotype (Klinefelter’s), Y-chromosome microdeletions.
- 🧩 Testicular Biopsy: Distinguishes obstructive vs non-obstructive azoospermia.
- 🧠 Pituitary MRI: If hypogonadotropic hypogonadism suspected.
⚠️ Major Causes & Management
- 🧪 Semen Abnormalities: Oligospermia, asthenospermia, teratospermia.
➡️ Lifestyle optimisation, medical therapy (clomiphene, hCG), ART (IUI, IVF, ICSI).
- 🚫 Obstructive Azoospermia: Blocked ducts or absent vas deferens.
➡️ Surgical repair (vasovasostomy/epididymovasostomy) or sperm retrieval + ICSI.
- 🩸 Varicocele: “Bag of worms” scrotal veins, worsens spermatogenesis.
➡️ Varicocelectomy for symptomatic/abnormal semen. ART if persistent.
- ⚖️ Hormonal Imbalance: Hypogonadotropic hypogonadism.
➡️ hCG or GnRH therapy, treat pituitary disorders, optimise lifestyle.
- 🧬 Genetic Factors: Klinefelter’s, Y-chromosome microdeletions, CFTR mutations.
➡️ Genetic counselling, consider ART (ICSI with TESE if viable sperm), donor sperm if severe defect.
💡 Management Approaches
- 🥦 Lifestyle: Healthy weight, stop smoking/alcohol/drugs, avoid prolonged heat (tight underwear, laptops on lap).
- 💊 Medical: Hormonal therapy in selected cases (hCG, GnRH, clomiphene).
- 🔪 Surgical: Varicocelectomy, vasectomy reversal, correction of duct obstruction.
- 🧫 ART (Assisted Reproductive Technologies):
- 🧴 IUI: Sperm placed directly into uterus.
- 🧫 IVF: Fertilisation outside body, embryo transfer.
- 💉 ICSI: Single sperm injected into egg (key for severe male factor infertility).
🧠 Psychological Support
- 🗨️ Counselling: Address anxiety, depression, relationship stress.
- 🤝 Support Groups: Peer support reduces isolation and stigma.
📈 Referral
- Couples with severe semen abnormalities, azoospermia, failed basic treatment, or complex endocrine/genetic causes → early referral to fertility specialist.
💡 Exam tip: Always start with lifestyle optimisation and semen analysis, then escalate to hormonal, surgical, or ART approaches depending on cause. Don’t forget psychological support – a key OSCE station mark!
