Makindo Medical Notes

Related Subjects: |Male Infertility |Prolactin |Prolactinoma |Sheehan's syndrome

👨‍⚕️ Male Infertility: Causes & Management

Male factors contribute to ~40–50% of infertility cases. Causes range from structural, hormonal, and genetic to unexplained. A structured approach—history, examination, semen analysis, and targeted investigations—is essential for diagnosis and management.

🔎 History (Key OSCE Points)

• Duration of Infertility: ≥12 months of regular unprotected intercourse?
• Sexual History: Erectile dysfunction? Ejaculatory issues (retrograde ejaculation, premature ejaculation)?
• Past Medical/Surgical History: Mumps orchitis, STIs, undescended testes, torsion, hernia repair, vasectomy?
• Medications: Anabolic steroids, chemotherapy, spironolactone, finasteride?
• Lifestyle Factors: Smoking, alcohol, recreational drugs, occupational heat exposure (drivers, welders), saunas/laptops?
• Family History: Genetic syndromes (Klinefelter, cystic fibrosis), infertility in siblings?
• Partner’s History: Always explore menstrual regularity, obstetric history, and gynaecological conditions.

🩺 Examination (Targeted)

• General: Height, weight, BMI, virilisation, secondary sexual characteristics.
• Breast Exam: Gynaecomastia (consider Klinefelter or endocrine imbalance).
• Genital Exam:
  • Testes size (orchidometer: normal ≥15 mL, soft/small = failure).
  • Varicocele (“bag of worms” above testis, more prominent standing).
  • Epididymis/vas deferens presence (absent in CFTR mutations).
  • Penile abnormalities (hypospadias, chordee).

🔎 Key Causes

• Varicocele: Painless scrotal swelling, may cause oligospermia. 🧪 Scrotal US. 💊 Varicocelectomy if symptomatic/abnormal semen; IVF/ICSI if persistent.
• Obstructive Azoospermia: Normal hormones, absent vas deferens or ejaculatory duct obstruction. 🧪 Semen analysis (azoospermia), TRUS, CFTR testing. 💊 Surgical correction or sperm retrieval + ICSI.
• Hypogonadotropic Hypogonadism: Low libido, delayed puberty, small testes. 🧪 ↓Testosterone, ↓FSH/LH, pituitary MRI. 💊 hCG + FSH, pulsatile GnRH, ART if needed.
• Genetic Causes (e.g. Klinefelter 47,XXY): Tall stature, gynaecomastia, firm testes. 🧪 Karyotype, ↑FSH, testicular biopsy. 💊 Testosterone replacement, micro-TESE + ICSI, genetic counselling.
• Infections: Epididymo-orchitis, STIs. 🧪 Urine/STI screen, scrotal US. 💊 Antibiotics, drainage if abscess. ART if residual damage.
• Testicular Cancer: Painless lump, ± gynaecomastia. 🧪 US, tumour markers (AFP, hCG, LDH). 💊 Orchiectomy, chemo/radio, sperm banking pre-treatment.
• Immunologic Infertility: Post-trauma/surgery → antisperm antibodies. 🧪 Antibody test, semen agglutination. 💊 ICSI or IUI; steroids rarely used.
• Idiopathic Infertility: No obvious cause, abnormal semen. 💊 Lifestyle changes, antioxidants, ART (IUI/IVF/ICSI).

🧪 Investigations

• Semen Analysis: At least 2 samples, ≥3 weeks apart. WHO reference: count ≥15 million/mL, motility ≥40%, morphology ≥4% normal.
• Hormones: Testosterone, FSH, LH, prolactin.
• Genetics: Karyotype (Klinefelter), Y-microdeletions, CFTR gene.
• Imaging: Scrotal US (varicocele/masses), TRUS (ejaculatory duct obstruction).
• Other: Sperm antibodies if clumping noted.

💊 Management Principles

• 🔄 Correct reversible causes (varicocelectomy, hormonal therapy, infection treatment).
• 🛑 Lifestyle optimisation (quit smoking, reduce alcohol, lose weight, avoid heat/androgens).
• 👶 ART options: IUI, IVF, ICSI depending on severity and female partner factors.
• 🧬 Genetic counselling where appropriate (Klinefelter, Y-microdeletions, CFTR).
• 💾 Sperm banking before gonadotoxic therapy (chemo/radiotherapy).

📚 Case Examples

• Case 1: 28-year-old with varicocele + oligospermia → varicocelectomy ± ART.
• Case 2: 35-year-old azoospermia, no vas deferens → CFTR mutation → sperm retrieval + ICSI.
• Case 3: 40-year-old tall man, firm testes, gynaecomastia, azoospermia → Klinefelter → testosterone + micro-TESE.
• Case 4: 30-year-old post-mumps orchitis, small testes, ↑FSH → primary failure → donor sperm ART.

💡 Exam Tip: In OSCEs, always adopt a couple-based approach (ask about partner’s history, cycle, previous pregnancies). Male infertility is rarely managed in isolation.

💡 Pearls

• Always repeat semen analysis before diagnosing infertility.
• Think: pre-testicular (endocrine), testicular (damage/genetics), post-testicular (obstruction, ejaculation).
• Don’t forget systemic risks: infertility may be the first clue to testicular cancer or pituitary disease.
• Multidisciplinary: urology, endocrinology, fertility specialists, geneticists.