Clinical summary guide

Male infertility

3 min

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The GP’s role

Do not wait before beginning assessments.

  • GPs can begin with simple, inexpensive, and minimally invasive investigations.

  • Infertility needs to be assessed and managed as a couple and may require several different specialists.

Diagnosis

Brief assessment and pre-pregnancy advice.

Table: Brief assessment and pre-pregnancy advice.

Reproductive history

Table: Reproductive history

Physical examination

Table: Physical examination

Investigations

Semen analysis is the primary investigation for male infertility.

Key points

  • Men should abstain from sexual activity for between 2-7 days before sample collection

  • Semen analysis provides guidance to fertility; it is not a direct test of fertility. Fertility remains possible even in those with severe deficits

Reference limits for semen analysis

Table: Reference limits for semen analysis

Serum testosterone and luteinising hormone (LH)

  • Testosterone is often normal 8-27 nmol/L, even in men with significant sperm defects

  • Some men with severe testicular problems display a fall in testosterone levels and rise in serum LH, these men should undergo evaluation for androgen deficiency

  • The finding of low serum testosterone and low LH suggests a hypothalamic-pituitary problem (e.g. prolactinoma) (serum prolactin levels required)

  • Testosterone reference range may vary between laboratories

Serum FSH levels

  • Elevated levels are seen when spermatogenesis is poor (primary testicular failure)

  • In normal men, the upper reference value is approximately I8 U/L

  • In an azoospermic man: -FSH > 10 IU/L suggests spermatogenic failure -FSH < 5 IU/L suggests obstructive azoospermia

Management 

Treatment options

Protecting and preserving fertility

Mumps vaccination, sperm cryopreservation (prior to chemotherapy, vasectomy or androgen replacement), safe sex practices, and early surgical correction of undescended testes.

Options for improving natural fertility

It may be possible to improve fertility for a minority of infertile men, including those with clinically diagnosed varicocele and abnormal semen parameters, pituitary hormonal deficiency or hyperprolactinemia, genitourinary infection, erectile and psychosexual problems and through the withdrawal of drugs (especially androgenic hormones). 

Assisted reproductive technology (ART)

ART options range in cost and invasiveness:

  • Artificial insemination with men’s sperm at midcycle

  • Conventional IVF

  • Intracytoplasmic sperm injection (ICSI) for severe male factor problems. Sperm can be readily obtained by testicular needle aspiration in the setting of obstructive azoospermia. Some azoospermic men with spermatogenic failure may have sperm recovered for ICSI by microdissection testicular sperm extraction (micro-TESE)

Donor insemination

For men with complete failure of sperm production.

Specialist referral and long-term management

Warning: Never institute testosterone replacement therapy in a newly recognised androgen deficient man who is seeking fertility. The fertility issue must be addressed first as testosterone therapy has a potent contraceptive action via suppression of pituitary gonadotrophins and sperm output.

When should I refer a patient?

GPs can refer couples immediately or after a few months during which baseline tests are performed.

Referral will depend on the associated problem:

  • Endocrinologist (endocrine associated problems)

  • Urologist (undescended testes, sperm extraction, varicocele surgery)

  • Fertility specialist/ART clinic that offers full assessment, including examination of the male partner

Long-term management:

  • Includes assessment for late-onset androgen deficiency, testis cancer

Fertility clinics

A list of Australian ART Clinics, accredited by the Reproductive Technology Accreditation Committee are available via Fertility Society of Australia.

Supporting the couple

  • Acknowledge both partners’ experience of infertility and encourage couple communication

  • Provide empathy and normalise feelings of grief and loss

  • Refer on to a psychologist or counsellor if the couple require further support

Clinical review

Dr Gideon Blecher, Alfred Health

Male infertility

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