The GP’s role
Diagnosis
Brief assessment and pre-pregnancy advice
| Age | What age is the couple? |
| Fertility history | How long have they been trying to conceive, and have they ever conceived previously (together/separately)? Do they have any idea why they have not been able to conceive? |
| Contraception | When it was ceased, and the likely speed of its reversibility |
| Fertile times | Whether the couple engage in regular intercourse during fertile times |
| Female risk factors | Aged 35+, irregular menstrual cycles, obesity, painful menses or concomitant medical conditions |
| Female health | Screening for rubella and chicken pox immunity, Cervical Screening Test (25 years or older) |
| Lifestyle: female | Diet, exercise, alcohol, smoking cessation and folate supplementation |
| Lifestyle: male | Diet, exercise, alcohol and smoking cessation |
Reproductive history
| Assess | Why? |
|---|---|
| Prior paternity | Previous fertility |
| Psychosexual issues (erectile, ejaculatory) | Interference with conception |
| Pubertal development | Poor progression suggests underlying reproductive issue |
| A history of undescended testes | Risk factor for infertility and testis cancer |
| Past genital infection (STI), mumps infection or trauma | Risk for testis damage or obstructive azoospermia |
| Symptoms of androgen deficiency | Indicative of hypogonadism |
| Previous inguinal, genital or pelvic surgery or trauma | Testicular vascular impairments, damage to vasa, ejaculatory ducts, ejaculation mechanism |
| Medications, alcohol, tobacco, illicit drugs and androgens | Transient or permanent damage to spermatogenesis |
| General health (diet, exercise and smoking) | Epigenetic damage to sperm affecting offspring health |
Physical examination
| General examination | Acute/chronic illness, nutritional status |
| Genital examination | Refer to Clinical Summary Guide ‘Step-by-Step Male Genital Examination’ |
| Lack of viritilisation | Androgen deficiency/Klinefelter syndrome |
| Prostate examination | If history suggests prostatitis/STI |
Investigations
Semen analysis is the primary investigation for male infertility.
Reference limits for semen analysis
| Volume | ≥ 1.4 mL |
| pH | ≥ 7.2 |
| Sperm concentration | ≥ 16 million spermatozoa/mL |
| Motility | ≥ 42% motile within 60 minutes of ejaculation |
| Morphology | ≥ 4% |
| Vitality | ≥ 54% live |
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)
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.
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
Clinical review
Dr Gideon Blecher, Alfred Health
