For health professionals: When it comes to infertility in couples, males contribute to half of all cases – Do you know what to look for?

With men contributing to half of all cases of infertility in couples, and low sperm counts being seen in around 1 in 20 men, GPs and other health professionals have an important role to play in the assessment of male fertility. The following guide provides an overview for health professionals to ensure vital information on men presenting with potential fertility problems is gathered during consultation.

Assessment

The initial assessment of the couple should include age, fertility history, contraceptive use and when it was ceased, regularity of intercourse during fertile times, and lifestyle factors for both partners, including diet, exercise, alcohol and smoking.

A comprehensive assessment¹ of a man’s reproductive history should include whether he has previously fathered children and if there are psychosocial issues that could interfere with conception (such as erectile or ejaculatory dysfunction²). It is important to investigate a history of undescended testes and abnormal pubertal development, as well as other factors that could impact on fertility including previous surgery to the genital, inguinal or pelvic region, previous infection such as STIs or mumps, and previous genital trauma. Patients should also be assessed for medication and drug use that could impair sperm production, and for their general health (e.g. diet, exercise and smoking) that could impact on sperm health and epigenetics. The patient should be assessed for symptoms of androgen deficiency³.

A physical examination of the male patient should include a general examination to assess acute/chronic illness and nutritional status, degree of virilisation, prostate examination (if history suggests prostatitis⁴ or STI) and genital examination⁵.

Investigations

Semen analysis is the primary investigation for male infertility. Men should be advised to abstain from any sexual activity for 2-5 days prior to providing a semen sample. Semen analysis should be performed twice, six weeks apart, and if the first test shows a poor assessment, the second test should be analysed in a specialist laboratory. Normal ranges for semen analysis are: volume ≥ 1.5mL, pH ≥ 7.2, sperm concentration ≥ 15 million spermatozoa/mL, motility ≥ 40% motile sperm within 60 minutes of ejaculation, vitality ≥ 58%, white blood cells < 1 million/mL, sperm antibodies <50% motile sperm with binding.

Serum total testosterone:  The normal reference range may vary between laboratories; an approximate range is 8-27nmol/L. Many men with normal testosterone can still have significant spermatogenic defects.  Serum total testosterone should be interpreted along with serum LH levels. Some men with severe testicular problems present with low testosterone and elevated FSH and should undergo evaluation for androgen deficiency³. Low serum testosterone and low LH suggests a hypothalamic-pituitary problem.

Serum FSH: In normal men, the upper reference value is approximately 8 IU/L. Elevated levels are seen during primary testicular failure. In a man with azoospermia (zero sperm count) FSH > 14IU/L strongly suggests spermatogenic failure. Low FSH (< 5IU/L) is suggestive of obstructive azoospermia, but a testis biopsy may be required to confirm.

Management

Treatment

For the majority of men/couples with defined infertility, referral for assisted reproductive technology including IVF, will be required. Options for improving natural fertility exist only in a minority of infertile men. These include the withdrawal of drugs that could interfere with fertility, or treatments for men with hyperprolactinemia, hormonal deficiency, genitourinary infection and erectile and psychosexual problems. The need for varicocele removal to improve fertility shows limited evidence, but may have a place in selected cases. Selected patients should be counselled for protecting and preserving fertility, for example safe sex practices, mumps vaccination and the need for sperm cryopreservation.

WARNING: Testosterone replacement therapy should never be initiated in an androgen-deficient man seeking fertility, as testosterone therapy exerts a potent contraceptive effect by suppressing pituitary gonadotrophins and sperm production.

Specialist referral

Couples can be referred immediately or after baseline tests have been performed. Specialist referral depends on the problem: fertility specialist/ART clinic for couples experiencing infertility; urologist for male patients requiring surgery such as undescended testes; endocrinologist for endocrine-associated problems.

Long term management

Long term management of the infertile male should include assessment for testis cancer and late-onset androgen deficiency. Management of the couple involves supporting each patient during their infertility experience, in particular acknowledging both partner’s experience of infertility, providing empathetic counselling to normalise feelings of grief and loss, and referral to a psychologist or counsellor where appropriate.

Footnotes and key resources

Footnotes refer to specific clinical summary guides on the management of male reproductive health which are available to download from our online Resource Library. Alternatively, order a free hard copy via our online store. For more information, visit healthymale.org.au.

¹ Healthy Male Clinical Summary Guide – Male Infertility

² Healthy Male Clinical Summary Guide – Ejaculatory Disorders and Erectile Dysfunction

³ Healthy Male Clinical Summary Guide – Androgen Deficiency

⁴ Healthy Male Clinical Summary Guide – Prostate Disease

⁵ Healthy Male Clinical Summary Guide – Step-By-Step: Male Genital Examination and Male Adulthood Genital Examination

Also available for clinical use is our male fertility assessment form, endorsed by The Fertility Society of Australia, which you can download and print from our website.