Examining Male Infertility

Susanne Quallich

Disclosures

Urol Nurs. 2006;26(4):277-288. 

In This Article

History

The general history of a male patient during an infertility evaluation begins with the duration of the attempts at pregnancy or reason for the evaluation (such as to establish if spermatogenesis has returned after chemotherapy). It includes many questions regarding the reproductive status of his partner, including her age, the duration of the couple's attempts at pregnancy, if they have had children or a positive pregnancy test together, and the results of any semen analyses prior to the current encounter. The history addresses whether or not either partner has conceived with another partner, and should include previous evaluation and treatment for male or female factor infertility in the past. Not every male patient is accompanied by his partner, but this information should be collected as completely as possible.

The male general history includes a discussion of any recent (within the last 6 months) systemic illness, particularly if it was a febrile illness, and any recent weight gain or loss. The patient should be asked if there are any complaints specific to the genitourinary (GU) structures. This may reveal complaints of a dull ache or fullness to the scrotum, or pain on one side that does not radiate. The review of systems will specifically include fevers, colds, sinus infections, anosmia (loss or impairment of the sense of smell), peripheral field visual problems, breast pain or secretions, and scrotal pain. It should establish that puberty started in the early or middle teens to confirm normal physiologic male development.

The general history includes any potential exposure to environmental toxins, either through occupation or hobbies. These include excessive heat, radiation, heavy metals, and glycol ethers or other organic solvents.

The evaluation should then proceed to a history of any condition that would potentially affect erectile function, the testes, or the hormonal status of the patient (including such things as cryptorchidism, epispadias, mumps, orchitis, diabetes, hypothyroidism, varicocele, or pituitary malfunction). It will also include a review of additional medical conditions for which the patient is being followed, including any condition that would require radiotherapy or chemotherapy. Any history of treatment for malignancy, regardless of site, should be documented. Diabetes, chronic obstructive pulmonary disease, sleep apnea, renal insufficiency, hemachromatosis, and hepatic insufficiency are known possible contributors to male subfertility (Burrows, Schrepferman, & Lipshultz, 2002). Infertility in the male can, in fact, be a hallmark symptom for other medical conditions in an apparently healthy adult male.

The surgical history during the male infertility visit focuses on any history of GU surgeries at any point during the life of the male undergoing evaluation. These include such diverse procedures such as orchidopexy; Y-V plasty to the bladder neck; inguinal hernia repair as infant, small child, or adult; epispadias or hypospadias repair; prostate surgery; bladder reconstructions; bladder surgeries; or testicular surgeries. The surgical history should ask about procedures which impair retroperitoneal sympathetic nerve function, such as retroperitoneal lymph node dissection (RPLND). The patient should be asked specifically about previous treatment for testicular or GU malignancies, either with surgery or radiation. The patient should be asked specifically if there is a history of a vasectomy.

The history should include the overall pattern of sexual activity during the period of time the couple has been trying to conceive, specifically in relation to ovulation. This includes questions regarding the use of ovulation-predictor kits or ovulation-promoting medications such as clomiphene citrate, a nonsteroidal anti-estrogenic. The optimal window for pregnancy occurs in the 6 days before ovulation, with day 6 being the actual day of ovulation (Wilcox, Weinberg, & Baird, 1995). Simply adjusting the timing of intercourse can result in a significantly increased chance for pregnancy.

Both partners should be asked about a history of sexually transmitted infections. Each patient should be queried regarding erectile function, ejaculation, and libido; these issues can be superimposed onto fertility concerns. Erectile difficulties may be accompanied by a history of declining erectile function, usually insidious and progressive, and may span the course of several years (as is a common scenario with diabetic patients). Alter natively, the patient may provide a history of relatively rapid or recent onset of a decline to erectile function, such as may be associated with the history of recently starting new medication or the stress of the fertility evaluation. The history should include several points specific to the patient's sexual functioning: the precise nature of the dysfunction (for example, whether the problem is attaining or sustaining an erection, insufficient rigidity, difficulty with penetration); the presence or absence of nocturnal and morning erections and their quality; and any treatments (pharmacologic and nonpharmacologic) that the patient has tried.

If the patient complains of low libido, he may also describe moodiness, loss of interest in his usual activities, a decline in erectile function, fatigue, and even complaints of diminished muscle bulk. It should be established if these complaints are new or long-standing.

If there are issues with ejaculation, the patient may have complaints of cloudy urine after ejaculation, decreased volume of ejaculate, hematospermia, difficulty with bowel movements, anejaculation, oligospermia (low sperm count), or azoospermia (no sperm in ejaculate) with a low-volume ejaculate on semen analysis. The patient may have complaints of pain on ejaculation, usually of relatively recent onset, and it may localize to a specific scrotal structure. These complaints can be the result of a variety of surgical procedures, progressive neurologic disease, or pre-existing treatment with certain antidepressants (see the article, "Premature Ejaculation" elsewhere in this issue for a more detailed description of ejaculation issues).

The couple must also be asked about the used of lubricants: saliva, K-YAE jelly, surgilube, and hand lotions are known to impair sperm motility (Burrows et al., 2002).

A careful medication history is a mandatory component of the initial evaluation of male-factor infertility. Prescription drugs can affect sperm count, motility, and morphology, and the dose and duration of use should be documented. Common antibiotics can temporarily contribute to a decline in the semen analysis quality; calcium channel blockers and spironolactone can contribute to a decreased fertilization capacity and a decline in spermatogenesis respectively (Brugh, Matschke, & Lipshultz, 2003) (see Table 1 ). Anabolic steroid use can result in a profound decline in sperm counts that may not recover with the cessation of the exogenous steroid, leaving the patient azoospermic or with persistently decreased counts. The patient must also be asked about the ingestion of nutraceuticals and other over-the counter medications, certain steroid hormones, or other harmful substances that may contribute to semen analysis derangements as well.

Cigarette smoking, excessive alcohol consumption, and consistent marijuana use are all known to be gonadotoxins (Burrows et al., 2002). A careful history of the use of these agents and other illicit drug use must be part of the complete male infertility evaluation. Cigarette smoking has been implicated as leading to changes in morphology, sperm production, and motility while chronic alcohol use contributes to feminization, erectile dysfunction, and hypogonadism (Nudell, Monoski & Lipshultz, 2002). Marijuana use can decrease sperm morphology over time (Nudell et al., 2002). Simply eliminating these agents can improve semen parameters in the absence of other physical findings.

Patients should be asked about recreational activities, as some activities, such as long-distance cycling, may put pressure on the perineal area and may result in possible impairment to erectile function.

The family history should include a discussion of testicular or other GU malignancies and specifically any cancer history, prostate or bladder problems in other family members (including female relatives with bladder conditions). It is helpful to include a history of maternal medication/drug use while pregnant with patient, if this information is known. The patient should be queried regarding siblings or extended family members who may have had fertility problems or diagnoses that are genetic in nature (such as cystic fibrosis).

The history of the patient's partner should include details of any previous pregnancies (including miscarriages or elective terminations), menstrual cycle length, whether she is undergoing evaluation for fertility issues, and any medical or surgical management that has been necessary. It is also helpful to include comments regarding the expected next step in her management (if known) if the male evaluation is negative.

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