Subfertility in Men
🔎 Initial Assessment of Subfertility in Men
- ⏳ Duration of Infertility: Failure to conceive after 12 months of regular unprotected intercourse (consider earlier investigation if age ≥35 or known risk factors present).
- ❤️ Sexual History: Frequency/timing of intercourse; erectile/ejaculatory dysfunction.
- 🤰 Pregnancy History: Previous conceptions or subfertility patterns help gauge reproductive potential.
- 🩺 Medical History: Thyroid disease, diabetes, mumps orchitis, testicular surgery or trauma.
- 👨👩👦 Family History: Genetic/inherited conditions (e.g., Klinefelter’s, CFTR mutations) that affect fertility.
- 🚬🍺 Lifestyle: Smoking, alcohol, drugs, obesity, heat exposure (e.g., tight underwear, laptops) and stress can impair semen quality.
👨 Physical Examination
- 🧍 General: Signs of hypogonadism: small testes, gynaecomastia, low muscle mass.
- ⚕️ Genital Exam: Testicular size, varicoceles (palpable “bag of worms”), absence of vas deferens.
- 💇 Secondary Sexual Features: Body hair, fat distribution, androgen deficiency signs.
🧪 Initial Investigations
- 💧 Semen Analysis: First‑line test; assesses sperm count, motility, morphology per WHO standards. If the first result is abnormal, repeat testing (ideally ~3 months later) is recommended.
- 🧬 Hormonal Profile: FSH, LH, testosterone, prolactin to differentiate testicular vs pituitary/endocrine causes.
- 🦋 Thyroid Function: Hypo/hyperthyroidism can affect fertility.
- 🖥️ Scrotal Ultrasound: Detects varicocele, duct obstruction, congenital anomalies like absent vas deferens.
🔬 Further Specialist Investigations
- 🧾 Genetic Testing: Karyotype, Y‑chromosome microdeletions for severe oligospermia/azoospermia.
- 🧩 Testicular Biopsy: Distinguishes obstructive vs non‑obstructive azoospermia.
- 🧠 Pituitary MRI: If hypogonadotropic hypogonadism suspected.
⚠️ Major Causes & Management
- 🧪 Semen Abnormalities: Oligospermia, asthenospermia, teratospermia.
➡️ Lifestyle optimisation and expectant management are first steps. ART (IUI/IVF/ICSI) may be discussed with couples; NICE CG156 notes limited high‑quality evidence for many empirical medical therapies.
- 🚫 Obstructive Azoospermia: Blocked ducts or absent vas deferens.
➡️ Surgical correction (e.g., epididymal/vas deferens procedures) may be considered where expertise exists; sperm retrieval for use with ART is another option.
- 🩸 Varicocele: Palpable dilated veins in the scrotum.
➡️ NICE does not recommend varicocele surgery solely to improve fertility as it has not been shown to improve pregnancy rates; focus may instead be on counselling and ART.
- ⚖️ Hormonal Imbalance: Hypogonadotropic hypogonadism.
➡️ Gonadotrophin therapy can be offered to improve fertility in selected cases.
- 🧬 Genetic Factors: Klinefelter’s, Y‑chromosome microdeletions, CFTR mutations.
➡️ Genetic counselling; consider ART or donor options depending on severity.
💡 Management Approaches
- 🥦 Lifestyle: Weight optimisation, stop smoking/alcohol/drugs, minimise heat exposure, ensure adequate sleep and exercise.
- 💊 Medical: Hormonal therapy in selected endocrine causes per specialist advice.
- 🔪 Surgical: Varicocelectomy is generally not offered for fertility per NICE; vasectomy reversal can be considered where appropriate.
- 🧫 ART (Assisted Reproductive Technologies):
- 🧴 IUI: Washed sperm into uterus.
- 🧫 IVF: Fertilisation outside the body, embryo transfer.
- 💉 ICSI: Single sperm injected into egg - often used for severe male factor.
🧠 Psychological Support
- 🗨️ Counselling: Address anxiety, depression, relationship strain related to subfertility.
- 🤝 Support Groups: Peer support to reduce isolation.
📈 Referral
- Couples with severe semen abnormalities, azoospermia, endocrine or genetic concerns, or failed basic management should be referred early to a fertility specialist.
💡 Exam tip: In OSCEs, start with lifestyle optimisation and accurate semen analysis (repeat if abnormal), then proceed with hormonal/specialist tests, and describe how management is tailored to the cause. Don’t forget shared decision‑making and psychological support - these are emphasised in NICE fertility guidance too.
📚 NICE References
