Algorithm for Evaluation of Male Infertility

In this episode of BackTable Urology, Dr. Zamip Patel discusses the assessment and treatment of male infertility with Dr. Silva.

Initial fertility consultations are usually made for couples who have not had success in conceiving for over a year. Dr. Patel will start with an initial semen analysis. He notes that cell differentiation depends on the quality of the lab performing the analysis. The presence of round cells and leukocytes may be indicative of a bacterial infection, and prednisone and antibiotics may be administered. Besides bacterial infections, Dr. Patel notes that there are 4 main factors for male infertility: genetic, environmental, anatomical, and hormonal.

Globozoospermia and azoospermia are two consequences of genetic mutations resulting in irregular sperm morphology and inadequate sperm production, respectively. Attribution of infertility to genetic mutations can be difficult, as microchip arrays only test for 10% of genetic defects. Sex chromosome aneuploidy can also result in male infertility, but can easily be identified via karyotyping.

Environmental factors may also contribute to male infertility. Dr. Patel notes that improving diet, exercise, and sleep is the most common solution for infertility. Additionally, he observes that supplementing diet with vitamin coenzyme Q10 has been shown to improve infertility. Finally, he explains that prolonged marijuana usage and THC intake may contribute to infertility on an individual and dose-dependent basis.

Next, Dr. Patel considers anatomical reasons for male infertility. Irregularities in vas deferens morphology and small testicular size can be observed through physical examination. A varicocele, or an enlargement of veins in the scrotum, can also cause low sperm production and quality. Patients with varicoceles will usually elect to undergo a varicocelectomy, a surgical intervention with minimal downtime and complications.

Lastly, low testosterone levels can cause male infertility. To get a clearer picture of testosterone levels, Dr. Patel recommends combining a free testosterone test with SHBG and albumin tests, which calculate bioavailability of testosterone. He will also measure TSH levels, but notes that measuring prolactin levels, which can vary individually, may potentially cause more confusion and lead to unnecessary further imaging. Although clomiphene and anastrozole can both increase testosterone concentration, Dr. Patel warns listeners about osteoporosis as a side effect of anastrozole. Additionally, he has had success with increasing testosterone levels using pituitary stimulation via hCG supplementation. Testosterone levels can also be naturally increased through healthier diets, daily exercise, and adequate sleep.