Given that a male factor can be identified as the cause of infertility in 30-40% of couples and is a contributing factor in 50% of cases, it is important to evaluate the male and female partners in parallel. Although infertility is defined as a failure to conceive after 1 year of unprotected sexual intercourse, couples may be anxious to proceed with an evaluation sooner and this may be appropriate. A complete urologic evaluation is important because male infertility may be the presenting symptom of otherwise occult but significant systemic disease. The evaluation involves collecting 4 types of information, as outlined in

Figure 42-4.

History

The cornerstone of the male partner evaluation is the history. It should note the duration of infertility, earlier pregnancies with present or past partners, and whether there was previous difficulty with conception. A comprehensive list of information relevant to the fertility history is given in

Table 42-4.

A sexual history should be addressed. Most men (80%) do not know how to precisely time intercourse to achieve a pregnancy. Since sperm reside within the cervical mucus and crypts for 1-2 days, an appropriate frequency of intercourse is every 2 days for most men. Lubricants can influence sperm motility and should be avoided. Commonly used products such as K-Y Jelly, Surgilube, Lubifax, most skin lotions, and saliva significantly reduce sperm motility in vitro. If needed, acceptable lubricants include vegetable, safflower, and peanut oils.

A general medical and surgical history is also important. Any generalized insult such as a fever, viremia, or other acute infection can decrease testis function and semen quality. The effects of such insults are not noted in the semen until 2-3 months after the event, because spermatogenesis requires 75 days to complete. Surgical procedures on the bladder, retroperitoneum, or pelvis can also lead to infertility, by causing either retrograde ejaculation of sperm into the bladder or anejaculation (aspermia), in which the muscular function within the entire reproductive tract is inhibited. Hernia surgery can also result in vas deferens obstruction in 1% of cases; this incidence may be rising because of the recent increased use of mesh patches that tend to be inflammatory to tissues.

Childhood diseases may also affect fertility. A history of mumps can be significant if the infection occurs postpubertally. After age 11, unilateral orchitis occurs in 30% of mumps infections and bilateral orchitis in 10%. Mumps orchitis is thought to cause pressure necrosis of testis tissue from viral edema. Marked testis atrophy is usually obvious later in life. Cryptorchidism is also associated with decreased sperm production. This is true for both unilateral and bilateral cases. Longitudinal studies of affected boys have shown that abnormally low sperm counts can be found in 30% of men with unilateral cryptorchidism and 50% of men with bilateral undescended testes. Differences in fertility have not been as easy to demonstrate, but it appears that boys with unilateral cryptorchidism have a slightly higher risk of infertility. However, only 50% of men with a history of bilateral undescended testes are fertile. It is important to remember that orchidopexy performed for this problem does not improve semen quality later in life.

Exposure and medication histories are very relevant to fertility. Decreased sperm counts have been demonstrated in workers exposed to specific pesticides, thought to result from a shift in the normal testosterone/estrogen hormonal balance. Ionizing radiation is also a well-described exposure risk, with temporary reductions in sperm production seen at doses as low as 10 cGy. Several medications (

Table 42-5) and ingestants such as tobacco, cocaine, and marijuana have all been implicated as gonadotoxins. The effects of these agents are usually reversible on withdrawal. Androgenic steroids, often taken by bodybuilders to increase muscle mass and development, act as contraceptives with respect to fertility. Excess testosterone inhibits the pituitary-gonadal hormone axis. The routine use of hot tubs or saunas should be discouraged, as these activities can elevate intratesticular temperature and impair sperm production. In general, a healthy body is the best reproductive body.

The family and developmental histories may also provide clues about infertility. A family history of cystic fibrosis (CF), a condition associated with congenital absence of the vas deferens (CAVD), or intersex conditions is important. The existence of siblings with fertility problems may suggest that a Y chromosome microdeletion or a cytogenetic (karyotype) abnormality is present in the family. A history of delayed onset of puberty could suggest Kallmann or Klinefelter syndrome. A history of recurrent respiratory tract infections may suggest a ciliary defect characteristic of the immotile cilia syndromes. It is important to remember that reproductive technologies enable most men afflicted with such conditions to become fathers and therefore allow for the perpetuation of genetic abnormalities that may not be normally sustained.