Male Infertility and Reproductive Urology
Semen analysis
Interpret by WHO reference limits: volume ≥1.4 mL, concentration ≥16 million/mL, total motility ≥42%, progressive motility ≥30%, normal morphology ≥4%. A single abnormal sample is repeated after 2–4 weeks; marked abnormalities warrant urology referral.
Causes and evaluation
Classify as pretesticular (hypogonadotrophic), testicular (varicocele, genetic, toxic, cryptorchidism), or post-testicular (obstruction, ejaculatory dysfunction). Key genetic causes: Klinefelter (47,XXY) and Y-chromosome microdeletions (AZF regions). Azoospermia is obstructive versus non-obstructive; FSH and testicular volume help distinguish, and micro-TESE may retrieve sperm in non-obstructive cases.
Traps
- Ordering ICSI without evaluating a correctable cause such as varicocele or hypogonadotrophic hypogonadism.
- Missing that exogenous testosterone suppresses spermatogenesis and is contraindicated in men trying to conceive.
- Confusing congenital bilateral absence of the vas deferens (CFTR mutation, often with absent uterus in female carriers) with simple obstruction.
- Forgetting that fever or recent illness can transiently depress semen parameters for up to 3 months.
Worked example
A man with low volume, low FSH, and low testosterone: this is hypogonadotrophic hypogonadism (pretesticular). Treat with hCG and/or FSH rather than testosterone, which would worsen suppression.