Male Infertility
The male evaluation in an infertile couple is built on one cornerstone test — the semen analysis — and one pivotal fork — if the man is azoospermic, is it obstructive or non-obstructive?
The big picture
The male evaluation in an infertile couple is built on one cornerstone test — the semen analysis — and one pivotal fork — if the man is azoospermic, is it obstructive or non-obstructive? That single distinction reorganises the entire workup and treatment. Around it sit the hormonal axis, a targeted genetic workup, and the correctable causes (varicocele, obstruction). The job is to find a treatable cause, identify genetic conditions that affect counselling and offspring, and get to sperm for use in ART when needed.
The framework: history + exam + semen analysis → hormonal evaluation → if azoospermic, split obstructive vs non-obstructive → genetic testing where indicated → treat the cause / retrieve sperm for ART.
Mechanism pathway
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Diagnostic algorithm
Each step answers one question. Tap to expand.
Board traps
Semen analysis is the cornerstone; add FSH + testosterone when there's ED/low libido/oligo-azoospermia/atrophic testes.
Azoospermia: OA (normal FSH, normal testes) vs NOA (high FSH, small testes) — the pivotal fork.
Karyotype for azoospermia or <5 M/mL; Y-microdeletion for severe oligo/azoospermia; CFTR for vasal agenesis.
Klinefelter (47,XXY) is the commonest genetic cause of NOA.
Never give exogenous testosterone to a man trying to conceive — it suppresses sperm production.
CBAVD/NOA → sperm retrieval (micro-TESE/MESA) + IVF/ICSI.
The semen-analysis abstinence period must be standardised/recorded — a non-standard interval skews results; confirm an abnormal sample on repeat.
Varicoceles are left-sided (left testicular vein → left renal vein, valvular incompetence). A right-sided or non-decompressing varicocele → look for a retroperitoneal mass.