14 - The urologic evaluation of the infertile male

Summary

Introduction

Infertility is defined as the failure to achieve pregnancy after unprotected coitus for at least 1 year. Approximately 15% of couples attempting their first pregnancy are unsuccessful. Diagnosis and treatment are often costly, time consuming, intrusive and for many diagnoses there is a variable but low chance of success. According to the Office of Technology Assessment (OTA, 1988), 2.4 million married couples were defined as infertile in 1982. Voluntary delayed child-bearing may also complicate this situation. The child-bearing potential of a couple is less dependent on the age of the male than the age of the female partner; the average woman experiences a gradual deterioration of her reproductive potential between the ages of 24 and 50 years (Speroff et al., 1989) which may not be apparent in the older man (Nieschlag et al., 1982).

Secondary infertility is defined as the inability to conceive after 1 year of unprotected intercourse following a previously documented pregnancy. Male fertility may have been altered by reproductive toxicants, drugs, inflammatory conditions, varicocele, or unknown factors. A ‘male factor’ is considered important in 40–50% of infertility evaluations (Jouannet et al., 1988).

The evaluation of the infertile couple must be thorough, blameless and should include a review of possible previous pregnancies of both partners. This chapter will discuss the male fertility examination from the perspective of the urologist as andrologist, with an overview of the normal and abnormal male reproductive system.

The male evaluation

The andrologist should emphasize the role of prevention long before the couple presents for evaluation. Education must begin much earlier regarding workplace toxicants and occupational hazards, use of both prescribed and abused drugs, and the long-term role of genital tract infections.