Discourage the use of the postcoital test. Patients may inquire about this test, in which the cervical mucus is obtained after intercourse to assess stretch ability and sperm motility. This test has been used for more than a century, but has poor predictive value and is not recommended.19
Or is it him?
Inquire about sexual development and medical history, including mumps orchitis or other infections, sinopulmonary symptoms suggesting cystic fibrosis, sexually transmitted infections (STIs) and genitourinary infections, and surgical procedures of the inguinal and scrotal areas. Also ask about prescription and illicit drug use, environmental exposures, and sexual history.
Physical exam. Look for signs of androgen deficiency, such as an arm span >2 cm longer than height (eunuchoidal proportions), or loss of pubic, axillary, or facial hair.20 Examine the external genitalia to evaluate for complete sexual development (Tanner stage of 5). The scrotum can provide clues to disorders that can affect sperm maturation and transport. Examination may reveal absence of the vas deferens, epididymal thickening, varicocele, or hernia.21 Testicular volume, if <15 mL with testicular length <3.6 cm, can point to a decreased number of seminiferous tubules.21
Semen analysis. If the physical examination is normal, analyze semen for volume and pH; microscopic debris and agglutination; sperm concentration, motility, and morphology; leukocyte count; and immature germ cells. Have the man abstain from sex for 2 to 7 days before semen collection. If collection is not possible to do in the office, the patient can drop it off at a lab within an hour of collection. Analyze 2 samples at least 2 weeks apart.22
More detailed semen analysis can be done, especially if evaluation of the female partner does not reveal a cause of infertility. Tests include sperm autoantibodies, sperm biochemistry, semen culture, sperm function tests, and sperm-cervical mucus interaction. Typically, these tests and further evaluation of the male partner after an abnormal semen analysis are best done by a urologist specializing in reproduction.
Oligospermia or azoospermia point toward hypogonadism. Elevated morning FSH and low total testosterone correlate with primary hypogonadism, whereas low levels of both hormones correlate with secondary hypogonadism. Hyperprolactinemia is a cause of secondary hypogonadism.3 Low volume of semen can be further evaluated by testing a postejaculatory urinalysis and transrectal ultrasonography to rule out retrograde ejaculation and ejaculatory duct obstruction.23
Fixing the problem
Focus initial counseling for couples on lifestyle modifications. Advise patients to quit smoking, reduce excessive caffeine and alcohol consumption, and engage in intercourse every day or every other day around ovulation. Patients should also avoid lubricants and douching as they can interfere with sperm deposition.
Managing female infertility
Tubal, pelvic, and uterine infertility. Patients with bilateral tubal obstruction may wish to undergo tubal reconstruction, especially if IVF treatments are not readily available to them. Counsel them that surgery for proximal tubal occlusion is not effective and the risk of ectopic pregnancy in the future is high, at approximately 20%.24 Because of the low efficacy of surgery and high ectopic rate, most patients with tubal disease favor IVF. Patients with endometriosis sometimes benefit from laser ablation or surgical resection, but often do well with intrauterine insemination (IUI) or IVF in conjunction with ovulation induction.25 Uterine abnormalities including submucous fibroid, endometrial polyp, septate uterus, or uterine synechiae frequently benefit from surgical correction.26 Patients with irreparable defects may want to consider a surrogate.
Ovulatory dysfunction. Anovulation can be hypogonadotropic hypogonadal (secondary to functional factors such as exercise and weight), normogonadotropic normoestrogenic with PCOS, or hypergonadotropic hypoestrogenic infertility (premature ovarian failure).
A body mass index >17 and <27 kg/m2 is optimal to achieve fertility and to sustain a healthy pregnancy.27 Individuals who are obese or very thin or who overexercise and do not respond to behavioral modification are known to benefit from pulsatile gonadotropin-releasing hormone therapy. This treatment, however, is not available in the United States.28
Dopaminergic agents can restore normal ovulation in patients with hyperprolactinemia,29 but they should receive ovulation induction first. Patients who have glucose intolerance may benefit from an insulin-sensitizing agent such as metformin. It is particularly useful if patients also have PCOS; however, it is not an FDA-approved indication for the medication. Clomiphene has recently been shown to result in a higher rate of ovulation, but not pregnancy, than metformin.30
Most patients with ovulatory dysfunction are best treated with clomiphene.31 Give 50 mg of the drug on cycle Days 3 through 7; ovulation occurs between Days 10 through 15.12 If, after the first cycle, pregnancy has not occurred, increase the dose by 50 mg with each cycle, to a maximum of 150 mg daily.32 Higher doses are not FDA approved, nor are they more effective. Clomiphene is most effective in the first 6 cycles, and the American Congress of Obstetricians and Gynecologists recommends limiting its use to fewer than 12 cycles due to the risk of ovarian neoplasm.33 Clomiphene yields an ovulation rate of 73% and a pregnancy rate of 36% per cycle. Multiple births, primarily twinning, occur at a rate of 8% to 13%.33 If clomiphene is unsuccessful, refer patients to a reproductive endocrinologist for evaluation for IVF and injectable ovulation-inducing agents.