Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Male Infertility

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In one line

·A couple cannot get pregnant after one year of trying, and the problem is on the man's side.

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Normal physiology

·Making a baby on the man's side needs four steps working in order: the brain sends hormone signals, the testicles make sperm and testosterone, the sperm travel through tubes to grow strong, and then the sperm shoot out during sex. Keep that picture in your head, because every weird finding is just one of those four steps failing.

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What goes wrong

·Usually one broken thing upstream explains why there is no pregnancy. It can break before the testicles (brain does not send the hormone signal), inside the testicles (damage from heat, genes, or infection), or after the testicles (tubes are blocked or sperm go backward).

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Hallmark signs

·Low sperm count (fewer than 15 million sperm per milliliter of semen)
·Poor sperm movement (fewer than 40% of sperm swim forward)
·Abnormal sperm shape (fewer than 4% have a normal oval head and single tail)
·Small or soft testicles (less than 4 cm long, or softer than normal firm feel)
·Visible or palpable varicocele (swollen, twisted veins above the testicle, usually on the left side, that feel like a bag of worms)
·Absent vas deferens on physical exam (the tube that carries sperm from the testicle to the urethra cannot be felt)
·No semen comes out during ejaculation (dry orgasm)
·Reduced sexual desire or difficulty getting or keeping an erection

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Red flags · escalate now

·No sperm at all in the semen on two separate tests (may mean a blockage in both vas deferens or complete testicular failure—needs urgent urology referral)
·Hard lump or swelling in the testicle (could be testicular cancer, which can raise hormone levels and harm fertility)
·Sudden severe testicular pain with swelling (may be testicular torsion, where the testicle twists and cuts off its own blood supply—this is a surgical emergency to save the testicle)
·Milky or cloudy discharge from the penis between ejaculations (may signal an untreated sexually transmitted infection that can scar the reproductive tract)

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Workup

·Semen analysis (two samples, 2–7 days apart, after 2–5 days of no ejaculation)
·Serum FSH (follicle-stimulating hormone)
·Serum testosterone (total, morning sample)
·Serum LH (luteinizing hormone)
·Scrotal ultrasound with Doppler
·Post-ejaculate urine analysis (if semen volume is very low or zero)
·Karyotype (chromosome test) and Y-chromosome microdeletion panel (if sperm count is very low or zero)
·CFTR gene mutation screening (if the vas deferens is absent on both sides)

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Treatment

·Varicocele repair (surgical ligation by microscope or percutaneous embolization by interventional radiology) if varicocele is present and sperm count is low
·Clomiphene citrate (25–50 mg by mouth every other day) or hCG injections (subcutaneous, 1,000–2,000 units three times per week) if testosterone or LH/FSH are low
·Testicular sperm extraction (TESE or micro-TESE) with intracytoplasmic sperm injection (ICSI) if tubes are blocked or absent, or if the testicles make very few sperm
·Intrauterine insemination (IUI) or in vitro fertilization (IVF with or without ICSI) if sperm count is low but some healthy sperm are present in the ejaculate
·Lifestyle modification: stop smoking, avoid hot tubs and saunas, lose weight if BMI is over 30, cut alcohol to fewer than 5 drinks per week, and avoid tight underwear
·Electroejaculation or penile vibratory stimulation (if the man cannot ejaculate because of spinal cord injury or nerve damage)
·Treatment of retrograde ejaculation: pseudoephedrine (60 mg by mouth 4 times daily) or imipramine (25–50 mg by mouth daily) to tighten the bladder neck, or sperm retrieval from post-ejaculate urine for IUI

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NCLEX trap

·Male infertility can be before the testicles (brain signals from the hypothalamus and pituitary gland that tell the testicles to make sperm), inside the testicles (damage, varicocele, or genetics), or after the testicles (blocked tubes or backward flow into the bladder). Find which one first with semen analysis, hormone tests, and physical exam, then treat the real problem.
·Semen analysis is the first test for male infertility. It tells you if sperm count, movement, or shape is broken. Without it, you cannot tell where the problem is. The test needs two samples, at least one week apart, to be accurate.
·Low testosterone from a broken brain signal (the hypothalamus and pituitary gland) in male infertility should be treated with clomiphene (a drug that wakes up the brain's sperm signals) or hCG (human chorionic gonadotropin, a hormone that tells the testicles to make testosterone and sperm). Testosterone replacement therapy shuts down the brain signals completely and stops sperm-making.
·Klinefelter syndrome (XXY chromosomes) causes small firm testicles, low testosterone, no sperm or very low sperm count, and higher risk of heart disease, diabetes, and osteoporosis. Do a genetic blood test (karyotype) if testicles are very small (less than 3 cm long) or sperm count is very low (less than 5 million per milliliter). Male infertility may be the first sign of this lifelong problem.
·A varicocele (enlarged twisted veins in the scrotum, like varicose veins) in a man with male infertility should be fixed with surgery or embolization (blocking the vein from the inside). The pooled blood heats up the testicles and damages sperm-making cells. Fixing it can improve sperm count and movement in about 60 to 70 percent of men.
·Retrograde ejaculation in male infertility can be treated with alpha-agonist drugs like pseudoephedrine (which tightens the bladder neck muscle so semen goes forward). If that does not work, sperm can be collected from urine right after orgasm and used for in vitro fertilization (IVF). This is a fixable problem.

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