Examining Male Infertility
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C O Examining Male Infertility N T I N U Susanne Quallich I N G n increasing number of Problems of male infertility can seem like minor issues within the couples seek evaluation larger realm of urology. But many male infertility diagnoses can be and treatment for infer- successfully treated, allowing the couple to conceive naturally or E tility, especially as more with minimal medical assistance. Some patients presenting with male D Acouples delay childbearing in infertility can have more significant disease. Treatments for male U order to establish their careers. A infertility will continue to progress, and as an increasing number of male factor alone is the cause of couples seek infertility services, the need to provide basic informa- C infertility in up to 20% of infer- tion grows as well. A tile couples and a contributing factor in another 30% to 40% of T all couples presenting for infertil- reproductive technologies. influence on overall male develop- I ity evaluations (American It is common to recommend ment and growth. Spermatogenesis O Urological Association [AUA] & an infertility evaluation in couples is driven by testosterone production N American Society for Reproduc- with a history of unprotected in the Leydig cells of the testes. tive Medicine (ASRM), 2001a; intercourse for at least 12 months Under the influence of luteinizing ASRM, 2004). Problems with without a pregnancy and with hormone (LH) and follicle-stimulat- infertility affect approximately 6.1 attempts to time intercourse with ing hormone (FSH), which are million people in the United ovulation, although this length of released from the anterior pituitary, States, or roughly 10% of the time can be shortened as the the testes begin to produce sperm in reproductive-age population. For female partner’s age increases to a four-step process of development: these couples, a lack of success over age 35 or if the couple is wor- spermatogonia, spermatocyte, sper- with conception is not just an ried about their fertility status. matid, spermatozoon. This cycle inconvenience but rather a disease This guideline is relevant even if takes roughly 74 days to complete, of their reproductive system(s). the couple has previously had with an additional 12 days for final Understanding the basics of male children together. A couple can maturation as the sperm traverse infertility is an important part of present with a history of little dif- the length of the epididymis providing complete urologic care ficulty achieving a first pregnancy, (Sigman, Lipshultz, & Howards, to male patients. and yet be unsuccessful in estab- 1997). The duration of this cycle There are causes of male infer- lishing a second pregnancy (sec- is important, as any changes in tility that are treatable, either ondary infertility). There are other the semen analysis following through medical or surgical man- reasons to consider an evaluation, medical or surgical intervention agement, and causes that can be such as female infertility issues, will not be reflected for at least 3 corrected, or improved, to the including age greater than 35, or a months. point where the couple is able to history of male risk factors for This process is governed by a conceive naturally or to take infertility, such as cryptorchidism negative feedback loop, with advantage of less-costly assisted or a history of cancer treatment. A testosterone acting as the primary screening evaluation for the cou- negative feedback component ple should include a reproductive that slows LH and FSH secretion. Susanne Quallich, APRN, BC, NP- history and at least two semen Inhibin, released during sper- C, CUNP, is a Nurse Practitioner, analyses at a laboratory that is matogenesis, also specifically Division of Andrology and qualified to perform the testing. inhibits activity or down-regu- Microsurgery, Michigan Urology lates FSH. This feedback system Center, University of Michigan Health Development of Sperm can be overridden by the admin- System, Ann Arbor, MI; and an Males do not begin to pro- istration of exogenous testos- Urologic Nursing Editorial Board duce sperm until puberty, when terone, or medications such as Member. testosterone begins to exert its luteinizing hormone-releasing UROLOGIC NURSING / August 2006 / Volume 26 Number 4 277 C hormone antagonists, both of ronmental toxins, either through cally if there is a history of a O which stop the body’s own pro- occupation or hobbies. These vasectomy. duction of testosterone (and halt include excessive heat, radiation, Sexual history. The history N spermatogenesis as well). heavy metals, and glycol ethers or should include the overall pat- T other organic solvents. tern of sexual activity during the I History Medical history. The evalua- period of time the couple has General history and review of tion should then proceed to a his- been trying to conceive, specifi- N systems. The general history of a tory of any condition that would cally in relation to ovulation. U male patient during an infertility potentially affect erectile func- This includes questions regard- I evaluation begins with the dura- tion, the testes, or the hormonal ing the use of ovulation-predic- tion of the attempts at pregnancy status of the patient (including tor kits or ovulation-promoting N or reason for the evaluation (such such things as cryptorchidism, medications such as clomiphene G as to establish if spermatogenesis epispadias, mumps, orchitis, dia- citrate, a nonsteroidal anti-estro- has returned after chemotherapy). betes, hypothyroidism, varico- genic. The optimal window for E It includes many questions cele, or pituitary malfunction). It pregnancy occurs in the 6 days regarding the reproductive status will also include a review of addi- before ovulation, with day 6 D of his partner, including her age, tional medical conditions for being the actual day of ovulation U the duration of the couple’s which the patient is being fol- (Wilcox, Weinberg, & Baird, C attempts at pregnancy, if they lowed, including any condition 1995). Simply adjusting the tim- have had children or a positive that would require radiotherapy ing of intercourse can result in a A pregnancy test together, and the or chemotherapy. Any history of significantly increased chance T results of any semen analyses treatment for malignancy, regard- for pregnancy. I prior to the current encounter. less of site, should be document- Both partners should be The history addresses whether or ed. Diabetes, chronic obstructive asked about a history of sexually O not either partner has conceived pulmonary disease, sleep apnea, transmitted infections. Each N with another partner, and should renal insufficiency, hemachro- patient should be queried regard- include previous evaluation and matosis, and hepatic insufficiency ing erectile function, ejaculation, treatment for male or female fac- are known possible contributors to and libido; these issues can be tor infertility in the past. Not male subfertility (Burrows, superimposed onto fertility con- every male patient is accompa- Schrepferman, & Lipshultz, cerns. Erectile difficulties may be nied by his partner, but this infor- 2002). Infertility in the male can, accompanied by a history of mation should be collected as in fact, be a hallmark symptom declining erectile function, usual- completely as possible. for other medical conditions in ly insidious and progressive, and The male general history an apparently healthy adult male. may span the course of several includes a discussion of any Surgical history. The surgical years (as is a common scenario recent (within the last 6 months) history during the male infertility with diabetic patients). Alter- systemic illness, particularly if it visit focuses on any history of GU natively, the patient may provide was a febrile illness, and any surgeries at any point during the a history of relatively rapid or recent weight gain or loss. The life of the male undergoing evalu- recent onset of a decline to erec- patient should be asked if there ation. These include such diverse tile function, such as may be asso- are any complaints specific to the procedures such as orchidopexy; ciated with the history of recently genitourinary (GU) structures. Y-V plasty to the bladder neck; starting new medication or the This may reveal complaints of a inguinal hernia repair as infant, stress of the fertility evaluation. dull ache or fullness to the scro- small child, or adult; epispadias The history should include sever- tum, or pain on one side that does or hypospadias repair; prostate al points specific to the patient’s not radiate. The review of sys- surgery; bladder reconstructions; sexual functioning: the precise tems will specifically include bladder surgeries; or testicular nature of the dysfunction (for fevers, colds, sinus infections, surgeries. The surgical history example, whether the problem is anosmia (loss or impairment of should ask about procedures attaining or sustaining an erec- the sense of smell), peripheral which impair retroperitoneal tion, insufficient rigidity, difficul- field visual problems, breast pain sympathetic nerve function, such ty with penetration); the presence or secretions, and scrotal pain. It as retroperitoneal lymph node or absence of nocturnal and should establish that puberty dissection (RPLND). The patient morning erections and their qual- started in the early or middle should be asked specifically ity; and any treatments (pharma- teens to confirm normal physio- about previous treatment for tes- cologic and nonpharmacologic) logic male development. ticular or GU malignancies, either that the patient has tried. The general history includes with surgery or radiation. The If the patient complains of any potential exposure to envi- patient should be asked specifi- low libido, he may also describe 278 UROLOGIC NURSING / August 2006 / Volume 26 Number 4 moodiness, loss of interest in his Table 1. C usual activities, a decline in erec- Common Medications with an Effect on Sperm Function O tile function, fatigue, and even complaints of diminished muscle Medication Effect N bulk. It should be established if Spironolactone Decreases spermatogenesis T these complaints are new or long- I standing.