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Infertility affects 15% of all couples
(an estimated 2.4 million) in their reproductive years.
As a result, one in eight couples will struggle with
infertility regardless of whether the diagnosis is primary
or secondary. Despite 40% of infertility causes attributed
to the male and 30% due to both the male and female,
most men are reluctant to appreciate the high prevalence
of their contribution. This distribution of etiologies
maintains across cultural and ethnic boundaries.
The simplest evaluation of a male is the
semen analysis (SA). Sperm density (greater than 20
million/mL), motility (greater than 50%), and morphology
(greater than 30%) an integral screen of sperm fertilization
potential. A persistently abnormal SA on two occasions
obtained one month apart, particularly if severely low,
warrants a genital examination by an experienced male
reproductive specialist. Most male infertility physicians
today are urologists with additional years of specialized
training in the field. An abnormal SA may be the first
sign of significant pathology and may be life threatening
in 2% of cases.
The diagnosis of infertility may not only
indicate a problem with the husband but also may put
the health of his offspring at risk. With a growing
understanding about the genetics behind male infertility,
a genetic cause may exist in up to 20% of patients.
The primary goal of the evaluation is
to determine the cause of the problem and to exclude
life threatening pathology. To accomplish these goals
all husbands will require at least a history, physical
examination, hormonal testing in addition to the semen
analyses. Other studies may be indicated but usually
occur after the core evaluation.
The secondary goal of the male evaluation
is to determine if the infertility is treatable. The
leading causes of male infertility are varicocele (42%),
idiopathic (23%), obstruction (14%) and cryptorchidism
(3%).
Once a diagnosis is made a discussion
ensues regarding treatment options. Today more options
exist that were previously unavailable. Despite severe
male factor infertility, pregnancy may still be achieved.
The other unique feature of infertility treatment is
the shared nature of the decision making process between
the physician and the couple. Not only must the status
of the wife be factored into the treatment decision
but the couple's psychological, ethical and financial
concerns as well. It is imperative during the male evaluation
that the wife have completed her evaluation and that
an open dialogue exists between the treating physicians
of both the husband and the wife.
A couple experiencing infertility should
not underestimate the significance of the problems that
can exist in the male. These problems may be the sole
or contributing reason for the couple's failure to conceive
and are best identified by a male infertility specialist.
Care and attention in looking for and identifying disease
processes in both the man and woman will prevent missed
opportunity for a potential cure and give the couple
the timeliest and most efficient pathway to start or
expand their family.
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