A 33-year-old man is referred for evaluation of male infertility. He and his 29 years old wife have been trying to conceive for last 2 years. She is gravida (G0), para (P0) with complete medical evaluation revealing regular ovulatory cycles and normal reproductive anatomy with no history of reproductive tract disorders, pelvic infection or surgery. The couple has had unprotected vaginal intercourse at least 2–3 times a week, having undergone a normal puberty and well previously, he complains of poor libido and poor erection with decreased volume of ejaculate for past 1 year. He shaves once a week. There is no past history of any chronic ailments or any reproductive disorders, and has taken no medications or any illicit drugs. He has no family history of hypogonadism, cleft palate or infertility; he has 2 brothers who have fathered children. He works as a software professional with no habitual smoking or drinking. He has never fathered a child. He is well virilized with normal male voice and normal upper/lower segment ratio. His body mass index (BMI) is 33.5 kg/m2 with bilateral nontender gynecomastia; a normal genitourinary examination with normally descended testes that are 12 mL bilaterally and easily palpable vasa deferentia. His laboratory tests (performed at 8.00 am) reveal total testosterone 220 ng/dL (N: 300–1000 ng/dL), luteinizing hormone (LH)-2 mIU/mL, follicle stimulating hormone (FSH)-6 mIU/ mL. Hematogram, urine analysis, hepatic and renal profiles, serum prolactin, thyroid profile and iron studies are normal. Repeat hormonal analysis reveal similar results. The seminal fluid analysis yields no sperms with volume of 2.45 mL, normal pH (≥7.2) and fructose. Repeat semen analysis shows similar results. Sella imaging reveals no hypothalamic/pituitary abnormality.
What are the relevant points to be covered in evaluation of clinical history?
Medicine
• Developmental history, including testicular descent, pubertal development, loss of body hair, or decrease in shaving frequency.
• Chronic medical illness.
• Symptoms of thyroid disease, corticosteroid excess: Hypothalamicopituitary masses (e.g. headaches and visual changes), or acromegaly. In patients with long-standing diabetes mellitus and neurological disorders, gastrointestinal symptoms such as postprandial fullness or vomiting, chronic diarrhea or constipation might indicate dysautonomia and greater risk of ejaculatory dysfunction. Postcoital micturition that is cloudy might indicate retrograde ejaculation.
• Infections, such as mumps orchitis, sinopulmonary symptoms, sexually trans-mitted infections, and genitourinary tract infections including prostatitis.
• Surgical procedures involving the inguinal and scrotal areas such as vasectomy, orchiectomy, and herniorrhaphy.
• Drugs and environmental exposures, including alcohol, radiation therapy, anabolic steroids, cytotoxic chemotherapy, drugs that cause hyperpro-lactinemia, and exposure to toxic chemicals (e.g. pesticides, hormonal disrupters).
• Sexual history, including libido, morning erections, frequency of intercourse, sexual dysfunction (erectile dysfunction, anorgasmia), pain or abnormal curvature with erections, loss of body hairs with decreased frequency of shaving, small or shrinking testes with enlargement of breasts and previous fertility assessments of the man and his partner.
• School performance, to determine if he has a history of learning disabilities suggestive of Klinefelter’s syndrome.
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