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 various components of physical examination in an infertile male?
Medicine
The physical examination should include a general medical examination with a focus on finding evidence of androgen deficiency. The clinical manifestations of androgen deficiency depend upon the age of onset. Androgen deficiency during early gestation presents as ambiguous genitalia; in late gestation as micropenis; in childhood as delayed pubertal development; and in adulthood as decreased sexual function, infertility, and eventually, loss of secondary sex characteristics. The examination of the man should include the following components: General appearance—eunuchoidal proportions (upper/lower body ratio <1 with an arm span 5 cm >standing height) suggest androgen deficiency antedating puberty. On the other hand, increased body fat and decreased muscle mass suggest current androgen deficiency. Skin—loss of pubic, axillary, and facial hair, decreased oiliness of the skin, and fine facial wrinkling suggest long-standing androgen deficiency. External genitalia—several abnormalities that can affect fertility can be recognized by examination of the external genitalia:
• The penis should be examined for any hypospadias and fibrosis.
• Incomplete sexual development can be recognized by examining the phallus and testes and finding a Tanner stage other than 5.
• Diseases that affect sperm maturation and transport can be detected by examination of the scrotum for absence of the vas, epididymal thickening, varicocele, and hernia. The presence of a varicocele should be confirmed with the man in recumbent and standing positions and performing a Valsalva maneuver; varicoceles should shrink significantly in the recumbent position. The testes should be carefully palpated for masses; testicular cancer is more prevalent in infertile men.
• Decreased volume of the seminiferous tubules can be detected by measuring testicular size by Prader orchidometer. In an adult man, testicular volume below 15 mL and testicular length below 3.6 cm are considered small. In infertile men with testes <15 cc, there generally is a direct correlation between testicular volume and successful medical treatment of fertility. A testicular volume >6 cc generally portends a better response to treatment.
• Breasts—gynecomastia suggests a decreased androgen to estrogen ratio.
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