| Semenalysis finding | Further workup | Interpreting findings |
|---|---|---|
| Azoospermia (absent sperm) | Semenalysis | Low volume + acidic pH indicates obstruction |
| Testis size | Cutoff testis axis 4.6cm determines whether obstruction present | |
| Vas deferens | Absence indicates obstruction | |
| FSH | Cutoff 7.6IU/L determines whether obstruction present | |
| Karyotype + Y Microdeletion (if elevated FSH or testicular atrophy) | Kleinfelter and Y deletions are most common causes of non-obstructive azoospermia | |
| TRUS (if normal T and vas, obstruction suspected) | Confirm ejaculatory duct obstruction | |
| Low volume | History | Caused by DM, SCI, RPLND |
| Post-ejaculate urinalysis | Confirms sperm ending up in bladder | |
| Round cells > 1mil/mL | Special stains | Differentiate pyospermia from germ cells |
| Sperm agglutination | Antisperm antibody testing | ICSI may be indicated for ASA instead of IUI |
| Poor sperm mobility | Viability testing | Assess whether nonmotile sperm can be used for ICSI |
| Test | Indication | If positive: |
|---|---|---|
| Post-ejaculate urinalysis | Low-volume ejaculate | Sperm retrieval |
| Karyotype | Nonoobstructive azoospermia | microTESE (for Kleinfelter) |
| Repeat pregnancy loss | Sperm aneuploidy - ICSI, adoption, donor sperm | |
| Y microdeletion | Nonobstructive azoospermia | Adoption (AZFa/AZFb) or ICSI (AZFc) |
| Transrectal US | Obstructive azoospermia + low volume/pH + normal T + palpable vas | TURED |
| CFTR gene panel | Absent vas deferens | Test female partner TESE |
| Sperm DNA fragmentation | Repeat IVF failure Repeat pregnancy loss |
TESE + ICSI |
| Antisperm antibody testing | Concern for obstruction, azoospermia, agglutination | Recommend ICSI Do not order if already planning ICSI |
| Scrotal US | Assess for varicocele in difficult scrotum (obese, high + tight) | Discuss clinical relevance of US varicocele |
| Abdominal imaging | Assess for malignant cause of new or nonreducible large right varicocele | |
| Renal US | Assess for renal absence if vas absent unilaterally (26-75%) or bilaterally (10%) | |
| Infertility Grouping | Diagnosis | Findings | Treatment |
|---|---|---|---|
| Gonadotropin Dysfunction | Kallman syndrome | Hypogonadotropic hypogonadism Anosmia |
HCG + FSH, GnRH pump |
| Incomplete hypoandrogenism | Increased LH Decreased T |
Clomiphene/Tamoxifen Anostrozole/Letrozole |
|
| Pituitary tumors | Elevated prolactin MR imaging if prolactin elevated (> 50ug/L) |
Bromocriptine/Cabergoline Transsphenoidal surgery |
|
| Exogenous suppression | Specific hx steroids or other drugs | Stop offening agent(s) | |
| Testicular dysfunction | Kleinfelter (XXY) | azoospermia (92%) + small testes + hypergonadotropins mosaic in 10-20% |
microTESE + IVF/ICSI |
| Leydig cell (steroidogenic) dysfunction | Elevated LH Decreased T |
microTESE + IVF/ICSI | |
| Y Microdeletions | azoospermia (AZFa/AZFb) | Adoption, donor sperm | |
| oligospermia (AZFc) | microTESE + IVF/ICSI | ||
| Antisperm antibodies | secondary to blood/testis barrier breakdown | IVF/ICSI | |
| Varicocele | Physical exam | Surgical repair | |
| DNA Fragmentation | Assess after repeat IVF failure | TESE + ICSI | |
| Transportation Dysfunction | Absence of Vas Deferens | Physical exam findings History renal agenesis |
TESE + IVF |
| Congenital Bilateral Absence of the Vas Deferens (CBAVD) | CFTR mutation | CFTR screen panel TESE + IVF |
|
| Hypospadias Epispadias |
Physical exam findings | Intrauterine insemination | |
| Ejaculatory duct obstruction | Azoospermia + Hypovolemia TRUS findings (SV > 15mm AP, ED > 2.3mm) |
TURED | |
| Retrograde ejaculation | Azoospermia + Hypovolemia Sperm on post-ejaculate urinalysis |
Sperm retrieval (alkalinize with bicarb) Sympathomimetic agents (25% success) |
|
| Anejaculation | Neurologic history Prior RPLND |
Penile vibratory device Electroejaculation |