Male Infertility Management

Non-Surgical Management of Infertility

Ejaculatory stimulation


Class Medication Dose Indication Side effects
Gonadotropin agonist Human Chorionic Gonadotropin (HCG) 1500-5000 IU 2-3x weekly
Titrate up to 10K IU/week
Titrate to T level
Hypogonadotropic hypogonadism Nausea (12%)
Breast enlargement/tenderness (1-10%)
Headache (34%)
Injection discomfort (1-10%)
Human Menopausal Gonadotropin (HMG) 75-150 IU 2-3x weekly
Selective estrogen receptor modulator Clomiphene citrate 25mg QD or 50mg EOD
Titrate to max 100mg QD
Titrate to T level
Headache (1%)
Blurred vision (2%)
Flushing (10%)
Breast discomfort (2%)
Nausea (2%)
Impaired libido
Gynecomastia (rare)
Aromatase inhibitor Anostrozole 1mg daily Hypergonadotropic hypogonadism (Kleinfelter syndrome) Nausea (11-19%)
Headache (9-10%)
Hot flashes (12-26%)
Chest discomfort (2-12%)
Lestrozole 2.5mg daily
Dopamine agonist Cabergoline 0.25mg 2x weekly
Titrate up to 1mg
Titrate per prolactin levels
Prolactin-secreting pituitary tumor Headache (26%)
Dizziness (15-17%)
Nausea (27-29%)
Constipation (7-10%)
a-agonist Pseudoephedrine 60mg PO QID Retrograde ejaculation restlessness

Surgical Management of Infertility

Surgical treatment

Class Procedure Indications Description Side effects
Azoospermia diagnosis Testis aspiration Confirm obstructive (vs nonobstructive) azoospermia Insert biopsy needle (thru skin or skin incision) and aspirate to assess for sperm Hematoma, hematocele, spermatocele, hydrocele
Testis biopsy Incise tunica albuginea, extrude tubules and remove, close incision Low risk bleeding
Sperm retrieval Tes(TESE) Obstructive azoospermia Obtain sperm via opening testis or epididymis and removing tubules Bleeding, postop pain
microTESE Nonobstructive azoospermia Obtain sperm via assessing and extracting microtubules
Epididymal sperm extraction Obstructive azoospermia with epididymal dilation Obtain sperm via assessing and extracting microtubules
Improve sperm delivery Vas reversal Obstructive azoospermia (after vasectomy) Obtain sperm via assessing and extracting microtubules Hematoma (0.3%), granulomas (5%), delayed failure (5%), can consider TESE instead
Transurethral resection of ejaculatory ducts (TURED) Obstructive azoospermia (ejaculatory ducts) Resect ducts to remove obstruction, can transrectally inject dye to improve identification Restenosis, pain, epididymoorchitis (chemical/infectious), retention, incontinence, hematuria
Assisted reproductive technology Intrauterine insemination (IUI) Normal sperm but unable to reach egg naturally, oligospermia (5-8mil) Inject collected/concentrated sperm into uterus (via cervix) to allow natural fertilization of egg Minimal risks
In vitro fertilization (IVF) Sperm unable to reach egg, oligospermia (< 5mil) Sperm placed in proximity to egg, natural fertilization, embryos placed within uterus for implantation Risks of egg stimulation/retrieval
Multifetal pregnancy
Intracytoplasmic sperm injection (ICSI) Sperm unable to fertilize egg, oligospermia (< 5mil) Sperm directly injected into egg, embryos placed within uterus for implantation Risks of egg stimulation/retrieval
4x risk for sex chromosome abnormalities
Congenital malformations (slight increased risk)
Spontaneous abortion/ectopic pregnancy