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    Cost-effective workup of the infertile male patient

    Thorough history/physical, high-quality semen analyses among critical components


    Endocrine evaluation. Due to the fact that >40% of our patients come from over 100 miles away, we have elected to have patients obtain a standardized endocrine workup and at least one semen analysis (preferably two) prior to their arrival (figure 1). The importance of obtaining these two semen analyses from a high-quality reference lab that can reliably confirm azoospermia or cryptozoospermia after examining a centrifuged pellet cannot be overstated.

    Distinguishing azoospermic spermatogenic failure from obstructive azoospermia

    We have also found that many men have normal bulk seminal parameters, hypoandrogenism, and primary infertility (Urology Feb. 28, 2015 [epub ahead of print]). We use a calculated bioavailable testosterone with a threshold of >155 ng/dL as optimal for spermatogenesis (testosterone, SHBG, albumin, calculated per the International Society for the Study of the Aging Male website [http://www.issam.ch/freetesto.htm]) (J Clin Endocrinol Metab 1999; 84:3666-72). Further, we evaluate estradiol to ensure that the testosterone:estradiol ratio is greater than 10:1. If the testosterone is low and labs indicate hypogonadotropic hypogonadism, we will also obtain a prolactin.

    READ: Biomarkers yet to fully justify claimed clinical utility

    GU exam. In addition to this endocrine evaluation, we also complete a thorough male genitourinary exam and document the secondary male sexual characteristics, longitudinal testis axis, and presence of varicoceles and vas deferens. Our rationale for completing this endocrine evaluation in everyone is that we often find treatable hypoandrogenism that can enable natural pregnancy or IUI through medical therapy alone. These treatments are far less expensive than surgical interventions or assisted reproductive technologies (ART).

    Per the American Society for Reproductive Medicine and AUA guidelines, we also obtain genetic testing consisting of a Y chromosome microdeletion and karyotype on all men with sperm concentration less than 5 M/mL and obtain a cystic fibrosis transmembrane conductance regulator test on any man without palpable vas deferens (https://www.auanet.org/education/guidelines/male-infertility-d.cfm). Our other rationale for obtaining the endocrine evaluation on all men is to reliably differentiate obstructive azoospermia from spermatogenic failure (figure 2).

    NEXT: Initial approach to the man with primary infertility


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