Infertility and Prostate Ultrasound

Pre-testicular etiologies

Hypogonadotropic hypogonadism (congenital, acquired)

Coital Disorders (Erectile Dysfunction, Ejaculatory disorders) secondary to organic etiologies (diabetes mellitus, spinal injury, vascular/neurogenic, multiple sclerosis) and iatrogenic etiologies (RPLND, bladder neck surgery)

Primary testicular etiologies

Cryptorchidism (especially bilateral forms)

Infection or inflammation of the testes (Orchitis)

Testicular trauma

Testicular torsion

Varicocele

Gonadotoxic medications (including chemotherapy)

Radiation injury

Iatrogenic surgical injury (prior inguinal surgery)

Systemic diseases

Congenital etiologies

- Klinefelter’s syndrome (47, XXY)

- Y-chromosome terminal deletions (Yq-)

- Structural autosomal abnormalities

Post-testicular etiologies

Obstructive/sub-obstructive lesions of the seminal tract (vasa deferentia, seminal vesicles, ejaculatory ducts)

Autoimmune infertility (autoimmunity against spermatozoa)

Infections and inflammation of the accessory glands (seminal vesicles, prostate, epididymis)

Congenital bilateral absence of the vasa deferentia

Sperm Parameters

Semen analysis is a fundamental component of evaluating and defining the severity of male factor infertility [3, 6–8]. Semen analyses should always be conducted according to the WHO Laboratory Manual [3] in order to ensure standardization. The current standards for a normal semen analysis are defined in the fifth edition of the WHO Laboratory Manual, published in 2010, and can be reviewed in Table 2 [8, 9]. Classification based on semen analysis involves a wide variety of terminology, often misused in the public literature. A summary of the appropriate terminology is listed in Table 3 [6].

Table 2

WHO 2010 semen analysis parameters

Semen analysis component	Fifth percentile (95 % CI)
Semen Volume	1.5 mL (1.4–1.7)
Total Sperm Number	39 million (33–46)
Sperm Concentration	15 million/mL (12–16)
Vitality	58 % live (55–63)
Progressive Motility	32 % (31–34)
Total (Progressive + Nonprogressive Motility)	40 % (38–42)
Morphologically Normal Forms	4.0 % (3.0–4.0)

CI, confidence interval

Table 3

Terminology based on semen analysis

Classification	Defining characteristics
Oligozoospermia	Sperm concentration <15 × 10⁶/mL, total sperm number <39 × 10⁶/mL
Asthenozoospermia	<32 % progressively motile spermatozoa
Teratozoospermia	<4 % morphologically normal spermatozoa
Oligo-astheno-teratozoospermia	Disturbance in all three parameters
Azoospermia	No spermatozoa in the ejaculate
Cryptozoospermia	Spermatazoa absent from fresh preparation, but observed in a centrifuged pellet
Aspermia	No ejaculate
Leucocytospermia	> 1 × 10⁶/mL leukocytes in the ejaculate

Primary and Secondary Infertility

Primary male factor infertility is defined as infertility in men who have never been able to conceive a child. In contrast, secondary male factor infertility describes men who have previously conceived a child without assisted reproductive techniques but now is unable to achieve a successful pregnancy.

Obstructive and Non-obstructive

The importance of this classification lies in its prognostic value and the ability to then define the subsequent management for the patient. Obstructive etiologies frequently tend to have a good prognosis and, as described later, are often responsive to surgical interventions. Additionally, obstructive pathologies are best-identified using ultrasound imaging, and, as such, will be a major focus of the remainder of this chapter.

Evaluation of Male Infertility

Initial History

A complete and thorough history is the foundation of the evaluation for infertility. As there are a multitude of possible factors that may affect a patient’s fertility and sexual function, a thorough medical, surgical, pharmaceutical (both legal and illicit), social and developmental history may help allude to these, and therefore focus further investigations. Key components of a sexual and fertility include enquiring about the length of time trying to conceive, frequency of sexual intercourse, previous fertility including any pregnancy or children, and any previous treatments for infertility

It is vital that this comprehensive history should encompass both long-term and short-term factors. Semen production has a 64-day cycle with 10–15 days for transit. During this period any disruption in spermatogenesis can cause an abnormal semen analysis, hence it is vital to expound any of these short term factors. At the same time long-term factors are also important to establish, as childhood chronic illness can cause long-term fertility changes [10]. The basis of a thorough history and factors/components to ask your patient when beginning their infertility evaluation are summarized in Table 4 [7, 11].

Table 4

Components of a thorough history in the evaluation of an infertile male

Reproductive/infertility history

Prior fertility/conceptions—current or previous partner, outcome

Prior fertility evaluation

Partner’s fertility history and evaluation

Sexual history/Coital practices

Sexually transmitted diseases

Erectile function, lubrication

Frequency/timing of intercourse

Developmental history (onset of puberty, sexual characteristics)

Past medical history

Chronic illnesses

Genital trauma

Childhood history (cryptorchidism, torsion, midline defects)

Prior infections

Family history

Infertility history

Genetic conditions

Substance use or exposure

Prescription medication history

Drug abuses

Toxin exposure

Prior surgical history

Orchiopexy

Retroperitoneal/pelvic surgery

Herniorrhaphy

Vasectomy

Bladder neck/prostate surgery

Spinal surgery

Physical Examination

Physical examination is another key component of the evaluation of the infertile male. Special attention should be given to the genitourinary examination; this portion of the exam may help identify testicular and post-testicular etiologies of infertility. The penis should be inspected for hypospadias, and the scrotum for testicular size, presence of bilateral spermatic cords, and other gross abnormalities of the scrotum such as the presence of a varicocele. The key components of the physical examination are found in Table 5 [7, 11].

Table 5

Components of a thorough physical examination in the evaluation of an infertile male

General examination

Body habitus (height, weight, body dimensions)

Secondary sexual development (body hair, temporal balding)

Gynecomastia

Thyroid examination

Abdominal examination (Hepatomegaly)

Evidence of chronic illness (diabetes, hypertension, vasculitis, neuropathy)

Genitourinary examination

Phallus (chordee, hypospadias, Peyronie’s)

Testes (size, masses, infection)

Epididymis (enlargement/induration, nodules, spermatoceles)

Spermatic cord (varicocele)

Vas deferens (presence or absence)

Inguinal region (hernia)

Prostate (nodules, infection, midline cysts)

Genitourinary infections

Labwork

Laboratory tests in the evaluation of the infertile male can be extensive. The initial laboratory test should be the semen analysis (Tables 2 and 3). These findings, in addition to those from the comprehensive history and examination will help direct further tests as required for a patient’s evaluation. In addition to the semen analysis, some key laboratory tests should include a complete blood cell count (to test for possible infection), renal and liver function studies, follicle stimulating hormone, luteinizing hormone and testosterone levels (to assess the hypothalamic–pituitary–gonadal axis), and a sexually transmitted infection evaluation. Additional laboratory test as may be ordered based on abnormal findings in the history, physical examination, and/or the initial laboratory test findings.

Imaging Modalities

While the ultrasound (transrectal, transperineal, and/or scrotal) remains the pillar of imaging for the infertile male, multiple imaging modalities are now available for the evaluation of an infertile male. Other modalities that may be utilized during the evaluation process include, but are not limited to, penile ultrasonography, abdominal ultrasonography, magnetic resonance imaging of the abdomen and pelvis, and PET scanning. A penile ultrasonography, using color Doppler, may be indicated if there is a history of Peyronie’s disease, penile fractures, and erectile dysfunction. All of these may decrease the patient’s sexual function, and henceforth cause decreased fertility [12, 13]. Abdominal ultrasound has a much more limited role in the evaluation process, as it is indicated to rule out associated renal abnormalities in patients with absent vasa deferentia. Occasionally, it may play a role in identifying renal or hepatic pathology as a contributor to infertility [12]. Magnetic Resonance Imaging has an emerging role in the evaluation of male infertility. It can provide a noninvasive alternative to traditional vasography, with or without endo-rectal coils, and is the gold standard for assessing the pituitary for possible adenomas causing hypothalamic–pituitary–gonadal axis. However it remains second line to ultrasonography for investigating possible causes of obstructive male infertility [12, 14]. As described in the remainder of this chapter, this imaging modality is an affordable, accessible, and versatile study that has an important role in a certain subset of infertile males.

Transrectal Ultrasound and Transperineal Ultrasound

Transrectal ultrasonography (TRUS) and transperineal ultrasound (TPUS) are important diagnostic tools in the field of male infertility. Historically diagnostic investigations of male infertility, such as vasography, were invasive, required general anesthetic, and had significant morbidity including iatrogenic stricture formation, vas obstruction, and radiation exposure. The vasograph has now given way to the ultrasound, and as the majority of the male reproductive system lies superficially, the ultrasound is an excellent non-morbid modality to evaluate the reproductive tract.

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