For other titles published in the series, go to

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2 Current Clinical Urology Eric A. Klein, MD, Series Editor For other titles published in the series, go to

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4 Male Infertility Problems and Solutions Edited by Edmund S. Sabanegh, Jr., M.D.

5 Editor Edmund S. Sabanegh, Jr., MD. Chairman, Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, Ohio USA Series Editor Eric A. Klein, Md Professor of surgery Cleveland Clinic Lerner College of Medicine Head, Section of Urologic Oncology Glickman Urological and Kidney Institute Cleveland, OH ISBN e-isbn DOI / Springer New York Dordrecht Heidelberg London Library of Congress Control Number: Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Humana Press, c/o Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Humana Press is part of Springer Science+Business Media (

6 Preface With almost 50% of infertility attributed either wholly or in part to male issues, it has become increasingly important to look at infertility from a couple s perspective. Advances in assisted reproductive technologies allow more conceptions than ever before, but such treatments may come with significant financial and safety cost. These costs are certainly justifiable with the targeted use of these innovative advances, but they should not be applied in a blanket fashion to all causes of infertility. Thorough evaluation of the male with the correction of underlying issues can maximize the potential for natural reproduction. In this text, we have assembled world-renowned experts in the field to provide a clear and concise overview of state-of-the-art developments in male infertility for both the novice and experienced p ractitioners in the field. We have placed special emphasis on diagnostic and treatment algorithms to allow the reader to obtain rapid answers to this challenging medical issue. The text is intended for general urologists, gynecologists, primary care providers, and allied health providers who manage infertility in both men as well as women. It is our sincere hope that this book allows rapid acquisition of pertinent background and development of management plans in this ever changing field. It is an exciting time to be involved in the treatment of infertility. We hope this book further stimulates your interest as together we manage couples in a compassionate, safe, and efficient fashion. Cleveland, OH, USA Edmund S. Sabanegh, Jr. v

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8 Acknowledgments Special thanks to my clinical fellows, Kashif Siddiqi, MD and John Kefer, MD for their diligent assistance throughout the preparation of this book and to my children, Emily and Ned and my wife, Amy. Without their support, none of this would have been possible. vii

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10 Contents Preface... v Contributors... xi The Initial Consultation for Male Infertility... Wayne Kuang 1 Interpretation of Basic Semen Analysis and Advanced Semen Testing... Ashok Agarwal and Tamer M. Said 15 Azoospermia: Diagnosis and Management... John C. Kefer and Dan B. French 23 Ejaculatory Dysfunction... Dana A. Ohl, Susanne A. Quallich, Jens Sønksen, Nancy L. Brackett, and Charles M. Lynne 31 Genetic Issues with Male Fertility... Robert D. Oates 39 Endocrinopathies in Male Infertility... Stephanie E. Harris, Hussein M.S. Kandil, and Craig S. Niederberger 47 Female Fertility: Implications to Management of Male Factor... Jeffrey M. Goldberg and Michelle Catenacci 57 Varicocele: To Fix or Not to Fix... Fábio Firmbach Pasqualotto, Edson Borges, Felipe Roth, Luana Venturin Lara, and Eleonora Bedin Pasqualotto 65 Medical Management of Male Infertility... Eric E. Laborde, Vishal Bhalani, Neal Patel, and Robert E. Brannigan 81 Surgical Reconstructions for Obstruction... Edmund S. Sabanegh, Jr. and Kashif Siddiqi 89 Techniques for Sperm Harvest... Wayland Hsiao and Peter N. Schlegel 99 ix

11 x Contents Sperm Banking: When, Why, and How?... Sajal Gupta, Lucky H. Sekhon, and Ashok Agarwal 107 Assisted Reproduction and Male Factor Fertility: Which Type Is Right?... James Goldfarb and Nina Desai 119 Ethical Dilemmas in Male Infertility... Barbara Chubak and Anthony J. Thomas 125 Index

12 Contributors Ashok Agarwal, Ph.D., H.C.L.D. Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA James Goldfarb, M.D., M.B.A. In-Vitro Fertilization Center, Cleveland Clinic, Cleveland, OH 44195, USA Vishal Bhalani, M.D. Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Sajal Gupta, M.D. Center for Reproductive Medicine and Andrology Laboratory and Reproductive Tissue Bank, Glickman Urological & Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A19.1, Cleveland, OH 44195, USA Edson Borges, Jr, M.D., Ph.D. Fertility - Center for Assisted Fertilization, São Paulo, SP, Brazil; Institute Sapientiae - Center of Post-Graduation in Human Assisted Reproduction Brazil Nancy L. Brackett, Ph.D. The Miami Project to Cure Paralysis, University of Miami School of Medicine, Miami, FL 33101, USA Robert E. Brannigan, M.D. Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Michelle Catenacci, M.D. Obstetrics/Gynecology and Women s Health Institute, Cleveland Clinic, Cleveland, OH, USA Barbara Chubak, M.D. Department of Bioethics, Cleveland Clinic, Cleveland, OH, USA Nina Desai, Ph.D., H.C.L.D. In-Vitro Fertilization Center, Cleveland Clinic, Cleveland, OH 44195, USA Dan B. French, M.D. Dallas Center for Pelvic Medicine, Suite 200, N Central Expressway, Dallas, TX, USA Jeffrey M. Goldberg, M.D. Obstetrics/Gynecology and Women s Health Institute, Cleveland Clinic, Cleveland, OH, USA Stephanie E. Harris, M.D. University of Illinois at Chicago, Chicago, IL, USA Wayland Hsiao, M.D. James Buchanan Brady Foundation, Starr 900, Department of Urology, Weill Cornell Medical College, The New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA Hussein M.S. Kandil, M.D. University of Illinois at Chicago, Chicago, IL, USA John C. Kefer, M.D., Ph.D. Center for Male Fertility/Andrology, Glickman Urological and Kidney Institute, Mailcode Q10, 9500 Euclid Ave, Cleveland, OH, USA Wayne Kuang, M.D. Division of Urology, University of New Mexico, Albuquerque, NM, USA Eric E. Laborde, M.D. Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA Luana V. Lara, B.Sc. CONCEPTION - Center for Human Reproduction, Caxias do Sul, RS, Brazil xi

13 xii Contributors Charles M. Lynne, M.D. Department of Urology, University of Miami School of Medicine, Miami, FL, USA Susanne A. Quallich, N.P.-C. Department of Sexual and Reproductive Medicine, University of Michigan, Ann Arbor, MI 48108, USA Craig S. Niederberger, M.D. University of Illinois at Chicago, Chicago, IL, USA Felipe Roth, M.D. CONCEPTION - Center for Human Reproduction, Caxias do Sul, RS, Brazil Robert D. Oates, M.D. Boston University School of Medicine, Boston, MA 02118, USA Dana A. Ohl, M.D. Department of Sexual and Reproductive Medicine, University of Michigan, Ann Arbor, MI 48108, USA Eleonora B. Pasqualotto, M.D., Ph.D. CONCEPTION - Center for Advanced Research in Human Reproduction, Infertility & Sexual Function, Center for Biological and Health Sciences, University of Caxias do Sul, Caxias do Sul, RS, Brazil; Department of Obstetrics Gynecology, General Hospital, University of Caxias do Sul, Caxias do Sul, RS, Brazil Fábio F. Pasqualotto, M.D., Ph.D. University of Caxias do Sul, RS, Brazil; Institute of Biotechnology, University of Caxias do Sul, RS, Brazil; Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil; CONCEPTION - Center for Human Reproduction, Caxias do Sul, RS, Brazil; Rua Pinheiro Machado, 2569, sl 23/24, Bairro São Pelegrino, Caxias do Sul, RS, Brazil Neal Patel, B.S. Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL 60061, USA Edmund S. Sabanegh, Jr., M.D. Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland, OH, USA Tamer M. Said, M.D., Ph.D. The Toronto Institute for Reproductive Medicine ReproMed, Toronto, ON, Canada Peter N. Schlegel, M.D. James Buchanan Brady Foundation, Starr 900, Department of Urology, Weill Cornell Medical College, The New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA Lucky H. Sekhon, B.Sc. Center for Reproductive Medicine and Andrology Laboratory and Reproductive Tissue Bank, Glickman Urological & Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A19.1, Cleveland, OH 44195, USA Kashif Siddiqi, M.D. Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland, OH, USA Jens Sønksen, M.D., Ph.D. Department of Urology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark Anthony J. Thomas Jr., M.D. Department of Bioethics, Cleveland Clinic, Cleveland, OH, USA

14 The Initial Consultation for Male Infertility Wayne Kuang MD Contents Introduction... Male Infertility... Sexual History... Developmental and Childhood History... Infection History... Medical History... Surgical History... Social History... Medications... Physical Exam... Summary... References Abbreviations Introduction AAS Anabolic androgenic steroids CAH Congential adrenal hyperplasia CF Cystic fibrosis Gy Gray HPG Hypothalamic gonadal axis IHH Isolated hypogonadotropic hypogonadism IVF In vitro fertilization LH Luteinizing hormone A thorough history and physical exam is a critical stepping stone towards the diagnosis and treatment of male infertility. This review focuses on obtaining a sexual, developmental, infection, medical, surgical and social history, providing an overview of medications that may impair a man s fertility potential and performing a careful physical exam (see Table 1). The interpretation of hormonal, seminal and genetic testing is discussed in later chapters in association with specific disease entities. Male Infertility W. Kuang ( ) Division of Urology, University of New Mexico, Southwest Fertility Center for Men, Albuquerque, NM, USA Infertility is defined as failure to conceive after 12 or more months of regular unprotected intercourse (Practice Committee of the American Society for From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: / _1, Springer Science+Business Media, LLC