Tests
1st tests to order
sperm concentration
Test
Oligozoospermia (<16 million sperm/mL) may indicate a disruption of spermatogenesis at many different levels.[33]
Result
<16 million sperm/mL
sperm motility
Test
May indicate the presence of antisperm antibodies, sperm necrosis, flagellar defects, or toxic exposure.
Result
<42% motile spermatozoa
sperm morphology
Test
Determines whether the sperm has successfully completed spermiogenesis, and is a measure of sperm fitness for fertilization and conception.
Result
<4% normal forms
seminal fluid parameters
Test
Low volume, decreased pH, or aspermia indicates reproductive tract disorders and should be followed up with prostate exam, transrectal ultrasound, and/or postejaculatory urine analysis.
The specimen may be assayed for the presence of fructose to determine whether the seminal vesicles are contributing.
Result
poor liquefaction; low ejaculate volume (<1.4 mL); decreased seminal pH; presence of fructose; increased leukocyte count
Investigations to avoid
antisperm antibody (ASA) serology
Recommendations
Do not perform antisperm antibody (ASA) testing in the initial evaluation of male infertility.[24][39] Only consider ASA testing if it will affect management of the patient.[24]
Rationale
Routine immunologic testing of couples with infertility is expensive and does not predict pregnancy outcome.[39]
Tests to consider
sperm viability
Test
Histologic test using eosin and nigrosin, referred to as the Live/Dead assay.
Greater than 46% sperm necrosis is often caused by antisperm antibodies, but may be due to idiopathic causes or toxic exposure.[33]
Result
>46% sperm necrosis
sperm membrane function
Test
Determines cell viability by using a hypo-osmotic solution to detect the osmoregulatory capacity of the sperm membrane.
Result
>40% reacted sperms
hormonal assays
Test
Measure follicle-stimulating hormone (FSH), luteinizing hormone (LH), free and total testosterone, estradiol, sex hormone-binding globulin, and prolactin levels. Albumin may be obtained for calculation of bioavailable testosterone.
Thyroid-stimulating hormone (TSH) can be ordered in cases of failed IVF among men >40 years or if there is association with erectile dysfunction.[36][37][38]
Result
abnormal levels depend on the laboratory standard
MRI of the pituitary and hypothalamus
Test
MRI of the brain is indicated to rule out pituitary or hypothalamic tumors or other disorders in the setting of hypogonadotropic hypogonadism (low LH and low testosterone).
Result
lesion in the pituitary or hypothalamus
color flow Doppler imaging
Test
May be used in conjunction with the physical exam to diagnose a low-grade varicocele.
Result
presence of a varicocele
post-ejaculation urine testing for retrograde ejaculation
Test
Performed by collecting a urine sample directly following the collection of any antegrade ejaculation. If positive, retrograde ejaculation is present.
Result
presence of semen
genetic analysis
Test
Karyotype analysis diagnoses Klinefelter syndrome and polymerase chain reaction for microdeletions of the Y chromosome.[15] Indicated with concentrations <5 million/mL and suspected etiology of spermatogenic dysfunction.[34] Additionally indicated in the setting of recurrent pregnancy loss.
Mutations in the CFTR gene are present in up to 80% of men with congenital bilateral absence of vas deferens (CBAVD).[24]
Result
chromosomal abnormalities; CFTR gene mutation
sperm DNA assays
Test
Suggested tests are the sperm chromatin structure, terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate nick-end labeling, or sperm chromatin dispersion test. Cut-off values that predict success with insemination remain controversial.[41]
DNA damage may be a cause of infertility, recurrent pregnancy loss, or recurrent IVF failures.[24][42][43]
Result
must be reported with internal control samples; normal range should be set by individual laboratories
acrosome reaction test
Test
Determines the ability of acrosome (anterior part of the sperm head) to successfully penetrate the outer coating of the egg.
The assay may determine whether there is a propensity for premature acrosome reaction. The assay should be run in conjunction with a simultaneous Live/Dead stain to be accurate.
Result
must be reported with internal control samples; normal range should be set by individual laboratories
sperm longevity test
Test
Aids in diagnosis of poor sperm survivability after ejaculation.
Result
gradual decline in sperm motility is seen over a 6- to 12-hour period with at least 4 time points included; sperm motility should be at least one half of initial value at 12 hours in washed sperm suspension
electron microscopy
Test
Requested when sperm motility is abnormal and microtubule dysfunction or nuclear/chromatin abnormalities are suspected.
Result
microtubule abnormality
testicular biopsy
Test
Diagnostic testicular biopsies are not routinely performed because laboratory and clinical findings may accurately predict obstructive versus nonobstructive etiology.[20]
Biopsy should be performed in conjunction with an experienced andrologist to assess the wet preparation of tissue for viable sperm, with a portion of the sample sent for histopathologic evaluation.
A follicle-stimulating hormone (FSH) >7.6 mIU/mL and testicular longitudinal axis (TLA) <4.6 cm predicts an 89% likelihood of spermatogenic dysfunction, while an FSH <7.6 mIU/mL and TLA >4.6 cm predicts a 96% likelihood of obstructive etiology.[44]
Microdissection testicular sperm extraction (micro-TESE) is recommended in males with nonobstructive azoospermia who are undergoing sperm retrieval (and subsequent cryopreservation for use with ICSI).[24] Micro-TESE allows examination of multiple regions of testicular tissue.
Result
arrested spermatogenesis
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