Differential Diagnoses

Workup

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Media Gallery

Male infertility. Hypothalamic-pituitary-gonadal axis stimulatory and inhibitory signals. Gonadotropin-releasing hormone (GnRH) from the hypothalamus stimulates the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary. FSH stimulates the Sertoli cells to facilitate sperm production, while LH stimulates testosterone release from the Leydig cells. Feedback inhibition is from testosterone and inhibin.
Male infertility. Testicular histology magnified 500 times. Leydig cells reside in the interstitium. Spermatogonia and Sertoli cells lie on the basement membrane of the seminiferous tubules. Germ cells interdigitate with the Sertoli cells and undergo ordered maturation, migrating toward the lumen as they mature.
Male infertility. Normal male ductal anatomy.
Male infertility. Varicocele. A - Physical examination revealing the characteristic "bag of worms." B - Anatomy of the dilated pampiniform plexus of veins.
Male infertility. Technique of open vasography: The vas distal to the site of incision is determined to be patent if saline is injected without resistance. Alternatively, radiographic contrast dye is injected through the vas deferens and radiography is performed, or blue dye may be injected and visualized in the urine to confirm patency. A vasovasostomy or vasoepididymostomy may then be performed at this level.
Male infertility. Technique of microscopic varicocelectomy. The individual veins of the pampiniform plexus are isolated (top) and ligated, taking care to preserve the testicular artery (bottom) isolated using the intraoperative Doppler.
Male infertility. Technique of vasovasostomy: Upper left is confirmation of sperm from the proximal vas deferens, proving proximal patency. Upper right is the inner layer anastomosis using interrupted #10-0 Prolene. Lower left is the inner layer anastomosis completed. Lower right is the outer layer anastomosis using #9-0 Prolene completed.
Male infertility. Technique of vasoepididymostomy. Left upper is confirmation of mature sperm in epididymis. Right upper is the inner layer anastomosis of the end of the vas to the side of the epididymal tubule using interrupted #10-0 Prolene. Left lower is the inner layer completed. Right lower is the outer layer anastomosis using interrupted #9-0 Prolene completed.
Male infertility. Technique of intracytoplasmic sperm injection (ICSI). A micropipette is used to inject a single sperm directly into an egg.

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Author

Chirag N Dave, MD Physician in Sexual and Male Reproductive Medicine and Urology, Advanced Urology Institute of Georgia

Chirag N Dave, MD is a member of the following medical societies: American Urological Association, Sexual Medicine Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Anisha Dave, MD Intern, Huron Valley-Sinai Hospital, Detroit Medical Center

Anisha Dave, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, American Medical Association, American Medical Women's Association, HIV Medicine Association, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Kristen Meier, MD Resident Physician, Department of Urology, Oakland University William Beaumont School of Medicine

Kristen Meier, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Phi Beta Kappa, Phi Kappa Phi

Disclosure: Nothing to disclose.

Richard C Bennett, MD Assistant Professor of Urology, Oakland University William Beaumont School of Medicine; Urologist, Comprehensive Urology

Richard C Bennett, MD is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Michigan State Medical Society, Sexual Medicine Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, The Scientific Research Honor Society, Society of University Urologists, SWOG

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Daniel B Rukstalis, MD Professor of Urology, Wake Forest Baptist Health System, Wake Forest University School of Medicine

Daniel B Rukstalis, MD is a member of the following medical societies: American Association for the Advancement of Science, American Urological Association

Disclosure: Nothing to disclose.

Jonathan Rubenstein, MD Urologist, Chesapeake Urology Associates

Jonathan Rubenstein, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Robert E Brannigan, MD Associate Professor, Department of Urology, Northwestern University, Feinberg School of Medicine

Robert E Brannigan, MD is a member of the following medical societies: American Society for Reproductive Medicine, American Society of Andrology, Society for the Study of Reproduction, Society for the Study of Male Reproduction, American Urological Association, Endocrine Society

Disclosure: Nothing to disclose.

Kassem Faraj Oakland University William Beaumont School of Medicine

Kassem Faraj is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, American Urological Association, Michigan State Medical Society

Disclosure: Nothing to disclose.

Paras Vakharia, PharmD Medical Student Researcher, Department of Dermatology, Henry Ford Hospital; Medical Student Researcher, Department of Ophthalmology and Department of Radiation Oncology, Oakland University William Beaumont School of Medicine

Paras Vakharia, PharmD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hematology, Michigan State Medical Society

Disclosure: Nothing to disclose.

Sections Male Infertility
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Analysis	Finding	Conclusion/Further investigation
Ejaculate volume	Low (< 1.5 mL)	Postejaculation urine (retrograde ejaculation) TRUS (absence of vas deferens) Hormonal evaluation (hypogonadism)
	High (>5 mL)	Likely contaminant
Semen quality	Does not coagulate	TRUS (ejaculatory duct obstruction)
	Does not liquefy	Hormonal analysis
Sperm density	Oligospermia (< 20 million per mL) Severe oligospermia (< 5 million per mL)	TRUS (partial ejaculatory duct obstruction) Antisperm antibody evaluation Hormonal analysis Physical examination for varicocele
	Azoospermia	Sperm centrifuged to verify azoospermia Postejaculation urine (retrograde ejaculation) Hormonal evaluation Testicular biopsy (testicular failure) TRUS (ejaculatory duct obstruction)
Motility	Decreased	Antisperm antibodies Physical examination for varicocele
*All semen analyses with abnormal results should be repeated.

Male Infertility Differential Diagnoses

Differential Diagnoses

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