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Last reviewed: 21 Mar 2025
Last updated: 27 Jan 2025

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • inability of an opposite-sex couple to conceive
  • vasectomy
  • palpable and dilated testicular veins
  • erectile dysfunction and decreased libido
  • testis atrophy (testis smaller than 20 cm³)
  • body habitus, abnormal hair distribution, and gynaecomastia
  • absent vasa or epididymis

Other diagnostic factors

  • headaches, galactorrhoea, and visual disturbance
  • anosmia
  • frequent respiratory infections
  • pain, blood, or pus with ejaculation

Risk factors

  • varicocele
  • cryptorchidism
  • prior chemotherapy or radiotherapy
  • current medications
  • cystic fibrosis and congenital bilateral absence of vas deferens (CBAVD)
  • Y chromosome abnormalities
  • Klinefelter syndrome (47,XXY)
  • endocrinopathy
  • previous infertility
  • genital tract infection
  • erectile dysfunction
  • retrograde ejaculation
  • obesity
  • testicular torsion or trauma
  • lifestyle factors including smoking, alcohol, and cannabis use
  • exposure to androgen
  • age >55 years
  • environmental toxin exposure
  • history of coronary artery disease or diabetes mellitus
  • history of STI
  • hot tub use

Diagnostic investigations

1st investigations to order

  • sperm concentration
  • sperm motility
  • sperm morphology
  • seminal fluid parameters

Investigations to consider

  • sperm viability
  • sperm membrane function
  • hormonal assays
  • MRI of the pituitary and hypothalamus
  • colour flow Doppler imaging
  • post-ejaculation urine testing for retrograde ejaculation
  • genetic analysis
  • sperm DNA assays
  • anti-sperm antibody (ASA) serology
  • acrosome reaction test
  • sperm longevity test
  • electron microscopy
  • testicular biopsy

Treatment algorithm

Contributors

Authors

Samuel Ohlander, MD

Assistant Professor

Co-Head of the Division of Andrology

University of Illinois

Chicago

IL

Disclosures

SO declares that he has no competing interests.

Mahmoud Mima, MD

Assistant Professor

Department of Urology

University of Illinois

Chicago

IL

Disclosures

MM declares that he has no competing interests.

Rodrigo Pagani, MD

Assistant Professor

Co-Head of the Division of Andrology

University of Illinois

Chicago

IL

Disclosures

RP declares that he has no competing interests.

Acknowledgements

Dr Samuel Ohlander, Dr Mahmoud Mima, and Dr Rodrigo Pagani would like to gratefully acknowledge Dr Ali A. Dabaja, Dr Ahmad O. Hammoud, and Dr Benjamin Emery, previous contributors to this topic.

Disclosures

AAD, AOH, and BE declare that they have no competing interests.

Peer reviewers

Peter N. Kolettis, MD

Associate Professor

Division of Urology

University of Alabama at Birmingham

Birmingham

AL

Disclosures

PNK declares that he has no competing interests.

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