A normal fucntioning of hypothalamus, pituitary gland and testes is required to give a fertile status to men. Variety of causes leads to the infertility, so evaluation may point to an underlying cause, which can guide treatment. In general evaulation begins with medical history, physical examination and a semen test.Other tests are specific as per requirement of particular person.

History :

Infertility history
Duration Prior pregnancies Previous treatments History of evaluation of wife
Medical history
Systemic illness Multiple sclerosis Previous / current therapy
Sexual history
Frequency of intercourse Intercourse during ovulation period Any use of lubricants Potency
Surgical history
orchiectomy (testis cancer, torsion) Retroperitoneal injury Pelvic injury Scrotal surgery (Hydrocele, Varicocele) Herniorrhaphy Fixaiton of undescended testis Prostatectomy [leads to retrograde ejaculation]
Family history
cyctic fibrosis Androgen recptor deficiency Infertility first degree relations

Childhood illness

• Congenital anomalies [ bladder extrophy / epispadias]
• Undescended testes
• Herniorrhaphy [ suggest iatrogenic vassal injury]
• Testicular torsion or trauma
• Y-V plasty of bladder (retrograde ejaculation)

History of Infections :-

• Viral, febrile
• Mumps or orchitis
• Venereal 
• Tuberculosis
• Filariasis
• Chlamydial

History of exposure to Toxins : -

Environmental :
Heat, ionizing radiation, some organic solvents, pesticides. [interferes with spermatogenesis or sperm function]

Gonadotoxic agents :
Caffeine, nicotine, alcohol, cimetidine, marijuana – [interfere with spermatogenesis]

Androgenic Steroids :
Interference with normal spermatogenesis and depress gonadotropin secretion

Laboratory Tests

1. Routine Tests :

a. Semen Analysis : -

- once the history and physical examination have been completed, the central component of the laboratory evaluation is the semen analysis

Method for Collection :- Masturbation, Coitus interruptus, special condom [No spermatocidal agents ]
Abstinence Period :- 3-4 days
Collection area  :- In close proximity to the laboratory (to avoid long transport)
Container :- Big mouth polypropelene plastic jar

WHO criteria for normal semen values :-

 If no significant abnormality found in any parameters of spermogram proceed with further test.

b. Blood Test :-

• Testosterone – Reflects leyding cell function and provides an easy available indicator of intra testicular testosterone.

• LH & FSH    - Level of LH & FSH determine if a patient’s endocrine dysfunction is the result of primary testicular failure or hypothalamic and / or pituitary deficiency.

2. Additional Laboratory test

a. Quantitation of Leukocytes :-
Endtz test : -   a histochemical technique in which peroxidase – positive granulocytes (leukocytes and PMN Cells) stain dark brown. The
                     Endtz test allows clear differentiation of WBCs from other immature germ cells in semen. Recently monoclomal antibody                      technology has been introduced for the identification of leukocytes in the semen.
b. Sperm Antibody:-

• Immunological analysis is an important part of the evaluation of infertile couple. Indications for testing may be a poor post coital test, sperm agglutination, poor sperm motility or simply overall unexplained infertility.
• Direct immuno bead test : - semen can be tested for the presence of antisperm antibodies by an immunobead test, which detects IgG, IgA, or IgM classes of antibodies that may be present on the surface of the sperm.
• Indirect Immunuo bead test :- The presence of antisperm antibodies also can be detected in serum or seminal plasma.

c. Semen Fructose Test :- Fructose is normally present in all semen specimens. The absence of fructose indicate congenital bilateral absence of the vas deferens or bilateral ejaculatory duct obstruction. Both qualitative and a quantitative measurement of fructose can be performed. 

3. Advanced Test

To assess the ability of the spermatozoon to fertilize, a combination of test should be performed as there is no single sperm assay that is a global indicator of male infertility.

a. Strict Morphology :- Sperm morphology can be assessed with a modified method of strict scoring developed by Dr.Thinus Kruger of the Tygerberg Institute of South Africa.

b. Computer Assisted Semen Analysis [CASA]:-  CASA –introduced in 1980 to provide an automated, objective and standardized evaluation of sperm concentration and movement. Sperm density, motility , straight line velocity, curvilinear velocity linearity, average path velocity can be measured by CASA.

C. Sperm Function Test :-

Hypo-osmotic Swelling Test [HOS]

- Dynamic test to evaluate the physiological integrity of sperm plasma membrane.
- Spermatozoa with functional membrane will show curled tail fibres due to influx of water.

d. Sperm viability test : - This test is used to determine the viability of sperm and the intact plasma membrane .Live cells can exclude dye where as damaged dead cells cannot. Eosin or trypan blue dye can be used for the test.

e. Post coital test :- The post coital test measures the ability of sperm to live and swim in the women’s cervical mucus. The PCT is performed during the days just before or  at the time of ovulation, when the mucus is clear, colourless, watery ,abundant and stretchable. These are prime conditions for sperm passage. About 2 to 12 hours after intercourse, a cervical mucus sample is taken from the woman during a pelvic examination and examined under a microscope. Because the accuracy of a PCT depends on correct timing, more than one test may be necessary. A PCT  can suggest problems with the quality of sperm or cervical mucus, or suggest the presence of antisperm antibodies or allergies to the sperm in the man or woman.

f. Sperm –Penetration Assay [SPA] :- In a sperm penetration assay [SPA] , also known as the hamster-egg penetration test or hamster test, eggs are taken from a female hamster and stripped of their zona pellucida, or outer shell like covering. These eggs are then exposed to human sperm in the laboratory. Human sperms are able to penetrate these specially treated eggs, but the eggs cannot develop into embryos. A normal test usually results in greater than 10-12% of eggs penetrated, or six penetrations per egg. A lower number of penetration may suggest that the sperm are unable to penetrate a woman’s egg. The SPA may be useful when other studies have failed to show a cause of infertility.

g. Reactive Oxygen Species [ROS] Assay :- ‘oxidative stress’ is a condition associated with an increased rate of cellular damage induced by oxygen and oxygen derived oxidants commonly known as ROS. The measurement of the rate of ROS generation by luminal induced chemilumincscence has been the most common method of quantitating ROS. Another method includes ROS generating peroxidation of spermatozoa assessed by determining the production of thiobarbituric acid reactive substance [TBABS].

4. Genetic Evaluation

• Cystic fibroids [CF]gene mutations leading to congenital absence of the vas deferens.
• Y- chromosome microdeletions leading to impaired spermatogenesis
• Karyotype abnormalities
• Klinefelter’s syndrome [classic 47, XXY]
• Mixed gonadal dysgenesis
• Chromosomal translocations and
• XYY syndromes.
  
  

Basic evaluation starts from history, physical examination and a well orchestrated work up can be completed in a single menstrual cycle.Work up includes transvaginal ultrasound to check ovarian reserve & uterus size & normality. Blood work for hormones can be done.

a) History:

1. Personal history           - Lack of libido           - physical or mental stress and strain           - smoking , alcoholism, any use of drugs. 2. Sexual history           - Frequency of intercourse           - intercourse during ovulation period           - use of lubricants           - use of contraceptives           - washing vagina thoroughly  after intercourse 3. Infertility history           - Duration           - prior pregnancies or loss of pregnancies           - previous treatments           - history of previous marriages if any           - treatment of male partner 4. Medical history           - systemic illness [ex. Tuberculosis ]           - taking drugs for other problems  5. Surgical History           - surgery on genital tract           - abdominal surgery or appendix  or other bowl  surgery 6. Family history           - infertile first degree relatives

b) Speculum Examination :
Vagina – look for vainitis
              - septum
              - cysts
 Cervix  – erosion
              - polyp
              - pinhole OS
              - any surgery on cervix
              - cervical mucus

c) Systemic Examination : Heart, lungs, liver, kidney etc.

LABORATORY TESTS :-

Summary of tests :

3. Evaluation of Genital tract
           Hystosalpingography  [or] sonohystosalpingography :

HSG is a radiological test where X-Ray of the pelvis is taken. Radio opaque dye is injected into the cervix to the uterus and tubes through a cannula. In this test out line of the cervix , uterus and the tubes can be seen. Presence of the dye in the pouch of Douglas indicate a positive tubal patency. This test is also indicated for conjenital abnormilaties of uterus, cervical problems, uterine polyps, or fibroids. HSG is scheduled between 7th to 10th day of the menstrual cycle.

4. Evaluation of peritoneal factors.
    Laparoscopy [Diagostic or surgical]

Generally Laparoscopy is scheduled in mid-luteal phase i.e day 21-26 of the menstrual cycle. (Methylene)Dye is injected through the cervix, uterus and tubes. Spillage of the dye indicates patency of tubes. Other factors like Tubal length, presence of tubal infection, fimbrial appearance, presence of adhesions in between tube, ovary, bowal, omentum, bodywall, presence of PCO, endometrisis, chocolatecysts can be identified with this procedure.

 Operative Laparoscopy is useful for procedure for

• Adhesionolysis (releasing adhesions inbetween organs)
• Fulguration of endometrial deposits in the pelvis
• PCOD - (Polycystic Overy) micro cautersation
• Removal of functional or chocholatecysts
• Tubalrecanalisation
• Myomectomy (fibroids)
• Prolapsed uterus repair

5. Evaluation of uterine cavity :
    Hysteroscopy  -

Diagnostic Hysteroscopy – It is a procedure to inspect the inside of the uterus to detect any abnormalities such as poly P, adhesions, fibroids, and uterine septum. A fine fibre-optic telescope is inserted through the cervix into the uterus. Operative Hysteroscopy – All the above conditions can be operated through hysteroscope.

6. Endometrial Biopsy [EB]

Secretory Endometrium : It shows glandular cells with secretary features and sub nuclear vaculisation, characteristic of progesterone dominance indicates post ovulatory period.

7. D & C : Dilatation of cervix helps free entry of sperm. Curettage helps
    receptivity of embryo. Sometimes people conceive immediately after this procedure.

8. Antisperm antibody :
a) cervical
b) serum
9. Post coital test : dead or immotile sperm after intercourse suggest vaginal
    hostile atmosphere.

10. Transvaginal sonography :

to detect uterine or ovarian pathology, fibroids, chocolate cyst, ovarian cyst, hydrosalpinx, uterine anamoly, adenomysis, endometrial thickness, polyps in endometirum. ovulation study.