EVALUATION OF THE SUBFERTILE MALE: PART 1 - PHYSICAL EXAMINATION

The physical examination of the subfertile male provides crucial insights into the underlying causes of male subfertility and guides the need for further testing. This is the first of several blogs on the evaluation of the subfertile male. In this blog I will cover a thorough, system-by-system evaluation, including the integumentary, skeletal, muscular, nervous, cardiovascular, respiratory, urinary, and reproductive systems. Understanding how each component contributes to diagnosing potential issues allows healthcare providers to develop more tailored and effective treatment plans.

Integumentary System (Skin, Hair, and Nails)

The integumentary system includes the skin, hair, and nails, which can reveal hormonal imbalances or genetic conditions that may impact fertility.

• Key Findings:

  • Sparse body hair or baldness may indicate hormonal imbalances, such as low testosterone.
  • Hyperpigmentation or thickened skin could signal endocrine disorders like Addison’s disease.
  • Gynecomastia (breast tissue development in males) may point to excess estrogen or low testosterone levels. Also, men taking supplemental testosterone can produce elevated levels of estrogen, resulting in gynecomastia.
  • Acne may indicate increased androgen levels, which can affect spermatogenesis.

• Further Testing:

  • Blood tests to measure hormone levels, including testosterone, estrogen, and prolactin.
  • Genetic testing for conditions such as Klinefelter syndrome if multiple signs of hormonal imbalance are present.

Skeletal System

A careful examination of skeletal structure can help identify signs of genetic syndromes and other conditions associated with male infertility.

• Key Findings:

  • Disproportionate limb lengths or gynoid body shape (wide hips) may suggest chromosomal abnormalities like Klinefelter syndrome.
  • Bone density abnormalities could indicate long-standing hypogonadism, as testosterone supports bone health.

• Further Testing:

  • Hormone panel, focusing on testosterone, FSH, and LH to assess for hypogonadism.
  • Bone density scan if signs of low testosterone or other hormonal imbalances are found.

Muscular System

The muscular system offers insights into hormone levels, as testosterone is essential for muscle mass and strength.

• Key Findings:

  • Reduced muscle mass or muscle weakness may indicate low testosterone levels or other endocrine disorders.
  • Muscle tenderness or pain could suggest myopathy, which may impact fertility if associated with systemic disease.

• Further Testing:

  • Blood tests for testosterone, FSH, LH, and estradiol levels to check for hypogonadism or hormonal imbalances.
  • Liver and kidney function tests if systemic illness is suspected.

Nervous System

Examining the nervous system is essential, as neurological issues may impact reproductive function, particularly if there is evidence of central (brain-related) hormone regulation problems.

• Key Findings:

  • Vision changes or headaches may suggest pituitary gland issues, such as a prolactinoma, which can affect hormone production.
  • Altered reflexes or neurological deficits may indicate neurogenic causes of sexual dysfunction.
  • 5th, 6th, and 7th nerve palsy. Nontraumatic causes of sixth nerve palsies in patients 20–50 years of age found MS to be the cause in 24% of cases.

• Further Testing:

  • MRI of the brain to evaluate the pituitary gland for possible tumors or other abnormalities.
  • Hormone panel to assess prolactin and other pituitary hormones if a pituitary disorder is suspected.

Cardiovascular System

The cardiovascular system indirectly influences reproductive health, as cardiovascular issues can affect overall hormonal and metabolic health.

• Key Findings:

  • High blood pressure may impact erectile function and is associated with metabolic syndrome, which can contribute to infertility.
  • Peripheral vascular disease can also affect sexual health and function by reducing blood flow to the genitalia, resulting in erectile dysfunction as well as impacting ejaculation.

• Further Testing:

  • Lipid profile and fasting glucose levels to assess for metabolic syndrome or diabetes.
  • Hormone testing if signs of metabolic syndrome, such as obesity and hypertension, are present.

Respiratory System

The respiratory system is assessed less frequently in direct connection to fertility but is important in cases of sleep apnea or chronic respiratory conditions, which can impact testosterone levels.

• Key Findings:

  • Signs of sleep apnea, such as excessive daytime sleepiness or observed apneic episodes, can reduce testosterone production.
  • Cyanosis (bluish skin) or other breathing difficulties could indicate hypoxia, impacting overall health and potentially hormone levels.

• Further Testing:

  • Sleep study for suspected obstructive sleep apnea, which can contribute to low testosterone.
  • Blood tests to assess testosterone levels, as sleep apnea can lower testosterone production.

Urinary System

The urinary system including the kidneys, bladder, and urethra, and its examination can reveal urinary tract infections, structural issues, or systemic conditions that might affect fertility.

• Key Findings:

  • Painful urination or urinary tract infections can signal infections or inflammation affecting the reproductive tract.
  • Frequent urination or difficulty voiding may indicate prostate issues.

• Further Testing:

  • Urinalysis to check for infection or signs of inflammation.
  • Imaging studies (such as ultrasound) to examine the prostate and kidneys if there are signs of obstruction or other urinary issues.

Reproductive System

The reproductive system examination is essential for identifying structural or functional abnormalities in the testicles, vas deferens, and other reproductive structures.

• Key Findings:

  • Small or undescended testicles may indicate genetic or hormonal issues affecting sperm production.
  • Varicoceles (enlarged veins in the scrotum) can elevate scrotal temperature, potentially affecting sperm quality.
  • Absence of the vas deferens on one or both sides could suggest congenital absence, often associated with cystic fibrosis gene mutations.
  • Hydrocele around one or both testes can cause elevated testis temperature and decreased spermatogenesis.

• Further Testing:

  • Scrotal ultrasound to assess testicular size, structure, and varicocele presence.
  • Genetic testing if congenital anomalies are found, especially in cases of absent vas deferens.
  • Hormone panel to evaluate levels of testosterone, FSH, and LH for cases with small or undescended testicles.

Physical Examination Findings and Additional Testing for Male Infertility

Conclusion

The physical examination of the subfertile male offers invaluable clues to underlying conditions that may impact fertility. By thoroughly examining the integumentary, skeletal, muscular, nervous, cardiovascular, respiratory, urinary, and reproductive systems, healthcare providers can identify signs pointing to hormonal imbalances, genetic syndromes, structural abnormalities, and other factors affecting reproductive health. This examination guides further diagnostic testing, including blood work, semen analysis, and imaging studies, ensuring a comprehensive and individualized approach to male fertility evaluation. In some cases, additional procedures, such as a testis biopsy, may be needed to confirm a diagnosis, providing a clear path forward for effective treatment. This detailed assessment ultimately helps patients and healthcare providers work together toward successful fertility outcomes.