Conflicts of interest None.
Basic diagnostics in andrology
Version of Record online: 19 AUG 2013
© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin
JDDG: Journal der Deutschen Dermatologischen Gesellschaft
Volume 11, Issue 9, pages 799–815, September 2013
How to Cite
Grunewald, S. and Paasch, U. (2013), Basic diagnostics in andrology. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 11: 799–815. doi: 10.1111/ddg.12177
Section Editor Prof. Dr. Jan C. Simon, Leipzig
Definition of infertility: failure to conceive after 12 months of regular unprotected intercourse.
The age of the woman is a key factor in the fertility status of a couple.
The patient history and couple's history should be elicited in a quiet atmosphere. The patient's partner should also be present, if possible.
Important points to recall when taking the patient's history are: how long the couple has been unable to conceive; any diseases that may affect fertility; previous and current medication use; exposure to toxic substances; and sex life.
In men, waist circumference and BMI are clinically relevant to hormonal status and fertility.
The testes and epididymis exhibit a homogeneous echo structure. Inhomogeneity is usually a sign of inflammation; in the testes, it is also correlated with a hematoma or an early-stage tumor.
Testicular microcalcifications may indicate an early-stage testicular tumor. Frequent clinical controls, and if the patient has additional risk factors, a testicular biopsy, are warranted.
Testicular tumors are echo-poor or “mixed echo” lesions in the parenchyma. Staging and therapy should be performed by an urologist.
Hydrocele is an accumulation of serous fluid in the tunica vaginalis or in the spermatic cord (funiculocele). Treatment is usually done for cosmetic reasons.
Spermatoceles are very common – and usually harmless – retention cysts on the epididymis.
Varicocele refers to enlargement of the veins of the pampiniform venous plexus. There are four degrees of severity. A varicocelectomy improves the quality of sperm and may have a positive effect on fertility.
A transrectal ultrasound can aid in the diagnosis of prostatitis, benign prostatic hyperplasia (BPH), and prostate cancer. It may also be useful, given detection of prostate gland or seminal vesicle cysts, for the differential diagnosis of occlusive azoospermia.
A spermiogram is central to fertility testing as part of andrological diagnosis.
In the new WHO laboratory manual from 2010, the reference values for all standard spermiogram parameters were corrected using an evidence-based approach.
Normozoospermia: normal ejaculate parameters
Oligozoospermia: low sperm concentration
Asthenozoospermia: reduced motility
Teratozoospermia: reduced percentage of morphologically normal sperm
Oligoasthenoteratozoospermia: density, motility, and morphology are pathological
Azoospermia: no sperm in the semen
Aspermia: no semen
The detection of intact, normomorphic, and motile sperm rules out sterility.
The liquidation time of semen is about 30 minutes at 37 °C; it is longer in patients with seminal viscopathy.
Volume is determined indirectly by measuring the weight of the ejaculate in a collecting tray (ejaculate density of 1 g/ml).
Microscopic analysis begins with an unstained specimen.
Sperm concentrations are obtained by counting in counting chamber. If no sperm are detected, centrifugation of the entire ejaculate is performed and the pellet examined.
The analysis of sperm motility has been simplified in the 2010 WHO laboratory manual. The former categories (“fast” and slow progressive motility”) were combined into a category called “progressive motility.” This results in fewer errors, but the loss of information is controversially discussed.
The change in the evaluation method for sperm morphology by adopting “strict criteria” has lowered the threshold to ≥ 4 % normomorphic spermatozoa.
Eosin staining is used to determine the percentage of vital sperm.
Leukocytes damage the sperm contained in semen through oxidative stress. Treatment of an underlying infection, or if there is lacking evidence of one, empirical treatment with anti-inflammatory drugs such as doxycycline and diclofenac, can significantly increase the fertility chances of affected men.
In agglutinations and especially immunological infertility, anti-sperm antibodies may be detected using a MAR or an immunobead test.
To test for occlusive azoospermia, the functional markers of the epididymis (α-glucosidase) and seminal vesicles (fructose) are used.
Common tests of sperm function include computer-assisted semen analysis (CASA) and an assessment of acrosomal status.
The assessment of the DNA fragmentation rate has proved to be a valuable part of routine andrological diagnosis.
The causes of an elevated DNA fragmentation rate vary. Improvement may be achieved by changing one's lifestyle to reduce oxidative stress affecting the sperm.
In clinical practice, the most commonly used tests are TUNEL, SCSA® (most standardized), and acridine orange staining.
Based on currently available data, the Halosperm® kit cannot supplant established methods of sperm DNA fragmentation analysis.
The guidelines of the German Medical Association on “Quality Assurance of Laboratory Medical Tests” (Rili-BÄK) mandate performing tests in duplicate for the spermiogram parameters concentration, motility, and morphology (at least 200 sperm). Andrological laboratories must take part regularly in internal and external quality controls.
Basic andrological hormonal diagnosis includes determining FSH, LH, testosterone, and inhibin B levels, and sometimes serum prolactin. Together with the spermiogram, this can yield information about the patient's fertility reserve.
In infertility patients, the diagnostic biopsy of the testis is usually also the treatment. The higher the FSH concentration, or the lower the inhibin-B concentration in serum, the less likely it is that sperm will be found with a testicular biopsy.
Karyotyping, detection of Y-chromosomal microdeletions, and a mutation analysis of the CFTR gene may be used for genetic diagnosis in infertile men.
- Issue online: 19 AUG 2013
- Version of Record online: 19 AUG 2013
- Manuscript Accepted: 17 JUN 2013
- Manuscript Received: 1 JUN 2013
Basic andrological diagnosis consists of taking the patient's medical history and the couple's history as well as performing a physical examination including genital ultrasound, spermiogram, and hormonal analysis. If needed, a testicular biopsy and genetic testing may also be performed. Recent studies have shown the effect of lifestyle factors on male fertility. Thus, the patient history and clinical/andrological examinations have been broadened to include information on metabolic disorders like obesity and diabetes mellitus.
The biggest changes occurred with the publication of the fifth edition of the WHO laboratory manual in 2010 and the introduction of a section on semen analysis in the German Medical Association guidelines (RiliBÄK). The reference values for almost all spermiogram parameters were adapted in an evidence-based approach using worldwide prospective population studies. For central parameters such as sperm motility and morphology, the assessment criteria were changed. New independent markers such as sperm DNA fragmentation rate are now routinely used in clinical diagnosis. For German andrological laboratories, there are now mandatory quality assurance measures for semen analysis (in the German “Rili-BÄK” guidelines). These include duplicate testing of all standard semen parameters and inter-laboratory comparison at regular intervals.