Reproductive · Year 2 · from Reproductive
Case 2: Male Factor Infertility with Varicocele
Clinical Image
Source: Wikipedia - Varicocele - CC BY-SA 3.0
Case Presentation
A 32-year-old man and his 30-year-old wife present for infertility evaluation after 14 months of trying to conceive. The wife has regular menstrual cycles, normal ovulation confirmed by ovulation predictor kits, normal HSG with bilateral tubal patency, and normal ovarian reserve testing. The husband's semen analysis reveals: volume 3.0 mL (normal), concentration 8 million/mL (low; normal >15 million/mL), motility 30% (low; normal >40%), and morphology 2% normal forms (low; normal >4%). The diagnosis is oligoasthenoteratozoospermia (OAT syndrome). Physical examination of the husband reveals a palpable left scrotal mass described as a "bag of worms" that increases with Valsalva maneuver. Scrotal ultrasound confirms a grade III left varicocele with veins measuring 4.5 mm. Hormonal evaluation shows normal testosterone, FSH, and LH. The couple is counseled about treatment options. The husband undergoes microscopic varicocelectomy. Repeat semen analysis 4 months post-surgery shows significant improvement: concentration 22 million/mL, motility 48%, morphology 6% normal forms. The couple conceives naturally 6 months after surgery.
Key Learning Points
- Male factors contribute to approximately 35% of infertility cases as the sole cause and another 20% as a contributing factor; semen analysis is essential in all infertility evaluations
- Varicocele is the most common surgically correctable cause of male infertility, present in 15% of all men and 40% of men with infertility; it causes elevated testicular temperature, leading to impaired spermatogenesis
- WHO criteria for normal semen: concentration >15 million/mL, motility >40%, morphology >4% normal forms, volume >1.5 mL
- Varicocelectomy improves semen parameters in 60-80% of men and results in spontaneous pregnancy in 30-50% of couples