Obgyn · Year 3 · from Obgyn
Case 2: Male Factor Infertility with Varicocele
Patient Demographics
- Age: 32 years (female patient presenting for couple's infertility)
- Partner Age: 35 years
- Occupation: Elementary school teacher
Chief Complaint
"We've been trying to conceive for 14 months. My periods are regular, but something might be wrong with my husband's sperm."
History of Present Illness
The female patient has regular 28-day menstrual cycles with positive ovulation predictor kits at mid-cycle. She has no history of pelvic infections, prior surgeries, or endometriosis symptoms. Her partner reports no erectile dysfunction or ejaculatory problems. He has noticed a painless scrotal swelling on the left side for several years. They have been having intercourse every other day during her fertile window without lubricant use.
Male Partner History and Examination
- History of undescended left testicle corrected surgically at age 2
- No history of sexually transmitted infections
- No medications; occasional alcohol use
- No history of chemotherapy or radiation
- Physical examination by urologist: Left-sided varicocele grade III (visible without Valsalva), normal testicular size bilaterally
Female Evaluation
- Day 3 FSH: 7.1 IU/L
- Day 3 Estradiol: 38 pg/mL
- AMH: 2.8 ng/mL (normal ovarian reserve)
- TSH: 1.8 mIU/L
- Prolactin: 14 ng/mL
- Mid-luteal Progesterone: 14.2 ng/mL (confirming ovulation)
- Hysterosalpingogram: Normal uterine cavity, bilateral tubal patency
Male Partner Semen Analysis (Repeated x2)
- Volume: 2.8 mL
- Concentration: 8 million/mL (oligospermia; reference >15 million/mL)
- Total Motility: 28% (asthenospermia; reference >40%)
- Progressive Motility: 18% (reference >32%)
- Morphology: 2% normal forms (teratospermia; reference >4%)
- Diagnosis: Oligo-astheno-teratospermia (OAT syndrome)
Male Partner Additional Workup
- FSH: 9.8 IU/L (upper normal, suggesting impaired spermatogenesis)
- LH: 5.2 IU/L (normal)
- Total Testosterone: 380 ng/dL (normal)
- Scrotal Ultrasound: Left varicocele with dilated pampiniform plexus vessels >3 mm; normal testicular parenchyma bilaterally
Diagnosis
- Male Factor Infertility - Oligo-astheno-teratospermia (OAT syndrome)
- Left Varicocele Grade III - most common correctable cause of male infertility
- History of cryptorchidism (additional risk factor for impaired spermatogenesis)
Management Plan
Option 1: Varicocele Repair
- Urology consultation for microsurgical varicocelectomy
- Improvement in semen parameters expected in 60-70% of men
- Timeline: 3-6 months for spermatogenesis cycle to complete after repair
- Natural conception may become possible if parameters improve sufficiently
Option 2: Assisted Reproductive Technology
- Given the severity of OAT, IVF with ICSI (intracytoplasmic sperm injection) offers the highest per-cycle pregnancy rate
- ICSI overcomes sperm motility and morphology defects by direct injection of single sperm into oocyte
- Fertilization and pregnancy rates with ICSI are comparable to conventional IVF when oocyte quality is normal
Recommended Approach:
- Discuss both options with couple; decision based on patient preference, timeline, and financial considerations
- If couple prefers to try varicocele repair first: proceed with surgery, repeat semen analysis at 3-4 months, attempt natural conception or IUI if improvement adequate
- If rapid conception desired or severe oligospermia persists: proceed directly to IVF with ICSI
Genetic Counseling:
- Karyotype analysis recommended for men with sperm concentration <5 million/mL (patient at 8 million)
- Y-chromosome microdeletion testing if severe oligospermia or azoospermia
- If genetic abnormality found, implications for offspring to be discussed before proceeding with ART
Counseling Points:
- Male factor contributes to infertility in approximately 35% of couples
- Varicocele repair improves semen parameters in majority but does not guarantee conception
- IVF/ICSI success rates 40-50% per cycle for female partner's age
- Consider cryopreservation of sperm before any treatment
Prognosis
With IVF/ICSI, expected per-cycle live birth rate of approximately 45% given female age of 32 with normal ovarian reserve. If varicocele repair pursued and semen parameters improve to allow IUI, per-cycle pregnancy rate of 10-15%.