Clinical Commander

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uro.male-infertility-eval.v1

Male Infertility Evaluation — chronic outpatient (azoospermia / oligospermia / asthenospermia / teratospermia / varicocele / HH / drug-induced / radiation)

urologychronicadultoutpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-12 initial author (2026-05-15): SCAFFOLDED with full §5.5 depth — 8 primary phenotypes + drug-induced + radiation overlays = 10 severity_triggers, 1 setting playbook (outpatient primary), verified guideline anchor set (AUA/ASRM Parts I+II, live-verified 2026-05-22), single 6-step regimen axis (lifestyle → empiric → varicocele repair → ART → TESE → hCG+FSH), 4 sibling rows pointing at REAL existing engines (uro.bph.v1, uro.prostatitis.v1, endo.t1dm.v1, endo.dm2.core.v1). WHO 5th edition semen thresholds (vol ≥1.5 mL, count ≥15M/mL, total motility ≥40%, normal morph ≥4% Kruger) load-bearing — calculator schema-blocked pending calc.semen_parameters_score. AUA 2020 male infertility guideline anchors phenotype matrix; pre-ART pyospermia routes to uro.prostatitis.v1; T2DM overlap routes to endo.dm2.core.v1 (avoid exogenous T in fertility pursuit — clomiphene preferred). Schema-blocked downstream: calc.semen_parameters_score, protocol.sperm_retrieval_TESE, protocol.varicocelectomy_microsurgical, panel.reproductive_hormones, cascade.azoospermia_workup — depth brief §5. Y-microdeletion AZFa = no retrieval, AZFc = retrieval feasible — genetic counseling load-bearing pre-TESE. Promoted SCAFFOLDED→INTEGRATED 2026-05-22 (shard-5 build campaign): all 6 prior placeholder PMIDs were mis-attributed (bioethics comment, proton-beam oncology, thalassemia genetics, ergonomics low-back, nanocomposite chemistry, depression PRS [recycled]) and replaced with the live-verified AUA/ASRM male-infertility guideline Parts I (33309062) & II (33309061); EAU/NICE/WHO semen reference cited by name. RxCUIs corrected: hCG 2360→340705, clomiphene 2599→2596 (was clonidine), follitropin alfa 50436→386938; anastrozole RxNav-verified.

Entry points (5)

  • symptom
    Couple with ≥12 mo unprotected intercourse without conception (≥6 mo if female partner >35y) — male partner evaluation (AUA 2020; EAU; NICE CG156)
    infertility_couple_12mo
  • lab_abnormality
    Abnormal semen analysis per WHO 5th ed thresholds (volume, count, motility, morphology) (WHO 2010 5th)
    abnormal_semen_analysis
  • history
    Planned gonadotoxic therapy → sperm cryopreservation counseling (AUA 2020; ASRM)
    planned_chemo_radiation_sperm_cryopreservation
  • history
    Known azoospermia on prior testing — phenotyping (obstructive vs non-obstructive)
    azoospermia_known
  • history
    Post-vasectomy reversal infertility OR post-chemotherapy infertility
    post_vasectomy_reversal_or_post_chemo

Required inputs (18)

  • agerequired
    demographic • used at FRAME
    Couple age + female partner age determine workup urgency; men >40 reduced sperm motility (AUA 2020)
  • female_partner_agerequired
    history • used at FRAME
    Female age >35 → start workup at 6 mo not 12 mo (NICE CG156)
  • duration_unprotected_intercourserequired
    history • used at ENTRY
    Duration ≥12 mo (or ≥6 mo if female >35) is the diagnostic gate (AUA 2020)
  • pubertal_history_cryptorchidism
    history • used at CONTEXT
    Cryptorchidism / undescended testis / delayed puberty raises azoospermia risk (AUA 2020)
  • prior_paternity
    history • used at CONTEXT
    Primary vs secondary infertility — secondary suggests acquired cause
  • testicular_trauma_torsion_surgery
    history • used at CONTEXT
    Torsion / trauma / hernia repair / hydrocele surgery → obstruction or atrophy (AUA 2020)
  • chemo_radiation_history
    history • used at CONTEXT
    Gonadotoxic; counsel cryopreservation; post-treatment infertility ~50%
  • anabolic_steroid_or_exogenous_Trequired
    history • used at CONTEXT
    Suppresses HPG axis → reversible azoospermia; discontinue + clomiphene/hCG restart
  • tobacco_alcohol_marijuanarequired
    history • used at CONTEXT
    ASRM smoking + alcohol + marijuana lower fertility; modifiable
  • heat_exposure_occupational
    history • used at CONTEXT
    Chronic scrotal heat (hot tubs, occupational) reduces spermatogenesis
  • sti_history_epididymitis
    history • used at CONTEXT
    Chlamydia / gonorrhea epididymitis → obstructive azoospermia or pyospermia (route uro.prostatitis.v1 if CP)
  • diabetes_status
    history • used at CONTEXT
    DM-related ED, retrograde ejaculation, autonomic neuropathy (route endo.dm2.core.v1)
  • scrotal_examrequired
    imaging • used at INITIAL_WORKUP
    Testicular volume (Prader orchidometer, normal 15-25 mL), vas deferens palpation (CBAVD detection), varicocele palpation (Valsalva)
  • semen_analysis_2xrequired
    lab • used at INITIAL_WORKUP
    Two semen analyses ≥1 wk apart per WHO 5th ed: volume ≥1.5 mL, count ≥15M/mL, total motility ≥40%, normal morph ≥4% Kruger strict (WHO 5th)
  • reproductive_hormonesrequired
    lab • used at INITIAL_WORKUP
    FSH, LH, total + free testosterone, prolactin, estradiol, TSH; pivots phenotype (HH vs primary failure) (AUA 2020)
  • karyotype_y_microdeletion_CFTR
    lab • used at BRANCHING_WORKUP
    Severe oligo / azoospermia → karyotype 47,XXY Klinefelter; Y-microdeletion AZFa/b/c; CFTR for CBAVD (AUA 2020)
  • scrotal_ultrasound
    imaging • used at BRANCHING_WORKUP
    Confirm varicocele grade; rule testicular mass (especially in infertile men — increased GCT risk)
  • pituitary_mri
    imaging • used at BRANCHING_WORKUP
    Hypogonadotropic hypogonadism workup — pituitary adenoma / Kallmann (AUA 2020)

12-phase flow (12)

  1. 1FRAME
    Adult male in couple ≥12 mo without conception (≥6 mo if female >35) — male partner workup; AUA 2020 / EAU / NICE CG156
    inputs: age, female_partner_age
    advance: engine scope confirmed
  2. 2ENTRY
    Couple-based referral; female workup parallel; cryopreservation if planned gonadotoxic therapy
    inputs: duration_unprotected_intercourse
    advance: entry point documented
  3. 3CONTEXT
    Pubertal hx, prior paternity, testicular trauma/surgery, chemo/radiation, anabolic steroid / exogenous T, tobacco/alcohol/marijuana, heat exposure, STI, DM, sexual function
    inputs: pubertal_history_cryptorchidism, prior_paternity, testicular_trauma_torsion_surgery, chemo_radiation_history, anabolic_steroid_or_exogenous_T, tobacco_alcohol_marijuana, heat_exposure_occupational, sti_history_epididymitis, diabetes_status
    advance: context documented
  4. 4RED_FLAGS
    Azoospermia + low T + visual field defect → pituitary MRI; testicular mass on exam → STAT scrotal US (GCT risk in infertile men); rapidly developing virilization changes / breast tenderness → endocrine workup
    advance: no red flags OR routed
  5. 5INITIAL_WORKUP
    Scrotal exam (volume, vas, varicocele), two semen analyses ≥1 wk apart per WHO 5th, reproductive hormone panel (FSH, LH, T, prolactin, E2, TSH) (AUA 2020)
    inputs: scrotal_exam, semen_analysis_2x, reproductive_hormones
    actions: panel.cbc, panel.renal, panel.lft
    advance: phenotype suggested
  6. 6BRANCHING_WORKUP
    Azoospermia → karyotype + Y-microdeletion + CFTR; HH → pituitary MRI; varicocele palpable → US grade confirm; pyospermia → urine culture + route uro.prostatitis.v1; post-ejac UA if retrograde ejaculation suspected
    inputs: karyotype_y_microdeletion_CFTR, scrotal_ultrasound, pituitary_mri
    advance: phenotype assigned
  7. 7DIFFERENTIAL
    Obstructive azoospermia / non-obstructive azoospermia / severe oligo / moderate oligo / asthenospermia / teratospermia / OAT / varicocele / HH / drug-induced / radiation / retrograde ejaculation / idiopathic
    advance: phenotype documented
  8. 8RISK_STRATIFICATION
    Severity (WHO thresholds, total motile count), female ovarian reserve, surgical candidacy (varicocelectomy, TESE)
    advance: severity assigned
  9. 9TREATMENT
    Lifestyle first; empiric clomiphene / aromatase inhibitor for idiopathic oligospermia; varicocele repair for palpable + abnormal semen; ART (IUI/IVF/ICSI) for severe male factor; surgical sperm retrieval (PESA/MESA/TESE/micro-TESE); hCG + FSH for HH
    inputs: anabolic_steroid_or_exogenous_T, tobacco_alcohol_marijuana
    advance: ladder step selected
  10. 10DISPOSITION
    Repro endocrinology / urology / ART center per severity
    advance: disposition documented
  11. 11MONITORING
    Repeat semen analysis q3mo on therapy; hormones q3-6mo on hCG/FSH; testosterone if on clomiphene
    advance: monitoring documented
  12. 12FOLLOWUP
    Coordinate with female partner workup; counseling for donor sperm / adoption if untreatable
    advance: follow-up scheduled