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uro.male-infertility-eval.v1PRODUCTION
uro.male-infertility-eval.v1

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

urologychronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult male in couple ≥12 mo without conception (≥6 mo if female >35) — male partner workup; AUA 2020 / EAU / NICE CG156

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Patient inputs (18)

Suppresses HPG axis → reversible azoospermia; discontinue + clomiphene/hCG restart

ASRM smoking + alcohol + marijuana lower fertility; modifiable

Duration ≥12 mo (or ≥6 mo if female >35) is the diagnostic gate (AUA 2020)

Couple age + female partner age determine workup urgency; men >40 reduced sperm motility (AUA 2020)

Female age >35 → start workup at 6 mo not 12 mo (NICE CG156)

Testicular volume (Prader orchidometer, normal 15-25 mL), vas deferens palpation (CBAVD detection), varicocele palpation (Valsalva)

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)

FSH, LH, total + free testosterone, prolactin, estradiol, TSH; pivots phenotype (HH vs primary failure) (AUA 2020)

Severe oligo / azoospermia → karyotype 47,XXY Klinefelter; Y-microdeletion AZFa/b/c; CFTR for CBAVD (AUA 2020)

Confirm varicocele grade; rule testicular mass (especially in infertile men — increased GCT risk)

Hypogonadotropic hypogonadism workup — pituitary adenoma / Kallmann (AUA 2020)

Cryptorchidism / undescended testis / delayed puberty raises azoospermia risk (AUA 2020)

Primary vs secondary infertility — secondary suggests acquired cause

Torsion / trauma / hernia repair / hydrocele surgery → obstruction or atrophy (AUA 2020)

Gonadotoxic; counsel cryopreservation; post-treatment infertility ~50%

Chronic scrotal heat (hot tubs, occupational) reduces spermatogenesis

Chlamydia / gonorrhea epididymitis → obstructive azoospermia or pyospermia (route uro.prostatitis.v1 if CP)

DM-related ED, retrograde ejaculation, autonomic neuropathy (route endo.dm2.core.v1)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationalsevereazoospermia_non_obstructive
    Non-obstructive azoospermia — elevated FSH + reduced testicular volume; Klinefelter 47,XXY / Y-microdeletion / post-chemo / cryptorchidism (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_oligospermia
    Severe oligospermia <5M/mL — usually genetic or anatomic; ART pathway (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypogonadotropic_hypogonadism_HH
    Hypogonadotropic hypogonadism — low FSH + LH + T; Kallmann syndrome / pituitary lesion / prior testosterone use (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereradiation_chemo_history
    Prior gonadotoxic therapy → post-treatment infertility; counsel sperm cryopreservation BEFORE therapy if planned (AUA 2020; ASRM)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateazoospermia_obstructive
    Obstructive azoospermia — normal FSH + normal testicular volume + absent sperm; CBAVD (CFTR), post-vasectomy, post-infectious (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemoderate_oligospermia
    Moderate oligospermia 5-15M/mL — empiric clomiphene OR varicocele repair OR IUI/IVF (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateasthenospermia
    Asthenospermia — reduced motility (<40%); evaluate for varicocele, leukocytospermia, antisperm antibodies, sperm DNA fragmentation (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateteratospermia
    Teratospermia — reduced normal morphology (<4% Kruger strict); often part of OAT (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevaricocele_grade_2_3_repair
    Palpable grade 2-3 varicocele + abnormal semen + reduced testicular volume OR pain → microsurgical varicocelectomy (AUA 2020;)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedrug_induced_anabolic_steroid_exogenous_T
    Exogenous testosterone / anabolic steroid use → HPG axis suppression → reversible azoospermia (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Male infertility — AUA 2020 ladder: lifestyle → empiric → varicocele → ART → sperm retrieval → HH gonadotropin therapy
axis: male_infertility_ladderstep 1 - Tier 1 — Lifestyle + reversible exposure removal
Selected step "Tier 1 — Lifestyle + reversible exposure removal" — All phenotypes; first line
  • Smoking cessation + alcohol moderation + marijuana cessation + heat avoidance + weight loss + anabolic steroid discontinuation
    first line
    lifestyle
    triggers: all_phenotypes, reversible_exposure_present
    ASRM smoking + AUA 2020 + EAU; modifiable risk factors improve parameters in 3-6 mo

outpatient playbook — drug actions (4)

  1. 1. clomiphene
    25-50 mg PO daily • PO • daily
    trigger: Idiopathic oligospermia + normal hormones (AUA 2020)
    Off-label SERM raises gonadotropins + T
  2. 2. anastrozole
    1 mg PO daily • PO • daily
    trigger: High E2:T ratio + idiopathic oligospermia (AUA 2020)
    Aromatase inhibitor for high E2:T
  3. 3. hCG
    1500-2500 IU SC 2-3x/wk • SC • 2-3x/wk
    trigger: Hypogonadotropic hypogonadism (AUA 2020)
    LH analog for HH
  4. 4. follitropin alfa
    75-150 IU SC 3x/wk • SC • 3x/wk
    trigger: HH + absent spermatogenesis after hCG alone (AUA 2020)
    Combined hCG+FSH for HH spermatogenesis

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Couple with ≥12 mo unprotected intercourse without conception (≥6 mo if female partner >35y) — male partner evaluation (AUA 2020; EAU; NICE CG156); Abnormal semen analysis per WHO 5th ed thresholds (volume, count, motility, morphology) (WHO 2010 5th); Planned gonadotoxic therapy → sperm cryopreservation counseling (AUA 2020; ASRM).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Male Infertility Evaluation — chronic outpatient (azoospermia / oligospermia / asthenospermia / teratospermia / varicocele / HH / drug-induced / radiation)** (uro.male-infertility-eval.v1).
Phenotype framing: Obstructive azoospermia / non-obstructive azoospermia / severe oligo / moderate oligo / asthenospermia / teratospermia / OAT / varicocele / HH / drug-induced / radiation / retrograde ejaculation / idiopathic
Scope: Adult male in couple ≥12 mo without conception (≥6 mo if female >35) — male partner workup; AUA 2020 / EAU / NICE CG156

No severity triggers fired against current inputs.

Plan

Regimen axis: **Male infertility — AUA 2020 ladder: lifestyle → empiric → varicocele → ART → sperm retrieval → HH gonadotropin therapy** — step "Tier 1 — Lifestyle + reversible exposure removal".
1. Smoking cessation + alcohol moderation + marijuana cessation + heat avoidance + weight loss + anabolic steroid discontinuation (lifestyle, first line) — ASRM smoking + AUA 2020 + EAU; modifiable risk factors improve parameters in 3-6 mo

Setting playbook (outpatient) — Comprehensive couple-focused evaluation; phenotype diagnosis by visit 2-3; ladder step selection at visit 3-4; 3-mo re-assessment
2. clomiphene 25-50 mg PO daily PO daily — Idiopathic oligospermia + normal hormones (AUA 2020) (Off-label SERM raises gonadotropins + T)
3. anastrozole 1 mg PO daily PO daily — High E2:T ratio + idiopathic oligospermia (AUA 2020) (Aromatase inhibitor for high E2:T)
4. hCG 1500-2500 IU SC 2-3x/wk SC 2-3x/wk — Hypogonadotropic hypogonadism (AUA 2020) (LH analog for HH)
5. follitropin alfa 75-150 IU SC 3x/wk SC 3x/wk — HH + absent spermatogenesis after hCG alone (AUA 2020) (Combined hCG+FSH for HH spermatogenesis)

Non-pharmacologic actions:
- Lifestyle counseling — smoking / alcohol / marijuana / heat / weight (ASRM)
- Discontinue exogenous testosterone or anabolic steroid (AUA 2020)
- Sperm cryopreservation if planning gonadotoxic therapy (AUA 2020)
- Microsurgical varicocelectomy referral (AUA 2020;)
- ART center referral for severe male factor (AUA 2020)
- TESE / micro-TESE referral for azoospermia (AUA 2020)
- Karyotype + Y-microdeletion + CFTR for azoospermia (AUA 2020)
- Pituitary MRI for HH (AUA 2020)
- Genetic counseling for Klinefelter / Y-microdeletion / CBAVD (AUA 2020)

AVOID / contraindication checks:
- Clomiphene_visual_disturbance_discontinue (AUA 2020)
- Anastrozole_estrogen_suppression_bone_density (AUA 2020)
- HCG_polycythemia_monitor (AUA 2020)
- Exogenous_testosterone_AVOID_in_fertility_pursuit (AUA 2020)
- Smoking_alcohol_marijuana_counsel_cessation (ASRM)

Monitoring

Regimen monitoring:
- semen analysis q3mo on therapy (AUA 2020)
- hormones q3-6mo on hCG FSH (AUA 2020)
- testosterone baseline and at 3mo on clomiphene (AUA 2020)
- CBC polycythemia on hCG (AUA 2020)

Setting (outpatient) monitoring:
- Semen analysis q3mo on therapy (AUA 2020)
- Hormones q3-6mo on hCG/FSH (AUA 2020)
- Testosterone at 3 mo on clomiphene (AUA 2020)
- CBC for polycythemia on hCG (AUA 2020)

Follow-up plan: Coordinate with female partner workup; counseling for donor sperm / adoption if untreatable
- Close-out criterion: follow-up scheduled

Monitoring phase: Repeat semen analysis q3mo on therapy; hormones q3-6mo on hCG/FSH; testosterone if on clomiphene

Disposition

Current setting: outpatient — Comprehensive couple-focused evaluation; phenotype diagnosis by visit 2-3; ladder step selection at visit 3-4; 3-mo re-assessment

Disposition criteria:
- Successful conception → discharge from infertility care
- Stable on therapy → q3mo follow-up (AUA 2020)
- Refractory → ART or TESE referral (AUA 2020)
- Untreatable → donor sperm / adoption counseling

Escalation triggers (move to higher acuity):
- New testicular mass on exam → STAT scrotal US + uro (GCT risk in infertile men) (AUA 2020)
- Visual field defect + low T + low FSH → STAT pituitary MRI (AUA 2020)
- Rapid progression / B symptoms → onc evaluation

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Non-obstructive azoospermia — elevated FSH + reduced testicular volume; Klinefelter 47,XXY / Y-microdeletion / post-chemo / cryptorchidism (AUA 2020)
- [SEVERE] Severe oligospermia <5M/mL — usually genetic or anatomic; ART pathway (AUA 2020)
- [SEVERE] Hypogonadotropic hypogonadism — low FSH + LH + T; Kallmann syndrome / pituitary lesion / prior testosterone use (AUA 2020)

Citations

- Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline — Part I evaluation (Schlegel PN et al, Fertil Steril/J Urol 2021 PMID 33309062) + Part II management (PMID 33309061). WHO laboratory semen-analysis reference values cited by name. [PMID:33309062](https://pubmed.ncbi.nlm.nih.gov/33309062/)
- Cited evidence (PMID 33309061) [PMID:33309061](https://pubmed.ncbi.nlm.nih.gov/33309061/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline — Part I evaluation (Schlegel PN et al, Fertil Steril/J Urol 2021 PMID 33309062) + Part II management (PMID 33309061). WHO laboratory semen-analysis reference values cited by name. — PMID:33309062
  • Cited evidence (PMID 33309061) — PMID:33309061