Andrology

• Medical history:
• Andrological and general history: testicular abnormalities (trauma, surgery, high standing), stimulants (alcohol, nicotine, hard drugs), stress, heat exposure, hypogonadism (loss of libido, erectile dysfunction, depression, diabetes mell., bronchial asthma, liver disease).
• Sexual history: Erectile dysfunction (act related, partner related, situation related, acute, chronic), ejaculation disorders (premature ejaculation), orgasm disorders (anorgasmia). State of knowledge about the time of conception (basal body temperature method: due to thermogenetic effects of progesterone, post-ovulatory morning temperature rises in the morning. Body temperature increases by 0.3-0.5 °C post-ovulatory in the morning). Frequency of sexual intercourse (ideally 3-5 days of sexual leave), suppression of spermatogenesis (high feverish infections in the last 12 weeks, mumpsorchitis, STD.
• Medical history: cytostatic drugs, glucocorticoids, colchicine, antidepressants, antiemetics, antibiotics (nitrofurantoins, gentamicin, cotrimoxazole).
• Partner findings: pregnancy, abortion, age, cycle, ovulation, medication, diseases, inseminations, in-vitro fertilization, tubal patency.

Cave! Often a distinction can be made between primary (congenital) and secondary infertility (acquired or caused by the partner) according to the medical history.

• Clinical examination:
• Inspection: body shape, fat distribution, mammary glands, hair pattern, penis ( phimosis, balanitis, urethra, epispadias, hypospadias, corpus cavernosum).
• Palpation: Organs of the scrotum (smooth, prallelastic), exclusion of pendulum testis (located at the outer inguinal ring) and testicular ectopy (perineal, crural, transcrural), sliding testis (permanently at the outer inguinal ring, reducible in the scrotum), epididymis definable, vasa deferentia (pencil-like palpable, difficult), rectal prostate palpation.
• Gynecomastia (puberty, obesity, Klinefelter's, hypogonadism, hyperprolactinemia, NNR tumor, spironolactone, mamma-ca).
• Varicocele diagnosis according to WHO scheme, see below varicocele.
• Apparative diagnostics:
• testicular volume measurement with orchidometer. Doppler or duplex sonography for varicocele exclusion (Valsalva manoeuvre), if necessary penis sonography, sonography of the scrotal content (testicular tumour 1% as reason for infertility), transrectal sonography (high urethral occlusion of the seminal ducts, prostate), if necessary mammography (in cases of gynaecomastia, among others), if necessary, sella-turcica target image with MRT, if necessary transfemoral selective phlebography of the internal spermatic cord, computer-aided sperm analysis (CASA).
• Spermiogram.
• testicular biopsy.
• Karyogram, if necessary.

• Inflammation diagnostics: blood count (leukocytes, erythrocytes, macrophages), peroxidase-positive cells (granulocytes, normally < 1 million/ml ejaculate, detection by peroxidase method), granulocyte elastase (normal: < 250 ng/ml ejaculate in detection by EIA), IgG, IgA, C3 complement (as detection in case of disturbance of the blood-sperm plasma barrier), reactive oxygen species (from leukocytes), syphilisserology , HIV ( ELISA), hepatitis serology.
• Microbiological examination of the sterile ejaculate for: Chlamydia (PCR, direct microscopic detection), Neisseria gonorrhoeae, Mycoplasma spp., E. coli spp., Pseudonomas aeroginosa, Proteus spp., Klebsiella spp., Enterococci spp., Mycobacterium tuberculosis.
• Immunology: MAR-Test (Mixed-Antiglobulin-Reaction-Test) for the detection of IgG or IgA on the sperm surface by latex-bound antibodies (test is considered positive if 50% of motile sperm have bound latex particles).
• Endocrinology (exclusion of androgen resistance, hypogonadism): GnRH, LH, HCG test, FSH, prolactin, short-term GnRH test, GnRH pump test, inhibin B.

1. Bollmann R et al (2001) Chlamydia trachomatis in andrologic patients--direct and indirect detection. Infection 29: 113-118
2. Köhn FM, Haidl G (2002) Andrological diagnostics. dermatologist 53: 761-779
3. Rowe PJ et al (2000) WHO manual for the standardized investigation, diagnosis, and management of the infertile male. Cambridge University Press, Cambridge
4. Shafik A, El-Sibai O (2000) Mechanism of ejection during ejaculation: identification of a urethrocavernosus reflex. Arch androl 44: 77-83
5. WHO (1999) Laboratory Manual for the Examination of Human Ejaculate and Sperm-Cervical Mucus Interaction, 4th ed. Springer, Berlin Heidelberg New York Tokyo
6. Wolff H et al (1994) Andrologic variables for in vitro fertilization. dermatologist 45: 605-610