The second section of the male infertility examination and diagnosis of a male history of Jinan Military Region General Hospital, Department of Urology, Liu Jianguo 1. male infertility patients diagnosis, should be detailed understanding of the fertility-related medical history, detailed records of infertility experienced when the past reproductive history, the use of birth control methods, couples sexual life frequency and time. 2. When diagnosing infertility combined with male dysfunction, the patient’s erectile function and ejaculatory function should be fully understood. Find out whether there is sexual stimulation during sexual intercourse and whether the patient really understands the meaning of sexual stimulation. Find out whether the patient has spontaneous erection, nocturnal erection or morning erection, and find out the degree and time of erection. Find out whether the penis can be inserted into the vagina after erection, whether ejaculation is before or after insertion into the vagina, whether repeated pumping of the penis can produce pleasure or ejaculation, and whether there is any discomfort during ejaculation. The International Index of Erectile Function (IIEF) can be used to evaluate erectile function. 3. Patients should be asked about the history of genitourinary tract infections, sexually transmitted diseases and mumps orchitis. For infertility combined with perineal pain or urethral symptoms, when prostatitis is suspected, detailed inquiries should be made about the nature, characteristics, location of perineal or pelvic pain and symptoms such as urinary abnormalities; to understand the course of treatment and recurrence; to evaluate the patient’s psychological state and the extent of the impact of the disease on the quality of life; and to recommend the application of the National Institutes of Health-developed Chronic Prostatitis Symptom Score (NIH-CPSI) for the Assessment. If the patient has a history of bilateral epididymitis and no sperm, it suggests obstruction of the epididymal ducts. 4. Carefully inquire about the patient’s developmental history to find out if there is a history of cryptorchidism, if there is a testicular descent fixation or the timing of the surgery. Find out when puberty appeared in the patient, and whether there is any delay or absence of puberty. Find out if the patient has a history of feminization of male breasts. 5. Know the patient’s history of previous surgery. Surgery in the pelvic area or retroperitoneum has the potential to affect the patient’s erectile and ejaculatory function; surgery on the bladder neck can cause retrograde ejaculation; lymph node dissection in the retroperitoneum can injure the sympathetic nerves, which can cause non-ejaculation or retrograde ejaculation; the vas deferens can be accidentally injured or the testicular blood supply cut off during hernia repair; and any surgery on the scrotum such as surgery for syringomyelia can result in injury to the vas deferens and/or epididymis; Testicular injury or testicular torsion can lead to testicular atrophy. 6. know if the patient has a history of abnormal semen analysis or systemic disease within 3 months. 7. know the patient’s drug history and work environment, and smoking history. 8. Know the patient’s family history and note the assessment of female fertility. Physical examination 1. A comprehensive physical examination should be performed on male infertility patients to identify infertility-related abnormalities and malformations. 2. Evaluate the patient’s physical condition and male sexual characteristics. 3. The penis should be examined to determine the presence of hypospadias and severe penile curvature, and the presence of sclerodactyly should be noted. 4. Examination of the scrotal contents should be performed in a warm room where the patient’s scrotum can be adequately relaxed. Palpation is performed to determine the presence of an extratesticular mass. Testicular volume can be measured using a testicular model, a calibrator, a testicular measuring board, and ultrasonography. Palpate the epididymis for abnormalities; if a hard nodule or cystic epididymal dilatation is palpated, this suggests the possibility of obstruction of the epididymal duct. Seminal cysts as well as epididymal cysts are often palpable, but are not associated with epididymal obstruction. 5. Palpate the vas deferens to determine its presence or absence and to confirm the site of abnormality. 6. Examination of the spermatic cord to determine the presence of varicocele. Mild varicose veins (grade I) can only be palpated during the Valsalva test; moderate varicose veins (grade II) can be palpated in the standing position but cannot be visualized; severe varicose veins (grade III) can be visualized through the scrotal skin. 7. Evaluate the condition of the prostate gland via rectal palpation for size, texture, and presence of nodules, and note whether there is cystic dilatation of the seminal vesicles above the prostate gland. Rectal palpation helps to identify whether the cause of the pain is from the perineum, rectum, neuropathy, or other disorders of the prostate. If necessary, the prostate gland is massaged to obtain prostate massage fluid (EPS), which is routinely analyzed and cultured for bacteria. Third, the general principles of male infertility diagnosis and treatment Couples living together without contraception for more than one year after marriage without childbearing, caused by the male cause of infertility, known as male infertility. In addition, infertility can also be caused by both men and women. The diagnosis and management of male infertility should follow the principles of evidence-based medicine. Infertile couples should participate in the diagnosis and treatment together, and take into account the cost and benefit of the diagnosis and treatment. 1. Diagnose the cause clearly and treat the cause. 2. For those whose cause is not clear, empirical treatment may be chosen. 3 In choosing treatment strategies, firstly, less damaging techniques [intrauterine insemination (IUI) or conventional IVF] should be chosen, followed by more complicated, expensive and damaging methods (e.g. ICSI and testicular biopsy). It is recommended that specific management of male infertility should be carried out according to the following WHO classification (I) Sexual dysfunction in men Sexual function in men consists of five links: sexual arousal, penile erection, penile insertion into the vagina, orgasm-ejaculation and sexual satisfaction, and disorders occurring in one of these links are known as sexual dysfunction. Clinical manifestations: 1. Erectile dysfunction includes erectile dysfunction (ED) and abnormal erection. 2. 2. Ejaculatory dysfunction includes premature ejaculation, non-ejaculation or retrograde ejaculation. Non-ejaculation is characterized by normal sexual intercourse but inability to reach orgasm and ejaculation. Retrograde ejaculation is characterized by normal sexual intercourse and orgasm, but no ejaculation of semen, and spermatozoa are detected in the post-coital urine. 3. Sexual desire disorders include low libido, sexual aversion, inversion of libido and sexual sensory disorders (pain during intercourse, lack of orgasm, etc.) 【Treatment Principles】 1. When the main cause of infertility is erectile dysfunction (ED), it is recommended to carry out the third line of treatment in accordance with the guidelines for the diagnosis and treatment of erectile dysfunction formulated by the Men’s Science Branch of the Chinese Medical Association. 2. Infertility (1) Evaluate the patient’s etiology for both organic and psychological causes and treat the cause. (2) If ineffective, AIH is preferred after sperm retrieval with a massager or transrectal point stimulator. (3) If AIH fails, or if the semen quality is poor, patients may choose to undergo IVF or ICSI treatment. (4) If all of the above methods fail, ICSI can be performed with epididymal, vas deferens or testicular sperm retrieval. 3. Retrograde ejaculation (1) α-adrenergic sympathetic nerve stimulants can be used. (2) If ineffective, collect sperm in alkalinized urine after orgasm for AIH or IVF; or testicular/epidymal puncture for sperm collection and ICSI. (B) Immunologic infertility 【Clinical manifestations】 1. Testing of semen reveals that at least 50% of the motile spermatozoa are encapsulated by immune beads. 2. Confirmed by antibody biology test, can choose sperm – cervical mucus contact test, in vivo post-coital hosiery or in vitro sperm – cervical mucus contact test. [Principles of treatment] 1. If the sperm is abnormal, treat associated factors, such as varicocele, infection, or incomplete obstruction. 2. Choose AIH if the cause is unknown. 3. If there is no successful conception in 2~3 cycles of AIH treatment, or severe oligo, weak, or abnormal spermatids, IVF or ICSI is recommended. (3) Unexplained infertility 【Clinical manifestations】 1. If the infertility is of short duration (<2< span="">years) and the female partner’s age is <32< span="">years old, expectant treatment is available. 2. If the duration of infertility is >2 years, or the age of the female partner is >32 years old, or if the expectant treatment fails, crude ovulation and AIH can be used. 3. If AIH treatment is unsuccessful in conception for 2-3 months, IVF or ICSI is recommended. (D) Simple seminal plasma abnormality 【Clinical manifestations】 1. Normal spermatozoa in the seminal fluid, but the physical properties of the seminal plasma, biochemistry, bacterial contents, leukocyte counts, or semen agglutination are abnormal. 2. Negative mixed antiglobulin reaction (MAR method) or simultaneous immunobead test. 3. Inability to determine whether there is an accessory gland infection or other diseases. [Principles of treatment] 1. Evaluate the female factor first. 2. AIH treatment is performed after semen processing. 3. IVF and its derivatives are adopted when ineffective. （Infertility caused by medication or surgical factors is considered as medical infertility. Clinical manifestations: History of drug use and/or surgery that may have an adverse effect on fertility. 1. Replacement of fertility-affecting medications with a different treatment regimen, if possible. 2. Freeze sperm in a sperm bank before receiving radiotherapy or chemotherapy. 3. Perform microsurgical vasectomy for vasectomy patients. 4. Failed vasectomy, treated as idiopathic azoospermia or idiopathic oligozoospermia, but without genetic screening. 5. A second procedure after failed microsurgery after vasectomy is also worth considering. 6. Treat as idiopathic infertility based on semen quality. (VI) Systemic causes [Etiology] 1. Sperm abnormalities are associated with the following systemic factors systemic diseases, excessive alcohol consumption, drug abuse, and environmental factors. 2. High fever within the last 6 months or ciliary immobility syndrome, etc.. [Principles of treatment] 1. Treat existing diseases, avoid alcohol and drug abuse, and correct bad life habits. 2. If ineffective, treat according to idiopathic infertility. 3. Ciliary immobility syndrome can be confirmed by electron microscopy. ICSI can be performed after genetic counseling of the patient. (VII) Congenital or genetic abnormalities Azoospermia caused by cryptorchidism or testicular descent insufficiency, karyotypic abnormality of chromosomes, congenital absence of vas deferens or other congenital diseases. Clinical manifestations: 1. Cryptorchidism or undescended testis not in the scrotum or absent testis, at least one testis is not palpable, history of trauma to the testis or not, no history of orchiectomy. 2. 2. Karyotypic abnormalities of Kernicterus syndrome or its chimeric forms, Y chromosome microdeletions. 3. Congenital bilateral vas deferens absence or dysplasia semen <2ml, pH <7; physical examination without palpable vas deferens (bilateral). Principles of treatment] 1. Cryptorchidism (1) If the patient has passed puberty and is younger than 32 years of age, perform surgery to fix the descending testicle. (2) If the testis has not descended by the age of 32, a testicular biopsy is recommended (at least for azoospermia and severe oligospermia) to rule out the possibility of carcinoma in situ of the testis. (3) Treat coexisting causes, such as varicocele and infection. (4) Depending on the quality of semen, treat as idiopathic infertility. 2. Chromosomal karyotype abnormality (1) In patients with Crohn's syndrome or its chimeric type or Y chromosome deletion, if there is severe oligo, weak, or abnormal spermatogenesis, ICSI treatment is performed using sperm in the semen or sperm obtained from testicular puncture. (2) Due to the presence of genetic defects that may be passed on to the offspring, it is important to provide detailed counseling to the patient's couple prior to surgery. (3) Depending on the risk of inheritance to the offspring, elective PGD is available. (4) If no sperm is available, sexual AID or adoption of a child is recommended. 3. Vas deferens (1) Screening for fibrocystic lesions is optional in patients with vas deferens. (2) After genetic counseling, ICSI with sperm obtained by testicular or epididymal puncture is applied. (3) Sexual PGD may be considered if both spouses have genetic defects. 4. Other congenital disorders such as neurological and metabolic anomalies should be considered with due consideration of the inheritance pattern and risk of transmission to the offspring, and PGD and prenatal diagnosis are recommended as options. (viii) Secondary testicular injury Sperm abnormalities due to mumps-induced orchitis, or other causes of testicular injury. Clinical manifestations] At least one side of the testis has a volume of less than 15 ml or the testis is not palpable. [Treatment principle] Depending on the quality of the semen, it is treated as idiopathic infertility. (ix) Varicocele infertility 【Clinical manifestations】 1. Varicocele (palpable or subclinical) with abnormal semen parameters can only be a cause of infertility. 2. If there is a varicocele but the semen analysis is normal, at this time the varicocele is not considered as a factor of infertility, but rather unexplained infertility. Treatment principle] 1, for subclinical and Ⅰ degree varicocele need further auxiliary examination. 2. If there is no pregnancy 12 to 24 months after successful surgery for varicocele, it is treated as idiopathic infertility according to semen results. 3. Surgical treatment of varicocele has limited benefit for eventual pregnancy if the following comorbidities are present. (1) Subclinical and first-degree varicocele with (grossly) reduced total testicular volume (<30 ml). (2) Azoospermia symptoms with normal testicular volume and normal FSH with suspicion of obstructive azoospermia. (3) Azoospermia with elevated FSH. (X) Male accessory gonad infection [Clinical manifestations] 1. History of urinary tract infection, epididymal inflammation and sexually transmitted diseases. 2. Physical examination reveals thickening or tenderness of the epididymis, thickening of the vas deferens, and abnormal rectal examination findings. 3. Abnormal urine after prostate massage. 4. Bacterial culture detects pathogenic bacteria, or positive culture results of Chlamydia trachomatis or Mycoplasma lysureum. 5. Abnormal semen parameters. [Treatment principle] Sensitive antibiotic treatment. If semen quality remains abnormal, treat as idiopathic infertility. (XI) Endocrine factors Endocrine-induced infertility is often characterized by hypogonadism. Clinical manifestations] Patients with normal or reduced FSH, low testosterone levels and/or persistently elevated PRL. Treatment principle] 1. Use gonadotropins to treat hypogonadotropic hypogonadism. 2. 2. If the diagnosis of hyperprolactinemia is clear, apply dopaminergic drugs, such as bromocriptine; if there is pituitary prolactinoma, surgical treatment if necessary. 3. Androgen therapy should be given as needed. 4. If oligozoospermia or azoospermia remains after treatment, IVF-ET or ICSI technology will be used. 5. If treatment fails, AID or adoption of children. (XII) Idiopathic oligozoospermia 【Clinical manifestations】 1. None of the previous diagnosis, sexual function and ejaculatory function are normal. 2. 2. Sperm density is less than 20X106/ml. 【Treatment principle】 1. If the serum FSH is normal, apply anti-estrogen treatment, such as tamoxifen, etc. 2. 2. According to semen, choose AIH or other assisted reproduction techniques. (XIII) Idiopathic weak spermatozoa 【Clinical manifestations】 The patient has normal sperm density, but the percentage of forward-moving spermatozoa is lower than the reference value in the laboratory, and a repeat semen analysis (on the same day or a few days later) still has a similar result and does not meet other diagnoses. [Principles of treatment] 1. Depending on the parameters after sperm processing, choose AIH or other assisted reproductive techniques. 2. If repeated fertilization fails, donor insemination or adoption of a child is recommended. (XIV) Idiopathic malformed spermatozoa [Clinical manifestations] Sperm density and viability are normal, but the normal rate of sperm morphology is lower than the reference value and is not consistent with other diagnoses. [Principles of treatment] 1. If the sperm deformity rate is moderate, then attempt to practice AIH or IVF. 2. If AIH or IVF repeatedly fails, or if there is severe teratozoospermia, select ICSI after systematic genetic evaluation and genetic counseling. 3. If repeated in vitro fertilization fails, then donor insemination or adoption of a child is recommended. (xv) Idiopathic cryptospermia 【Clinical manifestations】 No spermatozoa are detected in routine semen examination, but spermatozoa can be found in centrifugal precipitation and are not compatible with other diagnoses. [Principles of treatment] ICSI using spermatozoa after thorough genetic evaluation and counseling. (xvi) Obstructive azoospermia [Clinical manifestations] 1. Semen analysis is azoospermia, while testicular biopsy shows normal spermatogenesis in the seminiferous tubules. 2. and the following conditions are present: (1) Spermatozoa are present in the testicular biopsy specimen. (2) Total testicular volume >30 ml or unilateral volume >15 ml. (3) Serum FSH is essentially normal. (4) No other diagnosis is met. [Treatment principle] 1. Perform scrotal exploratory surgery and try microsurgical recanalization. 2. After genetic diagnosis and counseling, use epididymal spermatozoa or testicular spermatozoa for ICSI. 3. Failure of treatment, it is recommended to adopt a child by artificial insemination with donor sperm. (xvii) Idiopathic azoospermia. The diagnosis of idiopathic azoospermia is made because the cause of azoospermia is unknown. [Clinical manifestations] 1. Elevated serum FSH. 2. and/or total testicular volume ≤30 ml or unilateral testicular volume ≤15 ml. 3. no spermatozoa on semen centrifugation and no spermatozoa found in testicular biopsy. 4. Not in accordance with other diagnoses. [Principles of treatment] 1. For idiopathic, complete spermatogenesis and maturation disorders, or support cell-only syndrome (spermatogenic cell dysplasia), which cannot be treated at present, donor insemination or adoption of a child is used. 2 If focal spermatogenesis exists in localized seminiferous tubules, or spermatogenesis is normal in some of the seminiferous tubules, ICSI using testicular spermatozoa is performed after systematic genetic evaluation and genetic counseling. microscopic testicular sperm retrieval (MicroTESE) may be performed as an option. 3. ICSI using spermatogonia or spermatocyte nuclei is of experimental value in patients with idiosyncratic azoospermia.