Huyghe E, Izard V, Rigot J-M, Pariente J-L, Tostain J
Service d'urologie-andrologie, hôpital Rangueil, CHU de Toulouse, 1, avenue du Pr Jean-Poulhès, 31059 Toulouse cedex 9, France.
Prog Urol. 2008 Feb;18(2):95-101. doi: 10.1016/j.purol.2007.12.002. Epub 2008 Mar 20.
An infertility evaluation should be performed if a couple has not achieved conception after one year of unprotected intercourse. An evaluation should be performed earlier if male or female infertility risk factors exist and if the couple questions its fertility potential. The initial screening of the male should include a reproductive history and a physical examination performed by a urologist or a specialist in male fertility and two semen analyses. Additional procedures and testing may be used to elucidate problems discovered during the full evaluation. The minimal initial endocrine evaluation should include serum total testosterone and serum follicle-stimulating hormone levels. An endocrine evaluation should be performed if sperm concentration is abnormally low, sexual function is impaired, and when other clinical findings suggest a specific endocrinopathy. A postejaculatory urinalysis should be performed if ejaculate volume is less than 1 mL, except in patients with bilateral vasal agenesis or possible hypogonadism. With a diagnosis of retrograde ejaculation, specific management should be considered before advising assisted reproductive technology. Scrotal ultrasonography is indicated when physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected. Transrectal ultrasonography (TRUS) is indicated in patients who are azoospermic or have a low ejaculate volume. Specialized testing of semen is not required for routine diagnosis of male infertility. However, some tests may be useful for a few patients to identify a male factor contributing to unexplained infertility, or to select therapy (e.g., assisted reproductive technology). Before performing intracytoplasmic sperm injection, karyotyping and Y-chromosome analysis should be offered to men who have nonobstructive azoospermia and severe oligospermia. Genetic testing for gene mutations of the ABCC7 (ex-CFTR) gene should be offered to male and female partners before proceeding with treatments that use the sperm of men with congenital bilateral absence of the vasa deferentia or congenital unilateral abnormality of the seminal tract. Genetic counseling may be offered when a genetic abnormality is suspected in the male or female partner, and it should be provided when a genetic abnormality is detected. Genetic testing in the female partner, when non symptomatic, should only be advised by a physician from a multidisciplinary team registered by the ministry of health. Evaluation by testis biopsy and deferentography should be performed by a urologist or an andrologist registered for sperm retrieval.
如果一对夫妇在无保护性交一年后仍未受孕，应进行不孕症评估。如果存在男性或女性不孕风险因素，以及夫妇对其生育潜力存在疑问，则应更早进行评估。男性的初始筛查应包括生殖史、由泌尿科医生或男性生育专家进行的体格检查以及两次精液分析。可能会使用其他程序和检测来阐明全面评估中发现的问题。最低限度的初始内分泌评估应包括血清总睾酮和血清促卵泡激素水平。如果精子浓度异常低、性功能受损，以及其他临床发现提示特定内分泌疾病，则应进行内分泌评估。如果射精量少于1毫升，应进行射精后尿液分析，但双侧输精管缺如或可能性腺功能减退的患者除外。诊断为逆行射精时，在建议采用辅助生殖技术之前应考虑具体的治疗方法。当阴囊体格检查困难或不充分，或怀疑有睾丸肿块时，应进行阴囊超声检查。无精子症或射精量少的患者应进行经直肠超声检查（TRUS）。男性不育的常规诊断不需要进行专门的精液检测。然而，一些检测可能对少数患者有用，以确定导致不明原因不孕的男性因素，或选择治疗方法（如辅助生殖技术）。在进行卵胞浆内单精子注射之前，应为患有非梗阻性无精子症和严重少精子症的男性提供染色体核型分析和Y染色体分析。在进行使用先天性双侧输精管缺如或先天性单侧生殖道异常男性精子的治疗之前，应为男性和女性伴侣提供ABCC7（前CFTR）基因突变的基因检测。当怀疑男性或女性伴侣存在基因异常时，可提供遗传咨询，检测到基因异常时应提供遗传咨询。女性伴侣无症状时，基因检测仅应由卫生部注册的多学科团队的医生建议。睾丸活检和输精管造影评估应由注册从事取精的泌尿科医生或男科医生进行。
