A 32-year-old man comes to the clinic for an infertility evaluation. The man and his 31-year-old wife have been trying to conceive for the last 15 months and have unprotected sexual intercourse several times per week. The patient has no chronic medical conditions and takes no daily medications. His wife has no known medical conditions and has a child from a previous marriage. Her menstrual cycles are regular. The patient's vital signs are normal. On physical examination, the penis is uncircumcised and without lesions. Bilateral testes are palpable within the scrotum and are normal in size. There is no excessive firmness or tenderness within either testis. The left testis is positioned lower than the right. Superior to the left testis, there is a nontender clustered mass. It does not transilluminate and decreases in size when the patient is supine. A semen analysis shows a normal seminal volume but slightly reduced sperm count and decreased motility. Which of the following is the most likely cause of this patient's infertility?

Question

A 32-year-old man comes to the clinic for an infertility evaluation.  The man and his 31-year-old wife have been trying to conceive for the last 15 months and have unprotected sexual intercourse several times per week.  The patient has no chronic medical conditions and takes no daily medications.  His wife has no known medical conditions and has a child from a previous marriage.  Her menstrual cycles are regular.  The patient's vital signs are normal.  On physical examination, the penis is uncircumcised and without lesions.  Bilateral testes are palpable within the scrotum and are normal in size.  There is no excessive firmness or tenderness within either testis.  The left testis is positioned lower than the right.  Superior to the left testis, there is a nontender clustered mass.  It does not transilluminate and decreases in size when the patient is supine.  A semen analysis shows a normal seminal volume but slightly reduced sperm count and decreased motility.  Which of the following is the most likely cause of this patient's infertility?

Quizplus · Accepted Answer

11ec25c8_d47a_6246_bc81_437b4c2cfe8e_MD0003_00 This patient has a nontender, clustered scrotal mass superior to the left testis that is consistent with a varicocele, a tortuous dilation of the pampiniform plexus of spermatic veins. Varicoceles are very common and occur in up to 20% of males. The left testis (which frequently hangs lower than the right) and hemiscrotum are often affected due to drainage of the left spermatic (gonadal) vein into the left renal vein, which is subject to compression between the superior mesenteric artery and the aorta. The increased pressure and retrograde blood flow results in venous dilation and the classic "bag of worms" appearance that typically decreases with recumbency. The diagnosis is typically made clinically but can be confirmed with ultrasound. left spermatic (gonadal) vein Although most patients are asymptomatic, varicoceles are associated with decreased fertility in males, likely due to mildly increased scrotal temperatures. This can result in testicular atrophy, reduced sperm production, and impaired spermatic motility. Patients who desire fertility but have abnormal semen parameters or evidence of testicular atrophy are candidates for surgical venous ligation or embolization, which is associated with improved pregnancy rates. Older patients who do not desire fertility may be conservatively managed with nonsteroidal anti-inflammatory medications and scrotal support. (Choice A) The vas deferens is responsible for the transport of sperm from the testes to the ejaculatory ducts; its absence is common in patients with cystic fibrosis. However, due to the lack of transportation, the semen analysis would be expected to show a complete deficiency of sperm. In addition, most cases of cystic fibrosis are diagnosed at birth, and patients are typically symptomatic (eg, recurrent pulmonary infections). (Choice B) Ejaculatory duct obstruction (obstructive azoospermia) results in very low or absent sperm counts with normal sperm motility. (Choice C) Hydroceles are fluid collections within the tunica vaginalis. They can cause a painless testicular enlargement that reduces with recumbency but transilluminates on examination. Although hydroceles may occasionally cause pain or irritation of the scrotal skin, they are not associated with decreased fertility. (Choice D) Inguinal hernias can extend into the scrotum and may reduce with recumbency. Hernias are at risk of incarceration and ischemia but are not typically associated with infertility. Sperm counts and motility are expected to remain normal. Educational objective: Varicoceles typically present as a clustered scrotal mass above the testis. Men with a varicocele can have reduced fertility, possibly due to increased scrotal temperatures that can cause a reduced sperm count and decreased motility.

A 32-Year-Old Man Comes to the Clinic for an Infertility