How do I assess and manage male factor infertility in a primary care setting?

Assessment of Male Factor Infertility in Primary Care:

• Take a detailed history including previous genital pathology, urogenital surgery, sexually transmitted infections, varicocele, systemic illness, and any known causes of infertility such as prior cancer treatment.
• Perform a physical examination focusing on the genitalia to identify abnormalities such as varicoceles or signs of obstruction.
• Order an initial semen analysis following WHO guidelines: ensure the sample is complete, collected properly, and delivered to the lab within 30-50 minutes, with results interpreted against WHO reference values.
• If the first semen analysis is abnormal, repeat the test ideally after 3 months to confirm findings; if two abnormal results occur, refer to secondary care for further assessment.
• Screen for Chlamydia trachomatis infection as part of the assessment.

Management in Primary Care:

• Provide general advice on lifestyle factors affecting fertility such as smoking cessation, reducing excessive alcohol intake, weight management, and stress reduction.
• Inform men that treatments like anti-oestrogens, gonadotrophins, androgens, bromocriptine, or antibiotics for leucocytes in semen without infection are not effective and should not be offered.
• Refer men with hypogonadotrophic hypogonadism to specialists for gonadotrophin therapy.
• Do not offer surgery for varicoceles as it does not improve pregnancy rates; however, men with obstructive azoospermia may be referred for surgical correction if expertise is available.
• Offer counselling and psychological support to men and couples as infertility and its investigation can cause significant stress.