This document outlines the steps for a thorough physical examination for male infertility. It emphasizes the importance of examining the genitals, reproductive organs, and general body. The exam includes checking testicle size and consistency, feeling the epididymis and vas deferens for masses or tenderness, inspecting the penis and scrotum, and performing a digital rectal exam to evaluate the prostate. A complete exam can provide clues to potential causes of infertility like varicoceles, infections, or hormonal abnormalities. The document stresses that clinical examination remains important despite advances in medical testing.

1. Examination Of A Male
In Infertility
What Not To Miss
Dr. Shashwat Jani.
M. S. ( Obs – Gyn ), F.I.A.O.G.
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Male Reproductive System
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3. Prerequisites
• Physical examination is performed in a warm
room by an examiner with warm-gloved hands.
• Contraction of the dartos muscle induced by a
cold room or cold examining hands makes
examination of the scrotum and its contents
difficult.
• A proper fertility examination does not consist
of a casual observation of the scrotum and
palpation of its contents. Have the patient
completely disrobe and stand with his arms
outstretched.
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4. • Observe the general body habitus and hair
distribution.
• Men who are incompletely masculinized have
disproportionately long extremities due to absent
or deficient androgen stimulation required for
epiphyseal closure at the time of puberty.
This is seen in men with hypogonadotropic
hypogonadism (Kallmann's syndrome when
associated with absent sense of smell or other
midline defects) or Kleinfelter's syndrome.
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5. • Thyroid is Palpated and Heart & Lungs are
auscultated.
• Chronic bronchitis associated with congenital
epididymal dysplasia is seen in Young's syndrome.
• Situs inversus with associated immotile sperm is
seen in immotile cilia (Kartagener's) syndrome.
• The Breasts are observed and palpated for
gynecomastia, which can be associated with
estrogen secreting testicular neoplasms, adrenal
tumors, and liver disease.
• Nipple discharge or tenderness may be seen
with prolactin-secreting pituitary adenomas.
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6. • The Abdomen is palpated and percussed.
• A large varicocele that does not collapse in the
supine position warrants a search for an
abdominal mass.
• An enlarged Liver suggests hepatic
dysfunction, which may be associated with
infertility due to altered sex steroid
metabolism.
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8. TESTICLES
TWO TESTICLES, ONE ON EACH SIDE
It is important to make sure that a testicle can be felt
on each side.
If a testicle is not palpable,
• History of an undescended testicle that was not
repaired,
• Retractile testicles,
• Neonatal testicular torsion,
• Surgical removal of a testicle.
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9. Size And Consistency
• 95 % of the volume of the testicles is made up
by the cells that produce sperm.
• Therefore, a normal-size testicle is often a sign
that sperm production is not severely
impaired.
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10. • Small, firm testicles often indicate a problem with
sperm production that occurred before the onset of
puberty (such as Klinefelter’s disease).
• Small, soft testicles are typically more consistent
with sperm production problems that developed
after puberty.
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11. • Small soft testes indicate poor spermatogenesis.
• Small hard testes suggest postorchitis or
posttorsion atrophy or Kleinfelter's syndrome.
Focal irregularities in consistency raise the
suspicion of malignancy.
• Smooth firm nodules palpated on the surface of
the testis usually represent tunica albuginea cysts.
• Transillumination of the scrotum in a
darkened room differentiates solid from
cystic masses.
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12. Testicular volume
• Measured in one of several ways.
• One is to measure the testicles’ dimensions —
length, width, and height— and plug those into a
formula:
Volume = 4/3π × (length/2) × (width/2) × (height/2)
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13. • Calipers can also be used to approximate the
dimensions, although estimates can vary
somewhat depending on how tightly the
physician stretches the scrotal skin over the
testicle as the measurements are taken.
Normal testicular dimensions are:
1) Length: 3–5 cm
2) Width: 2–4 cm
3) Height: 3 cm
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14. • Normal testicular volume is about
20 cm cubed, with a range of 15 to
25 cm cubed.
( The units you see on a report may vary, but cubic
centimeters, which are abbreviated as cm3 or cc,
are the same as milliliters, which are abbreviated
mL: 1 cm cubed = 1 cc =1 mL. )
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15. Orchidometer
 It’s a series of plastic beads of
different sizes looped together on a
string.
 Each bead is labeled with its volume in
cubic centimeters or milliliters.
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16.  Same As with the use of
calipers, there is some
subjectivity involved in
measurement with an
orchidometer also, depending
on how tightly the physician
stretches the scrotal skin over
the testicle while making the
measurement.
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 The beads are held up alongside the scrotum
during the physical exam to get an estimation of the
testicular volume.

17. Testicular Masses
• Testicular cancer occurs in higher rates in
men with fertility problems.
• An abnormal testicular mass found on
examination should be evaluated further with
ultrasound.
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18. Scrotal Skin Abnormalities
• Genital warts (caused by HPV) are a fairly common form of
sexually transmitted disease.
• Certain types of HPV have been associated with an increased
risk of penile cancer in men and cervical cancer in women.
• If genital warts are found, they should be treated by ablative
therapy (such as topical creams, laser ablation, etc.).
• These treatments do not permanently cure the man of HPV,
but they can remove visible lesions and decrease (although not
eliminate) the risk of spread to sexual partners.
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19. Epididymis
PRESENT IN FULL ON BOTH SIDES
The epididymis, the structure on the side of the
testicles in which the sperm mature, has three
parts: the head, body, and tail.
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20. Masses
 Cysts of the epididymis are quite common.
 In men of reproductive age, these cysts are usually
relatively small and asymptomatic.
 On rare occasions, epididymal cysts can be associated
with chronic discomfort in the scrotum.
 Occasionally they can also grow to be very large
(grapefruit size or larger) and make sitting uncomfortable.
 By themselves, epididymal cysts generally do not cause
fertility problems unless they are very large.
 However, surgical removal of these cysts can cause
epididymal scarring, which can lead to obstruction
problems.
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21. All men of reproductive age should do regular
scrotal exams every few months in the shower.
If any significant changes are noted with an
epididymal mass over time, such as an increase
in size Or Pain then ultrasound imaging is
recommended.
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22. Fullness Or Congestion
• A skilled health care professional should be
able to determine if the epididymis feels swollen or
congested.
• This can be consistent with a blockage of sperm
transport, with sperm backing up into the
epididymis and causing congestion.
• Congenital epididymal obstruction and previous
vasectomy are two potential causes of this finding .
• Epididymal swelling can also be due to
inflammation or infection within the epididymis.
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23. Tenderness
• The nerve supply for the testicle enters
around the area of the head of the
epididymis.
• Due to its rich nerve supply, the epididymis is
often somewhat tender to the touch during a
physical exam.
• However, extra tenderness can also be due to
inflammation within the epididymis itself
(epididymitis).
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24. Spermatic Cord
• The spermatic cord contains the blood supply, nerves
& lymphatic drainage for the testicles.
• It also contains the VAS DEFERENS, which is a tube-
like structure that carries the sperm to the ejaculatory
ducts.
• In patients with congenital bilateral absence of the
vas deferens (CBAVD), the vas deferens is typically
missing on both sides.
• A vas deferens that is not palpable on only one side
can either represent an atypical variant of CBAVD or be
part of a mesonephric duct abnormality, affecting also
the kidney and ureter on that side.
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25. Varicoceles
• Dilated veins in the scrotum are called varicoceles; they
are similar to varicose veins in the legs.
• Small varicoceles are not clinically significant, but
larger varicoceles can have a negative impact on sperm
production and quality.
• Most varicoceles can be diagnosed by examining the man
while he is standing.
• When a man with a varicocele increases his intra-
abdominal pressure (by performing Valsalva maneuver—it’s
usually done by closing mouth and pinching your nose shut,
then trying to exhale), an impulse within the dilated veins.
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27. • Sometimes a physical exam reveals a varicocele
that is borderline in size.
• In other circumstances, a good evaluation of the
veins cannot be obtained, either because of
extreme obesity or because the patient experiences
sensitivity or discomfort with deep palpation in the
scrotal area.
• In these situations, a scrotal ultrasound can be
performed, measuring the diameter of the largest
scrotal veins while the man is in a standing position.
• Veins that are larger than 3.5 mm in size are
considered potentially clinically significant.
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29. Penis
Normal Size And Location Of Meatus
• The meatus (opening) of the penis is typically
located at the tip of the penile head.
• However, in men with hypospadias or
epispadias, the location of the meatus can be
elsewhere on the penis, or even in the perineal
region (the area of skin between the penis and
scrotum).
• If the meatus is located near the head of the
penis, then there is unlikely to be any significant
impact on fertility.
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30. Classification Of Hypospadias
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31. Causes Infertility…
• However, if the meatus is not near the head
of the penis, then during intercourse the sperm
are likely not being deposited near the woman’s
cervix, which can have a significant impact on
the ability to establish a pregnancy naturally.
• This problem can be treated with
intrauterine insemination.
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32. Penile Discharge
• A discharge of fluid from the opening of
the penis can be a sign of infection within the
urethra or genital duct system.
Penile Skin Abnormalities
• As with the scrotum, genital warts, caused
by HPV, are relatively common.
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33. Digital Rectal Examination
• Should always be performed.
• The size and consistency of the prostate is
noted.
• Masses, cysts, irregularities, tenderness, and
whether or not the seminal vesicles are
palpable are noted.
• Stool should be tested for occult blood.
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34.  Advances in medical knowledge & technology
do not exclude the importance of clinical
examination.
 Appropriate use of medical technology is based
on thorough history & physical examination.
 No lab. Reports should be interpreted without
correlating with clinical examination.
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