Male-factor infertility — structured oral station (12 minutes)

Opening prompt — "Walk me through your interpretation of this semen analysis."

Model response — say it in this order: ^[1][2]

• "I'll compare each parameter against the WHO 6th-edition (2021) lower reference limits: volume 1.0 mL — ABNORMAL, below the 1.4 mL lower limit; concentration 18 M/mL — normal, above 16; progressive motility 35% — normal, above 30%; morphology 5% — normal, above 4%; pH, total motility and vitality are all in range." ^[2]
• "Low volume raises three possibilities: incomplete collection, retrograde ejaculation (check post-ejaculate urine), or absent/reduced seminal vesicles — the latter two point to obstructive azoospermia, especially with absent vas on examination."
• "But a single abnormal sample is not diagnostic — I would repeat the semen analysis in 3 months, the spermatogenic cycle being around 74 days. If the volume remains low, I would add a post-ejaculate urine and re-examine the vas deferens carefully."

Examiner is listening for: the verbatim WHO limits, the differential for low volume, and the discipline of repeating the sample before declaring infertility. ^[1][3]

Probe 1 — "The repeat sample shows volume 0.8 mL, concentration 0, FSH 4 IU/L, testicular volumes 18 mL each, vas palpable. What is the differential and what next?" ^[2]

• "This is azoospermia with normal testicular volume and normal FSH — that pattern points to OBSTRUCTIVE azoospermia. Low volume with palpable vas is unusual — the common obstructive causes are vasectomy, CBAVD, or post-infective epididymal obstruction. The vas feels normal here, so I would check the post-ejaculate urine for retrograde ejaculation."^[2][6]
• "If the post-ejaculate urine is negative for sperm, I would proceed to the genetic cascade. CFTR screen is appropriate if there is any suspicion of CBAVD — even with palpable vas, partial CBAVD or vasal abnormalities can occur."^[6]
• "Treatment: surgical sperm retrieval (PESA, MESA, or micro-TESE) plus ICSI — spermatogenesis is intact, so live birth rates approach those of standard IVF."^[6]

Probe 2 — "The repeat shows volume 1.5 mL, concentration 0, FSH 32 IU/L, testicular volumes 4 mL each, vas palpable. What is the differential and what next?" ^[2]

• "This is azoospermia with small testes and elevated FSH — that pattern points to NON-OBSTRUCTIVE azoospermia — primary testicular failure. The commonest genetic cause is Klinefelter 47,XXY."^[2][5]
• "Genetic cascade — karyotype is the first test (Klinefelter is the yield); if 47,XXY, then Y-microdeletion is not needed (the diagnosis is established). Micro-TESE is the surgical retrieval option, with sperm retrieval in 30 to 50% of men and better outcomes in younger men."^[5]
• "Counselling before micro-TESE — the aneuploidy risk (some sperm carry the extra X chromosome), PGT-A option, and donor sperm as a backup. Genetic counselling is mandatory."^[5]

Probe 3 — "The same man has a clinical grade II left varicocele. Do you repair it?"

• "This is azoospermia with primary testicular failure — the varicocele is unlikely to be the cause. The Cochrane review (Kroese 2012) shows varicocele repair improves pregnancy in men with a CLINICAL varicocele and an ABNORMAL semen analysis — but the semen here is azoospermic, which is not the evidence base for repair."^[4]
• "If micro-TESE fails and the couple considers donor sperm or another retrieval attempt later, then varicocele repair could be discussed as adjunctive — but the evidence does not support it as a primary intervention in this scenario."

Probe 4 — "He tells you he has been on testosterone replacement for the last 3 years for fatigue. What now?"

• "Exogenous testosterone is contraceptive — it suppresses LH and FSH, intratesticular testosterone falls, and spermatogenesis stops. This may be the reversible cause."^[2]
• "Stop the testosterone AND switch to hCG (which preserves intratesticular testosterone and supports spermatogenesis), with FSH added if needed. Semen analysis every 3 months; expectation of spermatogenesis in 6 to 24 months in most patients."^[2]
• "I would also screen for the 'low T' being a normal age-related decline — the testosterone here was likely over-prescribed, and the partner's age may also be a factor."

Probe 5 — "The couple asks about the IVF/ICSI pathway and the transmission risk to a child."

• "Pre-ART counselling for any identified genetic defect is mandatory. For CFTR mutations — both partners must be screened; if both carry, PGT-M is offered to avoid an affected child with cystic fibrosis. For Y-microdeletion AZFc — ALL male offspring will inherit the deletion; PGT-M for sex selection is one option (with significant ethical implications). For Klinefelter — most offspring are chromosomally normal but there is a small increased risk of sex chromosome aneuploidy; PGT-A may be offered."^[5]
• "Donor sperm is an alternative pathway if retrieval fails or the couple declines the aneuploidy risk."^[5]
• "Genetic counselling before ART is mandatory when a genetic defect is identified."^[5]