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

Opening prompt — "Take me through your assessment of this man."

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

• "I would confirm the result on a second sample taken after 2 to 7 days' abstinence, because a single abnormal sample is not a diagnosis and pre-analytical error is common."^[1][2]
• "I would take a targeted history — prior paternity, coital function, childhood illnesses, surgeries, infections — and ask directly about anabolic steroids and exogenous testosterone, which he is being vague about."
• "My framework for the cause is pre-testicular, testicular, post-testicular; within that I separate obstructive from non-obstructive disease using the endocrine panel and examination."^[2]

Examiner is listening for: confirmation of the sample, the direct steroid question, and a structured compartment framework. ^[2]

Probe 1 — "His FSH is 1.5, LH 1.3, testosterone is low. How do you interpret that?"

• "That is a hypogonadotropic pattern — low FSH, low LH, low testosterone — which points to the pre-testicular compartment: central suppression of the hypothalamic-pituitary-gonadal axis. Combined with his body-building supplements, my leading diagnosis is exogenous androgen use suppressing his own axis."^[3]
• "If the FSH were raised with small testes, I would think primary testicular failure; if FSH were normal with normal testes and azoospermia, I would think obstruction. The low gonadotrophins here are the key discriminator."^[4]

Probe 2 — "He confirms he injects testosterone cypionate twice weekly. What do you do?"

• "Testosterone suppresses LH and FSH by negative feedback, collapsing intratesticular testosterone and stopping spermatogenesis — it is, in effect, a contraceptive. I would ask him to stop it immediately and not substitute another testosterone preparation."^[3]
• "I would counsel him that recovery takes roughly three months because spermatogenesis takes 2.5 to 3 months, and that recovery is likely but not guaranteed. If spontaneous recovery is inadequate I would use gonadotrophins — hCG, with FSH added if needed — to restore spermatogenesis. I would never give exogenous testosterone to a man trying to conceive."^[3]

Probe 3 — "Before any ART, what genetic tests would you order?"

• "Because his count is severely low, I would order a karyotype and a Y-chromosome microdeletion panel (AZF a, b and c)."^[4]
• "A complete AZFa or AZFb deletion means surgical retrieval will almost certainly fail, so I would counsel donor sperm before consenting him to retrieval. An AZFc deletion is compatible with sperm. AZF deletions are transmissible to all sons through ICSI, so I would counsel the couple accordingly."^[4]
• "If examination showed an absent vas deferens, I would screen him and his partner for CFTR, because CBAVD is a genital form of cystic fibrosis and a carrier couple risks an affected child. His vasa are present, so that is not the primary question here, but I would state the principle."^[5]

Probe 4 — "The couple is anxious and asks what their chances are. Speak to them."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[2]

• Move to their eye level, use their names, and frame it plainly: "Your semen result is low, and we think the supplements you have been taking are suppressing your body's own sperm production. The good news is this is very likely reversible — we need you to stop the testosterone, and we will recheck your sample in about three months."
• Acknowledge the uncertainty: recovery is likely but not guaranteed, and if it is incomplete we have good options including IVF with ICSI, where we can use your own sperm.
• Avoid jargon, avoid false promises, and commit to reviewing the plan together at the next visit.^[2]

Probe 5 — "If his count does not recover, what is your ART plan?"

• "Severe male factor — a count well below the threshold for intrauterine insemination — is an indication for IVF with intracytoplasmic sperm injection, in which a single sperm is injected into the egg. Palermo and colleagues reported the first ICSI pregnancies in 1992; it bypasses the deficits of count, motility and morphology."^[6]
• "What ICSI fixes is fertilisation. It does not fix the underlying cause or the genetics, so I would complete the karyotype and Y-microdeletion counselling first. If he remained azoospermic, I would consider surgical retrieval — micro-TESE for non-obstructive, PESA or MESA if obstructive."^[4][6]

Probe 6 — "He has a palpable left varicocele. Should you repair it?"

• "I would offer repair only if the varicocele is palpable, the semen is abnormal, the couple is otherwise unexplained, and there is no severe female factor. A Cochrane review found varicocele treatment may improve pregnancy (odds ratio 1.47) but graded the evidence very low quality, with benefit concentrated in clinical varicoceles with abnormal semen. Subclinical varicoceles and normal semen are not repaired."^[7]