E4

include:

• Chemicals-Certain pesticides (especially DBCP, or dibromochloropropane), some organic solvents, heavy metals, etc.

• Drugs-A partial listing includes some of the chemotherapeutic agents, cimetidine, sulfasalazine, nitrofurantoin, alcohol, marijuana, and androgenic steroids.

• Thermal exposure

Family History

Information about the fertility status of first and second degree relatives may provide helpful insight into a patient's underlying pathology. Furthermore, familial diseases such as cystic fibrosis, androgen receptor deficiency, Noonan's syndrome, Kallman's syndrome, and myotonic dystrophy are associated with impaired fertility.

Physical Examination

The physical examination of transplant patients presenting for infertility evaluation should be thorough, because any condition which impacts overall health can be detrimental to sperm production. A close inspection of the body should detect signs of inadequate virilization or androgen deficiency. These signs include eunuchoid body habitus, gynecomastia, and decreased body hair. The penis and scrotum should be carefully evaluated. Curvature of the phallus or ectopic location of the urethral meatus can result in abnormal deposition of the ejaculate within the vagina. Close attention should be paid to the scrotal exam, which should be done with the patient standing in a warm room. Testicular size, consistency, and volume (using an orchidometer) should be determined. The normal testicular length is > 4 cm, and normal testis volume is > 20 mL. The presence of the epididymis should be confirmed. Cysts, induration, and other abnormalities should be noted. Finally, the scrotum should be evaluated for the presence of varicoceles. Extremely large varicoceles are visible and have a characteristic "bag of worms" appearance. To examine for varicoceles, the patient should valsalva while the examiner palpates the spermatic cords. A dramatic impulse is usually felt in patients with clinically apparent varicoceles. This is due to transmission of the increased intraabdominal pressure to the veins of the pampiniform plexus; this pressure impulse is typically not felt in normal patients. A Doppler stethoscope, which can be easily used in the clinic, and scrotal ultrasonography (to evaluate for veins > 3 mm and reversal of venous blood flow) can be used to confirm clinically apparent varicoceles and to detect those which are subclinical.

Laboratory Evaluation

Laboratory testing is begun after the history and physical exam are completed. The tests ordered should be individually tailored to each patient. It is important to note that a semen analysis, although a vital component of the work-up, is not a "fertility test". The interpretation should take into account crucial factors, such as

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