Approach to evaluation and management of male infertility in Sub-Saharan Africa

The prevalence of infertility among couples globally is estimated at 15%. Male factor infertility contributes to 20%-70% of the cases depending on the specific region of the world. Male infertility accounts for up to 22.26% of cases in Africa. Causes are generally categorized as pre-testicular, testicular, or post-testicular, based on the level of dysfunction within the hypothalamic-pituitary-gonadal axis. Primary testicular failure is caused by intrinsic testicular dysfunction, while secondary testicular failure originates from a dysfunction in the hypothalamus or the pituitary gland. Post-testicular causes are attributed to obstructive, ejaculatory, or erectile dysfunction. Evaluation should thus entail a full history followed by a detailed physical exam and stepwise investigation. Semen analysis is recommended as the initial test, followed by hormonal tests, imaging, biopsies, and karyotyping as needed. Treatment is tailored based on the specific cause identified.