Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Infertility / Difficulty conceiving / Low sperm count / Abnormal semen analysis results
History of Present Illness:
Duration of infertility (time trying to conceive without success).
Frequency of sexual intercourse.
Partner’s fertility status (known or suspected issues).
Describe any new or concerning symptoms related to the reproductive system (e.g., testicular pain, erectile dysfunction, decreased libido).
Past Medical History:
Childhood illnesses or surgeries that may affect fertility (e.g., undescended testicles, mumps orchitis).
Chronic medical conditions (e.g., diabetes, cystic fibrosis) that can impact sperm production.
Previous surgeries or injuries involving the genitourinary system.
History of sexually transmitted infections (STIs) that can cause scarring and fertility problems.
Occupational exposures to toxins or radiation.
Medications:
List all current medications, including any medications that may affect sperm production (e.g., anabolic steroids, certain antibiotics).
Social History:
Inquire about tobacco use, alcohol consumption, and illicit drug use (all can impact sperm quality).
Ask about exposure to environmental toxins (e.g., pesticides, heavy metals).
Family History:
Inquire about a family history of male infertility in the patient or his father.
Lifestyle:
Assess diet, exercise habits, and stress levels. These factors can influence sperm health.
Physical Exam:
General observation: Assess for signs of:
Abnormal body habitus (obesity can affect fertility)
Gynecomastia (breast enlargement)
Varicoceles (enlarged veins in the scrotum)
Genital exam: Evaluate testicular size, symmetry, and presence of varicoceles.
Semen Analysis:
Summarize the results of the most recent semen analysis, including:
Sperm count (total number of sperm)
Motility (percentage of sperm that move progressively)
Morphology (percentage of sperm with normal shape)
Volume (total amount of ejaculate)
Mention any specific abnormalities identified.
Imaging Studies (if indicated):
Scrotal ultrasound: May be used to assess testicular size, identify varicoceles, and evaluate blood flow.
Hormonal testing: May be performed to assess testosterone levels and other hormones that regulate sperm production (LH, FSH, prolactin).
Assessment:
Cause of infertility (if identified): State the suspected cause(s) of male infertility based on history, physical exam, semen analysis results, and imaging studies (if available). This may include varicocele, hormonal imbalance, obstruction, or unexplained infertility.
Severity of male factor infertility: Describe the severity of the sperm abnormalities identified in the semen analysis.
Plan:
Treatment:
Outline the treatment plan based on the identified cause(s) of infertility and the couple’s overall fertility goals. This may include:
Treating underlying medical conditions: If an underlying medical condition is contributing to infertility, addressing that condition may improve sperm quality.
Lifestyle modifications: Encourage weight loss, exercise, smoking cessation, and limiting alcohol intake to optimize sperm health.
Varicocele repair: Surgical intervention may be considered for varicoceles.
Hormonal therapy: Hormone replacement may be used to address hormonal imbalances.
Referral for assisted reproductive technologies (ART): If conservative measures are unsuccessful, consider referral for sperm retrieval techniques (microsurgical sperm aspiration – MSΑ) or in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) depending on the severity of sperm abnormalities.
Counseling: Discuss the emotional impact of infertility and offer resources for emotional support and counseling.
Follow-up: Schedule follow-up visits to monitor response to treatment, repeat semen analysis as needed, and discuss next steps for achieving pregnancy.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. It is recommended to consult with relevant medical resources and male infertility treatment guidelines for comprehensive care planning.