recently noticed decreased libido and disinterest in intercourse although they still manage to have unprotected intercourse around the time of ovulation. While he is usually able to achieve erections, he is not always able to maintain them, but when he does, he is able to ejaculate inside his partner. They deny use of any lubricants. DC also complains of fatigue and is less interested in many of his usual activities, especially nding it harder to keep up at the gym.

A rst semen analysis revealed a concentration of seven million/mL, and total sperm count of 20 million. Sperm total motility was 30% and progressive motility 25%. Morphology was normal. Repeat semen analysis also revealed decrease concentration and motility. Volume and pH were within normal limit. His DNA fragmentation based on TUNEL was 20% (normal <7%).

General physical exam revealed no dysmorphic or syndromic features. His height was 6 ft. 3 in., and weight was 200 lbs. Abdominal examination was benign. There was no scar or mass felt. His genitourinary examination demonstrated a normal sized circumcised phallus. His meatus was in the orthotopic position and patent. Both testicles were normal sized with normal consistency. Epididymides were fat bilaterally and both vas deferens were identi ed. No hernia was detected. A grade 3b varicocele was appreciated on the left scrotum.

Bloodwork revealed a testosterone of 300 ng/dL. His scrotal ultrasound also con-rmed a grade 3 varicocele on the left-hand side.

Treatment options were discussed and DC decided to proceed with a microsurgical left subinguinal varicocelectomy which was performed uneventfully. He had an uncomplicated recovery. His pain was improved and so was his libido post-surgery. Testosterone went up signi cantly to 410 ng/dL. Repeat semen analysis showed an improved sperm concentration of 35 million/mL and motility of 45%. DNA fragmentation index improved to 12%.

DC and his wife were able to achieve a pregnancy naturally within 6 months from surgery and gave birth to a healthy baby boy.

Discussion

In patients presenting with scrotal pain and infertility, the differential diagnoses may be broad. For scrotal pain, the differential diagnosis includes [1]:

•\ Testicular malignancy •\ Orchitis

•\ Epididymitis •\ Prostatitis

•\ Sexual transmitted disease •\ Trauma

•\ Varicocele •\ Hydrocele

•\ Intermittent testicular torsion

––Exacerbating factors: urination, erection, ejaculation

––Relieving factors

––Associated symptoms: fever, chills, urinary frequency, dysuria, urethral discharge, scrotal swelling, change in height or position of the testis

––Methods used for relief

•\ Infertility History [3]:

––How many children would they like to have

––Primary or secondary infertility

––Duration of infertility (standard de nition of >12 months in young couples <35 years old)

––Partner history (age, gynecological history, previous pregnancies, work-up by gynecologist or reproductive endocrinologistAMH, ultrasound, HSG)

––History of childhood illness (i.e. orchitis)

––History of undescended testicle

––History of inguinal or pelvic surgery

––History of infertility surgery (i.e. vasectomy or varicocelectomy)

––History of pelvic or genital trauma

––History of infections of the genitourinary tract (including sexually transmitted infections)

––Exposure to gonadotoxins (i.e., medications, environmental exposures, chemotherapy, radiation)

––Steroid or testosterone use

––Signs and symptoms of any genetic conditions

––History of abnormal vision or visual changes

––Family history of fertility issues

•\ Sexual History [3]:

––Sexual drive/desire

––History of erectile dysfunction

––History of ejaculatory dysfunction

––Intercourse frequency and intravaginal ejaculation

––Use and type of lubricants

––Use of contraception.

•\ Hypogonadism (low testosterone) History:

––Decreased libido

––Decreased mood

––Loss of muscle mass

––Fatigue

––Decreased energy

––Hot sweats

––Altered cognition

––Change in body hair distribution