SQU Med J, December 2010, Vol. 10, Iss. 3, pp. 350-353, Epub. 14th Nov 10 
Submitted 22nd May 10
Accepted 20th July 10

1Department of Obstetrics and Gynaecology, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman; 
Departments of 2Surgery and 3Pharmacy, Sultan Qaboos University Hospital, Muscat, Oman
*Corresponding Author email: kprasadv@gmail.com

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 2008 2005
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
 

aBstract: Objectives: The objectives of this study were to compare the demographics, semen parameters 
and hormone profiles in men with primary and secondary infertility. Methods: The study was designed as a 
retrospective analysis of data collected from men attending a combined infertility clinic (seen together by urologist 
and gynaecologist) from January 2005 to December 2008 at Sultan Qaboos University Hospital, a tertiary care 
hospital in Oman. Ninety-eight consecutive male patients with one or more abnormalities in semen analysis were 
referred to the combined infertility clinic. A complete physical examination was carried out by a urologist followed 
by hormone evaluation of follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T) and 
prolactin (PRL). Results: The semen parameters and the sex hormone evaluation were not significantly different 
between the men with primary and secondary infertility. The men with primary infertility were younger than the 
men with secondary infertility. A total of 24% of the men in the primary group and 16% in the secondary group were 
azoospermic with normal gonadotropin values in 9 men and 1 man in the primary and secondary group respectively. 
Conclusion: Azoospermia was more common in the primary infertile group and, based on gonadotropin levels, 
obstructive causes seemed more prevalent in the primary group compared to secondary group. 

Keywords: Male infertility; Primary infertility; Secondary infertility; Varicocele; Sex Hormones; Semen parameters; 
Oman

Comparison of the Demographics, 
Semen Parameters and Hormone Profiles in 

Men with Primary and Secondary Infertility
Vaidyanathan Gowri,1 *Krishna P Venkiteswaran,2 Ibrahim Al-Zakwani,3 Josephkunju Mathew,2 Khalid 

Abdul Rahman,2 Mohammed Al-Marhoon2

CLINICAL & BASIC RESEARCH

Advances in Knowledge
1. This is one of the first studies from the Arabian Gulf region on male infertility
2. Hormonal evaluation results for all men with azoospermia/oligospermia is not very different in primary or secondary types of infertility.

Application to patient care
1. Based on the results of this study, men with primary subfertility need to be more thoroughly investigated for obstructive causes.
2. Serum hormone level estimation obviates the need for invasive procedures on the testes.



Vaidyanathan Gowri, Krishna P Venkiteswaran, Ibrahim Al-Zakwani, Josephkunju Mathew, Khalid Abdul Rahman  
and Mohammed Al-Marhoon

Clinical and Basic Research | 351

Infertility is a common problem faced by the clinician and could arise from male factors, female factors or both. Though infertility is 
conventionally divided into primary and secondary 
types, the aetiology is not always different.1 Semen 
analysis is an integral part of evaluation of an 
infertile couple. In males with abnormal semen 
parameters, including reduced sperm count or 
sperm motility, sex hormones are evaluated to rule 
out testicular causes and aid in the management. 
Low levels of follicle stimulating hormone (FSH) 
suggest a hypothalamo-pituitary axis problem 
and high levels of FSH signify testicular failure. 
Primary testicular failure and hypothalamic causes 
are more likely to result in primary male infertility 
than causes like sexually transmitted diseases, 
trauma, environmental factors and social habits 
like smoking and consuming alcohol. Obstructive 
azoospermia secondary to sexually transmitted 
infection is a preventable cause of secondary male 
infertility. Bayasgalan et al. found a high prevalence 
of obstructive azoospermia (8.4%) and acquired 
testicular damage (5.4%) in their study.2 This study 
aimed to examine and compare the semen and 
serum hormone parameters in the two groups of 
men with primary and secondary infertility.

Methods 
The study was approved by the institutional ethics 
committee and was designed as a retrospective 
analysis of data collected from men attending 
the combined infertility clinic (seen together by 
urologist and gynaecologist) from January 2005 
to December 2008 at Sultan Qaboos University 
Hospital, Oman, a tertiary care centre. Semen 
analysis was done as part of initial evaluation for all 
couples with infertility. Men with abnormal semen 
analysis (reduced count, reduced motility and/
or abnormal sperm morphology) were referred to 
the combined infertility clinic. A thorough history 
and complete examination of the male partner was 
carried out by the urologist. Sex hormone assays 
of follicle stimulating hormone (FSH), luteinizing 
hormone (LH), testosterone (T) and prolactin 
(PRL) on the male partner and/or ultrasound of 
the testes with Doppler was requested. The optimal 
treatment modality was chosen based on the results 
of investigations of both the female and male 
partners. 

Semen specimens were collected at the study 
site and transferred immediately to the laboratory. 
Men were asked to abstain for 72 hours prior to 
collection. Sperm concentration was determined 
by counting the two sides of a haemocytometer. 
Semen volume was measured in a graduated 
pipette. Motility was evaluated as the proportion 
of sperms that were progressively motile at  
370o C using a Makler chamber. Men were 
considered azoospermic if no sperms were seen. 
Dried semen smears were treated with Berg’s stain 
(carbol fuchsin and methylene blue) and assessed 
for morphological abnormalities by one examiner 
using strict criteria.

Serum concentrations of FSH, LH, T and 
PRL were measured using the Access® system 
(Beckmann Coulter Inc.). The Access hFSH and LH 
assays were sequential two-step immunoenzymatic 
(sandwich assay) with a sensitivity of 0.2 miu and 
a coefficient of variation less than 10%. The Access  
testosterone assay was a competitive binding 
immunoenzymatic assay. PRL was also measured 
by a sandwich technique, immunochemical method 
(Access® system, Beckmann Coulter Inc.) with a 
sensitivity of 0.25 ng/ml and coefficient of variation 
of 10%. The analytical sensitivity for testosterone 
was 0.1 ng/mL and the interassay and intraassay 
coefficients of variation were 2.71% and 5.65% 
respectively.

Descriptive statistics were used for the 
data. For categorical variables, frequencies and  
percentages were reported. Differences in 
prevalence of varicocele between groups 
(primary and secondary infertility) were 
analysed using Pearson’s chi-squared test.  
For continuous variables, means and standard 
deviations (SD) were presented. Since the 
distributions of the continuous variables (age, 
duration, volume, motility, count, abnormal 
forms, FSH, LH, PRL and T) were significantly 
non-normal, the analysis was conducted using the 
Mann-Whitney test. An a priori two-tailed level 
of significance was set at the 0.05 level. Statistical 
analysis was conducted using STATA, Version 10.1, 
(STATA Corporation, College Station, TX).

Results
The total number of men during the study 
period (January 2005 to December 2009)  



Comparison of the Demographics, Semen Parameters and Hormone Profiles  
in Men with Primary and Secondary Infertility

352 | SQU Medical Journal, December 2010, Volume 10, Issue 3

was 98. There were 67 men with primary and 31 
with secondary infertility. Hormone analysis was 
done for 46 patients in the primary group and 25 in 
the secondary group. Men in the primary infertile 
group were significantly younger than the men in 
secondary infertility group (33 versus 37 years; P = 
0.002). The duration of infertility as well as volume, 
sperm motility, sperm count and abnormal forms of 
the semen were not significantly different between 
the primary and secondary groups [Table 1]. There 
were also no statistical differences in the hormonal 
parameters between the two groups [Table 2]. 
Furthermore, the prevalence of varicocele was also 
not significantly different between the groups. Only 
nine men admitted to smoking in the primary group 
and six men in the secondary group. There was no 
clinical evidence or history of sexually transmitted 
disease except for one in the primary infertility 
group. A history of diabetes was present in four men 
and cardiomyopathy in one in the primary group. 
Azoospermia was present in 16 of 67 (24%) men 
in the primary group and 5 of 31 (16%) men in the 
secondary group. Serum gonadotropin values were 
normal in 9 of 16 (56%) in the primary group and 
one out of the five (20%) in the secondary group. 
There was weak negative correlation between LH 

and sperm counts in both groups (-0.0971 and 
-0.08897 in primary and secondary respectively). 
The testosterone levels correlated positively with 
sperm motility in both groups (0.400 and 0.315 in 
the primary and secondary groups respectively).

Discussion
In the present study, except for the age of men in 
the primary infertility group which was significantly 
less than in men with secondary infertility, the other 
assessed parameters were not significantly different. 
There were only six men with FSH equal to or more 
than 15 IU in the primary infertile group, but seven 
in the secondary group. In the secondary infertility 
group, the cause for elevated FSH was due to 
orchidectomy in one man and bilateral small testes 
in another, but there was no obvious cause in the 
others except a history of smoking in two men. The 
FSH levels and the sperm counts correlated inversely 
in the primary and secondary infertility groups, 
(0.28157, -0.2702 respectively) and this fits with 
other observations in the literature.3,4,5 Although the 
serum gonadotropin values were not significantly 
different between the two groups, analysis of  serum 
FSH levels in both groups, after excluding men with 

Table 1: Demographics and semen characteristics of the primary and secondary infertility groups

Parameter Primary infertility 
(n = 67)

Secondary infertility  
(n = 31)

P value

Age, mean ± SD 32.72 ± 8.08 36.71 ± 10.09 0.002

Duration, mean ± SD 6.07 ± 5.83 5.17 ± 4.15 0.663

Volume, mean ± SD 2.54 ± 1.40 3.39 ± 4.12 0.888

Motility, mean ± SD 30.62 ± 26.74 23.71 ± 19.83 0.359

Count, mean ± SD 32.05 ± 59.19 27.66 ± 37.61 0.904

Abnormal forms, mean ± SD 26.51 ± 33.58 39.231 ± 35.59 0.075

Varicocele, n (%) 30 (45%) 11 (35%) 0.386

Note: Analysis was conducted using the Mann-Whitney test for all the variables except for the varicocele variable for which Pearson’s chi-squared test 
was used.
Legend: SD = Standard deviation.

Table 2: Sex hormonal characteristics of the primary and secondary infertility groups

Sex Hormone Primary infertility (n = 46) Secondary infertility (n = 25) P value

FSH, mean ± SD 5.68 ± 7.12 9.20 ± 10.32 0.106

LH, mean ± SD 4.17 ± 3.82 5.48 ± 5.41 0.414

PRL, mean ± SD 124.40 ± 145.54 131.32 ± 129.81 0.623

Testosterone, mean ± SD 10.97 ± 9.85 12.51 ± 7.21 0.551
Legend: SD = standard deviation; FSH = follicle stimulating hormone; LH = luteinizing hormone; PRL = prolactin; 
Note: Analysis was conducted using the Mann-Whitney test. 



Vaidyanathan Gowri, Krishna P Venkiteswaran, Ibrahim Al-Zakwani, Josephkunju Mathew, Khalid Abdul Rahman  
and Mohammed Al-Marhoon

Clinical and Basic Research | 353

very high values (≥15 iu), revealed a mean higher 
FSH value in the primary group compared to the 
secondary group with a trend to significance. A 
negative correlation between LH and sperm count 
and a positive correlation between testosterone and 
sperm motility go with the reports of Meeker et al. 
in 2007.6  

Measuring serum FSH and LH will help in 
the diagnosis of hypothalamic hypogonadotropic 
causes and possible treatment with gonadotropin 
injections in such males. There was no patient with a 
hypothalamic/hypopitutary disorder in the present 
study. The usefulness of measuring the hormonal 
parameters is only to diagnose obstructive causes 
versus testicular failure especially in men with 
azoospermia.

Although compared to other populations the 
prevalence of clinically evident sexually transmitted 
disease appeared to be much lower in this 
population, obstructive azoospermia was present 
in at least 9 patients in the primary group based 
on serum gonadotropin values. The only patient 
in the secondary group who had normal serum 
gonadotropin values gave a history of trauma to 
posterior urethra and false passage. Of the nine 
men with normal serum gonadotropin values in 
the primary group, testicular biopsy was done in 2 
patients and there was history of Behçet’s disease, 
right inguinal hernia repair and epididymal cyst in 
three others. A thyroid stimulating hormone test 
was not routinely performed in all men. 

According to Bayasalgan et al., sexually 
transmitted infections (STI) as a predictor of 
azoospermia had a very high odds ratio, being 
5.6 in patients with gonorrhea and 7.6 in patients 
with other STIs in Mongolia. The same authors 
concluded that a history of pathology involving 
testicular damage appeared to have the strongest 
impact on male infertility in Mongolia. STIs 
have less impact on semen quality except when 
complicated by orchitis, epididymitis and vasal 
obstruction.7 Obstructive azoospermia was present 
in 8.4% men in a Mongolian study along with 
previous testicular damage, and testicular biopsy or 
vasography was done in 16 patients.2 The numbers 
are comparable to this group, but testicular biopsy 
was done only in 2 patients in our study.2 Based on 
serum gonadotropin levels in the present study, 
obstructive azoospermia was found to be more 
common in the primary infertile men compared to 

secondary infertility.
The major limitations of the present study include 
the retrospective nature of the study and the 
absence of sex hormonal evaluation in all patients. 
Also testicular biopsy to obtain the final diagnosis of 
testicular failure versus obstruction was performed 
in only two patients with azoospermia. Finally, 
the cause of obstructive azoospermia was not 
discovered in this study.

Conclusion
In this study, while the seminal parameters and sex 
hormonal evaluation were not significantly different 
in males with primary and secondary infertility 
based on normal serum FSH values, obstructive 
causes seemed more prevalent in primary infertile 
males compared to those with secondary infertility. 
Further well constructed prospective studies with 
larger numbers of patients are needed to verify this 
hypothesis.

c o n f l i c t o f i n t e r e s t
The authors reported no conflict of interest.

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