Male Infertility

Male infertility means that a male factor has a share in a couple's failure to conceive despite regular unprotected intercourse. A delay in pregnancy is often not the problem of one person alone; infertility is dealt with as a couple's problem, and the assessment covers both partners. The male share is present in a significant proportion of infertile couples. The information below draws a general framework; it does not replace a diagnosis or treatment recommendation specific to you.

What is male infertility?

In male infertility, sperm production, sperm transport or the sperm's ability to fertilise is impaired at one or several levels. This is more of an outcome than the name of a disease; very different causes may lie behind it. In some men the investigations find a single cause, in some several factors are present together, and in many no cause can be found. Not finding a cause does not mean that the problem does not exist; it only shows that it cannot be explained with the tests available. In making the diagnosis and choosing the treatment, what matters is not the question of "whose problem it is" but how the couple will go forward together; the emotional burden of the process is real for both partners, and it is appropriate to ask for psychological support when needed.

What are the causes of male infertility?

The causes of male infertility are very wide. The main groups are congenital or genetic factors; anatomical causes such as varicocele, a history of undescended testis, blockage in the sperm pathways or congenital absence of the vas deferens; hormonal disorders; sexual function and ejaculation problems; factors related to the immune system; infections of the genital system; cancer and its treatments; certain medicines; and toxic exposures. Lifestyle factors and advanced paternal age can also contribute. Which of these groups applies is shown by the examination and tests; the detailed assessment and the route of treatment are different for each cause.

How is the assessment done?

According to current guidelines, the male assessment starts at the same time as the female assessment. The man's examination and semen analysis are done without waiting for the result of the woman's assessment; the woman's assessment also continues without waiting for the semen result. This simultaneity prevents unnecessary loss of time. The speed of the assessment is determined by the couple's age, the duration of trying for pregnancy and the history; as the woman's age advances, seeing a doctor early becomes even more important.

What is assessed in the history and examination?

Your doctor asks about the infections you have had, your childhood testis history, your operations, your chronic illnesses, the medicines you use, your sexual function and your lifestyle habits. At the examination, the state of your testes and sperm pathways, and whether there is a varicocele, are looked at. Because the use of anabolic steroids or testosterone preparations can suppress sperm production, you need to tell your doctor; you should make the decision about starting or stopping medicines together with your doctor, not on your own.

What does semen analysis show?

Semen analysis is the first and basic test of the male assessment; it is done with a standard laboratory method. By itself it does not show for certain whether you are infertile; for this reason the result is read together with the history and examination. A normal result does not make the assessment of the female side unnecessary either. Your doctor decides how the results will be interpreted and whether repeat testing is needed.

When are additional tests considered?

Additional tests are not a package applied to everyone; they are chosen according to the semen result and the examination finding. If your sperm count is very low or no sperm are seen, hormone tests (FSH, LH, testosterone) are recommended; in couples whose semen analysis is normal, routine hormone testing is not recommended. In severe situations where the sperm count is very small or zero, genetic investigation is considered. Because a genetic finding can be passed on to the child, genetic counselling is important. Scrotal ultrasonography is recommended in infertile men because of the risk of testicular cancer; in unexplained infertility with a normal semen analysis, routine testicular imaging is not recommended. Whether imaging will be done is decided by your doctor according to the examination finding and the semen result. If you have a newly noticed hardness or lump in your testis, you need to have it assessed without delay.

What are the treatment options?

Treatment is determined according to the cause found and the couple's situation; the woman's age and assessment results also affect the route. Often, rather than a single method, lifestyle adjustments, treatment directed at the cause and, if necessary, assisted reproduction techniques are considered in sequence or together.

Why are lifestyle adjustments recommended?

Current guidelines point to low-cost lifestyle adjustments (diet, alcohol, smoking, physical activity, body weight) before and during treatment as a non-definitive recommendation. Because obesity, inactivity, smoking and excessive alcohol are known to harm sperm quality, counselling and change in these areas are recommended. If you use anabolic steroids, stopping them and the recovery of your sperm production are planned under medical supervision.

How is treatment directed at the cause decided?

If a cause is found, treatment is planned to address it. In a deficiency of the hormone that starts spermatogenesis, hormone treatment; in blockage of the sperm pathways, microsurgical repair or surgical sperm retrieval may be considered. In varicocele, the decision is made according to the person: in clinical varicocele, particularly if the semen values are abnormal, surgery or radiological treatment may be preferred over waiting; but if your semen analysis is normal, or your varicocele is too small to be detected on examination, treatment is not recommended. That is, not every varicocele is operated on. You should discuss the risks and benefits of the procedure with your doctor. Treatments given with medicines that do not target a cause rest on limited data in the idiopathic situation (when no cause can be found).

When do assisted reproduction techniques come in?

If the cause cannot be removed, or pregnancy does not occur despite treatment, assisted reproduction techniques come in. These options include insemination, in which prepared sperm is placed in the uterus at the time of ovulation, IVF, and microinjection, in which a single sperm is placed directly into the egg. If there is no sperm in your semen or very little, sperm can be obtained from the testis or the sperm pathways by surgical methods. Which method is suitable is decided by your doctor according to the sperm findings, the woman's age and the results of the assessment done in the woman.

In which areas is the evidence unclear?

In some practices the evidence is insufficient, or recommendations vary according to which group they are aimed at. Antioxidant supplements are one of these: current guidelines have no definite recommendation on this subject; routine use in idiopathic male infertility is not recommended, and additional antioxidants are most likely not recommended in men undergoing treatment. Sperm DNA fragmentation testing is also debated: it can be recommended in recurrent pregnancy loss, in failure of assisted reproduction treatment or in unexplained infertility, but it is not recommended when your semen analysis is normal or as a routine. This test is not a routine investigation; your doctor decides in selected situations. You should be cautious about unsourced promises of herbal products and supplements.

Is male infertility linked to general health?

Yes, it can sometimes be linked. A sperm problem can sometimes be the first sign of a condition related to the body's general health. Current guidelines recommend that infertile men and those with abnormal semen values be given counselling on general health problems that may accompany them. For this reason the assessment is not limited to the question "is there a sperm problem"; hormone balance, genetic conditions and testicular health are also reviewed. If the woman's age is advancing, postponing the male assessment can lengthen the couple's overall process.