MALE INFERTILITY (SUBFERTILITY)

1. What is infertility?

In medical terms, “infertility” means that a couple:

• Has regular sexual intercourse

• Without using contraception

• For at least 1 year

and pregnancy still has not happened.

In women over 35, many specialists suggest starting investigations after 6 months rather than waiting a full year, because age affects fertility more strongly on the female side.

Infertility is not “a women’s problem”. Studies show that:

• In about half of couples with difficulty conceiving, there is a male factor involved

• Sometimes the problem is mainly on the male side, sometimes mainly on the female side, and often both contribute

So the most sensible approach is to assess both partners.

1. What are the main causes of male infertility?

Male infertility is rarely due to just one reason. Often there are several contributing factors.

The main “mechanical” problems are:

• No sperm production at all (azoospermia)

• Very low sperm count

• Poor sperm movement (low motility)

• Abnormal sperm shape (poor morphology)

• Sperm is produced but cannot get out because of a blockage (obstructive azoospermia)

• Problems with ejaculation (for example, retrograde ejaculation, where sperm goes backwards into the bladder)

Underlying reasons may include:

• Varicocele (enlarged veins around the testicle)

• Hormone problems (issues with FSH, LH, testosterone and other reproductive hormones)

• Genetic conditions (for example Klinefelter syndrome, Y chromosome microdeletions)

• Congenital absence or blockage of the sperm ducts

• Previous infections (such as mumps affecting the testicles)

• Previous surgery, trauma, radiotherapy or chemotherapy affecting the testicles

• Certain medicines (for example some cancer drugs, inappropriate use of anabolic steroids)

• Smoking, heavy alcohol use, obesity, lack of exercise

• Excess heat around the testicles (frequent sauna, hot baths, laptop on the lap for long periods, very tight underwear)

Sometimes, despite detailed tests, no clear reason is found. This is called “idiopathic” or “unexplained” male infertility.

1. How is male infertility first assessed?

The main aim of the first assessment is to work out at which level the problem lies.

History (medical and lifestyle background)

Typical questions include:

• How long you and your partner have been trying for a baby

• Whether you or your partner have had any previous pregnancies (in this or other relationships)

• Past illnesses (for example mumps, high fevers, serious infections, cancer)

• Previous surgery to the testicles, groin or abdomen

• Current medicines and supplements

• Smoking, alcohol use, recreational drugs

• Job-related exposures (heat, chemicals, radiation)

Physical examination

Your urologist will examine:

• Testicle size and firmness

• Presence of varicocele (enlarged veins)

• Penis and scrotum for any structural problems, surgical scars or hernias

Semen analysis (sperm test)

This is a key test.

• You are asked to abstain from ejaculation for 2–3 days before the test

• The sample is usually produced by masturbation into a sterile container at the clinic or lab

• The lab then measures:

  • Total sperm count

  • Sperm movement (motility)

  • Sperm shape (morphology)

  • Volume and other features of the semen

If the first test is abnormal, it is usually repeated after a few weeks. Decisions should not be based on a single test, because sperm quality can vary.

Blood tests

These often include:

• FSH and LH (hormones from the pituitary gland that control the testicles)

• Total testosterone

• Sometimes prolactin, thyroid tests, blood sugar and other general health markers

Genetic tests

These may be advised if:

• There is azoospermia (no sperm seen)

• There is a very severely reduced sperm count

In that case you may be offered:

• A karyotype (chromosome analysis)

• Y chromosome microdeletion testing

Scans

• Scrotal ultrasound to look at the testicles, epididymis and veins (varicocele)

• Occasionally MRI or other imaging if a hormone-secreting tumour is suspected

1. Common problems found in male infertility

Varicocele

• This is an enlargement of the veins draining the testicle, causing blood to pool and testicular temperature to rise slightly

• It is one of the most common “treatable” causes of male infertility

• You already have a dedicated varicocele section; patients can be directed there for detail

Hormonal disorders

• If the brain does not send enough FSH and LH to the testicles, sperm production can fall

• In some of these cases (for example hypogonadotrophic hypogonadism), carefully tailored hormone treatments can restore or improve sperm production

Genetic problems

• Some men have chromosomal conditions such as Klinefelter syndrome (an extra X chromosome)

• Others may have small missing segments on the Y chromosome (Y microdeletions)

• In some genetic cases there may be no sperm at all, but in others, special testicular procedures like microTESE may still find a small number of sperm that can be used with IVF/ICSI

Obstructive azoospermia (blockage type)

• Here, sperm are produced normally in the testicles, but a blockage somewhere in the reproductive tract stops them reaching the ejaculate

• Causes can include:

  • Congenital absence of the vas deferens

  • Scarring after infection

  • Previous surgery (including vasectomy)

• Treatment may involve microsurgery to reconnect or bypass the blockage, or sperm retrieval directly from the testis or epididymis for use in IVF/ICSI

Non-obstructive azoospermia (production problem)

• In this situation, sperm production in the testicles is severely reduced or absent

• Causes include genetic conditions, severe hormone problems, previous chemotherapy or radiotherapy, or long-standing damage to the testicles

• In some men, specialised surgery (microTESE) can find small pockets of sperm within the testicular tissue, even when none appear in the semen

1. What treatment options are available?

Treatment is always based on the underlying cause or causes. The plan is usually individualised rather than “one size fits all”.

a) Lifestyle changes

These alone do not work miracles, but they are the foundation:

• Stop smoking

• Reduce or stop heavy alcohol intake

• Achieve a healthy weight with a balanced diet and regular exercise

• Avoid prolonged heat to the testicles (long hot baths, very tight underwear, placing laptops directly on the lap for extended periods)

b) Hormone treatment

Used in selected cases:

• If the problem is low FSH and LH from the pituitary (so the testicles are not being stimulated), hormone injections can sometimes improve sperm production

• Low testosterone must be treated very carefully: giving standard testosterone replacement can actually switch off sperm production completely

• For men trying to conceive, testosterone and other hormone drugs should only be used under the guidance of an infertility specialist, not as general “energy boosters”

c) Varicocele surgery

• In men with a clinical (palpable) varicocele, abnormal semen analysis and a wish for children, microsurgical varicocelectomy can improve sperm parameters in many cases and may increase chances of pregnancy

• Not every varicocele needs surgery; it depends on symptoms, semen quality and the couple’s plans

d) Surgery for blockages

If the problem is obstruction of the sperm ducts, options include:

• Microsurgical vasectomy reversal (vasovasostomy)

• Microsurgery on the epididymis to relieve a blockage

In well-selected patients, natural conception may become possible again.

e) Surgical sperm retrieval

For men who have no sperm in the ejaculate (azoospermia), it may still be possible to obtain sperm directly from the testicles or epididymis and use these with IVF/ICSI.

Common techniques include:

• TESA (Testicular Sperm Aspiration): sperm are drawn out using a fine needle

• TESE (Testicular Sperm Extraction): small pieces of testicular tissue are removed and examined for sperm

• MicroTESE (Microsurgical TESE): testicular tissue is inspected under an operating microscope and carefully chosen areas are sampled to maximise the chance of finding sperm while minimising damage

These procedures are almost always done as part of an assisted reproduction plan (IVF/ICSI).

1. What are TESE and microTESE?

TESE – Testicular Sperm Extraction

• A small cut is made in the testis and pieces of testicular tissue are taken

• These are examined under a laboratory microscope to look for sperm

• TESE is particularly effective in obstructive azoospermia, where sperm production is good but there is a blockage in the transport pathways

microTESE – Microsurgical TESE

• A more advanced, refined version of TESE

• The testis is opened and examined under an operating microscope, which magnifies the internal structures many times

• The surgeon looks for areas of tubules that appear fuller and more promising for sperm production, and samples these specifically

• The goal is to find the maximum number of usable sperm while removing as little tissue as possible

microTESE is often used in non-obstructive azoospermia, where spermatogenesis is very limited. In this group, microTESE tends to give higher sperm-retrieval rates and may reduce the risk of long-term damage to the testicle compared with older “blind” TESE techniques.

1. Is TESE only done for IVF?

In practice, yes.

• Sperm obtained with TESE or microTESE are usually used immediately for ICSI (a form of IVF in which a single sperm is injected directly into an egg)

• Alternatively, the sperm can be frozen (cryopreserved) and stored for future IVF/ICSI cycles

These procedures are not used to “restore normal ejaculation”; they are designed to provide sperm that can be used in the laboratory with assisted reproduction techniques.

1. What are the advantages of microTESE?

Compared with conventional TESE, microTESE offers several potential benefits:

• The operating microscope allows the surgeon to see the internal structure of the testis in great detail and select the most promising tubules

• Less tissue may need to be removed, which can reduce trauma to the testis

• It may improve sperm retrieval rates in non-obstructive azoospermia

• It may lower the risk of long-term decline in testicular size and hormone production compared to blind or random tissue sampling

Because of these advantages, many international guidelines recommend microTESE as the preferred method of surgical sperm retrieval in non-obstructive azoospermia, provided it is performed in experienced centres.

1. What determines the chance of pregnancy after treatment?

Sadly, there is no single procedure that guarantees pregnancy. Success depends on several factors, including:

• The man’s baseline sperm status and how much it improves with treatment

• The woman’s age and ovarian reserve

• Any female factor problems (tubal damage, ovulation disorders, uterine issues)

• The experience and quality of the IVF/ICSI centre

• The number and quality of embryos and the condition of the womb lining

Procedures such as varicocele repair, hormone treatment and microTESE can:

• Improve sperm parameters in suitable men

• Increase the chances of natural pregnancy in some couples

• Improve the success rate of IVF/ICSI in selected cases

But no method can promise a baby. Treatment should be seen as part of a stepwise fertility plan, agreed together by the couple, the urologist and the fertility specialist.

1. A note on guidelines and individual care

The approach described here is based on:

• Current international guidelines on male infertility

• Evidence from studies on varicocele repair, hormonal treatments and surgical sperm retrieval

• Everyday clinical experience with couples going through fertility treatment

However, every man and every couple is different.

The right plan for you will depend on:

• Your semen results

• Hormone and, where relevant, genetic tests

• Your partner’s age and fertility assessment

• Your overall health and your priorities as a couple

Decisions about investigations and treatment should always be made after a detailed, face-to-face discussion with a urologist experienced in male infertility, and ideally in collaboration with a gynaecologist or IVF specialist.