When a pregnancy does not happen, attention traditionally turns to the woman. The truth is different: in roughly half of all couples who have trouble conceiving there is a male factor – on its own or together with a female factor. That is why testing of the man should start at the same time as testing of his partner.
Many of the causes of male infertility can be found with a few readily available tests, and a good number of them can be treated. Dr Penev sees men with reproductive problems in Plovdiv and Karlovo and, when needed, works together with the gynaecologists and embryologists who are looking after the couple.
What is male infertility
We speak of infertility when a pregnancy has not happened after one year of regular unprotected sex; if the female partner is over 35 or the man has a known risk factor, testing starts after six months. A male factor means that the sperm are too few, poorly motile, abnormally shaped or completely absent (azoospermia), or that they cannot reach the egg because of a blockage or a problem with ejaculation. Fertility is not a measure of masculinity – a man with excellent erections can have a severely abnormal semen analysis.
Symptoms
Male infertility usually causes no symptoms – the only sign is that a pregnancy does not happen. Some complaints, however, point towards the cause:
- heaviness or a feeling of a “bag of worms” in the scrotum, typical of varicocele;
- small or soft testicles, a lump or swelling in the scrotum;
- reduced libido, problems with erection or ejaculation, a small amount of semen;
- burning when passing urine or a discharge from the urethra – signs of infection.
When it is urgent. Sudden severe pain and swelling of a testicle need immediate assessment in an emergency department – testicular torsion can damage the testicle irreversibly within hours.
Causes and risk factors
- Impaired sperm production – the most common group: varicocele (the most common treatable cause), past cryptorchidism (undescended testicle), mumps with inflammation of the testicle, injury, chemotherapy and radiotherapy, genetic and hormonal disorders.
- Blockage of the sperm ducts – after infections of the epididymis (often chlamydia or gonorrhoea), after operations in the groin or on the scrotum, or with a congenital absence of the vas deferens.
- Problems with intercourse and ejaculation – erectile dysfunction, reverse (retrograde) ejaculation in diabetes or after prostate surgery, certain medicines.
Lifestyle plays a measurable role: smoking, regular alcohol, being overweight, frequent overheating of the scrotum and, above all, anabolic steroids and testosterone taken for building muscle. In a significant proportion of men no cause is found – this is called idiopathic infertility.
Diagnosis
The consultation starts with a detailed conversation – how long you have been trying, past childhood illnesses and sexually transmitted infections, operations, medicines, smoking and alcohol – and a physical examination of the testicles, epididymides, vas deferens and penis.
The key test is the semen analysis – an analysis of the semen after two to seven days of abstinence, which assesses the volume and the number, motility and shape of the sperm. The values vary, so an abnormal result is confirmed with a repeat semen analysis a few weeks later. If there are abnormalities, hormones are tested (FSH, LH, testosterone, prolactin), which distinguish a problem in the testicles themselves from a treatable hormone deficiency. Doppler ultrasound of the scrotum measures the volume of the testicles and detects varicocele, changes in the epididymis and tumours, which are more common in men with infertility. When the sperm count is very low or there are no sperm, genetic tests are added, and microbiological tests if an infection is suspected.
Treatment
Treatment depends on the cause, and the result is assessed no earlier than about three months later – that is how long one cycle of sperm production takes.
- Lifestyle – stopping smoking and anabolic steroids, drinking alcohol only in moderation, getting your weight to a healthy level, avoiding overheating. Antioxidants and supplements are popular, but the evidence that they help is limited.
- Treatment of infections of the prostate, epididymis and urethra.
- Varicocele surgery – with a clinically significant varicocele and an abnormal semen analysis, it can improve the values and the chances of natural conception; the techniques are described under scrotal surgery.
- Hormone treatment – effective when there is a shortage of pituitary hormones. Testosterone is not used to improve fertility – it suppresses sperm production even further.
- Microsurgery – restoring blocked sperm ducts or retrieving sperm from the epididymis or the testicle.
- Assisted reproduction – intrauterine insemination, in vitro fertilisation or injection of a sperm into the egg (ICSI) with a severe male factor, when other methods have failed or when the female partner’s age does not allow waiting.
When to see a urologist
Book a consultation if you have been trying for a child for more than a year (six months if your partner is over 35); if you already have an abnormal semen analysis; if you have had cryptorchidism, mumps after puberty, an injury or an operation on the scrotum; if you can feel a varicocele, a lump or a change in your testicles; or if you have problems with erection or ejaculation. Examining the man is simpler than the tests for the woman and often gives a quick answer.
Prevention
- Have undescended testicles in boys treated in good time and vaccinate children against mumps.
- Protect yourself from sexually transmitted infections and have every infection treated fully.
- Do not take anabolic steroids or testosterone without a medical reason.
- Cut down on smoking and alcohol, keep a healthy weight and avoid prolonged overheating of the scrotum.
- Before chemotherapy or radiotherapy, discuss freezing your semen.
Male infertility is a medical condition, not a life sentence and not a question of blame. The earlier the man is tested, the more options remain open to the couple. Book an appointment with Dr Penev for a consultation in Plovdiv or Karlovo.
Frequently asked questions
How many days of abstinence are needed before a semen analysis?
Usually two to seven days. Shorter abstinence reduces the volume and the number of sperm, while longer abstinence makes their motility worse, so the result would not reflect the real situation. The laboratory will also tell you how to collect the sample.
Does one bad semen analysis mean I am infertile?
No. The values vary considerably – a recent fever, stress or medication can make them temporarily worse. That is why an abnormal result is confirmed with a repeat test a few weeks later, and even reduced values do not rule out natural conception; they only make it less likely.
Is varicocele always operated on when there is infertility?
Not always. Surgery is considered when the varicocele can be felt on examination, the semen analysis is abnormal and there is no other clear cause of the infertility. A varicocele that is only visible on ultrasound is usually not a reason for surgery.
Can testosterone improve the semen analysis?
Quite the opposite. Testosterone taken from outside the body, including for building muscle, switches off the signal from the pituitary gland to the testicles, and sperm production can stop completely. Recovery after stopping takes months, sometimes more than a year.
If there are no sperm in the ejaculate, is there still a chance of having my own child?
Often, yes. When there is a blockage, sperm are retrieved from the epididymis or the testicle, and when production is impaired, microsurgical extraction from the testicle finds sperm in a sizeable proportion of men. The sperm are then used for in vitro fertilisation with ICSI.
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.