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Male infertility can be related to various factors that affect sperm production, quality, or transport. There are several causes that can influence a man's reproductive capacity.
Subfertility is defined as the inability of a sexually active couple without contraception to achieve a spontaneous pregnancy for 1 year.
Primary infertility refers to couples who have never had a child and are unable to conceive after at least twelve consecutive months of unprotected sexual intercourse. Secondary infertility refers to infertile couples who have been able to conceive at least once before.
It is necessary to differentiate infertility from recurrent miscarriage, in which there are two or more miscarriages that do not reach term.
One in eight couples have problems when trying to conceive their first child and one in six when trying to conceive a subsequent child, so it is a very common situation in clinical practice.
In 50% of couples, a factor associated with male infertility is found, usually along with abnormal semen parameters. For this reason, all male patients should undergo a medical evaluation by a urologist trained in male reproduction.
Male fertility can be affected as a result of multiple factors:
In 35% of cases of male subfertility, no associated factor is found to explain the abnormal sperm parameters (as measured in a semen analysis), a condition historically termed idiopathic male infertility. These men have no prior history of fertility-related illnesses and have normal results on physical examination and endocrine, genetic, and biochemical laboratory tests, although semen analysis reveals pathological findings.
Advanced paternal age has emerged as one of the main risk factors associated with the progressive increase in the prevalence of male factor infertility.
In all men with fertility problems, a complete medical and reproductive history, physical examination, semen analysis and hormonal analysis should be performed, in addition to specific semen analysis or imaging tests in necessary cases.
Our Andrology Unit, comprised of four renowned andrologists—Javier Romero Otero, Borja García Gómez, Esther García Rojo, and Manuel Alonso Isa—offers personalized care of the highest caliber, regardless of your specific situation. After conducting a comprehensive evaluation of the subfertile male, we will help identify the possible causes and offer the appropriate treatment option.
Infertility is defined as the absence of spontaneous pregnancy after one year of sexual intercourse within a sexually active couple and in the absence of contraceptive treatments.
In half of couples who are unable to conceive, there is a male factor contributing to their infertility, usually in the form of abnormal semen analysis. For this reason, all male partners in infertile couples should be evaluated.
The main causes of the disorders that can produce male infertility are:
In one third of cases there is no male factor that explains the worsening of the semen analysis parameters, which has historically been called idiopathic male infertility.
These men have no prior history of illnesses or infections that could affect fertility, along with a normal physical examination and normal laboratory results. However, semen analysis may yield abnormal results.
Increasing paternal age has been shown to be one of the main risk factors associated with the progressive increase in the frequency of male factor infertility. A similar trend is observed with maternal age. In both cases, although it is difficult to draw a clear line, it appears that the age of either parent over 35 is a risk factor for infertility.
To make a good diagnostic approach, a parallel evaluation of the fertility status of both members of the couple should be carried out, including the woman's ovarian reserve, as this could determine the decision-making in terms of time and therapeutic strategies.
Risk factors, behavioral patterns, and toxic habits that may affect male fertility should be evaluated. These include lifestyle, family history of testicular cancer, comorbidities (including systemic diseases such as hypertension, diabetes, obesity, and metabolic syndrome), genitourinary infections (including sexually transmitted infections), history of testicular surgery, and exclusion of any other potential gonad toxins.
Typical findings in a patient with infertility include:
In addition to collecting personal history, important aspects such as the duration of subfertility or whether it is primary or secondary will be evaluated.
A focused physical examination will be performed, paying special attention to:
The size, texture, and consistency of the testicles should be taken into account. In everyday practice, testicular volume can be measured using a Prader orchidometer, which, however, tends to overestimate size when compared to ultrasound examination.
Testicular volume varies depending on several factors such as geographical area, racial and environmental factors, although the average testicular volume in healthy men is 20 ml, being somewhat less (18 ml) in infertile men.
We must also evaluate the vas deferens, palpate the epididymis, and check for varicocele. Similarly, we examine for abnormalities of the testicles, epididymis, and vas deferens. Other abnormalities to consider include phimosis, a short frenulum, fibrotic nodules, epispadias, and hypospadias.
Typical findings on physical examination of men with testicular deficiency include abnormal development of secondary sexual characteristics, abnormal testicular volume or consistency, the presence of testicular masses, absence of testicles, the presence of gynecomastia (enlargement of breast tissue), and varicocele.
A functional semen analysis (semen analysis or spermiogram) will be requested. If the result is normal, no further testing is necessary. If abnormalities are observed, a second confirmatory semen analysis is required.
To perform this test, all semen must be collected from the ejaculate after a period of abstinence of 3 to 5 days. It is important to collect the entire sample without loss and deliver it to the laboratory that will perform the analysis no later than 1 hour after collection.
The most frequently observed abnormalities are those related to sperm concentration, morphology, and motility, and combinations of these may be present. In cases of complete absence of sperm, the condition is called azoospermia, and a second sample is not required.
In cases of azoospermia and oligozoospermia (low sperm count in semen), a hormonal evaluation should be performed, including an analysis of total serum testosterone and follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
On the other hand, depending on the semen analysis findings, it may be necessary to study genetic factors that can establish the diagnosis (karyotype, Y chromosome microdeletions, cystic fibrosis gene). In any case, it is a test performed with a simple blood analysis.
The Y chromosome microdeletion test is recommended in men with sperm concentrations of < 5 million sperm/mL, but should be mandatory in men with concentrations of < 1 million sperm/mL.
Finally, testicular Doppler ultrasound is a necessary test to evaluate morphological alterations of the testicles, their size, and the presence of nodules and/or calcifications. Doppler allows us to assess the presence and, if applicable, the severity of a varicocele.
Semen analysis has three levels of depth:
A sperm count is performed with the greatest possible accuracy—even at very low sperm levels. Since the total sperm count has greater prognostic value than sperm concentration, it is necessary to accurately measure the ejaculate volume. Sperm motility is also determined by assigning a grade from A to D (rapid progressive, slow progressive, non-progressive, non-motile). The presence of rapid progressive sperm is a clinically significant factor.
Determination of sperm shape (Tygerberg criteria) after Papanicolaou staining is also recommended.
The determination of leukocytes and other markers of inflammation of the genital tract, antibodies, determination of the multiple sperm defects index, ejaculation sequence, detection of aneuploidy, seminal biochemistry and DNA fragmentation is carried out.
This is particularly necessary in men with partners who have experienced recurrent miscarriages and unexplained infertility. Some studies suggest that the DNA of these patients may be damaged, leading to the inability to conceive and/or the recurrence of miscarriages.
The treatment will depend on the results obtained in the diagnostic tests.
In men with abnormal sperm motility and concentration without an apparent cause, lifestyle changes, including weight loss, increased physical activity, and reduced alcohol and tobacco intake, can help improve semen quality and increase the chances of conception.
Although moderate alcohol consumption does not appear to affect gonadal function, consuming large amounts of alcohol (more than 2 alcoholic drinks per day) does have a negative impact on testosterone levels, which are restored after cessation of intake.
Likewise, the use of vitamin complexes and antioxidants can improve semen parameters.
Hormone replacement therapies will be used in cases of hypogonadotropic hypogonadism (secondary hypogonadism), including congenital causes.
Congenital causes should be treated with a combination of human chorionic gonadotropin (hCG) and follicle-stimulating hormone (FSH) or with gonadotropin-releasing hormone (GnRH) in pulses using pump therapy to stimulate spermatogenesis.
Testosterone therapy should never be used to treat male infertility.
Varicocele (dilation of the veins that drain into the testicle) is a cause of impaired fertility in men.
It is necessary to treat it in the following cases:
Varicocele treatment is not recommended in infertile men with normal semen analysis and in men with subclinical varicocele.
Microsurgical varicocelectomy is the technique of choice and can also be considered in men with high DNA fragmentation and unexplained infertility or who have suffered the failure of assisted reproduction techniques including recurrent pregnancy losses, embryogenesis failures and implantation failures.
At ROC Clinic, we perform microsurgical varicocelectomy, which, through a small incision above the pubic area, allows us to sever the dilated veins causing the condition. The use of a microscope, in addition to allowing for more precise evaluation of the structures, reduces the potential complications of the procedure and has demonstrated the highest rates of varicocele resolution and improvement in semen quality.
Obstructive azoospermia
This is the least common form of azoospermia, occurring in 20-40% of all cases. It generally affects men with normal FSH levels, normal-sized testes, and an enlarged epididymis. The vas deferens may be absent unilaterally or bilaterally, and the obstruction can occur at various levels (intratesticular, epididymal, vas deferens, ejaculatory ducts).
The treatment will be primarily surgical, aiming to diagnose the level of obstruction and, if possible, resolve it. If surgery is not possible, the next step would be sperm retrieval for assisted reproductive technology.
It is defined by the absence of sperm in a semen analysis with a normal ejaculate volume, which must be repeated at least twice. The cause may be a problem with the hypothalamic-pituitary-gonadal axis or a testicular disease. It is essential to always try to find the underlying cause.
The best treatment option is the detection and retrieval of live sperm directly from the testicles. This treatment is part of assisted reproductive therapies.
There are several steps involved in completing an assisted reproduction cycle. First, the woman is pharmacologically stimulated to produce multiple ovarian follicles, while her menstrual cycle is suppressed. Once these follicles have reached the appropriate stage of development, medication is administered to mature the eggs, which are then selected and retrieved. After obtaining genetic material from the man, fertilization is performed using IVF (in vitro fertilization) or ICSI. The embryos are then implanted in the uterus after determining the optimal time for implantation in the endometrium.
There are several assisted reproduction techniques:
We treat our patients at the ROC Chamberí clinic and in the HM Hospitals network of centers in Madrid: Sanchinarro, Montepríncipe, Madrid Río, Rivas, Puerta del Sur, Nuevo Belén, Policlínico HM Moraleja and Nuevo Norte.
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We treat our patients at the ROC Chamberí clinic and in the HM Hospitals network of centers in Madrid: Sanchinarro, Montepríncipe, Madrid Río, Rivas, Puerta del Sur, Nuevo Belén, Policlínico HM Moraleja and Nuevo Norte.
Coming soon
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