Male infertility describes a male’s inability to achieve pregnancy with a fertile female partner after a year or more of regular, unprotected intercourse. A urologist, specializing in both the male reproductive system and urinary tract, is the primary medical specialist who evaluates and manages male infertility, identifying and addressing factors that impair a man’s ability to father a child.
Diagnosing the Underlying Causes
Identifying the specific factors contributing to male infertility begins with a thorough evaluation by a urologist, involving a detailed patient history and a physical examination. The patient history explores past medical conditions, surgeries, medications, lifestyle habits, and any previous fertility attempts. During the physical examination, the urologist assesses the genitals for abnormalities, such as varicoceles, or issues with testicular size and consistency.
A primary diagnostic tool is semen analysis, providing information on sperm quantity and quality. This test measures several parameters, including sperm concentration (number of sperm per milliliter of semen), motility (percentage of moving sperm), and morphology (percentage of normally shaped sperm). Additional analyses may include semen volume, pH, and the presence of white blood cells, which can indicate infection.
Hormone testing helps identify imbalances that may affect sperm production. Common tests include levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, and prolactin. Elevated FSH can suggest primary testicular failure, while low testosterone might indicate a problem with hormonal signaling from the brain. Results guide further investigation and treatment strategies.
Genetic testing may be recommended, particularly in cases of severe sperm abnormalities or unexplained infertility. A karyotype analysis checks for chromosomal abnormalities, such as Klinefelter syndrome. Y-chromosome microdeletion testing screens for missing segments on the Y chromosome important for sperm production. These genetic insights can explain the cause of infertility and inform reproductive counseling.
Imaging studies provide visual information about the reproductive organs. A scrotal ultrasound can detect varicoceles, evaluate testicular size, and identify any masses or obstructions within the epididymis or testicles. A transrectal ultrasound might be performed to visualize the prostate gland, seminal vesicles, and ejaculatory ducts, helping to identify blockages or cysts. These techniques pinpoint structural issues.
Post-ejaculatory urinalysis is performed when there is low semen volume or no sperm in the ejaculate, despite normal testicular function. This test checks for sperm in the urine after ejaculation, indicating retrograde ejaculation—a condition where semen flows backward into the bladder. Detecting sperm in the urine confirms this diagnosis and guides appropriate management.
In some cases, a testicular biopsy may be performed to directly examine testicular tissue. This procedure involves removing a small sample of tissue to determine if sperm production is occurring within the testicles, differentiating between production issues and blockages in the reproductive tract.
Medical and Lifestyle Interventions
Urologists use medical therapies to address underlying causes of male infertility, particularly hormonal imbalances. For instance, clomiphene citrate or anastrozole may be prescribed to stimulate the body’s own production of hormones like FSH and LH, which can enhance sperm production. These medications work by influencing the pituitary gland’s regulation of testicular function, aiming to improve sperm count and quality.
When hormonal deficiencies are present, like low gonadotropin levels, exogenous gonadotropins may be administered through injections. These hormones directly stimulate the testicles to produce sperm and testosterone, used in cases of hypogonadotropic hypogonadism. This approach can lead to improvements in sperm parameters over several months of treatment.
Infections or inflammation within the reproductive tract can negatively affect sperm health. Urologists may prescribe antibiotics to treat bacterial infections found in semen cultures, reducing inflammation and improving sperm function. Anti-inflammatory medications might also be used to alleviate discomfort and improve the local environment for sperm development.
Some urologists may suggest antioxidant supplements, such as CoQ10, L-carnitine, or vitamins C and E, as oxidative stress can damage sperm. While research on their effectiveness varies, these supplements are thought to protect sperm from cellular damage. Patients are advised on the potential benefits and limitations of these interventions.
Lifestyle modifications are recommended to improve overall reproductive health. This includes counseling on healthy diet, regular exercise, and avoiding harmful substances like excessive alcohol and tobacco. Managing heat exposure to the testes, for example, by avoiding hot tubs or prolonged laptop use, is also advised as elevated scrotal temperatures may impair sperm production.
Urologists also manage ejaculatory dysfunction, which prevents sperm from reaching the egg. This may involve medications to improve ejaculation, such as alpha-adrenergic agonists for retrograde ejaculation, or counseling on timed intercourse. Vibratory stimulation or electroejaculation may be employed to obtain sperm for assisted reproductive technologies.
Surgical Treatments
Surgical intervention by a urologist corrects structural issues that impede male fertility. Varicocelectomy is a common procedure performed to repair a varicocele. This condition can lead to increased scrotal temperature and impaired sperm production; its repair aims to improve semen parameters and increase natural conception chances.
For men who wish to father children after a vasectomy, a vasectomy reversal can be performed. The two primary types are vasovasostomy, which reconnects the vas deferens, and vasoepididymostomy, a more complex procedure connecting the vas deferens directly to the epididymis when a blockage is closer to the testicle. The choice of procedure depends on the specific site and nature of the obstruction.
Ejaculatory duct obstruction can be surgically addressed through a transurethral resection of the ejaculatory ducts (TURED). This minimally invasive procedure involves removing the obstruction, such as a cyst or scar tissue, to allow for normal sperm passage into the ejaculate. Improving sperm flow can enhance fertility.
Orchiopexy may be performed for undescended testicles (cryptorchidism) not corrected in childhood, particularly if related to fertility concerns. This surgery repositions the testicle into the scrotum, improving the environment for sperm production. Fertility improvement depends on the age of surgery and initial condition severity. Though often done in childhood, it is relevant in adult fertility evaluations if prior correction was insufficient.
Sperm Retrieval Procedures
When sperm is absent from the ejaculate or of poor quality, urologists perform various sperm retrieval procedures to obtain sperm directly from the epididymis or testicle. This sperm is used for assisted reproductive technologies (ART), such as in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). These methods bypass issues with sperm transport or severe production deficiencies.
Percutaneous Epididymal Sperm Aspiration (PESA) is a less invasive technique where a needle is inserted through the scrotal skin into the epididymis to aspirate sperm-containing fluid. This procedure is performed under local anesthesia and is used when an obstruction prevents sperm from exiting the epididymis.
Microsurgical Epididymal Sperm Aspiration (MESA) involves a small incision in the scrotum, allowing microscopic visualization of the epididymis. This micro-surgical approach enables precise aspiration of epididymal tubules, often yielding more motile sperm than PESA, beneficial for subsequent ART procedures.
Testicular Sperm Aspiration (TESA) involves inserting a needle directly into the testicle to aspirate sperm-containing tissue. This method is used when epididymal sperm retrieval is not feasible or when there is a sperm production issue within the testicles. The aspirated tissue is then processed to extract any available sperm.
Testicular Sperm Extraction (TESE) is a slightly more invasive procedure where a small incision is made in the testicle, and a piece of testicular tissue is removed. This tissue is then dissected in the laboratory to find sperm. TESE is employed when TESA does not yield sufficient sperm or in cases of non-obstructive azoospermia.
Microdissection TESE (Micro-TESE) represents an advancement of TESE, where the urologist uses a high-powered operating microscope to identify and extract small, dilated seminiferous tubules more likely to contain sperm. This targeted approach minimizes testicular tissue removal, reducing damage while maximizing the chances of finding viable sperm, especially in men with severely impaired sperm production.