Infertility is often mistakenly considered primarily a female problem.

In reality, male fertility factors contribute to a substantial proportion of couples experiencing difficulty conceiving.

For this reason, fertility assessment should usually involve both partners from the beginning.

How Is Male Fertility Assessed?

The cornerstone of male fertility assessment is the semen analysis.

It examines several characteristics, including:

• Semen volume
• Sperm concentration
• Total sperm number
• Motility
• Progressive motility
• Morphology
• Vitality when appropriate

One abnormal semen analysis does not always establish a permanent problem.

Sperm production takes several weeks, and results can be influenced by illness, fever, medications and other factors.

Repeat testing may therefore be recommended.

What Causes Male Infertility?

There are many possible causes.

Varicocele

A varicocele is enlargement of veins around the testicle.

Some clinically significant varicoceles are associated with impaired sperm production.

Whether treatment is beneficial depends on individual circumstances.

Hormonal Problems

The brain, pituitary gland and testes work together through a complex hormonal system.

Disruption of FSH, LH or testosterone signalling can affect sperm production.

Hormonal testing may therefore be appropriate in men with significantly abnormal semen parameters or relevant clinical findings.

Genetic Conditions

Some severe sperm abnormalities are associated with genetic factors.

Depending on sperm concentration and clinical history, investigations may include karyotype testing or Y-chromosome microdeletion testing.

Genetic counselling may be appropriate when abnormalities are identified.

Obstruction

Sperm may be produced normally but unable to reach the ejaculate because of obstruction of the reproductive tract.

Previous surgery, infection or congenital conditions may contribute.

Cancer Treatment

Chemotherapy, radiotherapy and some surgical treatments can impair fertility.

Where possible, sperm freezing should be discussed before potentially gonadotoxic treatment begins.

Lifestyle and Male Fertility

General health and reproductive health are connected.

Factors associated with poorer semen parameters can include:

• Smoking
• Heavy alcohol consumption
• Obesity
• Recreational drugs
• Anabolic steroid use
• Testosterone therapy
• Significant heat exposure
• Poorly controlled medical conditions

Lifestyle improvement cannot correct every cause of male infertility, but optimising health remains worthwhile.

Testosterone and Fertility

This deserves particular attention.

Men sometimes assume that taking testosterone will improve fertility.

The opposite can occur.

External testosterone can suppress the hormonal signals required for sperm production and may result in extremely low sperm counts or even azoospermia.

Men who are trying to conceive should discuss testosterone or anabolic steroid use with an appropriately qualified clinician.

What Is Azoospermia?

Azoospermia means that no sperm are detected in the ejaculate.

It does not necessarily mean that biological fatherhood is impossible.

The first step is determining whether the problem is caused by impaired sperm production or obstruction.

Some men may have sperm retrieved directly from the epididymis or testicle for use with ICSI.

Others may benefit from hormonal, surgical or other management depending on the underlying cause.

IVF and ICSI

When sperm numbers, movement or other parameters are significantly impaired, IVF with ICSI may be recommended.

With ICSI, an embryologist injects a selected sperm directly into a mature egg.

This can overcome some barriers to fertilisation, but it does not guarantee normal embryo development or pregnancy.

Advanced Sperm Selection

Techniques such as microfluidic sperm selection and physiological sperm-selection methods are available in some laboratories.

These may have specific applications, but they should not automatically be assumed to improve live-birth rates for every patient.

The evidence, indication and additional cost should be discussed before use.

Male Age Matters Too

Female age has the strongest age-related effect on fertility, but male reproductive ageing should not be ignored.

Increasing paternal age is associated with changes in sperm biology and certain reproductive and offspring risks.

This does not mean older men cannot father healthy children, but age should form part of comprehensive reproductive counselling.

When Should a Man See a Specialist?

Earlier evaluation may be appropriate with:

• Previous undescended testes
• Testicular surgery
• Testicular cancer
• Chemotherapy
• Radiotherapy
• Testicular injury
• Sexual dysfunction
• Ejaculatory problems
• Testosterone or anabolic steroid exposure
• Previous abnormal semen analysis
• A known genetic condition

The Take-Home Message

Male fertility assessment should not be delayed while the female partner undergoes extensive investigation.

A semen analysis is simple, non-invasive and provides valuable information early in the fertility journey.

When an abnormality is found, further assessment can identify potentially reversible causes and determine whether natural conception, medical or surgical treatment, IUI, IVF or ICSI provides the most appropriate pathway.

Fertility is a couple’s issue, and investigating both partners simultaneously can save valuable time.