Understanding Infertility in the Male Partner

Infertility can affect both women and men. About 15 to 20% of married couples apply to an IVF department because of infertility, and a male infertility factor is present in approximately half of these cases. Infertile couples receiving treatment in our department are evaluated by a team which includes a gynecologist, a urology / andrology specialist, an embryologist and genetic experts.  All are experts in their fields and work in close collaboration with each other. Thorough investigations are made and necessary examinations and treatments are planned and carried out by doctors in the fields of their expertise.

GENERAL INFORMATION

How does the male reproductive system function?

The follicle stimulating hormone (FSH) and the luteinizing hormone (LH) are secreted from the pituitary glands. LH regulates the production of testosterone in the testes. FSH stimulates the development of spermatozoa. 

Hormones of male reproductive system

How are sperm produced?

• FSH and testosterone act on the germ cells located in the tubules of the testes. 
• The daily sperm production in healthy men is around 123 million. 
• The formation of a mature sperm cell takes from 42 to 76 days. 

What are “sperm transmission channels”?

Sperm cells produced in the testes travel through a series of ducts: the epididymis, the ductus deference (vas deference), the seminal vesicle and the ejaculatory duct.

Sperm transmission channels

What is ejaculate? 

Ejaculate is a whitish, mother of pearl-colored liquid containing sperm cells, called semen. The average volume of this fluid is 1.5 to 4 ml. Most of it is secreted from the testes, the prostate gland and the seminal vesicle. 

This fluid includes substances which are important for sperm development and for keeping sperm alive until they reach the woman's egg (ovum).  During sexual stimulation a little sticky liquid appears at the tip of the male sexual organ. This fluid is secreted from the gland around the urethra, and does not contain sperm. However, the first part of the ejaculate contains the greatest number of sperm cells. 

What are “Azoospermia” and “Aspermia”

“Azoospermia” is the absence of sperm in the ejaculate. It occurs for two reasons:

1. Azoospermia may be due to impaired sperm production in the testes. This is termed Non-obstructive Azoospermia (NOA).
2. Azoospermia may be due to obstruction or congenital absence of, the sperm transmission channels. This is termed Obstructive Azoospermia (OA).

“Aspermia” is the absence of ejaculate. It may be due to obstructive azoospermia. It can also be caused by some systemic diseases, such as diabetes and diseases of the nervous system and by using certain  medications.

What are “Hypospermia” and “Hemospermia”?

The term “Hypospermia” means that the volume of ejaculate is smaller than normal. It may be due to obstruction or to abstaining from sexual activity for only short periods. 

“Hemospermia” is the term for the presence of blood in the ejaculate. It is not usually considered to be a cause for concern in young men, and may be due to long term sexual abstinence or to infection. 

CAUSES OF MALE INFERTILITY

What can cause male infertility?

There is a range of causes of infertility in men, including:

1. Varicocele 
2. Undescended testis (chriptorsidism)
3. Infectious disease
4. Genetic factors
5. Endocrine  (hormonal) disorders
6. Surgery
7. Smoking, alcohol consumption 
8. Toxic substances in the environment 
9. Immunologic infertility
10. Chemotherapy and radiotherapy 
11. Medications 
12. Systemic diseases 
13. Obstruction of sperm transmission channels or ejaculation problems (retrograde ejaculation)

Causes are not found in around 20 to 30% of cases. This phenomenon is termed idiopathic infertility.

VARICOCELE

What is Varicocele?

Varicocele is the varicous dilatation of testicular veins. It is the most common cause of male infertility, and is observed in around 20 to30% of infertile males. However, it can occur in 5 to10 % of the normal population. 

What causes varicocele? 

The causes of varicocele are not known. However, it is more common in tall men, in obese men, in men who have chronic constipation, lung disease or a chronic cough, in men who work in a standing position for a long time and in men who do strenuous sports, such as weightlifting. 

For anatomic reasons, varicocele is more common on the left side (90%). In 8 to 9 % of cases, it is bilateral; and in only 1 to 2% it is found on the right. 

What are the symptoms of varicocele? 

Scrotal pain and swelling on testis are the most common symptoms of varicocele. Over the long term, the testes may decrease in size.  

What effect does varicocele have on male fertility?

Increased intratesticular temperature, decreased testicular blood flow and increased levels of toxic substances due to varicocele result in decreased sperm production.

How can varicocele be diagnosed? 

It is diagnosed by physical examination. Scrotal Doppler ultrasonography is helpful for diagnosis. 

How can variocele be treated?

It is treated surgically. However, an operation is not recommended in all cases It is advised if the patient has any of the following:

1. Varicocele diagnosed during his teenage years as leading to  testicular atrophy
2. Decreased semen analysis parameters
3. Repeated unsuccessful attempts at assisted reproduction.

UNDESCENDED TESTIS/TESTES (CRYPTORCHIDISM)

What is undescended testis (cryptorchidism)? 

Testes develop in the abdomen of the unborn baby, just below the kidneys, and descend into the scrotum just before birth. In some babies they remain in a high position or outside the scrotum.  This condition is called undescended testis/testes or cryptorchidism.

How common is cryptorchidism? 

It is one of the most common congenital abnormalities, and is present in 2% to 5% of full-term newborn baby boys. However, it is more common in premature baby boys (around 30%). 

What effect does cryptorchidism have on male infertility? 

Sperm production is negatively affected by the higher testicular temperature which results if the testes are undescended. While sperm production may be between 70% and 80% in cases of unilateral undescended testis, it is as low as 20%-30% in bilateral cases. 

When should it be treated? 

The testes may descend into the scrotum without medical intervention during the first year of life. If this does not happen naturally, it should be done surgically before the age of two. Sperm production is irreversibly affected after the age of 6.

INFECTIOUS DISEASES

What infectious diseases can cause male infertility?

Prostate infection (prostatitis) or sexually transmitted infections affect sperm function by increasing the number of white blood cells (leukocytes) in the ejaculate, and may result in male infertility.

Untreated gonorrhoea can lead to obstruction of sperm transmission channels. Tuberculosis affects the epididymis in the male reproductive system. Untreated tuberculosis can lead to obstruction.

Testicular infections, known as orchids, can lead to infertility by affecting the structure of the reproductive system and impairing sperm production. Mumps orchids developed after mumps infection are the most common cause of orchids. Before adolescence, mumps disease usually has no effect on sperm. However, after puberty, mumps orchids may develop in 40% of cases of unilateral or bilateral testicular infection.

GENETIC FACTORS

What are the genetic causes of male infertility?

The genetic structure of a normal male is 46, XY. This is made up of 22 pairs of autosomal chromosomes and one X and one Y sex chromosome.

There are several molecular mechanisms that affect sperm production, maturation and function. As yet, most of them have not been clearly identified.

Genetic disoders can cause male infertility by affecting sperm production in different ways:

1. Male sex chromosome disorders

    a. number anomalies

    b. structural abnormalities

2. Autosomal chromosome abnormalities in men

3. Abnormality in the genetic materials of the sperm 

Normal male chromosome structure

 

Disorders of the sex chromosome number 

Klinefelter syndrome is the most common disorder of the sex chromosome number. It occurs in between 1 in 500 and 1 in1,000 of baby boys. These babies have one extra X chromosome, so their genetic structure is 47,XXY. Men with this syndrome are tall, with longer arms and legs than normal. They have poorly developed gender-specific characteristics, and small testicles (less than 5ml in volume). They have high levels of FSH and LH levels and their testosterone level is lower than normal. Generally, these patients have azoospermia. 

In  Klinefelter cases, sperm can be obtained by microscopic testicular sperm extraction (Micro TeSe). Using this method, our success rate is 53%.

Male sex chromosome structure abnormalities 

Three different regions on the male Y chromosome control sperm production: AZF-a, AZF-b and AZF-c. Deficiencies in any of these areas affect sperm production in varying degrees. Deficiencies in the AZF-c region are the most common abnormality and are associated with decreased sperm count. Deficiencies in the AZF-a and AZF-b regions are associated with severe problems in sperm production and maturation.

Y Chromosome structure

Autosomal chromosome disorders 

Some defects in the 22 pairs of chromosomes can cause male infertility.

Sperm genetic structure disorders 

Defects in the genetic structure of sperm lead to functionally and morphologically impaired sperm. Infections, varicocele, smoking, environmental toxic agents and fever can all be causes.

PLEASE CLICK HERE FOR DETAILED INFORMATION ABOUT GENETIC PROBLEMS AND DIAGNOSTIC METHODS IN MALE INFERTILITY. 

ENDOCRINE (HORMONAL) DISORDERS

What endocrine disorders can cause male infertility? 

Endocrine, or hormonal, disorders are present in around 3% to-5% of cases of male infertility. These problems are: 

1. Lowered levels of f testosterone
2. Increased secretion of prolactin from the pituitary gland (blood prolactin level higher than 50 ng/mL)
3. Raised levels of serum estrogen, due, for example, to drug use or obesity.. 
4. Adrenal gland disorders
5. Thyroid gland disorders

What is hypogonadism? 

Hypogonadism is a clinical condition resulting from decreased testosterone production. It leads to male infertility and sexual dysfunction. There are two types of hypogonadism: “primary” and” secondary”. 

In primary hypogonadism, also known as “primary testicular failure”, the serum testosterone level is low and FSH and/or LH levels are high. 

In secondary hypogonadism, both testosterone and FHS/LH levels are low. This condition is one of the most common treatable endocrine abnormalities found in male infertility.

SURGERY

What kind of operations can lead to male infertility? 

Testicular operations or any kind of operation in the inguinal region, such as hernia repair, or surgery for varicocele, can cause damage or injury to testicular vessels or sperm transmission channels, and can lead to infertility. 

Surgical operations for lymph nodes in the back of the abdomen for cancer (retroperitoneal lymph node surgery), aorta surgery, colon surgery and spinal cord surgery can damage the neural mechanisms, affecting sperm transport, and leading to sperm escaping back into the bladder.  Some prostate or bladder surgery can lead to a similar situation.

SMOKING AND ALCOHOL CONSUMPTION

What effect do smoking and alcohol consumption have on sperm production and function? 

Smoking is the one of the main causes of damage to the genetic material of sperm.DNA damage. Moreover, smoking can result in the failure of assisted reproductive methods.

Alcohol consumption affects hormonal mechanisms, and can lead to a decrease in the production of testosterone over a long-term period. 

TOXIC SUBSTANCES IN THE ENVIRONMENT

What environmental factors cause male infertility?

Heavy metals such as lead and mercury, pesticides, organic solvents, high ambient temperatures and electromagnetism have detrimental effects on sperm. Mobile phones, computer monitors and laptop computers affect sperm production through electromagnetic waves and the thermal effects.  However, it is difficult to be precise about the length and intensity of exposure to environmental factors needed to bring about these adverse effects on human sperm. 

Acidic fluids and lubricants are toxic to sperm.

Working in hot environments, such as furnaces or metallurgical plants, hot showers and frequent saunas can affect sperm quality.

IMMUNOLOGIC INFERTILITY

What is immunologic infertility?

Infectious diseases, scrotal trauma and surgery on the testes can result in disturbance of the testicular structure. This can lead to the human immune system being activated against sperm cells and a decrease in sperm motility. Reproductive techniques are recommended methods for immunologic infertility.

CHEMOTHERAPY AND RADIOTHERAPY 

How do chemotherapy and radiotherapy affect sperm production?

The drugs used in cancer treatment are toxic to all cells that are rapidly growing in number. In particular, the drugs used for Hodgkin's lymphoma and leukemia are extremely toxic. As a result, within eight to twelve weeks of starting chemotherapy, the production of sperm is interrupted. Depending on the dose and the duration, it may restart in only 15% to 30% of patients in one to five years after discontinuation of the treatment. 

Radiotherapy has a similar effect. With applications above 600 Rad, azoospermia develops in 10 weeks.

Sperm freezing is advisable for all men in their reproductive years before cancer treatment, radiotherapy and/or chemotherapy.

Click here to get more detailed information about freezing sperm.

MEDICATIONS

Which drugs affect sperm production?

As well as cancer drugs, many other drugs can affect sperm production. 

1. Antibiotics: Nitrofurantoine, gentamycin, erythromycin, and tetracycline have harmful effects on the testes.
2. Drugs that inhibit the production of testosterone: Sprinolactone, ketoconazole and cimetidine block the production of testosterone and affect the production of sperm.
3. Sulfasalazine affects sperm count and motility.
4. Alpha-blockers: Alpha-blockers used to treat prostate diseases  and hypertension can cause ejaculate to escape back into the bladder.
5. 5-alpha reductase inhibitors: finasteride and dutasteride are used in the treatment of prostate disease. They prevent testosterone activation and can cause a decrease in the volume of the ejaculate.
6. Antidepressants: serotonin reuptake inhibitors, phenothiazines, and lithium affect the functions of the hypothalamus and pituitary.
7. Exogenous testosterone and steroids: These drugs cause hypogonadism and azoospermia. Sperm production can be achieved six months after stopping medication. However, azoospermia is irreversible if they are taken over a long period.&nbsnbsp;

SYSTEMIC DISEASES

What illnesses can affect male fertility?

Diabetes, multiple sclerosis and spinal cord diseases can cause sperm transport problems, and lead to retrograde ejaculation, the ejaculation of semen backward towards   the bladder instead of forward through the urethra. 

Sperm production can be affected by hormonal imbalance in patients with liver and kidney failure. Immunosuppressive drugs taken after kidney or liver transplants may decrease sperm production.

Thyroid diseases can affect sperm production.

OBSTRUCTION OF SPERM TRANSMISSION CHANNELS 

What is obstructive azoospermia?

If the volume of the ejaculate is less than 1.5 ml, the most likely cause of azoospermia is obstruction of the sperm transmission channels. In these cases, sperm production in the testes and testicular size are normal.  However, the sperm cannot flow out because of anatomical or functional problems of the sperm transmission channels. Some causes of obstructive azoospermia can be treated surgically. 

What is the congenital absence of sperm channels? 

In some infertile men, the vas deferens is absent. This condition is associated with a genetic disorder called cystic fibrosis. Additional genetic tests should be performed in this condition.  

What other congenital disorders cause obstruction? 

Masses such as epididymal cysts, spermatocele or a cystic mass on the urethra can block the passage of sperm. 

Are there other causes of obstruction?

Infections such as untreated gonorrhea and tuberculosis, surgery in the inguinal area, such ashernia repair or varicocele surgery, and some diagnostic techniques for male infertility such as vasography, can cause the obstruction of sperm channels. In some cases, reconstructive surgery is possible. 

What is retrograde ejaculation? 

During ejaculation, bladder muscles contract, pushing ejaculate through the urethra into the penis. If there are any defects in the structure of these muscles, they fail to contract, and ejaculate flows back into the bladder. 

What causes retrograde ejaculation? 

Retrograde ejaculation results from: 

  a. Diseases of the nervous system, such as diabetes, and spinal cord diseases.
  b. Previous surgery, such as prostate or bladder neck surgery, some abdominal operations and oncologic operations.
  c. Some medications, such as those prescribed for prostate disease or psychiatric disorders.

In this section you will find information on the steps involved in diagnosing male infertility:

• Initial Assessment
• Medical History
• Clinical Examination

• Physical Appearance
• Testicular Examination
• Penile Examination

• Laboratory Tests (Routine)

• Semen Analysis and Providing a Semen Sample

• Macroscopic analysis
• Microscopic analysis

• Further Tests

• Motile sperm organelle morphologic examination (MSOME)
• DNA fragmentation test
• Sperm FISH test
• Electron microscopic examination of sperm
• Hormone Tests
• Ultrasonography
• Testicular biopsy

 
•  INITIAL ASSESSMENT

Both partners should be evaluated together in the initial assessment.

The husband’s  medical history

The first step towards the successful diagnosis and treatment of male infertility is a detailed evaluation of the husband’s medical history. This can include: 

•Previous treatments for infertility: 

Types, number and dates of any previous treatments such as surgery (varicocele, orchidopexy, TeSe/Micro TeSe, etc…).

• The timing and frequency of intercourse and conception methods: 
• The chances of pregnancy can be increased by having sexual intercourse on alternate days, starting two or three days before ovulation. This is calculated by keeping a diary. Ovulation occurs halfway between the first day of menstruation and the first day of the following menstruation
• Problems during childhood or puberty which could lead to infertility
• Sexual transmitted diseases
• Any kind of surgical operation, especially abdominal surgery
• Systemic diseases such as hypertension or diabetes 
• Medications

Clinical examination

Examination begins with the assessment of the general appearance: height, weight, distribution of body hair, genital organs, whether there is evidence of the growth of breast tissue. 

• Testicular examination 

This is done in a standing position at a room temperature of 22°C. First, the position and size of the testicles are checked.

The doctor also checks to see whether other structures in the scrotum such as epidydimis and vas deferens are present and normal, and whether there is evidence of varicocele. 

• Penile examination 

The size and shape of the penis may be significant. If the penis is unusually small, the doctor will recommend a detailed hormonal evaluation. Penile curvature and hypospadias may affect the transport of ejaculate into female genital system. 

LABORATORY TESTS

• Semen analysis

Semen analysis  is an inexpensive test which provides valuable information about the quality and quantity of spermatozo, and is one the most important laboratory tests for evaluating male infertility.  At the Memorial Andrology Laboratoty, semen analysis is perfomed according to WHO 2010 guidelines.

Semen analysis giving room

 

Important points to remember when providing a semen sample are:

• There should be 2 to 5 days sexual abstinence before collection.
• It should be repeated  after an interval of 15 to 20 days.
• Masturbation is the recommended method.
• The sample should be given in a private room near the laboratory.
• The penis should be cleaned with a wet paper towel before collection. Soap and lubricant substances   must not be used. 
• A clean, sterile container provided by the  laboratory should be used for the collection.
• The whole ejaculate should be collected into the container. If any escapes, laboratory staff should be informed. 
• If there are erection problems, the patient should inform the laboratory staff. Some medications can be recommended. 

How is semen analysed?

Semen is analysed both “macroscopically “ and “microscopically”.

Macroscopic evaluation

1. Volume: The volume of the ejaculate should be more than 1.5 ml. The absence of ejaculate is termed aspermia.

2. Acidity: The acidity level (pH) should be between 7.2 and 7.8. 

3. Colour: The normal colour of semen is whitish gray or pearl-white

4. Liquefaction: Fresh ejaculate has a coating consistency. It coagulates liquefies in 20 minutes.

5. Viscosity: The fluidity of ejaculate is checked. 

Microscopic examination

Microscopic analysis gives information about the number (sperm count), motility, morphology and viability of sperm..

Sperm count

A normal sperm count is more than 15 million per ml and more than 39 million in the whole ejaculate. A sperm count of less than this, is termed “oligozoospermia”.

Sperm motility 

This evaluates the ability of sperm to propel themselves forward. Normal sperm show “progressive” rapid motility. Motility is divided into four grades: 

Grade a: Sperm with progressive motility. These are the strongest and swim fast in a straight line. Sometimes it is also denoted motility IV.

Grade b: (non-linear motility): These also move forward but tend to travel in a curved or crooked motion. Sometimes also denoted motility III.

Grade c: These have non-progressive motility because they do not move forward despite the fact that they move their tails. Sometimes also denoted motility II.

Grade d: These are immotile and fail to move at all. Sometimes also denoted motility I.

Motility is calculated per 100 sperm. The percentage of normal sperm (grades a and b) should be over 32%. Less than this is termed “asthenozoospermia” (reduced sperm motility).

Evaluation of sperm motility

Sperm morphology

This is carried out using special dyes under a microscope of x400 magnification. The form and structure of the sperm and are evaluated using the Kruger criteria. The percentage of morphologically normal sperm should be more than 4%. Less than this is termed “teratozoospermia”.

Nomal sperm morphology

Different sperm morphologic abnormalities

 

 

Round head		Free head
Multiple head and tail		Broken neck
Dag defect		Multiple tail
Pinhead		Tail-Stump

Sperm vitality 

If the percentage of grade “a” and “b” progressively motile sperm is less than 30%, further tests are done to evaluate sperm vitality. Eosin Y test and HOS test can be used for the evaluation of sperm viability.

Sperm cells after eosin-Y staining

 

Cells that swell under hypoosmotic conditions (those with a coiled tail) are alive whereas those with straight tails are dead

Other cells found in the ejaculate

White blood cells, early stage sperm cells and epithelial debrides can be found in the ejaculate. All of these are identified using special dyes. 

Leucocyte in the ejeculate

 

Inmature germ cells in the ejeculete

Further sperm tests

In some cases, we need to do a more detailed evaluation of the sperm using further tests: 

1. Motile sperm organelle morphologic examination (MSOME)
2. DNA fragmentation test
3. Sperm FSIH test
4. Electron microscopic examination of sperm

None of these tests are performed routinely, but only for patients with any of the following:

1. A history of  unsuccessful attempts at assisted reproduction
2. Severe  morphological defects in semen analysis
3. Genetic abnormality
4. A history of miscarriages

MSOME test: Motile sperm can be examined under x6600-8050 magnification. This provides more detailed information about sperm morphology than routine semen analysis. It enables the detection of vacuoles in the sperm heads, which can be associated with sperm DNA damage. These sperms can result in unsuccessful attempts at assisted reproduction. Using MSOME evaluation, normal sperms without vacuoles can be selected for ART. 

 

Grading of sperm cells under high magnification (8050x)

DNA fragmentation Test: The causes of sperm DNA damage are not clear. Smoking, infections, high fever, varicocele, genetic factors, air pollution, long term sexual abstinence have all been named as possible causes. 

There is a close relationship between damage to sperm genetic material (DNA) and male infertility. Increased sperm DNA damage results in repeated miscarriages as well as a reduction in fertilization.  

For patients with elevated levels of sperm DNA damage, using testicular sperm instead of ejaculated sperm is recommended for ART/IVF techniques. 

The acridine orange test and the Tunnel test are used for the evaluation of sperm DNA damage. 

The Acridine orange test	The Tunnel test

Sperm FISH test: This test is used for the evaluation of sperm genetic material.  

Electron microscopic examination: This test is used only for diagnostic purpose in cases having severe morphological abnormalities. 

Hormone Tests

In the basic evaluation, serum FSH and total testosterone levels are recommended. Blood tests should be done between 8 and 10 am in the morning. This is because serum testosterone level is higher in the morning, and lower in the afternoon. 

Additional hormonal tests 

If there is a sexual problem or any findings of endocrinologic disorders, detailed hormonal evaluation should be performed. Patients having any kind of hormonal treatment may also be advised to have these tests. 

erum prolactin, estrogen and thyroid hormone levels can be measured if necessary.  

Ultrasonogaphy

Ultrasonography is recommended only in certain cases:

• Scrotal ultrasonography is recommended to patients who have any scrotal mass. 
• Scrotal Doppler ultrasonography is used in the evaluation of testicular vessels in patients with variocele. 
• Transrectal ultrasonography (TRUS) is performed in cases of obstructive azoospermia. Only TRUS can show sperm transport channels and vesicle seminalis. TRUS may also be performed for patients suffering from hematospermia (blood in the ejaculate). 

Testicular biopsy 

Diagnostic biopsies are not normally advised  for infertile patients. However, a biopsy can be performed following  Micro TeSe, as it allows, testicular histology to be evaluated. Furthermore, testicular tumors are more common in infertile men and biopsy can allow early stage tumors to be detected.. 

GENETIC TESTING

If sperm counts are less than 1 million/ml, chromosome analysis is recommended. Chromosome analysis provides information about the number and genetic structure of chromosomes.

If azoospermia has been diagnosed, a Y chromosome analysis should be performed. The Y chromosome is related to the male gender, and also includes some genes related to sperm production. 

In cases of obstructive azoospermia, especially when there is a congenital absence of channels, the possibility of a cystic fibrosis gene mutation should be investigated. Even if neither partner has symptoms of the disease, but both are carriers, their child is at risk of being born with severe cystic fibrosis. In such cases, preimplantation genetic diagnosis is recommended.

Please click here for detailed information about genetic tests and preimplantation genetic diagnosis.

Chromosome abnormalities in infertile men 

Klinefelter syndrome is a condition in which there is an extra X chromosome: the genetic structure is 47 XXY. It is the most common genetic abnormality in infertile men and is observed in 10-15% of cases of azoopsermia. . Micro TeSe is recommended for these patients and a sperm retrieval rate of around 55% is achieved in our department.

The importance of Y chromosome analysis

There are three regions on chromosome Y which affect  sperm production. These are AZF-a, AZF-b and AZF-c. There may be complate or partial deletions of these regions. All azoospermic men should have a Y chromosome investigation because micro TeSe is not advisable for patients who have complete  AZF-a and/or AZF-b deletion, whereas, if there are partial deletions of these regions or partial or complete deletions of the AZF-c region, Micro TeSe can be performed. However, the male offspring  of these men may be infertile in adulthood. 

TREATMENT OF MALE INFERTILITY

General advice for all infertile men

All patients are advised to:

1. stop smoking and consuming alcohol
2. change medication, where appropriate
3. avoid contact with toxic substances

Medication

For some conditions, you may be prescribed medication:

• Hypogonadotropic hypogonadism can be treated with hormonal drugs to achieve sperm production.. However, this treatment takes at least 6 months.
• Exogenous testosterone application is not recommended for infertile male patients.
• Symptomatic infection is treated with antibiotics.
• Vitamins, antioxidant agents, clomide etc. may be prescribed  during a preparation period for assisted reproductive methods 

Varicocele 

In some cases, varicocele is treated surgically. However, surgery is not necessary for all patients. It is  recommended for patients who have any of the following:

1. affected sperm parameters (decreased sperm count, motility and morphology)
2. short infertility period 
3. testicular atrophy
4. unsuccessful attemps at assisted reproductive techniques 
5. grade 2 or 3 varicocele

Azoospermia

Sperm can be retrieved from the testes of  azoospermic  men either by  

• Microscopictesticular sperm extraction (Micro TeSe) or 
• Testicular Sperm Aspiration (TESA) 

Micro TeSe 

Micro TeSe is done under general anesthesia using an operation microscope to find mature sperm. It can take two hours or more.  

Advantages and disadvantage of Micro TeSe

The main advantages are;

• Removal of less tissue 
• Minimal testicular damage 
• Evaluation of a larger area 
• Selection of larger tubules which include mature spermatozoa 
• Identification of blood vessels and avoidance of vascular injury 

Disadvantages of Micro TeSe are;

• Larger incision 
• Increased cost and time
• Need for microsurgical instruments and expertise 

Possible complications of Micro TeSe

Wound infection, hematoma and pain are the most common complications of Micro TeSe. However, these are observed very rarely (less than 1%). During the first three months after the operation, there can be a decrease in testosterone production, but it returns to a normal level at the end of the first year.  However, patients who already have low testosterone levels are advised to have hormonal treatment to increase it before having surgery.

Micro TeSe is a standard treatment for azoospermia and can be performed for patients who have previously had  TESE . However, we do not recommend repeated attempts to find sperm using Micro TeSe.

TESA 

TESA is performed under local anesthesia. Sperm are aspirated with a thin needle.. 

It is recommended for 

• patients who have  obstructive azoospermia 
• patients  patients who have immotile sperm in their ejaculate
• patients who have previously had repeated unsuccessful attempts at reproductive techniques

Complications of TESA

TESA is very a simple method, with no serious complications.  Pain and hematoma may occur only rarely.