What is male infertility?
Infertility is defined as a couple’s inability to conceive within 12 months of regular, unprotected intercourse. Infertility is not only a women’s issue: in about half of couples, a male factor plays a role, either on its own or together with female causes. This is why it is important for the man to be assessed as well when a couple is having difficulty conceiving.
Male infertility often causes no symptoms at all. Sex life and ejaculation may be entirely normal, and the problem only becomes apparent with a semen analysis. Some men, however, may also have testicular swelling or pain, small testes, erection or ejaculation problems, or symptoms of hormone deficiency.
When should you seek advice?
If a couple has not conceived within one year of regular, unprotected intercourse, both partners should be assessed together. It is advisable not to wait this long if the female partner is over 35, if the man has a history of undescended testis, testicular surgery, mumps orchitis (testicular inflammation after mumps), chemotherapy or radiotherapy, or if he notices testicular swelling or an obvious varicocele.
Causes of male infertility
- Varicocele: An enlargement of the veins of the testis, and one of the common, correctable causes found in men being investigated for infertility. See the varicocele page for details.
- Hormonal causes: Inadequate stimulation of the testes by the pituitary gland in the brain (hypogonadotropic hypogonadism), raised prolactin levels or thyroid disease can affect sperm production.
- Blockages (obstructive causes): Sperm production may be normal, but the ducts that carry sperm may be blocked, either from birth or as a result of infection or surgery.
- Genetic causes: This group includes chromosomal differences such as Klinefelter syndrome, Y chromosome microdeletions and gene changes that lead to the congenital absence of the vas deferens.
- Testicular causes: A history of undescended testis, mumps orchitis, testicular torsion, trauma, chemotherapy or radiotherapy can reduce sperm production.
- Lifestyle and environmental factors: Smoking, excessive alcohol, being overweight, anabolic steroids and testosterone use, prolonged exposure of the testes to heat and certain medications can have a negative effect on sperm quality.
In some men no clear cause is found despite detailed investigation; this is called unexplained (idiopathic) infertility.
How is it diagnosed?
The assessment begins with a detailed history: how long the couple has been trying to conceive, previous illnesses and operations, medications, and work and living conditions. The physical examination looks at the size and consistency of the testes, the presence of the vas deferens and whether there is a varicocele.
- Semen analysis: The cornerstone of the assessment. A sample, usually provided after 2–7 days of sexual abstinence, is examined according to World Health Organization (WHO) criteria for volume, sperm count, motility and shape (morphology). Because semen parameters vary from day to day, an abnormal result is usually confirmed with a repeat test.
- Hormone tests: Hormones such as FSH, LH, testosterone and, where needed, prolactin help to determine whether the problem is hormonal or arises in the testis itself.
- Scrotal Doppler ultrasound: Shows the structure and volume of the testes and is used to assess a varicocele and to check for any other problem in the testis.
- Genetic tests: In men with no sperm in the semen (azoospermia) or a very low sperm count, chromosome analysis (karyotype) and a Y chromosome microdeletion test are recommended. If the vas deferens is congenitally absent, the relevant gene test may also be requested.
- Additional tests: In selected patients, a sperm DNA damage (DNA fragmentation) test or a post-ejaculation urine test may be carried out.
What is azoospermia?
The complete absence of sperm cells in the semen is called azoospermia. There are two main types. In obstructive azoospermia, sperm production in the testes is normal, but sperm cannot get out because of a blockage in the ducts. In non-obstructive azoospermia, the problem lies in sperm production in the testis. The distinction is made on the basis of testicular size, hormone levels, semen volume and, where needed, ultrasound findings, and it directly determines the treatment plan.
Treatment options for male infertility
Treatment is planned individually after examination, according to the cause identified and the female partner’s age and assessment. Whenever possible, the most appropriate approach is to consider the couple together.
Lifestyle changes
Stopping smoking, limiting alcohol, losing excess weight, exercising regularly and avoiding prolonged exposure of the testes to heat all support sperm quality. Men who use anabolic steroids or testosterone need to stop these products under medical supervision. Because sperm production takes about three months, the effect of these changes is assessed after this period.
Medication and hormone therapy
In men with hormone deficiency originating in the pituitary gland, treatment with gonadotropin hormones can restart sperm production. In conditions such as raised prolactin or thyroid disease, treating the underlying problem comes first. When no specific cause is found, the benefit of hormone or vitamin supplements is limited, so their indiscriminate use is not recommended.
Varicocele surgery (varicocelectomy)
Varicocele surgery may be a suitable option for men with a palpable varicocele and abnormal semen parameters. In suitable patients, microsurgical varicocelectomy, performed through a small incision below the groin, involves tying off the enlarged veins under an operating microscope. The effect of the operation on semen parameters is assessed over the following months with follow-up semen analyses.
Sperm retrieval from the testis (TESE and micro-TESE)
In men with azoospermia due to a blockage, sperm can be retrieved from the epididymis or testis using a needle or a small incision. When sperm production is impaired, micro-TESE may be performed, in which the testicular tissue is examined under an operating microscope. In coordination with the IVF centre, the retrieved sperm is either used the same day for microinjection (ICSI) or frozen and stored.
Recovery and follow-up
Varicocele surgery and TESE procedures are usually performed as day cases or with a short hospital stay, and most patients return to their daily routine within a few days. There may be temporary pain, swelling or bruising at the surgical site. Less commonly, bleeding, infection and, after varicocele surgery, a fluid collection around the testis (hydrocele) or recurrence of the varicocele may occur. Follow-up semen analyses are usually planned at 3-month intervals.
Fertility preservation
In men who are going to receive chemotherapy or radiotherapy for cancer, treatment may permanently affect sperm production. For this reason, sperm freezing (sperm banking) should be discussed before treatment begins. Avoiding smoking, maintaining a healthy weight, not using anabolic steroids or testosterone without medical advice, timely treatment of an undescended testis in childhood and seeking emergency care immediately for sudden testicular pain all help to protect male fertility.
Male infertility treatment in Bursa, Turkey
Op. Dr. Mücahit Kabar graduated from Uludağ University Faculty of Medicine and completed his urology residency at the Urology Clinic of Ankara Training and Research Hospital. He has a scientific study, published in an international peer-reviewed journal, examining the effect of varicocele surgery on sperm DNA damage in infertile men. He sees patients in Bursa (Nilüfer) at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00) and Özel Jimer Hastanesi (weekdays 13:00–17:00).
Consultations are held in English or Turkish. The hospitals’ international patient departments can arrange interpreters for other languages and help with airport transfers and accommodation. If you are travelling from abroad, you can book your appointment in advance through the online booking page or appointment line of Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) or Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). You can share any previous test results, such as semen analyses, via WhatsApp (+90 541 622 54 82) beforehand. More information is available on the international patients page and the contact page.
