Male Subfertility

Andrological assessment and surgical treatment for male factor subfertility

Note: This condition is often managed initially by a GP or other specialist. Dr Hadjipavlou accepts both GP referrals and self-referrals for complex or specialist cases. Please contact the secretary to discuss whether an appointment is appropriate.

Overview

Subfertility is defined as failure to conceive after twelve months of regular, unprotected sexual intercourse. It affects approximately one in six couples. Male factor — meaning an abnormality in sperm production, function, or delivery — contributes to approximately half of all cases of couple infertility and is the sole identified cause in around one in five couples.

Male subfertility is not synonymous with complete infertility. Many men with subfertile semen parameters can father children, either naturally (particularly when the female partner’s fertility is optimal) or with the assistance of reproductive techniques.

Common causes of male subfertility include:

Varicocele — the most common identifiable and treatable cause; present in approximately 35–40% of men investigated for infertility
Idiopathic — no identifiable cause found despite thorough investigation; the most common diagnosis overall
Obstructive azoospermia — absence of sperm due to blockage of the outflow tract (post-vasectomy, congenital absence of the vas deferens, epididymal blockage)
Non-obstructive azoospermia — impaired or absent sperm production; causes include hormonal disorders, genetic abnormalities, orchitis, undescended testes, or prior chemotherapy
Genetic causes — Klinefelter syndrome (47,XXY), Y-chromosome microdeletions, or cystic fibrosis gene mutations affecting sperm transport
Hormonal causes — hypogonadism, hyperprolactinaemia, thyroid disease
Lifestyle factors — smoking, excessive alcohol, anabolic steroid use, heat exposure, obesity

Symptoms

Male subfertility itself has no symptoms — the presenting concern is difficulty conceiving. However, the andrological assessment may identify associated conditions:

Scrotal ache or heaviness — may indicate a varicocele
Reduced sexual drive or erectile dysfunction — may suggest a hormonal cause
Absent or reduced ejaculate volume — may indicate a blockage or hormonal issue
History of previous surgery or infection — vasectomy, orchitis, torsion, or hernia repair may have relevance
Medication or occupational history — chemotherapy, anabolic steroids, heat exposure

Diagnosis

Assessment of the male partner should be performed at the same time as investigation of the female partner.

Semen analysis The cornerstone of male fertility investigation:

Volume — reduced volume may indicate obstruction or ejaculatory dysfunction
Concentration (sperm count) — oligozoospermia (low count) or azoospermia (absent sperm)
Motility — the percentage of sperm moving progressively (asthenozoospermia if reduced)
Morphology — the proportion of sperm with normal shape (teratozoospermia if reduced)
At least two separate samples, taken a few weeks apart, should be analysed before conclusions are drawn

Further investigations

Hormone profile — FSH, LH, testosterone, prolactin; FSH is particularly informative about testicular function
Scrotal ultrasound — evaluates for varicocele, testicular abnormalities, epididymal obstruction
Genetic testing — karyotype (chromosomal analysis), Y-chromosome microdeletion analysis; recommended in men with severe oligozoospermia or azoospermia
Post-ejaculatory urinalysis — to exclude retrograde ejaculation when semen volume is very low

Treatment

Treating identifiable causes

Varicocele repair — surgical ligation (microsurgical subinguinal approach) or embolisation for men with clinical varicocele and abnormal semen parameters; evidence supports improvement in semen parameters in a proportion of men
Hormonal treatment — for hypogonadism or hyperprolactinaemia where appropriate; note that testosterone replacement therapy impairs sperm production and should not be used in men seeking fertility
Lifestyle optimisation — cessation of smoking, anabolic steroids, and excessive alcohol; weight reduction; avoiding excessive heat exposure (hot baths, tight clothing)

Surgical sperm retrieval For men with obstructive azoospermia, sperm can be retrieved surgically for use in IVF with ICSI (intracytoplasmic sperm injection):

PESA (percutaneous epididymal sperm aspiration) — a fine needle inserted into the epididymis under local or general anaesthesia
TESA (testicular sperm aspiration) — a needle or biopsy device used to obtain sperm directly from the testicular tissue
Micro-TESE (testicular sperm extraction) — for selected men with non-obstructive azoospermia; an operating microscope is used to identify areas of the testis more likely to contain sperm

Assisted reproduction When sperm quality is reduced but not absent, and treatable causes have been addressed, the couple may be referred for IUI (intrauterine insemination), IVF, or IVF/ICSI depending on the severity of the male factor and the female partner’s fertility status.

Dr Hadjipavlou provides andrological assessment and performs surgical procedures relevant to male fertility, including varicocele repair and surgical sperm retrieval. Overall couple management, including assisted reproductive techniques, is coordinated with the referring fertility unit.

Frequently Asked Questions

: Male factor is identified as a contributing cause in approximately 40–50% of couples experiencing difficulty conceiving. In around 20% of couples, a male factor is the sole identified cause. Subfertility affects approximately one in six couples overall. These figures highlight the importance of investigating both partners at the outset rather than focusing initial investigations on only one.
: Azoospermia means there are no sperm present in the ejaculate. It may be obstructive (the sperm are produced normally but a blockage prevents their appearance in the semen — for example, after vasectomy or due to a congenital absence of the vas deferens) or non-obstructive (impaired sperm production in the testes). In obstructive azoospermia, surgical sperm retrieval (PESA or TESA) can obtain sperm for use in IVF/ICSI. In non-obstructive azoospermia, sperm may sometimes be found by testicular microdissection (micro-TESE), though success is not guaranteed.
: Dr Hadjipavlou provides andrological assessment of the male partner — including semen analysis review, hormonal and scrotal ultrasound evaluation, and identification of treatable causes such as varicocele. He performs surgical procedures relevant to male fertility, including varicocele repair and surgical sperm retrieval (PESA, TESA). The overall management of the couple — including IVF or ICSI — is coordinated with a fertility unit.

Need an assessment?

To arrange an appointment or discuss your situation, please contact the secretary.