Male-factor infertility

A couple sits in your fertility clinic. They have been trying for 18 months. The woman has had her day-3 hormones, her cycle is regular, and her tubes are patent — and the first semen report comes back at 3 million per mL. The temptation is to send the man to the urologist and wait. Resist it. Male factor is assessed in parallel with the female workup, it carries its own genetic obligations, and the single most dangerous prescription in the room — exogenous testosterone — feels like a kindness to a man with low libido and is, in fact, a contraceptive. This topic is the structured way through.^[3][14]

Overview and definition

Infertility is the failure to achieve a clinical pregnancy after 12 months of regular unprotected intercourse; evaluation begins earlier — at 6 months — when the woman is over 35 or there is a known male risk. Male factor is involved in about half of all infertile couples: an isolated male factor in roughly 20% and a combined male-plus-female factor in a further 30%.^[3][4]

Two principles frame everything that follows: ^[4][14]

• Parallel, not serial. Order the semen analysis, the female day-2/3 hormones and AMH, and the ovulation and tubal assessment at the same time. A man investigated only after the woman is "cleared" has lost months he could not afford.
• A semen defect is a descriptor, not a diagnosis. Oligozoospermia, asthenozoospermia and teratozoospermia describe what is abnormal — they do not say why. Your job is to find the why: pre-testicular, testicular, or post-testicular.^[4]

References15ShowHide

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2. [2]Boitrelle F, Shah R, Saleh R, et al. The Sixth Edition of the WHO Manual for Human Semen Analysis: A Critical Review and SWOT Analysis Life (Basel), 2021.PMID 34947899
3. [3]Agarwal A, Mulgund A, Hamada A, et al. A unique view on male infertility around the globe Reprod Biol Endocrinol, 2015.PMID 25928197
4. [4]Practice Committee of the American Society for Reproductive Medicine Diagnostic evaluation of the infertile male: a committee opinion Fertil Steril, 2012.PMID 22698639
5. [5]Palermo G, Joris H, Devroey P, et al. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte Lancet, 1992.PMID 1351601
6. [6]Practice Committee of the American Society for Reproductive Medicine; Society for Male Reproduction and Urology Report on varicocele and infertility: a committee opinion Fertil Steril, 2014.PMID 25458620
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8. [8]Showell MG, Mackenzie-Proctor R, Brown J, et al. Antioxidants for male subfertility Cochrane Database Syst Rev, 2014.PMID 25504418
9. [9]Practice Committee of the American Society for Reproductive Medicine Management of nonobstructive azoospermia: a committee opinion Fertil Steril, 2018.PMID 30503112
10. [10]Practice Committee of the American Society for Reproductive Medicine; Society for Male Reproduction and Urology The management of obstructive azoospermia: a committee opinion Fertil Steril, 2019.PMID 31029241
11. [11]Vloeberghs V, Verheyen G, Haentjens P, et al. How successful is TESE-ICSI in couples with non-obstructive azoospermia? Hum Reprod, 2015.PMID 26082482
12. [12]Page ST, Amory JK, Anawalt BD, et al. Testosterone gel combined with depomedroxyprogesterone acetate is an effective male hormonal contraceptive regimen and is not enhanced by the addition of a GnRH antagonist J Clin Endocrinol Metab, 2006.PMID 16940442
13. [13]Sharma R, Harlev A, Agarwal A, et al. Cigarette Smoking and Semen Quality: A New Meta-analysis Examining the Effect of the 2010 World Health Organization Laboratory Methods for the Examination of Human Semen Eur Urol, 2016.PMID 27113031
14. [14]Björndahl L, Barratt CLR, Mortimer D, et al. Standards in semen examination: publishing reproducible and reliable data based on high-quality methodology Hum Reprod, 2022.PMID 36112046
15. [15]Omar MI, Pal RP, Kelly BD, et al. Benefits of Empiric Nutritional and Medical Therapy for Semen Parameters and Pregnancy and Live Birth Rates in Couples with Idiopathic Infertility: A Systematic Review and Meta-analysis Eur Urol, 2019.PMID 30630643