Male Infertility

See also Vasectomy for the procedure itself and reversal.

Why this matters in general practice

A male factor contributes to infertility in up to ~50% of couples, yet surveys suggest the male partner goes unevaluated in 18–27% of cases — often because attention defaults to the female partner first. A basic male work-up (history, examination, semen analysis) is a simple, low-cost first step that shouldn’t be delayed.

Causes

• Pre-testicular: hypogonadotropic hypogonadism, hyperprolactinaemia, other endocrine causes — see male hypogonadism.
• Testicular: varicocele (see below), cryptorchidism, testicular trauma/torsion, chemotherapy/radiotherapy, genetic causes (e.g. Klinefelter syndrome), idiopathic non-obstructive azoospermia.
• Post-testicular (obstructive): vasectomy, congenital absence of the vas deferens, ejaculatory duct obstruction, infection-related scarring.
• Other: lifestyle factors (smoking, heavy alcohol use, obesity, anabolic steroid use), heat exposure, some medications.

Basic assessment

• History: duration of attempted conception, prior fertility (own or partner’s), sexual history/frequency, developmental history (undescended testes, puberty timing), surgical history (hernia repair, orchidopexy, vasectomy), medical history (mumps orchitis, chemo/radiotherapy), medications, and lifestyle factors above.
• Examination: testicular volume and consistency, presence/absence of the vas deferens, a varicocele (“bag of worms” — see scrotal lump), signs of hypogonadism.
• Semen analysis: the key initial investigation — needs at least 2–3 days but no more than 5 days of abstinence beforehand; repeat if abnormal, since results vary between samples. Azoospermia or severe oligospermia warrants hormone testing (FSH, LH, testosterone) to distinguish obstructive from non-obstructive causes, and specialist referral.

Surgical management (urology-led, referral-relevant detail for GPs)

• Varicocele repair: varicoceles are found in ~40% of men with primary infertility (vs ~15% of the general population). Correcting a clinically palpable varicocele improves spontaneous pregnancy rates (meta-analysis odds ratio ~4.15). Microsurgical repair has the lowest recurrence (~0.4%) compared with other techniques (2.6–29%); complications include hydrocele formation and testicular atrophy.
• Sperm retrieval for IVF/ICSI: for obstructive azoospermia, MESA/PESA/TESA techniques succeed in 80–90% of cases. For non-obstructive azoospermia, microTESE is now preferred over conventional TESE, with meaningfully better retrieval rates (42.9–63% vs lower for conventional TESE).
• Routine diagnostic testicular biopsy to distinguish obstructive from non-obstructive azoospermia is no longer routinely recommended, given the risk of fibrosis and because imaging/hormone testing usually suffices.

When to refer: any couple who hasn’t conceived after 12 months of regular unprotected intercourse (or 6 months if the female partner is over 35), any abnormal semen analysis, a clinically significant varicocele, or a history suggesting an obstructive cause. Refer to a urologist trained in male reproductive health/microsurgery — outcomes for varicocele repair and vasectomy reversal are meaningfully better with subspecialist technique.