Male infertility

Disease Description (Causes and Symptoms)

• Definition: Infertility refers to a couple’s inability to achieve pregnancy despite having regular sexual intercourse without contraception for more than 1 year. Male factors account for approximately 40% of all infertility cases. (If the female partner is aged 35 or older, the timing of diagnosis and testing may be brought forward.)
• Main causes
  • Abnormal sperm production (decreased sperm count, reduced motility, abnormal sperm) — hormonal abnormalities involving the testes, hypothalamus, or pituitary gland; genetic abnormalities (e.g., Klinefelter syndrome, Y-chromosome microdeletion); previous testicular injury, radiation, exposure to toxic substances, etc.
  • Obstruction of the sperm transport pathway (vas deferens obstruction, congenital absence, adhesions after surgery or infection)
  • Abnormalities of semen and accessory glands (prostate and seminal vesicles) (inflammation, secretion problems)
  • Sexual function problems (erectile dysfunction, ejaculation disorders, condoms, spermicides, etc.)
  • Systemic diseases, medications, and lifestyle factors (steroids, anticancer drugs, psychiatric medications; alcohol consumption, smoking, overheating, exposure to toxic substances)
  • Infections (gonorrhea, chlamydia, etc.), varicocele, cryptorchidism, etc.
• Pathophysiology summary: The production of sperm (count, morphology, and motility), regulation by gonadal and pituitary hormones, patency of the sperm transport pathway, and the protective and nutritional condition of semen affect the likelihood of pregnancy.
• Symptoms: Most cases are asymptomatic (the main problem is failure to achieve pregnancy). When hormonal abnormalities are present, decreased libido, erectile dysfunction, changes in body hair, gynecomastia, etc. may occur; with infection, testicular or scrotal pain or a sensation of heat may occur.
• Prevalence and pregnancy statistics: The monthly pregnancy rate among healthy couples is approximately 20–25%, approximately 70% within 6 months, and approximately 85–90% within 1 year.

Treatment Methods

• Evaluation and diagnosis first: Medical history and physical examination (checking the scrotum, testes, epididymides, and varicocele), semen analysis at least twice (recommended; collected after 2–3 days of abstinence), hormone tests (testosterone, LH, FSH, prolactin), urine and semen cultures, scrotal ultrasonography, transrectal ultrasonography, testicular biopsy (if necessary), genetic testing (chromosomal abnormalities, Y-chromosome microdeletion), etc.
• Conservative treatment and lifestyle measures
  • Stop smoking and limit alcohol consumption, manage weight, exercise regularly, and manage stress
  • Avoid exposure to high temperatures (avoid hot tubs, saunas, and tight underwear), and avoid exposure to toxic substances and toxic medications
  • Stop or switch causative medications (e.g., anabolic steroids)
• Medication treatment
  • Hypogonadotropic hypogonadism: Gonadotropin replacement (human chorionic gonadotropin [hCG] ± FSH, or consideration of clomiphene, tamoxifen, etc.) — determined by a specialist according to the cause
  • Infectious causes: Appropriate antibiotic treatment (according to culture and test results)
• Surgical treatment
  • Vasovasostomy (when restoration is desired after previous vasectomy)
  • Varicocele repair (determined according to symptoms and the likelihood of improvement in semen analysis)
  • Obstructive lesions (resection and anastomosis of the obstructed area)
  • If an underlying condition such as a pituitary tumor is present, endocrine or neurosurgical treatment
• Assisted reproductive technology (ART)
  • Intrauterine insemination (IUI): When sperm count and motility are above certain levels
  • In vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI): When sperm count is low, there are motility problems or severe abnormalities, or sperm retrieval is required due to vas deferens obstruction or abnormal semen. ICSI may be performed after TESE/MD-TESE (testicular sperm extraction).
  • Donor sperm: Considered when use of the patient’s own sperm is impossible or the genetic risk is high
• Complications and precautions
  • Complications of surgery (vasectomy reversal and varicocele repair): Bleeding, infection, and surgical failure
  • Adverse effects of hormone therapy: Gynecomastia, mood changes, acne, etc.
  • Complications of ART: Multiple pregnancy and procedure-related complications
  • Genetic counseling is recommended when a genetic cause is identified (because of the possibility of a disease that can be passed on to future generations)

Checklist Before an Outpatient Visit (Items to Prepare and Medical History Questions)

• Items to prepare
  • A list of medications currently being taken (including prescription and nonprescription medications, supplements, and herbal medicines)
  • Records of previous surgeries (especially vasectomy, testicular or pelvic surgery, and abdominal surgery)
  • Previous test results (existing semen analysis, hormone test, ultrasonography results, etc.)
  • Lifestyle records (smoking, alcohol consumption, occupational exposure, exercise, and weight changes)
  • The time symptoms began and how they have changed (erection or ejaculation problems, history of pain or fever)
• Precautions before testing
  • Collect the semen sample after 2–3 days of abstinence (recommended)
  • If a febrile infection (fever) has occurred recently, it may affect the test results—repeat testing is recommended after 1–3 months
  • Avoid smoking, excessive alcohol consumption, saunas, etc. on the day of testing
• Key information to provide to the doctor in advance during the outpatient visit (examples)
  • The duration of attempts to conceive (how many months/more than 1 year)
  • Whether infertility tests or treatment have been received previously
  • The partner’s age and whether there are any known problems on the female partner’s side
  • Whether there has been occupational exposure to chemicals or radiation

Examples of General Questions to Ask the Doctor

• What is the meaning of my semen analysis results? (Including the criteria for concentration, motility, and morphology)
• What disease is suspected as the cause, and are additional tests needed?
• What treatment options are recommended, and what are the benefits and risks of each treatment?
• What is the expected pregnancy success rate with treatment?
• Are there any lifestyle changes that I must make?
• Should I undergo genetic testing, and if so, which tests do you recommend?

Examples of Disease-Specific Questions

• My semen analysis showed “azoospermia / severe oligozoospermia / increased abnormal sperm rate.” How can the cause be distinguished, and what will the treatment plan be?
• I previously had a vasectomy. Which treatment is more suitable for me: reversal (vasovasostomy) or IVF/ICSI? What are the success rate, cost, and recovery period?

(Recommendations vary depending on detailed test results and individual medical history at the time of consultation. Please consult your treating specialist for a specific diagnosis and treatment.)