Subfertility is defined as the inability of a sexually active couple to achieve a spontaneous pregnancy for 1 year. It is therefore important to stress that it should not be considered the existence of a problem below this time limit, counting from the moment the decision to attempt pregnancy has been made (from the time contraceptive methods were abandoned). Taking into account these precepts, it is considered that about 15% of the couples that actively attempt pregnancy will not achieve it during the first year. It is important to point out that it is considered a problem of the couple, since alterations in one member may be compensated by the other and, therefore, it is necessary to study both partners at the same time. In our case, we will study the subfertile men, usually in collaboration with the HM Group Fertility Centre.
There are numerous conditions that can affect male fertility, such as congenital and genetic abnormalities, lower urinary tract infections, history of malignant diseases, increased scrotal temperature (varicocele), hormonal disorders, or immunologic factors. However, in up to 30-40% of cases no clear cause is found, so it is defined as idiopathic subfertility. It is considered primary subfertility if no previous pregnancies have been achieved with the current partner (or previous ones), and secondary if otherwise.
Clinical interview with a super-specialised andrologist.
In addition to collecting personal background, important aspects such as the duration of the subfertility, whether primary or secondary, and the age and fertile status of the partner will be evaluated. A focused physical exam will be performed, with special attention to the presence of signs of hypogonadism, testicular volume and consistency, and the presence of varicocele (dilation of the veins that drain blood from the testicles).
- The first step is to order a seminogram or spermiogram since, if the result is normal, no further studies are needed. If alterations are observed, it is necessary to obtain a second confirmatory seminogram. For this purpose, all the semen from the ejaculate must be obtained after a period of abstinence of 3 to 5 days. It is important to collect all the sample without losses, and deliver it to the laboratory that will perform the analysis no later than 1 hour after it is obtained. The most frequently observed alterations are those related to the concentration of spermatozoa, their morphology and their motility. A combination of these alterations may also occur. If there is a complete absence of spermatozoa, it is called azoospermia, and it is not necessary to collect a second sample.
- If alterations have been observed in the first seminogram, in addition to the confirmatory one, it will be necessary to perform a general analysis with a hormone profile that includes testosterone, LH, FSH, and prolactin, which will contribute to establishing a possible diagnosis and evaluate the severity of the problem, if applicable.
- Genetic studies: Depending on the findings, it may be necessary to study genetic factors to confirm the diagnosis (karyotype, microdeletions of the Y chromosome, cystic fibrosis gene). In any case, this test is performed with a simple blood test.
Testicular Doppler ultrasonography:
It is necessary to evaluate morphological imbalances of the testicles, such as size, presence of nodes and/or calcifications. The Doppler ultrasonography allows us to determine the presence and, if necessary, the degree of a varicocele.
The treatment will depend on the results obtained and, in any case, it will be carried out with the collaboration of the corresponding fertility unit. Several treatments are defined depending on the findings, and can generally be differentiated into two large groups:
A – Alterations in concentration, motility and morphology. Although in many cases no clear cause is found, there are situations that may aggravate or provoke this pathology, so the following therapeutic measures should be taken:
- Lifestyle changes. It is necessary to lead a healthy lifestyle, with a healthy and balanced diet, moderate (not intense) physical exercise, quitting smoking or other drugs, if appropriate, as well as moderate alcohol intake. All these factors indirectly influence semen quality.
- Vitamin supplements. There are multiple formulations on the market that can help improve semen quality in certain cases. However, their great heterogeneity, as well as the absence of factors clearly causing semen alterations in most cases, prevent giving general recommendations for their use.
- Treatment of varicocele. It has been shown that the dilation of the testicle draining veins can have a negative influence on semen quality. Correction is therefore indicated in the case of men with significant varicocele and alterations in the seminogram that present subfertility. In our centre, we perform microsurgical varicocelectomy which, through a minimal incision on the pubic bone enables sectioning the dilated veins that are causing the pathology. The use of the microscope, in addition to allowing the structures to be evaluated more accurately, reduces the possible complications of the procedure, and has been shown to have the best rates of varicocele resolution and improvement of semen quality.
B – Total absence of spermatozoa in the ejaculate. This may be due to hormonal disorders, testicular failure or previous section of the vas deferens (vasectomy). In other cases, no clear cause can be found.
- Hormonal disorders. If these are due to exogenous administration of hormones (usually to improve sports performance), correction of the pathology can be achieved by discontinuing administration and/or with different hormone treatments.
- When the pathology is due to testicular malfunction or insufficiency, either genetic (Klinefelter syndrome) or acquired (chemotherapy treatments or no clear cause), a testicular biopsy may be necessary to definitively diagnose the pathology and to preserve spermatozoa if found. It is a simple operation, which can be performed under local anaesthesia, during which, a sample of the testicular pulp is collected through an incision in the scrotum.
- The most common cause of azoospermia in the general population is that the patient has had a previous vasectomy. In this case, it would be necessary to consider the time since the operation and the age of the partner, being possible to perform a revascularisation of the vas deferens or vasovasostomy. This procedure can be performed under local anaesthesia and sedation and, through two lateral incisions in the scrotum, the vas deferens are sutured. The help of a surgical microscope is necessary, and its success is influenced by both patient and partner-related factors and the surgeon’s experience. During surgery, a biopsy of the testicle may also be taken to freeze the sperm cells for assisted reproductive procedures if the treatment does not result in a successful pregnancy.