Andrology is a medical discipline that studies the biological and medical aspects of male reproduction. The andrologist is an expert in male hormones and how they relate to the patient’s problems and can answer the question if testosterone and similar hormones are helpful for treating the man.
When the infertility issues of a couple are examined, andrological studies are often needed to assess the reproductive capacity of the man and the reason for the problem, if there is one. Treatment decisions are then based on what is found. Reliable background information is important for assessment of male fertility. Chronic illnesses, regular medication (especially hormones), surgery in the abdominal and groin areas, infections (sexually transmitted diseases, prostatitis and mumps), development during adolescence and any chemical expositions are important.
The primary examination is semen analysis which usually provides a preliminary answer to the question of whether infertility problems of a couple are due to the man or not. The hormonal activity and the regulation of hormonal activity of the testicles are evaluated by blood testing of certain hormones. The goal of the andrological examination is to establish the functional state of the male reproductive system. A normal masculine habitus (male type of musculature and hair distribution) signifies that the production of testosterone during adolescence has been adequate. If the testicles are of normal size and have normal consistency, this is usually a sign that that the production of spermatozoa is normal. The epididymides located behind the testicles are palpated by the physician to examine if there is an inflammation. There may be a very prominent venous enlargement (varicocele) behind and above one of the testicles (more often the left one). There is one vas deferens running upward from each testicle. They are easy to identify by palpation. The prostate of men who are treated with hormonal medicines should be palpated by digital rectal examination (DRE) to follow up the prostate for possible enlargement during treatment.
Semen analysis and testicle ultrasound
The semen is studied under microscope magnification and the density (normal ≥15 million/mL), total count (normal≥40 million), mobility, (normal 32% moving forward) and microstructure (morphology) (normal≥4%) of the spermatozoa are recorded. The level of antisperm antibodies is measured with the Mixed Antiglobulin Reaction (MAR-test). To secure a reliable result, it is essential that delivery of the semen sample from the client all the way to the laboratory follows closely the instructions provided. If only one of the measures of semen quality is abnormal, this may influence fertility only mildly. If several of the measures are clearly reduced, this usually means that fertility is probably poor.
(See instructions for providing a semen sample.)
An ultrasound of the testicles is then taken to examine if there are structural changes in the testicles that might explain poor semen quality.
Treatment of male infertility
If the semen quality is slightly reduced (the number or mobility of spermatozoa subnormal), insemination is often an effective treatment. Insemination involves enrichment of the best spermatozoa in a small volume of culture medium which is then injected into the uterus at the time of ovulation (i.e., when the egg cell is released from the ovary).
If the disturbance is more severe, it is generally possible to start a pregnancy by microfertilization. Microfertilization must always be combined with in vitro fertilization (IVF), a technique where egg cells are collected from the ovaries after a course of hormone medication taken by the woman. In microfertilization, a single spermatozoon is introduced directly into the mature egg cell under microscopic guidance. After IVF, the development of the fertilized egg cells is followed for a few days. The best embryo is then transferred into the uterus. If there are several high-quality embryos, they may be frozen for future use.
A small number of males with fertility problems have faulty regulation of their testicles which leads to poor semen quality. In this case, hormone treatment may improve the semen quality. Hormone treatment is followed up with repeated blood testing. Once a reasonable hormone response has been identified, it takes 4–6 months before this is reflected in the form of improved semen quality at semen analysis. For hormone testament, either daily tablets by mouth or 2–3 subcutaneous injections per week may be used.
Azoospermia – complete absence of spermatozoa
For some men, a semen analysis shows complete lack of spermatozoa. This finding must always be controlled by repeat semen analysis. There are several reasons why spermatozoa may be completely absent from the semen. Some men have a genetic disorder. A microdeletion (a-, b- or c-deletion) in the Y-chromosome results in loss of a part of the Y‑chromosome – a part that is essential for the production of spermatozoa. Males with the Klinefelter syndrome have an extra X-chromosome (47,XXY). This syndrome is characterized by complete absence of spermatozoa due to a production deficit. Absence of spermatozoa may also be due to a disturbance in the regulation of testicular function (Kallmann syndrome). Hormone injections may be used to induce production of spermatozoa for these men. Obstruction (due to inflammations or sterilization) of the vasa deferentia may also cause loss of spermatozoa in the semen.
Based on a thorough physical examination by the doctor and on hormone values, the doctor can decide it there are possibilities to recover spermatozoa with a needle biopsy or if a more invasive surgical procedure is needed where the testicle tissue is examined under microscopy for identification of sampling sites containing spermatozoa. Spermatozoa recovered by surgical means can be used for fertilizing egg cells. This treatment requires that the woman undergoes hormone treatment and egg cell collection (IVF) and that the collected egg cells are fertilized in a laboratory under microscopy with the use of a microinjector.
If the concentrations of testosterone in the blood are low, some men develop typical symptoms: erection problems, poor libido, muscle weakness, poor mental concentration, poor sleep and even depression. Overweight may also be the cause, and weight reduction is an effective means of treatment. Some men are prescribed testosterone injections or gel, which may provide good symptom alleviation. However, testosterone treatment hardly ever improves male fertility. In fact, the effect may be quite the opposite and production of spermatozoa may stop completely. If a man has low testosterone values in blood tests, it is important to be clear about his wishes of having children before symptoms are treated with testosterone. Anabolic steroids (e.g., nandrolone, stanozolol, oxandrolone, xymesterone, mestanolone) are especially damaging to the production of spermatozoa and it may take up to a year for the production of spermatozoa to recover after these hormones have been discontinued.
Medicines, lifestyle and male fertility
There are several medicines that impair male fertility. Cytostatic drugs have the most profound negative effect on the production of spermatozoa, and spermatozoa production may stop completely. Sulfasalazine, cimetidine and ketoconazole are some drugs that may affect spermatozoa production significantly. There are, in addition, many drugs whose effects on spermatozoa production is unknown.
Overweight reduces significantly testicular function and impairs spermatozoa production. Some men exhibit a very notable reduction in the blood concentration of testosterone, and this is often associated with poor semen quality. Testosterone treatment may reduce symptoms but it never improves spermatozoa production.
The results of semen analyses come in figures, which makes it very difficult to separately identify the toxic effects of alcohol and smoking on spermatozoa production and fertility. Nevertheless, research has clearly shown that male smokers have a lower success rate of natural as well as in vitro fertilization.
The veins around the testicles may dilate and cause symptoms, e.g.,pain. Such dilatated veins constitute what is called a varicocele, which may impair the quality of semen. Treatment of the varicocele may slightly improve the numerical values of the semen analysis, but surgery only seldom improves male infertility.