What is infertility?

Infertility refers to inability of a couple to conceive after one year of unprotected sexual intercourse. In unprotected sexual intercourse, 70% of couples achieve conception within 6 months, while 90% of couples achieve conception within 1 year. Male factor accounts for 45% of infertility cases. Abnormal male infertility may be caused by anatomical conditions, such as varicocele; congenital or acquired genital disorders; genital system infections; hormonal disorders secondary to elevated scrotal temperature and growth of substances that harm cells; genetic disorders; and immune system problems.

No factor is identified in 60%-75% of cases. In other words, we cannot always identify the underlying cause of infertility.

Your doctor examines your testes, penis and overall health. Imaging studies and blood tests can be prioritized, if any abnormality is identified or suspected. It is important to examine the ovaries. Varicocele is also checked in addition to structural deformities and abnormalities.

What is Varicocele and When does it develop?

Varicocele occurs in early adolescence. However, the condition does not generally produce any sign. Thus, varicocele is usually detected in early adolescence during routine physical examination, when the patient visits a doctor for other reasons. In adult patients, the condition is generally manifested by pain or infertility at early stages.

At this point, it is useful to further mention about “varicocele”. The incidence rate is about 15%. Even though many research has been conducted on varicocele, it is not exactly known how this condition plays a role in infertility. Certain theories are still discussed, including but not limited to high testicular and peri-scrotal temperature, low vascular supply to testis due to reflux of toxic metabolites and hormonal changes in testis.  Postoperative improvement in semen quality and pregnancy results is usually reported. One should always remember that when benefit(s) expected from repair of varicocele is/are evaluated, the conception rate is 40 to 60 percent event if scientific studies. In other words, varicocelectomy alone may not solve the infertility. In some cases, it may be necessary to increase success of assisted reproductive techniques. Microsurgical approach is used to minimize potential postoperative complications  One-day hospitalization is expected in most of patients, who maintain routine activities of daily life quickly. Patients are evaluated 3 months later and pregnancy rates are, in fact, significant in Year 1. In other words, it is not rational to consider “Why is not pregnancy achieved?” 3 months after surgery. Patients are not expected to face serious problem during and after the procedure.

Spermiogram is the first and most important parameter for male infertility. This test measures number and mobility of cells that are found in semen and help conception. Semen analysis can indicate many abnormalities, including but not limited to low sperm count, poor mobility and morphological abnormality (shape and structure). These abnormalities are usually detected in combination.

The way to collect specimen for spermiogram test is subject to certain rules. Three-day sexual abstinence and lack of ejaculation is required. The specimen is collected with masturbation on day four at the healthcare facility, where test will be performed, if required. Minimum two specimens are tested for a period that is determined by your doctor. If any abnormality is identified in these tests, underlying causes are investigated with hormone analyses. Possible problems that can be detected in spermiogram not only include numerical problems, but also clustering, immobility and acid-base abnormalities. In such cases, immunological analyses and extra imaging tests can also be ordered.

How should treatment be?

Treatment is based on various factors, such as expectation and age of the couple, if the underlying cause cannot be identified. Although some diseases can be cured with medications, while other cases may require surgical procedure and therefore, it is necessary to discuss expectations with doctor.

As already written above, surgery is the primary option for infertility caused by anatomic etiology, such as varicocelectomy and excision of seminal vesicle cyst, but medical treatment and assisted reproductive techniques are primarily considered for infertility, where genetic factors play a role, such as hormonal or testicular insufficiency. Their combination is not a rare condition.

When assisted reproductive techniques are needed, the spouse is prepared and a mini surgery that can be performed with a series of techniques can also be required to collect sperm from testis. Insemination or IUI and IVF-ICSI can be considered depending on spermiogram result of male, age of spouse and also genital condition.

After the best possible assisted reproductive technique is decided, sperm can be searched in testis with certain procedures, such as “Micro-TESE”, for in vitro fertilization, if required.