For many couples, the longed-for desire to have children does not materialize. A long-held misconception that only women are affected by infertility is still widespread. In fact, however, the physical causes of unwanted childlessness are shared by both partners in around 40% of couples.

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When is a fertility disorder present?

According to the World Health Organization (WHO), infertility or sterility is to be diagnosed if pregnancy persists for 24 months despite regular and unprotected sexual intercourse. In addition, a distinction is made between two other types of fertility disorders.

If there is no pregnancy after six months despite regular sexual intercourse during the fertile period, then there is “slight subfertility”. This is the case for around 20% of couples who wish to have children. About 10% of all couples with a desire to have children that are not fulfilled for longer than 12 cycles suffer from “significant subfertility”.

Sperm quality can be adversely affected by various factors such as an unhealthy lifestyle and exposure to environmental pollutants. In addition, organic or hormonal causes, such as a lack of testosterone, can also be the cause of poor sperm quality. In this regard, men can consult a urologist or andrologist.

Clarification of male infertility at the doctor

Some examinations can provide information if male infertility is suspected:

• Spermiogramm
• Ultrasound examination of the testicle
• hormone analysis
• If necessary, karyotyping to detect genetic abnormalities

Spermiogramm

The spermiogram is used to determine the number, mobility, and shape of the sperm. According to the WHO, a normal spermiogram (normozoospermia) is characterized by an ejaculate volume of ≥ 1.5 ml, a pH value of ≥ 7.2, and a sperm concentration of ≥ 15 million spermatozoa per milliliter.

Other features include a total sperm count of ≥ 39 million spermatozoa and a proportion of ≥ 32% progressively motile sperm per ejaculate. In addition to good motility, the morphology must be normal in ≥ 4% of the sperm. The proportion of living sperm should be at least 50%. If no normozoospermia can be detected, it is important to find out why, for example, there is a reduced sperm count or sperm motility is restricted.

Ultrasound examination of the testicle and testicular vessels

Diseases of the testicles are among the most important causes of sterility in men. An ultrasound can be used to determine changes in the testicular tissue, such as testicular tumors or a varicocele, which, like other testicular diseases, can be the reason for unwanted childlessness.

This also includes underdeveloped testicles, undescended testicles, and testicular inflammation (orchitis). Men with testicular damage of this type often have reduced testosterone production and as a result, can suffer from what is known as primary hypogonadism. This is characterized by low testosterone levels combined with high LH (luteinizing hormone) and FSH (follicle-stimulating hormone) levels.

Hormone analysis to clarify hormonal causes

In addition to organic causes, hormonal imbalances that impair spermiogenesis can also be the reason for unwanted childlessness. These include:

• Thyroid disorders (hypothyroidism or hyperthyroidism)
• Hyperprolactinemia
• Hypogonadism

An overactive or underactive thyroid gland results in reduced sperm concentration, mobility, and altered morphology. A prolactinoma, a tumor of the anterior pituitary gland, can be the cause of increased production of prolactin and thus hyperprolactinemia. Secondary hypogonadism is often the result. However, it can also be triggered by certain medications, marijuana abuse, excessive alcohol consumption, and various diseases (e.g. obesity or type 2 diabetes).

According to the guidelines of the European Association of Urology (EAU), men have hypogonadism if the following criteria apply: First, the total testosterone level must be below 12, 1 nmol/L or the serum-free testosterone level is below 243 pmol/L and second, the man must be suffering from persistent symptoms suggestive of testosterone deficiency. In this case, men could be subjected to testosterone therapy with recommendations of the best supplements for testosterone.

What do the guidelines recommend for hypogonadism and the desire to have children?

According to EAU guidelines, hypogonadism can be easily treated with exogenous testosterone intake using testosterone preparations. However, it should be noted that testosterone therapy is contraindicated in hypogonadal men who wish to have children.

This can be explained by the fact that testosterone administration would strongly inhibit the FSH secretion required for spermiogenesis due to the negative feedback in hormone regulation. As a result, sperm production would drop even further. Therefore, treatment with human chorionic gonadotropin (hCG) in combination with FSH treatment should be considered in male hypogonadism with concomitant infertility, particularly in men with low gonadotropins (secondary hypogonadism).

Treatment with hCG alone can result in FSH suppression, further reducing testosterone production through negative feedback. This form of therapy is not recommended for the long-term therapy of male hypogonadism, since there is still insufficient information on therapeutic and undesirable side effects. An exception is the indication for fertility treatment. [6]