Male Factor Infertility: Semen Testing and Varicocele Treatment

Most commonly amenorrhoea or very scanty periods, occasionally heavy bleeding. Diagnosis relies on TB-PCR and D&C with histopathology, but because PCR can be falsely negative, Dr. Pai prefers laparoscopy for direct visual confirmation, alongside a chest X-ray, palpation of cervical and groin lymph nodes, family history, sputum AFB testing on three consecutive days where indicated, interferon-gamma release assays and a Mantoux test. Treatment is AKT-4 for two months followed by AKT-2 continuation therapy, nine months in total, which must be completed fully to avoid multidrug-resistant TB; laparoscopy and hysteroscopy are repeated afterward before trying IUI, and IVF only if that fails.

WHO's pathway is stepwise: rule out anovulation with day-21 progesterone above 10 ng/ml, rule out tubal block with an HSG, rule out uterine factors with 2D or 3D ultrasound, and test semen; if all are normal, try timed intercourse with clomiphene for 3 to 6 months, then 2 to 3 cycles of IUI (up to 6 if needed), which Dr. Pai's practice sees succeed in about 30% of cases, before moving to IVF. He named failure to conceive as IVF's biggest drawback, though across three attempts roughly 80 to 90% of patients achieve pregnancy, and frozen-embryo banking means most repeat cycles no longer require re-stimulation. In his estimate, about 80% of patients never need IVF at all if laparoscopy, hysteroscopy, ultrasound and a competent IUI lab are available; only 20% require it.

Age is the dominant factor. Citing the US SART and UK HFEA registries, Dr. Pai gave approximate success rates by age band: under 35 about 40%, 35 to 37 roughly 35 to 40%, 37 to 39 about 25 to 30%, 39 to 41 about 15%, and over 41 about 5 to 10%, because genetic abnormality rates in eggs rise with age even when embryos form. Low ovarian reserve, with AMH sometimes as low as 0.3 to 0.4 ng/ml, is the other major factor; for patients who decline donor eggs, he tries platelet-rich plasma injected under ultrasound or laparoscopic guidance and, in some cases, stem-cell therapy, using the laparoscopy to also rule out genital tuberculosis, which can itself lower ovarian reserve.

This is usually a fungal infection, and both partners need treatment, along with lactobacillus supplements. Because a wet mount or culture can miss organisms such as Trichomonas, Chlamydia or Mycoplasma, Dr. Pai often gives combination therapy (an antifungal such as fluconazole plus an antibiotic such as azithromycin) with local clotrimazole cream, and screens for diabetes, since fungal infections are common in patients who are obese or diabetic.

If antibody titres are very high, management becomes difficult. Where it is legally available, Dr. Pai suggested surrogacy carried by an Rh-negative surrogate as a way to avoid maternal antibody-mediated complications and repeated interventions such as cord blood transfusion, rather than risking complications like kernicterus in the baby.

Roughly half of all infertility cases involve a male factor, so the guideline includes a complete male evaluation as part of the mandatory couple-based workup from the first visit, rather than as a fallback once female causes have been ruled out.

An abnormal semen test is repeated after 11 weeks, since sperm production takes roughly that long to turn over.

The systems are inexpensive to run: the analyser itself costs about 1,500 dollars, with each individual test costing 5 to 7 dollars.

For men with a clinical varicocele and abnormal semen parameters who are not undergoing IVF, WHO suggests surgical or radiological treatment; the preferred surgical approach is high ligation.

Where sperm counts are effectively zero, microscopic testicular sperm extraction under an operating microscope retrieves sperm directly, followed by IVF with intracytoplasmic sperm injection to fertilise the retrieved eggs. A Sudanese patient settled in France achieved pregnancy this way after eight failed attempts across four countries over 17 years.