A fertility investigation is a structured look at why a couple has not conceived. It involves both partners from the start. Male factors contribute to a large share of couples' difficulty conceiving, and they are often simpler and less expensive to identify than female factors, yet men are frequently tested last. At NYMD Center our urologists evaluate the male partner while our gynecologists evaluate the female partner, so the work happens in parallel rather than one person at a time.
Most of the initial male workup is done in our office with a semen analysis, blood work and an ultrasound, and it rarely requires anything invasive. The goal is not to run every test available. It is to find what is treatable, fix it where possible, and recognize early when a couple's best path is assisted reproduction, so that time is not wasted.
When to start, and why age sets the pace
The American College of Obstetricians and Gynecologists recommends an evaluation after one year of regular unprotected intercourse without pregnancy, after six months if the woman is older than 35, and right away if she is older than 40. Couples should also come sooner if either partner has a known problem, such as irregular periods, prior pelvic infection, a history of undescended testicles, a varicocele, or past or current testosterone or steroid use.
In our experience the female partner's age is the single most important factor in planning. When she is under 30, there is room to investigate thoroughly and treat male or female causes before moving to assisted reproduction. Between 30 and 40, we investigate and refer to a reproductive endocrinologist in parallel, so that treating a male factor does not delay the couple's options. Near 40, we expedite, because IVF is often the most time-efficient route and waiting costs more than it gains.
How we evaluate the male partner
The male evaluation starts with a history covering prior children, puberty, surgeries, infections, medications, supplements, heat exposure, and any use of testosterone or anabolic steroids, followed by a physical exam of the testicles, the spermatic cords and the veins above the testicles.
A semen analysis measures sperm count, motility and shape. Because results vary naturally from sample to sample, we obtain two analyses before drawing conclusions. A hormone panel, including testosterone, FSH, LH, estradiol and prolactin, shows whether the testicles are receiving the right signals and responding to them. A scrotal ultrasound, done in our office, evaluates testicular size and texture and identifies varicoceles and other structural problems.
Any man with a significant sperm abnormality, particularly a very low count or no sperm, should have genetic testing. Certain chromosomal and gene findings explain the problem, affect which treatments can work, and can be passed on to children, so they matter for the couple's planning.
How we evaluate the female partner
Our gynecologists review the menstrual history and confirm whether ovulation is occurring, assess ovarian reserve with blood tests and ultrasound, and look at the uterus and fallopian tubes. Depending on the history, that may include a pelvic ultrasound, a saline sonohysterogram, hysterosalpingography to check whether the tubes are open, or hysteroscopy to examine the uterine cavity directly. Conditions such as PCOS, thyroid disease, fibroids and endometriosis are evaluated and treated where they bear on fertility.
Treatment options, least invasive first
Removing what is harming sperm
The simplest fixes come first. Testosterone therapy and anabolic steroids are a common cause of very low or absent sperm, and the effect is often reversible with time. The first step is to stop them; medications that restart the body's own production can help. Heat, smoking, heavy alcohol use, some medications and excess weight also matter. New sperm take about three months to develop, so any change is judged on a semen analysis done roughly three months later.
Treating hormonal problems
When the hormone panel shows a correctable imbalance, oral or injectable medications that stimulate the testicles, rather than replace their hormones, can raise sperm production. These avoid surgery but require monitoring over several months.
Varicocele embolization
A varicocele is a cluster of enlarged veins above the testicle that can impair sperm production. When it is clinically significant, we prefer varicocele embolization, performed by our interventional radiologists through a small catheter in a vein, typically with local anesthesia and light sedation, no incision in the groin and a quick return to normal activity. Open surgical repair remains an option, but it involves an incision and a longer recovery. Improvement, if it comes, appears over the following months as new sperm mature.
Assisted reproduction
When the female partner's age, the severity of the findings or the results of earlier treatment point that way, we refer promptly to a reproductive endocrinologist for intrauterine insemination or IVF. For men with no sperm in the ejaculate, sperm can sometimes be retrieved directly from the testicle for use with IVF.
What to expect at your visit
The first male visit includes the history, exam and orders for semen analyses and blood work, which is best drawn in the morning. Scrotal ultrasound is often done the same day or at a short follow-up. The semen sample is usually collected after a short period of abstinence, following the instructions we provide. Once results are back we review them with you, and with your partner if you wish, explain what each finding means, and agree on a plan and a timeline that fits her age. Our urology and gynecology teams share information so that both partners' results inform the same plan.
Questions patients ask
When should we see a doctor about trouble conceiving?
ACOG recommends an evaluation after one year of regular unprotected intercourse without pregnancy, after six months if the woman is older than 35, and promptly if she is older than 40. Come sooner if either partner has a known issue such as irregular periods, a prior pelvic infection, a varicocele, undescended testicles, or current or past testosterone or steroid use.
Why does the male partner need to be tested?
Male factors contribute to a large share of couples' difficulty conceiving, and the first tests are simple: a semen analysis, blood work and an exam. Testing the man early can reveal treatable problems such as a varicocele, a hormone imbalance or testosterone use, and it prevents a woman from undergoing more invasive testing before the basics are known.
Why do I need two semen analyses?
Sperm counts and motility vary naturally from one sample to the next, influenced by illness, fever, abstinence time and collection. A single abnormal result may not reflect your usual fertility. Two analyses give a more reliable picture before any conclusions or treatment decisions are made. Your physician will give instructions on abstinence and collection to make the samples as accurate as possible.
Can testosterone use cause infertility?
Yes. Testosterone and anabolic steroids signal the brain to stop stimulating the testicles, which can reduce sperm to very low levels or none at all. This is often reversible after stopping, but recovery takes time, and new sperm take about three months to develop. Medications that restart natural production can help. Anyone trying to conceive should tell us about any hormone use.
What is varicocele embolization and why do you prefer it?
Varicocele embolization closes the enlarged veins above the testicle from inside, using a thin catheter placed through a small puncture in a vein. It is typically done with local anesthesia and light sedation, without a surgical incision in the groin, and most men return to normal activity quickly. Open surgical repair is an alternative, but it involves an incision and a longer recovery.