Male-related factors account for infertility in approximately 20% of cases independently and contribute alongside female factors in an additional 30–40%, resulting in male involvement in nearly half of all infertility cases (Lesley et al., 2024). This substantial contribution underscores the crucial role of urology in modern fertility care. Male infertility arises from a wide range of causes, many of which are identifiable through comprehensive urological evaluation.
A significant proportion of male infertility is attributable to acquired urogenital conditions, including varicoceles, obstruction or ligation of the vas deferens, epididymitis, retrograde ejaculation, and prior urogenital surgery. Among these, varicocele affects up to 15% of men and represents one of the most common and correctable causes of male infertility (Biyani et al., 2009). Congenital abnormalities, such as congenital absence or obstruction of the vas deferens, epididymal dysfunction, undescended testes, and ejaculatory duct cysts, further emphasize the importance of early referral to a urologist for assessment and management (Lesley et al., 2024).
In addition to structural causes, endocrinological, genetic and environmental factors play a critical role in impaired male fertility. Conditions such as congenital GnRH deficiency, Kallmann syndrome, thyroid dysfunction, chromosomal abnormalities, Y-chromosome microdeletions, and CFTR mutations may disrupt spermatogenesis. Furthermore, lifestyle and environmental exposures, including smoking, excessive alcohol intake, environmental toxins, and medications such as exogenous testosterone or chemotherapeutic agents, can negatively affect hormonal regulation and sperm production (Lesley et al., 2024).
These diverse conditions highlight the essential role of urologists in the systematic evaluation of infertile men, incorporating detailed history-taking, physical examination, and targeted hormonal, genetic, and imaging investigations. Identifying reversible or treatable causes remains a cornerstone of effective male fertility care.
Urologists are pivotal in the management of male infertility, prioritizing correction of underlying pathology before progressing to invasive interventions. Management strategies may include lifestyle changes, pharmacological therapy, and surgical treatments. For example, microsurgical varicocelectomy is an established treatment for men with clinically palpable varicoceles and abnormal semen parameters and has been shown to improve sperm quality and, in some cases, natural conception or assisted reproductive technology (ART) outcomes. In addition, when reproductive tract obstruction is identified, interventions such as transurethral resection of the ejaculatory ducts or reconstructive microsurgery (e.g., vasovasostomy) may allow sperm to reappear in the ejaculate. (Kaltsas et al., 2023).
Although surgical sperm retrieval techniques, including PESA, TESA, TESE, and microTESE, play an important role in selected cases of non-obstructive azoospermia or severe spermatogenic failure, it has been suggested they are sometimes employed more frequently than necessary. Inadequate evaluation or failure to treat reversible conditions such as varicocele, hormonal dysfunction, infection, or ejaculatory duct obstruction may lead to premature use of sperm retrieval (Lesley et al., 2024). MicroTESE, while effective in selected patients, is a complex procedure and should be reserved for well-selected cases following comprehensive hormonal and genetic assessment.
In conclusion, male infertility is a multifactorial condition in which urological expertise plays a central role. Through comprehensive evaluation, urologists are uniquely positioned to identify reversible or treatable causes, implement targeted medical or surgical interventions, and optimize sperm quality before progression to assisted reproductive technologies. By prioritizing correction of underlying pathology and reserving invasive sperm retrieval techniques for appropriately selected cases, urologists can enhance natural fertility potential, improve ART outcomes, and reduce unnecessary interventions, underscoring their indispensable role in modern male fertility care.
Biyani CS, Cartledge J, Janetschek G. Varicocele. BMJ Clin Evid. 2009 Jan 6;2009:1806. PMID: 19445764; PMCID: PMC2907779.
Leslie SW, Soon-Sutton TL, Khan MAB. Male Infertility. [Updated 2024 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562258/
Kaltsas A, Dimitriadis F, Zachariou D, Zikopoulos A, Symeonidis EN, Markou E, Tien DMB, Takenaka A, Sofikitis N, Zachariou A. From Diagnosis to Treatment: Comprehensive Care by Reproductive Urologists in Assisted Reproductive Technology. Medicina (Kaunas). 2023 Oct 15;59(10):1835. doi: 10.3390/medicina59101835. PMID: 37893553; PMCID: PMC10608107.
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