Infertility affects approximately 1 in 6 couples. It is commonly perceived as primarily a female concern — but in 40-50% of all infertility cases, a male factor is identified either as the primary cause or as a contributing factor. This clinical reality is frequently underestimated, both by couples seeking help and, at times, by clinicians who default to female workup before considering andrological evaluation.
A semen analysis remains the cornerstone of male fertility evaluation. However, a 'normal' semen analysis does not exclude male factor infertility, just as an abnormal one does not determine its cause. Azoospermia (complete absence of sperm) may be obstructive — caused by a blockage in the vas deferens or epididymis — or non-obstructive, reflecting impaired sperm production. These require very different treatments: surgical reconstruction in the former, hormonal or surgical sperm retrieval in the latter.
Varicocele — dilated veins within the scrotum — is the most commonly correctable cause of male infertility, present in 15% of the general male population and up to 40% of men presenting with infertility. Microsurgical varicocelectomy has the best outcomes, with natural conception rates of 40-60% at 12 months post-surgery in properly selected patients. Several myths persist: that boxers improve sperm count (evidence is weak), that cycling causes infertility (evidence is very limited), or that male infertility is untreatable. The reality is nuanced and increasingly optimistic.
A structured andrological evaluation — including full history, clinical examination, hormonal panel, scrotal and transrectal ultrasound, and genetic studies where indicated — provides a roadmap for treatment. Most causes of male infertility are either treatable or manageable with assisted reproductive technology such as IVF-ICSI. The first step is evaluation, not assumption.