It is important to emphasize that the term infertility applies equally to men and women. As for the causes, in 40% the male factor is involved, in 40% the female factor and in the remaining 20% both are "responsible". It is divided into primary, when the couple has not had a previous pregnancy, and secondary, when one of the two partners has had a child in the past.
Infertility should be treated as a couple's problem and not an individual problem. Regardless of age, it is estimated that about 1 in 8 couples trying to have a child face some minor or major infertility problem.
The role of the doctor, who monitors the infertile couple, is central, he directs them to only the necessary tests and offers them therapeutic solutions respecting the time, effort and expenses required. At the same time, he must constantly remind them, in the painstaking effort to have the child they desire, of the message of optimism that nowadays stems from scientific knowledge and reality: the chances are on their side by following modern diagnostic and therapeutic medical methods.

About 15% of couples do not achieve pregnancy within a year and seek treatment for infertility.

During the clinical examination, the doctor will check the penis, the scrotum, in which the testicles are located, the epididymis and the vas deferens, which is the passageway for sperm from the testicles and epididymis to the urethra. Finally, secondary sexual characteristics, such as hair growth, muscle mass and voice timbre, will also be examined.

In summary, the clinical examination should include:
• Record the height and weight of the man
• Control of body proportions
• Hair distribution
• Skin texture
• Breast control
• Examination of the external genitalia (penis, size and structure of the testicles, epididymis)
• Presence or absence of varicocele (by Valsava test, inspection and palpation of the inguinal areas)
 

A key tool in controlling a man's fertility is the sperm chart. It must be performed in specialized centers and its main characteristics are sperm volume, sperm concentration per ml of semen, total sperm count and sperm motility.

• It is important to emphasize that there are no clear boundaries between "normal" and "pathological" spermogram. Thus, the World Health Organization has delineated some reference values, which when not met in a sperm chart, the man has reduced chances of achieving conception in the normal way.

In general, semen should have:
• volume over 2ml,
• sperm count >15 million per ml,
• total sperm count over 40 million,
• motility >45% of fast or moderately moving sperm and
• morphology of more than 4% normal spermatozoa.
 

When spermatozoa are not found in the semen analysis, then we speak of azoospermia. Causes of azoospermia are obstructive or non-obstructive. In obstructive azoospermia, sperm produced at normal rates in the testicles are unable to exit the urethra due to obstruction of the ejaculatory duct of the sperm (e.g., inflammation) or due to a genetic abnormality.
Non-obstructive azoospermia can be due to inherited chromosomal abnormalities and syndromes or acquired conditions such as trauma, testicular torsion, testicular tumor, drugs, toxic substances, radiation, etc.

Measurement of sperm DNA fragmentation (DFI, DNA Fragmentation Index)
Sperm DNA fragmentation is a new test for the assessment of male infertility. The DNA Fragmentation Index (DFI) measurement of sperm is used in the investigation of male fertility, as well as to screen for repeated failed IVF attempts, premature births and miscarriages. Often the causes of infertility are treatable or allow us to take preventive action. For this reason, the recognition and understanding of the diseases by the specialized Urologist is of crucial importance. Despite the great progress of assisted reproduction techniques, the goal of the specialist is not only to find sperm, but to maximize the male reproductive potential which will consequently allow the couple to have a child with the use of less invasive assisted techniques and with the least possible medical , pharmaceutical, psychological but also financial loss.

In the context of prevention, but mainly treatment, the urologist is called upon to offer modern surgical solutions such as:
• correction of clinical varicocele,
• surgical retrieval and collection of testicular tissue and sperm directly from the epididymis or testicles;
• restoration of excretory tract obstruction.

These operations today can and should be performed with the help of microsurgery and the use of sophisticated surgical microscopes that achieve the maximization of the special skills required by the urologist specialized in microsurgery.
Skill and experience in the use of the surgical microscope offer greatly improved results in urological procedures to treat male infertility.

Mr. Gorgoraptis Petros holds a master's degree in "Male Infertility: Laboratory Investigation and Therapeutic Treatment" with a high level of training and a special interest in couple infertility.

What are the main causes of male infertility?
- Cryptorchidism (the man is born with one or both testicles in a higher position than normal, which may be inguinal or inside the abdomen).
- Smoking. Smoking is a recognized risk factor.
- Infections of the genitourinary system (orchitis, epididymitis, prostatitis, urethritis) and sexually transmitted diseases.
- History of testicular torsion (the testicle turns on its axis and does not bleed)
- Chemotherapy at some point in the man's life for malignant diseases, eg leukemia or testicular cancer.
- Radiation therapy
- Genetic factors (p. Klinefelter, cutting off parts of the Y chromosome)
- Medicines, stress, environmental exposure to toxic agents, e.g
- Thyroid diseases
- Varicocele
- Sexual dysfunction/ ejaculation disorders
- Idiopathic (of unknown etiology)

How much does smoking harm fertility? Will stopping it help?

The smoking habit is known to increase the possibility of heart and vascular problems (coronary heart disease, myocardial infarction, narrowing of large and small vessels of the body, such as the carotid and iliac arteries). However, it seems that its role is also important in fertility problems for both men and women. So there are studies that prove that the possibility of erectile dysfunction and complications during pregnancy is greater for smokers.
In women, nicotine and carbon monoxide from tobacco accelerate egg loss. Unfortunately, when an egg 'dies', it is not replaced. For this reason, menopause in smokers can occur 1 to 4 years earlier. The chance of infertility is almost twice as high for women who smoke. This probability increases according to the number of cigarettes per day and the years of smoking.

In male smokers, a reduced number of spermatozoa (oligospermia), reduced motility (asthenospermia) and an increased number of shape abnormalities (teratospermia) are often found in the sperm count. Smoking appears to reduce the sperm's ability to fertilize the egg.
The effect of tobacco seems to be important even in the probability of success of assisted reproduction (insemination or IVF). Assisted reproductive success rates are about 30% higher in prospective parents who are non-smokers. Even after conception, smoking increases the chance of a chromosomal abnormality (such as Down syndrome and trisomy 18), ectopic pregnancy, premature birth and low birth weight. Children of smokers have an increased chance of sudden infant death syndrome (SIDS) and asthma.
The next logical question is whether smoking cessation can be beneficial. The answer is yes. Although lost eggs cannot be replaced, the chance of pregnancy complications is reduced.
Quitting smoking is clearly a difficult task. Today, however, we should know that there are special smoking cessation clinics operating all over the country that have helped tens of thousands of people succeed.

Genetic assessment - karyotype

A significant number of male fertility disorders, also described as idiopathic male infertility, are essentially genetic in origin.
Taking the family history and analyzing the karyotype reveals some of these disorders and allows the appropriate guidance of the individual. This is very important later in the intracytoplasmic sperm injection (ICSI) process, because fertility disorders and possible genetic abnormalities can be passed on to the offspring.
Chromosomal abnormalities are more common in men with severe oligozoospermia and with azoospermia. The most common sex chromosome disorder is Klinefelter syndrome (47 XXY), which affects about 10% of men diagnosed with azoospermia. Klinefelter syndrome is characterized by gynecomastia and hypogonadism, but not always! A eunuchoid phenotype and psychological disturbances are sometimes found. Both testicles are very small. 60% of patients have decreased testosterone levels with age and require hormone replacement. In men with extremely poor sperm quality, chromosome translocations and excisions can be found, which can be inherited and cause frequent miscarriages and congenital abnormalities in the offspring.

Empirical treatments

We often prescribe empirical treatments, such as the administration of vitamin E, tamoxifen, or complexes of vitamins and antioxidant agents. There is no strong literature, but some men with idiopathic oligoasthenospermia will benefit.

Surgical treatment
Varicocele
The treatment of varicocele is a controversial topic in andrology. This is based not only on the actual need to treat varicocele, but also on its importance as a cause of spermatogenesis disorder. The results of a significant number of non-randomized studies support that varicocele may be a cause of infertility. Successful treatment leads to a significant improvement in sperm quality in at least 40-50% of operated men.

Specialized microsurgical procedures
They require a specialized andrologist and the use of an excellent microscope in the operating room. Depending on the problem, epididymal anastomosis or vas deferens can be done when there is an obstruction. Even so, normal pregnancy rates after surgery are still low, below 20-30%.
Male infertility is particularly common and today around 30% of couples do not achieve pregnancy within a year. The urologist (and not the gynecologist) is the specialist doctor who will investigate the man and explain to him the available treatment options.