Three years into their infertility workup, after a second failed transfer, a couple came to see me. She had been the patient that entire time. Hysterosalpingogram, diagnostic laparoscopy, two retrievals, somewhere north of $40,000 that their insurance didn’t touch. He came to the appointment because their REI had finally suggested it, and I think he was mostly there to be supportive.
He brought a folder. In it was a semen analysis from a year and a half earlier, about 4 million per milliliter with poor motility, flagged abnormal at the bottom of the page. It had never been repeated. He told me he figured that if it mattered, somebody would have called him. I asked him to stand up. He had a grade 3 varicocele on the left, visible through the scrotal skin before I put a hand on him, and the left testis was smaller and softer than the right. He had felt a dull ache on that side for years, worse at the end of a long day, and had never mentioned it to a physician because it did not seem like a medical problem to him. It seemed like a thing his body did.
We did a microsurgical subinguinal varicocelectomy. At six months his count was around 20 million with meaningfully better motility, which is a good result and not a guaranteed one, since a fair number of men improve less than that and some don’t improve at all. They conceived on their own about a year after surgery. That case is not unusual. Some version of it comes through my clinic most weeks. What gets to me is not that the diagnosis was difficult, because it wasn’t difficult at all. It took a physical exam and about thirty seconds. What failed was the order in which things happened.
Why the workup starts with her
Male factor contributes to roughly half of infertility cases and is the sole cause in about one in five. Both the American Urological Association (AUA) and the American Society for Reproductive Medicine (ASRM) recommend evaluating both partners at the same time rather than in sequence. That is not what happens in practice, and I don’t think the reason is that anyone forgot.
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Most women in their thirties have a physician they see annually. Most men in their thirties do not have a physician at all. So when a couple decides that something is wrong, they go to the office where one of them is already established, and everything after that follows from that first appointment. The referral goes to reproductive endocrinology, her workup starts, and he becomes a bystander to a diagnosis that may well be his.
There’s a second reason that I find harder to talk about at meetings. ICSI works. We can take one sperm out of a man who has almost none and produce a healthy pregnancy, which is a genuine triumph, and which also means male factor infertility can be worked around indefinitely without anyone establishing what caused it. The technology removed most of the pressure to diagnose. So a couple spends $20,000 a cycle routing around a TSH of 11, or a prolactin of 90 that should have prompted a pituitary MRI six months ago, or a varicocele nobody has laid hands on.
The semen analysis gets misread in both directions
A single semen analysis is a screening test. Parameters swing considerably in the same man from month to month depending on illness, sleep, abstinence interval, and nothing identifiable at all, so an abnormal result should be repeated in two to four weeks with two to five days of abstinence. Mail-in kits are not a substitute for an andrology lab and I have had to repeat almost every one I’ve been handed.
The reference values are also more slippery than most people treat them. They come from the fifth percentile of men who conceived within a year of trying. They are not a line between fertile and infertile. Men inside the normal range are sometimes the reason a couple is not pregnant, and men below it father children all the time. If you take nothing else from this piece, take that the number needs interpretation and the interpretation requires a history.
The three questions
Here is the history I take before I order anything. It takes maybe ninety seconds and it changes what I do with the result. The first is whether he has ever taken testosterone, or anything from a clinic, a gym, or a website. I ask it in those words deliberately. If you ask a man whether he takes any medications, you will miss pellets, creams, peptides, SARMs, clomiphene he bought online, and anything sold to him as hormone optimization, because he does not think of those as medications. He thinks of them as part of working out. In my clinic this question accounts for more azoospermia than anything else I ask, and it is the most reversible cause I see.
The second is whether he has ever gotten anyone pregnant. Any partner, any time, including pregnancies that didn’t continue. Primary and secondary infertility carry different differentials, and a man who fathered a child four years ago and can’t now has developed something in the interval, which pushes varicocele, weight gain, new medications, and obstruction up the list. The question also tends to open the childhood history that nobody has ever taken from him, which is where the undescended testis, the torsion at fourteen, the mumps after puberty, the hernia repair, and the chemotherapy live.
The third is to have him describe what actually happens when he ejaculates. Volume, sensation, frequency, timing relative to her cycle, whether he’s using a lubricant. Low volume with no sperm is a different problem than normal volume with no sperm. Retrograde ejaculation turns up here, so does erectile dysfunction he has not mentioned to a single person, so does a couple having intercourse on the wrong days, so does a commercial lubricant that is spermicidal. None of that appears on a lab requisition.
What we find, and what else we find
A lot of it is fixable. Varicoceles are present in about 40 percent of men with primary infertility and in the majority with secondary infertility, and repair is outpatient. Thyroid disease, prolactinoma, poorly controlled diabetes, obesity. Finasteride, sulfasalazine, opioids, some SSRIs, alpha-blockers. The part I did not appreciate early in my career is how often the fertility evaluation turns up something with nothing to do with fertility. Infertile men have higher rates of testicular cancer, undiagnosed hypertension and diabetes, and Klinefelter syndrome, and there is reasonable evidence now linking poor semen quality to higher all-cause mortality. For a lot of these men, this is the first time a physician has examined them since high school. I have found testicular masses on men who came in about their sperm count.
When to refer him
Standard practice is to refer at twelve months of unprotected intercourse without conception, or six if the female partner is over 35. I think three months is the right number, and I want to make the case for it rather than just assert it.
The twelve-month mark is a definition of infertility. It was never meant to be a trigger for a semen analysis. It exists because most couples conceive within a year and we don’t want to commit the ones who would have gotten there anyway to invasive and expensive treatment. That logic is sound when the intervention is a laparoscopy or a retrieval cycle. It falls apart when the intervention is a $150 lab test and a scrotal exam. The obvious objection is that referring at three months means evaluating a lot of men who were going to conceive on their own by month nine, and that’s true. I’d argue it costs almost nothing to be wrong in that direction. He gets a semen analysis and a physical exam, and if both are clean you have removed half the differential and everyone can stop wondering. Compare that to being wrong in the other direction, where a man with a correctable problem loses nine months before anyone looks, and then loses another six on top of that because spermatogenesis runs on a 72-day cycle and nothing we do to fix his sperm shows up in a sample for at least three months after we do it. Varicocele repair takes six months to declare itself. Stopping testosterone can take a year. Every month of delay in identifying the problem is a month added to the front of a treatment timeline that is already slow, and it is spent while his partner’s ovarian reserve is doing what it does.
So: three months, and immediately, without waiting at all, if he has a history of cryptorchidism, torsion, chemotherapy or pelvic radiation, prior inguinal or scrotal surgery, or if he is taking testosterone in any form. Send him while you are working her up, not after. Two things make my first visit much more useful. Get a semen analysis at an actual andrology lab, and if it is abnormal, or if he reports low libido, fatigue, or erectile dysfunction, add a morning total testosterone with LH and FSH. With those in hand the first appointment becomes a conversation about a diagnosis instead of an intake form. The money in these cases is real, but the money is not what bothers me. It’s the years, and it’s watching a woman go through stimulation and retrieval twice for a problem that was never hers, and it’s the couple sitting across from me already worn down, asking why nobody looked here first. I usually don’t have a good answer for them. Nobody was asked to.
Justin Houman is a urologist.ho
