Andrology
Andrology is the part of Medicine that deals with the study, diagnosis and treatment of pathologies that affect the sexual and reproductive health of men.
Male sexual dysfunctions are disorders suffered by men that prevent or make it difficult for them to have satisfactory or pleasurable sexual relations. They appear when organic and/or psychological factors block the normal performance of sexual relations.
Visit to the andrologist
An andrological examination is advisable in all cases of conjugal sterility and is obligatory whenever seminal alterations are observed or there is a known history of risk of male sterility, such as cryptorchidism, varicocele, chemotherapy, radiotherapy, etc.
What is the purpose of the male evaluation?
The purpose of the male evaluation is to diagnose the alterations causing infertility, and aims to:
- Identify potentially treatable disorders.
- Diagnose pathologies relevant to the patient’s health.
- To detect irreversible alterations in which assisted reproduction techniques can be applied using the couple’s spermatozoa.
- Diagnose transmissible genetic abnormalities that may affect the health of the offspring or have repercussions on the success of assisted reproduction techniques.
- To provide guidance on possible alternatives (pre-implantation genetic diagnosis (PGD), sperm donor, adoption).
What does the first sterility visit with the andrologist consist of?
During the first visit, the patient’s medical history is taken, gathering all the information on possible family and personal history that may be related to sterility. Subsequently, a physical examination is carried out, paying special attention to the genital examination. Finally, a clinical evaluation of the semen analysis is carried out. Depending on the evaluation of all these data, it is usually necessary to carry out complementary tests.
What does the physical examination consist of in the andrology consultation?
The situation, volume and consistency of the testicles are assessed. The finding of a varicocele (varicose veins of the testicle) is important, as it is responsible for a large number of semen alterations. The penis should also be explored, because a pathologically short penis or abnormal locations of the urinary meatus may hinder or prevent intravaginal semen deposition, and the prostate, to rule out congestive or infectious pathologies of the prostate that may alter semen.
What is the clinical evaluation of the semen analysis?
We must distinguish the seminological diagnosis, established by the semen laboratory on the basis of the normality or abnormalities found in the semen analysis, resulting from the separate analysis of the different parameters, from the clinical diagnosis resulting from the joint evaluation of all these parameters. An altered semen analysis does not necessarily imply a decrease in the fertilising capacity of the semen. For example, a moderately low percentage of motile sperm could be compensated by the existence of a high total number of spermatozoa.
What additional tests can be ordered?
Depending on each case, it may be necessary to perform other studies or complementary tests to help us establish the aetiological diagnosis. Among the complementary tests of interest in the study of male infertility are the following:
- Seminal plasma biochemistry: Indicated in those cases in which obstruction of the seminal tract is suspected, they can help to determine the site of obstruction. The biochemical markers used are citric acid or zinc as prostatic markers, fructose as a marker of seminal vesicle function and L-carnitine and alpha-glucosidase as markers of the epididymis.
- Semen culture to rule out infection: The presence of leucocytes in the semen at a concentration above 1 million/ml is suspicious for seminal infection, which will be checked by performing a semen culture.
- Hormonal analysis: Hormonal evaluation is indicated in azoospermia, oligozoospermia < 10 million/ml, in the presence of sexual dysfunction or suspected endocrinopathy. FSH and testosterone are usually sufficient. In suspected non-obstructive azoospermia, Inhibin B is added.
- Karyotype study: Some sterilities are chromosomal in origin, and can affect both constitutional and germ cells. Karyotyping is a blood test that allows the chromosomal constitution to be determined. Karyotype abnormalities are up to 13 times more frequent in infertile patients than in the general population.
- Y chromosome microdeletion study: The Y chromosome contains genes important for spermatogenesis. Loss of these genes will negatively influence the ability to produce sperm. Molecular analysis techniques have identified AZFa, AZFb, AZFc and AZFd regions as a function of microdeletions. Sixty percent of the microdeletions affect AZFc, which contains a family of genes called DAZ (Deleted in Azoospermia) genes. The presence of these microdeletions implies the transmission of infertility to male offspring. Although their prevalence varies according to the published literature, it is generally 15% in non-obstructive azoospermia and 5% in severe oligozoospermia (< 5 million/ml).
- Study of cystic fibrosis gene mutations: Indicated especially in patients with azoospermia due to congenital bilateral agenesis of the vas deferens.
- Testicular biopsy: This is a minor procedure that consists of making a small incision to remove a piece of testicular tissue. This methodology generally has a diagnostic purpose, although in some cases it can be therapeutic. It is mainly indicated in certain cases of male sterility. The aim is to assess the function of the testicle in terms of sperm production. Testicular biopsy may also be recommended in cases of repeated miscarriages or suspected genetic alterations. As a treatment, it may be indicated in order to obtain spermatozoa for use in assisted reproduction techniques.
- Histopathological study: assesses the function of the testicle in terms of sperm production. Sometimes it allows the discovery of tumour lesions that had not been suspected. However, testicular cancer is up to 20 times more frequent in infertile patients with altered seminograms, and up to 10 times more frequent in cryptozoospermia, a frequent cause of male infertility.
- Cytogenetic study of meiosis: evaluates chromosomal alterations affecting germ cells or sperm. Between 6-8% of infertile males who undergo this study have alterations. But in cases with severe oligoasthenozoospermia (< 1 million/mL) the frequency increases to 17%.
- Sperm retrieval: Especially in azoospermia, it is used to retrieve sperm from the testicle for cryopreservation and subsequent use in IVF-ICSI techniques, or synchronously with oocyte retrieval for microinjection with fresh sperm.
- FISH in spermatozoa: This study allows an indirect evaluation of the state of meiosis as it analyses the end product of meiosis, the spermatozoa. It allows an evaluation of whether there is an increase in chromosomally abnormal spermatozoa and whether this is statistically significant with respect to the fertile population.
- Immunological studies: The existence of asthenozoospermia and the presence of agglutination phenomena in the semen analysis may indicate the existence of antisperm antibodies that immobilise the spermatozoa. The immunological study is indicated in cases of asthenozoospermia and a history of risk (testicular trauma, scrotal surgery, testicular torsion or a history of genital infection).
- Testicular ultrasound: In some cases it may be necessary to perform a testicular ultrasound to confirm the findings provided by the physical examination.
- Testicular Doppler study: Indicated to confirm the existence and degree of varicocele.
- Deferento-vesiculography: This is a radiological study of the spermatic ducts, used to determine the existence and level of obstruction of the same.
- Transrectal ultrasound: Useful in the study of the prostate and patients with low ejaculate volume.
- Is the cause of semen alterations always found?
- There are seminal alterations without a known cause and therefore without a reasonable possibility of treatment. In these cases, it is more practical to limit oneself to the diagnosis of those pathologies that could have repercussions on the final result of Assisted Reproduction techniques and to resort to these as the best solution to the sterility problem.
