Aleksandre Bochorishvili
Urologist, MD, PhD in Medicine
An Often Overlooked Cause of Infertility
Today, infertility is one of the most significant challenges worldwide, affecting approximately 15% of couples. In our reality, the responsibility is often unfairly placed more heavily on women. This is a misconception, as the causes of infertility are equally distributed between both sexes. Unfortunately, sometimes even we doctors make the mistake of focusing solely on laboratory tests without delving deeply enough into the patient’s medical history. As a rule, a couple is considered infertile if pregnancy does not occur after 1–1.5 years of regular, unprotected sexual intercourse. This definition requires proper clarification with the couple, because in practice, these conditions are not always fully met.
The Importance of Evaluating the Male Factor
There is a misconception that if a man’s sperm quality is satisfactory (especially since providing a semen sample can be associated with certain difficulties) and the results show normozoospermia, the male factor is automatically ruled out. This is not always correct. This is exactly where the problem begins. A semen analysis provides only a single snapshot and does not fully reflect a man’s reproductive potential.
In andrological practice, evaluating a male patient must be comprehensive and include assessing the hormonal profile (Testosterone, LH, FSH, Prolactin), an ultrasound examination of the testicles, and an analysis of the mechanisms regulating spermatogenesis. It is particularly important to differentiate between functional and organic causes, as the management strategy depends directly on this.
Sperm Quality and Actual Fertility
In clinical practice, we frequently encounter cases where, despite normozoospermia, fertility remains reduced. This can be related to functional defects in the spermatozoa, including DNA fragmentation, subclinical motility disorders, or disruptions in the ejaculatory mechanism. Consequently, a standard semen analysis alone cannot always reflect true reproductive potential.
Medical History and the Real Picture of Sexual Life
Unfortunately, the question of how frequently sexual intercourse occurs — or whether it occurs at all — is often simply not asked. In today’s stressful environment, erectile dysfunction in men is far more common than ever before, affecting approximately 20% of men of reproductive age. The causes vary widely: chronic stress, an unhealthy lifestyle, and various underlying conditions that accompany sexual dysfunction.
In clinical practice, we repeatedly see cases where, against the backdrop of a technically “normal” semen analysis, there is actually an insufficient frequency of sexual intercourse, naturally reducing the probability of conception. For this reason, a detailed medical history and an objective evaluation of the couple’s sex life are an essential part of the diagnostic process.
Erectile Dysfunction and Hormonal Imbalance
At this stage, I would highlight two main causes: one manifests as decreased libido, while the other is related to insufficient erections that fail to support a complete sexual act.
A decrease in libido is most often associated with a decline in various hormone levels, particularly changes in androgenic status, leading to a weakened sex drive. In such situations, the female partner might feel that the man has lost interest in her, no longer loves her, or has found another partner. This is a situation where emotional alienation begins between the couple. Unfortunately, instead of jointly acknowledging the root causes and trying to solve the problem, the opposite often happens — the rift in the relationship deepens even further.
There is also a second issue, where a man struggles to achieve an erection, maintain it, or reach ejaculation. In such cases, a drop in libido might not be the primary issue, yet the man often experiences intense stress. He develops performance anxiety, which, over time, exacerbates the condition even more.
It is important to note that erectile dysfunction is often not just a localized problem; it can be associated with endothelial dysfunction, cardiovascular risks, and metabolic syndrome. Therefore, its evaluation must be viewed in the context of both reproductive and general health. If this problem is not diagnosed early and properly treated, it could develop into a more complex, long-term, and in some cases, barely reversible condition.
Urological Recommendations
It is crucial that during the evaluation of infertility, urological factors such as varicocele, chronic prostatitis, urogenital infections, and metabolic disorders are taken into consideration. Attention should also be paid to chronic inflammatory processes, which might be subclinical but can still have a significant impact on both sperm quality and sexual function. Accordingly, diagnostics should encompass both laboratory and instrumental examinations, alongside a tailored treatment plan.
The most important thing is for couples to communicate openly with one another and then, if necessary, consult medical professionals so that the problem can be identified in a timely manner and appropriate treatment can begin without delay.