Male infertility is often overlooked — yet it contributes to nearly half of all fertility challenges. In this live Q&A session, Dr Elias Tsakos, MD, FRCOG, Medical Director of Embryoclinic, Thessaloniki, takes a clear and compassionate look at the causes, diagnosis, and treatment options for male factor infertility. A must-watch for couples, individuals, and anyone seeking to better understand this important but under-discussed topic.
The biggest myth is that age is irrelevant for men and that men can have children well into their eighties. People often quote examples from public figures or celebrities, but male fertility is absolutely associated with age.
Female fertility declines significantly after 35. In men, decline usually starts after 40, but sperm quality worldwide has also been declining over the last few decades. This reflects environmental factors such as air, water, food quality, and overall lifestyle.
Another myth is that young men have nothing to fear regarding fertility. This is not true. Some men are born with fertility issues, and others acquire them later. I believe that every man should have at least one semen analysis before the age of 25, not just for fertility but as a general health indicator. If I had to recommend one test for a healthy 30-year-old man, it would be a semen analysis, because it reflects genetic, hormonal, environmental, and general health factors.
A third myth is that lifestyle damage can be reversed quickly. For example, quitting smoking for a few months does not erase years of damage.
A fourth myth concerns sexually transmitted infections. They affect men as well, even if symptoms are less obvious. Prostatitis, for example, can fluctuate significantly and seriously impact semen quality over time.
Finally, male ageing itself is underestimated. Emerging research suggests that age-related genetic mutations in sperm may be even more pronounced than those associated with female ageing. Men have been kept in the shadow of fertility care for too long, and they need to come into the light.
First, a urologist is not necessarily an andrologist, just as a gynaecologist is not necessarily a fertility specialist. Male infertility requires additional years of specialised training and ongoing certification.
DNA fragmentation has been clinically relevant for 10–15 years. Initially, it was linked mainly to natural conception and IUI, but recent evidence clearly shows it also affects IVF, ICSI, blastocyst development, and miscarriage rates. I strongly disagree with the idea that it is not important.
Oxidative stress is complementary to DNA fragmentation. It reflects overall health and is linked to inflammation, metabolic disease, diabetes, cancer, and ageing. Measuring oxidative stress allows targeted intervention rather than blind supplementation.
Sperm-sorting devices can be demanding for laboratories, but they benefit patients. When clinics are properly staffed, there is time to use technologies such as Zymot and newer AI-based sperm selection tools that detect micro-movements invisible to the human eye. These technologies support embryologists in selecting better-quality sperm.
Regarding supplements such as ashwagandha, supplementation is complex and highly individualised. It is not something that can be recommended generically. Quality, formulation, and correct use all matter.
I would recommend a much more extensive assessment. This should include repeated semen analysis, semen culture, PCR testing for infections, microbiome testing, karyotype analysis, cystic fibrosis screening, full blood tests, and a detailed ultrasound of the testes and prostate.
I would also consider Y-chromosome microdeletion testing and oxidative stress measurement. Lifestyle optimisation is important, but supplementation must be carefully planned and individualised.
This requires a dedicated sperm clinic and a multidisciplinary approach. It is not as simple as taking supplements. Proper assessment, time, and repeated follow-up are essential.
Yes. In a small but important percentage of men with severely abnormal semen parameters, an underlying malignancy may be present. Semen analysis is not just about fertility. It can be an indicator of serious disease. Clinical examination and ultrasound of the testes and prostate should never be skipped.
Yes. In such cases, sperm retrieval directly from the source, such as FNA or testicular extraction, may provide better-quality sperm. Sperm is not just a DNA carrier; it has many functional roles.
This type of severe male infertility requires careful assessment by a multidisciplinary male fertility expert team.
Female age may also be a significant factor in this situation. At advanced maternal age, success rates with own eggs are extremely low, sometimes around 1%. If egg donation is acceptable, it may be the most realistic option.
However, even in egg donation cycles, optimising sperm quality remains critical. Better sperm quality can make the difference between 1 blastocyst and 2 or 3, which has a major impact on cumulative success rates.
In our practice, grade one varicoceles are generally managed conservatively. Surgery is usually considered only for higher grades, pain, or other clear indications. Grade 1 varicocele is not typically associated with morphology issues.
Severe male factor conditions like this require thorough investigation before deciding on treatment. Additional diagnostic work is essential before considering any intervention.
Thank you for allowing me to share my views. Sometimes they are strong, but I believe we, as doctors, must work harder. Patients give us trust and hope, and that carries responsibility.
Male fertility has not been addressed properly in the past, and we must acknowledge that. Patients should expect a scientific, equal approach from both partners. By doing so, we respect women, men, and future children. Thank you for your curiosity and for pushing us to be better.
