Male infertility. Erectile dysfunction. Vasectomy reversal. Treated with discretion.

Male infertility accounts for approximately half of all infertility cases in couples. The causes can be divided into three categories. Pre-testicular causes include hormonal imbalances (low FSH, LH, or testosterone), which may be treatable with medication. Testicular causes include azoospermia (no sperm in the ejaculate), oligospermia (low sperm count), poor sperm motility, and abnormal sperm morphology - often due to varicocele, previous infections (mumps orchitis, tuberculosis), genetic conditions (Klinefelter syndrome, Y-chromosome microdeletions), or damage from chemotherapy/radiotherapy. Post-testicular causes include blockages in the vas deferens or epididymis, either congenital (CBAVD in cystic fibrosis carriers) or acquired (previous vasectomy, infection, trauma). A thorough semen analysis, hormonal profile, scrotal ultrasound, and sometimes genetic testing maps the cause - and the cause determines the treatment.

Azoospermia means no sperm are found in the ejaculate. It affects about 1% of all men and 10–15% of infertile men. There are two types: obstructive azoospermia (OA), where sperm are produced normally in the testes but cannot get out due to a blockage; and non-obstructive azoospermia (NOA), where the testes produce insufficient sperm. Obstructive azoospermia is treated with surgical sperm retrieval (PESA/TESA) or surgical reconstruction of the blockage (vasovasostomy, vasoepididymostomy). Non-obstructive azoospermia is more challenging - testicular sperm extraction (TESE or microTESE) can find sperm in some cases even when none appear in the ejaculate. Recovered sperm are used with ICSI (intracytoplasmic sperm injection) in IVF. Dr. Nitin will first determine which type of azoospermia you have, as this completely changes the approach.

TESA (Testicular Sperm Aspiration) and PESA (Percutaneous Epididymal Sperm Aspiration) are minimally invasive procedures to retrieve sperm directly from the testis or epididymis. They are performed under local anaesthetic as a day procedure - no hospital admission required. PESA involves a fine needle aspiration from the epididymis (the coiled tube behind the testis where sperm mature). TESA involves a small needle inserted into the testis itself to aspirate testicular tissue. The retrieved tissue is immediately handed to an embryologist who identifies viable sperm under the microscope. Recovered sperm can be used fresh for IVF-ICSI the same day, or frozen for future use. Recovery is rapid - most men return to normal activity within 24–48 hours.

A varicocele is a dilation of the veins draining the testis (similar to varicose veins in the scrotum). It is found in approximately 15% of all men and 35–40% of infertile men - making it the most commonly identified correctable cause of male infertility. Varicoceles raise testicular temperature, impair sperm production, and can progressively reduce sperm count and quality over time. Varicocele repair (varicocelectomy) - performed microsurgically through a small inguinal or subinguinal incision - has been shown in multiple trials to improve semen parameters and natural pregnancy rates in men with a clinical varicocele and abnormal semen. Dr. Nitin performs microsurgical varicocelectomy using loupes or an operating microscope to minimise the risk of injury to the testicular artery and lymphatics.

Erectile dysfunction (ED) is the consistent inability to achieve or maintain an erection sufficient for satisfactory sexual intercourse. It becomes more common with age - affecting approximately 40% of men at 40 and 70% of men at 70 - but it is not a normal part of ageing that must be accepted. ED has both psychological and physical causes. Physical causes include cardiovascular disease (ED is often an early warning sign of underlying coronary artery disease), diabetes, hypertension, hormonal imbalances, and medication side effects. First-line treatment is PDE5 inhibitors (sildenafil, tadalafil), often in combination with lifestyle changes, hormonal correction, or switching medications. Men who do not respond to tablets may be candidates for vacuum devices, penile injections (alprostadil), or penile prosthesis surgery. A urologist should be consulted if ED is persistent, if it has developed suddenly, or if it is accompanied by symptoms that suggest an underlying cause needing investigation.

Vasectomy reversal (vasovasostomy) re-joins the two cut ends of the vas deferens. When performed by an experienced microsurgeon within 10 years of the original vasectomy, pregnancy rates are 55% or higher. Beyond 10 years, if the epididymis has been under pressure for long enough, a secondary obstruction may develop - in which case a vasoepididymostomy (joining the vas directly to the epididymis) is required, which is technically more demanding. The procedure is performed under general anaesthetic through a small scrotal incision, using an operating microscope. Results are seen in semen analysis at 6–8 weeks post-op. Dr. Nitin performs microsurgical vasectomy reversal and will assess your specific situation - time since vasectomy, hormonal status, partner age and fertility - before advising on whether reversal or sperm retrieval with IVF is the better strategy for your family.

Low testosterone (hypogonadism) and male infertility are related but distinct problems. Testosterone levels affect libido, energy, mood, bone density, and muscle mass - but testosterone treatment can paradoxically worsen fertility. External testosterone suppresses the pituitary signals (FSH and LH) that stimulate sperm production, reducing sperm count and potentially causing azoospermia. Men who want to father children should not take testosterone supplementation. Instead, if the underlying problem is low pituitary output (hypogonadotrophic hypogonadism), treatment with gonadotrophin injections (FSH + hCG) can simultaneously improve both testosterone levels and sperm production. Dr. Nitin will measure FSH, LH, testosterone, and prolactin to distinguish between primary (testicular) and secondary (pituitary) hypogonadism and choose the right treatment.