Category: Male Fertility

TESE, Micro-TESE, and Low Testosterone

Woman on husbands back with arms around chest, both smiling

TESEs were first performed in the early 1990s and provided men with a fertility option even if semen analysis showed no sperm – known as azoospermia. This ushered in an era of male fertility options that allowed urologists to retrieve sperm in about 30% of men, ultimately resulting in about 25% of men being able to become fathers. With 1% or so of all American men not having usable sperm in their semen, this was a major step forward.

Around the same time, we began to understand the landscape of male versus female infertility, and we now know that about a third of all infertility issues can be attributed to the male patient, a third to the female patient, and a third to both. So, finding a way to improve male fertility has addressed a key concern of couples struggling to conceive.

The TESE and even micro-TESE is an invasive procedure used for sperm extraction from the testes. Both require cutting into the testicle, at which point the urologic surgeon tests areas of the testicle for sperm. If sperm are found, they are extracted for later insemination.

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What to Know About Testicular Mapping

Older man smiling in woods sitting on log

While there’s plenty we don’t know, we have learned a lot about male fertility and reproduction over the past few decades. One of the most exciting areas of research and advancement has been in the management of male fertility concerns. Nonobstructive azoospermia was at one time considered difficult or impossible to treat, yet now, many men with no detectable sperm in their semen have become fathers. Today, there are several sperm extraction techniques available to these men, but most are invasive. As such, there has been a need for minimally invasive diagnostics to see whether sperm can be found in the testes.

This is where testicular mapping or FNA mapping comes into play. Testicular mapping is a highly effective, mildly invasive diagnostic procedure in which the testicles are mapped using fine needle aspiration. During the procedure, testicular tissue samples are removed and then analyzed to see if sperm is present. This has been a game-changer for patients that once only had the more invasive micro-TESE as their only option. The following information on testicular mapping should be of interest to men suffering from Azoospermia.

  • We expect to find sperm in about 50% of men with azoospermia
  • Over 30% of men are eventually able to become fathers as a result
  • It’s a Less-Invasive, similarly effective diagnostic option versus a Micro-TESE
  • It doesn’t reduce testosterone levels appreciably
  • Only a few physicians perform it around the US

Why a Second Procedure?

Knowing that testicular mapping is purely a diagnostic procedure, why wouldn’t we just use a micro-TESE that allows for both diagnosis and treatment? The answer is simple. About 50% of men with nonobstructive azoospermia do not have viable sperm in the testes. Both testicular mapping and micro-TESE are very good at identifying patients with viable sperm, but the micro-TESE does so in a much more invasive manner. That means that about 50% of our patients will have an unnecessarily invasive procedure that inhibits their lives and lifestyles and may even cause longer-term low testosterone.

Will It Hurt?

One of the best qualities of testicular mapping is how minimally invasive it is and how little the procedure hurts. To be sure, there will be some discomfort after the procedure as the anesthetic wears off. However, anesthesia is administered during the procedure, and patients do not feel appreciable discomfort. On the other hand, a micro-TESE can cause significant discomfort during the recovery period.

Is Micro-TESE a Bad Procedure?

While the above discusses the downsides of a micro-TESE versus testicular mapping, understand that these limitations are only in the diagnostic realm, and that is why Dr. Kapadia is one of the few urologic surgeons around the country to offer testicular mapping. However, as a sperm extraction procedure (something that testicular mapping cannot do), micro-TESE is the gold standard. If we know there is viable sperm in the testes, a micro-TESE is the most effective way to extract it and help our patients become fathers.

In short, working with Dr. Kapadia to optimize a diagnostic and sperm extraction plan can save time and discomfort in appropriate patients. Dr. Kapadia sees azoospermia patients from all over the southeast United States, and we look forward to scheduling a consultation with you to learn more about the diagnostic options that you may have.

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Research Suggests That THC Use Has an Effect on Fertility

THC oil on plate with dropper out of bottle

As if the number of fertility-issue-causing concerns wasn’t long enough, recent (2021) research¹ has shown that regular consumption of THC, the psychoactive compound of marijuana, is potentially harmful to male fertility. The study showed that in current and past human users, marijuana had a significantly higher risk of abnormal sperm morphology versus non-users. Semen volume was also lower in current and past users.

Another study² conducted on non-human subjects (rhesus macaque monkeys), giving them daily THC, showed the testes of the animal subjects reduced in size and increased fragmentation of DNA. These associations were directly correlated to increased use.

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Male Infertility and Testicular Heat

Man in white shirt and underwear with hand on hip

You probably heard it at some point in your life – stay away from those “tighty whiteys.” It may seem like a trivial piece of advice that was never fully explained to you as a child or young adult. However, it is a warning rooted in excellent science and can make a difference in a man’s fertility.

To understand precisely how the proper function of the testicles makes a difference in male fertility, we need to understand more about the anatomy. There is a good reason why the testicles hang outside of the body exactly the way they do – for temperature regulation. Sperm production and quality are most efficient at several degrees below average body temperature – around 93 degrees Fahrenheit.

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Testing for Male Infertility

Depiction of sperm swimming in-front of blue background

Couples looking to conceive are often hypersensitive about their fertility. Many couples do not realize how long it can take to conceive – the general guidance for seeking fertility assistance is after about one year of trying. We’ve also learned much more about the causes of infertility over the past few decades, and we now know that male infertility accounts for about 50% of all cases. Before we get into testing, it is important to understand why males may be infertile. Ultimately, there are three overarching reasons:

  • First is a production problem. If the testes do not produce enough semen or sperm, they typically cannot reach the egg for fertilization.
  • Second, the shape (morphology) and movement (motility) of the sperm will also play a role, as these dysfunctional or deformed sperm cannot efficiently travel to the egg.
  • Finally, some men will also experience a blockage that prevents sperm from being ejaculated.

How We Test for Infertility

When couples suspect infertility, the next step is to see their respective sexual health specialists. For men, a urologist and men’s health specialist like Dr. Kapadia has the tools and diagnostic equipment to best assist. We take a stepwise approach toward understanding what issues, if any, may be preventing our patients from conceiving. These include:

When we first meet a male patient with infertility concerns, we perform a complete medical and lifestyle workup to understand more about potential contributory factors. We will discuss stress, diet, exercise, and other markers that may be impeding proper sexual health. The psychological component of infertility should not be overlooked, so we will discuss those concerns.

Semen analysis. As a first step, a semen analysis is required. This involves getting a sample and analyzing semen and the sperm contained therein. We will be looking at several markers, including the volume of semen produced, the amount of sperm within it, the ability of the sperm to move properly, known as motility, and the shape or morphology of the sperm. Semen analysis is very straightforward and performed in our office. However, we will take multiple semen samples over a few weeks as levels can change over time.

Hormonal analysis. Our body is regulated by chemicals produced in various areas of the body known as hormones. High or low hormone levels can cause infertility, so checking these levels through simple bodily fluid tests is a quick way to understand if there are any problems. Most commonly, we check on follicle-stimulating hormone (FSH) and testosterone. Other hormones may be checked as well.

Urinalysis. We may test patients’ urine for white blood cells, a sign of infection in the body, and test for sperm in the urine, known as retrograde ejaculation.

Ultrasound and X-ray. Using diagnostic imaging tools, we can check to see if there are blockages that would limit the flow of sperm into the semen,

Biopsy. In some cases, a biopsy of the testes, removing a small piece of tissue, may be appropriate to understand how sperm are produced and if there is a problem on the testicular level.

Can You Test at Home?

Most of the advanced diagnostic testing will be performed at your urologist’s office or a lab. However, there are home test kits to check for sperm count problems. These tests can be very accurate and relatively easy to use. However, low sperm counts should be confirmed and ultimately diagnosed by an appropriate specialist. Remember that the causes of infertility are many and varied, so using only one marker may not give a complete and accurate picture.

Is Male Infertility Getting More Prevalent?

The short answer to this question is yes. It seems that fertility rates are declining in men. This also appears to be happening in women. The most likely cause of this decline is endocrine disruption which involves hormonal or chemical imbalances. Research has been done on hormone-disrupting chemicals, many of which have been popularized by Dr. Shanna Swan. Public awareness of what is in our food and the products we use is starting to increase, but slowly. Chemicals in just about everything we consume, like BPA, phthalates, and PFAs, may all contribute to this fertility decline. Sadly, health regulatory agencies have not caught up to this potential threat.

Is It My Partner?

As mentioned above, about 50% of infertility cases are caused by a man, and a woman causes the other half. Breaking it down further, approximately 1/3 of cases can be attributed to the woman, 1/3 to the man, and the final third represents issues associated with both partners. We typically suggest that both partners visit their respective reproductive health specialists to get a complete picture of what may be causing infertility and receive appropriate treatment. Dr. Kapadia works with his female reproductive health counterparts to develop a comprehensive treatment plan if one or both partners have a fertility problem.

The Bottom Line

Infertility is becoming more prevalent in modern society because of several modifiable and non-modifiable factors. Speaking to a qualified men’s health specialist is truly the best way to understand more about infertility and possible treatments. However, patients should be aware that pregnancy does not often happen on the first or second try, so they should not jump to conclusions and do not need to visit a specialist for about a year without any luck. It is also crucial that partners keep an ovulation calendar, as this can dramatically improve the chances of conception. Lastly, a healthier lifestyle can improve the quality of sperm and the chances of getting pregnant sooner.

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Can Tongkat Ali Boost My Testosterone? A Urologist’s Perspective

Disclaimer: We want to address Tongkat Ali due to its recent and sudden rise in popularity, however, it is important to note that these studies are poorly designed and lack high-quality data. We can’t be sure of the benefits of Tongkat Ali until they are shown in well-designed clinical trials. Patients should consult with a physician regarding safety before starting any supplement regimen.

man dumping Tongkat Ali supplement from bottle into hand

Tongkat Ali or Longjack, an herb found in Southeast Asia and commonly used as part of traditional holistic medicine there, has risen in popularity due to claims about its effectiveness in increasing testosterone, reducing stress, and potentially even boosting male fertility. Various podcasters, including Joe Rogan and Professor of Neurobiology at Stanford University Andrew Huberman, have discussed this herb in depth. They posit that taking Tongkat Ali boosts antioxidant levels in the body to fight free radicals while normalizing certain hormones like testosterone and Cortisol. Do these claims hold water? Let’s dive in.

Before we evaluate each of these claims, it is important to note that the FDA does not oversee supplements. Therefore, you must do your due diligence about which supplements to buy, as their purity and concentrations can vary. Safety should be your primary concern. Continue reading “Can Tongkat Ali Boost My Testosterone? A Urologist’s Perspective”

Can “Forever Chemicals” Be Causing Male Infertility?

Several takeout containers including cups and bag lying across a counter

In the spirit of bringing you the latest research that affects male fertility, a Danish study¹ was recently published about the effects of forever chemicals and, in particular, PFAS or per and polyfluoroalkyl substances on sperm count and mobility. The study sought to understand how a mother’s exposure to these toxic chemicals during pregnancy could affect the child’s fertility later in life. Why does this matter? Testicular development in males occurs during the first trimester of pregnancy, and this is also a time when external endocrine disruptors can make a big difference. In this case, PFAS made up of thousands of different chemicals, accumulates in the human body and crosses the placental barrier into the child.

What This Study Showed

Approximately 860 men were evaluated. Their mothers provided blood samples during the first trimester of their pregnancy between 1996 and 2002. The study found that mothers with higher PFAS levels had children who were more likely to have a lower sperm count and mobility issues than adults.

Why This Study Matters

When we look at the increasing rates of male infertility, we know that there is no single cause. Instead, cases of infertility must be discussed and evaluated both from an individual and a societal level. It seems that exposure to these, amongst other environmental chemicals, may be partly to blame for some infertility cases. Most Americans have been exposed to and therefore retain PFAS in their blood – remember, once exposed, the body cannot remove these chemicals (hence the “forever” moniker).

Beyond infertility, these chemicals can also cause significant diseases later in life. Research suggests that these chemicals may cause metabolic disorders, including type-2 diabetes, high cholesterol, obesity, and more, all of which can also affect urinary health.

What’s the Prognosis?

Unfortunately, because of the ubiquitous nature of these chemicals, most pregnant mothers have been exposed to these toxic chemicals. Virtually every adult has been as well. Why? These chemicals are often used in food product packaging to improve their water and grease-resistant properties. The result is that many of your fast food and takeout containers have PFAS. Some of the most egregious packaging includes fast-food wrappers and boxes, popcorn bags, and pizza boxes.

How Can You Avoid These Chemicals?

Unfortunately, we do not yet have a regulatory structure identifying and regulating these chemicals. However, much like BPA and phthalates, consumers and food producers are taking note. Companies like Chick-fil-A, Chipotle, Whole Foods, and Burger King have alluded to or promised to remove these chemicals from their packaging. Of course, the time and cost to do so are such that we can expect to be exposed to these chemicals for many more years unless something is done from a public awareness or regulatory standpoint. For the time being, the fact that PFAS is not visible nor has acute effects (that we are aware of) often makes it a lower priority for many people. Regardless, working with a men’s health specialist like Dr. Kapadia is an essential first step to understanding the potential causes of infertility and developing a treatment plan to address it.

In the meantime, do your research to find out if any of the products you or your family members consume contain harmful chemicals. You may even wish to consider choosing products that specifically exclude these chemicals from their packaging. Even though it’s likely that we have all been exposed to PFAS already, reducing our future exposure can only be beneficial. Be your own health advocate by ensuring that what you eat and drink is not tainted by harmful chemicals.


  1. Petersen KU, Hærvig KK, Flachs EM, Bonde JP, Lindh C, Hougaard KS, Toft G, Ramlau-Hansen CH, Tøttenborg SS. Per- and polyfluoroalkyl substances (PFAS) and male reproductive function in young adulthood; a cross-sectional study. Environ Res. 2022 Sep;212(Pt A):113157. doi: 10.1016/j.envres.2022.113157. Epub 2022 Mar 19. PMID: 35318009.

Can Your Partner Get Pregnant After a Vasectomy?

Early image of an ultrasound next to a positive pregnancy test

If you are researching a vasectomy, you probably already know it is the most effective and least invasive surgical procedure couples can pursue when they no longer wish to have children but want to continue their active sex life.

A vasectomy is straightforward. It is not uncommon to hear that some urologists have performed the surgery on themselves. However, one point of concern is if there is any chance that they can get their partner pregnant after a vasectomy. Before we delve into why, the answer is yes, it’s possible but rare.

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Spotlight On Male Fertility When Couples Are Trying to Conceive

About 12-15% of all couples are not able to conceive after 1 year of trying. For about 10%, that lasts past 2 years. Traditionally, and mistakenly, women have been seen as the primary cause of infertility in couples that are unable to conceive. Our research and understanding about couples’ fertility has yielded that men and women each account for about 1/3 of the cause while the last third cannot be attributed or is attributable to both partners. This paradigm shift has allowed us to improve cost and quality of care to couples who are unable to conceive.

Trying to conceive is easier when you consider both the male and female perspectives of fertility according to Atlanta men's health expert Dr. Akash Kapadia

Before we delve into the potential diagnostic tools and treatments that a male fertility specialist like Dr. Kapadia has to offer, it is important to understand a few key points about male and female fertility.

1.     There are a host of hormonal issues that may affect fertility. For example, obesity can reduce fertility in both men and women. Therefore, those suffering from excess weight, should take steps to lose some of that weight and improve obesity related conditions, if any, when trying to conceive.

2.     Second, conceiving a child can take some time. Most couples will conceive within a year with regular sex, but it may not happen in the first few months. As couples age, this may take longer. Of course, there are times where this happens sooner or later, but if you have tried for a few months with no success, this is not necessarily an indication of infertility.

3.     Stress, alcohol intake, drug use, and smoking can all reduce the likelihood of getting pregnant. Addressing these is also important for the patient’s general health beyond their fertility and that of their unborn child.

4.     Discuss any medications you are taking with your primary care physician or Dr. Kapadia. It is always a good idea to let your medical team know that you are trying to conceive. He or she will be able to look over your medical chart and see if there are any impediments to conception.

If all the modifiable causes of infertility have been addressed, it is important that each partner see their respective fertility specialist. It should not be assumed that infertility is more common or exclusive to female patients. Men need to see a fertility specialist as well. After an initial consultation with Dr. Kapadia, which both partners should attend, we can move on to the diagnostic process that may include testing to understand whether there may be a concern with the man’s reproductive system. Most commonly we find:

–       Abnormalities in sperm production
–       Issues with sperm function or quality (often due to varicocele)
–       Trouble with sperm delivery
–       Damage because of cancer or the treatment thereof
–       Vasectomy

These concerns can be addressed with treatments such as:

–       Medication for hormonal imbalance (low testosterone)
–       Testicular mapping (for no sperm in the ejaculate)
–       Varicocele treatment
–       Sperm retrieval
–       Vasectomy Reversal

The next step is to visit a urologist specializing in male fertility to understand more about the potential issues you may be experiencing. Conceiving may be as simple as minimally invasive or medical therapy or could require a more involved process. Either way, Dr. Kapadia has the resources and knowledge to increase the chances of successfully conceiving.