An andrologist is a doctor who deals with male reproductive and sexual function and hormonal health. People turn to them with infertility, decreased libido, erection problems, suspected low testosterone, and also after self-directed use of hormonal drugs. The editorial team explains what the examination consists of and why each stage is needed.
When it is worth seeing an andrologist
The most frequent reason is infertility in a couple. If pregnancy does not occur within a year of regular sexual life without contraception, both partners need to be examined at the same time. The male factor, according to WHO and urological societies, is present in roughly half of cases of infertile couples, so there is no sense in the man postponing the visit.
The second large group is symptoms that may indicate androgen deficiency: decreased libido, rarer morning erections, chronic fatigue, loss of muscle mass and strength, an increase in fat tissue, lowered mood. These signs are nonspecific, so a diagnosis of hypogonadism is made only after laboratory confirmation.
People also turn to an andrologist with erectile dysfunction, ejaculation disorders, pain or enlargement in the scrotum, gynecomastia, delayed sexual maturation. A sudden change in the size or consistency of a testicle is grounds for an urgent visit, since a tumor must be ruled out.
A separate group is men who have used anabolic steroids or other hormonal agents. After discontinuing them, a temporary and sometimes prolonged hypogonadism and impaired spermatogenesis often develop. An honest account to the doctor about all substances used is key to the correct interpretation of the tests.
Consultation and physical examination
The examination begins with a conversation. The doctor clarifies the complaints, their duration, past illnesses (in particular mumps, scrotal trauma, operations for inguinal hernias or cryptorchidism), chronic diseases, medications, habits — smoking, alcohol, heat exposure, training and nutrition regimen. For couples, the duration of conception attempts and the partner's examination data are important.
The physical examination includes an assessment of build, distribution of fat tissue, hair growth, presence of gynecomastia. The doctor measures blood pressure, height and body weight, waist circumference — these indicators are connected with hormonal status and metabolism.
Next an examination of the genitals is carried out: the structure of the penis, the position of the urethral opening, the size and consistency of the testicles, the condition of the epididymes and spermatic cords are assessed. Testicular volume is measured with an orchidometer or using ultrasound. Reduced, soft testicles may indicate impaired spermatogenesis or suppression of gonadotropins.
A mandatory element is the search for varicocele, that is, dilation of the veins of the spermatic cord. It is assessed in a standing position, in particular during straining. In older men or in the presence of urinary complaints, the doctor may perform a digital rectal examination of the prostate.
Laboratory tests
The basis of hormonal diagnostics is total testosterone, determined in the morning on an empty stomach. The Endocrine Society guidelines (2018) recommend confirming a low result with a repeat test, since the hormone level fluctuates over the course of the day and from day to day. A single low value is not yet a diagnosis.
If the testosterone level is low or borderline low, LH and FSH are determined. They make it possible to distinguish primary hypogonadism (the problem is in the testicles, gonadotropins are high) from secondary (the problem is in the hypothalamus or pituitary, gonadotropins are low or «normal» against a background of low testosterone). Further tactics depend on this.
| Indicator | Why it is determined |
|---|---|
| Total testosterone | Basic assessment of androgen status |
| SHBG, free testosterone | When total testosterone is borderline or the SHBG concentration is altered (obesity, age, liver diseases) |
| LH, FSH | Level of the lesion: testicles or pituitary |
| Prolactin | Exclusion of hyperprolactinemia in secondary hypogonadism and decreased libido |
| Estradiol | Gynecomastia, obesity, androgen intake |
| TSH, glucose/HbA1c, lipids | Concomitant endocrine and metabolic disorders |
| Complete blood count, PSA | Baseline data before possible therapy |
As indicated, other studies are added: ferritin (exclusion of hemochromatosis), inhibin B and AMH as markers of Sertoli cell function, genetic tests — karyotype (Klinefelter syndrome) and Y-chromosome microdeletions in severe disorders of spermatogenesis.
For couples planning a child, the laboratory examination also includes screening for sexually transmitted infections, according to local protocols.
Spermogram and instrumental diagnostics
The spermogram is the key study in assessing male fertility. It is performed according to the standards of the WHO Laboratory Manual for the Examination of Semen (sixth edition, 2021). The ejaculate volume, the concentration and total count of sperm, their motility, morphology and viability are assessed.
Because of significant biological variability, one «bad» result is not a verdict. In case of deviations the test is usually repeated. The spermatogenesis cycle lasts approximately 70–75 days, so the effect of lifestyle changes or treatment is assessed no earlier than after 2–3 months.
Ultrasound of the scrotal organs with Doppler imaging makes it possible to assess the volume and structure of the testicles, detect cysts, microcalcifications, tumors, and confirm varicocele. Transrectal ultrasound of the prostate is prescribed when obstruction of the ejaculatory ducts is suspected (for example, with a small ejaculate volume) or with prostate problems.
In erectile dysfunction, questionnaires may be used (in particular the International Index of Erectile Function, IIEF), Doppler imaging of the penile vessels, an assessment of cardiovascular risk factors. Erectile dysfunction is often an early marker of atherosclerosis, so the doctor may refer the patient to a cardiologist.
Preparation and specifics for athletes
Blood for hormones is taken in the morning, usually before 10–11 o'clock, on an empty stomach, after normal sleep. The day before, it is advisable to avoid exhausting training, alcohol and significant sleep deprivation — all of this can temporarily lower testosterone. If you take biotin in high doses, warn the laboratory: it can distort the results of some immunoassays.
For a spermogram, sexual abstinence of 2–7 days is considered the standard. For several weeks before the test it is worth avoiding overheating (sauna, hot baths), and in case of an acute illness with high temperature — postpone the study, because fever temporarily worsens sperm parameters.
- bring with you a list of all medications, supplements and hormonal drugs, including those used in the past;
- previous test and spermogram results — to assess the dynamics;
- data on the training regimen, calorie deficit, changes in body weight;
- if possible — the results of the partner's examination.
Athletes with a prolonged energy deficit should know that a chronic lack of energy can lower testosterone even without any drugs. Therefore «low testosterone» in a lean athlete does not always mean disease — sometimes it is enough to restore nutrition. Correct interpretation requires the full picture.
After the use of androgenic anabolic steroids, the results of hormonal tests can be distorted for months. The doctor assesses the time since the last intake, the level of gonadotropins and the sperm parameters in order to understand whether the axis is recovering on its own. Self-treatment with «restorative» drugs without supervision only complicates diagnosis.
Editorial conclusions
An andrological examination is not a single test but a sequential process: conversation, examination, hormones, and if needed a spermogram and ultrasound. Each stage answers a specific question, and there is no sense in skipping basic steps in favor of «extended panels».
A diagnosis of low testosterone is made only with a combination of symptoms and repeatedly confirmed laboratory data with determination of LH and FSH. Self-prescribing hormones «by feel» can mask the cause and worsen fertility.
For athletes it is especially important to prepare correctly for the tests and to tell the doctor openly about the training regimen, diet and all substances used.
Related topics on our blog: «Stress and Libido», «Obesity and Estrogen in Men» and «Prostate and Strength Training».
References
- World Health Organization. WHO laboratory manual for the examination and processing of human semen. 6th ed. Geneva: WHO; 2021.
- Bhasin S, Brito JP, Cunningham GR, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(5):1715–1744.
- European Association of Urology. EAU Guidelines on Sexual and Reproductive Health. Arnhem: EAU; актуальна редакція.
- Rosen RC, Riley A, Wagner G, et al. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49(6):822–830.
- Rahnema CD, Lipshultz LI, Crosnoe LE, et al. Anabolic steroid-induced hypogonadism: diagnosis and treatment. Fertil Steril. 2014;101(5):1271–1279.
- Nieschlag E, Behre HM, Nieschlag S (eds). Andrology: Male Reproductive Health and Dysfunction. 3rd ed. Berlin: Springer; 2010.
Andriy Melnyk
A strength-sports coach and author of programs for beginner and intermediate levels. Writes about training planning.
