Nobody has actually examined me

Why is examining the man important?

A physical examination can identify information that no semen analysis can provide, including:

• testicular size and consistency;
• a palpable varicocele;
• absence or abnormality of the vas deferens;
• epididymal enlargement suggesting obstruction;
• previous surgical or developmental abnormalities;
• penile or scrotal pathology;
• features suggesting an endocrine or genetic condition.

Sometimes the examination changes treatment directly. A clinically palpable varicocele with abnormal semen parameters, for example, may be considered for repair in selected couples trying to conceive naturally.²

In other situations, the examination helps decide which further tests are justified.

What do current guidelines say?

The 2025 European Association of Urology guideline emphasises a thorough urological assessment of all men seeking medical help for fertility problems.³

NICE became more explicit in March 2026. If a man has two or more abnormal semen analyses, NICE recommends offering physical examination of the scrotum and testes and considering serum testosterone and gonadotrophin testing.⁴

So the modern direction of guidance is clear: persistent abnormal semen results should trigger assessment of the man, not simply referral of the couple onward to IVF.

What should a male fertility history cover?

A proper history is broader than “How long have you been trying?” It should usually include:

Reproductive history

• previous pregnancies with any partner;
• duration of infertility;
• timing and frequency of intercourse;
• previous fertility treatment.

Childhood and developmental history

• undescended testes;
• orchidopexy;
• testicular torsion or trauma;
• childhood hernia surgery;
• mumps orchitis.

Medical and surgical history

• chemotherapy or radiotherapy;
• pelvic, inguinal or scrotal surgery;
• diabetes and other systemic illness;
• infections and sexually transmitted infections.

Medications and hormones

One particularly important question is the use of testosterone replacement therapy or anabolic steroids. Exogenous testosterone can suppress LH and FSH from the pituitary and dramatically reduce or even stop sperm production. A man trying to conceive should not simply be prescribed testosterone for a low blood result without considering fertility goals.

Sexual and ejaculatory function

Erection, ejaculation, libido and intercourse frequency can all affect conception and may also identify endocrine or neurological disease.

Lifestyle and occupational exposures

Smoking, recreational drugs, obesity, significant heat exposure and other factors may be relevant—but should be discussed proportionately rather than used to blame the patient.

Should every man have hormone tests?

Not necessarily every man, but hormones are particularly useful when sperm concentration is markedly reduced, azoospermia is present, testicular size is abnormal or symptoms suggest androgen deficiency.

Common tests include:

• FSH;
• LH;
• morning testosterone;
• sometimes prolactin or other targeted tests.

The pattern helps distinguish failure of the testes to produce sperm from inadequate hormonal stimulation from the brain/pituitary.

What about genetic tests?

In severe male-factor infertility, genetics can be central.

NICE 2026 recommends:⁴

• Y-chromosome microdeletion testing in idiopathic azoospermia or sperm concentration below 1 million/mL;
• karyotype testing in idiopathic azoospermia, and consideration when persistent sperm concentration is below 5 million/mL;
• CFTR testing where obstructive azoospermia or an abnormal/absent vas deferens is suspected.

These results can affect whether sperm retrieval is likely to work, whether a genetic condition might be transmitted, and whether genetic counselling is appropriate.

Do I need a scrotal ultrasound?

Not every man does.

Ultrasound can be valuable when the examination is uncertain, there is testicular asymmetry or a mass, pain, previous surgery, or a question about anatomy. But ultrasound should complement clinical assessment, not replace it.

This distinction is important for varicocele. Current NICE recommendations refer specifically to a varicocele detected on clinical examination in men with reduced semen parameters who are trying naturally.² An incidental tiny vein found only on ultrasound is not automatically a reason for intervention.

How often are men reaching ART before specialist male assessment?

More often than many patients assume.

A cohort of 8,962 men attending a male-fertility specialty clinic found that 1,545 men—17.2%—had already undergone IUI or IVF before specialist male evaluation.⁵

This does not prove that those ART cycles were unnecessary. Female age and other couple factors can make immediate ART entirely appropriate. But it does demonstrate a structural issue: assisted conception can sometimes become the treatment for the couple before the male diagnosis has been fully investigated.

Why does this matter beyond fertility?

Male infertility can occasionally be a marker of wider health problems. The EAU guideline highlights associations between male infertility and later health risks and recommends using the fertility assessment as an opportunity to identify modifiable or significant medical conditions.³

The clinician survey authors also noted that around 1% of men presenting with infertility have been reported to harbour a serious medical condition such as cancer, endocrine disease, systemic disease or a genetic syndrome.¹

That does not mean fertility patients should be frightened. It means that the man deserves to be treated as a patient, not merely as the provider of a specimen.

What should I ask if I feel my side has not been assessed?

Useful questions include:

1. Has my semen analysis been repeated if it was abnormal?
2. Do I need a physical examination of my testes and scrotum?
3. Do my semen results justify hormone or genetic tests?
4. Is there a potentially treatable male cause?
5. Would seeing a urologist/andrologist change our management?
6. How does the female partner’s age affect how much time we have to investigate or treat me before ART?

These are not demands for unnecessary testing. They are reasonable questions about whether the male factor has been characterised properly.

How strong is the evidence?

The finding that men are sometimes under-assessed comes from an international clinician survey rather than a population audit, so the exact percentage should not be assumed to represent every fertility service.¹

However, the conclusion is consistent with current EAU guidance, NICE recommendations and observational data showing ART can precede specialist male-factor assessment.[3–5]

Bottom line

If you have had abnormal semen analyses but nobody has actually examined you, it is reasonable to ask whether your male fertility work-up is complete.

IVF and ICSI are extraordinarily valuable treatments, and sometimes they are the fastest or best route. But assisted reproduction should not automatically substitute for diagnosing the male partner.

A semen sample is part of the assessment. You are the patient.

An examination takes four minutes and can find a varicocele, absent vasa, small testes or a mass. None of those show up on a semen analysis, and the last one matters a great deal. If you have been through fertility treatment without being examined, that is not a small omission and you are entitled to say so.