What is cryptorchidism and how does it affects fertility?

When considering male fertility, not only semen quality needs to be taken into account. There are other conditions that can influence a man’s reproductive capacity. One of these is cryptorchidism, a condition that is more common than it may seem, originates before birth and, if not treated in time, can have consequences for fertility.

Understanding what cryptorchidism is, how it is related to fertility and what options there are available to address it, even in adulthood, is essential in order to make informed decisions about reproductive health.

What is cryptorchidism?

Cryptorchidism is a developmental condition in which one or both testicles have not descended correctly into the scrotum before birth. In most cases it is unilateral, and it commonly affects the right testicle.

Under normal circumstances, the testicles descend from the abdomen into the scrotum during the final trimester of pregnancy. When this descent is not completed, the testicle may remain in the abdomen, in the inguinal canal or in an abnormal position. Cryptorchidism therefore refers to this lack of testicular descent.

This congenital malformation is relatively common in newborns, especially premature babies. In many cases, the testicle eventually descends spontaneously during the first 12 months of life. If this does not happen, medical follow-up is important, as it may compromise the child’s future fertility.

Risks to fertility

The relationship between cryptorchidism and fertility is well known. When the testicle is not located in the scrotum but in the abdomen, it is exposed to a higher temperature, which can damage the germ cells responsible for producing sperm cells.

The main risks to fertility include:

· Altered sperm production.

· Reduced semen quality.

· Increased risk of male infertility, particularly in cases of bilateral cryptorchidism.

· Increased risk of irreversible testicular damage if not treated in time.

These fertility risks associated with cryptorchidism are reduced if surgery (orchidopexy) is performed during the first two years of life. The later it is corrected, the greater the likelihood of developing testicular atrophy or a low sperm count in adulthood.

Why does it affect fertility?

Cryptorchidism affects fertility due to a series of biological and degenerative changes that occur when the testicle is not in its correct location.

The main reasons are:

· Inappropriate temperature: The testicles must be between 2 and 3 °C below body temperature for spermatogenesis (sperm production) to occur normally. If the testicle is not in the scrotum but in the abdomen, excess heat can damage the germ cells, which are the precursors of future sperm cells.

· Histological changes: Over time, if the testicle has not descended, it may develop fibrosis and testicular atrophy, meaning that it decreases in size. If this atrophy continues and is not corrected in time, the Sertoli and Leydig cells, which are essential for nourishing sperm cells and producing testosterone, may be lost.

· Hormonal failure: Cryptorchidism may be linked to a deficiency of gonadotrophins (FSH and LH) from birth. This hormonal failure may prevent the testicle from maturing correctly and from being able to produce good-quality semen in adulthood.

· Autoimmune response: Different studies have shown that cryptorchidism can trigger an immune-system reaction against the body’s own sperm antigens, creating antibodies that attack sperm cells, even after successful surgery.

Diagnosis and when to act

Cryptorchidism is usually diagnosed during the first check-ups of the newborn through a physical examination involving palpation of the scrotal sac and then of the abdominal area and inguinal canal in order to locate the testicle or testicles. In some cases, imaging tests may be needed to locate the undescended testicle.

If the testicles cannot be located using any of these tests, laparoscopic surgery will be required. This surgical technique allows the surgeon to look inside the abdomen to diagnose non-palpable testicles and, often, to correct the problem during the same procedure.

When should action be taken in cases of cryptorchidism? Ideally, it should be addressed as early as possible to minimise the potential consequences for fertility. Current recommendations are:

· 0 to 6 months: Observation is recommended, as in many cases the testicles descend spontaneously during the first 3 to 4 months of life.

· 6 to 12 months: If the testicle has not descended by 6 months, it is very unlikely to do so on its own. This is the ideal time for surgery (orchidopexy).

· 18-month limit: Specialists agree that surgery should not be delayed beyond 18 months, as from this age onwards cellular damage caused by body heat starts to become irreversible.

Treatment options

The most common treatment for cryptorchidism is orchidopexy, a surgical procedure that involves permanently placing the testicle in the scrotum. It is a safe operation with good outcomes, especially when performed at an early age (before two years of age).

In selected cases, hormonal treatment may be considered, although its effectiveness is limited and depends on each clinical situation.

Is there treatment in adulthood? From the age of 20 or 30 onwards, the approach to treating cryptorchidism changes radically: the aim is no longer to preserve fertility (which is usually already compromised), but to prevent testicular cancer. For this reason, the most recommended option is removal of the testicle (orchiectomy). It should be noted that a testicle that has spent decades outside the scrotum has a higher risk of developing malignant tumours. In addition, at this age the testicle is usually already very atrophied and is not functional for producing good-quality sperm.

Cryptorchidism, fertility and assisted reproduction

In adulthood, many men discover the relationship between cryptorchidism and fertility when they experience difficulties achieving a pregnancy. Even after successful surgery in childhood, semen quality may be insufficient for natural conception. This is especially the case if the cryptorchidism was bilateral (in both testicles) or if surgery was performed late.

In these cases, assisted reproduction makes it possible to overcome many of the reproductive problems associated with cryptorchidism. At Tambre, the study and treatment of male fertility is carried out in a highly specialised way thanks to our own Andrology laboratory, equipped with advanced technology and specialist professionals. This approach allows us to analyse semen quality, testicular function and the real impact that cryptorchidism has had on each patient with precision.

Depending on each case, advanced techniques such as in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) may be indicated, making it possible to achieve pregnancy even when sperm quantity or quality is altered.

In more complex situations, when the semen analysis shows no sperm cells or severe abnormalities are present, it is also possible to obtain sperm cells directly from the testicle using specific techniques, such as testicular biopsy (TESE). This simple surgical procedure allows tissue to be extracted from the testicle through small incisions. This tissue is processed in our Andrology laboratory in order to recover the sperm cells needed for in vitro fertilisation. The sperm cells obtained can be frozen and/or used fresh in a fertility treatment using the ICSI technique. In this way, through testicular biopsy, men with no sperm cells in the ejaculate (azoospermia) may have the opportunity to become fathers using their own gametes.

If you have any questions about how cryptorchidism may affect fertility or need a specialist assessment, contact Tambre. At our clinics in Madrid and Alicante, you will have access to specialised teams for complex fertility cases, who will study your case and guide you on the most suitable options to help you achieve pregnancy despite cryptorchidism or other male infertility or sterility problems.

Frequently asked questions about cryptorchidism and fertility