Male Infertility

Male infertility affects approximately one in seven couples trying to conceive, with the male partner being solely or partially responsible in about half of all infertility cases. While the inability to have a biological child can be emotionally challenging, many treatment options and assisted reproductive technologies are available to help couples achieve pregnancy.

Table of contents

• What is male infertility?
• How common is the condition?
• Signs and symptoms
• Causes and risk factors
• Diagnosis and testing
• Treatment options
• Emotional and psychological impact
• Lifestyle changes to improve fertility

What is male infertility?

Male infertility is defined as the inability of a male to make a fertile female pregnant after at least one year of regular unprotected sexual intercourse^[1]. It is a condition that affects the male reproductive system and interferes with its ability to impregnate a female partner^[2].

When a couple cannot conceive after one year of trying (or six months if the woman is over 35 years old), there may be a fertility problem. The male partner is solely responsible in about 20 percent of cases and is a contributing factor in another 30 to 40 percent of all infertility cases^[3]. This means that overall, the male factor substantially contributes to about 50 percent of all cases of infertility^[3].

How common is the condition?

Infertility is a widespread issue affecting millions of people. Approximately one in six couples experience fertility difficulties^[8]. Infertility affects 186 million people worldwide, and the male partner is the cause in about half of the cases^[2].

Some studies show that male infertility affects about 10 to 15 percent of males in the United States who are trying to conceive^[2]. The condition affects at least 180 million couples worldwide^[3].

It’s important to understand that conception is not an easy process. The human species is considered a species with low reproductive capacity. A fertile and young couple, for every month of regular intercourse, has only a 20 to 25 percent chance of conceiving^[2].

Signs and symptoms

The main sign of male infertility is the inability to conceive a child. In many cases, there may be no other obvious signs or symptoms^[1]. The primary symptom is being unable to have a biological child after repeated unprotected sexual intercourse for over a year^[2].

However, in some cases, an underlying problem such as an inherited disorder, hormonal imbalance (a condition where the body produces too much or too little of certain hormones), or a condition that blocks the passage of sperm causes additional signs and symptoms. These may include^[1]:

• Problems with sexual function, such as difficulty with ejaculation or small volumes of fluid ejaculated
• Reduced sexual desire or difficulty maintaining an erection (erectile dysfunction, the inability to get or keep an erection firm enough for sexual intercourse)
• Pain, swelling, or a lump in the testicle area
• Recurrent respiratory infections
• Inability to smell
• Abnormal breast growth (gynecomastia, enlargement of breast tissue in males)
• Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
• A lower than normal sperm count (fewer than 15 million sperm per milliliter of semen or a total sperm count of less than 39 million per ejaculate)^[1]

Sometimes, male infertility can be associated with low production of testosterone from the testicles. In this case, symptoms such as tiredness, impotence, depression, weight gain, and apathy may occur^[2].

Causes and risk factors

Male infertility can be caused by multiple biological and environmental factors. The major causes include obstructions to the passage of sperm, problems with sperm quality or quantity, functional problems, and hormonal issues^[8].

Main causes of male infertility

Male infertility can result from^[2]:

• Sperm problems, including malformed sperm, low sperm count (oligospermia, when semen contains fewer sperm than normal), and the absence of sperm in semen (azoospermia, a condition where no sperm are present in the ejaculate)
• Genetic disorders, including Klinefelter syndrome and myotonic dystrophy
• Some medical conditions, including diabetes, certain autoimmune diseases that attack sperm, and cystic fibrosis
• Infections, including epididymitis (inflammation of the tube at the back of the testicle), orchitis (inflammation of one or both testicles), and sexually transmitted infections, including gonorrhea or HIV
• Swollen veins in the testicles (varicoceles, enlarged veins in the scrotum that can affect sperm production and quality)
• Cancer treatments, including chemotherapy, radiation therapy, or surgical removal of the testicles
• Testicular trauma
• Hormonal disorders that affect the hypothalamus or pituitary glands

Blockages or absences of tubes, including the vas deferens (the tube that carries sperm from the testicles), are the cause of around one in three cases of male infertility. These blockages or absences may be present since birth or due to vasectomy or injury^[8].

Risk factors

Any male may have infertility, but the chances of having male infertility may be higher if you^[2]:

• Have a body mass index greater than 25 (overweight or obesity)
• Are 40 or older
• Have been exposed to radiation

There are a number of medical conditions that put patients in a high-risk group for male infertility. These include endocrine disorders or hormone imbalances, physical injury to the testicle, undescended testicles, surgery on the testis or in this area (such as hernia repairs), exposures to toxic chemicals including chemotherapy or radiation, physical blockage of the sperm delivery routes, and use of testosterone or other anabolic steroids^[5].

Some lifestyle habits may put a man at higher risk for infertility. They include^[5]:

• Smoking: Tobacco use has been shown to damage sperm and also to limit the chances of survival for embryos that are created
• Excessive alcohol consumption: Drinking to excess can lower testosterone levels and cause erectile dysfunction
• Exposure to heat: Spending too much time in the sauna or hot tub can lead to lower sperm counts. Patients are also warned against working with laptop computers on their laps
• Poor diet: Recent studies have shown that poor diets—those high in saturated fats and low in nutrients—can decrease sperm production
• Stress: Just as unmanaged stress can wreak havoc on the body as a whole, it can contribute to a male fertility problem
• Drugs: From marijuana to anabolic steroids to the whole family of opiates, many medications or illicit drugs are linked to lower sperm counts

• Testicles
• Epididymis
• Vas deferens
• Ejaculatory duct
• Prostate gland
• Seminal vesicles
• Urethra
• Penis
• Hypothalamus
• Pituitary gland

Diagnosis and testing

It is important to be evaluated if you think you have male infertility issues because there may be treatable or reversible procedures available. The initial evaluation will include a semen analysis, and if abnormal, a referral to a reproductive urologist is recommended^[5].

Initial evaluation

Diagnosing male infertility problems usually involves^[10]:

General physical examination and medical history: This includes examining your genitals and asking questions about any inherited conditions, chronic health problems, illnesses, injuries, or surgeries that could affect fertility. Your doctor might also ask about your sexual habits and about your sexual development during puberty.

The first step in evaluation involves a detailed patient history questionnaire and physical examination. This step is important because a small number of patients will present with a serious condition (such as testis cancer, brain tumor, etc.) or a significant medical condition such as diabetes^[5].

The physical examination may identify enlarged veins or a varicocele that can be treated to improve semen quality^[5].

Semen analysis

Semen analysis is a key diagnostic test. Semen samples can be obtained in a couple of different ways. You can provide a sample by masturbating and ejaculating into a special container at the doctor’s office. Because of religious or cultural beliefs, some men prefer an alternative method of semen collection. In such cases, semen can be collected by using a special condom during intercourse^[10].

Your semen is then sent to a laboratory to measure the number of sperm present and look for any abnormalities in the shape (morphology, the form and structure of sperm) and movement (motility, the ability of sperm to move properly) of the sperm. The lab will also check your semen for signs of problems such as infections^[10].

A comprehensive semen analysis includes^[9]:

• Sperm volume: Amount of sperm per ejaculate
• pH: A measurement of acidity or basicity
• Sperm concentration: Number of sperm per milliliter of semen
• Total sperm count: Number of sperm in the whole ejaculate
• Velocity: How fast the sperm travels
• Motility: The percentage of sperm that are moving
• Morphology: The shape and structure of the sperm

Normal semen values are based on men who achieved pregnancy within a year. These values include: volume of at least 1.5 milliliters, sperm count of 15 million per cubic centimeter, 40 percent motility, and 4 percent normal forms^[22].

Often sperm counts fluctuate significantly from one specimen to the next. In most cases, several semen analysis tests are done over a period of time to ensure accurate results^[10].

Additional testing

Blood tests may be recommended to identify hormone imbalances or genetic abnormalities^[5]. An optional scrotal ultrasound can be performed if abnormalities are found^[3].

Couples will meet to discuss their medical history, physical examination findings coupled with the results of blood tests and semen analyses, including semen volume, sperm concentration, motility, and sperm morphology^[5].

Treatment options

Treatments will vary depending on the cause of the infertility. A number of treatments are available for male infertility, and many couples treated for infertility are able to have babies^[6].

Nonsurgical treatments

Lifestyle changes: There is increasing evidence that lifestyle can have a large impact upon male fertility. Weight loss and regular exercise can have a direct, positive effect on hormone levels and sperm production. Quitting smoking, including tobacco and marijuana, can have similar effects^[12].

Medication: Medical therapies can be very effective for men with certain causes of infertility, such as hormonal abnormalities. A regimen of drugs may be used to improve sperm production, correct hormone imbalances, treat infections that affect sperm, or bolster testosterone^[5].

For men with low testosterone, a number of medications, such as clomiphene citrate, human chorionic gonadotropin, and anastrozole, can help to boost the body’s natural production of testosterone. It’s important to note that testosterone supplementation through gels, injections, or other methods can have a negative effect on fertility^[12].

Surgical treatments

Varicocele repair (varicocelectomy): A varicocele is the condition of varicose veins surrounding the testicle. When these veins become enlarged, they trap blood around the testicle, which can damage sperm through heat and other mechanisms. A microsurgical procedure can ligate the enlarged veins, which can lead to healthier semen and even the possibility of natural conception as soon as three months after the procedure^[12].

Sperm extraction: For men who do not have any sperm in their ejaculate, sperm extraction may be an appropriate option. During this procedure, a surgical microscope is used to open the testicle and extract sperm, if they are present. These sperm can then be used to fertilize an egg through in vitro fertilization^[12].

Vasectomy reversal: Men who have had a vasectomy have a blockage that does not allow sperm in the ejaculate. Vasectomy reversal is a good option for these men. Using a surgical microscope, the two ends of the vas deferens are repaired using very small sutures the size of a human hair. If the reversal is successful, men may be able to conceive naturally with their partner^[12].

Transurethral resection of the ejaculatory duct: Some men with infertility may have a blockage in the prostate or ejaculatory duct. Using a small camera through the urethra, a number of techniques can be used to open the obstruction and restore the path for semen to exit the body^[12].

Assisted reproductive technologies

Treatment options for poor sperm quality include inseminating the man’s partner with a concentrated sample of the man’s semen and intracytoplasmic sperm injection (ICSI), where the woman’s eggs are retrieved and a single sperm is injected into each egg using a microscopic needle^[8].

Many couples now conceive through in vitro fertilization (IVF), a process where eggs are fertilized by sperm outside the body. In fact, in the past 30 years, 1 million IVF babies have been born in the United States^[17].

Emotional and psychological impact

The inability to conceive a child can be stressful and frustrating^[1]. Finding out that you are infertile can be a devastating experience. A man might feel less male and as if they have failed. Some men believe that their masculinity is wrapped up in their ability to give their partner a child, and so feeling that they have lost that ability can produce strong negative emotions^[17].

The primary symptom of male infertility is being unable to have a biological child. But male infertility can also lead to many psychological and emotional symptoms, including feelings of depression, loss, grief, inadequacy, and failure^[2].

Men and women tend to respond to the experience of infertility differently: historically, women have thought that men deal with the issue easier, but in reality, men are simply less likely to open up about their emotions^[17].

If you or your partner experiences any of these feelings, it’s a good idea to talk to a therapist or psychiatrist^[2]. Talking with an infertility specialist also helps you to realize that you are not alone^[17].

Lifestyle changes to improve fertility

What is good for general health is good for sperm health^[5]. There are several lifestyle changes that can improve male fertility.

Diet and nutrition

One of the first steps doctors recommend is improving your diet. Eat more dark vegetables, fruits, and high-protein foods and increase your intake of polyunsaturated fats from sources such as tree nuts^[21]. A diet full of whole foods can improve your fertility. Minimizing or avoiding ultra-processed foods and sugar is also helpful^[19].

Plenty of foods offer a hefty dose of antioxidants, including fruits, vegetables, nuts, and seeds. Some research suggests that antioxidants have a positive effect on male fertility^[19].

Weight and exercise

Losing excess weight is important because obesity causes decreased testosterone. In addition, bigger thighs can increase the temperature of the scrotum (where the testicle is held) and decrease sperm production^[21].

Exercising for 30 minutes or more each day is beneficial because improved metabolism means better sperm production^[21].

Avoiding harmful substances

Quitting smoking can boost your chances of conceiving and your health in general. A study found that men who quit smoking saw improvements in their sperm count, quality, and motility^[19].

If you drink alcohol, stick to a moderate amount. For men, this is two drinks per day or less. Regularly drinking more than this can lower your testosterone levels and sperm production^[19]. Limiting alcohol consumption to two drinks a day is recommended; binge drinking can impair sperm production for months^[21].

Temperature management

Sperm quality depends on the right temperature—about two degrees cooler than body temperature. To maintain this balance, the testicles naturally drop slightly away from the body when things get too warm. To maximize your fertility, avoid anything that might heat the scrotum area. Don’t place laptops or other electronic devices on your lap, and avoid hot environments like saunas, hot tubs, and hot yoga. Also, avoid tight underwear that keeps the testicles too close to your body^[19].

Other recommendations

Getting six or more hours of sleep each night helps reduce stress and recharge the pituitary gland, which is responsible for sperm production. Taking a prenatal vitamin designed for men may improve sperm health^[21].

Minimizing exposure to chemicals is also helpful. Pesticides, heavy metals, bisphenol A, and other toxins may harm sperm and male fertility. You can lower your chemical exposure by avoiding fragrances and air fresheners, harsh cleaning chemicals, outdoor exercise during rush hour when pollution is highest, paints and solvents, pesticides and herbicides, and products that contain BPA, such as some plastic water bottles and canned foods^[19].