Male Factor Infertility: Causes, Semen Analysis and Treatment

What is male factor infertility?

Male factor infertility means a problem with the production, quality or delivery of sperm is contributing to a couple’s difficulty conceiving. It is common, and it is often found alongside a female factor. That is why both partners should be evaluated early, ideally at the same time.

Causes

• Sperm production problems, which can come from hormonal imbalances, genetic conditions or past testicular injury, infection or cancer treatment.
• Varicocele, an enlargement of veins in the scrotum that is common and sometimes affects sperm quality.
• Blockages in the tubes that carry sperm, including after vasectomy or infection.
• Ejaculation problems, such as retrograde ejaculation.
• Medications and substances, including testosterone therapy, anabolic steroids, some prescription drugs, tobacco, heavy alcohol and cannabis.
• Heat and environment, such as frequent hot tub use or occupational heat exposure.
• Age, which can reduce sperm quality gradually.

In some men no clear cause is found.

The semen analysis

The first test is a semen analysis, a simple, non-invasive test done after a few days of abstinence (typically 2 to 7 days, but follow the lab’s instructions). It reports:

• Volume of semen
• Concentration and total count of sperm
• Motility, the share of sperm that move, and how well
• Morphology, the share with a typical shape

Because results vary from day to day, an abnormal result is usually repeated after a few weeks. A semen analysis can be done at a lab, a clinic or, with some programs, at home with a mailed kit. See male fertility testing.

Further evaluation

If the semen analysis is abnormal, a urologist, ideally one with reproductive training, may examine for a varicocele and order blood tests (FSH, LH, testosterone, prolactin), genetic testing or imaging.

Treatment options

• Lifestyle changes and stopping harmful substances. See partner health.
• Treating infections and adjusting or stopping medications that reduce sperm.
• Surgery such as varicocele repair or reversal of blockages. See fertility surgery.
• IUI for mild problems.
• IVF with ICSI, in which a single sperm is injected into each egg, for more significant problems.
• Surgical sperm retrieval from the testicle or epididymis when no sperm are found in the ejaculate.
• Donor sperm when other options are not suitable or not wanted.

Understanding semen analysis terms

Reports can read like a foreign language, so a short glossary helps.

• Oligospermia means a lower than expected sperm concentration.
• Asthenospermia means reduced motility.
• Teratospermia means a higher proportion of abnormally shaped sperm.
• Azoospermia means no sperm in the ejaculate, which has different causes: a blockage or a problem with production.
• Oligoasthenoteratospermia (OAT) combines all three.

Morphology results in particular vary between labs because the criteria are strict, so an abnormal-shape result alone does not always carry the weight people fear.

When a urologist is needed

A reproductive urologist is a specialist in male fertility. Referral makes sense if the semen analysis is abnormal on repeat testing, if sperm are absent, if there is pain or swelling in the testicles, if there is a history of testicular injury, surgery or undescended testicle, or if hormone levels are abnormal. The urologist will take a history, examine the testicles and look for a varicocele, and may order blood tests and genetic tests.

Genetic causes

In men with very low or absent sperm counts, genetic causes are more common. Tests may look at the karyotype (chromosomes) and for small deletions on the Y chromosome, and may check for changes in genes linked to cystic fibrosis and absence of the vas deferens. These tests matter for treatment planning and for understanding what might be passed to a child. Genetic counseling helps people interpret results and plan.

Hormonal causes

Sperm production depends on hormones from the brain and pituitary (FSH and LH) and testosterone made in the testes. Problems anywhere along that chain can reduce sperm production. Some are treatable with medication. It is important to note that supplemental testosterone suppresses the brain’s signals and can lower sperm production, so it is not a treatment for male infertility. Clinicians sometimes use other medications that raise the body’s own signals, and the choice should be made with a specialist.

Lifestyle changes that are worth the effort

Because sperm take about three months to develop, healthy changes take time to help. The most evidence-supported steps are to stop smoking, limit alcohol, avoid anabolic steroids, manage weight, treat infections, and avoid prolonged heat exposure. Our guide to partner health covers each. Be cautious about supplements marketed for sperm: evidence is mixed, and some products are not well regulated.

Emotional aspects

Male infertility is often under-discussed. Men may feel shame, pressure to hide it, or a sense of failure, and their partners may feel unsure how to talk about it. It helps to remember that sperm health is a medical issue, not a measure of masculinity. Open conversations, counseling, and peer communities can reduce isolation. See stress and emotional health.

Questions to ask

• What do my semen analysis results mean for our chances?
• Should I see a urologist, and what tests will they order?
• Could a medication or supplement I take be affecting sperm?
• Is a procedure such as varicocele repair likely to help in my case?
• Which treatment fits best: IUI, IVF with ICSI, or surgical sperm retrieval?

When to get tested

Ask for a semen analysis at the start of any fertility evaluation, and sooner if there is a history of testicular problems, surgery, cancer treatment or use of testosterone. Learn more in fertility testing.