Male Infertility: Causes, Options & IVF

Male infertility is defined as the inability to achieve pregnancy after 12 months of regular, unprotected intercourse due to male factors - specifically, issues with sperm production, sperm function, or sperm delivery. It affects approximately 7% of all men (WHO), and global sperm counts have declined by roughly half since the 1970s, according to the systematic review and meta-regression by Levine and colleagues published in Human Reproduction Update in 2023 (PMID 36377604).

Yet in most fertility clinics, the male partner's testing is an afterthought - performed weeks or months after the female partner has already undergone invasive testing and treatment. This approach wastes time and resources. Both partners should be evaluated simultaneously from day one.

A Semen Analysis Is a Health Test, Not Only a Fertility Test

This is the part that gets skipped when infertility is treated purely as a route to IVF, and it is the reason the examination matters as much as the sample.

Men with impaired fertility have a higher rate of testicular cancer than men without it. It remains uncommon, and the point is not to frighten anyone - it is that an infertility work-up is one of the few times a man in his thirties gets his testicles examined by a doctor, and a scrotal ultrasound looking for a varicocele will also show a mass if there is one. That is a good reason to have the examination and the scan rather than jumping to a sperm sample and a treatment plan.

Between appointments, anything you can feel yourself - a lump, a hard area, one testicle changing in size or weight, or a persistent ache - should be seen promptly rather than mentioned at the next scheduled visit. Caught early, testicular cancer is one of the most treatable there is, and treatment may also affect fertility, which is a reason to raise sperm freezing at that point rather than afterwards.

The wider point holds too: an abnormal semen analysis can be the first sign of a hormonal or general health problem that has nothing to do with wanting a child. A urologist or andrologist should be part of the work-up, not an optional extra once IVF is already booked.

What Causes Male Infertility?

Varicocele (35-40% of cases)

A varicocele is a dilation of the veins in the spermatic cord (similar to varicose veins in the legs). This dilated venous drainage raises scrotal temperature and creates oxidative stress, impairing sperm production and quality. Varicoceles are present in approximately 15% of all men but in 35-40% of men presenting with infertility.

Treatment: Microsurgical varicocelectomy repairs the dilated veins and improves semen parameters in 60-70% of cases within 6-12 months. This is one of the most evidence-backed and cost-effective interventions in male fertility treatment (Mayo Clinic).

Hormonal Factors (5-10%)

• Hypogonadism: Low testosterone production impairs spermatogenesis. Paradoxically, exogenous testosterone therapy (testosterone replacement) suppresses sperm production and should never be used in men trying to conceive.
• Hyperprolactinemia: Elevated prolactin suppresses GnRH, reducing FSH and LH - the hormones that drive sperm production.
• Thyroid disorders: Both hyper- and hypothyroidism can impair semen quality.

Genetic Causes (10-15%)

• Y-chromosome microdeletions: Deletions in the AZF (Azoospermia Factor) regions of the Y chromosome are found in 10-15% of men with severe oligospermia or azoospermia.
• Klinefelter syndrome (47,XXY): Affects 1 in 500-1,000 males. Causes small testes, low testosterone, and usually azoospermia. Micro-TESE can retrieve sperm in 30-50% of cases.
• CFTR mutations: Mutations in the cystic fibrosis gene can cause congenital bilateral absence of the vas deferens (CBAVD) - leading to obstructive azoospermia.

Why Genetic Testing Needs Genetic Counselling

ICSI works by injecting a single sperm directly into an egg. It bypasses the steps that would normally stop that sperm fertilising anything - which is precisely why it succeeds, and also why the genetic findings above are not just diagnostic labels. They can travel to the child.

• Y-chromosome microdeletions pass to every son. A boy conceived by ICSI from a father with an AZF deletion inherits the same Y chromosome and can be expected to have the same fertility problem. Daughters are unaffected. This is not a reason not to proceed - many couples do, knowing it - but it is something to be told before the cycle, not after.
• CFTR mutations mean your partner needs testing too. Congenital absence of the vas deferens is usually linked to mutations in the cystic fibrosis gene. If your partner also carries a mutation, the child can be born with cystic fibrosis. Her carrier test is part of your diagnosis, and it should be arranged before treatment.
• Karyotype abnormalities can carry a risk of miscarriage or of a chromosomal condition in the child, and the specifics differ case by case.

Any of these findings should come with a referral to a clinical geneticist or genetic counsellor - someone whose job is this conversation, not the doctor who is also arranging your cycle. If a clinic reports a genetic result and moves straight to booking, ask for the counselling referral. Where you are being treated abroad, ask before you travel who provides that counselling, in what language, and whether it happens before the cycle or after the result arrives.

Lifestyle and Environmental Factors (20-30%)

• Obesity: BMI >30 reduces testosterone, increases estrogen, and impairs semen parameters. Weight loss improves fertility.
• Smoking: Reduces sperm count by 13-17% and motility by 10-16%. Effects are reversible with cessation.
• Heat exposure: Laptops on lap, hot baths, tight underwear, prolonged sitting - all raise scrotal temperature. Sperm production requires 2-3°C below body temperature.
• Medications: Anabolic steroids (devastating effect), SSRIs, calcium channel blockers, and some antibiotics can impair fertility.
• Alcohol: Heavy consumption (>15 drinks/week) reduces testosterone and impairs sperm production.

How Is Male Infertility Diagnosed?

Semen analysis is the cornerstone of male fertility evaluation. WHO 2021 reference values:

• Volume: ≥1.4 mL
• Concentration: ≥16 million sperm/mL
• Total count: ≥39 million per ejaculate
• Motility: ≥42% total motility; ≥30% progressive motility
• Morphology: ≥4% normal forms (strict Kruger criteria)

Important: a single abnormal result does not diagnose infertility. Semen parameters fluctuate significantly with illness, stress, abstinence interval, and sample conditions. Two analyses, 2-4 weeks apart, are necessary for accurate assessment.

What Happens at a Male Fertility Work-Up?

Knowing the shape of the assessment in advance makes it less daunting — and makes it easier to ask for the parts that often get skipped.

The semen analysis

Your clinic will give you an abstinence window to follow beforehand. Follow it precisely: the interval materially changes the result. The sample is usually produced at the clinic, because delays and temperature swings in transit degrade it. This is an awkward appointment for most men, and clinics know it — say so if you would rather produce the sample at home, and ask what their transport rules are.

The repeat

One result is not a diagnosis. Parameters swing with illness, fever, stress, sleep, and abstinence, so a single poor sample may simply reflect a bad few weeks. If your first analysis is abnormal and no one has offered a repeat, ask for one.

Examination and history

A urologist or andrologist examines the testes and scrotum — this is how a varicocele is usually found — and takes a history covering childhood surgery, undescended testes, infections, injuries, medication, anabolic steroid use, and occupational heat or chemical exposure. Be candid here. Steroid use in particular is common, often reversible, and easy to miss if no one raises it.

Targeted tests

Depending on what those steps show, your specialist may add a hormone panel, a scrotal ultrasound, genetic testing, or a sperm DNA fragmentation test. None of these are routine for everyone; each should be ordered because something specific prompted it. When a test is suggested, ask what result would actually change your treatment.

What Do Semen Analysis Findings Actually Mean?

A result sheet is not a verdict. Each finding points towards a set of possible causes and a sensible next step rather than a fixed conclusion.

What Are the Treatment Options for Male Infertility?

Lifestyle Optimization (First-Line)

For mild abnormalities, lifestyle changes can produce meaningful improvement within 3-6 months (one full spermatogenesis cycle takes approximately 74 days):

• Weight management, exercise (moderate - not excessive endurance training), smoking cessation, alcohol moderation, heat avoidance, stress reduction, adequate sleep (7-8 hours)
• Antioxidant supplementation: Coenzyme Q10, L-carnitine, zinc, selenium, vitamin C, vitamin E. Trials report some improvement in semen measurements, but the evidence that this translates into more pregnancies or more babies is low-certainty rather than established, and the studies are generally small. They are inexpensive and low-risk, so they are a reasonable thing to try - just not a reason to delay a proper work-up. See our IVF diet and nutrition guide for dietary strategies that support sperm quality.

Medical Treatment

• Varicocelectomy: Microsurgical repair for varicocele. 60-70% improvement rate.
• Hormonal therapy: Clomiphene citrate or gonadotropin injections to boost FSH/LH and stimulate sperm production (for hormonal causes - never exogenous testosterone).
• Antibiotics: For infections (prostatitis, epididymitis) that impair semen quality.

Assisted Reproduction

• IUI (Intrauterine Insemination): For mild male factor - washed sperm placed directly in the uterus. Requires ≥5 million motile sperm post-wash. Our IVF vs IUI comparison explains when each approach is appropriate.
• IVF with ICSI: A single sperm is injected directly into each egg. The established approach for moderate-to-severe male factor infertility (ASRM). ICSI fertilization rates: 70-80% regardless of sperm quality.
• Surgical sperm retrieval: For azoospermia (zero sperm in ejaculate):
  • Micro-TESE: Microsurgical testicular sperm extraction. Uses an operating microscope to identify sperm-producing tubules. Sperm retrieval rate: 40-60% in non-obstructive azoospermia.
  • MESA: Microsurgical epididymal sperm aspiration. For obstructive azoospermia, where sperm production is normal and the blockage is the problem - retrieval succeeds in the large majority of genuine obstruction.

What Drives the Cost of Male Factor Treatment?

Prices cannot be quoted meaningfully in the abstract, but the variables that move them are predictable. Establish which of these apply to you before comparing quotes.

• Depth of diagnosis: a semen analysis is inexpensive. Hormone panels, genetic testing, and DNA fragmentation testing each add to it.
• Whether surgery is involved: varicocele repair and surgical sperm retrieval are separate procedures carrying their own theatre and anesthetic costs.
• ICSI versus conventional insemination: ICSI is a laboratory technique billed on top of the IVF cycle itself.
• Freezing and storage: usually an initial fee plus an ongoing annual one. Check how long the initial fee actually covers.
• How many cycles: the single biggest driver. A quote for one cycle is not a budget.

Questions to Ask Your Urologist or Andrologist

Male evaluation is the part of a fertility work-up most often rushed. These questions are the quickest way to tell whether yours has been thorough.

• Has my analysis been repeated, and did the two results agree?
• Have I been physically examined, and was a varicocele specifically looked for?
• Is there a treatable cause here, or are we working around the problem?
• Would varicocele repair or hormonal treatment be reasonable before moving to ICSI?
• How long would we need to wait before a change in my parameters would show up?
• Is genetic testing indicated for me, and what would we do with the result?
• If no sperm is found in a sample, what is the retrieval plan, and who performs it?
• Should any of my current medications or supplements change?

If the answers are vague, or if your evaluation stopped at a single sample with no examination, it is reasonable to ask for a referral to a urologist who specializes in male fertility.

Male Fertility at Wholecares

Some partner fertility centres have a dedicated andrology department with urologists or andrologists working in reproductive medicine; what is available varies, so ask before you travel who would actually assess you and whether you would see them in person. Where offered, services can include semen analysis, hormonal panels, genetic screening, microsurgical varicocelectomy, micro-TESE, and integrated IVF/ICSI treatment planning.

Male infertility is not a character flaw. It is a medical condition, often treatable, and it deserves the same clinical attention given to female fertility factors - which in practice means being examined and investigated properly rather than handed a sample pot and a price for ICSI.

Two things to establish before travelling for any of this. Ask who provides genetic counselling if a genetic cause is found, in what language, and whether it happens before the cycle. And note that a clinic in Turkey is not HFEA-licensed, so there is no HFEA inspection or complaints route behind the treatment, and any dispute is governed by Turkish law. Sperm DNA fragmentation testing is often offered as an extra; the HFEA does not list it among add-ons shown to improve outcomes, so ask what would change in your treatment as a result of the answer before paying for it.