Male Infertility: Why It Is More Common Than You Think

When a couple struggles to conceive, the focus of investigation often defaults to the woman. Yet male factor infertility contributes to approximately 40–50% of all cases, and in a further 20% of cases it is a contributing factor alongside female factors. Understanding male infertility — its causes, how it is investigated, and what can be done — is essential for any couple on a fertility journey.

What Is a Normal Semen Analysis?

The primary investigation for male fertility is a semen analysis. The World Health Organisation (WHO) 2021 reference values for a normal semen analysis are: total motile sperm count above 9 million, concentration above 16 million per ml, normal morphology (Kruger strict criteria) above 4%, and total progressive motility above 30%. A single abnormal result should be confirmed with a repeat test 2–3 months later before drawing conclusions.

Causes of Male Infertility

Varicocele — dilated veins in the scrotum — is the most common correctable cause, found in about 40% of infertile men. It raises scrotal temperature and impairs sperm production. Surgical repair (varicocelectomy) can significantly improve sperm parameters in appropriately selected patients.

Hormonal imbalances — low FSH, LH, or testosterone — can suppress sperm production. These are treatable with appropriate hormonal therapy once the underlying cause is identified.

Obstructive azoospermia (no sperm in the ejaculate due to a blockage) can result from prior vasectomy, infection, or congenital absence of the vas deferens (often associated with CFTR mutations). Sperm can typically be retrieved surgically (TESA/PESA/micro-TESE) for use in ICSI.

Non-obstructive azoospermia (no sperm due to a production failure) is more challenging but not always untreatable. Micro-TESE (microsurgical testicular sperm extraction) finds sperm in 40–60% of cases even when none are present in the ejaculate.

Lifestyle factors — smoking, alcohol, recreational drugs, anabolic steroids, heat exposure (frequent saunas, tight underwear), obesity, and chronic stress — all impair sperm quality to varying degrees. Optimising lifestyle takes 3 months to show its full effect (the time for a new cohort of sperm to mature).

Investigations Beyond Semen Analysis

• Hormonal panel: FSH, LH, testosterone, prolactin
• Scrotal and testicular ultrasound (for varicocele, structural abnormalities)
• Genetic testing: karyotype, Y-chromosome microdeletion, CFTR mutation screen
• DNA fragmentation index (DFI) in selected cases of recurrent IVF failure or miscarriage

Treatment and Assisted Reproduction

Where sperm counts are mildly reduced, IUI with the partner's sperm is often the first-line treatment. For more significant impairment, ICSI — in which a single sperm is injected directly into each egg — achieves fertilisation rates equivalent to those in couples with normal sperm parameters. Even in cases of very poor sperm quality, outcomes with ICSI are good provided sperm can be retrieved.

It is worth noting that a couple's fertility is a joint equation. Treating the male factor without simultaneously optimising the female evaluation wastes time. At Dr. Unnati's practice, both partners are assessed together from the outset.

If you are concerned about male fertility or have already received an abnormal semen result, a specialist review will establish the cause and the most appropriate treatment path.