Not being able to start a family is one of the most stressful phases for many couples — and yet the idea that “the problem is usually with the woman” persists. Large analyses show that male factors are fully or partly involved in about half of cases; organisations such as the World Health Organization estimate that roughly one in six people worldwide will be affected by infertility during their lifetime. This article focuses on the male side: what exactly does “male infertility” mean, which causes are possible, how is a good work-up performed and which treatment options are actually available — from lifestyle changes to IVF and ICSI — so you can better judge which next steps make sense for you or you as a couple.
What is male infertility?
The WHO defines infertility as the failure to achieve pregnancy after at least twelve months of regular, unprotected sexual intercourse. This definition applies to all genders — the cause may be in the man, in the woman, in both, or remain unexplained despite investigations.
In male infertility the core issue is that sperm quality or number are insufficient for a natural conception or for maintaining a pregnancy. Clinicians distinguish:
- Primary infertility: You have not previously fathered a child.
- Secondary infertility: A pregnancy occurred previously, but now conception does not happen despite trying.
Important: a single mildly abnormal semen analysis is not a diagnosis. Sperm values fluctuate and must always be interpreted together with your history, age, any comorbidities and the fertility of your partner.
Common causes of male infertility
The current guideline of the European Association of Urology describes a range of typical causes. Often several factors play a role at the same time.
Problems with sperm production
Sperm are produced in the testes. If production is disturbed, there may be too few sperm (oligozoospermia), poor motility (asthenozoospermia) or abnormal morphology (teratozoospermia). Common triggers include undescended testis in childhood, testicular injury, chemotherapy or radiotherapy, severe infections or hormonal disorders.
Varicocele (varicose veins in the scrotum)
A varicocele is a varicose-like dilatation of the veins in the scrotum. It can cause heat accumulation and disturb sperm maturation. Many men have a varicocele without symptoms — it becomes relevant mainly if sperm quality is reduced and there is a desire to have children.
- Diagnosis: Palpation and Doppler ultrasound by a urologist or andrologist.
- Treatment: Microsurgical ligation or embolisation when there is a clear indication.
Obstruction of the sperm ducts
If the vas deferens or other ducts are blocked, scarred or congenitally absent, sperm may be absent or greatly reduced in the ejaculate. Causes include prior surgeries, infections, congenital anomalies or vasectomy.
In some cases the obstruction can be reconstructed. If that is not possible, sperm can often be retrieved directly from the testis or epididymis and used with ICSI.
Hormonal disorders
Testicular function is closely regulated by hormones from the brain and pituitary gland. Disturbances in this axis — for example due to tumours, injuries, genetic diseases or medications — can cause sperm production to decline or not start at all.
- Typical constellations: Low testosterone, altered LH/FSH levels, elevated prolactin, thyroid disorders.
- Treatment: Treat the underlying condition, possibly hormonal stimulation (e.g. hCG, FSH) under close supervision.
Genetic causes
Genetic changes such as Klinefelter syndrome (47,XXY), Y-chromosome microdeletions or CFTR mutations in men with absent vas deferens can severely limit or prevent sperm production. In addition to diagnostics, detailed genetic counselling is always indicated.
Infections and inflammation
Inflammations of the testes, epididymis or prostate can damage sperm and scar the ducts. Sexually transmitted infections (STIs) such as chlamydia or gonorrhoea are often implicated, as can mumps orchitis.
- Diagnosis: Urine and swab tests, possibly antibody tests and ultrasound.
- Treatment: Appropriate antibiotic or antiviral therapy according to guidelines and treatment of the partner.
Lifestyle, environment and work
Smoking, heavy alcohol use, drugs, obesity, lack of exercise, poor sleep and chronic stress can significantly reduce sperm count and quality. Environmental toxins, heat exposure (sauna, tight clothing, laptop on the lap) and workplace chemicals also contribute.
Idiopathic infertility
Despite modern diagnostics, in some men the cause remains unclear. This is called idiopathic male infertility. Here lifestyle measures, realistic counselling and an individual fertility strategy are particularly important.
Lifestyle & Sperm Quality: What you can do yourself
You cannot control everything — but much more than many think. Professional societies and institutions such as the MoHFW, ICMR or AIIMS and ESHRE emphasise that lifestyle factors have a measurable effect on sperm quality and hormones.
- Weight: A BMI in the normal range and even a 5–10% weight loss in overweight men can improve hormones and sperm values.
- Diet: Plenty of vegetables, fruit, whole grains, legumes, nuts and healthy oils; limit highly processed foods, sugar and trans fats.
- Exercise: At least 150 minutes of moderate aerobic activity plus one to two strength sessions per week is a reasonable target.
- Smoking & Alcohol: Quitting smoking is one of the most important single measures; keep alcohol to small amounts if possible.
- Sleep: 7–8 hours of sleep with a fairly regular schedule supports hormones and recovery.
- Stress: Exercise, relaxation techniques, coaching or psychotherapy can help reduce chronic stress.
Supplements can be useful if there are proven deficiencies (e.g. vitamin D, zinc, folate). “Miracle cures” without diagnostics rarely deliver what they promise.
Diagnostics in men: How the work-up proceeds
A good assessment of male fertility follows a clear plan. Ideally it is performed by an andrologically experienced urologist or in a fertility centre.
- Detailed history (anamnesis): Duration of trying to conceive, partner's cycle information, previous pregnancies, medical history, surgeries, infections, medications, drugs, occupation, lifestyle.
- Physical examination: Testicular volume, epididymis, spermatic cords, varicoceles, malformations, pain or nodules.
- Semen analysis according to WHO standard: Analysis of volume, concentration, motility and morphology. A sample is usually recommended after 2–7 days of abstinence and if abnormal a second semen analysis after several weeks. The basis includes the WHO laboratory manual for the examination of human semen.
- Hormone profile: Testosterone, LH, FSH, possibly prolactin and thyroid tests to assess hormonal control of testicular function.
- Infection diagnostics: Urine and swab tests for sexually transmitted infections and other pathogens, possibly prostatic secretions or blood tests.
- Genetic tests: With markedly abnormal semen analyses, azoospermia or malformations: karyotype, Y-microdeletions, CFTR mutations and others as indicated.
- Imaging: Ultrasound of the testes and scrotum, and additional imaging if findings are unclear.
Important: the goal is not to assign blame but to gain clarity. The more precisely the baseline situation is known, the more targeted the treatment planning can be.
Treatment & Fertility care
The optimal treatment depends on your situation: cause, age, duration of trying, partner's fertility, prior treatments and life plans. Reputable fertility centres use a stepwise approach.
Treat the cause where possible
- Varicocele: Microsurgical repair or embolisation when sperm quality is reduced and there is a desire to have children.
- Hormonal disorders: Treatment of hypogonadism or other endocrine disorders with targeted hormonal therapies.
- Infections: Antibiotic or antiviral treatments, partner treatment and follow-up checks.
- Medication change: If possible, switching medications that impair fertility.
- Erection and ejaculation problems: Combination of medication, sexual and couples counselling and, if needed, technical aids.
Improve lifestyle sustainably
Without a healthy lifestyle even the best medical treatment has limits. Many centres recommend working consistently on weight, exercise, sleep, substance use and stress for at least three to six months before or alongside treatments — because sperm maturation takes roughly three months.
Assisted reproduction (IVF, ICSI & co.)
When sperm quality and other factors require it, assisted reproductive techniques are used. A helpful overview is available on the ESHRE information page for patients.
- IUI (intrauterine insemination): Prepared sperm are placed into the uterus at ovulation — suitable for mild male factor impairment.
- IVF (in vitro fertilisation): Eggs are collected and placed in a culture dish with many sperm; fertilisation happens in the medium.
- ICSI (intracytoplasmic sperm injection): A single sperm is injected directly into the egg. Standard for severely impaired sperm quality or after failed IVF.
- TESE/MESA: Retrieval of sperm directly from the testis (TESE) or epididymis (MESA) when none or very few sperm are present in the ejaculate.
- Cryopreservation: Freezing sperm before chemotherapy/radiotherapy or surgeries that might threaten fertility.
Chances & prognosis
Success chances depend on many factors: the cause of infertility, duration of trying, age of both partners, the partner’s ovarian reserve, sperm quality and the treatments chosen.
- With treatable causes (e.g. varicocele, hormonal imbalance, infections) chances can often be markedly improved.
- Lifestyle changes take time but can have measurable effects on testosterone levels and semen analysis.
- With genetic causes or severe azoospermia options are more limited, but TESE/ICSI or donor sperm remain possible paths to parenthood.
- Sometimes multiple treatment rounds do not achieve the desired result — then it can be useful to consider alternatives such as donor sperm, adoption or a life without biological children.
Structured counselling in fertility centres can help assess realistic probabilities of success for different strategies.
Psychosocial aspects: masculinity, shame and communication
Male infertility is more than a lab result. Many men experience the thought “it might be my fault” as deeply wounding. Society still often links fertility with masculinity — this creates pressure and shame, even though infertility is a medical condition.
What helps many:
- Talk openly with your partner about feelings, worries and limits.
- Use information from reliable sources instead of myths and half-knowledge from forums.
- Seek psychological support or couples counselling if the desire to have children dominates life.
- Connect with others affected — for example through support groups or online communities.
Important: reduced sperm quality does not make you “less of a man”. It says nothing about your character, your sexuality or your worth.
When should you see a doctor?
It is sensible to start a urological or andrological assessment at least in these situations:
- You have had about twelve months of regular, unprotected sex without achieving pregnancy.
- You had undescended testis, testicular torsion or surgeries in the groin or genital area.
- You notice lumps, hardening, marked size differences or persistent pain in a testis.
- You can feel “worm-like” veins in the scrotum or notice a sensation of heaviness.
- You have persistent erectile dysfunction or problems with ejaculation.
- You have had or plan to have chemotherapy or radiotherapy.
- You have used anabolic steroids or unregulated testosterone preparations for an extended period.
Acute severe testicular pain is an emergency — you should seek medical help (emergency department, urology clinic) the same day.
Clinic checklist: Well prepared for the fertility consultation
With a little preparation the first appointment at a fertility centre or andrology clinic will be much less stressful — and you will get more out of it:
- Ask in advance how semen collection is organised and how many days of abstinence are recommended.
- Write down all medications, supplements and past hormone or anabolic steroid courses.
- Bring existing findings (semen analyses, hormone results, operation reports, medical letters).
- Check with your health insurance which examinations and treatments are fully or partially covered.
- Consider as a couple which options are acceptable in principle (e.g. IVF/ICSI, TESE, donor sperm, adoption).
- Note specific questions so nothing is forgotten during the consultation.
Conclusion
Male infertility is common but often remains in the shadows — medically and emotionally. The good news is that many causes can be treated or at least improved, especially if you pursue a structured diagnostic approach early, honestly review your lifestyle and choose a reputable fertility centre as a partner so you can make informed decisions about whether spontaneous conception, IVF or ICSI, donor sperm, adoption or another life path is best for you — without blame and with a realistic, compassionate view of yourselves.