Clinical Summary
Seek evaluation after 12 months of regular unprotected intercourse without conception (6 months if female partner is over 35). Male factors contribute to 40-50% of infertility cases. Early evaluation and treatment significantly improve conception rates.
Indications for Fertility Evaluation
Consider fertility evaluation if:
- 12 months of unsuccessful conception attempts (female partner under 35)
- 6 months if female partner over age 35 (age-related fertility decline)
- Known risk factors for infertility in either partner
- History of undescended testicles (cryptorchidism)
- Previous groin or testicular surgery
- Childhood cancer treatment (chemotherapy or radiation)
- Varicocele (enlarged veins in scrotum)
- Erectile or ejaculatory dysfunction
Fertility Basics
Male fertility depends on adequate sperm production, sperm function, and successful delivery of sperm. Optimal conception requires at least 15 million sperm per milliliter with good motility and normal morphology.
Clinical Pearl: Male factor infertility is present in 40-50% of infertile couples, yet men are often evaluated later than female partners. Concurrent evaluation is recommended.
Etiology
Sperm Production Disorders
- Varicocele: Enlarged scrotal veins (most common correctable cause) - found in 40% of infertile men
- Hormonal imbalances: Low testosterone, elevated FSH/LH, hyperprolactinemia
- Genetic conditions: Klinefelter syndrome, Y chromosome microdeletions
- Undescended testicles: Cryptorchidism, even if surgically corrected
- Infections: Orchitis (mumps), epididymitis, STIs
- Heat exposure: Frequent hot tubs, saunas, tight underwear, laptop on lap
Sperm Transport Issues
- Ejaculatory duct obstruction: Congenital or acquired blockage
- Absent vas deferens: Congenital (associated with cystic fibrosis gene mutations)
- Vasectomy: Prior sterilization procedure
- Retrograde ejaculation: Semen enters bladder instead of urethra (diabetes, medications, surgery)
- Erectile dysfunction: Inability to achieve intercourse
Lifestyle and Environmental Factors
- Smoking: Reduces sperm count and motility
- Alcohol: Excessive consumption lowers testosterone
- Recreational drugs: Marijuana, anabolic steroids, cocaine
- Obesity: Associated with hormonal changes, reduced sperm quality
- Medications: Testosterone replacement, certain antibiotics, chemotherapy
- Occupational exposures: Heavy metals, pesticides, radiation
Idiopathic Infertility
No identifiable cause found in 30-40% of cases despite thorough evaluation.
Diagnostic Evaluation
Semen Analysis
Gold standard initial test - evaluates sperm count, motility, and morphology:
- Collection: 2-5 days abstinence, fresh sample within 1 hour
- Normal parameters (WHO criteria):
- • Volume: ≥1.5 mL
- • Concentration: ≥15 million/mL
- • Total count: ≥39 million
- • Motility: ≥40% moving
- • Progressive motility: ≥32%
- • Normal morphology: ≥4%
- Repeat if abnormal: Confirm with 2nd test 2-3 months later
Hormonal Testing
- Testosterone: Total and free testosterone (morning sample)
- FSH and LH: Evaluate testicular function
- Prolactin: Elevated levels suppress fertility
- Estradiol: May be elevated in obesity
Additional Testing
- Scrotal ultrasound: Identify varicocele, testicular masses
- Genetic testing: Karyotype, Y chromosome microdeletions, cystic fibrosis carrier
- Post-ejaculatory urinalysis: Check for retrograde ejaculation
- Testicular biopsy: Differentiate obstruction from production failure
Treatment Approaches
Medical Management
- Hormonal therapy: Clomiphene, hCG for hypogonadotropic hypogonadism
- Antibiotics: For infection-related infertility
- Medications for sexual dysfunction: PDE5 inhibitors for ED, alpha-blockers for retrograde ejaculation
- Discontinue harmful substances: Steroids, testosterone, recreational drugs
Surgical Interventions
- Varicocelectomy: Surgical repair of varicocele - improves parameters in 60-70%
- Vasectomy reversal: Vasovasostomy or vasoepididymostomy
- Sperm retrieval: TESE (testicular sperm extraction), MESA (microsurgical epididymal sperm aspiration)
- Transurethral resection: For ejaculatory duct obstruction
Assisted Reproductive Technology (ART)
- Intrauterine insemination (IUI): Washed sperm placed directly in uterus - mild male factor
- In vitro fertilization (IVF): Eggs fertilized outside body
- Intracytoplasmic sperm injection (ICSI): Single sperm injected into egg - severe male factor
- Success rates: ICSI achieves fertilization even with very low sperm counts
- Donor sperm: Option if no viable sperm or genetic concerns
Lifestyle Optimization
- Maintain healthy weight: BMI 20-25 associated with optimal fertility
- Quit smoking: Improves sperm parameters within 3-6 months
- Limit alcohol: No more than 2 drinks per day
- Avoid heat exposure: No hot tubs, keep laptops off lap, wear loose underwear
- Reduce stress: Chronic stress affects hormone production
- Exercise regularly: Moderate activity beneficial, avoid excessive endurance training
- Antioxidants: Vitamins C and E, selenium, zinc may improve sperm quality
- Timing intercourse: Every 1-2 days during fertile window (days 12-16 of cycle)
Medical Review
Reviewed by: Ricardo Hamilton, MD
Last Updated: November 26, 2025
Sources: American Society for Reproductive Medicine (ASRM), American Urological Association, World Health Organization (WHO)