Male Infertility: Causes, Tests and Treatment
Male infertility means a male factor is reducing a couple’s chance of pregnancy. Common causes include problems with sperm production, blockage of sperm transport, varicocele, hormonal disorders, genetic conditions, previous testicular problems, medicines or anabolic steroids, and sometimes no single cause is found. Evaluation usually starts with a reproductive history, examination and semen analysis. Treatment depends on the cause and may include correcting reversible factors, treating a clinical varicocele, hormonal treatment in selected men, microsurgery for obstruction, sperm retrieval for IVF/ICSI, or fertility preservation. A single abnormal semen report does not by itself define a man as infertile.
What is male infertility?
Infertility is usually assessed as a couple problem rather than a problem belonging to only one partner. A male factor may be the main reason for difficulty conceiving, may contribute together with a female factor, or may be found even when the female evaluation is normal. The purpose of evaluating the man is not merely to obtain a sperm count. It is to identify potentially correctable disease, recognise conditions that affect general health, estimate reproductive options and avoid unnecessary delay.
A semen analysis is central to the evaluation, but it is not a simple fertile-versus-infertile test. Semen values vary between samples, and WHO reference limits describe the distribution seen in fertile men rather than a hard biological border. The overall pattern, especially when several parameters are abnormal, is more useful than one isolated number.
Common causes of male infertility
| Cause group | Examples |
|---|---|
| Reduced sperm production | Genetic conditions, prior undescended testis, testicular injury, chemotherapy/radiation, severe systemic illness, primary testicular failure |
| Sperm transport blockage | Vas deferens obstruction or absence, epididymal obstruction, previous infection or surgery, ejaculatory duct obstruction |
| Varicocele | Dilated scrotal veins that may impair sperm production or sperm DNA quality in selected men |
| Hormonal causes | Pituitary or hypothalamic disorders, low gonadotropins, high prolactin in selected cases |
| Medicines and hormones | Exogenous testosterone, anabolic steroids and some other medicines can suppress sperm production |
| Sexual/ejaculatory problems | Erectile dysfunction, failure of ejaculation, retrograde ejaculation or very infrequent intercourse |
| Lifestyle/systemic factors | Smoking, obesity, poorly controlled metabolic disease, heat exposure and recent febrile illness may contribute |
| Unexplained/idiopathic | No definite cause is found even after appropriate evaluation |
When should a man be evaluated?
A male evaluation should be considered when a couple has not conceived after regular unprotected intercourse, and earlier when there is a known risk factor. Evaluation should not be postponed simply because the female partner is also being investigated. Both partners are usually assessed in parallel.
- Known abnormal semen analysis or azoospermia.
- Previous undescended testis, testicular torsion, major scrotal injury or testicular surgery.
- Varicocele with infertility or abnormal semen parameters.
- History of chemotherapy, radiotherapy or cancer treatment.
- Use of testosterone injections, gels, anabolic steroids or performance-enhancing hormones.
- Very small testes, delayed puberty, reduced body hair, gynaecomastia or other signs of a hormonal/genetic disorder.
- Erectile or ejaculatory difficulty that prevents semen deposition in the vagina.
- Recurrent pregnancy loss, failed fertility treatment or unexplained infertility where a male contribution still needs assessment.
Tests used in male infertility
Semen analysis
The report usually includes semen volume, sperm concentration, total sperm number, motility, morphology and sometimes vitality, pH, round cells or leukocytes. WHO 2021 lower reference values commonly used by laboratories include a semen volume around 1.4 mL, sperm concentration around 16 million/mL, total sperm number around 39 million per ejaculate, total motility around 42%, progressive motility around 30% and normal morphology around 4%. These are reference values, not guarantees of fertility or infertility.
Hormonal tests
FSH and testosterone are commonly used when the sperm count is low or absent, testes are small, libido is reduced or the examination suggests a hormonal problem. LH, prolactin, estradiol or other tests may be added depending on the pattern. High FSH often points toward impaired sperm production, whereas low FSH/LH with low testosterone can suggest a pituitary-hypothalamic problem.
Genetic testing
Karyotype, Y-chromosome microdeletion testing and CFTR testing are not routine for every man with infertility. They are used in selected men, particularly azoospermia, very severe oligozoospermia, suspected impaired sperm production or congenital absence of the vas deferens. Genetic counselling may be important because some abnormalities affect sperm-retrieval chances or can be transmitted to children.
Scrotal ultrasound and other imaging
Ultrasound is useful when examination is difficult, there is a testicular lump, marked size difference, suspected varicocele or another scrotal abnormality. Transrectal ultrasound is reserved for selected men with low-volume azoospermia or suspected ejaculatory duct obstruction; it is not a routine test for every infertility evaluation.
How male infertility is treated
Treatment is matched to the cause and to the couple’s reproductive timeline. The female partner’s age, ovarian reserve and prior fertility treatment matter because a treatment that may improve semen over several months may not be the best strategy when time is limited.
| Situation | Possible approach |
|---|---|
| Clinical varicocele + abnormal semen + infertility | Microsurgical varicocelectomy may be considered after couple-based counselling |
| Hormonal deficiency with low gonadotropins | Cause-specific endocrine treatment may restore sperm production in selected men |
| Exogenous testosterone/anabolic steroid suppression | Stop or modify under medical supervision; recovery may take months and sometimes needs specialist treatment |
| Obstructive azoospermia | Microsurgical reconstruction or sperm retrieval with IVF/ICSI depending on the cause and couple factors |
| Non-obstructive azoospermia | Genetic/endocrine evaluation; micro-TESE may be considered when appropriate |
| Mild-moderate semen abnormality without a correctable cause | Optimise health and discuss natural conception, IUI or IVF/ICSI according to total motile count and female factors |
| Cancer or gonadotoxic treatment planned | Sperm freezing before treatment whenever feasible |
What should not be self-treated?
Do not start testosterone simply because a fertility blood test shows a low testosterone value. External testosterone can suppress the pituitary signals that drive sperm production and may markedly lower the sperm count, sometimes to azoospermia. Likewise, antibiotics, antioxidants, hormonal tablets and fertility supplements should not be used as a substitute for finding the cause of a clearly abnormal semen analysis.
When is urgent evaluation needed?
Infertility itself is rarely an emergency, but certain associated findings should not wait for a routine fertility appointment.
- A new hard testicular lump or rapidly enlarging testis.
- Severe sudden testicular pain, which may represent torsion.
- High fever with painful swollen testis or epididymis.
- A cancer diagnosis or planned chemotherapy/radiotherapy when future fertility matters; sperm banking is time-sensitive.
- Azoospermia discovered before an urgent fertility cycle, especially when the female partner has already started ovarian stimulation.
What happens after the first evaluation?
The next step may be repeat semen testing, targeted blood tests, examination for varicocele or obstruction, genetic counselling, or a discussion with the fertility team. The goal is to choose the least invasive effective route without losing reproductive time. Some men need treatment of a specific cause; others mainly need a clear plan for assisted reproduction. Both are legitimate outcomes of a good male infertility evaluation.
Emergency warning signs
Infertility itself is not an emergency. Sudden severe testicular pain, rapidly increasing scrotal swelling, fever with scrotal redness, major testicular trauma or severe pain with nausea/vomiting needs urgent assessment because torsion or infection can threaten the testis.
What to bring for consultation
Bring these if available:
- All semen analysis reports with dates, including any previous normal report.
- FSH, LH, morning testosterone and prolactin reports if already tested.
- Scrotal Doppler, genetic tests, previous surgery records or cancer-treatment records if relevant.
- A complete list of medicines, supplements, testosterone products or anabolic/gym steroids.
- How long the couple has been trying, previous pregnancies, and the partner’s basic fertility evaluation if available.
FAQs
Can a man with a low sperm count father a child naturally?
Yes. A low count reduces probability but does not automatically mean sterility. Motility, total motile sperm count, female fertility factors and time trying for pregnancy all matter.
Does one abnormal semen analysis mean infertility?
No. Semen parameters vary. If one or more values are abnormal, the WHO 2025 infertility guideline suggests repeating semen analysis after at least about 11 weeks, unless the clinical situation requires earlier action.
Can testosterone improve sperm count?
External testosterone is generally the wrong treatment when fertility is desired because it can suppress sperm production. Men with low testosterone and fertility goals need a cause-based evaluation.
Is varicocele surgery useful for every infertile man?
No. Benefit is most established in men with a palpable clinical varicocele, infertility and abnormal semen parameters. A varicocele seen only on ultrasound is usually not an indication for surgery.
What if there are no sperm in semen?
Azoospermia should be confirmed properly and then classified as obstructive or non-obstructive. Treatment options differ greatly between the two.
Should the female partner be evaluated at the same time?
Yes. Male and female evaluation should proceed in parallel because the couple’s combined findings determine how quickly and which treatment should be chosen.
Related reading
- Semen Analysis Report Explained
- Low Sperm Count: Causes and Treatment
- Azoospermia: No Sperm in Semen
- Hormonal Tests for Male Infertility
- Genetic Testing in Male Infertility
- Urologist in Latur
References
- World Health Organization. Guideline for the prevention, diagnosis and treatment of infertility. 2025 https://www.who.int/publications/i/item/9789240115774
- World Health Organization. WHO laboratory manual for the examination and processing of human semen, 6th ed https://www.who.int/publications/i/item/9789240030787
- European Association of Urology. EAU Guidelines on Sexual and Reproductive Health: Male Infertility. 2026 https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/male-infertility
- American Urological Association/American Society for Reproductive Medicine. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline (2020; Amended 2024) https://www.auanet.org/documents/Guidelines/PDF/2024%20Guidelines/Male%20Infertility%20Unabridged%20Final.pdf