Male Infertility: Causes and Treatments Explained

There's a conversation that happens too rarely: the one about male infertility. When a couple struggles to conceive, the default assumption-spoken or unspoken-often places the question mark on her body. She's the one who schedules the first appointment, who tracks cycles, who submits to ultrasounds and blood draws. By the time anyone thinks to evaluate him, months or years may have passed.

But here's the reality: male factors contribute to approximately 40-50% of all infertility cases. In about 20% of cases, the male factor is the primary cause. In another 30-40%, both partners have contributing factors. This isn't a women's problem that occasionally involves men-it's a couples' problem where he's just as likely to be part of the equation.

If you're a man reading this after an abnormal semen analysis, or because your partner mentioned it might be worth understanding, or because you're just starting to investigate why pregnancy isn't happening-this guide is for you. We'll cover what can cause male infertility, how it's diagnosed, what treatments exist, and perhaps most importantly, what this means for your path forward. Because there's usually a path forward, even when the news isn't what you hoped.

Understanding Male Fertility: The Basics

Male fertility depends on producing healthy sperm in sufficient quantities and delivering them effectively. This sounds straightforward, but it involves a complex system of hormones, anatomy, and timing.

How Sperm Are Made

Sperm production (spermatogenesis) takes place in the testes and takes approximately 72-74 days from start to finish. Unlike women, who are born with all their eggs, men continuously produce new sperm from puberty onward-roughly 1,500 sperm per second, or about 100 million per day.

The process is regulated by hormones from the brain-primarily follicle-stimulating hormone (FSH) and luteinizing hormone (LH)-which signal the testes to produce testosterone and sperm. This hormonal axis is important: problems anywhere along it can affect sperm production.

Newly formed sperm travel to the epididymis, a coiled tube behind each testicle, where they mature for about two weeks, developing the ability to swim and fertilize an egg. From there, during ejaculation, sperm travel through the vas deferens, mix with fluids from the seminal vesicles and prostate (creating semen), and exit through the urethra.

What Sperm Need to Do

For conception to occur, sperm must survive the female reproductive tract (which is initially hostile to them), swim through the cervix and uterus to the fallopian tube, find and penetrate the egg, and deliver genetic material. This journey is extraordinarily demanding-of the millions of sperm in each ejaculation, only a few hundred reach the egg, and only one fertilizes it.

This is why sperm quality matters: count (how many sperm you produce), motility (how well they swim), and morphology (whether they're normally shaped) all affect the odds that at least one sperm completes this journey successfully.

Common Causes of Male Infertility

Male infertility can result from problems with sperm production, sperm transport, sexual function, or a combination. Understanding the cause helps direct treatment.

Sperm Production Problems

Varicocele: The most common treatable cause of male infertility, affecting about 15% of men generally and 40% of men with fertility issues. A varicocele is an enlargement of veins within the scrotum, similar to varicose veins in the legs. It's thought to impair sperm production by raising testicular temperature and potentially through other mechanisms.

Varicoceles are often detected through physical examination or ultrasound. Surgical repair (varicocelectomy) can improve sperm parameters in many men, though improvement may take 3-6 months to appear.

Hormonal imbalances: Low testosterone, elevated prolactin, or thyroid dysfunction can affect sperm production. Importantly, testosterone replacement therapy actually suppresses sperm production-one of the more common iatrogenic causes of male infertility. If you've been prescribed testosterone for low T and are trying to conceive, discuss alternatives with your doctor.

Genetic factors: Certain genetic conditions directly affect fertility. Klinefelter syndrome (an extra X chromosome) results in low testosterone and often no sperm production. Y-chromosome microdeletions can cause low or absent sperm counts. Cystic fibrosis gene mutations can cause absence of the vas deferens. Genetic testing can identify these conditions and inform family planning decisions.

Undescended testicles (cryptorchidism): Testicles that didn't descend into the scrotum during childhood may have impaired sperm production even after surgical correction. The earlier the correction, the better the long-term fertility outlook.

Infections: Past or current infections can damage the reproductive tract. Sexually transmitted infections like chlamydia or gonorrhea can scar the epididymis or vas deferens. Mumps occurring after puberty (mumps orchitis) can damage testicular tissue. Prostatitis may affect semen quality.

Cancer treatments: Chemotherapy and radiation can damage sperm-producing cells, sometimes permanently. If you're facing cancer treatment and want to preserve fertility, sperm banking before treatment is strongly recommended.

Testicular injury or torsion: Direct trauma or twisting of the testicle can damage sperm-producing tissue.

Heat exposure: Chronic exposure to elevated temperatures can impair sperm production-saunas, hot tubs, occupations involving heat, tight underwear, or prolonged laptop use on the lap. These effects are typically reversible.

Sperm Transport Problems

Obstruction: Sperm can be produced normally but blocked from reaching the ejaculate. Causes include previous infections (causing scarring), congenital absence of the vas deferens (often associated with cystic fibrosis genes), prior surgeries (like hernia repair), or vasectomy.

Retrograde ejaculation: Semen enters the bladder during orgasm instead of exiting through the penis. This can result from diabetes, spinal cord injuries, certain medications, or surgery affecting the bladder neck.

Sexual Function Problems

Erectile dysfunction: The inability to achieve or maintain an erection sufficient for intercourse. ED can have physical causes (vascular issues, diabetes, medications) or psychological causes. Treatments are often effective.

Ejaculation issues: Premature ejaculation, delayed ejaculation, or failure to ejaculate can prevent sperm from being deposited where they need to be.

Unknown Causes (Idiopathic)

In about 30-40% of cases, no identifiable cause is found despite thorough evaluation. This "idiopathic" male infertility is frustrating but doesn't necessarily mean treatment won't help.

Diagnosing Male Infertility

Evaluation typically begins with a semen analysis-and ideally, this should happen early in the fertility investigation, not after extensive testing of the female partner.

Semen Analysis

A semen analysis measures:

Volume: The amount of ejaculate. Normal is 1.5ml or more. Low volume might indicate an obstruction or issue with seminal vesicles.

Concentration (count): Sperm per milliliter. Normal is 15 million/ml or higher. This is often what people mean by "sperm count."

Total sperm count: Concentration times volume. Normal is 39 million or more per ejaculation.

Motility: The percentage of sperm moving, and how well. At least 40% should be motile, with 32% or more showing progressive movement (swimming forward, not just twitching).

Morphology: The percentage with normal shape. Using strict criteria, "normal" is 4% or higher-yes, even having 96% abnormally shaped sperm is considered normal.

Other factors include pH, white blood cells (which might indicate infection), and liquefaction (whether semen becomes liquid after ejaculation as it should).

Preparing for the test: You'll typically abstain from ejaculation for 2-5 days beforehand. The sample is collected via masturbation, usually at the clinic to ensure it stays at proper temperature. The entire sample must be collected-missing the first portion significantly affects results.

One test isn't definitive: Sperm parameters vary from sample to sample. If your first analysis is abnormal, it should be repeated in 2-3 months. Only consistent abnormalities warrant concern.

Additional Testing

Depending on semen analysis results and clinical findings, further tests might include:

Hormone evaluation: Blood tests for FSH, LH, testosterone, prolactin, and thyroid function. Hormone imbalances can reveal underlying causes and sometimes guide treatment.

Physical examination: A urologist will examine the testicles, epididymis, and vas deferens for abnormalities like varicocele.

Genetic testing: Karyotype (chromosome analysis), Y-chromosome microdeletion testing, or cystic fibrosis gene testing may be appropriate depending on the clinical picture.

Post-ejaculatory urinalysis: If low or absent sperm in the ejaculate, checking urine for sperm can diagnose retrograde ejaculation.

Scrotal ultrasound: Can identify varicocele, masses, or other structural issues.

Specialized sperm testing: Tests for DNA fragmentation, oxidative stress, or sperm function may be considered in specific situations, though their role in routine evaluation is debated.

Treatment Options

Treatment depends on the underlying cause. Many cases of male infertility can be addressed, though "addressed" sometimes means assisted reproduction rather than reversing the problem.

Lifestyle Modifications

Before pursuing medical treatment, optimizing lifestyle factors is worthwhile-particularly if you'll be providing sperm for assisted reproduction anyway.

Stop smoking: Smoking impairs sperm count, motility, and morphology, and increases DNA damage.

Limit alcohol: Heavy drinking affects testosterone and sperm production. Moderate or eliminate alcohol while trying to conceive.

Avoid recreational drugs: Marijuana, cocaine, anabolic steroids, and opioids all negatively affect fertility. Anabolic steroids are particularly problematic-they suppress the body's natural testosterone and sperm production.

Maintain healthy weight: Obesity affects hormone levels and sperm quality. Weight loss can improve parameters.

Reduce heat exposure: Switch to loose-fitting underwear, avoid hot tubs and saunas, limit time in hot environments, and keep laptops off your lap.

Manage stress: While the fertility-stress connection is complex, chronic severe stress may affect hormone levels.

Review medications: Some medications affect sperm production. Discuss any medications with your doctor-don't stop anything without medical guidance, but alternatives may exist.

These changes take time to show results-remember, sperm production takes about three months.

Medical Treatments

Hormonal therapy: If hormone imbalances are identified, treatment can improve sperm production. Clomiphene citrate or hCG injections can boost testosterone and sperm in men with certain hormonal profiles. If testosterone replacement was causing the problem, switching to fertility-preserving alternatives is essential.

Treating infections: Antibiotics for current infections may prevent further damage, though they can't always reverse scarring already done.

Medications for ejaculation issues: Various medications can help with erectile dysfunction or ejaculatory problems.

Surgical Treatments

Varicocele repair (varicocelectomy): Surgically correcting a varicocele improves sperm parameters in about 60-70% of men. Improvement typically appears 3-6 months post-surgery. Pregnancy rates improve in many, though not all, couples.

Vasectomy reversal: For men who previously had a vasectomy, reversal surgery (vasovasostomy) can restore sperm to the ejaculate in 70-90% of cases, though pregnancy rates are lower and depend on how long ago the vasectomy was performed.

Transurethral resection of ejaculatory duct (TURED): For obstruction at the ejaculatory duct level, this procedure can relieve blockage.

Surgical sperm retrieval: When sperm aren't present in the ejaculate but are produced in the testes, sperm can be directly extracted. Techniques include TESE (testicular sperm extraction), micro-TESE (microsurgical version for better precision), and PESA/MESA (extracting from the epididymis).

Assisted Reproduction

When natural conception remains unlikely despite treatment, assisted reproduction offers excellent options.

IUI (Intrauterine Insemination): Washed and concentrated sperm are placed directly in the uterus, bypassing the cervix. This can help with mild male factor issues but requires adequate sperm numbers and motility.

IVF (In Vitro Fertilization): Eggs and sperm are combined in a laboratory. More sperm reach the eggs than in natural conception, which can overcome moderate male factor issues.

ICSI (Intracytoplasmic Sperm Injection): A single sperm is injected directly into each egg. This technique revolutionized treatment for severe male factor infertility-even men with very low counts or poor motility can become biological fathers if sperm can be obtained. ICSI is used with surgically retrieved sperm (from TESE or PESA) when none are present in the ejaculate.

With ICSI, the quality and quantity requirements for sperm drop dramatically. One viable sperm per egg is technically all that's needed.

When Sperm Aren't Available

Azoospermia (no sperm in ejaculate) is divided into two categories:

Obstructive azoospermia: Sperm are produced but blocked. Surgical sperm retrieval is usually successful, and prognosis for ICSI is good.

Non-obstructive azoospermia: Sperm production itself is impaired. Micro-TESE can sometimes find small pockets of sperm production; success rates vary (typically 40-60% find usable sperm). Hormonal optimization before surgery may improve odds.

If no sperm can be obtained, donor sperm is an option for achieving pregnancy. This is a significant decision-genetic parenthood matters differently to different people, and there's no right or wrong answer.

The Emotional Impact

Male infertility carries a psychological burden that isn't always acknowledged. Men are often raised with messages-implicit or explicit-that tie masculinity to virility. Fertility struggles can feel like a challenge to identity.

What Men Often Experience

Shame and inadequacy: Feeling like less of a man, particularly if male factor is the primary issue.

Guilt: If the diagnosis means your partner needs medical treatment (like IVF) to conceive.

Isolation: Men typically don't discuss fertility struggles with friends the way women might. This can feel very alone.

Pressure to be strong: The expectation to support your partner while suppressing your own distress.

Grief: For the assumed future, for the children you expected to have easily.

What Helps

Acknowledge your feelings: They're normal and valid. Fertility is tied to identity in ways that aren't always logical but are very human.

Talk about it: Whether with your partner, a trusted friend, or a therapist. Men often benefit from spaces where vulnerability is acceptable.

Seek counseling if needed: Fertility counselors understand these specific challenges. There's no weakness in needing support.

Remember this isn't about worth: Your value as a person, partner, or future parent isn't determined by your sperm count.

Male Infertility in the UAE Context

Men in the UAE face similar biological realities to men anywhere, but the cultural context adds dimensions.

Seeking help: In some cultural contexts, admitting fertility challenges-especially male factor-carries stigma. This can delay evaluation and treatment. Remember: infertility is a medical issue, not a character flaw.

Privacy concerns: UAE clinics understand the importance of confidentiality. Reputable clinics maintain strict privacy around fertility treatment.

Quality of care: Major fertility centres in Dubai and Abu Dhabi have urologists and andrologists with expertise in male infertility. Advanced treatments including surgical sperm retrieval and ICSI are widely available.

Partner dynamics: In couples where male factor is primary, how this information is handled within the relationship-and within extended families-varies. Decide together what to share and with whom.

Key Takeaways

• Male factors contribute to 40-50% of infertility cases-this isn't primarily a women's issue.

• Semen analysis is the key first test and should happen early in any fertility investigation, not as an afterthought.

• Many causes are treatable: Varicocele repair, hormone treatment, and surgical sperm retrieval can address many underlying issues.

• ICSI has transformed severe male infertility: Even men with very low sperm counts or requiring surgical retrieval can often father biological children.

• Lifestyle factors matter: Quitting smoking, limiting alcohol, avoiding heat exposure, and maintaining healthy weight can improve sperm quality.

• The emotional impact is real: Seek support if you're struggling. Your feelings about this are valid.

• There's usually a path forward: Whether through treatment, assisted reproduction, or alternative family-building, most couples ultimately find their way.

This content is for educational purposes only and should not replace professional medical advice. If you have concerns about your fertility, please consult with a qualified healthcare provider or reproductive urologist.