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: according to the American Urological Association and ASRM, a male factor is the sole cause in about 20% of infertile couples and a contributing factor in another 30-40%. In other words, a male factor plays a part in roughly half of couples who struggle to conceive. 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. For a complete overview of both male and female fertility factors, see our fertility conditions guide.

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 roughly two to two and a half months from start to finish (one tracer study measured about 64 days on average before new sperm appeared in the ejaculate). Unlike women, who are born with all their eggs, men continuously produce new sperm from puberty onward-millions every 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, 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 tiny fraction 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. For a fuller explanation of how sperm are made and what a semen analysis measures, see male fertility basics. This guide focuses on what goes wrong and how it's treated.

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: One of the most common treatable causes of male infertility, affecting about 15% of men generally and around 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 usually detected through physical examination, and ultrasound can confirm them. Repair is recommended for consideration when a varicocele can be felt and semen results are abnormal; varicoceles seen only on ultrasound are not usually treated. Repair can improve sperm parameters in many men, though improvement takes several 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, according to European urology guidelines. 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

If your results show a specific problem, our dedicated guides go into more depth: low sperm count, sperm motility issues and azoospermia.

A semen analysis measures:

The figures below are the WHO's 2021 lower reference limits (6th edition laboratory manual), which NICE also uses. They describe the lowest 5% of men whose partners conceived within a year, so results just below them do not on their own mean you are infertile.

Volume: The amount of ejaculate. The lower reference limit is 1.4ml. Low volume might indicate an obstruction or issue with seminal vesicles.

Concentration (count): Sperm per milliliter. The lower reference limit is 16 million/ml. This is often what people mean by "sperm count." For an in-depth look at this specific issue, see our guide on low sperm count.

Total sperm count: Concentration times volume. The lower reference limit is 39 million per ejaculation.

Motility: The percentage of sperm moving, and how well. The lower reference limits are 42% moving in total, with 30% showing progressive movement (swimming forward, not just twitching). Older reports may still use the 2010 figures of 40% and 32%.

Morphology: The percentage with normal shape. Using strict criteria, the lower reference limit is 4%-yes, even having 96% abnormally shaped sperm can be within the normal range.

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 be asked to abstain from ejaculation for a few days beforehand; follow your laboratory's instructions. 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, NICE recommends a repeat test, ideally about 3 months later (or as soon as possible if no sperm or very few sperm were found). 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. NICE recommends Y microdeletion testing when there are no sperm or fewer than 1 million/ml without a known cause, and considering a karyotype when the count stays below 5 million/ml.

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 are offered by some clinics, but their role is debated. NICE's 2026 guideline advises against sperm DNA fragmentation testing, while American guidance suggests it mainly for couples with recurrent pregnancy loss.

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 a clear hormone problem is identified, treatment can improve sperm production. Men whose pituitary does not produce enough hormones (hypogonadotropic hypogonadism) should be offered gonadotropin injections (hCG and FSH). Clomiphene citrate or similar medicines can raise testosterone in some men, but evidence that they improve pregnancy rates without a clear hormonal cause is limited, and NICE advises using them for that purpose only in clinical trials. If testosterone replacement was causing the problem, stopping it and 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): For a varicocele that can be felt in a man with abnormal semen results, surgical or radiological repair is associated with better sperm parameters and higher natural pregnancy rates in studies. Improvement typically takes several months to appear. Pregnancy rates improve in many, though not all, couples.

Vasectomy reversal: For men who previously had a vasectomy, microsurgical reversal (vasovasostomy) restored sperm to the ejaculate in roughly 70-97% of men in a large study, depending on how long ago the vasectomy was done, though pregnancy rates are lower (from about 76% when the vasectomy was under 3 years earlier to about 30% after 15 years or more).

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, recommended when sperm production is very low), 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; overall, sperm are found in roughly half of men (a large 2019 review found about 47%). Hormonal treatment before surgery is sometimes tried, but guidelines note that the evidence it helps is limited, except for men with a hormonal (hypogonadotropic) cause.

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. Sperm donation is not permitted in the UAE, so couples who choose this route have treatment abroad.

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

• A male factor plays a part in roughly half of infertile couples-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.

Sources

• AUA/ASRM: Diagnosis and Treatment of Infertility in Men (guideline, amended 2024) (checked October 2026)
• EAU Guidelines on Sexual and Reproductive Health: Male infertility (checked October 2026)
• WHO laboratory manual for the examination and processing of human semen, 6th edition (2021) (checked October 2026)
• NICE NG257: Testing for male factor fertility problems (2026) (checked October 2026)
• NICE NG257: Management of male factor fertility problems (2026) (checked October 2026)
• Misell et al. Measuring human spermatogenesis kinetics in vivo. J Urol, 2006 (checked October 2026)
• Belker et al. Results of 1,469 microsurgical vasectomy reversals. J Urol, 1991 (checked October 2026)
• Corona et al. Sperm recovery and ICSI outcomes in non-obstructive azoospermia. Hum Reprod Update, 2019 (checked October 2026)

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.