Understanding male infertility – debunking myths, exploring causes, symptoms and modern fertility treatments for men.

by Mithun Agarwal

Infertility affects millions worldwide and carries significant social stigma, especially in cultures where childbearing is highly valued (who.int, ncbi.nlm.nih.gov). In many societies, women are unfairly blamed for a couple’s difficulty conceiving. In reality, male factors play a major role: studies estimate that male issues contribute to roughly 40–50% of infertility cases (crystaivf.com). The World Health Organization (WHO) notes that about one in six people of reproductive age experience infertility in their lifetime. In India, for example, about 15–20% of couples are infertile, with male causes accounting for roughly half of these cases (ainuindia.org). Experts say the prevalence of male infertility has been rising in recent years, driven by lifestyle, environmental and health factors (newindianexpress.com, newindianexpress.com).

Infertility is defined by WHO as a disease of the reproductive system characterized by the “failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse”. It can be primary (never having conceived) or secondary (after at least one prior pregnancy). Causes may be male, female or unexplained. For men, common causes include sperm production problems (low count, poor motility or abnormal shape), blockages or injuries in the genital tract, and hormonal or genetic disorders. Lifestyle and health issues like smoking, heavy alcohol use, obesity, stress, exposure to toxins (pesticides, heavy metals, etc.), and chronic illnesses (e.g. diabetes) can also impair sperm quality.

Causes of Male Infertility

Male infertility has diverse causes, which can be intrinsic (medical) or extrinsic (lifestyle/environmental):

• Sperm abnormalities: Low sperm count (oligospermia), absent sperm (azoospermia) or poor motility/morphology. For example, varicocele (dilated veins in the scrotum) and infections (orchitis, epididymitis) can damage sperm production (my.clevelandclinic.org).

• Hormonal and genetic issues: Disorders of hormones from the hypothalamus, pituitary or testicles (like Klinefelter’s syndrome) can reduce sperm production. Genetic conditions (e.g. Y-chromosome deletions) may also underlie infertility.

• Obstructions: Blockages in the reproductive tract (e.g. vas deferens or ejaculatory ducts) – from injury, surgery or infection – prevent sperm delivery.

• Health factors: Chronic illnesses (diabetes, kidney disease, certain cancers), and injuries to the groin or testicles can affect fertility. Cancer treatments (chemotherapy/radiation) often impair sperm production.

• Lifestyle and environment: Habits and exposures can have a large impact. Smoking, heavy drinking and illicit drug use are linked to reduced sperm counts. Obesity, poor diet and lack of exercise also harm fertility. Environmental toxins (pesticides, heavy metals) and even excessive heat from saunas, tight clothing or prolonged sitting can lower sperm quality. Modern lifestyle factors – high stress, late parenthood, and exposure to radiation from electronic devices – have also been cited as contributors.

In India, experts note that rising stress levels, unhealthy diets (fast food), obesity and substance use are key drivers of male infertility. Other factors include environmental pollution and socioeconomic barriers to healthcare. Just as in women, advancing age can reduce a man’s fertility: studies show sperm quality tends to decline after age 35.

Symptoms and Signs

Unlike women, male infertility often has no obvious symptoms. Men may appear healthy even if fertility is compromised. However, certain signs can hint at underlying problems:

• Sexual dysfunction: Men might experience difficulty getting or maintaining an erection (erectile dysfunction) or reduced sexual desire. The Cleveland Clinic notes that when low testosterone or other hormonal issues are present, symptoms such as “tiredness, impotence, depression, weight gain and apathy” may occur. Premature ejaculation or difficulty ejaculating at all can also contribute to infertility.

• Ejaculate changes: Noticeable differences in ejaculate, such as very low semen volume or the presence of blood (hematospermia), warrant evaluation. Watery or runny semen might indicate a low sperm count.

• Scrotal symptoms: Pain, swelling or a lump in the testes or groin should prompt medical attention. These can signal infections, varicocele or tumors that affect fertility.

• General health issues: Recurrent infections, chronic health problems or endocrine symptoms (e.g. gynecomastia from low hormones) can be clues.

Because men may feel embarrassed or blame themselves, many delay seeking help. Cultural stigma can make it hard to talk about fertility issues. However, any man who has tried to conceive for over a year without success (or 6 months if over age 35) should consult a specialist. Early evaluation is key to identifying treatable conditions.

Diagnosis of Male Infertility

Diagnosing male infertility begins with a comprehensive medical evaluation. This includes reviewing the couple’s medical and sexual history, lifestyle habits, and any previous fertility tests (ncbi.nlm.nih.gov). A physical examination checks for testicular abnormalities, hormonal signs (like gynecomastia) and varicoceles.

The cornerstone test is a semen analysis, usually done on at least two separate samples. This measures sperm count (concentration), total number, motility (movement), morphology (shape) and semen volume. Abnormal results may need to be repeated for confirmation. Even if sperm count is low or zero, there are treatments available, so men should not lose hope based on one test.

Additional laboratory tests include blood tests for hormonal levels (testosterone, FSH, LH, prolactin, thyroid hormones) to check for endocrine causes. A urine test after ejaculation can detect retrograde ejaculation (sperm entering the bladder). Doctors may also test for genetic causes (e.g. karyotype, Y-chromosome microdeletions) especially in cases of very low sperm count or elevated FSH.

Imaging studies can identify blockages or varicocele: for example, scrotal ultrasound visualizes the testicles and veins, and transrectal ultrasound checks for ejaculatory duct obstructions. A transrectal ultrasound may reveal ejaculatory duct cysts or abscesses blocking sperm flow.

If obstruction is suspected or for severe azoospermia (no sperm in semen), more invasive tests can be done. For instance, a testicular biopsy can determine if sperm are being produced and even retrieve sperm directly from testicular tissue for use in assisted reproduction.

Newer diagnostic tools are emerging. For example, the sperm DNA fragmentation test assesses the integrity of sperm DNA. Research shows that high DNA fragmentation (breaks in genetic material) correlates with poor sperm parameters and lower pregnancy rates (pmc.ncbi.nlm.nih.gov). Identifying damaged DNA can guide treatment decisions or the use of assisted techniques. Other advanced tests like fluorescent in situ hybridization (FISH) can detect sperm chromosomal abnormalities (aneuploidy), although these are specialized and not routinely done.

“Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse,” according to WHO (who.int). Once infertility is established, a thorough male evaluation should always accompany the female partner’s assessment, since male and female factors often coexist (ncbi.nlm.nih.gov, ncbi.nlm.nih.gov).

Treatment of Male Infertility

Treatment depends on the cause. Lifestyle changes are universally recommended as the first step: this means stopping smoking and recreational drugs, cutting back alcohol, adopting a healthy diet and regular exercise, and managing stress. Losing excess weight and controlling conditions like diabetes or hypertension can improve sperm quality. As one expert notes, modern lifestyles – stress, poor diet and lack of exercise – are strongly linked to declining sperm counts. Similarly, minimizing toxin exposure (avoiding unnecessary X-rays, heat, pesticides or heavy metals) can help fertility.

If an infection (e.g. prostatitis, epididymitis) is found, appropriate antibiotics can clear it and improve fertility. Hormonal imbalances (like low testosterone) may be treated with medications or hormone therapies. If a varicocele is diagnosed and painful or severe, surgical repair (varicocelectomy) can be considered, which sometimes improves sperm count and pregnancy rates.

Men with sexual dysfunction (erectile dysfunction or premature ejaculation) should also seek treatment. Erectile problems can often be managed with medications (PDE-5 inhibitors) or counseling, enabling successful intercourse. Premature ejaculation can be addressed with behavioral techniques or therapy.

In cases of obstructive azoospermia (blockage preventing sperm delivery), surgery may be an option. Microsurgical procedures like vasovasostomy or vasoepididymostomy can reconnect the reproductive tract. If obstruction cannot be repaired, sperm can be retrieved directly from the testes or epididymis. Techniques include percutaneous aspiration (PESA, TESA) or microsurgical testicular sperm extraction (micro-TESE) in which surgeons use a microscope to find pockets of sperm in the testicle. Even men with no sperm in ejaculate (azoospermia) can often have sperm extracted for use in assisted reproduction.

Assisted Reproductive Technologies (ART)

When simpler treatments are insufficient, assisted reproductive techniques offer hope. Common ART options include:

• Intrauterine Insemination (IUI): After preparing/“washing” the sperm in the lab, a concentrated sample is placed directly into the woman’s uterus during ovulation. IUI is often used when sperm count or motility is low, or in cases of mild male factor. It has lower cost but also lower success rates than IVF. (One fertility center notes IUI is useful when “sperm count is low, sperm has low mobility or there is retrograde ejaculation”)

• In Vitro Fertilization (IVF): Eggs are retrieved from the woman’s ovaries and fertilized by sperm in a laboratory dish. A resulting embryo is then transferred to the uterus. IVF bypasses many natural barriers to fertilization. WHO acknowledges that “treatment of infertility often involves in-vitro fertilization (IVF) and other types of medically assisted reproduction”. IVF can help in male factor cases by allowing multiple sperm to compete to fertilize the egg.

• Intracytoplasmic Sperm Injection (ICSI): This is an advanced form of IVF specifically for male infertility. A single selected sperm is injected directly into an egg. ICSI has revolutionized severe male-factor infertility: it enables men with extremely low sperm counts or very poor sperm function to achieve fertilization. As one expert explains, in cases of severe male infertility “ICSI offers a more targeted approach” and is “highly effective for men with very low sperm counts or poor sperm motility”.

Many couples use IVF with ICSI when male factor is present. Sperm for these procedures may come from ejaculated samples, surgically extracted sperm, or even donor sperm if needed. In difficult cases (e.g. no sperm found on biopsy), donor or donor sperm IUI/IVF may be considered.

• Other techniques: Doctors may also use specialized methods like IMSI (intracytoplasmic morphologically-selected sperm injection), where sperm are chosen under high magnification to pick the best candidates. For men banking fertility (e.g. before cancer treatment), sperm cryopreservation (freezing) preserves fertility. New devices (like the Sperm VD cryopreservation device) allow freezing of very small numbers of sperm. Micro-TESE (microdissection testicular sperm extraction) can find sperm in men with no sperm in ejaculate, as a more sensitive alternative to older biopsy techniques.

Living with and Preventing Male Infertility

It’s important to dispel myths: male infertility is not uncommon or shameful. Couples should approach the issue together and seek care as a team. Early consultation (after one year of trying, or sooner if needed) can identify underlying problems and lead to timely intervention. Psychological support or counseling is also valuable, as the emotional impact on men can be significant (timesofindia.indiatimes.com). Breaking stereotypes and raising awareness that both partners contribute to fertility is crucial for better outcomes.

Prevention focuses on general health:

• Maintain a healthy weight and balanced diet (rich in antioxidants, whole foods).

• Exercise regularly and manage stress (stress reduction can improve hormonal balance and libido).

• Avoid smoking and limit alcohol.

• Protect reproductive health: seek prompt treatment for infections, and use protection to prevent sexually transmitted infections (STIs) which can cause scarring.

• Avoid excessive heat or radiation to the testes.

By adopting healthy habits, men can optimize their fertility potential.

Conclusion

Male infertility is a complex medical condition influenced by biological, environmental and lifestyle factors. Its prevalence is rising globally and in India, making awareness and early action key. Modern medicine offers a range of diagnostic tests and treatments – from basic lifestyle interventions and medical therapy to advanced assisted reproduction – that enable many men to father children. Importantly, couples should recognize that infertility is a shared issue: both partners deserve evaluation and support.

“Infertility in males lowers the chances of getting pregnant,” but it is not a punishment or taboo – it’s a treatable health condition (timesofindia.indiatimes.com). With open communication, medical care and often creative solutions (like IVF or ICSI), many “infertile” couples eventually succeed. Current research even emphasizes factors like sperm DNA integrity (pmc.ncbi.nlm.nih.gov), which underscores that routine semen tests don’t capture everything. By staying informed and seeking timely help, men can take control of their reproductive health and partner equally in the journey to parenthood.