A Urologist’s Guide to Male Fertility

Regardless of whether babies are on your brain right now or just a speck in the distant future, here is guidance and clarification on male fertility.

By Dr. Andrew Y. Sun

Infertility can affect up to 15% of heterosexual couples. The cause of infertility is shared pretty equally among men and women: roughly a third is attributed to women alone, a third is attributed to men alone, and the remaining third is attributed to a combination of the two. 

Male infertility (often referred to as “male factor infertility”) is defined as any health issue in a man that lowers the chances of a female partner getting pregnant. In the cases where male-factors are to blame for difficulties conceiving, they generally fall into four groups:

• Problems with sperm production (the biggest list, including varicoceles, genetics, hormonal problems)
• Problems with sperm delivery (ejaculatory duct obstruction)
• Problems with sexual function (erectile and ejaculatory dysfunction)
• Lifestyle and environmental factors (smoking, obesity, drugs, medications)

Taking a step back: Sperm 101

Conception is the magic that happens between the sperm and the egg; successful fertilization depends on happy and healthy (and fast!) sperm. So what makes sperm healthy? There are several aspects of sperm health: 

• First off is semen volume: the amount of fluid expelled in the ejaculate. Sperm is about five percent of the volume in ejaculatory fluid (most if it is fluids from the prostate and seminal vesicles). 
• Next is sperm concentration: the number of individual sperm per milliliter of semen. 
• Then, you’ve got sperm motility: your swimmers’ ability to move efficiently through the female reproductive tract. A semen analysis will look at the percentage of motile sperm, which should be 40 percent or higher. Progressive motility, the rate of forward movement, is also measured. 
• Finally there’s morphology, the shape and size of the sperm. A normally shaped sperm is a mere three micrometer-wide oval with a distinctive tail. Misshapen sperm can be a cause of infertility. 

To evaluate sperm, a doctor will generally recommend a semen analysis, which looks at the measures above as well as a host of other factors including: pH (which should be between 7.2 and 8.0), sperm agglutination (the amount of sperm that stick to one another from a sample), total sperm count, viscosity (the rate at which semen liquefies), and more. These can all factor into your ability to conceive successfully. Some men prefer a more discrete route for their first step to discovering their sperm’s health and quality by using an at home sperm test kit.

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Diagnosis of male infertility

If you think you may be suffering from infertility, seeing a physician to get a medical history and simple physical exam is a good place to start. It is recommended to get screened for infertility after 12 months of trying (or sooner with known risk factors or if the female partner is over 35 years old). Men can ask their primary care provider for an evaluation, or they may directly seek specialty care from a urologist who specializes in male reproductive health. 

Many doctors start off by ordering a semen analysis. To provide a sample, you’ll either ejaculate into a sterile container, or, you might be instructed to acquire a sample at home, using a special condom. Be aware: you’ll have to abstain from sex for two to five days before the sample is collected. This is to ensure there is enough semen to analyze. 

Data from World Health Organization, 2010

Your doctor will also probably review past prescription or recreational drug use, including nicotine and alcohol. Past surgeries, infections, hormonal imbalances, and STDs can lower sperm quality and chances of conceiving, so will likely also be discussed. 

Your physician may order some blood tests to check your hormone levels to make sure they are balanced. They might also suggest a scrotal or transrectal ultrasound. This admittedly sounds unpleasant, but it’s just a simple scan to rule out abnormalities in the testes or blockages in the ejaculatory duct that prevent healthy sperm production and transport.

Causes of male infertility

The most common male infertility issue is due to a problem in the testicles (aka testes, or “balls”) leading to a defect in sperm production, which accounts for 65-80% of cases. In about 10% of those cases, the man is also facing a testosterone deficiency in addition to problems with sperm production. Another five percent of male infertility cases are due to a blockage in the pathway sperm use to leave the body during ejaculation. And a small number of cases (2-5%) are due to conditions affecting the pituitary gland or hypothalamus which essentially puts hormones out of whack. 

Finally, for about 20-30 percent of men with infertility, there are no identifiable causes (we call this “unexplained infertility”). 

Lifestyle factors that affect sperm

Some issues of semen quality can be addressed with simple lifestyle changes. 

• Environmental factors: Some research suggests an association between poor semen quality (here we’re talking about sperm concentration, morphology, and motility) and airborne pollutants. Some pesticides like DBCP (a soil fumigant banned a while ago in the US but still found in some groundwater) can also have negative effects on fertility. Of course, it’s impossible to totally avoid all environmental contaminants, but they are something to keep on your radar while you’re trying for a baby. 
• Alcohol: Binge drinking is not good for your fertility or other aspects of your health. Drinking excessively can lower testosterone levels, cause erectile dysfunction, and decrease sperm production. There’s also evidence that alcohol abuse and acute intoxication are associated with sexual dysfunction. Since The American College of Obstetricians and Gynecologists (ACOG) recommends women stop drinking altogether when trying to conceive, now would be a good time to switch to mocktails in solidarity. 
• Diet: There’s a lot of conflicting advice online about diets that increase sperm count and volume. A look at nearly 8,500 men across various studies concluded that diets including fruits, vegetables, fish, and low‐fat dairy products as the main source of proteins are associated with better semen quality. So the basic guidance is this: try to maintain a healthy diet and avoid too many of the highly processed foods that are so good, but so bad for you. And if you want to cover your bases, though, try adding foods like asparagus, spinach, garbanzo beans, and lentils to your diet. They’re all rich in folate, which increases sperm growth (spermatogenesis). This nifty little vitamin is important for DNA maintenance, RNA transfer, and protein synthesis, too. Read my Q&A for more information on nutrition and male fertility. In addition to maintaining a healthy diet, you may want to consider supplementing with important vitamins for male fertility, like vitamin D or CoQ10, to ensure optimal sperm health.
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• Smoking: In addition to its numerous other harmful effects on your body, cigarette smoking has proven adverse effects on sperm health and overall fertility in both men and women, so stopping is in good interest.

Medical interventions

As we’ve said before, male infertility can add time to the conception process, but isn’t the end of the road and can often be treated by a doctor. Treatment options depend on the cause for infertility. 

➡️Surgery

• For example, a varicocele (dilation of veins in the scrotum) can be surgically corrected. This is a common procedure done to restore proper blood flow and health to the testes.
• Or if a man needs to “undo” his vasectomy, a vasectomy reversal procedure can be done using a special microscope ("microsurgery"). The tubes are reconnected so sperm can again flow to the urethra. This is a highly technical procedure which should be performed by a urologist who specializes in microsurgery and male infertility. The surgery is an outpatient procedure done under anesthesia. 

➡️Medication

• If fertility issues arise because of problems with erections or ejaculation, treatments for sexual dysfunction are available including medication and/or counseling. 
• Sometimes, medications to optimize hormone levels may be necessary to achieve maximal fertility.
• Infections or inflammation of the genitourinary tract may require anti-inflammatories or antibiotics to treat.
• Sometimes, advanced blood or semen testing may be necessary to get to the root of the problem.

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Frictionless fertility lube

Natalist’s FDA-cleared, fertility-friendly personal lubricant is made without parabens, is pH balanced, and designed to mimic fertile cervical mucus to help sperm thrive. 

Don't forget to check out the Natalist blog for more helpful information on male fertility, nutrition, and more. 

What if none of that works?

Some parts of our health just aren’t within our control, as frustrating and worrying as that can be. You might be genetically predisposed to certain conditions like maturation arrest (where the sperm just don’t develop fully) that can make it harder to conceive, which means that no amount of alcohol abstention or dietary modification will help. But there are other routes to genetic parenthood, thanks to reproductive technologies: 

• PESA (Percutaneous Epididymal Sperm Aspiration): If sperm are not found in the ejaculate, they may be able to be retrieved directly from the epididymis (a structure that sits on top of the testes where sperm grow and mature before being ready to swim!). The simplest form of this involves collecting sperm from the epididymis using a small needle and syringe.
• mTESE (microscopic Testicular Sperm Extraction) is a specialized procedure done with a microscope under anesthesia where a surgeon directly goes into the testis through an incision in the scrotum to extract sperm. This may be necessary if the number of sperm in the ejaculated semen is very, very low or zero.
• IUI (intrauterine insemination) is a procedure where sperm are directly placed in a woman’s uterus around the time of ovulation. These sperm are concentrated and washed thoroughly beforehand. Sperm with higher motility and normal morphology can be specially selected for the procedure. This means that you can still be biologically related to your child, they just won’t be conceived through sex, but this is a route that countless people (heterosexual, lesbian, and transgender couples and single parents by choice) have relied on to grow their families. The total cost of IUI varies depending on insurance coverage and doctor’s fees. Usually it is around $500 – $4,000. Some people may choose to have the procedure done by midwives at home. 
• IVF (in vitro fertilization) involves a procedure where eggs are extracted from a woman’s body and combined with a sperm sample in a laboratory dish. This process fertilizes the egg, creating an embryo that is placed right back into the woman’s uterus where, if all goes well, it will implant and grow. Cost is again something to take into consideration for this procedure. One IVF cycle can cost anywhere from $15,000 to $20,000.
• ICSI (intracytoplasmic sperm injection) is yet another treatment option that is part of IVF. Here, a specialized needle isolates and retrieves a single sperm cell from a sample—this helps ensure that the most viable sperm is selected, leaving nothing up to chance. Then, the needle is inserted into the egg’s cytoplasm (the gelatinous outer layer of the cell), and again, the resulting embryo is placed securely in the woman’s uterus. 

These are all options that allow men with male factor infertility to still maintain a biological relationship with their future child, if that remains important in the face of infertility. But of course, there is also the option to use donor sperm in any of these reproductive technologies, if your partner and you are open to it! 

Stay positive ✨

Although low semen quality can be upsetting, it isn’t the end of the road for conceiving with your partner. These days, there are plenty of options at your disposal, ranging from small lifestyle changes, to fertility boosting supplements, to assisted reproduction technologies, and they’re all normal things that couples who are trying to conceive turn towards regularly. 

Speaking with a urologist or reproductive endocrinologist can help you plan what’s best for you, your partner, and your budget.