Male infertility
About half of all fertility problems involve a male factor. A proper urological assessment finds the cause — and in many men that cause is treatable.
Why the male partner needs assessing properly
When a couple has been trying to conceive for a year without success, both partners should be investigated. In roughly half of cases a male factor is involved, and in about one in five couples it is the only factor. Despite this, men are often given a single semen analysis and told the result is “low” without anyone establishing why.
That matters for two reasons. First, several causes of male infertility are correctable, and correcting them can allow natural conception or improve the results of IVF. Second, a semen abnormality is occasionally the first sign of a more significant medical problem — including testicular cancer, hormonal disorders and genetic conditions — which needs picking up regardless of your fertility plans.
Symptoms and signs
Most men with fertility problems feel entirely well. The problem is usually discovered through semen testing rather than through symptoms. Where symptoms do occur, they may include:
- A lump, swelling or aching in the testicle or scrotum
- Reduced sex drive, poor erections or problems with ejaculation
- Reduced facial or body hair, or other signs of low testosterone
- Small or soft testicles, or a testicle that never descended in childhood
- Recurrent respiratory infections, which can point to specific genetic conditions
Common causes
Male infertility is a symptom, not a diagnosis. The underlying causes fall into broad groups:
- Varicocele — enlarged veins in the scrotum, found in around 15% of all men but far more commonly in men with abnormal semen. It is the most frequently identified correctable cause.
- Obstruction — a blockage anywhere between the testicle and the urethra, whether from previous surgery, infection, a vasectomy, or a condition present from birth.
- Testicular failure — where the testicles produce little or no sperm, sometimes after chemotherapy, radiotherapy, mumps, torsion or an undescended testicle.
- Hormonal causes — problems with the pituitary gland or testosterone axis. Importantly, testosterone replacement therapy itself suppresses sperm production and is a common and reversible cause of a very low count.
- Genetic causes — chromosomal abnormalities such as Klinefelter syndrome, Y chromosome microdeletions, or cystic fibrosis gene mutations.
- Ejaculatory problems — including retrograde ejaculation, where semen passes backwards into the bladder.
- Lifestyle and drug factors — anabolic steroids, some prescription medicines, smoking, significant alcohol intake, obesity and heat exposure.
How I assess male infertility
A first consultation covers your medical, surgical, sexual and family history, any previous test results, your medications and your occupation. I then examine you — this is essential, and it is where varicoceles, absent vas deferens and testicular abnormalities are found. Examination alone frequently changes the diagnosis.
Investigations are then tailored rather than routine. They may include:
- Two semen analyses performed to WHO standards, since results vary considerably between samples
- Hormone profile — testosterone, FSH, LH, prolactin and others as indicated
- Scrotal ultrasound, and transrectal ultrasound where obstruction is suspected
- Genetic testing, including karyotype, Y microdeletion and CFTR analysis where the count is very low or absent
- Sperm DNA fragmentation testing in selected cases, particularly after recurrent miscarriage or failed IVF cycles
- Post-ejaculatory urine analysis where retrograde ejaculation is suspected
Second opinions
A large proportion of the men I see have already been told that donor sperm or IVF is their only option. That is sometimes correct, but not always. If nobody has examined you, checked your hormones or explained why your count is low, the assessment is incomplete.
Treatment
Treatment depends entirely on the cause. Options include correcting a varicocele with microsurgery, reversing an obstruction with microsurgical reconstruction, adjusting or stopping medication that is suppressing sperm production, hormonal treatment where there is a pituitary cause, and surgical sperm retrieval such as microTESE where no sperm reach the ejaculate.
Where assisted conception is needed, the aim is still to optimise sperm quality first, because that influences fertilisation, embryo quality and miscarriage risk. I work jointly with fertility specialists so that decisions about IVF and ICSI are made with full information about the male side, rather than around it.
My practice
I established the largest male infertility service from south of the Thames to the south coast at Guy's Hospital in 2012, specialising in microsurgery and onco-fertility. I run a national training fellowship in male infertility surgery, and with Julia Kopeika I set up one of the few joint fertility clinics within the Guy's Assisted Conception Unit for complex cases. I am currently involved in writing national practice guidelines for fertility, and I offer only evidence-based treatments.
Frequently asked
How long should we try before getting checked?
Twelve months of regular unprotected intercourse is the usual threshold. Seek advice sooner — at around six months — if the female partner is over 35, or if either of you has a known risk factor such as previous cancer treatment, undescended testicle, testicular surgery or a history of chemotherapy.
Can a low sperm count be improved?
Often, yes, depending on the cause. Correcting a varicocele, stopping a drug that suppresses production, treating a hormonal problem or clearing an infection can all improve semen parameters. Improvements take time — sperm production runs on roughly a three-month cycle, so repeat testing is usually done at three months.
Does testosterone therapy affect fertility?
Yes, significantly. Testosterone replacement switches off the signal from the brain that drives sperm production, and can reduce the count to zero. It is a common cause of infertility in men who have been prescribed it for low testosterone or who have used it in the gym. In most men the effect reverses after stopping, but recovery can take many months and is occasionally incomplete, so it should never be started in a man who wants children without a fertility discussion first.
Do I need a referral from my GP?
Not for a private consultation, although most insurers require one before they authorise your appointment. Bring any previous semen analyses and blood tests with you — it saves repeating them.
Should my partner be investigated at the same time?
Yes. Fertility is a couple issue and parallel investigation avoids months of wasted time. I am happy for partners to attend consultations, and I liaise directly with fertility units where joint decisions are needed.
Speak to my team
Appointments at The Shard and Canary Wharf are arranged by my PA, Jeanette Bush. Tell us briefly what the problem is and we will find the right clinic slot for you.