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Quick Answer: Male infertility means a man's sperm production, sperm quality or sperm delivery is reducing a couple's chance of pregnancy. Diagnosis starts with two semen analyses, a medical history and a physical exam, followed by hormone tests, targeted ultrasound and genetic tests when needed. Most causes are treatable with lifestyle changes, medicines, microsurgery such as varicocele repair, or sperm retrieval with ICSI.
Key Takeaways
- Male factors contribute to roughly half of all infertility cases, so both partners should be tested together from the very first visit.
- The WHO 2021 semen manual treats its numbers as reference points, not a strict fertile or infertile cut-off.
- Testosterone injections, gym steroids, and many "testosterone boosters" can switch off sperm production completely. Stop them if you are trying for a baby.
- A zero sperm count (azoospermia) does not always mean no biological child. Sperm can often be retrieved surgically and used for ICSI.
- Sperm take about three months to mature, so any treatment needs at least 90 days before results show.
- An abnormal semen report can be an early warning sign for other health problems, so it deserves a proper medical workup.
What is Male Infertility?
Infertility is usually diagnosed when a couple has not conceived after 12 months of regular, unprotected intercourse. The World Health Organization estimates that around 1 in 6 people worldwide face infertility at some point in their lives.
Male infertility is the part of that problem that comes from the man's side. It happens when sperm are not made in enough numbers, do not swim well, are abnormally shaped, carry damaged DNA, or cannot reach the semen at all.
Many men still delay testing because of embarrassment or the belief that infertility is a "women's issue". That belief costs couples time, money and sometimes the chance to treat a simple cause early.
The Main Types of Male Infertility
When Should a Man Get Tested?
You do not need to wait for your partner's tests to finish. Book a male fertility evaluation if:
- You have been trying for 12 months without success
- You have been trying for 6 months and your partner is 35 or older
- You had undescended testicles, mumps after puberty, testicular injury or groin surgery (such as hernia repair)
- You have had chemotherapy or radiation, or are about to start it (freeze sperm first)
- You notice low libido, erectile problems, a small or soft testicle, or a swelling in the scrotum
- You use or have used testosterone, anabolic steroids or SARMs
- Your partner has had recurrent miscarriages or failed IVF cycles
What Has Changed in Male Infertility Care (2024 to 2026)
If you read about male infertility a few years ago, some advice has moved on. Here is what is current.
1. Both partners are evaluated together. The AUA/ASRM recommendations on male infertility, amended in August 2024 with 54 statements, advise starting assessment of the male and female partner at the same time. Testing the woman first and the man "later" is no longer the standard.
2. A normal semen report does not always end the evaluation. The 2024 update lists situations, such as recurrent pregnancy loss or unexplained infertility, where a man should still be assessed even if his semen analysis looks normal.
3. No testosterone for men who want children soon. Current recommendations clearly advise against exogenous testosterone for men trying to conceive now or in the near future.
4. Scrotal ultrasound is targeted, not routine. It is used when the exam is difficult or a specific problem is suspected, rather than for every patient.
5. Testicular sperm for high DNA damage. For men with high sperm DNA fragmentation, using sperm taken directly from the testicle for ICSI is now listed as a reasonable option.
6. WHO 2021 changed how semen numbers are read. The sixth edition of the WHO semen manual is based on about 3,500 fertile men from 12 countries. It stresses that its lower values describe fertile men, but do not draw a hard line between fertile and infertile.
7. Male fertility as a health marker. The European Association of Urology's 2025 update recommends counselling infertile men about associated health risks, added a section on exome sequencing for genetic causes, and reviewed the evidence on probiotics.
8. India's legal framework for ART. Under the Assisted Reproductive Technology (Regulation) Act, 2021, in force since January 2022, ART clinics in India can treat men between 21 and 55 years of age. Courts are still hearing challenges to these age limits, so ask your clinic about the current position if you are close to 55.
The Step-by-Step Male Fertility Evaluation
A structured workup avoids random tests, saves money and points straight to treatment.
Step 1: Medical History and Risk Assessment
The first visit feels like a conversation, but every answer is a clue. Your urologist will ask about:
- How long you have been trying and how often you have intercourse
- Childhood conditions like undescended testicles
- Mumps, sexually transmitted infections or recurrent urinary infections
- Groin, scrotal or pelvic surgery
- Medicines and supplements, including hair loss tablets, gym products and testosterone
- Smoking, vaping, alcohol and recreational drugs
- Work exposures such as heat, pesticides, solvents or radiation
- Diabetes, thyroid disease, obesity and sleep quality
Burning or pain during urination may point to an infection that can affect semen. Our post on burning urination causes beyond UTI explains these in more detail.
Step 2: Physical Examination
The exam takes a few minutes and is done privately. Your doctor checks:
- Testicular size and consistency. Small, soft testicles often mean reduced sperm production.
- Varicocele. Enlarged veins above the testicle, often described as feeling like a "bag of worms".
- Vas deferens. Whether the sperm-carrying tubes are present on both sides.
- Penis and urethral opening. Conditions such as hypospadias can affect sperm delivery.
- Hormone signs. Reduced body hair, breast enlargement or obesity.
Step 3: Semen Analysis
Semen analysis remains the foundation of male infertility diagnosis. For an accurate result:
- Abstain from ejaculation for 2 to 7 days before the sample
- Collect the full sample in the sterile container from the lab
- Deliver it to the lab within 60 minutes, kept close to body temperature
- Repeat the test after 2 to 4 weeks, because results vary naturally
WHO 2021 (6th Edition) Lower Reference Values
Remember, these numbers describe the lowest 5 percent of men who fathered a child naturally within a year. Men slightly below them can still conceive, and men above them can still struggle. Your doctor reads the whole picture, not one number.
Step 4: Hormone Tests
Hormones control sperm production, so a blood test is advised when sperm count is low, sexual function is affected, or the exam suggests a hormone problem.
Step 5: Scrotal and Transrectal Ultrasound
Ultrasound is painless and is used when there is a specific question to answer.
- Scrotal ultrasound looks for varicocele when the exam is unclear, testicular tumours, and signs of blockage.
- Transrectal ultrasound (TRUS) checks the prostate, seminal vesicles and ejaculatory ducts. It is useful when semen volume is low or sperm are absent. Some prostate conditions, including chronic prostatitis, can also affect semen quality. Learn more on our prostate disease treatment page.
Step 6: Genetic Testing
Genetic tests are recommended when sperm concentration is 1 million per mL or lower, or when there are no sperm at all.
- Karyotype detects chromosomal conditions such as Klinefelter syndrome (47,XXY).
- Y chromosome microdeletion testing shows whether sperm retrieval is likely to succeed. Some deletions mean sperm cannot be found, which saves a man an unnecessary operation.
- CFTR gene testing is advised when the vas deferens is missing, since it is linked to cystic fibrosis gene changes. The partner should be tested too.
- Exome sequencing is an emerging option in specialised centres for unexplained severe cases.
Genetic results do not always change the condition, but they shape the treatment plan and help couples understand the risk of passing a condition to their child.
Step 7: Advanced Tests
When basic results do not explain the problem, your urologist may add:
- Sperm DNA fragmentation (SDF) test for recurrent miscarriage, failed IVF or ICSI, varicocele with borderline results, or unexplained infertility
- Post-ejaculate urine analysis when semen volume is very low, to check for retrograde ejaculation
- Semen culture and white cell count when infection is suspected
Antisperm antibody testing is no longer recommended as a routine first test.
Obstructive vs Non-Obstructive Azoospermia
Hearing "zero sperm count" is frightening. The first job is to find out which type you have, because the outlook is very different.
Causes of Male Infertility
In many men, more than one factor is involved. In a sizeable share, no single cause is found, which is called unexplained or idiopathic infertility.
Medical Causes
- Varicocele: Found in about 15 percent of all men and around a third of men with primary infertility. It raises testicular temperature and increases oxidative stress on sperm.
- Infections: Prostatitis, epididymitis, sexually transmitted infections and past mumps orchitis.
- Hormonal disorders: Low pituitary hormones, high prolactin, thyroid disease.
- Genetic conditions: Klinefelter syndrome, Y chromosome microdeletions, CFTR gene changes.
- Undescended testicles: Even when corrected in childhood, sperm production can be affected.
- Cancer and its treatment: Testicular cancer, chemotherapy and radiation.
- Ejaculation problems: Retrograde ejaculation from diabetes, spinal injury or some prostate surgeries, and blockages along the urethra.
- Chronic illness: Uncontrolled diabetes, obesity, kidney and liver disease.
Medicines and Supplements That Affect Sperm
This is one of the most common and most overlooked causes we see in young men today.
- Testosterone injections, gels and anabolic steroids: Can drop sperm count to zero. Recovery after stopping may take 6 to 12 months or longer.
- SARMs and some "natural testosterone boosters": Several contain hidden hormones.
- Finasteride and dutasteride (hair loss and prostate tablets): Can reduce semen volume and count in some men.
- Opioid painkillers used long term.
- Some medicines for ulcerative colitis, gout and depression.
Never stop a prescribed medicine on your own. Ask your doctor about fertility-friendly options.
Lifestyle and Environmental Causes
- Smoking and vaping: Lower sperm count, motility and DNA quality.
- Heavy alcohol use: Disturbs testosterone and sperm production.
- Obesity: Converts testosterone into oestrogen and heats the scrotum.
- Heat: Laptops on the lap, long hot baths, saunas, tight underwear and long hours of sitting.
- Poor sleep and chronic stress: Affect hormones and sexual function.
- Air pollution and chemicals: Studies, including some from India, have linked pollution, pesticides and plasticisers to poorer semen quality.
Matching Causes, Tests and Treatment
Treatment Options After Diagnosis
The best treatment depends on the cause, the female partner's age and fertility, how long you have been trying, and your personal preferences.
Lifestyle Changes
Lifestyle changes help almost every man, whatever the cause.
- Lose weight if your BMI is high. Even 5 to 10 percent weight loss can improve hormones.
- Quit smoking, vaping and recreational drugs.
- Limit alcohol.
- Exercise regularly, but avoid extreme endurance training and steroids.
- Keep the scrotum cool. No laptop on the lap, loose underwear, short showers.
- Sleep 7 to 8 hours.
- Eat a Mediterranean-style or traditional Indian diet rich in vegetables, fruits, dals, nuts and whole grains.
Sperm take around 70 to 90 days to develop. Give any change at least three months before repeating the semen analysis.
Medical Treatment
- Hormone therapy: Clomiphene, hCG and FSH can restart or boost sperm production in men with low hormone levels, including many men recovering from steroid use.
- Aromatase inhibitors: Used in selected men with a poor testosterone to oestrogen balance.
- Antibiotics: For proven infections only.
- Antioxidants: May help some men with oxidative stress, but evidence is mixed. Avoid expensive combination packs without a diagnosis.
Surgical Treatment
- Microsurgical varicocelectomy: The preferred technique, with lower recurrence and complication rates. It is advised for varicoceles that can be felt on exam in men with abnormal semen. Small varicoceles seen only on ultrasound, with normal semen, usually do not need surgery.
- Vasectomy reversal and vasoepididymostomy: Reconnect blocked tubes so natural conception becomes possible.
- TURED (transurethral resection of ejaculatory ducts): Opens blocked ejaculatory ducts.
- Sperm retrieval: PESA, TESA, TESE, and microTESE collect sperm directly for ICSI. MicroTESE uses an operating microscope to find the small pockets of sperm production in men with NOA, while removing minimal tissue.
Assisted Reproductive Techniques (ART)
ICSI has changed the outlook for severe male infertility. Even men with very few sperm, or with sperm retrieved surgically, can become biological fathers.
How the Right Treatment Plan Is Chosen
There is no one plan that suits every couple. Your urologist and your partner's gynaecologist or IVF specialist will weigh:
- The exact cause and whether it is reversible
- The female partner's age and ovarian reserve
- How long you have been trying
- Results and timelines of each option
- Budget, travel and emotional readiness
For example, a 29-year-old couple with a clinical varicocele may try surgery and natural conception first. If the female partner is 38, moving to IVF or ICSI sooner may make more sense. Shared decision-making is the key.
Cost of Male Infertility Treatment in India
Costs vary with the city, hospital, technique, and what the package includes. As an indicative range, varicocele surgery in India costs about ₹30,000 to ₹2,50,000, with microsurgical repair at the higher end. Semen analysis and hormone tests are relatively affordable, while sperm retrieval and ICSI cycles cost more.
Always ask for a written estimate that lists consultation, tests, surgery, anaesthesia, hospital stay, and follow-up. Some surgical procedures may be covered by health insurance, but most IVF and ICSI costs are not, so check your policy.
Realistic Treatment Timeline
Questions to Ask Your Urologist
- What is the exact cause of my infertility?
- Is it reversible, or will we need IVF or ICSI?
- Do I need genetic tests, and what will they change?
- How long before we see results?
- What are the success rates and risks of each option?
- Should I freeze sperm now?
- Is my semen result a sign of any other health problem?
The Emotional Side of Male Infertility
Many men feel guilt, shame or a sense of failure after an abnormal report. Couples may also face pressure from family. These feelings are common and valid.
Talk openly with your partner, consider counselling, and remember that infertility is a medical condition, not a reflection of masculinity. Getting tested is one of the most responsible steps a man can take for his family.
Why See a Urologist for Male Infertility?
A urologist trained in andrology can diagnose hormonal, structural, and genetic causes, perform microsurgery and sperm retrieval, and work alongside your partner's fertility team. That combined approach often finds a treatable cause that would be missed if only the female partner were evaluated.
Dr. Ashish Saini is an AIIMS-trained urologist with over 15 years of experience. He evaluates men facing fertility problems at Excel Advanced Urology Centre, Greater Kailash 1, New Delhi, and creates a clear, step-by-step plan based on current international evidence.
Ready to get answers? Book an online or in-person consultation with Dr. Ashish Saini.
Frequently Asked Questions
1. What is the first test for male infertility?
The first test is a semen analysis, which checks volume, sperm count, motility and shape. Because results naturally vary, doctors usually repeat it after two to four weeks before concluding. A history and physical examination happen alongside it.
2. What is a normal sperm count according to WHO 2021?
The WHO sixth edition lists 16 million sperm per millilitre, 30 percent progressive motility and 4 percent normal forms as the lower fifth centile of fertile men. These are reference points, not a strict pass or fail line.
3. Can a man with zero sperm count become a father?
Often, yes. In obstructive azoospermia, sperm can usually be retrieved or the blockage repaired. In non-obstructive azoospermia, microTESE finds usable sperm in roughly half of men in many studies, and those sperm can be used for ICSI.
4. Does taking testosterone improve male fertility?
No. External testosterone, including gym steroids and many injections, signals the brain to switch off sperm production and can cause a zero sperm count. Men trying to conceive should avoid it and ask a urologist about fertility-friendly alternatives.
5. How long does it take to improve sperm quality?
Sperm take roughly 70 to 90 days to develop and mature. Any lifestyle change, medicine or varicocele repair therefore needs about three months before a repeat semen analysis shows its effect. Many men see further gains by six months.
6. Is varicocele surgery worth it for infertility?
For men with a varicocele that can be felt on examination and abnormal semen results, microsurgical repair often improves sperm parameters and natural pregnancy chances. Surgery is not usually advised for small varicoceles seen only on ultrasound with normal semen.
7. When is genetic testing needed for male infertility?
Genetic testing is advised when sperm concentration is one million per millilitre or lower, or when no sperm are present. Karyotype and Y chromosome microdeletion tests are standard, and CFTR testing is added if the vas deferens is absent.
8. Should both partners be tested at the same time?
Yes. Current international recommendations advise evaluating both partners together from the start. Testing only the woman first delays diagnosis, can lead to unnecessary procedures, and may miss a male health problem that needs treatment on its own.
9. Can laptops, phones and pollution reduce sperm count?
Heat from laptops on the lap, tight clothing, and long hot baths can lower sperm quality. Studies have also linked air pollution and keeping phones in trouser pockets to poorer semen results, though evidence for phones is less consistent.
10. Which doctor should I see for male infertility in Delhi?
See a urologist with andrology experience who can treat hormonal, structural, and surgical causes and coordinate with your IVF team. Dr. Ashish Saini, an AIIMS-trained urologist, consults at Excel Advanced Urology Centre, Greater Kailash 1, New Delhi.
