Infertility is often spoken about as if it is exclusively a woman’s experience. It is not. In approximately 40 to 50 percent of couples experiencing difficulty conceiving, the primary cause is a male factor — and in a further 20 percent, both partners contribute to the challenge.
Despite this, men rarely seek help proactively. The subject is wrapped in shame, silence, and misunderstanding that can delay diagnosis and treatment by years.
This guide is written to change that. It covers everything men and their partners need to know about male infertility: what causes it, how it is diagnosed, what treatment options are available, and the genuine reasons for optimism in modern reproductive medicine.
Understanding Male Fertility
For conception to occur, a man needs to produce enough healthy, motile sperm that can travel through the female reproductive tract and fertilise an egg. This depends on several interconnected systems working correctly:
- The testes, where sperm are produced over approximately 72–90 days
- The epididymis, where sperm mature and are stored
- The vas deferens, the tube through which sperm travel toward the urethra
- The accessory glands (seminal vesicles and prostate), which produce the fluid that transports and nourishes sperm
- The hormonal axis (hypothalamus, pituitary, testes) that regulates sperm production
A disruption at any point in this system can affect fertility — and because sperm take approximately three months to develop from start to finish, even temporary events (an illness, excessive heat exposure, stress) can affect sperm quality for several months.
How Common Is Male Infertility?
Male infertility affects a significant and apparently growing proportion of men. Research has documented a steady decline in average sperm counts in Western countries over recent decades, with some studies suggesting a reduction of more than 50% in average sperm concentration over the last 40 years.
In South Africa, male infertility is at least as prevalent as in other parts of the world. At major fertility clinics across the country, male factor infertility is identified as a contributing cause in a large proportion of couples who present for treatment.
Important to know: Male infertility is a medical condition, not a reflection of masculinity, sexual performance, or overall health. A man can be perfectly healthy in every other way and still have a sperm issue. The two are entirely unrelated.
What Causes Male Infertility?
Problems with sperm production
The most common cause of male infertility is impaired sperm production in the testes. This can be caused by:
- Varicocele: Enlarged veins in the scrotum that raise testicular temperature. This is the most common correctable cause of male infertility, found in approximately 15% of all men and up to 40% of infertile men
- Hormonal imbalances: Low testosterone, elevated prolactin, or dysfunction of the pituitary gland affecting the signals that regulate sperm production
- Genetic causes: Including Klinefelter syndrome (an extra X chromosome), Y chromosome microdeletions, and other chromosomal abnormalities
- Cryptorchidism: Undescended testicle(s) in childhood, even if surgically corrected, can affect sperm production
- Previous infections: Mumps orchitis, sexually transmitted infections, and other infections can permanently damage testicular tissue
- Cancer treatment: Chemotherapy and radiation therapy can severely damage sperm production, often temporarily but sometimes permanently
Problems with sperm transport
- Vasectomy (intentional obstruction of the vas deferens)
- Congenital bilateral absence of the vas deferens (CBAVD) — a genetic condition often associated with cystic fibrosis mutations
- Obstruction from previous infection or surgery
- Retrograde ejaculation — sperm travel backward into the bladder instead of being ejaculated
Lifestyle and environmental factors
- Smoking: Significantly reduces sperm count, motility, and morphology
- Excessive alcohol consumption
- Anabolic steroid use: Suppresses the body’s natural hormone signals, often causing severe reductions in sperm production
- Heat exposure: Hot baths, saunas, or occupational heat exposure
- Obesity: Associated with hormonal disruption and reduced sperm quality
- Certain medications: Including some antibiotics, antifungals, antidepressants, and blood pressure medications
- Environmental toxins: Pesticides, heavy metals, and industrial chemicals
How Is Male Infertility Diagnosed?
The semen analysis
The semen analysis (sperm test) is the cornerstone of male fertility investigation. It provides detailed information about:
- Sperm count (concentration): The number of sperm per millilitre of semen
- Total motility: The percentage of sperm showing any movement
- Progressive motility: The percentage of sperm moving forward purposefully
- Morphology: The percentage of sperm with a normal shape under the microscope
- Volume: The total volume of the ejaculate
- Liquefaction time: How long the semen takes to become liquid after ejaculation
World Health Organisation (WHO) reference ranges define the lower limit of normal for these parameters. Results below these thresholds do not mean pregnancy is impossible — they indicate that a sperm issue is present and guide what level of treatment may be needed.
Hormone blood tests
Blood tests measuring FSH, LH, testosterone, and prolactin can identify hormonal causes of reduced sperm production.
Genetic testing
If the sperm count is very low or absent, genetic testing (karyotype and Y chromosome microdeletion analysis) may be recommended to identify chromosomal causes.
Ultrasound
A scrotal ultrasound can identify varicoceles, testicular masses, or other structural abnormalities.
Testicular biopsy
In cases of azoospermia (no sperm in the ejaculate), a testicular biopsy can determine whether sperm are being produced (obstructive azoospermia) or whether production has failed (non-obstructive azoospermia). This distinction is critical for treatment planning.
Male Infertility Treatment Options
Lifestyle changes
When lifestyle factors are contributing to poor sperm parameters, addressing these can meaningfully improve results:
- Stopping smoking
- Reducing or eliminating alcohol
- Stopping anabolic steroids (sperm production may recover over 12–18 months)
- Achieving a healthy body weight
- Avoiding recreational heat exposure
- Reviewing any medications with your doctor
Because sperm take approximately three months to develop, improvements from lifestyle changes take time to appear in a semen analysis.
Medical treatment
- Hormonal therapy: Where a hormonal imbalance is identified as the cause, medication can sometimes restore sperm production
- Antibiotic treatment: For infections affecting the reproductive tract
- Varicocele repair: Surgical or interventional repair of varicoceles can improve sperm parameters in selected men, though results vary
Surgical sperm retrieval
In men with azoospermia or very low counts, sperm can often be retrieved surgically from the reproductive tract:
- PESA (Percutaneous Epididymal Sperm Aspiration): Sperm aspirated from the epididymis
- TESA (Testicular Sperm Aspiration): Sperm aspirated directly from the testis
- TESE (Testicular Sperm Extraction): Small biopsies taken from the testicular tissue to find sperm
- Micro-TESE: A microsurgical technique that maximises the chance of finding sperm in men with non-obstructive azoospermia
Surgically retrieved sperm is used in conjunction with ICSI — because the numbers retrieved are very small, direct injection into eggs is required.
IUI (Intrauterine Insemination)
In cases of mild to moderate male factor infertility, IUI may be appropriate. Prepared sperm are placed directly into the uterus at the time of ovulation, bypassing the cervix and improving the concentration of sperm reaching the egg.
IVF with ICSI
For moderate to severe male factor infertility, IVF combined with ICSI is the most effective treatment. Even very small numbers of sperm — including those surgically retrieved — can be used to fertilise eggs through ICSI.
Donor sperm
In cases where no sperm can be found, or where a genetic condition makes it inadvisable to use the male partner’s sperm, donor sperm is an option. South Africa has established sperm banks, and donor insemination is a well-regulated, commonly used treatment.
Myths About Male Infertility
Myth: If I can have an erection, my sperm must be fine
Fact: Erectile and ejaculatory function are completely separate from sperm production and quality. A man can have a normal sex life and still have a significant sperm issue.
Myth: Male infertility is rare
Fact: Male factor infertility is a contributing cause in 40 to 50 percent of couples who struggle to conceive.
Myth: Wearing tight underwear causes infertility
Fact: The evidence for this is weak. Moderate warmth reduction probably has minimal impact for most men, but for those with borderline sperm parameters, it makes sense to switch to looser clothing as a low-cost, low-effort measure.
Myth: There is nothing that can be done
Fact: The majority of men with infertility diagnoses have treatment options. Even men with severe azoospermia — no sperm in the ejaculate at all — can often have sperm retrieved surgically and used for ICSI.
The Emotional Side of Male Infertility
Receiving a male infertility diagnosis can be deeply painful and disorienting. Many men describe feelings of failure, shame, and inadequacy that are entirely understandable but entirely misplaced.
These feelings often discourage men from talking about their diagnosis, which in turn can put enormous pressure on the relationship with their partner. It is worth knowing that:
- Male infertility is a medical condition, not a personal failing
- Treatment options exist for the vast majority of cases
- Your partner is not alone in this, and neither are you
- Couples who face fertility challenges together, with open communication and mutual support, consistently report better outcomes — both medically and emotionally
Fertility counselling is available and valuable. It is not a sign of weakness — it is a sign of taking this seriously.
Frequently Asked Questions
How long should we try before investigating male fertility?
Current guidance recommends investigation after 12 months of regular unprotected sex for women under 35, and after 6 months for women over 35. However, if there is a known or suspected male factor, investigation can be sought sooner — a semen analysis is a simple, inexpensive starting point.
Can sperm quality improve?
Yes — in many cases. Lifestyle changes, treatment of underlying conditions (such as hormonal imbalances or varicoceles), and the removal of environmental or pharmaceutical factors can all lead to meaningful improvement over the three-month sperm development cycle.
What if our only option is donor sperm?
Donor insemination has helped many thousands of South African families. It is a well-established, legal, and safe option. Counselling support is available to help couples process the emotional dimensions of this decision.
Next Steps
If you or your partner are concerned about male fertility, the starting point is a semen analysis — ideally ordered through a fertility specialist who can interpret the results in context.
Fertility Solutions can connect you with reproductive medicine specialists and fertility clinics in your area who have the expertise to diagnose and treat male factor infertility with the care and respect it deserves.
Disclaimer: This content is for educational purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider before making decisions about fertility treatment.
About the Author
Leigh-Ann Geydien is the founder of Fertility Solutions, South Africa’s only dedicated fertility directory. With a deep commitment to patient advocacy, she built the platform to bridge the gap between those navigating fertility challenges and the clinics and reproductive health specialists best placed to help them.
