Male Infertility: Causes, Semen Analysis, IVF and ICSI
Quick answer: What is male infertility? Male infertility means a man's sperm production, sperm quality or sperm delivery is reducing the couple's chance of conceiving. Common causes include varicocele, hormone imbalance, infections, blocked tubes, genetic conditions, steroid use, smoking and heavy drinking. The first test is a semen analysis. Treatment depends on the cause and may involve lifestyle change, medicines, surgery, IUI, or IVF with ICSI.
Male infertility is when a problem on the man's side lowers a couple's chance of getting pregnant. Usually the issue lies in how many sperm he makes, how well they swim, how they are shaped, or whether they can leave the body at all. A semen analysis is the test that picks it up, and many of the causes can be treated or bypassed with IUI, IVF or ICSI.
In most Indian homes, questions about a delayed pregnancy land on the wife. Fertility doctors see where that leads. A couple spends a year on her scans, blood tests and tablets, while the husband's semen test, which needs one visit to a lab, gets done last or not at all.
Male factors play a part in a large share of couples who struggle to conceive. That is the reason fertility guidelines ask for both partners to be checked at the first visit.
Why should both partners be tested for infertility?
A pregnancy needs a healthy egg, healthy sperm, open fallopian tubes and a uterus that can hold an embryo. If any one of those is missing, it does not happen. Checking only the woman leaves half the picture blank.
The semen test is also the cheapest and least invasive test in the whole fertility workup. No injections, no scans, no waiting for a particular day of the cycle. Getting it done in the first month can save a couple many months of treatment aimed at the wrong problem.
And it changes how the couple talks about it at home. When both reports are on the table, there is less room for blame and more room for planning.
How long should a couple try before getting tested?
The usual advice is to see a doctor after 12 months of regular unprotected sex without a pregnancy. If the woman is 35 or older, six months is enough.
Men with certain histories should not wait that long. That includes a history of undescended testes (even if surgery fixed it in childhood), past surgery in the groin or scrotum, mumps after puberty with testicular swelling, chemotherapy or radiation, trouble with erections or ejaculation, low sex drive, or any use of testosterone injections or gym steroids. A previous low sperm count is another reason to come in early.
How does sperm production work?
A little biology makes the semen report far easier to follow.
Sperm are made inside the testes, in long, tightly coiled tubes. The brain runs the process. A small gland at its base, the pituitary, releases two hormones called FSH (follicle stimulating hormone) and LH (luteinising hormone). LH tells the testes to make testosterone. FSH and testosterone together keep sperm production going.
One sperm takes roughly two to three months to form and mature. Keep that number in mind. A bad fever six weeks ago can still drag down today's report, and a man who quits smoking this week won't see the effect on a test for a couple of months.
Once mature, sperm move through the epididymis, a coiled storage tube behind each testis, and then up the vas deferens. They mix with fluid from the seminal vesicles and the prostate and leave the body as semen.
Trouble anywhere along that route, from the brain's signals to the last stretch of tube, can cause infertility.
What causes male infertility?
Doctors tend to sort the causes into four groups. The hormone signals may be weak. The testes themselves may not be producing well. A blockage may be trapping sperm inside. Or a sexual or ejaculation problem may be stopping sperm from reaching the egg.
Some men go through every test and no cause turns up. This is called idiopathic, or unexplained, male infertility, and it is fairly common. Treatment can still go ahead.
Varicocele
A varicocele is a cluster of swollen veins in the scrotum, much like varicose veins in the legs. It is one of the most frequent findings in men tested for infertility. The pooled blood may warm the area around the testes and affect sperm.
Plenty of men have a varicocele and father children without any trouble. Whether it needs surgery depends on its size, the semen results and the couple's overall situation, and that call is made by a urologist.
Hormonal causes
These are less common, but worth finding because some respond well to treatment.
In hypogonadotropic hypogonadism, the brain does not release enough FSH and LH, and the testes slow down. Hormone injections can often restart production. A raised prolactin level can lower testosterone and sperm output. Thyroid disorders may affect sperm and sexual function too.
Then there is testosterone itself. Men who take testosterone injections, anabolic steroids, or gym products laced with steroids often have no idea this can shut sperm production down, sometimes completely. The body sees plenty of testosterone coming in from outside and the brain stops signalling the testes. Production frequently recovers after stopping, but recovery can take months, and any prescribed hormone should only be stopped on a doctor's advice.
Problems in the testes
Undescended testes in childhood, even when corrected, can affect sperm production in adult life. So can mumps after puberty (mumps orchitis), a past injury, testicular torsion, and cancer treatment with chemotherapy or radiation. Some genetic conditions also act directly on the testes.
Genetic causes
In men with a very low count or no sperm at all, a genetic cause is sometimes found. Klinefelter syndrome, where a man carries an extra X chromosome, is one. Small missing segments on the Y chromosome, called Y chromosome microdeletions, are another. Certain changes in the CFTR gene, the gene linked to cystic fibrosis, can leave a man born without the vas deferens.
Genetic tests are not routine. They come up when the sperm count is severely low or zero.
Blockages
Sometimes the testes make sperm perfectly well and the sperm simply can't get out. Old infections, injury, earlier surgery, a vasectomy, or being born without the vas deferens can all block the way. These men usually have normal hormone levels and normal-sized testes, which is one of the clues doctors look for.
Infections
Infections of the prostate, epididymis or testes, including some sexually transmitted infections, can damage sperm or leave scarring behind. An active infection needs treating, often in both partners.
Erection and ejaculation problems
Erectile dysfunction makes regular intercourse difficult. In retrograde ejaculation, semen flows backward into the bladder instead of out through the penis, which can happen with diabetes, after some prostate surgery, or with certain medicines. Premature or delayed ejaculation can also get in the way.
Men often sit on these problems for years before mentioning them. In a fertility clinic they are routine, and most can be treated.
Lifestyle and environment
Habits rarely cause infertility on their own, but they add up. Smoking cigarettes or chewing tobacco and gutka, heavy drinking, cannabis and other recreational drugs, obesity, and poorly controlled diabetes can all affect sperm. So may frequent heat around the groin from hot tubs, saunas, or long hours with a laptop resting on the lap.
Some jobs bring exposure to pesticides, heavy metals or industrial chemicals. Certain prescription medicines can play a role as well, so it helps to carry a list of everything you take to the appointment.
Age matters for men too, though less sharply than for women. Sperm quality tends to drift downward slowly over the years.
What are the symptoms of male infertility?
For most men, there are none. Sex is normal, the semen looks normal, he feels fine. The only sign is a pregnancy that isn't happening.
A smaller group does notice something. Erections may be difficult, or sex drive low. The amount of semen may be very small. There may be pain, swelling or a lump in the scrotum. Less body or facial hair, or some breast enlargement, can point toward a hormone problem. Rarely, frequent chest or sinus infections link to a genetic condition that also affects fertility.
Sperm can only be seen under a microscope. How semen looks to the eye says nothing reliable about what is in it.
What is a semen analysis and how is it done?
A semen analysis is a lab test that measures the volume of semen and checks the number, movement and shape of the sperm inside it. It is the first and most useful test for male fertility.
How to prepare for a semen test
Avoid ejaculation for 2 to 7 days beforehand. A shorter gap tends to lower the count, and a much longer one leaves more old, sluggish sperm in the sample.
Collect the whole sample in the sterile container the lab gives you, since the first portion usually carries the most sperm. Skip lubricants, oil and saliva, all of which can harm sperm. Regular condoms are a problem too, because many contain substances that kill sperm.
If you are collecting at home, get the container to the lab within about an hour and keep it close to body temperature on the way, for example in an inside pocket. And tell the lab if you had a fever, an illness or started any new medicine in the past three months.
Most labs in Bangalore have a private room for collection. Plenty of men find the whole thing awkward. The staff deal with it all day, every day.
How to read a semen analysis report
The World Health Organization (WHO) publishes reference values drawn from men whose partners got pregnant within a year. The figures below are the lower reference limits from the WHO laboratory manual published in 2021.
| Parameter | What it measures | WHO lower reference limit |
|---|---|---|
| Semen volume | Total amount of fluid | 1.4 mL |
| Sperm concentration | Sperm per millilitre | 16 million per mL |
| Total sperm count | Sperm in the whole sample | 39 million per ejaculate |
| Total motility | Percentage of sperm moving | 42% |
| Progressive motility | Percentage moving forward | 30% |
| Vitality | Percentage of live sperm | 54% |
| Normal morphology | Percentage with normal shape | 4% |
Read these as reference points rather than a pass mark. A man just under the line can still father a child naturally, and a man comfortably above it isn't guaranteed fertility.
The morphology figure surprises people. Seeing "4% normal forms" sounds terrible, yet it sits inside the reference range. Under strict lab criteria, most sperm in every man look imperfect.
Common terms you may see on the report
| Term | Meaning in simple words |
|---|---|
| Normozoospermia | All main values within reference range |
| Oligozoospermia | Low sperm count |
| Asthenozoospermia | Low sperm movement |
| Teratozoospermia | Low percentage of normally shaped sperm |
| OAT (oligoasthenoteratozoospermia) | Low count, movement and shape together |
| Azoospermia | No sperm found in the sample |
| Necrozoospermia | High percentage of dead sperm |
| Pus cells (leukocytes) | White blood cells, which may suggest infection |
Why one test is rarely the final word
Sperm counts swing quite a bit from one sample to the next. A recent fever, a stressful week or a short abstinence gap can all pull numbers down. When the first report comes back abnormal, doctors usually ask for a repeat after a few weeks to three months before deciding anything.
What other tests may be needed?
An abnormal semen report often leads to a few more investigations. Which ones depends on what the first test showed.
| Test | Why it may be done |
|---|---|
| Physical examination | To check testis size, look for a varicocele and feel for the vas deferens |
| Hormone tests (FSH, LH, testosterone, prolactin, TSH) | To find hormonal causes and judge how well the testes are producing |
| Scrotal ultrasound | To look at the testes and detect a varicocele or lump |
| Post-ejaculation urine test | To check for retrograde ejaculation when semen volume is low |
| Genetic tests (karyotype, Y microdeletion, CFTR) | For very low or zero sperm counts |
| Semen culture | When infection is suspected |
| Sperm DNA fragmentation test | In selected cases, such as repeated miscarriage or unexplained IVF outcomes |
Sperm DNA fragmentation testing is still argued over. It can help in particular situations, but experts have not agreed on using it for everyone. It is fair to ask your doctor whether the result would actually change your plan.
Assessing the male partner often brings in a urologist or andrologist, a doctor who focuses on male reproductive health. At EVE Women and Fertility Clinic, Dr. Swati Shree reviews semen reports as part of the couple's assessment and arranges referral to a male fertility specialist when the findings call for it.
What does it mean if no sperm is found?
The report says azoospermia. No sperm seen. For most men this is a hard thing to read, and it is natural to assume the worst. In many cases, though, it is not the end of the road to a biological child.
There are two broad types.
In obstructive azoospermia, the testes are making sperm but a blockage keeps them from reaching the semen. Sperm can often be collected straight from the testis or the epididymis through a minor procedure.
In non-obstructive azoospermia, the testes produce very little or nothing. Some men still have small patches of active production. A specialised operation called micro-TESE (microdissection testicular sperm extraction) can find sperm in a portion of these men, though it does not work for everyone.
Hormone levels, testis size and genetic results help the doctor work out which type is more likely and what is worth trying.
What are the treatment options for male infertility?
The plan depends on the cause, how severe it is, the female partner's age and fertility, and how long the couple has been trying. Doctors generally aim for the least intensive route that has a fair chance of working.
Lifestyle changes
Quitting cigarettes and tobacco, cutting alcohol right down, and getting weight and blood sugar under control all support sperm production. So does steering clear of recreational drugs, unsupervised steroids and so-called testosterone boosters. Keep heat away from the groin for long stretches.
Food does not need to be fancy. A regular Indian plate with dal, vegetables, fruit, whole grains, millets, some nuts and enough protein covers most of what sperm need. Sleep and regular physical activity help too.
Give any of these changes two to three months before judging them by a new test. That is how long a fresh batch of sperm takes to come through.
Treating the underlying cause
Some causes have direct treatments. Low FSH and LH can often be corrected with hormone injections under specialist care. High prolactin and thyroid problems may settle with medicines. Infections are treated with the right antibiotics, frequently in both partners.
Retrograde ejaculation sometimes improves with medication, and if it doesn't, sperm can be recovered from urine for use in treatment. Erection and ejaculation problems usually respond well to a mix of medical treatment and counselling.
Antioxidants and supplements
Many men end up on antioxidant capsules for sperm health, either prescribed or bought over the counter. The research on whether they lead to more pregnancies is mixed, and not strong enough to recommend them for everyone. Talk to your doctor before starting a combination of products on your own.
Varicocele repair
Surgery may be offered when a varicocele can be felt on examination, the semen report is abnormal and the couple is actively trying. It does not help every man, and any improvement in the semen may take several months to show. If the female partner is older or has fertility issues of her own, the doctor may advise moving straight to assisted reproduction instead of waiting.
Surgical sperm retrieval
When the semen contains no sperm, they can sometimes be taken directly from the reproductive tract. PESA draws sperm from the epididymis with a fine needle. TESA does the same from the testis. TESE involves a small surgical biopsy, and micro-TESE uses an operating microscope to search for pockets of production. The sperm collected are generally used with ICSI and can often be frozen for later cycles.
Donor sperm
When no sperm can be retrieved, some couples consider donor sperm. In India this falls under the Assisted Reproductive Technology (Regulation) Act, 2021, and there are eligibility rules. A detailed discussion with the fertility specialist and a counsellor is the right place to start.
How do IUI, IVF and ICSI help with male infertility?
All three help sperm and egg meet more effectively. The choice comes down mostly to how many good, moving sperm are available and how the female partner's fertility looks.
IUI (intrauterine insemination)
For IUI, the semen sample is washed and concentrated in the lab so that the best swimmers are separated out. Around the time of ovulation, these are placed directly into the uterus through a thin, soft tube. It takes a few minutes, needs no anaesthesia, and most women describe it as mildly uncomfortable at worst.
IUI suits mild male factor problems, provided the woman's tubes are open and she is ovulating. When counts or motility are very low, it has less to offer. EVE Women and Fertility Clinic offers IUI and follicle monitoring in Gunjur as part of its ART Level 1 services.
IVF (in vitro fertilisation)
In IVF, the woman takes hormone injections for about a couple of weeks so that several eggs grow at once. The eggs are collected in a short procedure, mixed with prepared sperm in the lab, and the embryos that form are grown for a few days. One is then transferred into the uterus.
IVF may come up for moderate male factor problems, after IUI cycles that did not result in pregnancy, or when the woman also has fertility concerns.
ICSI (intracytoplasmic sperm injection)
ICSI is done as part of an IVF cycle. Rather than leaving sperm to find and enter the egg, an embryologist picks a single sperm and injects it into each mature egg with a very fine needle under a microscope.
Doctors usually suggest ICSI when the count, motility or shape is severely affected, when sperm have been taken surgically, when eggs failed to fertilise in an earlier IVF cycle, or when only a small amount of frozen sperm is available.
ICSI raises the chance of fertilisation when sperm are the main obstacle. It can't make up for egg quality and it doesn't promise a pregnancy. If a genetic cause has been found in the man, genetic counselling is usually advised before going ahead.
IUI vs IVF vs ICSI at a glance
| Feature | IUI | IVF | ICSI |
|---|---|---|---|
| Where fertilisation happens | Inside the body | In the lab | In the lab, one sperm injected per egg |
| Sperm needed | A reasonable number of moving sperm | A moderate number | Very few can be enough |
| Steps for the woman | Ovulation monitoring, sometimes tablets or injections | Injections, egg collection, embryo transfer | Same as IVF |
| Usually considered for | Mild male factor | Moderate male factor or problems in both partners | Severe male factor or surgically retrieved sperm |
Where IVF and ICSI happen for EVE patients
EVE Women and Fertility Clinic is an ART Level 1 clinic. Assessment, counselling, follicle monitoring and IUI take place at EVE itself. For IVF or ICSI, Dr. Swati Shree evaluates the couple at EVE and then guides treatment through her partner fertility centres in Bangalore, Apollo Fertility and Motherhood Fertility, where she works as a visiting consultant.
What are the risks and limitations of treatment?
No treatment comes with a guarantee. Results lean heavily on the woman's age and ovarian reserve, on sperm quality, and on a long list of smaller factors.
Varicocele surgery may leave the semen report unchanged. In non-obstructive azoospermia, a sperm retrieval operation may not find sperm. With IVF and ICSI, the woman goes through the injections and procedures even when the main problem lies with the man, and couples do well to talk about that openly.
Fertility injections carry a small risk of ovarian hyperstimulation syndrome (OHSS) for the woman. Cost and time weigh on people too, especially when more than one cycle is needed.
Common myths about male infertility
Is infertility mostly the woman's problem?
It isn't. Male factors turn up often, sometimes alone and sometimes alongside a female factor. Both partners need testing.
If a man can have sex and ejaculate, is he fertile?
Not necessarily. Sexual function and sperm production run on separate systems. The majority of men with low counts have completely normal sex lives.
Does thick semen mean strong sperm?
Thickness or colour tells you nothing dependable about count or quality. Only a lab test can.
Does one bad report mean he can never be a father?
One report is a snapshot. Results vary between samples, many causes respond to treatment, and assisted reproduction can work around many of the rest.
Does zero sperm rule out a biological child?
Often it doesn't, particularly when a blockage is to blame. Sperm can frequently be retrieved directly from the testis or epididymis.
Will testosterone tablets or injections boost fertility?
They usually do the opposite. Testosterone taken from outside tends to suppress sperm production.
Can herbal mixes fix a low count?
There is no reliable evidence for unregulated herbal products in male infertility. Some have been found to contain hidden steroids, which can make things worse.
How can couples look after their emotional wellbeing?
An abnormal semen report can shake a man more than he lets on. Embarrassment and guilt are common. So is the feeling that his masculinity is somehow on trial, which is one reason many men put off the test in the first place.
It may help to see the report for what it is, a medical finding about one organ system. It doesn't measure strength, character or how good a husband he is.
Couples who attend appointments together tend to find it easier, and so do those who agree beforehand how much to tell the family. If stress starts eating into sleep, work or the relationship, a fertility counsellor can help. And try to stay off the internet at 2 a.m. Write the questions down and bring them to the doctor.
For parents and in-laws, the most useful thing is patience and no blame in either direction.
Questions to ask your fertility doctor
- Is my semen report normal, borderline or clearly abnormal?
- Should I repeat the test, and when?
- Do I need hormone tests, an ultrasound or genetic testing?
- Could any of my medicines or supplements be affecting my sperm?
- If I have a varicocele, is it worth treating?
- Does IUI make sense for us, or should we look at IVF or ICSI?
- How does my wife's age and fertility change our options?
- Should I see a urologist or andrologist?
- Can my sperm be frozen before surgery or cancer treatment?
When should you see a fertility specialist?
Book an evaluation after 12 months of trying without a pregnancy, or after six months if the woman is 35 or older. Come sooner if the man has a known risk factor, such as past testicular surgery, undescended testes, cancer treatment, steroid use, or difficulty with erections or ejaculation.
Men about to start cancer treatment should ask about sperm freezing before the first dose.
Get urgent medical care for any of the following.
- Sudden, severe pain in a testicle, which can be testicular torsion and needs emergency treatment
- A painless lump or hard area in a testicle
- Fever with a painful, swollen scrotum
For the female partner on ovulation medicines or IVF injections, severe abdominal pain, marked bloating, breathlessness or passing much less urine than usual need urgent attention, as these can be signs of OHSS.
Couples in Gunjur, Varthur, Whitefield, Sarjapur Road and the rest of East Bangalore who want their semen analysis reviewed alongside the woman's tests can start with a combined fertility consultation.
Key Takeaways
- Male infertility is common, and both partners should be tested from the start.
- Most affected men have no symptoms.
- The semen analysis is the first test, and an abnormal result is usually repeated.
- WHO reference values are guides rather than strict cut-offs.
- Causes include varicocele, hormone problems, blockages, infections, genetic conditions, steroid use and lifestyle factors.
- Testosterone and anabolic steroids can sharply lower sperm production.
- Treatment ranges from lifestyle change and medicines to surgery, IUI, IVF and ICSI.
- Even with no sperm in the semen, sperm can sometimes be retrieved surgically.
- ICSI helps when sperm are very few, but it does not promise a pregnancy.
Final Thoughts
- Medical Disclaimer
- This article is for educational purposes only and does not replace professional medical advice. Fertility treatment outcomes vary from person to person. Please consult a qualified doctor for diagnosis and treatment.
Male infertility belongs to the couple, and it is a medical condition like any other. A semen test early on can save a great deal of time and worry. Many causes respond to treatment, and where they don't, assisted reproduction often still leaves a workable route to pregnancy.
If you and your partner have been trying for a while and want both sides looked at properly, you can book a fertility consultation with Dr. Swati Shree at EVE Women and Fertility Clinic in Gunjur, Bangalore. She will go through your reports with you, explain what the numbers mean, and plan the next step with both of you in the room.
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FAQs
Can a man with a low sperm count still father a child?
Many men with a low count do become fathers, some naturally and some with treatment. A lot depends on how low the count is, how well the sperm move, what is causing the problem and how fertile the female partner is. Milder cases may respond to lifestyle changes, treatment of the cause or IUI. Severe cases often move to IVF with ICSI.
How many days of abstinence are needed before a semen analysis?
The WHO recommends 2 to 7 days without ejaculation before giving a sample. Too short a gap tends to lower the count, while a very long gap leaves more old, slow sperm in the sample. Collect the whole ejaculate in the sterile container from the lab, and avoid lubricants, saliva and ordinary condoms, since these can damage sperm.
Does a normal semen analysis mean a man is definitely fertile?
A normal report is reassuring but not a guarantee. The test measures count, movement and shape, and it cannot fully judge whether sperm will fertilise an egg. In the other direction, results a little below the reference limits don't rule out a natural pregnancy. Doctors read the report together with the couple's history and the woman's test results.
What is the difference between IVF and ICSI?
With standard IVF, eggs and prepared sperm are placed together in a lab dish and the sperm fertilise the eggs on their own. With ICSI, an embryologist injects one sperm directly into each mature egg. ICSI is usually chosen for severe male infertility, for surgically retrieved sperm, or after eggs failed to fertilise in an earlier IVF cycle. The woman's side of treatment is the same for both.
Does every varicocele need surgery?
Most men with a varicocele have normal fertility and need nothing done. Surgery may be considered when the varicocele can be felt on examination, the semen report is abnormal and the couple is trying to conceive. The woman's age also matters, because waiting several months for semen to improve after surgery does not suit every couple. A urologist usually makes this call.
Can gym supplements or testosterone injections lower sperm count?
They can, and often quite sharply. Testosterone injections, anabolic steroids and some gym products with hidden steroids signal the brain to stop driving sperm production, sometimes down to zero. Production frequently comes back after stopping, though it may take months. Anyone on prescribed testosterone should speak to their doctor before stopping it.
Where can couples get a fertility evaluation in East Bangalore?
Couples from Gunjur, Varthur, Whitefield, Sarjapur Road and nearby areas can see Dr. Swati Shree at EVE Women and Fertility Clinic in Gunjur, Bangalore. The consultation looks at both partners, including guidance on the semen analysis, and EVE provides follicle monitoring and IUI. When IVF or ICSI is needed, she guides treatment through her partner fertility centres in Bangalore.
Does a man need a separate doctor for male infertility?
The first visit is often with a fertility specialist who sees both partners and reviews the semen report. If it points to something significant, such as no sperm, a varicocele, a hormone problem or a possible blockage, the next step may be a urologist or andrologist. These specialists handle male examinations, surgery and sperm retrieval procedures.