Male Infertility: What You Need To Know

It’s something you’ve long imagined. Maybe even spent months or more trying for: a baby to hold and love. But it isn't as easy as they warned you it would be in health class. And while you may want to avoid playing the “blame game,” after a while of trying without success, the thought may cross your mind. Is it my partner? Is it me? Or is it both of us? 

About 15% to 20% of couples in heterosexual relationships trying to conceive will have problems with fertility. In fact, at least a third of the time, factors involving the sperm are the primary reason for infertility. But so often, dialogue about infertility and assisted reproduction focuses on the female side of the equation. Questions about male infertility related to suboptimal sperm—its causes, how common it is, how it is treated, and how it affects a person emotionally and psychologically—have gotten much less attention. I’ve been practicing reproductive medicine for more than 30 years, and here’s what I want you to know about infertility issues related to the sperm, commonly referred to as male infertility.

A 2017 study that got a lot of attention found that the average sperm count declined by more than 50% over the last 30 years, from an average of 99 million sperm per milliliter of semen in 1973 to 47 million per milliliter in 2011. Even taking into account that there are many limitations to this study, that’s a significant drop. And it’s likely that environmental factors like obesity, smoking, and exposure to chemicals have played a role in this decline.

Even the relatively lower average sperm levels of today are still well within the “batting average” needed to constitute a normal sperm count capable of achieving pregnancy.

For a long time, a normal sperm count was considered to be at least 20 million sperm with at least 50% motility—meaning the sperm can actually swim to, get into the egg, and create an embryo. But more recent research has suggested that an even lower sperm count, around 15 million sperm with 40% motility, has about the same chance of getting a partner pregnant over the course of a year with unprotected intercourse than the higher numbers suggested in the past. As you can see, whether we use either the old measure or the new measure, the average male sperm count is still well within the normal range.

Hands down, the biggest issue in fertility is the fact that people are waiting to a later age to have children. This delay in childbearing has its greatest effects on female fertility, but males shouldn’t just assume that they can easily and safely procreate well into their retirement years. It is true that individuals in their 50s regularly father children, and can even reproduce well into their 60s and beyond. For examples, we need only look at famous older names like Billy Joel, who fathered two children in his 60s; Mick Jagger, who fathered a son in his early 70s; and Steve Martin, who became a father for the first time at the age of 67. But one can’t assume that will be true for all.

Sperm production and motility start to decline more gradually with age than a female’s fertility. Beginning in their 40s, the average male will experience a slow decrease in his testosterone levels, accompanied by a decrease in the quality and quantity of sperm. One study found that, in traditional hetero couples, even among young women (aged 25 and under), having a male partner 45 or older meant a fourfold increase in the time it took a couple to conceive. Among women 35 and older with male partners 45-plus, it took five times longer to conceive.

And there are also potential health issues associated with older fathers. One study, which followed the results of over 40 million live births for a decade, found that “advanced paternal age” put the pregnant woman at higher risk of pre-eclampsia, gestational diabetes, and even premature birth. Babies born to fathers who were over 45 years old at conception had a 14% higher chance of premature birth than younger fathers, as well as a 14% increased chance of low birth weight.

Most studies on the emotional impact of infertility have focused on females, but research shows that men generally want to have children just as much as their partners do, and that they often experience increased levels of depression and anxiety during the process of diagnosis and treatment for infertility. But these emotions are often expressed very differently.

Males tend to compartmentalize their anxiety, depression, and feelings of shame and don’t readily share them. When I see a traditional hetero couple that is having difficulties getting pregnant and male factors are involved, the discussion is often more somber. This may have something to do with dated societal notions, but lesser emotional communication doesn’t mean they’re not being experienced.

What we can do about male factor infertility depends on the situation. If the sperm count is just a little low, we can prescribe a fertility drug to the individual’s partner to stimulate what is termed superovulation—where more than one egg is released from the ovaries at one time. More eggs means more targets for the sperm, and more chance of successful fertilization even with a lower sperm count.

But if there are fewer than 5 million motile sperm in the sample, we usually turn to in vitro fertilization using a specialized technique, intracytoplasmic sperm injection (ICSI), in which a tiny needle is used to inject a single sperm into the egg. Taking all ICSI cycles performed annually in all age groups, the chances of achieving a live birth using this technology are about one in four.

True azoospermia—where no sperm are found, or, alternatively, cases where no motile (swimming) sperm are noted—is rare, occurring in only about 1% of all sperm samples obtained. These situations still represent extreme challenges in infertility management and may require the use of an alternate sperm source.

Having said all that, there are still steps that can be taken in daily life to improve sperm count and chances of achieving pregnancy. First, taking the hormone testosterone for any reason is detrimental to fertility as it decreases levels of another hormone, follicle-stimulating hormone (FSH), known to be important for stimulating sperm production. Fortunately, the effects of testosterone are reversible once stopped, but the reversal can take about three months for the sperm count to recover. Other things that can impact sperm counts are fever (short-term) and more significantly, chemotherapy, for which the impact can be longer depending on the type of drugs used.

On the other hand, you probably don’t need to worry about tight briefs, hot tubs, or riding a bike affecting your sperm count. In the case of professional athletes, wearing extremely tight sports attire for hours and then soaking in hot tubs for a long time, I do see sperm counts go down significantly during their “season” and then see them come back up once the rigorous sports routine has lessened. But for most men, riding a bike for 10 miles or getting in the hot tub once in a while doesn’t have a significant effect.

Whether the cause of infertility is female factor, male factor, or a combination of the two, our goal as fertility specialists is to help you and your partner realize your dream of expanding your family and holding a healthy baby in your arms.

• Meet Dr. Nicole Noyes, reproductive endocrinologist.
• Your checklist to fertility: Five things to know if you’re thinking about fertility treatments.
• Shopping for a fertility doctor: 10 questions to ask to find the right provider for you.