Male Factor Infertility: Why a Semen Analysis Is Only the Beginning

When a couple is struggling to conceive, the focus can very quickly fall on the woman.

Her hormones are tested.
Her ovarian reserve is checked.
Her cycle is monitored.
Her tubes may be investigated.

And meanwhile, the man may be sent for one semen analysis and told that everything is “normal” or “abnormal”.

But male fertility deserves much more attention than this.

Infertility affects around one in six people worldwide, according to the World Health Organization, and infertility can arise from male factors, female factors, a combination of both, or sometimes remain unexplained.

When we look at the causes of infertility, male and female factors each make a substantial contribution. Dr Olivia Pojer, whose work I have recently been studying, highlights the importance of bringing the male partner much more fully into fertility assessment and treatment.

Her book, Integrative Treatment of Male Infertility with Chinese Medicine, brings together Western reproductive medicine and Chinese medicine to explore the causes of male infertility and how sperm health can be supported.

A semen analysis is a snapshot — not the whole story

A standard semen analysis looks at important things such as sperm concentration, total sperm number, motility, morphology and semen volume.

These measurements matter.

But one semen analysis is essentially a snapshot of what is happening at that point in time.

Sperm production is a dynamic process, and semen parameters can vary from one sample to another. This is why current guidelines recommend repeating an abnormal semen analysis rather than making conclusions from a single result. NICE recommends a repeat test ideally around three months later, allowing a complete cycle of sperm formation to take place.

So if a man receives a result showing low motility, low morphology or a low sperm count, I don’t think the conversation should simply stop at the number.

The more useful question is:

Why?

What is happening in this man’s health, lifestyle and reproductive system that might be contributing to this result?

And what can we do about the factors that are modifiable?

Sperm are constantly being made

One of the encouraging things about male fertility is that sperm production is ongoing.

A complete cycle of sperm development takes roughly 2–3 months.

This means that what a man does today can potentially influence the sperm being produced over the coming months.

It also means that if something has negatively affected sperm — an illness, fever, significant lifestyle changes, excessive heat, smoking, alcohol, certain medications or nutritional problems, for example — there may be an opportunity to improve the environment in which the next generation of sperm develops.

This is one reason I like the idea of looking at male fertility as a three-month project rather than a fixed diagnosis.

It isn’t about becoming perfect.

It is about identifying the things that may be working against sperm health and changing what we can.

What can affect sperm health?

There are many potential influences.

Lifestyle

Smoking, excessive alcohol, recreational drugs, poor sleep, inactivity, significant weight issues and chronic stress can all be relevant when considering sperm health.

Nicotine exposure — including smoking and nicotine products such as snus — is worth discussing. Cannabis, cocaine and other recrearional drugs can also negatively affect reproductive health and sperm parameters, and these should always be included in a fertility history.

This isn’t about blame.

It is about information.

If a man knows that something he is doing may be affecting sperm health, he has the opportunity to make a change.

Heat

The testes are outside the body for a reason.

They need to be kept cooler than core body temperature for optimal sperm production.

Excessive heat exposure can therefore be relevant — hot tubs, saunas, prolonged heat exposure and even repeated heating around the groin are worth considering. This is the one time i advocate for cold showers or cold plunge!

Varicoceles are also important.

A varicocele is an enlargement of the veins around the testicle and can be associated with impaired sperm production and increased sperm DNA fragmentation. Current European guidance recommends assessing testicular volume and considering varicocele in the appropriate clinical context.

Illness and infection

Previous infections are another important part of a man’s fertility history.

Some infections affecting the reproductive tract may have few obvious symptoms but can still be relevant to sperm health.

A history of sexually transmitted infections, epididymitis, prostatitis, testicular infection or significant fever should therefore be discussed with the appropriate medical professional.

Infection and inflammation are particularly interesting when we are thinking about sperm DNA integrity.

Don’t forget medications

This is an area that is often overlooked.

Men don’t always think to mention their regular medication when discussing fertility.

But some medications can affect sperm production, sperm function, hormone signalling, sexual function or ejaculation.

The evidence varies considerably between medications.

For example, there is stronger evidence for some drugs — including testosterone and anabolic steroids — than for others. Othere evidence has also suggested possible effects from particular antihistamines and their regular use.  

This is why I always think it is worth looking at the whole medication and supplement history.

And importantly:

Never stop prescribed medication because you are trying to conceive without speaking to your doctor.

Sometimes there may be an alternative. Sometimes there may be no concern at all. The important thing is to ask.

What about stress and oxidative stress?

This is another area where the picture becomes more interesting.

Sperm cells are particularly vulnerable to oxidative stress.

Oxidative stress occurs when reactive oxygen species outweigh the body’s antioxidant defences.

Lifestyle factors, inflammation, illness, smoking, poor metabolic health and environmental exposures can all contribute to the overall oxidative environment.

And chronic stress can also influence the body through hormonal and inflammatory pathways.

Infertility is much more complicated than being stressed, and telling someone to simply “relax” is neither helpful nor accurate.

But it does mean that supporting sleep, stress regulation, nutrition, exercise and general health may be worthwhile parts of a fertility plan.

Dr Pojer’s integrative approach places considerable emphasis on oxidative stress, lifestyle, nutrition and the environment in which sperm develop, alongside conventional investigation.

Sperm DNA fragmentation — the piece we don’t see on a standard semen analysis

This is perhaps one of the most important reasons why a “normal” semen analysis doesn’t necessarily mean that everything about sperm health is optimal.

A standard semen analysis looks at the sperm we can see:

How many?
How well do they move?
What do they look like?

But it doesn’t tell us about the integrity of the DNA inside those sperm.

Sperm DNA fragmentation refers to breaks or damage within sperm DNA.

There is growing evidence linking higher levels of sperm DNA fragmentation with certain fertility difficulties, including recurrent pregnancy loss and some assisted reproductive outcomes.

This is particularly relevant when a couple has experienced:

  • recurrent miscarriage

  • unexplained infertility

  • repeated IVF or ICSI difficulties

  • poor embryo development

  • implantation difficulties

  • certain varicocele or lifestyle risk factors

Importantly, this does not mean every man needs a DNA fragmentation test.

Guidelines differ on when it should be used. Current European guidance supports considering sperm DNA fragmentation testing in recurrent pregnancy loss, unexplained infertility and certain ART situations, while the current NICE guideline does not recommend routine sperm DNA fragmentation testing.

This is exactly why fertility investigation needs to be individualised.

Recurrent miscarriage: don’t forget the male partner

When a couple experiences recurrent miscarriage, it can be incredibly difficult.

Historically, much of the investigation has focused on the woman.

But we now understand that the male partner can also contribute to reproductive outcomes.

The HSE’s Irish National Clinical Practice Guideline on recurrent miscarriage specifically recognises male factors, including paternal age, smoking, alcohol, exercise and body weight, and discusses the emerging role of sperm DNA fragmentation.

The current ASRM guidance also lists sperm DNA fragmentation testing as something to consider in recurrent unexplained pregnancy loss or concurrent infertility, alongside reproductive urology assessment.

So after recurrent miscarriage, it can be appropriate to ask:

Have we properly assessed the male partner too?

Could the semen analysis give us clues about a man’s general health?

This is an area I find fascinating.

A semen analysis isn’t a cardiovascular health check.

It cannot diagnose diabetes, hypertension or heart disease.

But male infertility and poorer reproductive health can sometimes exist alongside broader metabolic and cardiovascular risk factors.

Recent research has found associations between male infertility and an increased risk of cardiometabolic conditions such as hypertension, diabetes and heart disease, although the reasons for these associations are complex and not fully understood.

So if a man presents with significant semen abnormalities, it can be an opportunity to step back and ask:

How is his overall health?

What is his blood pressure?

How is his weight and metabolic health?

Does he exercise?

How does he sleep?

Does he smoke?

How much alcohol does he drink?

Could there be insulin resistance or diabetes?

Are there symptoms suggesting a hormonal problem?

The semen analysis isn’t diagnosing these conditions.

But it can sometimes be the reason we start asking better questions about the man’s health.

What about hormones?

Hormones are another piece of the puzzle.

The hypothalamic-pituitary-testis axis is involved in regulating sperm production and testosterone production.

Depending on the semen analysis and clinical picture, doctors may investigate hormones such as:

  • testosterone

  • FSH

  • LH

  • prolactin

  • thyroid function

These tests aren’t necessary for every man with fertility concerns.

But in men with abnormal semen parameters, low sperm concentration, sexual dysfunction, signs of hypogonadism or suspected endocrine problems, hormonal evaluation may be appropriate.

FSH and LH can help give information about how the hormonal signalling system is functioning, while testosterone tells us about androgen status.

Again, it is about putting the pieces together rather than looking at one isolated number.

Testicular size, ultrasound and varicocele

The testes are where sperm are produced, so their size and structure matter.

Testicular volume can be assessed clinically and, when appropriate, with ultrasound.

Ultrasound can also help investigate particular concerns, including suspected varicocele or other structural abnormalities.

But it is important to say that a scrotal ultrasound is not routinely required for every infertile man. Current guidelines recommend targeted imaging based on the clinical findings rather than scanning everyone.

A good fertility history and physical examination therefore remain extremely important.

Previous testicular surgery or trauma?

Undescended testicle?

Infection?

Varicocele?

Pain or swelling?

Problems with puberty?

These details can tell us a great deal.

And sometimes genetics need to be considered

For some men with severe sperm abnormalities, genetic testing can be an important part of the investigation.

Depending on the presentation, this may include:

Karyotyping — looking at the chromosomes.

Y-chromosome microdeletion testing — particularly in severe oligospermia or azoospermia.

CFTR testing — in selected men with suspected obstructive azoospermia or absence of the vas deferens.

These aren’t tests that every man needs.

But when sperm production is severely impaired, genetics can be an important part of understanding why.

Current NICE and AUA/ASRM guidance recommends targeted genetic investigation in specific severe male-factor presentations.

Where does acupuncture fit?

This is where I think an individual approach is particularly important.

I don’t treat “low morphology”.

I don’t treat “poor motility”.

I treat the person who has those results.

Two men can have exactly the same semen analysis and have completely different health pictures.

One may be exhausted, sleeping poorly, highly stressed and struggling with digestion.

Another may have a varicocele.

Another may have hormonal abnormalities.

Another may have a history of infection.

Another may be metabolically unhealthy.

Another may have no obvious explanation at all.

The treatment approach needs to reflect the individual.

Acupuncture is not a replacement for medical investigation, and I would always encourage men to have appropriate medical and andrological assessment alongside complementary treatment.

But acupuncture can be part of an integrative approach to supporting the man’s overall health, stress regulation and the individual patterns that may be relevant to his fertility.

Dr Olivia Pojer’s work has been particularly influential in bringing Western reproductive medicine and Chinese medicine together in the treatment of male infertility, including pattern differentiation, lifestyle, nutrition, supplements, oxidative stress and acupuncture.

Fertility belongs to both partners

Perhaps the biggest message I would like couples to take away is this:

Don’t automatically put the woman at the centre of every fertility investigation.

Both partners should be assessed.

Both partners have a reproductive history.

Both partners have health factors that may be relevant.

And both deserve support.

A man’s fertility isn’t simply about whether there are enough sperm.

It is about sperm production, sperm function, DNA integrity, hormones, testicular health, general health, lifestyle and the environment in which those sperm develop.

And there are often things that can be investigated and supported.

If you’re trying to conceive, start with the bigger picture

If you or your partner has been told there is a male-factor fertility issue, don’t panic when you see a number on a semen analysis.

Instead, ask questions.

What exactly is abnormal?

Has the semen analysis been repeated?

What does the rest of the man’s health look like?

Have medications and lifestyle factors been considered?

Has there been any history of infection, injury or varicocele?

Are hormones appropriate to investigate?

Could further investigation be warranted because of recurrent miscarriage or unexplained infertility?

And, where appropriate, could there be a role for complementary support alongside conventional fertility care?

The aim isn’t to chase every possible test.

It’s to understand the individual man in front of us.

Because male fertility is about much more than a semen analysis.

If you are trying to conceive and would like to discuss how acupuncture could support you or your partner, you can get in touch with me at Log House Clinic in Tramore.

Fertility is a journey for two — and the male side deserves to be part of the conversation.

Acupuncture is a complementary therapy and does not replace medical assessment or treatment. If you have concerns about fertility, please discuss appropriate investigations with your GP, fertility specialist or reproductive urologist.