Truth about explosion in male infertility: Sperm quality has halved in 50 years. Now doctors reveal the surprising causes, little-known ways it can be solved – and why every man who suffers MUST get checked

When Frank Fallon and his wife Frankie underwent fertility tests after struggling to conceive, he assumed that any problem would probably lie with her.

The couple had been trying unsuccessfully for a baby for nine months and Frank was convinced that this was down to Frankie’s menstrual cycles being affected after coming off the Pill.

‘You normally hear about fertility being all about the woman – so I went into it confidently,’ recalls Frank, 38, who lives in west London with Frankie, 32, a project manager for a charity.

Standard initial fertility tests for men involve checking the number and quality of sperm in a semen sample, while women have blood tests to check levels of hormones, including follicle-stimulating hormone (FSH), luteinizing hormone (LH) and anti-mullerian hormone (AMH) – this indicates how many eggs a woman has left. Women may also have an ultrasound scan to examine their ovaries and womb.

So Frank was profoundly shocked when Frankie’s tests came back normal, but his showed his sperm count was low. So low, in fact, that the couple were told it would be impossible to conceive naturally.

A low sperm count is classified as below 15 million sperm per millilitre of semen – Frank’s was under four million.

‘I felt a lot of guilt and shame – ultimately, that I was doing my wife a disservice and couldn’t provide something we had our hearts set on,’ says Frank, whose work involves helping people with mental health problems to find employment.

‘No support was offered – I was left to get on with it and just told to book an appointment to discuss options such as IVF. It was constantly on my mind.’

His experience is far from unusual – infertility (defined as the inability to conceive after a year of unprotected sex) affects one in seven couples. But, while it’s commonly assumed to be a woman’s issue, 50 per cent of the time it’s actually down to the male, a figure widely quoted in studies and guidelines.

This misconception is because of ‘lack of education about male fertility, and because women are far more attuned to their reproductive biology than men are’, says Allan Pacey, a professor of andrology at the University of Manchester.

He adds that men are either not targeted for relevant information or else ‘we don’t provide it in a format they understand’.

The main causes of male infertility include hormonal abnormalities; lifestyle factors such as smoking and drinking alcohol; past injury or damage to the testicles; previous cancers (chemotherapy and radiotherapy can harm fertility); an obstruction along the male reproductive tract; having a varicocele (a swelling in the veins of the scrotum, which interferes with the body’s ability to make and store sperm); and genetic causes.

But one of the main causes is starting a family later in life as men’s fertility also declines – the average age of fathers is rising and is now the highest on record, 33.8 years in 2023 – and this is driving a rise in male infertility.

It’s thought there has also been a 50 per cent reduction in sperm quality in the past 50 to 70 years. This is believed to be because of exposure to industrial chemicals such as pesticides, says Professor Suks Minhas, a consultant andrologist at Imperial College Healthcare NHS Trust in London.

These are hormone disruptors, ‘and can lead to testicular dysgenesis – when the testicles aren’t working as they should – which affects fertility and hormone function’, he explains, adding that women who are exposed to these chemicals during pregnancy may then go on to have sons with testicular dysgenesis.

In around 40 per cent of male infertility cases, men do go on to have a baby with their partners (typically following a cycle of ICSI or intracytoplasmic sperm injection – where sperm is inserted directly into the egg, rather than IVF where the eggs are ‘bathed’ in the sperm). This rises to around a 70 per cent success rate after three cycles.

But experts warn that male infertility shouldn’t be dismissed, or forgotten about once that longed-for baby arrives – or sadly doesn’t – because it’s an important signal of other health problems.

Male infertility is linked, for instance, with shorter life expectancy and an increased risk of testicular cancer and heart disease. Yet the causes of male infertility are usually not investigated further, says Professor Pacey.

‘No one picks up on the fact that perhaps these men need more screening later in life or even a warning to take care of themselves, to get health checks such as blood pressure tests from their GP, or to look out for symptoms.

‘They’re just told, ‘There’s a fertility issue, we’ll deal with that, then you’ve got your baby, move on,’ ‘ he says.

Ideally, a man who has had an abnormal semen analysis would have his testicles scanned (to rule out cancer), along with hormone tests and advice about how to improve his lifestyle, adds Professor Minhas.

As well as health checks, men with very low sperm counts should be tested for genetic faults – which might, for instance, reveal they’re missing genes that affect sperm production, or if they have genes that could make them carriers of cystic fibrosis, but these genes can also mean that the carrier himself is missing the tubes that transport sperm from the testicles to the penis, he says.

Although a man whose semen sample contained no sperm would be referred to a urologist, the treatment pathway is patchy and disjointed, he suggests – so men aren’t automatically referred to andrologists, specialists in men’s health. 

They might instead be seen in fertility clinics ‘largely run by gynaecologists’ who focus on female reproductive health and aren’t trained in the wider issues of male infertility.

As a result, the opportunity to screen men to benefit their long-term health ‘is usually missed’, says Professor Minhas.

‘As long as some sperm is in the ejaculate – even if it’s very low – the male causes of infertility are basically ignored,’ adds Pippa Sangster, a consultant urological surgeon and andrologist and the clinical lead for male infertility at University College London Hospitals NHS Foundation Trust.

‘Men are simply told they can have ICSI, where the man’s best-quality sperm is injected directly into an egg.’

Yet the causes of an abnormal sperm count should be investigated and treated if possible, given the links with other serious health conditions, she says.

For instance, infertile men are three times more likely to develop testicular cancer than men who don’t have fertility problems, so it’s important that men with low sperm counts regularly examine their testicles for lumps, pain or swelling that could be signs of cancer, she explains.

Testicular cancer is strongly linked to testicular dysgenesis syndrome, where the testicle doesn’t form or develop properly, so sperm isn’t produced properly. adds Miss Sangster.

It’s not known how many men have the syndrome, which is thought to be present from birth. It’s often a cause of ‘unexplained infertility’ but men could have it without being aware of it, explains Professor Minhas.

Male infertility is also linked to undescended testicles (when the testicles are not in their usual position in the scrotum, a problem that affects one in 25 boys, according to the NHS). As well as infertility, this increases the risk of testicular cancer four-fold.

Another cause of male infertility is low testosterone levels – which are linked with heart problems. ‘Up to 30 per cent of men with fertility issues have low testosterone, and this hormone is important for cardiovascular health as well as for sperm production,’ says Professor Minhas.

Low testosterone is linked to an accumulation of fat around the abdomen, which can increase the risk of heart disease. In turn, this fat is also thought to produce hormonal changes that hamper sperm production. However, it’s not clear which comes first – and more research is needed to establish the mechanisms, says Professor Minhas.

‘We know infertile men have a higher risk of metabolic syndrome [a combination of obesity, high blood pressure and type 2 diabetes] and therefore a higher risk of cardiovascular disease but we don’t follow these patients up,’ he says, adding that the NHS should routinely check cholesterol and blood sugar levels for men affected by infertility.

Separately, obesity can also damage the DNA of sperm, adds Professor Minhas, while excess fat around the scrotum can generate heat, raising the temperature of the testicles, where sperm are produced. This is key because sperm need cooler temperatures (which is why the testicles hang outside the body).

Although the relationship between these conditions and infertility isn’t fully understood, it’s usually the case that infertility is a sign of the underlying problem, says Professor Minhas.

But it’s not just physical. ‘The impact of infertility on a man’s mental health is huge and men often do not seek support or delay accessing it, which can make mental health problems such as anxiety and depression harder to overcome,’ says Alejandra Lozada Andrade, a psychotherapist at Fertility Support, a psychotherapy practice in London.

A major reason for our lack of understanding, clear guidelines and potential treatments for male infertility boils down to a lack of research. ‘It doesn’t feel like much has changed in the past 30 years,’ says Professor Pacey.

‘Ideally, what you need is a joint clinic where men are seen by andrologists and women by gynaecologists – and everyone works collaboratively and the man’s long-term health implications are also considered. But it doesn’t happen that way at the moment,’ adds Professor Minhas.

He says that another factor is that some hospitals don’t have specialised andrologists.

Additionally, there may be conflicts of interest in private fertility clinics because there is a financial interest in them suggesting IVF, even if men have correctable factors or need other treatments to optimise their health before or at the same time as undergoing fertility treatment, he adds.

Occasionally, male fertility tests discover a clear reason for the problem – this is usually when there’s no sperm in semen, a condition known as azoospermia, which occurs in 1 per cent of adult males, says Miss Sangster.

‘Most of the time we never find an explanation for non-obstructive azoospermia [when the testicles aren’t working properly], while obstructive azoospermia [where sperm can’t leave the body because of a blockage in the man’s reproductive tract] is often caused by an infection or congenital defect.’

Frank was never given an explanation for his own problems – he wasn’t particularly overweight and hadn’t been drinking alcohol for several months before his initial tests, and was otherwise in good health.

Thankfully for the couple, their first round of ICSI worked and their twin boys, Ezra and Theo, were born in July 2022.

‘Finding out Frankie was pregnant was like a weight had been lifted,’ says Frank. However, he made little progress when he asked experts why his sperm count was so low and if there was anything he could do to improve it. He also noticed there were no information leaflets or posters in the urology department at hospital, where he was seen.

While the couple still have six frozen embryos, he has taken steps to improve his sperm – including losing 2 st 7 lb, reducing his caffeine intake, avoiding alcohol – and hot baths – and taking supplements meant to boost male infertility, all steps gleaned from his own research.

He is having his sperm tested again at a private clinic soon, as he says: ‘It’s my dream to have another child naturally.’

Little-known procedure could be a ray of hope 

A rare surgical procedure is available to help men whose semen contains no sperm, caused by their testicles not functioning properly, and has a success rate of up to 50 per cent. 

It is called MicroTESE and involves having sperm surgically removed from the testicles.

The testicles are cut open and surgeons use microscopes to find sperm within the tubules. It can then be frozen and used for IVF.

Jonathan Luwagga, 35, a business officer for a transport company who lives in London, successfully had the procedure after discovering he was infertile in 2021.

After struggling to conceive for 18 months he and his now ex-partner went to a private fertility clinic, where a gynaecologist ‘bluntly’ told the couple the problem was likely to lie with Jonathan as his partner’s body was ‘functioning fine’.

Tests showed no detectable sperm in Jonathan’s samples – despite him taking measures including avoiding hot showers, exercising, eating healthily and taking supplements.

‘It was an awful shock and hugely affected my mental health,’ says Jonathan. ‘There were times when I stayed in bed crying. I shut off and felt embarrassed to talk about it.’

Jonathan was given up to a 20 per cent chance that MicroTESE would work.

Fortunately the surgical team were able to retrieve sperm from his left testicle when he had the procedure in October 2022.

‘It was a massive relief knowing I had a chance of becoming a biological father,’ he says. ‘But I was never given any explanation for my non- obstructive azoospermia [when the testicles are not working properly].’

Despite NHS guidelines published in 2016 stating men with non-obstructive azoospermia are entitled to up to two MicroTESE procedures, the treatment is rarely offered in practice.

Consultant urological surgeon Pippa Sangster explains: ‘There are only a handful of people around the country who do MicroTESE, and we know that GPs and gynaecologists aren’t aware of this, and men aren’t being referred.

‘Instead they might have a gynaecologist perform a biopsy of their testicle [to assess the possibility of sperm retrieval].

‘This is something urologists such as myself and andrologists are uncomfortable with, because specialists in female fertility often lack the expert knowledge and training to perform these procedures.’

Men are also sometimes pushed down the sperm donation route, ‘even when it otherwise might have been possible for them to have a biological child – because the chance of MicroTESE being successful is up to 50 per cent when done by an experienced urological surgeon’, adds Miss Sangster.

Though the stress of the situation took its toll on Jonathan and his partner’s relationship, which ended before they tried IVF, he still hopes to use the sperm extracted in future (he has five samples stored).

‘It affects my dating life because I need to discuss my situation early on,’ says Jonathan. ‘Talking about my fertility was challenging at first but now I find discussing it helps me heal.’

When he first found out about his fertility problems he also discovered that little support was available for those in his situation. ‘But that’s starting to change – it’s useful knowing there are men going through the same thing,’ he says. ‘Fertility is a man’s problem too and we need to talk about it.’

Jonathan leads a ‘walk and talk’ men’s fertility help group. For details Email: [email protected]