Male Infertility: Why It's Often Overlooked and What to Do About It

An uncomfortable statistic: in nearly half of all infertility cases, male factor is part of the cause. Yet I see couples in clinic — sometimes two years into trying — where the woman has been through every test in the book and the man has had no investigation at all. This is a problem in Indian fertility care that hides in plain sight. Here's what it looks like, why it happens, and what to do.

The numbers

Of the estimated 1 in 6 couples globally who experience infertility:

• About 30% have a primarily female factor cause
• About 30% have a primarily male factor cause
• About 30% have a combined / mixed cause
• About 10% remain unexplained

That means male factor is involved in roughly 40-50% of all cases. It's neither rare nor unusual.

Why it gets missed

A few patterns I see consistently:

1. Cultural assumption. Family pressure tends to focus on the woman first, partly because pregnancy is "visible" in her. Many couples come to us after years of the woman being put through repeated investigations by family doctors, while the man has never been asked for a semen analysis.
2. The "I'm fine" reflex. Many men associate fertility with virility, and being asked to give a semen sample feels like a challenge to their manhood. So they don't ask their doctor, and sometimes resist when offered.
3. Lack of obvious symptoms. Female fertility issues often come with cues — irregular periods, PCOS symptoms, painful periods. Male infertility usually has no symptoms at all. A man can have severe oligozoospermia (very low sperm count) and feel perfectly healthy.
4. Doctors who don't insist. Some clinics still start treatment without a current semen analysis. This is bad practice.

The basic investigation: semen analysis

One test, done in-house, ~₹500-1500. Looks at:

• Count (concentration): normal >15 million/mL
• Total motility: normal >40%
• Progressive motility: normal >32%
• Morphology (normal-shaped sperm): normal >4% (by strict criteria)
• Volume, pH, liquefaction, white cells

One abnormal result doesn't mean a verdict — sperm parameters vary day-to-day, so we usually confirm with a second test 2-3 weeks later, ideally after 2-5 days of abstinence.

Common causes of male infertility

• Varicocele — varicose veins of the testicle. Common, often correctable surgically.
• Hormonal imbalance — low testosterone, elevated FSH/LH, prolactin issues, thyroid problems.
• Genetic causes — Y-chromosome microdeletions, Klinefelter syndrome, cystic fibrosis carriers.
• Infections — past STIs, mumps after puberty, recurrent UTIs.
• Trauma, surgery, or torsion — affecting blood supply or vas deferens.
• Lifestyle — smoking, heavy alcohol, anabolic steroid use, certain medications, sustained heat exposure (saunas, laptops on lap, tight underwear).
• Obstructive causes — blocked vas deferens preventing sperm release.
• Unexplained — surprisingly common, often responsive to lifestyle change.

What treatment looks like

For most male factor diagnoses, treatment is straightforward and successful:

• Mild abnormalities: often respond to lifestyle changes (weight, smoking, alcohol, heat avoidance) and supplements like CoQ10, zinc and folate. Improvement visible in 3 months.
• Hormonal abnormalities: medication can restore sperm production.
• Varicocele: surgical correction improves parameters in 60-70% of cases.
• Moderate male factor: IUI with prepared (washed) sperm.
• Severe male factor: IVF with ICSI — a single sperm injected into each egg. Even men with extremely low counts can achieve fatherhood this way.
• Azoospermia (no sperm in ejaculate): surgical sperm retrieval (TESA, micro-TESE) is often successful.
• Donor sperm: if all options are exhausted — an entirely legitimate, increasingly accepted option in India.

Talking to your partner about this

If you're a woman reading this and your husband has resisted being tested, here's what I'd say:

• This isn't about blame — half of infertility cases involve male factor. It's almost expected, not exceptional.
• An abnormal semen analysis isn't a verdict on manhood. It's a medical test, like a blood test for thyroid or sugar.
• Without his result, we're guessing at the right treatment. With his result, we're aiming.
• You can't logically reduce treatment to "treat the woman more" when his side hasn't been checked.
• The clinic experience is private, brief, and dignified. We have a discreet andrology room with private access.

Get both partners tested. Always.

If there's one piece of advice every fertility specialist would give: a couple's first investigation must include both partners. It's faster, more accurate, more honest, and almost always less expensive in the long run.

If you've been investigating only one side of this for a while, the second consultation should focus on the other. We do it routinely at Srishti SAFE — and most men, after they've come through the process, find it far less daunting than they imagined.