Men don't think about their fertility until they need to. Which makes sense - it's invisible, mostly silent, and rarely comes up in conversation until a couple has been trying for a year or two. By then, there's usually already confusion, frustration, and a lot of assumptions about whose body is "the problem."
Here's what surprises most people: about one in eight couples struggle with infertility, and roughly half the time, the male partner is either the main contributor or part of the picture. Not always - sometimes not at all - but often enough that it's worth understanding early, not late.
The strange part is how long it takes for men to get tested. I've seen couples spend years focused entirely on the female side - tracking cycles, adjusting hormones, undergoing procedures - before anyone thinks to check the man's sperm. And when they finally do, sometimes the answer was sitting there the whole time.
The Semen Analysis: A Snapshot, Not a Sentence
The first step is simple: a semen analysis. It's a screening tool - a quick look at what's happening with sperm production and function at that particular moment. It's not a verdict. It's not definitive. It's more like checking your blood pressure once and seeing where things stand.
What we're looking at:
Volume: How much semen is produced per ejaculation. We want at least 1.5 milliliters - that's about a third of a teaspoon. Less than that might suggest an obstruction somewhere in the reproductive tract, or an issue with the seminal vesicles (the glands that produce most of the fluid).
Concentration: How many sperm are packed into each milliliter of semen. We're looking for about 15 to 20 million per milliliter. Anything significantly below that - oligospermia, meaning low sperm count - warrants further investigation.
Motility: How well the sperm move. We want at least 40% of them swimming forward with purpose. Motility matters because sperm have to travel a long way - through the cervix, up the uterus, into the fallopian tubes - and if they're not moving efficiently, they're not reaching the egg.
Morphology: What the sperm look like under a microscope. Ideally, at least 4% should have a normal shape - oval head, intact midpiece, single tail. Interestingly, morphology is the least predictive of these factors. Even men with low morphology scores can still father children naturally. The shape matters less than the count and movement.
White blood cell count: Elevated white cells can indicate infection or inflammation somewhere in the reproductive tract - prostatitis, epididymitis, or something subclinical that's quietly interfering with sperm health.
pH: The acidity or alkalinity of the semen. Normal is around 7.2 to 8. A pH that's too low might suggest an ejaculatory duct obstruction; too high could indicate infection.
The two most important numbers? Concentration and motility. When you multiply them together - taking into account the total volume - you get what's called the total motile count. That's the number that matters most. We want at least 20 to 40 million motile sperm in the entire sample. Below that, fertility potential drops. Not to zero - never to zero unless we're dealing with complete absence of sperm - but enough that conception might take longer, or might require assistance.
Why One Test Isn't Enough
Here's the thing people don't expect: sperm production fluctuates. A lot. More than you'd think.
A man's semen analysis can vary significantly from month to month - sometimes week to week - depending on stress, sleep, illness, heat exposure, alcohol intake, even recent fevers. Sperm take about 72 days to mature, so what you're seeing in a semen analysis today reflects what was happening in your body two to three months ago.
That's why we always recommend at least two semen analyses, spaced three to four weeks apart. One abnormal result doesn't mean infertility. It means we need more information. Two abnormal results? Now we're paying attention. Three? Now we're investigating why.
I've seen men come in devastated after one bad result, convinced they're infertile, only to have the second test come back completely normal. And I've seen the opposite - men who assume everything's fine after one decent result, only to find out later that their baseline is actually lower than expected.
Multiple data points give us the real picture. Sperm production is not static. It's dynamic, responsive, influenced by dozens of variables we're only beginning to fully understand.
What Causes Low Sperm Count?
The list is long. And sometimes, despite testing everything we can test, we still don't know. About 40% of male infertility cases are idiopathic - meaning we can't find a clear cause. Which is frustrating, but also means there's room for improvement through lifestyle changes alone.
Varicocele: Enlarged veins in the scrotum that raise testicular temperature and impair sperm production. It's the most common correctable cause of male infertility, present in about 15% of all men and 40% of men with infertility. Sometimes you can feel it on exam - like a "bag of worms" in the scrotum. Sometimes you can't, and we need an ultrasound.
Hormonal imbalances: Low testosterone, elevated prolactin, thyroid dysfunction - all of these can suppress sperm production. Testosterone replacement therapy, ironically, is one of the most common causes of reversible male infertility. Men take it for energy or muscle mass, not realizing it shuts down their body's own testosterone production in the testicles, which is what drives sperm production.
Infections: Past or current infections - sexually transmitted or otherwise - can damage the reproductive tract. Epididymitis, prostatitis, mumps orchitis. Sometimes the damage is permanent. Sometimes it's treatable.
Genetic conditions: Klinefelter syndrome, Y chromosome microdeletions, cystic fibrosis gene mutations. These affect sperm production at a fundamental level.
Environmental and occupational exposures: Heat, radiation, heavy metals, pesticides. Anything that raises scrotal temperature - tight underwear, hot tubs, laptops on laps - can temporarily reduce sperm count.
Lifestyle factors: Smoking, excessive alcohol, obesity, poor diet, inadequate sleep, chronic stress. All of these chip away at sperm quality in ways that are often reversible.
Medications: Not just testosterone. Anabolic steroids, certain blood pressure medications, some antidepressants, chemotherapy drugs - all can impair sperm production.
And sometimes - often, actually - it's a combination. A man with a mild varicocele who also drinks heavily and sleeps five hours a night might have a significantly lower sperm count than someone with just the varicocele alone.
What You Can Do: The Boring, Effective Stuff
If your semen analysis comes back abnormal, the first move isn't panic. It's patience. And then it's optimization.
Sleep: At least seven hours. Consistently. Studies show that men who sleep fewer than six hours a night have significantly lower sperm counts and testosterone levels. Sleep is when your body does most of its repair work - including sperm maturation. Chronic sleep deprivation is a quiet saboteur of fertility.
Diet: Not a fertility superfood diet. Just a healthy diet. Complex carbohydrates, lean proteins, healthy fats - omega-3s from fish, nuts, avocados. Antioxidants from vegetables and fruits. Your testicles are metabolically active organs. They need good fuel.
There's some evidence that certain micronutrients - zinc, selenium, vitamin D, folic acid, coenzyme Q10 - might support sperm health, but the data is mixed. Supplements can help if you're deficient, but they're not magic. Food first.
Exercise: A mix of cardiovascular work and resistance training. At least two days of each per week. Heavy weightlifting - squats, deadlifts, compound movements - helps maintain healthy testosterone levels. Cardio improves circulation, reduces inflammation, helps with weight management. But don't overdo it. Excessive endurance exercise - ultramarathons, extreme cycling - can actually suppress testosterone and impair sperm production.
Stress reduction: Easier said than done, I know. But chronic stress elevates cortisol, which suppresses the hypothalamic-pituitary-gonadal axis - the hormonal pathway that drives sperm production. Meditation, therapy, time outdoors, whatever works for you. This isn't New Age advice. It's neuroendocrinology.
Avoid heat exposure: Keep your testicles cool. No hot tubs, no saunas (or at least limit them), no laptops directly on your lap for hours. Boxers vs. briefs probably doesn't matter as much as people think, but if you're already borderline, it might be worth the switch.
Limit alcohol: Moderate drinking - one or two drinks a day - probably doesn't hurt. But heavy drinking absolutely does. Alcohol impairs testosterone production, damages Sertoli cells (the cells in the testicles that support sperm maturation), and increases oxidative stress, which damages sperm DNA.
Stop smoking: Smoking reduces sperm count, motility, and morphology. It increases sperm DNA fragmentation. It's one of the most consistent lifestyle factors associated with poor sperm quality. If you smoke and you're trying to conceive, quitting is one of the most effective things you can do.
When Lifestyle Changes Aren't Enough
Sometimes - often - lifestyle changes help. A man makes adjustments, repeats his semen analysis three months later, and his numbers improve. Not always dramatically, but enough.
But sometimes they don't. Or the initial numbers are so low that lifestyle changes alone aren't going to bridge the gap.
That's when we dig deeper. Hormone panels. Genetic testing. Scrotal ultrasound. Physical exam looking for varicoceles, testicular masses, signs of obstruction. Sometimes referral to a reproductive endocrinologist or urologist who specializes in male infertility.
And sometimes, despite everything, the answer is assisted reproductive technology - intrauterine insemination (IUI), in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), where a single sperm is injected directly into an egg. These aren't failures. They're tools. And they work.
What I Wish More Men Knew
Fertility isn't just a female issue. It never was. But the cultural narrative has always leaned that way - women track their cycles, women see fertility specialists, women undergo most of the testing and procedures. Men show up, provide a sample, and wait.
But half the time, the issue is at least partly male. And even when it's not, male fertility still matters. Sperm quality affects not just the chance of conception, but also embryo quality, pregnancy outcomes, even long-term health of the child. Sperm DNA fragmentation - something we're only beginning to measure routinely - correlates with miscarriage rates and developmental issues.
So if you're trying to conceive, or planning to in the future, get tested early. Not after a year of trying. Not after your partner has already undergone multiple rounds of fertility treatment. Early. A semen analysis is simple, inexpensive, non-invasive. There's no reason to wait.
And if the results are abnormal? Don't catastrophize. One test is a data point. Two tests are a trend. Three tests are a pattern. And even then, patterns can shift. Bodies change. Sperm production responds to intervention - sometimes medical, sometimes lifestyle, sometimes just time.
I've seen men with severe oligospermia - sperm counts in the low millions - conceive naturally after making changes. I've also seen men with seemingly normal counts struggle. Biology doesn't follow perfect rules. But information helps. And the earlier you have it, the more options you have.
Most of the time, male fertility isn't about dramatic interventions or expensive treatments. It's about understanding what's normal, recognizing what's not, and making space for the small, boring, effective changes that actually matter. Sleep. Diet. Exercise. Stress management. Avoiding the things that quietly damage sperm production over time.
And if those aren't enough? That's what medicine is for. But you can't treat what you don't test. And you can't optimize what you don't understand.
So if you're in that one-in-eight, or heading there, start with the basics. Get tested. Get information. And then - whatever the results - go from there.
