Share your experiences by joining our Patient Engagement Forum.In this blog, Ian, founder of testhim, discusses the issue of male infertility and what more needs to be done to shift the “blame” away from women.
Historically, fertility in heterosexual couples has been thought of as a female issue, with the focus of testing and treatment sitting unfairly on the woman.
The last couple of decades have seen a dramatic decline in sperm quality1, and we now know that around 30% of fertility issues sit purely with the man, according to the British Fertility Society.
Even though male factor fertility is often indicated in issues such as recurrent miscarriage and failed IVF (in-vitro fertilisation)2, men are seldom led to believe that they have an issue and are rarely offered the level of testing or treatment that could make a significant difference to their chances of becoming a father.
When a couple present to their GP for fertility issues, they will be offered some standard tests. For the woman this will include scans, bloods, and a referral to a gynaecologist. For the man, however, he’ll likely get a standard semen analysis and little else. From here it tends to follow a standard path, which often leads a couple towards IVF with treatment mainly focussed on the woman. If the man has a suboptimal semen analysis, he’s usually offered some generic advice and reassured that IVF or ICSI (intra-cytoplasmic sperm injection) will help.
ICSI can be performed as a part of some IVF cycles. In a standard IVF cycle sperm are mixed with the egg to fertilise it. During an ICSI cycle instead of mixing them together a skilled embryologist will inject a single sperm into the egg to fertilise it.
Find out more: Intracytoplasmic sperm injection (ICSI)
It’s rare for further information or testing to be offered to try and ascertain the cause of the suboptimal semen analysis, meaning the couple continue towards fertility treatment with no other help or focus on the man.
Unfortunately, many couples go through these limited investigations and often end up with the dreaded “unexplained infertility” diagnosis. But my question is whether it is actually “unexplained” or simply “un-investigated”.
It is well documented that the likelihood of the issue sitting with the man is roughly equal to that of it sitting with the woman, and that male factor infertility is responsible in more than half of cases where a couple requires IVF3. Yet, despite these statistics, most couples still head into fertility treatment with only a basic semen analysis under their belt.
Although still an area of debate among some fertility clinicians, there are further tests and examinations that could be considered for men, some of which show promising data in male infertility aetiology diagnosis:
These tests could help identify other, easily treatable, causes of infertility that are unlikely to get picked up on a semen analysis, such as:
By missing opportunities for further tests and not investigating the man more thoroughly, we run the risk of putting women through unnecessary treatment.
It seems crazy to go into something as invasive, expensive and emotionally charged as IVF without investigating both parties fully, yet this is happening regularly.
For men specifically, depression, low mood, and loss of libido are all common issues going through fertility treatment, as well as the profound effect it has on them and their relationships. However, there is considerably less support available to men, which could be attributed to the outdated view that they “have the easy bit” or that they just need to “man up”.
Men need support too, in fact when men are given the opportunity to talk and are invited to be part of the conversation many will open up and be more honest about the struggles they’re facing.
Fertility education is crucial for both men and women, and it’s time we helped men get a better understanding of their fertility and the choices they have, because there is so much more out there for them if they know where to look. However, this works both ways. Good education and more thorough testing are needed, and if men were to be offered more comprehensive tests from the very beginning, it could completely change the treatment pathway for many couples.
For this, we need to look at the patient pathway and how to better support men through the journey. This starts with a clear referral pathway from GPs, which currently only exists in extreme cases, as well as a focus on the research into the impact sperm have on fertility outcomes, and a push to recruit or train more Urologists with male fertility expertise.
I would always urge couples to ask for clear guidance on testing to ensure they are fully informed, that both individuals are being properly investigated, and that their voices are heard.
References
Sengupta, p., borges, e., dutta, s., krajewska-kulak, e. (2018). Decline in sperm count in european men during the past 50 years. Human & experimental toxicology, 37(3), 247-255. Doi:10.1177/0960327117703690.
Agarwal, a., mulgund, a., hamada, a., & chyatte, m. R. (2015). A unique view on male infertility around the globe. Reproductive biology and endocrinology, 13, 37. Doi:10.1186/s12958-015-0032-1.
https://www.ncbi.nlm.nih.gov/pmc/articles/pmc10789276/
Winters, b. R., & walsh, t. J. (2014). The epidemiology of male infertility. Urologic clinics of north america, 41(1), 195-204. Doi:10.1016/j.ucl.2013.08.006
https://iris.who.int/bitstream/handle/10665/343208/9789240030787-eng.pdf?sequence=1
https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Unexplained-infertility
Agarwal, a., deepinder, f., cocuzza, m., agarwal, r., short, r. A., sabanegh, e., & marmar, j. L. (2007). Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology, 70(3), 532-538. Doi:10.1016/j.urology.2007.04.011.
Smit, m., romijn, j. C., wildhagen, m. F., veldhoven, j. L., weber, r. F., & dohle, g. R. (2010). Decreased sperm dna fragmentation after surgical varicocelectomy is associated with increased pregnancy rate. Journal of urology, 183(1), 270-274. Doi:10.1016/j.juro.2009.08.160.
Blumer, c. G., restelli, a. E., giudice, p. T., soler, t. B., fraietta, r., nichi, m., ... & bertolla, r. P. (2012). Effect of varicocele on sperm function and semen oxidative stress. Bju international, 109(2), 258-265. Doi:10.1111/j.1464-410x.2011.10250.x.
Ian Stones
Ian is co-founder and co-director of testhim a company aimed at changing the world of male fertility. With over 16 years' experience as a practitioner supporting couples going through fertility difficulties Ian knows how much of a battle infertility is for men and that they are often the neglected part of the equation. Through testhim, Ian is keen to do all he can to tackle male fertility head on.
Disclaimer: The views expressed in this blog are those of the author, they do not necessarily represent the views of the HFEA.
Review date: 10 October 2026
