Male Infertility: Signs, Symptoms And What You Can Actually Do About It
If you and your partner have been trying to conceive for a year or more without success, then there is a 50% chance that a male factor will be part of the equation. This statistic is a big surprise to most couples, as the dialogue on fertility still focuses primarily on the female partner. Male infertility is a big problem, a well-understood problem, and a problem that can be solved with the appropriate combination of medicine and lifestyle change, aided by appropriate nutrition.
At Floralia Wellness, our naturopaths work in conjunction with fertility experts and GPs to support sperm health using a holistic approach. If you suspect something is amiss and wish to get started with some one-on-one advice, you can book a consultation.
How common is male infertility (and why is it still overlooked?)
Around 15% of couples experiencing difficulties in conceiving suffer from infertility. Of these, 30% have problems that are totally related to the male factor. In another 20%, there are problems in both partners. These are not small figures. The male factor causes around half of all infertility cases, yet it remains one of the least researched areas in human reproduction.
Still, male fertility is an afterthought in many clinics. The female is often investigated before the male, sometimes extensively, before anyone even mentions the possibility of a semen analysis on the male. This not only costs time but also can cost money as couples seek treatments that only work on half the equation.
Some of this is cultural in nature. Men are less likely to seek fertility testing, and the emotional impact of being diagnosed with infertility can be stigmatising and stressful in its own right, which can affect the relationship. A systematic analysis published in the Asian Journal of Andrology in 2024 revealed that being diagnosed with male infertility is associated with depression, anxiety, and decreased quality of life. It is the reality we see every day. The men we see in our clinic have gone for many months thinking the problem is elsewhere until the semen analysis shows them the reality.
The most productive method is to assess both partners at the same time, so that no factor is overlooked and treatment can be targeted where it will actually have an effect.
Warning signs that something may be affecting your fertility
Physical symptoms to pay attention to
Most men with fertility difficulties may experience no symptoms at all, or may not connect the dots with how they are feeling, and its impact on fertility, which is one reason it can be so easily to overlooked. But there are some physical symptoms to be aware of.
Erectile dysfunction, or difficulty in achieving an erection during sexual intercourse, may indicate hormonal or vascular imbalances, and in some instances, neurological imbalances, which are associated with fertility problems. In other instances, premature ejaculation or retrograde ejaculation, in which semen is pumped back into the bladder instead of out through the penis, may result in a decrease in sperm count in the semen. Painful or swollen testicles may indicate a varicocele, a testicular infection, or a physical deformity in the genital area. A history of undescended testicles or surgery in the groin area, as well as a history of STDs, although in the past, may still have a bearing on fertility problems.
Low libido and unusual fatigue can be signs of low testosterone, and other signs include changes in body composition, such as breast tissue growth or decreased muscle mass. While these signs can be easy to write off, it is definitely worth mentioning them to your GP or fertility specialist. If testosterone is an issue, testosterone testing can help determine whether your levels are contributing to the problem.
When your semen analysis tells a different story
For many men, the initial sign of a fertility issue will be revealed by the results of a semen analysis, rather than by any obvious symptom. The results can be quite a shock when everything else in life appears to be normal.
There are several parameters that are measured during a semen analysis. These include the sperm count (the number of sperm), the concentration of sperm (the number of sperm per millilitre), the motility of the sperm (the movement of the sperm), and the morphology of the sperm (the percentage of normal-shaped sperm). Low levels of any of these may cause problems in conception.
What surprises people is the fact that one analysis is not sufficient. Sperm parameters vary from one semen sample to another because of recent illnesses, stress, heat exposure, and even the time elapsed since your last ejaculation. It is recommended to perform at least two semen analyses, with the tests done two to four weeks apart, before making any conclusions. If the results come back abnormal for both tests, further investigation is required. Our male fertility testing page explains the full process and what to expect.
What causes male infertility
Hormonal imbalances and the role of the pituitary gland
The production of sperm is a complex process that requires a chain of hormones. The pituitary gland in the brain sends out a message to the testes to produce sperm by sending out follicle-stimulating hormones (FSH) and luteinising hormones (LH). Any disruption in this process will stop the production of sperm.
The hormone most people think of when they think of hormone imbalances is low levels of testosterone, but high levels of prolactin, as well as imbalances in thyroid hormones, can contribute to this problem, as can imbalances in sex hormone-binding globulin. Even replacement therapy for low levels of testosterone, which is now commonly prescribed for people who have low energy or a decrease in libido, can shut off signals to the testes to produce sperm, a situation we are seeing more of than you would think, although this can be overcome if the patient stops taking the replacement hormones, a process that can take months. Comprehensive hormone testing can identify exactly where the disruption sits.
Structural and obstructive causes
Sometimes, there is a mechanical problem. The sperm are made in the testes, but they are not getting to the semen because of a blockage in the process.
The vas deferens, which transports the sperm from the epididymis to the urethra, may be absent, which is associated with cystic fibrosis gene mutations, or may be obstructed due to previous surgery or infections. Dilated ejaculatory ducts can also result in obstruction. The causes of obstruction are manifested by a very low or zero sperm count in the semen, with normal hormone levels and normal-sized testes.
Varicoceles, which are enlarged veins in the scrotum, are the most common correctable cause of male infertility. Varicoceles increase the temperature in the testicles, which can reduce the quality as well as the quantity of the sperm. While not all varicoceles are corrected, those that are associated with abnormal semen parameters are corrected to enhance the outcome.
Genetic factors
Genetic abnormalities are more common in infertile men than in the general population, especially in cases of severe oligospermia (a very low sperm count) or azoospermia (a complete absence of sperm in the ejaculate).
Klinefelter syndrome, where a male has an extra X chromosome, is another of the more well-known genetic causes. Y chromosome microdeletions are another type that specifically affects the genes controlling sperm development. Tests are generally advised when sperm count drops below five million per millilitre, or if there is no sperm in the ejaculate at all.
The implications of a genetic discovery can be varied. Some indicate that there is no hope of enhancing sperm production, but that sperm can be retrieved by techniques like testicular sperm extraction or microscopic testicular sperm extraction and used in IVF with intracytoplasmic sperm injection. Others, like the genetic carriers of cystic fibrosis who have a lack of the vas deferens, indicate that there is a physical problem, but one that can be circumvented with assisted reproduction techniques.
Lifestyle factors that lower sperm quality
This is an area where you have the most direct control, and one of the first things we work on in a clinic.
Smoking decreases sperm count and motility, and also affects sperm morphology. The more you smoke, the more it will affect your sperm. Similarly, alcohol consumption in large quantities has adverse effects on sperm. Consuming large amounts of alcohol decreases testosterone levels in the body, resulting in abnormal spermatogenesis. Moderate alcohol consumption has a less significant impact on sperm. According to a review published in Clinics and Practice in 2024, obesity, dietary habits, psychological stress, smoking, and alcohol all have adverse effects on sperm count, sperm motility, and DNA integrity.
One of the most important but least appreciated causes of male factor infertility is obesity. The excess fat leads to an overproduction of oestrogen relative to testosterone by an enzyme called aromatase. The hormonal imbalances interfere with the normal production of healthy sperm cells. Excess abdominal fat also increases scrotal temperature. Weight loss in obese men often leads to improvement in semen quality, sometimes significantly so.
Another factor is heat exposure. Sitting too long, wearing tight underwear, using saunas and/or hot tubs frequently, and working on a computer placed on your lap can increase your testicular temperature enough to impact sperm quality. The reason testicles hang outside the body is that they must be a couple of degrees cooler than body temperature to make sperm properly.
Environmental exposures most people don't consider
Aside from the well-known lifestyle factors, environmental factors are increasingly being seen as one of the factors behind the degradation of sperm quality, and one that rarely receives the attention it deserves during fertility consultations.
Occupational exposures are a good place to begin. Men working in farming, manufacturing, painting, and construction may be exposed daily to pesticides, solvents, heavy metals such as lead and cadmium, and industrial chemicals. These chemicals have been shown to affect male fertility by direct toxic effects on cells that produce sperm and by endocrine disruption, which affects hormone levels.
However, you do not have to work in a factory setting to be exposed to these types of substances. There are endocrine disruptors in everyday items you may use. Bisphenol A (BPA) is in plastic food containers and food cans. It is also in thermal receipt paper. Phthalates are in fragrances and personal care items, as well as soft plastic containers. Parabens are in shampoos and moisturisers, as well as in a lot of deodorants. These substances mimic or block hormone activity in the body and have been shown in more research to have a possible effect on sperm count and DNA fragmentation.
We discuss these issues with male patients in terms of environmental exposures during the initial assessment. For example, changing food storage to glass or stainless steel, using fragrance-free toiletries, washing hands after handling receipts, and consuming organic foods to decrease pesticide exposure. All of these steps are not difficult. The point is, most people have not been informed that these steps can make a difference.
Another factor to consider is heat exposure related to occupational activities. Welders, bakers, drivers, and men who work in environments with high temperatures for long periods may be subjecting their testicles to high temperatures that can affect spermatogenesis. It is important to consider this if you work in any of these fields and are trying to conceive. It is recommended to consider cooling techniques with your practitioner.
How male infertility is diagnosed
Semen analysis: what the numbers actually mean
The first step in any investigation of male fertility is a semen analysis, which involves providing a semen specimen, typically after two to five days of sexual abstinence, and having several parameters analysed in a laboratory.
The reference values provided by the World Health Organisation are a guide for what is considered to be within the normal range. Having a total sperm count of over 39 million per ejaculate volume, a concentration of over 15 million per millilitre of sperm, 40% or greater motility, and 4% or greater normal forms are the reference values for a man to be considered normal. Not meeting these standards does not mean that a person is unable to conceive naturally.
Semen volume is also significant. If the semen volume is small, it could mean retrograde ejaculation or obstruction. It could also mean hormonal problems. If your semen volume is consistently small, your doctor might want to check for enlarged ejaculatory ducts or whether the semen collection is complete. Sperm DNA fragmentation tests are available in some clinics, even if the other tests come up normal. This is because conception is not happening.
Blood tests and hormonal profiling
If your semen analysis is abnormal, the next set of tests is blood tests to measure hormone levels. One of the most useful blood tests is for the level of serum follicle-stimulating hormone. High levels of this hormone may indicate difficulty in producing sperm, and the pituitary gland is working harder to compensate. Low levels of this hormone, with low levels of testosterone, may indicate difficulty with the pituitary gland.
Levels of testosterone, LH, prolactin, oestradiol, sex hormone binding globulin, and thyroid function are all part of a comprehensive hormonal analysis. The results of these tests will give an indication of whether the problem is hormonal or testicular in nature and/or if a blockage is present, and will inform treatment options. If thyroid function is indicated as an area of concern, a thyroid test will give a better insight into the role of your thyroid on your reproductive health.
When further investigation is needed
A physical examination is part of the standard evaluation. Your doctor will want to examine the size of your testicles and look for any signs of varicoceles and any other abnormalities. Scrotal ultrasonography may also be ordered to have a better view of the problem, especially if there are concerns about testicular cancer risk factors and azoospermia.
Genetic tests should be performed in men who have severe oligospermia or azoospermia. Karyotype analysis detects chromosomal abnormalities, and Y chromosome microdeletion tests look for gaps in the chromosomes related to sperm formation. If the count of white blood cells in the semen is high (over one million per millilitre), a culture of the semen is done.
In cases where there is no sperm present in the ejaculated fluid, testicular biopsy procedures or sperm extraction techniques such as percutaneous epididymal sperm aspiration or testicular sperm extraction can help ascertain whether sperm is being produced in the testes, though not present in the seminal fluid.
The 90-day sperm cycle and why it matters for treatment timing
This is perhaps one of the most significant concepts to grasp if you are about to embark on any type of fertility treatment, whether this is a naturopathic program, a lifestyle overhaul, hormonal therapy, or IVF.
The development of sperm, from immature germ cell to mature spermatozoon ready for ejaculation, takes 72 to 76 days. Then, there are another 10 to 14 days spent maturing in the epididymis before they are available in the ejaculate. So, there are about 90 days, or three months, between the start of sperm production and their first appearance in a semen sample.
The practical implication is considerable. If you decide to quit smoking, change your diet, start your supplement regimen, or initiate hormonal therapy today, the sperm you produce over the next few weeks were in development before you made those lifestyle changes. It is not possible to see the full effects of your lifestyle changes on your semen analysis in less than three months. More realistically, practitioners suggest waiting four to six months to see the effects of two full cycles of new sperm development.
This time frame can be quite frustrating, and rightly so. Three to six months can feel like an eternity when trying to conceive. However, understanding this beforehand can help avoid a common pitfall: stopping a treatment too soon because the semen analysis results have not altered significantly after the initial follow-up. At Floralia, we make sure to educate patients about this from the start. This ensures that patients will make the necessary adjustments, which take time to work.
The 90-day cycle also has a bearing on IVF. If you're planning an IVF procedure involving intracytoplasmic sperm injection, you should know that the quality of sperm you're going to have on the actual date of retrieval is a function of what was happening in your body three months before that date. Therefore, if you're planning to have an IVF procedure, you should start a preconception support plan at least three months before the actual date of the procedure. While six months is ideal, three months is the minimum you should put in to see significant improvement.
The same principle holds in eliminating harmful exposures. If you have been exposed to a gonadotoxin or have stopped a recent round of testosterone replacement therapy, it will take at least a full cycle of spermatogenesis, and sometimes longer, for sperm production to resume. Patience is part of the treatment.
Medical and surgical treatment options
Hormonal therapies and when they are appropriate
The hormonal treatment of male infertility is based on the signalling pathway between the pituitary gland and the testes. The main aim is to improve the hormonal conditions for the production of sperm.
One of the more commonly used medications is clomiphene citrate. It works by blocking oestrogen receptors in the brain. This fools the pituitary gland into releasing more FSH and LH. This then stimulates the testes to produce more testosterone, and hence more sperm. Clomiphene can be used for those with low hormone levels, as well as those suffering from idiopathic infertility, where there is no known cause for the infertility.
Aromatase inhibitors, on the other hand, have a different mechanism of action. They block the conversion of testosterone to oestrogen, which is particularly useful for overweight men who have high levels of oestrogen. By doing so, the feedback inhibition on the pituitary gland is reduced, thus releasing more gonadotropin.
Gonadotropin injections of FSH and hCG are reserved for hypogonadotropic hypogonadism, in which the pituitary gland does not produce enough FSH and LH. Hypogonadotropic hypogonadism is one of the most treatable causes of male infertility. The results of gonadotropin injections can be excellent, although the injections must often be given for six to twelve months before sperm can be found in the ejaculate.
One common scenario that often arises in practice is men who have been put on testosterone replacement therapy for fatigue or low libido, but are not informed about the impact it has on fertility. Exogenous testosterone inhibits the pituitary signals that control sperm production, and prolonged use can lead to low sperm counts or even the absence of sperm. The good news, however, is that this can be fully reversed, but it can take anywhere from three months to over a year.
Surgical interventions for structural problems
If the cause of male infertility is structural in nature, then surgery can help correct the problem.
Varicocelectomy is the most frequently performed surgery for male infertility and involves repair of a varicocele by ligation of the dilated veins, reducing scrotal temperature and improving sperm count, motility, and sometimes morphology as well. It is not necessary to operate on all cases of varicoceles; however, when associated with abnormal semen analysis in a couple planning a family, repair is advised.
Vasectomy reversal, which includes vasovasostomy or vasoepididymostomy, is a procedure to reinstate sperm in a man who has undergone a vasectomy. The rate of success varies according to the number of years since a vasectomy was performed, with a higher rate of patency if performed within ten years.
For men with obstructive azoospermia who are not candidates for reconstructive surgery, sperm retrieval techniques provide an alternative. Percutaneous epididymal sperm aspiration and testicular sperm extraction provide methods for the direct procurement of sperm from the male reproductive system for IVF with ICSI.
Assisted reproductive techniques: IUI, IVF and ICSI
If conception is not likely to happen naturally or if other forms of treatment have not been effective, assisted reproductive technologies offer a solution.
The process of intrauterine insemination consists of selecting the most viable sperm from the ejaculate and inserting them into the uterus during the time of ovulation. This treatment method is most successful in cases of mild male infertility or unexplained infertility. It can also be used in cases of reduced sperm motility but normal sperm count. This treatment method is less invasive and less costly compared to IVF.
The most common treatment for severe male infertility is in vitro fertilisation combined with intracytoplasmic sperm injection. ICSI involves the injection of a single sperm into an egg. This bypasses many of the obstacles to fertilisation, which can occur when the sperm are of poor quality. It can be performed with either ejaculated or surgically collected sperm. If the sperm count is low, or the sperm have poor motility, or there are many anti-sperm antibodies, then ICSI gives the best opportunity for fertilisation.
The choice between IUI and IVF with ICSI depends on the severity of the male factor and the female partner’s age, as well as the duration for which the couple is trying. Your fertility specialist will be able to help you with this decision based on your combined results.
How naturopathic support can improve sperm health alongside medical treatment
This is where our practitioners at Floralia Wellness can offer support. Naturopathic care for male infertility is not a replacement for medical and surgical interventions, where they are required. Rather, it is a focused intervention to address those aspects of male infertility that are modifiable, namely nutrient status, oxidative stress, dietary habits, sleep, and hormonal balance. An umbrella review of 11 systematic reviews found that there are several interventions in complementary medicine that have a positive effect on sperm motility and concentration, although the quality of evidence varies.
In the clinic, we work alongside your fertility specialist. If you are preparing for IVF, we will time our programs according to your cycle schedule. If you are trying naturally, we will develop a program according to your semen analysis test results, as well as your blood work and overall health history. The idea is to provide your body with the best possible conditions to produce healthy sperm during the 90-day development window. You can read more about our approach on our male infertility support page.
Targeted nutritional and antioxidant support
Oxidative stress is one of the most common modifiable factors affecting sperm quality. Sperm cells are particularly susceptible to oxidative stress because of their high concentration of polyunsaturated fatty acids and lack of antioxidant defences. The excess of reactive oxygen species, beyond what the body can counteract, leads to oxidative stress, causing sperm cell membrane alterations, reduced sperm motility, and increased sperm DNA fragmentation. The review article published in Reproductive Medicine and Biology in 2024 reaffirmed oxidative stress as a leading factor in poor sperm quality, recommending dietary and lifestyle interventions along with antioxidant therapy as a mode of management.
This is where targeted supplements come in. Zinc is involved in testosterone synthesis and is present in high quantities in seminal fluid. It is involved in sperm maturation and has antioxidant effects. Coenzyme Q10 is involved in mitochondrial energy production in sperm, which has a direct effect on motility. A 2025 meta-analysis of nine randomised controlled trials showed that taking CoQ10 supplements significantly increases sperm concentration and motility, as well as seminal volume. The supplements were most effective when taken for three months or more. L-carnitine is involved in fatty acid transport into the mitochondria and has been associated with increases in concentration and motility. Folate and vitamin B12 are involved in DNA synthesis and methylation, both of which are important in sperm formation.
The difference between purchasing a generic "men’s fertility multivitamin" on a store shelf and working with a practitioner is dosing and form, as well as context. A practitioner-grade supplement uses bioavailable forms of nutrients in therapeutic dosing, and the blend is individualised based on your test results. A man with high oxidative stress and DNA fragmentation requires a different approach than a man struggling with low motility and normal parameters in all other areas. A systematic review of antioxidants including CoQ10, zinc, selenium, vitamins C and E, and L-carnitine noted that most of the included studies showed a positive correlation between these nutrients and improved sperm parameters.
At Floralia, we utilise baseline blood work and semen analysis to determine supplementation protocols, not a set formula for each patient, and we also adjust protocols based on progress and changes in results over subsequent 90-day cycles.
Dietary patterns that support sperm quality
The Mediterranean dietary pattern is the most extensively supported for enhancing male fertility. The Mediterranean diet is high in fruits and vegetables, legumes, whole grains, nuts, and fish, and low in processed foods and refined sugars; trans fatty acids are absent.
The reason why this diet pattern works so well is that it works through multiple mechanisms simultaneously. The colourful plant foods provide a large amount of antioxidants, which help to reduce oxidative damage to sperm. The healthy fats help to support the cell membranes. The fibre and low glycaemic load help to support insulin sensitivity, which in turn can help to support testosterone metabolism. The anti-inflammatory effects of the diet can help to reduce inflammation, which can disrupt fertility.
Specific foods that should be highlighted include oily fish as a source of omega-3 fatty acids, walnuts, tomatoes (which are rich in lycopene and accumulate in high quantities in the testes), leafy green vegetables, berries, and legumes. Reducing processed meat and sugary drinks is also worthwhile, as is reducing caffeine intake. A clinical nutritionist can assist in applying these general principles in a way that is suitable to your tastes and health profile.
We're not advocating a rigid meal plan. The key is not to worry about what you're eating on a particular day, but to look at the big picture, the whole diet, over time. Making small, incremental changes to a diet is more likely to lead to successful weight loss than making large, abrupt changes.
Stress, sleep and the hormonal connection
Chronic stress causes cortisol levels to increase. Cortisol levels that remain high over time can impair the hypothalamic-pituitary-gonadal axis, which controls levels of testosterone and sperm. If you have been in a stressful situation for some time, your hormones are already being affected by that stress, whether you feel it or not.
The other part of this puzzle is sleep, which is not given due importance either. It is a known fact that testosterone production is at its highest during sleep, especially during deep sleep cycles. Men who get fewer than six hours of sleep each night have lower testosterone levels compared to men who get seven to eight hours of sleep each night. Shift work and sleep apnea add fuel to the fire, as does poor quality of sleep in general.
In reality, telling people to "reduce stress" is not really helpful. At Floralia, we know it is really important to think about what this means in terms of making actual changes. Does this mean implementing a new relaxation technique, such as yoga or breathing exercises? Does this mean working on sleep hygiene factors, such as avoiding screens before bed and making sure the bedroom is cool and dark, or trying to establish a more regular sleep routine? Does this mean using herbal medicine to support the body’s stress response and sleep quality, such as using adaptogenic herbs like ashwagandha and withania, which have been shown to support both cortisol and testosterone production? Does this mean using fertility acupuncture as part of a stress reduction and hormone support plan?
What helps is consistent improvement in the areas that you have control over, and that continues for at least two to three spermatogenesis cycles before those changes appear in your next semen analysis.
When to seek help and what the first appointment looks like
If you and your partner have been trying to conceive for more than twelve months, then it is probably time to seek support. If you are both older than 35, this should be done within six months. And if you know you have a risk factor (previous surgery, hormone problems, undescended testicles, chemotherapy exposure), then there is no reason to wait at all.
Your initial appointment with Floralia Wellness will include an extensive health history, including your medical history, surgical history, reproductive history, and lifestyle history. We will also review any existing test results you have on hand, such as your semen analysis test results and your blood work. If your tests have not been performed yet, we will refer you to the right facilities to obtain your baseline.
From there, a specific naturopathic treatment plan is designed and tailored to your results and situation. There is no one-size-fits-all approach to natural fertility treatments. A man with idiopathic male infertility and marginal semen parameters will require a different approach than a man who has a diagnosed varicocele and is undergoing surgery to correct his fertility problem, or a man who is undergoing an IVF procedure with a high level of sperm DNA fragmentation. Our fertility naturopaths have decades of experience in natural fertility treatments.
We also work in conjunction with your female partner if she is a patient in the clinic, so that both sides of the fertility equation are being addressed. If you are already a patient of a fertility specialist or consultant in reproductive medicine, we can work in conjunction with them to ensure that your naturopathic care does not interfere with your medical care.
