Male Fertility FAQs
Atlantic Reproductive Medicine’s Dr. Matt Coward, a urologic microsurgeon specializing in treating male fertility, answers some of the most commonly asked questions about male fertility.
The only way to definitively know about fertility potential is with a semen analysis. The majority of men with infertility will be asymptomatic, other than having difficulty conceiving with a partner. If 12 months goes by without success (or 6 months if your partner is over 35), a man should be checked with a semen analysis. Despite most being completely asymptomatic, some infertile men will have symptoms such as problems with their libido or sex drive, erections, or ejaculation. Particularly if symptoms of sexual dysfunction are new or worsen over time, there could be an associated fertility problem. Most men will not be able to know their fertility status until they do a semen analysis.
The only truly natural male fertility test is actually causing a pregnancy! If pregnancy isn’t occurring within 12 months (or 6 months if your female partner is over 35), an evaluation of some sort needs to take place, and most of the time this begins with a semen analysis. I assume this question is from someone who either is unable to collect a semen analysis, or is unwilling to do one. Reasons for this often center around not wanting to masturbate or not wanting to ejaculate anywhere other than within their partner’s vagina with the intention to cause a pregnancy. There is often a religious component to this concern, which I am sensitive to. Fertility specialists have a variety of things we can do during an initial evaluation which can act as a surrogate marker for fertility instead of a semen analysis. These include physical examination of the testicles as well as blood reproductive hormone levels which often correlate with the status of sperm production. Lastly, when there are religious reasons for not wanting to ejaculate at any other time or place than when trying to conceive, many couples will find an excellent solution which is to use a special perforated condom. These condoms allow for ejaculation to occur during intercourse, and a few sperm can sneak out of the perforations technically still allowing for potential conception, while the majority of the sample can still be submitted for a semen analysis. Men who are unable to ejaculate or have such severe sexual problems limiting the ability to collect a semen sample should be evaluated–often the treatments will involve improving sexual function sufficiently to allow for standard semen collection.
This has been a moving target over the years, and additionally, there are multiple numbers that are often called the “count,” like concentration, total sperm count, and total motile sperm count. The criteria for what is considered a normal semen analysis are set by the World Health Organization. They are now in the sixth edition of the WHO manual for semen analysis, which was published in 2021 – here is the full text: https://www.who.int/publications/i/item/9789240030787. The latest low-end cutoffs for a normal semen analysis are a volume of 1.4 mL, a sperm concentration of 16 million/mL, sperm motility of 42%, and strict morphology of 4%. Keep in mind that these cutoffs don’t determine normal or abnormal, or fertile or infertile; these numbers are all on a long continuum of normal fertility. The cut-offs for each low parameter come from a large study of normally fertile men who have recently caused a pregnancy, and the cut-offs are somewhat arbitrarily determined to be drawn at the 5th percentile of normal. If each parameter is plotted on a bell curve of normal, the cutoffs are on the lower end of the curve, but these are still coming from men who successfully caused a pregnancy. The more parameters that are abnormal, the more likely the problem is significant; on the contrary, if only one or two parameters are abnormal, this is less severe. There is an important calculation that most patients should understand: the volume, multiplied by the concentration, gives a total sperm count; and the total sperm count multiplied by the percentage of motile sperm, gives a total motile sperm count. The total motile sperm count, or TMC, is, therefore, the best summary number from a semen analysis, and the best way to compare one sample from another. An average normal TMC for a fertile male is around 100 million, and an accepted low cutoff for the number needed to conceive naturally is around 30 million. A low number would be 10-30 million TMC, which is typically what is required for intrauterine insemination (IUI). When TMC’s are less than 10 million, this is a severely low count, and this is a count that is in range only for IVF. We only need one sperm per egg for IVF, so a typical IVF range goes from rare sperm identified in the ejaculate all the way up to around 10 million TMC. You’ll notice I’m not talking much about sperm morphology; this is a larger discussion, but in general, this is the least important parameter compared with volume, concentration, motility, and total motile counts.
A total motile count (TMC) of 30 million is the generally accepted low-end cutoff to conceive naturally, although it happens more quickly and easily if the TMC is over 50 million.
The best way to raise your sperm count is to live a healthy lifestyle. Always see your primary care physician (PCP) for an annual physical, and keep a close eye on things like weight, blood pressure, cholesterol, and blood sugar. The three most important tenets of health are diet, exercise, and sleep. Eat well with a sensible heart-healthy diet, sleep 7 hours per day, and maintain a healthy body weight by exercising with moderately strenuous exercise for 30 minutes per day. Even though exercise is one of the healthiest things you can do, you should avoid workout supplements, protein powder, or any testosterone boosters. Keep any indiscretions to a minimum: drink less than 10 alcoholic drinks per week and no more than two at a time, avoid tobacco and vape completely, and minimize cannabis use to less than once per month.
As soon as a man quits smoking weed or using cannabis of any type, sperm production begins to improve. It probably takes a month to get the toxic substances out of the system. The total production and transit time for sperm production to ejaculation takes another 74 days. For these reasons, it typically takes 4-6 months to see improvements in the semen after major changes in lifestyle like quitting weed.
Sperm incrementally moves up the foot-long vas deferens with each ejaculation. After the blockage is created in the scrotal portion of each vas during a vasectomy, it takes about 20 ejaculations and two months to completely clear out all of the sperm to achieve a zero count. During that time, a man is firing live rounds of ammo and is still very fertile, so continued contraception (such as condoms or female birth control) is required until a semen analysis is obtained approximately 3 months after vasectomy.
A healthy body makes healthy sperm, so the best advice is to maintain a healthy body weight, exercise for 30 minutes daily, sleep 7 hours per night, and eat a healthy diet. Regularly seeing your PCP for general screening of your blood pressure, cholesterol, and blood sugar is important, in addition to closely monitoring and managing any chronic health problems. Avoiding known causes of impaired sperm production such as tobacco, alcohol, and cannabis (marijuana) will help to maintain optimal sperm production. Men should avoid supplements, especially workout-related supplements, protein powders, and any over-the-counter products marketed toward strength, vitality, or sexual function. Many of these workout products contain ingredients that can be harmful to sperm production. Despite all of this general advice, some men will have conditions that cause decreased sperm production which need to be evaluated by a trained reproductive urologist. The most common of these conditions is a varicocele which affects 15% of all men and is the most common cause of an abnormal semen analysis. This is best diagnosed by a physical exam during a consultation for possible male factor infertility.
Masturbation is a healthy activity so long as it does not interfere with or take away from intercourse or the sexual relationship. The male body is built to ejaculate about twice a week on average, so it is healthy for a male to masturbate if intercourse frequency is irregular or infrequent for other reasons. The optimal sperm quality is seen with ejaculation frequency of 2-3 times per week. The sperm are coming off an assembly line, with the total transit time of around 74 days, and then when they get near the finish line at the prostate they wait their turn for each ejaculation. More frequent ejaculations than 2-3 per week can result in diluted semen with less sperm, and more infrequent ejaculations can result in lower motility and lower quality sperm. Studies show the optimal ejaculation frequency for sperm quality when a couple is trying to conceive is around 2 days. During the female partner’s fertile window, intercourse about every other day is best. Masturbation during this time period should be avoided if possible as it can take away from the chances to conceive during that cycle.
There is no upper limit of normal semen volume, but there is also no way to actually improve semen volume, assuming the body is working properly. The majority of semen volume is fluid that comes from the prostate and seminal vesicles, not actually sperm. Keep in mind that after a vasectomy, semen volume shouldn’t change, because the sperm only contribute about 5% to the volume. A man’s semen volume has more to do with his prostate size as well as his age than anything. Semen volumes decline with aging. All that being said, there are a number of conditions that can arise which can reduce semen volume or create a problem from birth where semen volume is very low. These conditions vary from blockages to issues with ejaculation. Many of these problems that are essentially problems of sperm delivery can result in low or decreased semen volume. If the amount has decreased over time or has lower or slower velocity, or if it comes out in a delayed fashion, such as more than a few seconds after orgasm, there could be a problem that needs medical attention. Treatable blockages can develop from infection or inflammation such as from injury or trauma. Retrograde ejaculation is a very common cause of decreased semen volume, and this can be a symptom of new or worsening diabetes. Other hormonal abnormalities can cause disorders of ejaculation as well. If you are experiencing changes in semen volume or have noticed a decrease, having a semen analysis with retrograde urine assessment, along with a full evaluation with a reproductive urologist is recommended. The treatments vary from lifestyle improvements, to medications to surgery. Changes in semen volume cannot be treated with supplements or any simple home-based therapies. Any purported treatment directed toward semen volume is not coming from evidence-based medicine, so be wary of these false claims.
There are almost too many causes for low sperm count to list in a short response, but the most common causes can be grouped into, 1) general health concerns, like obesity, or an uncontrolled or even yet-to-be-diagnosed medical condition, 2) prior medical problems like childhood illnesses or surgeries, 3) exposures like tobacco, alcohol, cannabis, workout supplements, or other occupational or environmental chemicals, 4) anatomical problems with the testicles that expose them to too much heat, the most common of which is a dilation of veins above the testicle called a varicocele, 5) hormone problems like low testosterone, and 6) genetic problems that a man was born with, most often of which cause no other noticeable health concern other than male infertility. When sperm counts are low, a man should take a close look at his potential exposures, but the most important thing he can do is seek an evaluation with a reproductive urologist for a complete evaluation including physical exam and blood work.
This is generally not possible due to the production time plus the transit time of sperm which is around 74 days from the time a sperm is being created to when it is ejaculated. Most effects we see after lifestyle changes, a medication is started, or a procedure is performed, are seen at least months later. If a man is thinking about this question because he is preparing to give an important semen sample such as on the day of the egg retrieval during the IVF process, the best advice I can give is to sleep well the night before and do your best to manage any stress or anxiety prior to giving the sample. Meditation, relaxation, or simply enjoying your favorite foods, music, or other activities in the couple hours before giving the sample can help to clear your mind.
Yes, all forms of cannabis negatively impact sperm quality. The effect is variable, but in most cases ranges from a moderate to a severe effect. Cannabis comes from the marijuana plant, and the products that can cause sperm problems include smoking weed, taking gummies or other edibles, as well as any other types of vapes, tinctures, and oils. It’s not just the THC (the main psychedelic ingredient in cannabis) that can impact sperm, but also many types of CBD products that come from cannabis are also toxic to the testicles. Because cannabis and marijuana take root in the body’s fat cells, their effects tend to last several weeks beyond their use. Regular users typically need 6 months for it to both clear out of the system, and also to allow for a new batch of sperm to come off the assembly line which is around 3 months.
The best diet for sperm is a balanced, heart-healthy diet rich in fruits and vegetables, limited red meats, and minimal fried foods or other processed foods high in saturated fats. A vegetarian or pescatarian diet are both very healthy diets for sperm. Foods to consider adding to an otherwise balanced, heart-healthy diet would be any green leafy vegetables that are high in antioxidants. Because of the long transit time from production to ejaculation which takes around 74 days, diet changes are not observed in a semen sample for a minimum of 3 months.
Most foods and drinks in moderation are safe to consume, and soft drinks are no exception with sperm. Similarly, caffeine from coffee, tea, and soft drinks are safe with moderate or typical use. We start to see problems when patients are drinking two pots of coffee a day, or soft drinks all day long. These types of choices are also indications that the rest of the diet is otherwise unhealthy. There is a myth from grade school that some of the chemicals in yellow or green soft drinks is a problem, but that has not borne out to be true in well-conducted medical studies. Coffee in the morning, and a tea or soft drink in the afternoon are fine. Just remember that late evening caffeine can interfere with good sleep. The three most important tenets of a healthy body are diet, exercise, and sleep. If these tenets are kept top of mind during the day-to-day choices a man makes, he will generally live healthier and live longer, in addition to having healthier sperm.
A “gonadotoxin” is the term for a substance, drug, or chemical that is toxic to sperm or eggs. In the modern industrial world, most gonadotoxins have come into existence over the past 100 years, which is why sperm counts have been declining over this time frame. These include tobacco, alcohol, marijuana, supplements, many pharmaceuticals, and chemicals and hormones that are put into our food. Of course, chemotherapy and radiation are one of the most potent gonadotoxins, so men who have been treated for cancer often suffer from infertility. These days, of the most common unrecognized sources of very low and zero sperm counts among men of reproductive age are testosterone, anabolic steroids, and even many over-the-counter workout supplements and testosterone boosters. External sources (called “exogenous” sources, which means something a man takes as a pill, injection, powder, or cream) of androgens, such as testosterone or anything even remotely related to testosterone, completely shut down sperm production. If a man of reproductive age is found to have low testosterone, he should meet with an endocrinologist or urologist to discuss alternative ways of raising testosterone before starting testosterone. This is not something I do as a fertility urologist, although I am able to make recommendations and prescribe the antidote medications to the testosterone poison if a man is looking to conceive a child in the near term and has already been taking testosterone. Therefore, if a man has been found to have a low or zero sperm count during an infertility evaluation, and he has been taking any type of testosterone in the recent or sometimes even in the remote past, he needs to make an appointment with us to sort this out!
Vasectomy Reversal FAQs
Amazingly, the testicle continues to work perfectly normally after a vasectomy. The testicles’ two main functions are sperm production and testosterone production, and neither is affected by vasectomy. The testicles continue to produce around one hundred million healthy sperm daily, which move out of the testicles, into the epididymis, and then into the part of the vas deferens below the vasectomy site. During a vasectomy reversal, which is often a number of years after the vasectomy, the first procedure done is to open the vas deferens beneath the vasectomy to sample the fluid for sperm. In what many consider to be a miracle of modern medicine, many years after the vasectomy, we often find healthy sperm coming right up to the vasectomy site, ready to cross through the new connection during a vasectomy reversal.
Success rates are often very individualized, so these numbers are difficult to provide. After a patient comes in with his partner and has a full evaluation, including history and physical exam, a detailed expectation of success rates can be provided. Success rates can be defined as either sperm coming back to the ejaculate or pregnancy, and most success rates in the vas reversal literature refer to the sperm only. On average, at 5 years, around 95% of males will have successful return of sperm to the ejaculate. At 10 years, it’s around 80%. Even when the vasectomy interval is over 15 or 20 years, the success rates of return of sperm will be lower, but they remain around 50%.
Patients should really keep in mind that these percentages are not pregnancy rates. Pregnancy often occurs after a successful vas reversal, but only in the setting of a fertile female partner. Good prognostic factors on the female side are prior pregnancies, normal menstrual cycle, age less than 40, and normal AMH levels indicating good ovarian reserve.
Pregnancy rates decline with longer vasectomy intervals for various reasons, including female factor infertility combined with lower sperm counts even in reversals that were successful.
For example, if a man has had a vasectomy for 15+ years and undergoes a reversal that is successful, the sperm count might come back low for a variety of different reasons (he is 15 years older, other medical issues have come up in the interval, or simply the testicles are not making as much sperm). If his female partner is close to 40 years of age or has other causes of infertility, it can still be difficult to conceive despite the successful reversal. However, if this same man’s female partner is 25 years old, it is quite possible he will have a successful pregnancy even with his low sperm count.
Yes, absolutely. The main exceptions are when other causes of male fertility or abnormal sperm quality have occurred in the interim, such as starting testosterone therapy after the vasectomy which is known to deteriorate sperm production. Sperm extraction after vasectomy is successful approximately 99% of the time. For many men with a vasectomy who are trying to achieve pregnancy again, the decision comes down to extracting sperm and proceeding with IVF for the female partner or a vasectomy reversal. At Atlantic, we uniquely offer a sperm retrieval for banking as a part of a vasectomy reversal without any additional cost. By removing the cost barrier for sperm banking at the time of the reversal, it becomes an excellent backup option for the small fraction of men who will undergo a reversal unsuccessfully, in which case another surgery and recovery would typically be required in that instance.
When female fertility is not normal, such as for a female partner over age 40 or if she is not having regular menstrual cycles, assisted reproduction with techniques like IUI or IVF are often necessary regardless of the sperm count or quality. In these settings, it’s best to have a female fertility evaluation first. If the evaluation finds that natural conception is still possible with good chances, a vasectomy reversal could be considered. If assisted reproduction is going to be required anyway, the couple should consider a sperm retrieval by itself instead of a vasectomy reversal. There are two disadvantages of vasectomy reversal to consider: 1) having success but then finding out that assisted reproduction is still going to be necessary, and 2) failing the vasectomy reversal and not having had sperm extracted in case of a failure. Men who are at relatively high risk of failure are those whose vasectomies are over 20 years ago, those who are on testosterone or other anabolic steroids, and those with significant risk for abnormal sperm production such as men with obesity or other uncontrolled medical issues, alcoholics, or men who use cannabis regularly.
The pain after a vasectomy reversal is typically only marginally more than the pain experienced with the original vasectomy. Even though small incisions are required, and the procedure takes longer, the work is all done with a high-powered microscope, tiny instruments, and tiny sutures. This results in only very mild pain afterward. Most patients only need pain medication for 1-2 days if any is needed at all. The majority of men undergoing reversal don’t take any pain medication at all. We prefer a post-operative regimen of non-narcotics that includes ice, rest, Tylenol, and anti-inflammatory medicines.
About 1-2% of men who undergo vasectomy will have some degree of chronic pain. The majority of these men will have had traditional or conventional vasectomies, as no-scalpel no-needle vasectomies have a lower incidence of chronic pain. While most post-vasectomy pain is mild and self-limiting, about 1 in 1000 men who undergo vasectomy will have such severe pain that surgical measures might be considered. It’s unclear what causes this, but it’s most likely scarring and pulling from the vasectomy site to the surrounding muscle that moves and contracts with temperature. Occasionally the chronic pain can be from epididymitis or congestion of the epididymis. Reversing the vasectomy resolves or improves the pain in about 90% of cases, but a careful preoperative assessment of other causes of scrotal pain should be pursued before reversal is considered.