Male infertility treatment

All risk factors should be identified and tackled, such as:

• reduction of smoking and drinking
• suggested measures include avoidance of saunas, hot baths, the wearing of tight underwear, and other situations in which scrotal temperature may be raised
• any infection should be treated

Low semen volume may produce insufficient contact with the cervical mucus for adequate sperm migration, and may be overcome by artificial insemination with the partner's semen.

High semen volume but low sperm numbers may be overcome by concentrating the semen - collection of a "split ejaculate" is often useful, as frequently, most of the sperm are present in the first part of the ejaculate.

Oligospermia may respond to treatments such as clomiphene or interferon - although this condition is now not a hurdle to successful in-vitro fertilisation

• clomiphene citrate is a well-established agent that has been described to empirically treat idiopathic oligospermia (2)
  • clomiphene citrate increases pituitary secretion by blocking the feedback inhibition of estradiol, thus increasing serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, with the latter gonadotropin stimulating the testicular synthesis of testosterone

Azoospermia due to mechanical blockage may respond to an epididymovasostomy. There is a 50% success rate provided that underlying spermatogenesis is normal.

When semen quality cannot be improved, intrauterine insemination timed to coincide with ovulation may be successful. This technique may also be effective in cases of infertility associated with female sperm antibodies as the cervical mucus is the main source of such antibodies.

In-vitro fertilisation with sperm from men with oligospermia or abnormal morphology may be undertaken with ICSI (intracytoplasmic sperm injection). Testicular sperm extraction (TESE)/ICSI currently represents the treatment of choice for male infertility resulting from non-obstructive azoospermia (3)

• testicular sperm retrieval is a feasible and successful procedure
  • among surgical techniques testicular sperm extraction (TESE) and microsurgical epididymal sperm aspiration (MESA) have become the most popular techniques
  • testicular spermatozoa can be retrieved from the testis in up to 70% of patients, even in cases with testicular azoospermia and severe disorders of spermatogenesis. However, surgical damage of the testis might also compromise the interstitial compartment of the testis with testosterone deficiency as a consequence

Artificial insemination with donor sperm may be considered if the patients with azoospermia where TESE is not possible.

NICE suggest that (2):

• with respect to tight underwear
  • men, and trans women and non-binary people with male reproductive organs should be informed that there is an association between elevated scrotal temperature and reduced semen quality, but that it is uncertain whether wearing loose-fitting underwear improves fertility
• Medical management:
  • men, and trans women and non-binary people with male reproductive organs with hypogonadotrophic hypogonadism should be offered gonadotrophin drugs because these are effective in improving fertility
  • consider gonadotrophin or anti-oestrogen therapy for men, and trans women and non-binary people with male reproductive organs who have impaired semen parameters and no hypogonadotropic hypogonadism as part of a clinical trial
  • do not offer androgens to treat semen abnormalities
  • do not offer supplements, antioxidants or medical treatments to improve sperm DNA integrity (fragmentation)
• Surgical management (male factor infertility)
  • men, and trans women and non-binary people with male reproductive organs should be offered surgical correction or surgical sperm retrieval to treat obstructive
    azoospermia
    • when deciding which treatment to offer, take into account the following factors:
      • female fertility factors (for example, age, ovarian reserve, tubal patency and ovulatory status)
      • the obstructive interval if known
      • the risks and benefits of the surgical intervention
      • the person's preference
    • surgical sperm retrieval to manage non-obstructive azoospermia
  • do not offer surgical sperm retrieval in the presence of Y chromosome AZF a or b microdeletion
  • do not offer surgical sperm retrieval as a way to improve outcomes for men, and trans women and non-binary people with male reproductive organs who have non-azoospermia and reduced sperm DNA integrity (elevated fragmentation levels)
  • with respect to the presence of a varicocele
    • consider radiological or surgical treatment (taking into account female fertility factors) for men, and trans women and non-binary people with male reproductive organs who have varicocele detected on clinical examination, and who:
      • are trying to conceive spontaneously, and
      • have reduced semen parameters
• Management of ejaculatory failure
  • for men, and trans women and non-binary people with male reproductive organs who have ejaculatory failure, identify the cause to determine the most appropriate and least invasive method of managing the issue

Reference:

1. Evers JH, Collins J, Clarke J.Surgery or embolisation for varicoceles in subfertile men. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD000479
2. NICE. Fertility problems: assessment and treatment. Clinical guideline CG156. Published February 2013, last updated March 2026.
3. Pantke P et al. Testicular Sperm Retrieval in Azoospermic Menimage European Urology Supplements2008; 7 (12):703-714.