Introduction
Low Sperm Count in Men is usually defined as the inability of a couple to conceive even after 1 year of unprotected, frequent sexual intercourse. The male is solely responsible in about 20% of cases and is a contributing factor in another 30% to 40% of all Low Sperm Count in Men cases. As male and female causes often co-exist, it is essential that both partners are investigated for Low Sperm Count in Men and managed together. Overall, the male factor substantially contributes to about 50% of all cases of Low Sperm Count in Men.
The initial evaluation includes a detailed sexual history and physical examination, together with 2 separate semen analyses. Hormonal testing and an optional scrotal ultrasound can then be performed if abnormalities are found. This is usually sufficient to make an initial determination of the nature and severity of the underlying problem. For a deeper comparison of health-related conditions, you can also explore resources like Migraine vs Headache Differences and PCOD vs PCOS Differences.
The key purpose for evaluating a male for Low Sperm Count in Men is to identify the contributing factors, offer treatment for those that are reversible, determine if the patient is a candidate for assisted reproductive techniques, and offer counseling for irreversible and untreatable conditions.
This activity highlights the etiology and epidemiology of male Low Sperm Count in Men. The course also reviews the evaluation and management of male Low Sperm Count in Men as well as the role of the interprofessional team in evaluating and treating patients with this condition. For more details on clinical approaches, visit the Mayo Clinic’s guide to diagnosis and treatment of low sperm count.
Etiology
There are multiple causes for male Low Sperm Count in Men, which can be broadly classified due to their general underlying etiology. These include endocrine disorders (usually due to hypogonadism) estimated at 2% to 5% of cases, sperm transport disorders (such as vasectomy) at 5%, primary testicular defects (which include abnormal sperm parameters without any identifiable cause) at 65% to 80%, and idiopathic (where an infertile male has normal sperm and semen parameters) at 10% to 20%.
These are broad estimates only, as accurate statistics are unavailable due to general underreporting, cultural factors, and regional variations. Patients sent to a tertiary referral center are more likely to have their condition reported, while private patients may never have their data collected. A partial summary of specific etiologies is listed below as follows:
Acquired Urogenital Abnormalities
Bilateral obstruction or ligation of the vas deferens, bilateral orchiectomy, epididymitis, TURP, varicoceles, and retrograde ejaculation.
Congenital Urogenital Abnormalities
Absent, dysfunctional, or obstructed epididymis, congenital abnormalities of the vas deferens, undescended testes, and ejaculatory duct disorders (cysts).
Endocrinological Causes
Congenital GnRH Deficiency (Kallmann syndrome), Prader-Willi syndrome, Laurence-Moon-Beidl syndrome, iron overload syndrome, familial cerebellar ataxia, head trauma, intracranial radiation, testosterone supplementation, and hyperthyroidism.
Environmental Toxins
Insecticides, fungicides, pesticides, smoking, excess alcohol, Agent Orange, and other chemical exposures.
Genetic Causes
Mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene, primary ciliary dyskinesia, Kallmann syndrome, Klinefelter syndrome, Young syndrome, Sertoli cell-only syndrome, Kal-1, Kal-2, FSH, LH, FGFS, GnRH1/GNRHR PROK2/PROK2R gene deficiencies, chromosomal anomalies, Y chromosome microdeletion, AR mutations, and gr/gr deletion.
Idiopathic Causes
Idiopathic male Low Sperm Count in Men (10% to 20%) where semen parameters are all normal, but the male remains infertile.
Immunological Causes
Lymphocytic hypophysitis, hemosiderosis, hemochromatosis, sarcoidosis, histiocytosis, tuberculosis, and fungal infections.
Malignancies
Sellar masses, pituitary macroadenomas, craniopharyngiomas, and surgical or radiation treatment for these conditions, testicular tumors, and adrenal tumors leading to an excess of androgens.
Medications or Drugs
Cannabinoids, opioids, psychotropic drugs that can cause inhibition of GnRH, exogenous testosterone or androgenic steroids supplementation, GnRH analogs and antagonists used in prostatic carcinoma, chronic glucocorticoid therapy, alkylating agents, antiandrogens, ketoconazole, cimetidine, and alpha-blocker medications for BPH.
A complete list of potentially toxic drugs can be found at PFCLA’s comprehensive guide on low sperm count treatment.
Sexual Dysfunction
Premature ejaculation, anejaculation, infrequent sexual intercourse, and erectile dysfunction.
Urogenital Tract Infections
Gonococci, chlamydia, syphilis, tuberculosis, recurrent urogenital infections, prostatitis, and recurrent prostatovesiculitis.
Medical Intervention Classification of Male Low Sperm Count in Men
- Treatable causes (18% of cases): Obstructive azoospermia, ejaculatory duct and prostatic midline cysts, gonadotropin deficiency, sexual function disorders, sperm autoimmunity, varicoceles, and reversible effects of toxins.
- Uncorrectable causes (70% of cases): Oligozoospermia, asthenozoospermia, teratozoospermia, and normospermia with functional defects. Assisted reproductive technology (ART) will generally be necessary for reproduction.
- Untreatable causes (12% of cases): Primary seminiferous tubular failure, Sertoli cell-only syndrome, and bilateral orchiectomy.
Epidemiology
The prevalence of Low Sperm Count in Men is variable, and epidemiologically, male Low Sperm Count in Men has been documented less in developing countries. The burden of Low Sperm Count in Men is generally worse in the developing world due to constrained medical resources and the high cost of treatment, as well as cultural fears, taboos, and stigmas. It is much more challenging to identify and manage Low Sperm Count in Men in areas where medical resources for basic health care are already strained.
Globally, Low Sperm Count in Men affects approximately 13% to 15% of all couples, while 1 in 5 couples is unable to achieve pregnancy in the first year of trying.
About 50% of young, healthy couples in the U.S. who could not create a pregnancy during their first year of unprotected sexual intercourse will successfully conceive during the subsequent 12 months, even without any specific treatment. With the first child, 1 in 6 couples encounter some fertility problems, and with a subsequent child, 1 in 6 couples still has issues. In 20% to 30% of Low Sperm Count in Men cases, males can be solely responsible, with an overall contribution to Low Sperm Count in Men in couples of about 50%.
Pathophysiology
Male Low Sperm Count in Men can also be classified as follows:
Pre-testicular Causes
These include hypogonadotropic hypogonadism, erectile dysfunction, or coital disorders such as retrograde ejaculation, anejaculation, genetic factors, and chromosomal abnormalities.
Testicular Disorders
These include testicular tumors, orchiectomy, primitive testicular dysfunction, cryptorchidism, and atrophic testes. Varicoceles are associated with male Low Sperm Count in Men, most likely through impairment of testicular thermoregulation due to disruption of the pampiniform venous plexus heat regulation mechanism. Epididymal dysfunction can be caused by fetal intrauterine exposure to estrogens, various drugs and chemical toxins, epididymal cysts, spermatoceles with or without surgery, epididymitis, or may be idiopathic.
Post-testicular Etiologies
These include lesions of the seminal tract, inflammatory diseases, congenital absence of the vas deferens, post-vasectomy, erectile dysfunction, premature ejaculation, and the use of a condom or diaphragm. This category would also include bladder neck surgery, post-TURP surgery, retroperitoneal lymph node dissection, rectal surgery, multiple sclerosis, and alpha antagonist medications such as tamsulosin.
Any medication, tumor, disease, or disorder that affects the pituitary gland or hypothalamus can potentially cause male Low Sperm Count in Men by altering gonadotropic releasing hormone or causing gonadotropin deficiency such as idiopathic hypogonadotropic hypogonadism (IHH), Kallmann syndrome (IHH with anosmia), and combined pituitary hormone deficiency. Pituitary neoplasms such as sellar tumors, macroadenomas, and prolactinomas will also result in male Low Sperm Count in Men due to alterations in gonadotropin production as well as various genetic causes such as Prader-Willi, Young, and Laurence-Moon-Biedl syndromes.
Various acquired disorders, such as primary androgen overproduction and exogenous testosterone supplementation, will also directly decrease gonadotropic secretion, causing reduced sperm counts and Low Sperm Count in Men. A few special cases will be discussed below.
Special Cases of Male Low Sperm Count in Men
Cryptorchidism
Men with a history of undescended testicles tend to have lower fertility than men without that history, even if the cryptorchid testicle was surgically repaired at an early age. This is thought to be due to an inherent testicular defect. Men with cryptorchid testicles will typically have poorer quality sperm (lower motility, high abnormal morphology) and lower sperm counts. Interestingly, testosterone levels and Leydig cell performance are usually not affected despite the disruption in sperm counts and Sertoli cell function.
The longer the testicle remains undescended, the greater the risk to future fertility. For this reason, surgical repair of an undescended testicle is now recommended before age 1. Starting even before 1 year of age, the germ cell density of the cryptorchid testicle starts to decrease. There is generally no spermatogenesis at all in untreated abdominal testes after puberty. The risk of Low Sperm Count in Men increases as the distance from the normal anatomical testicular location lengthens.
The disruption of spermatogenesis in undescended testes is related to the underlying hormonal, developmental, and genetic abnormalities associated with cryptorchidism. Some of these may be reversible with early surgical intervention. Adult sperm counts seem to be related to the existing and functioning germ cells at the time of orchidopexy. The risk of Low Sperm Count in Men is increased in cases of bilateral cryptorchidism, abdominal testicles, and delayed orchidopexy.
Klinefelter Syndrome
This is a genetic mutation where the male has XXY instead of the usual XY chromosomes. Patients are typically affected by Low Sperm Count in Men with hypogonadism. There is a spectrum of symptoms, but the most typical are bilateral atrophic or hypertrophic testes, reduced muscle mass, scant body and facial hair, and gynecomastia. Often, the diagnosis is not made until adulthood, and Low Sperm Count in Men with azoospermia or severe oligozoospermia is a common presenting symptom.
Low Sperm Count in Men treatment usually consists of adoption, use of donor sperm, or possibly sperm harvesting with microscopic testicular sperm extraction together with IVF and ICSI. Even in Klinefelter patients with clinical testicular atrophy, modern ART now offers a 40% to 60% rate of successful sperm recovery, with 60% resulting in a pregnancy. Aside from fertility concerns, the usual treatment of Klinefelter syndrome in adults is full testosterone replacement therapy.
Prolactinoma
Prolactin levels in men usually are quite low. When elevated, they suggest a possible prolactin-secreting pituitary tumor. Such tumors may cause Low Sperm Count in Men, hypogonadism (low testosterone), gynecomastia, galactorrhea, and possibly a reduction of the peripheral visual fields due to compression of the optic chiasm.
Dopamine agonists, such as cabergoline and bromocriptine, are generally used as medical therapy to suppress prolactin secretion, and many men will then normalize their testosterone levels and sperm counts. Surgical treatment with a trans-sphenoidal resection of the prolactinoma is successful in 80% to 90% of cases, but the tumors often recur. Surgery is usually reserved for patients with visual field loss and for those where medical therapy is unsuccessful or not well tolerated.
Testosterone Supplementation
Anabolic steroid abuse and testosterone supplementation therapy are growing worldwide. At least 25% or more of physicians who prescribe testosterone to patients are unaware that it will cause significant, possibly long-term Low Sperm Count in Men problems in their patients. Patients are often not informed of this likely complication.
Exogenous androgen causes Low Sperm Count in Men by suppressing FSH and LH production by the pituitary. The loss of FSH and LH shuts down endogenous intratesticular testosterone production and spermatogenesis. It only takes about 3.5 months for testosterone therapy to inhibit spermatogenesis.
Testosterone supplementation has no role in male Low Sperm Count in Men patients trying to conceive. Patients who need testosterone supplementation can preserve their fertility by taking clomiphene, which helps maintain FSH and LH levels.
Most patients who become affected by Low Sperm Count in Men on testosterone therapy will eventually regain their sperm counts and fertility, but it will take time, and there are no guarantees. The best available data indicate that two-thirds of testosterone-treated men can expect the recovery of sperm production in 6 months, 90% after 1 year, and almost 100% after 2 years.
Viral Mumps Orchitis
Mumps and several similar viruses constitute the most common cause of acquired testicular failure, and their incidence is increasing. This is probably due to a reduction in the usage of the MMR vaccine in children during the early 1990s.
About one-quarter of the adults who get mumps will develop orchitis. Of these, one-third will have bilateral disease. The infection may cause damage directly to the seminiferous tubules or indirectly from compressive ischemia caused by severe intratesticular swelling while being restricted by the very tough tunica albuginea.
Testicular atrophy may occur from 1 to 6 months after the infection, and some shrinkage will be apparent in about half of all men with mumps orchitis. The degree of testicular atrophy is unrelated to the severity of the infection or the ultimate degree of possible Low Sperm Count in Men. One-quarter of the adult patients with unilateral mumps orchitis will develop Low Sperm Count in Men, as well as two-thirds with bilateral disease.
History and Physical
The purpose of evaluating the male partner of a couple suffering from Low Sperm Count in Men is as follows:
- To determine if the male factor is contributing to the couple’s Low Sperm Count in Men issue
- To identify the small percentage of cases (about 20%) that can be normalized with treatment
- To determine if ART would ultimately benefit the couple
- To identify significant underlying pathology or associated medical comorbidities
- To determine if there are age, health, lifestyle, or genetic factors that could affect the outcome or success rate if ART is required
While an initial evaluation such as a history and physical can be performed by primary care clinicians and an initial semen analysis ordered, it is generally recommended that all men with Low Sperm Count in Men have an evaluation performed by a male reproductive specialist, especially if any abnormalities are found, as the workup and treatment are complex. Patients who have previously been on testosterone supplementation should also be referred directly to a specialist in male reproduction.
Key Aspects of History Taking
The evaluation starts with a complete and comprehensive sexual and medical history, including reproductive history, family history, history of significant trauma to the pelvis, testicles or head, sexual performance, libido, occupation, systemic diseases, intake of alcohol, smoking, recreational drugs, medications, steroid abuse, previous chemo/radiotherapy, pubertal development, testicular descent, surgical history involving the scrotum and inguinal regions, exposure to toxic chemicals such as pesticides, loss of body hair, shaving frequency, sexually transmitted infections (STIs), tuberculosis, mumps, scrotal infections such as epididymitis, prior biological children produced, maternal exposure to DES, anosmia, breast enlargement and galactorrhea, and precocious puberty.
Physical Examination
- Assess body form, signs of endocrinopathy, gynecomastia, skin, hair distribution, and secondary sexual characteristics
- If muscular with low sperm count, check endocrine profile (testosterone, FSH, LH)
- Assess obesity effects on estrogen conversion and sperm count
- Examine penis for hypospadias, phimosis, and Peyronie plaques
- Measure testicular size: normal adult volume ≥15 ml and length ≥4 cm
Notable Clinical Findings
- Bilateral absence of the vas deferens (1%–2% of men with Low Sperm Count in Men, linked to CFTR mutations)
- Hydrocele presence (requires ultrasound for proper evaluation)
- Testosterone deficiency signs vary by life stage
- Varicoceles (15% of men, up to 40% with abnormal semen analysis; left-sided more common)
- Right-sided varicoceles (may indicate retroperitoneal pathology, but routine imaging no longer required unless large or non-reducible)
- Cushing disease signs: buffalo hump, moon face, thin skin, multiple bruises
- Iron overload signs: diffuse hyperpigmentation
In general, if a patient has azoospermia with bilateral atrophic testes, a good outcome from treatment may be possible only with IVF and ICSI.
Treatment of Low Sperm Count in Men
The treatment of Low Sperm Count in Men depends largely on its underlying cause. In many cases, lifestyle changes, medical treatments, or assisted reproductive techniques can significantly improve fertility outcomes.
Lifestyle and Natural Remedies
A healthy routine can have a positive effect on sperm quality. Eating a balanced diet, maintaining a healthy weight, and exercising regularly are all crucial steps. Stress management through yoga or meditation is also important, as high stress levels are often linked with reproductive challenges. Some factors, such as differences between migraine and headache, highlight how overall lifestyle and stress-related conditions can affect reproductive health.
Men are also advised to avoid smoking, alcohol, recreational drugs, and unnecessary exposure to heat or toxins, as these can worsen sperm quality.
Medical Treatments
When Low Sperm Count in Men is linked to medical conditions, treatment options may include:
- Hormonal therapy – Correcting imbalances that affect sperm production.
- Antibiotics – To treat infections in the reproductive system.
- Surgery – To repair varicocele (enlarged veins in the scrotum) or blocked vas deferens.
Certain hormonal and reproductive issues may overlap with conditions like PCOD vs PCOS differences, which also impact fertility in women.
Assisted Reproductive Techniques (ART)
For severe cases, advanced methods may help couples conceive:
- Intrauterine insemination (IUI) – Injecting healthy sperm directly into the uterus.
- In vitro fertilization (IVF) – Fertilizing eggs with sperm in a lab and transferring the embryo.
- Intracytoplasmic sperm injection (ICSI) – Injecting a single sperm directly into an egg.
When to Seek Help
If a couple is unable to conceive after one year of unprotected intercourse, consulting a fertility specialist is recommended. Doctors may suggest further testing and tailor treatment based on the cause and overall health of both partners.
For more professional insights, refer to the Mayo Clinic’s treatment guide on Low Sperm Count in Men which provides detailed, evidence-based solutions.
FAQs on Low Sperm Count in Men
Q 1. What is Low Sperm Count in Men?
Ans:-Low Sperm Count in Men refers to a condition where the semen contains fewer sperm than the normal range required for fertility. It is one of the leading causes of male infertility and affects nearly half of infertility cases in couples.
Q 2. What are the common causes of Low Sperm Count in Men?
Ans:-The causes of Low Sperm Count in Men include hormonal imbalances, genetic conditions, lifestyle factors (such as smoking, alcohol, or obesity), exposure to toxins, infections, and varicocele (enlarged veins in the scrotum).
Q 3. How is Low Sperm Count in Men diagnosed?
Ans:-Doctors usually recommend a detailed sexual history, physical examination, and semen analysis to diagnose Low Sperm Count in Men. Additional tests such as hormonal testing, scrotal ultrasound, or genetic testing may also be performed if needed.
Q 4. Can Low Sperm Count in Men be treated?
Ans:-Yes, treatment for Low Sperm Count in Men is available. Depending on the cause, options may include medications, surgery, hormonal therapy, lifestyle changes, or assisted reproductive techniques like IVF and ICSI.
Q 5. Does lifestyle affect Low Sperm Count in Men?
Ans:-Absolutely. Lifestyle factors such as poor diet, excessive stress, smoking, alcohol consumption, and lack of exercise can significantly impact sperm health. Improving these factors often helps in managing Low Sperm Count in Men naturally.
Q 6. When should I see a doctor for Low Sperm Count in Men?
Ans:- If you and your partner have been trying to conceive for more than 12 months without success, it’s important to consult a doctor. Early diagnosis of Low Sperm Count in Men improves the chances of successful treatment.
Conclusion
Low Sperm Count in Men is a complex but often manageable condition that requires comprehensive evaluation, tailored treatment, and lifestyle adjustments. Early diagnosis and intervention—whether through hormonal therapy, surgical correction, or assisted reproductive technologies—can significantly improve outcomes. It’s essential to view this condition in the context of overall health: hormonal imbalances, stress, and systemic illnesses all play a role.
For broader health insights that can influence fertility, explore topics such as PCOS explained: warning signs, mental health and stress resilience in Powerful Stress and Mental Wellness, and even underlying disease mechanisms in What is Cancer?. Each of these subjects intersects with hormonal, metabolic, and psychological health, all of which can influence sperm quality.
In sum: by addressing root causes, adopting healthy habits, and leveraging medical advances, many men with Low Sperm Count in Men can restore fertility or achieve parenthood through assisted methods.
