Male Infertility: Testing & Treatment | Dr. Theodore Cisu

The short answer: Male factors play a role in about half of couples who have trouble getting pregnant. A male fertility evaluation starts with a reproductive history, a physical exam and a semen analysis, with hormone and genetic tests when needed. Many causes can be treated, including a varicocele, hormone problems and testosterone use. When a couple needs IVF or other assisted reproduction, a urologist works alongside the fertility specialist.

Written by Theodore Cisu, MD, board-certified urologist. Based on the American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM) guideline on the diagnosis and treatment of infertility in men (2020, amended 2024). Last reviewed November 2026.

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What is male infertility?

Infertility usually means a couple hasn't conceived after a year of regular sex without birth control. An evaluation is often recommended after six months if the female partner is 35 or older. You don't need to wait if there's a known concern, such as a past undescended testicle, cancer treatment, a vasectomy or testosterone use.

The AUA/ASRM guideline recommends evaluating both partners at the same time. Checking the male partner early can save time and sometimes points to a simple fix.

What causes male infertility?

• Varicocele. Enlarged veins in the scrotum, similar to varicose veins in the legs.
• Hormone problems. Low signals from the pituitary gland, high prolactin or other imbalances.
• Testosterone or anabolic steroid use. These can shut down sperm production.
• Blockages. A past vasectomy, infection, a missing vas deferens or a blocked ejaculatory duct.
• Genetic conditions. Such as Klinefelter syndrome or small missing pieces of the Y chromosome.
• Past conditions or treatments. Undescended testicles, testicle injury, chemotherapy or radiation.
• Ejaculation or erection problems.
• Lifestyle factors. Smoking, heavy drinking, extra weight and some medicines.

In many men, no single cause is found.

How is male infertility evaluated?

Reproductive history and exam

Your urologist will ask how long you've been trying, about past pregnancies, childhood conditions, surgeries, medicines, supplements and any testosterone use. The exam checks the size of the testicles, whether the vas deferens is present, and whether a varicocele can be felt.

Semen analysis

A semen analysis measures the volume of semen, the number of sperm, how well they move and their shape. Results can vary a lot from one sample to the next, so a second analysis is often done if the first is abnormal. You will usually be asked to avoid ejaculation for a few days before the sample. The 2024 amendment updated the reference values used to read these results.

Hormone tests

The guideline recommends testing hormones, including FSH and testosterone, in men with low sperm counts, sexual problems or signs of a hormone issue. Other hormones are added as needed.

Genetic tests

For men with no sperm or very low sperm counts, the guideline recommends a chromosome test (karyotype) and a test for missing pieces of the Y chromosome. The 2024 amendment updated when these tests are advised. Men born without a vas deferens are offered testing for cystic fibrosis gene changes, and their partners may be tested too.

Imaging, when needed

A scrotal ultrasound isn't routine. It's used when the exam is difficult or something unusual is felt. The 2024 amendment added pelvic MRI as an option when a blocked ejaculatory duct is suspected.

A check on your overall health

The guideline notes that men with infertility may have a higher risk of other health problems, including testicular cancer. A fertility evaluation is a good chance to look at your general health too.

Varicocele and fertility

A varicocele is common, and many men with one father children without trouble. The AUA/ASRM guideline says repair should be considered for men trying to conceive who have a varicocele that can be felt on exam and abnormal semen results. Repair isn't recommended for varicoceles seen only on ultrasound, or for men with normal semen results.

A varicocele can be repaired with microsurgery through a small incision, or closed off from inside the vein by an interventional radiologist. Sperm take about three months to develop, so changes in semen results take time to show.

Testosterone and fertility

This is one of the most important points in male fertility. Testosterone shots, gels, pellets and anabolic steroids send a signal to the brain to stop making LH and FSH. Without those signals, the testicles slow or stop making sperm. Counts can fall to zero.

• The guideline advises against testosterone therapy for men who want children now or in the near future.
• Sperm production often returns after stopping, but it can take many months, and recovery isn't guaranteed.
• For men with low testosterone who want children, medicines such as clomiphene, hCG or aromatase inhibitors can raise your own testosterone while supporting sperm production. Some are used off-label.

If you are on testosterone now and hope to conceive, talk with a urologist before you stop. A planned transition can help your body restart sperm production.

Treatment options

Healthy habits and a medication review

Quitting smoking, limiting alcohol, reaching a healthy weight and reviewing medicines and supplements are good first steps. The guideline notes the benefit of antioxidant supplements on pregnancy rates is uncertain.

Hormone treatment

When hormone problems are found, medicines such as clomiphene, hCG or aromatase inhibitors may improve sperm production.

Varicocele repair

For the right candidates, as described above.

Fixing a blockage

Vasectomy reversal or surgery for a blocked ejaculatory duct can restore sperm in the semen for some men. Your urologist can discuss these, and Dr. Cisu can coordinate referral to a male fertility microsurgeon when appropriate.

Sperm retrieval

Men with no sperm in the semen may still have sperm in the testicles. Surgical sperm retrieval can collect it for use with IVF. The 2024 amendment also allows testicular sperm in some men who do have sperm in the semen but have high levels of sperm DNA damage.

Sperm banking before cancer treatment

Chemotherapy, radiation and some surgeries can harm fertility. The guideline recommends discussing sperm banking before treatment begins.

Working with your fertility specialist

Treatments such as intrauterine insemination (IUI) and IVF, including injecting a single sperm into an egg (ICSI), are done by a reproductive endocrinologist at a fertility center. Dr. Cisu does not perform IVF. His role is the male side of care: finding and treating male factors, protecting sperm production, and sharing results and timing with your fertility team so you get one coordinated plan.

When to see a urologist

• No pregnancy after a year of trying, or six months if the female partner is 35 or older
• An abnormal semen analysis
• You use or have used testosterone or anabolic steroids
• A past vasectomy, undescended testicle, cancer treatment or testicle injury
• A lump, swelling or heaviness in the scrotum

Seeing Dr. Cisu for male infertility

Dr. Theodore Cisu evaluates male infertility at his clinics in Charlottesville and Fishersville. You can start with a telehealth visit from anywhere in Virginia. Our office can request semen analyses, lab work and records from your fertility clinic so Dr. Cisu reviews them first. Second opinions are welcome, and no referral is needed. Book a visit.

Frequently asked questions

How long should we try before getting checked?

Usually a year, or six months if the female partner is 35 or older. Come in sooner if either partner has a known fertility concern.

Is one semen analysis enough?

A normal result is reassuring, but results vary from sample to sample. If the first one is abnormal, a repeat test is often recommended.

Can a varicocele cause infertility?

It can lower sperm count and quality in some men. Repair is considered when the varicocele can be felt on exam and semen results are abnormal.

Does testosterone therapy cause infertility?

It can. Outside testosterone lowers sperm production, sometimes to zero. Men who want children have other options for treating low testosterone.

Can I have children after a vasectomy?

Yes, in many cases. Options include vasectomy reversal or sperm retrieval combined with IVF. Learn more about vasectomy.

Do male fertility supplements work?

The evidence is mixed. The AUA/ASRM guideline says the benefit of antioxidants on pregnancy rates is uncertain. A full evaluation is a better place to start.

Does Dr. Cisu perform IVF?

No. IVF is done by fertility specialists. Dr. Cisu evaluates and treats the male partner and coordinates with your fertility team.

Sources

• American Urological Association and American Society for Reproductive Medicine. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline (2020, amended 2024).
• American Urological Association. AUA releases male infertility guideline amendment (August 2024).

This article is for general education and isn't a substitute for medical advice. Don't stop a prescribed medicine, including testosterone, without talking with your doctor.