Quick summary: Male factors contribute to roughly 40–50% of infertility cases, yet men are consistently the last to be investigated in clinical settings, with assessment often deferred until after extensive female-focused treatment has already begun. Standard semen analysis remains the default diagnostic tool despite growing evidence that sperm DNA fragmentation, oxidative stress, and hormonal irregularities can affect outcomes without appearing in routine results. A more balanced approach, one that introduces male assessment early, expands diagnostic options, and addresses the psychological burden men carry, would improve both clinical efficiency and patient well-being.
Fertility has long been framed as a women’s issue. Clinical pathways, public health campaigns, and even everyday conversations tend to centre on ovulation cycles, ovarian reserve, and maternal age. These are legitimate concerns, but they tell only half the story. Male factors contribute to roughly 40–50% of infertility cases, yet men are frequently the last to be investigated.
This imbalance is not simply a clinical oversight. It reflects deeper structural and cultural assumptions that have shaped reproductive healthcare for decades, and it has real consequences for couples trying to conceive.
The investigation gap
When a couple first seeks help with fertility, the focus almost invariably falls on the woman. Hormonal panels, ultrasounds, and ovulation tracking are initiated promptly, while male assessment is often deferred or limited to a basic semen analysis much later in the process.
From an evidence-based standpoint, this is difficult to justify. Both partners form part of the same biological system. Investigating one thoroughly while delaying assessment of the other introduces unnecessary delays and can result in misdirected treatment. Couples may spend months, sometimes years, pursuing interventions that address only part of the problem.
Earlier, parallel assessment of both partners would provide a clearer diagnostic picture from the outset and reduce the time spent ruling out causes that could have been identified sooner.
Semen analysis is not enough
Semen analysis remains the standard entry point for male fertility assessment. It measures sperm count, motility, and morphology, and it is a useful starting point. But reproductive science has moved on, and a single routine test does not capture everything that matters.
Sperm DNA fragmentation, oxidative stress levels, and subtle hormonal irregularities can all affect fertility outcomes and are not visible in a standard semen report. Men with apparently normal results may still face significant fertility challenges, while those with borderline results may respond well to targeted interventions if the underlying cause is identified.
Without access to more comprehensive diagnostics, clinicians and patients are working with incomplete information. Couples may go through multiple cycles of IVF or ICSI without a clear explanation for failure, when earlier or more thorough male investigation might have pointed to a treatable issue.
Why men disengage
Clinical pathways do not operate in a vacuum. Cultural attitudes shape who seeks help, when they seek it, and how they respond to findings.
Male fertility remains a topic that many men find difficult to discuss. Stigma, embarrassment, and the assumption that fertility problems are more likely to affect women all contribute to delayed engagement. Some men avoid testing altogether until a partner has already undergone extensive investigation.
This reluctance is understandable given the cultural context, but it is costly. Time matters in fertility, particularly for couples where age is a factor on either side. Normalising male fertility testing and framing it as a routine part of reproductive healthcare rather than a last resort would make meaningful inroads here.
The psychological weight
Fertility challenges carry a significant psychological burden for men, even when that burden goes largely unacknowledged. Anxiety, diminished self-worth, and a sense of isolation are common responses, yet men are far less likely than women to be offered emotional support within fertility care settings.
A more integrated model of care, one that addresses both the physical and psychological dimensions of male fertility, would better serve patients. Mental and physical health are not separate concerns in this context. Stress itself can affect hormonal balance and sperm quality, which means that overlooking the psychological side can have clinical consequences too.
What needs to change
The changes required are not radical. They are practical and overdue.
Male fertility assessment should be introduced early in the clinical pathway, ideally at the same point that female investigations begin. Diagnostic options beyond routine semen analysis should be available where clinically indicated. And the cultural framing of fertility as a predominantly female concern needs to shift, in public health messaging, in clinical practice, and in broader social conversation.
Reproductive healthcare cannot claim to be evidence-based if it consistently investigates only one half of the equation. Treating male fertility as a routine part of the process, rather than an afterthought, is not simply fairer. It is more effective medicine.
Tharb Faisl is the founder of Marylebone Diagnostic Centre, a diagnostic centre specialising in fertility diagnostics and preventative healthcare, with a particular interest in male fertility and evidence-based clinical pathways.
