Male factors play a part in about half of couples who struggle to conceive, yet the man is often not assessed until late. A pharmacy can make sure he is thought of from the start, and the clinic can investigate in parallel with his partner.
In the pharmacy
Spot the opportunity
When a woman asks about fertility, ovulation tests or folic acid, ask about her partner too: men are often left out. A man may also ask directly about fertility, low energy, or supplements for sperm health.
Ask a few questions
- How long have they been trying, and how often do they have sex? (Every 2 to 3 days gives the best chance.)
- Does he use anabolic steroids, testosterone or bodybuilding products? These switch off sperm production.
- Does he smoke, drink heavily or use cannabis?
- Any erection or ejaculation problems, or past testicular problems?
Counsel and recommend
- Stop smoking, cut down alcohol and avoid recreational drugs.
- Stop anabolic steroids and testosterone, and see a prescriber for support.
- Keep the testes cool: avoid laptops on the lap, hot baths and tight underwear.
- Aim for a healthy weight and stay active.
- Coenzyme Q10. Oxidative stress damages sperm. In a placebo-controlled trial, coenzyme Q10 200 mg daily for 6 months raised CoQ10 and ubiquinol (its active form) in semen and sperm cells and improved sperm motility, with the best response in men who started with the lowest motility. Recommend daily use for at least three to six months, the time sperm take to develop.
Refer
- To a prescriber or laboratory for a semen analysis, if the couple has been trying for 12 months (6 months if she is 35 or over).
- To a prescriber promptly for a lump, swelling or pain in the testes, or erection or ejaculation problems.
In the clinic
History and examination
- Previous children, mumps after puberty, undescended testes, testicular injury or surgery, sexually transmitted infections.
- Medicines and substances: anabolic steroids, testosterone, sulfasalazine, some chemotherapy, long-term opioids, cannabis, alcohol and smoking.
- Examine for testicular size, lumps and varicocele (a soft swelling above the testis).
Semen analysis
Ask for a sample after 2 to 7 days without ejaculation. The WHO 2021 lower reference limits are:
| Measure | Lower reference limit |
|---|---|
| Volume | 1.4 mL |
| Sperm concentration | 16 million per mL |
| Total sperm number | 39 million per ejaculate |
| Total motility | 42% |
| Progressive motility | 30% |
| Normal forms (shape) | 4% |
These limits describe the lowest 5% of results in fertile men, so they are a guide rather than a strict cut-off. If a result is abnormal, repeat the test, ideally after about three months, or sooner if the result is very poor.
Treat and support
- Address lifestyle factors and stop medicines or substances that impair sperm where possible.
- Antioxidant support such as coenzyme Q10 for at least three to six months, as above. A Cochrane review of antioxidants also found higher pregnancy rates, although the evidence is of low certainty.
- Investigate and treat the female partner in parallel.
Refer to a urologist or fertility specialist
- Two abnormal semen analyses, or one with no sperm or very few sperm.
- A testicular lump, swelling or pain, or a significant varicocele.
- Erection or ejaculation problems not responding to first-line treatment.
- The couple has been trying for 12 months (6 months if she is 35 or over, as the American Society for Reproductive Medicine advises).
Key references
- World Health Organization. WHO laboratory manual for the examination and processing of human semen. 6th edition, 2021.
- Balercia G, et al. Coenzyme Q10 treatment in infertile men with idiopathic asthenozoospermia: a placebo-controlled, double-blind randomized trial. Fertil Steril 2009;91(5):1785-1792.
- de Ligny W, et al. Antioxidants for male subfertility. Cochrane Database Syst Rev 2022;5:CD007411.
- National Institute for Health and Care Excellence (NICE). Fertility problems: assessment and treatment (CG156).
Prepared by the Draxer Clinical Advisory Department for health professionals. It supports, and does not replace, clinical judgement and national guidelines.