Why male fertility deserves better: The evidence for individualised care

When infertility is discussed, the focus tends to default to female biology. Yet the evidence shows that a male factor contributes to approximately half of all cases of infertility.

A 2017 meta-analysis reviewed data from 185 studies spanning four decades. The findings showed that sperm concentration among men from Western countries fell by 52.4 percent between 1973 and 2011, with total sperm count declining by 59.3 percent over the same period. A subsequent analysis by the same group, published in 2023, found that this trajectory has continued and has now extended to non-Western populations, suggesting a global decline.

The causes are likely multifactorial and not fully understood. Environmental exposures to endocrine-disrupting chemicals, rising rates of obesity, heat stress, and psychosocial stress have each been implicated. What is clear is that sperm quality is not a fixed biological constant; it is modifiable, and it is measurable.

A Mediterranean diet has been shown to be positively associated with improvements in sperm motility and morphology. Weight loss in overweight and obese men has been shown to have a positive effect on sperm concentration and total motile sperm. Similarly, physical activity has been associated with improved semen parameters, while sedentary behaviour and smoking have the opposite effect.

The Human Fertilisation and Embryology Authority (HFEA) reports that male factor infertility accounts for around 37 percent of cases where a cause is identified, and is a contributing factor in a further proportion of 'unexplained' cases. Despite this, men are frequently the last to be tested, often only after a female partner has undergone more invasive investigation.

Research consistently finds that men are less likely to visit their GP, less likely to present early with symptoms, and more likely to minimise or dismiss health concerns. In the UK, men account for approximately three in every four suicide deaths, a figure that has remained consistent across years of ONS data. Men cannot, or choose not to, engage with traditional healthcare services.

Research on men, masculinity, and help-seeking identified several factors: self-reliance norms, stigma associated with perceived weakness, and a lack of health literacy around male-specific conditions. Fertility sits within this dynamic. For many men, seeking a semen analysis requires first acknowledging that there may be a problem, knowing that it can be objectively measured, and understanding how to access a test in the first place.

The consequence is delayed diagnosis, delayed treatment, and, for some couples, missed windows for intervention. A man who might have benefited from lifestyle-based improvements to sperm quality or earlier referral to fertility services may never have had the opportunity simply because the pathway to testing was too inconvenient, too embarrassing, or too unfamiliar.

There is clinical evidence for why fertility results should be delivered within a supported consultation rather than sent as a raw data report.

A diagnosis of male factor infertility is potentially a very serious diagnosis. Research documents that men who receive such a diagnosis frequently report feelings of shame, diminished masculine identity, anxiety, and a sense of personal failure, even though the clinical reality is that semen parameters exist on a spectrum and are often amenable to intervention.

These responses are not irrational; they are a predictable consequence of receiving significant health information without context or support. The risk of such a diagnosis is elevated in the consumer health world, where the control and quality of at-home diagnostics can easily fall behind clinical standards.

This, combined with the nuance of interpreting a biological result as variable as semen analysis, presents a real potential for misinterpretation and perpetuation of inappropriate, poorly tailored advice. Personal context, combined with a deep understanding of the diagnostic test taken, is critical for delivering responsible, valuable and safe clinical advice and support, and ultimately for ensuring men are appropriately supported whatever their result.

A comprehensive review of psychological and social aspects of infertility in men found that men with male factor infertility are at a higher risk of depression and anxiety, and this is often impacted by a lack of appropriate psychosocial support within clinical pathways. Men in this situation are less likely than women to seek emotional support, making the consultation itself a rare and important opportunity to offer it.

The National Institute for Health and Care Excellence (NICE) Fertility Guideline recommends that people being investigated for fertility problems should be given information at every stage and should have access to counselling from healthcare professionals with the appropriate training, not as an optional add-on, but as part of standard care. Results, delivered by a clinician who can explain what the findings mean, what they do not mean, and what options exist, produce better outcomes than a dataset with numbers and percentages.

In practice, a consultation following semen analysis can ensure that an abnormal result is discussed appropriately. It provides space for questions, allows clinicians to identify men who may benefit from further investigation or referral, and creates an opportunity to address psychological aspects alongside clinical ones. For men who are already reluctant to engage with healthcare, receiving a confusing or concerning result without guidance is more likely to result in disengagement than further investigation.

Video consultation, in particular, has demonstrated strong acceptability in men's health contexts because it removes the need to present in a clinical environment that many men find inhibiting. The combination of at-home sample collection and remote specialist consultation is not a compromise on clinical care. For many men, it may be the only model that actually reaches them.

Digital health has transformed access to healthcare in a number of areas such as remote consultations, at-home diagnostic testing, and personalised health tracking. All have demonstrated meaningful improvements in health engagement, particularly among populations who are traditionally underserved or who disengage from conventional clinical environments.

At-home sample collection, when combined with rigorous clinical analysis, has been validated as a reliable pathway for diagnostic testing in reproductive health contexts, provided that temperature-controlled logistics and standardised collection protocols are maintained.

Male fertility assessment is currently positioned as a last resort and something that men do when a problem is already apparent. We believe it should be positioned as a first step: a proactive, informed decision to understand where you stand.

This matters for individual men and couples navigating fertility journeys. It also matters at a population level. If declining sperm counts represent a genuine and continuing trend, as the evidence suggests, then earlier and wider engagement with male reproductive health is a public health priority.

Individualised care, where a man receives not just a result but a clear explanation, a clinical interpretation, and practical guidance on next steps, is central to this. The NICE Fertility Guideline recommends that both partners are investigated simultaneously when a couple has been trying to conceive for 12 months or more. In practice, this rarely happens in the right sequence.

We are also aware that this work does not exist in isolation. Male fertility is bound up with male health more broadly, with hormonal health, metabolic health, and psychological wellbeing. A man who learns that his sperm parameters are below the WHO reference values needs context, information, and a clear path forward. That is what evidence-based, individualised patient care can provide.

The science documenting declining sperm quality is growing, and the barriers to male health engagement are well documented. The psychological risks of unsupported results disclosure are recognised in clinical guidance. And the technology to deliver accessible, clinically rigorous testing with supported consultation now exists. What has been missing is a coherent effort to bring these elements together, and at Malebox Health, we are attempting to do that.