We stand at a peculiar crossroads in history of mankind. We’ve conquered diseases, prolonged lifespan, and edited the gene. Yet, a more subtle, insidious threat is emerging—one that challenges the essence of our biological imperative: male infertility. It’s a topic often drowned out by the noise of our fast-paced world. But the scientific data, as well as the personal stories of many of my patients, and those of millions of men and women around the world, are painting a disturbing picture.  Are we engineering our own extinction?

A few years ago, I saw JL, a 32-year-old software engineer who was struggling with infertility. His wife had already undergone extensive fertility testing, which was unremarkable. Except for being overweight, JL was generally healthy, led an active lifestyle, and had no obvious risk factors. When he came to my clinic, he had already undergone extensive hormone testing. The only notable abnormal results were his low testosterone level, and his semen analysis showed abnormally low sperm count and motility. This was perplexing for someone so young and health-conscious.

As I delved deeper into his history, I discovered that JL was an avid gym-goer and relied heavily on protein shakes and workout supplements to boost his fitness routine. Unbeknownst to him, many of these products contained hidden chemicals—unregulated and not listed on the labels. These compounds had disrupted his body’s natural hormone balance, suppressing his testosterone production and compromising his fertility.

With guidance, JL stopped all supplements and adopted a clean, whole-food diet. Over time, his natural testosterone levels rebounded, and his sperm parameters improved. It was a long road, but JL eventually regained his fertility.

This story is just one of many I’ve encountered over the years. Unexplained infertility, low testosterone, and abnormal semen analysis are increasingly common, underscoring the urgent need to address this growing issue.

The Unfolding Reality: Numbers That Demand Attention

Infertility, the inability to conceive after a year of regular, unprotected intercourse (or six months for women over 35) is a problem that affects millions worldwide. While both male and female factors play a role, the focus here is on the concerning rise of male infertility, which is estimated to contribute to approximately 50% of all cases when both partners are evaluated.

It is estimated that around 20% of cases are due to male factors alone, and another 30% of cases are due to both male and female factors. The issue is further compounded by an even more disturbing trend: a dramatic decline in sperm counts and quality. Studies indicate a more than 50% drop in sperm levels among men in Western countries over the past four decades. This isn't just a slight dip; it’s a precipitous fall. Worse, that decline has accelerated since 2000, more than doubling in pace. Shanna Swan, a leading scientist in this field, has concluded that reproductive development is declining at a rate of about 1% each year, stating that, "The modern world is on pace to become an infertile one".

**"Count Down"** by Shanna Swan, PhD, examines the alarming decline in sperm counts and fertility rates worldwide, linking these trends to environmental chemicals, lifestyle factors, and their implications for human reproduction and overall health.

This is not some distant, theoretical threat. This is happening now, a canary in the coal mine, warning us of deeper problems with the way we live. It is imperative that we pay attention and understand.

Decoding the Culprits: Common Causes of Male Infertility

To understand the problem, we must first identify the recognized causes. Male infertility isn't a singular condition, but a complex tapestry of interconnected issues:

Endocrine and Systemic Disorders: Hormones play a crucial role in sperm production. Any disruption to the intricate balance of hormones in the hypothalamus, pituitary gland, or testes can lead to infertility. These disorders account for roughly 20% of male infertility cases. These can be due to:

Congenital Conditions: Some men are born with conditions, such as Kallmann syndrome, or other less common conditions, that affect the production of hormones from the hypothalamus and the pituitary that regulate sex hormones and sperm production.
Acquired Conditions such as head trauma, pituitary tumors, or autoimmune conditions can cause pituitary hormone deficiencies (termed hypopituitarism). Importantly, some commonly prescribed (or recreationally used) drugs, such as steroids, testosterone, opioids, cannabinoids, and some antipsychotic medications can inhibit hypothalamic and pituitary hormones, leading to functional hypopituitarism and infertility.
Systemic Conditions: Any severe systemic disease (think heart, liver, or kidney diseases), nutritional deficiency, or significant obesity can result in hypothalamic dysfunction, leading to low testosterone and sperm production. Obesity, with its rising prevalence, is particularly concerning. It can lead to low testosterone, low free testosterone and low or inappropriately normal pituitary hormones. Obesity is also linked to metabolic syndrome, diabetes mellitus and sleep apnea, which can further exacerbate fertility problems.

Primary Testicular Defects: In many cases, the problem lies directly within the testicles. This is the most common cause of male infertility, estimated to be about 60-70% of all cases.

Congenital Problems: Klinefelter syndrome, where a man has an extra X chromosome (XXY), is a common genetic cause. It results in small testes and azoospermia (zero sperms in the ejaculate), though some with mild cases can have low sperm concentrations. Other congenital issues that affect the testicles and sperm production include cryptorchidism, or undescended testicles.
Acquired Problems: These can arise from varicocele, which are enlarged veins in the scrotum that cause overheating of the testes leading to impaired sperm production. Other problems include infections such as mumps orchitis during childhood and exposure to environmental toxins. Exposure to radiation, and certain medications such as chemotherapy drugs and anabolic steroids, can also damage the testicles and impair sperm production.
Idiopathic Causes: Many cases of primary testicular defects have no known cause (yet). This is referred to as idiopathic dysspermatogenesis, where there is a defect in sperm production, and is characterized by abnormal semen analysis.

Sperm Transport Disorders: The journey of sperm from the testes to the outside world can be blocked. This affects 2-5% of men.

Congenital Issues: These include congenital absence of the vas deferens.
Acquired Issues: These can include infections, inflammation or scarring of the vas deferens or epididymis, and ejaculatory duct obstruction.

Idiopathic Male Infertility: In 10-20% of cases, men have normal semen analyses and no apparent cause of infertility. This is different from idiopathic dysspermatogenesis because semen analyses are normal in idiopathic male infertility.

Disturbingly, a significant number of cases fall into the "idiopathic" category, which means that there is no known cause, highlighting the gaps in our understanding.

The Shadow of Modernity: Environmental and Lifestyle Factors

While known medical conditions contribute, there’s growing concern about the role of modern life in the decline of male fertility. We’ve created a world that is constantly assaulting our bodies with novel chemicals and unnatural stimuli, and the effects on our reproductive health are concerning.

Here are some of the leading concerns:

The Chemical Onslaught: Environmental Toxins We’ve inadvertently created a toxic environment. Endocrine-disrupting chemicals (EDCs) such as Bisphenol A (BPA), phthalates, pesticides, and microplastics are now ubiquitous in our surroundings. They’re found in food containers, personal care products, building materials, and even the air we breathe. These chemicals interfere with our hormones, particularly androgen production and reception, which are critical for sperm production and development. It is thought that these chemicals mimic natural hormones, binding to hormone receptors and disrupting normal physiological processes. Exposure to these toxins is linked to abnormal sperm morphology and DNA damage in germ cells.
The Obesity Epidemic: The obesity epidemic, which has spread in developed nations and is spreading in the developing world, is also having a significant impact. Obesity causes hormonal imbalances, including decreased testosterone levels and altered hypothalamic and pituitary signals to the testes. Additionally, obesity commonly results in metabolic syndrome, diabetes mellitus, and sleep apnea, all of which can negatively impact fertility.
The Anabolic Steroid Trap: The increasing use of TRT and other anabolic steroids as performance enhancers is suppressing the body’s natural hormone production, causing a decrease in sperm production. The rise of TRT and related drugs as a performance enhancer, especially among youths sourcing it from online compounding pharmacies without doctor oversight, is alarming. This quick-fix culture ignores the long-term harm to natural testosterone and sperm production, prioritizing instant gains over sustainable well-being.
Lifestyle Factors: The way we live can also impact our fertility.
- Smoking: There is evidence that tobacco smoking is associated with decreased sperm quality and quantity. In utero exposure to smoking may also detrimentally impact sperm production in adulthood. Smoking has also been shown to change microRNA content inside the sperm, which are associated with cell death.
- Alcohol: Excessive alcohol consumption has also been linked to lower semen quality.
- Marijuana: Marijuana use has been associated with decreased sperm concentration and motility.
- Too Many Supplements: Unregulated ingredients in some supplements can compromise sperm quality, amplifying the risk of infertility. Additionally, certain workout supplements may contain excessive amounts of soy-based protein, which is rich in phytoestrogens—plant-derived compounds with estrogen-like effects. Consuming high levels of soy can elevate estrogen levels in men, potentially suppressing natural testosterone production and impairing sperm production.
- Heat Exposure: Prolonged exposure to heat, such as from hot tubs or laptops placed directly on the lap, has been theorized to impact spermatogenesis. However, the data is inconsistent. Prolonged high testicular temperatures may also explain the infertility associated with varicocele.
Diet: The food we eat matters. A diet high in carbs and processed foods and low in fruits and vegetables has been associated with poorer semen quality.

These factors paint a picture of a world where our bodies are constantly under assault. Our modern lifestyle may be optimized for efficiency and productivity, but it is demonstrably sub-optimal for our reproductive health.

**Common endocrine disruptors.** *Source: National Institutes of Environmental Health Sciences.* https://www.niehs.nih.gov/health/topics/agents/endocrine

What Can Men Do to Improve Fertility?

While the situation may seem dire, it's not a hopeless case. Men can take proactive steps to improve their fertility prospects. It is important to acknowledge that some men may have irreversible causes of infertility, but there are things we can all do to improve our general and reproductive health.

Here's a guide:

Achieve a Healthy Weight: If you're overweight or obese, shedding those extra pounds can significantly improve hormone levels and sperm quality. This can be achieved by eating healthy and engaging in regular physical activity.
Minimize Exposure to Environmental Toxins: Limit your exposure to EDCs as much as possible.
- Choose glass or stainless steel containers over plastic.
- Avoid plastic water bottles.
- Opt for personal care products that use fewer chemicals.
- Eat organic when possible to reduce exposure to pesticides.
• Avoid Anabolic Steroids: Stop using anabolic steroids if you are using them. This is best done under supervision to avoid or minimize withdrawal symptoms. We are here to help!
• Quit Smoking: Smoking is detrimental to sperm health. Kicking the habit can lead to improvements in sperm count and quality.
• Moderate Alcohol Consumption: Limit alcohol intake.
• Limit Marijuana Usage: Some studies have found that marijuana can decrease sperm concentration and motility.
• Adopt a Healthy Diet: Focus on a diet rich in whole foods, fruits, vegetables, and lean protein, and reduce your intake of processed foods. Avoid excessive use of supplements.
• Engage in Regular Physical Activity: Staying active has many health benefits, and is critical to optimal hormonal balance.
• Manage Stress: Chronic stress can disrupt hormone levels and impair reproductive health. Find healthy ways to manage your stress levels, such as exercise, meditation, or spending time in nature.
• Avoid Prolonged Heat Exposure: Limit time in hot tubs, saunas and avoid keeping laptops directly on your lap.

These lifestyle changes can empower men to take control of their reproductive health. It is important to acknowledge that these changes may not be enough for some, so it's important to seek further medical advice.

**Normal semen analysis parameters:** *Source: World Health Organization (WHO) Laboratory Manual for the Examination and Processing of Human Semen, Sixth Edition (2021)*

Medical Intervention: Navigating the Options

Beyond lifestyle modifications, several medical treatments and interventions can help:

Medical Therapies:
- Hormonal Imbalances: For men with hypogonadotropic hypogonadism, caused by issues in the hypothalamus or pituitary, treatment with gonadotropins can help restore sperm production and fertility. Human chorionic gonadotropin (hCG), selective estrogen receptor modulators (SERMs) or aromatase inhibitors (AIs) may also be helpful for men with low testosterone.
- Hyperprolactinemia: If a man has hyperprolactinemia due to a prolactin adenoma, a dopamine agonist can be used to reduce prolactin levels and restore fertility.
- Idiopathic Infertility For men with idiopathic infertility, clomiphene or other SERMs have limited benefit. Treatment with FSH analogues may also be considered, but is not FDA approved for this use and may have limited benefit.
Surgical Interventions:
- Varicocele Repair: A varicocele, or enlarged veins in the scrotum, can be surgically repaired in men with a palpable varicocele, abnormal semen analyses and infertility.
- Obstructions: Surgical procedures can correct blockages in the reproductive tract such as ejaculatory duct obstruction or congenital absence of the vas deferens.
Assisted Reproductive Technologies (ART): When other treatments fail, ART can be effective.
- Intrauterine Insemination (IUI): Involves inserting processed semen into the uterus. IUI may be less effective in men with a low total motile sperm count.
- In Vitro Fertilization (IVF): Involves fertilizing eggs outside the body, and then implanting the resulting embryo in the uterus.
- Intracytoplasmic Sperm Injection (ICSI): A technique where a single sperm is injected directly into an egg. ICSI can overcome some sperm quality issues.
- Surgical Sperm Retrieval: This can be used when there are no sperm in the ejaculate. This can be achieved through testicular mini-procedure termed testicular sperm extraction (TESE), or microTESE, which involves slicing of the testis to extract sperm.
Sperm Freezing (Cryopreservation): Cryopreservation of sperm can preserve fertility for men who will be undergoing medical treatments that may affect fertility such as chemotherapy or radiation therapy, or men who wish to have fertility options in the future, but currently need TRT for testosterone deficiency. See resources at the end of this article.

It’s important to emphasize that medical and surgical interventions should always be guided by a specialist with experience in male reproduction. Endocrinologists oversee medical treatments, while urologists specialize in surgical care, ensuring safe, precise, and effective outcomes.

A Call to Action: Reclaiming Our Future

The decline in male fertility is a wake-up call, a flashing red light on the dashboard of our society. We can’t afford to ignore it. By making informed choices and advocating for systemic changes, men can take control of their reproductive health. This is about more than just having children, this is about safeguarding the future of our species.

This blog post is intended as an entry point for understanding this topic. The sources below provide a wealth of information for those interested in diving deeper, and all readers are encouraged to consult with qualified medical professionals for personalized guidance.

Here are some additional resources for you to explore:

Sperm Freezing in Pittsburgh Metro Area:

The male infertility crisis: are we Engineering Our Own Decline?

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