How can fertility be improved in a 35-year-old male?

How to Increase Fertility in a 35-Year-Old Male

The most effective approach to increasing fertility in a 35-year-old male begins with identifying any underlying causes through semen analysis and hormonal evaluation, followed by targeted treatment based on specific findings—with assisted reproductive technology (ART) being the most effective option for most cases of documented male factor infertility. 1

Initial Diagnostic Evaluation

Before initiating any treatment, proper diagnosis is essential:

• Obtain at least two semen analyses separated by 2-3 months to confirm any abnormalities and establish a baseline, as single tests can be misleading 2
• Measure serum FSH, LH, total testosterone, and prolactin to identify correctable endocrine causes of infertility 1, 3
• Perform a thorough physical examination focusing on testicular volume (normal >15 mL), consistency, presence of varicoceles, and vas deferens patency 3, 4
• Both partners should be evaluated simultaneously rather than sequentially, as male factors contribute to approximately 50% of couple infertility cases 5

Critical Lifestyle Modifications (Immediate Implementation)

These interventions should begin immediately regardless of test results:

• Complete smoking cessation, as tobacco directly impairs sperm production and function 3, 5
• Eliminate or severely limit alcohol consumption to optimize fertility potential 3, 5
• Discontinue all recreational drugs, which negatively affect spermatogenesis 3
• Reduce caffeine intake to less than 5 cups per day to minimize potential negative effects 3
• Avoid heat exposure from hot tubs, saunas, or prolonged laptop use on the lap, as elevated scrotal temperature damages sperm production 3
• Achieve and maintain a healthy BMI between 18.5-25, as both obesity and being underweight impair fertility 3
• Optimize frequency of intercourse to every 1-2 days during the fertile window (6 days ending on ovulation day) 5

Treatment Based on Specific Diagnoses

For Hypogonadotropic Hypogonadism (Low LH, Low FSH, Low Testosterone)

• Initiate hCG injections first to stimulate testosterone production, monitoring serum testosterone levels 1, 6
• Add FSH or FSH analogues after testosterone normalizes to optimize sperm production, as this combination successfully initiates spermatogenesis in 75% of men with this condition 1, 2
• Refer to an endocrinologist or male reproductive specialist for management of this condition 1

For Low Testosterone with Normal/Elevated LH and FSH

• Consider aromatase inhibitors (AIs), hCG, or selective estrogen receptor modulators (SERMs) alone or in combination to increase endogenous testosterone production 1
• These medications work by different mechanisms but all aim to stimulate the body's own testosterone production rather than suppressing it 1

For Varicocele (Palpable on Physical Examination)

• Surgical varicocele repair should be considered, as correction of palpable varicoceles can improve both semen quality and natural fertility rates 2

For Idiopathic Infertility (Normal Examination, Mildly Abnormal Semen Parameters)

• FSH analogues may be considered with the aim of improving sperm concentration, pregnancy rate, and live birth rate, though benefits are limited 1
• Inform the patient that SERMs have limited benefits relative to assisted reproductive technology outcomes 1

What NOT to Do (Critical Contraindications)

• Never prescribe testosterone monotherapy to any male interested in current or future fertility, as it completely suppresses spermatogenesis through negative feedback on the hypothalamus and pituitary 1, 2
• Do not recommend antioxidants or vitamin supplements as routine treatment, since existing data show questionable clinical utility and inadequate evidence for specific agents 1
• Avoid delaying referral to ART when medical therapies fail, as female partner age is a critical factor in fertility outcomes 2

When to Proceed Directly to Assisted Reproductive Technology

• For severe oligospermia or asthenozoospermia, IVF with intracytoplasmic sperm injection (ICSI) should be first-line treatment, as it directly overcomes sperm defects 2
• After 3 failed cycles of intrauterine insemination (IUI), progression to IVF/ICSI is recommended 2
• For total motile sperm count <5 million after processing, IUI success rates are significantly reduced and ART should be considered 1
• ART (IVF/ICSI) offers superior pregnancy rates compared to empiric medical therapies for most cases of male factor infertility 2

Timeline Considerations

• For couples where the female partner is under 35 years, the standard 12-month observation period of regular unprotected intercourse applies before formal infertility evaluation 5
• For female partners aged 35 or older, evaluation should begin after only 6 months of attempting conception due to age-related fertility decline 5
• Repeat semen analysis and hormonal evaluation in 1-2 years if initial parameters are borderline but not severely abnormal, to monitor for progressive decline 3

Common Pitfalls to Avoid

• Do not assume normal fertility based on sperm concentration alone—motility and morphology are equally crucial factors 3
• Do not limit assessment to the male partner alone when the couple has not conceived, as concurrent female evaluation is essential 5, 2
• Do not delay treatment in older couples waiting for "natural" improvement, as time is a critical factor especially with advancing female age 5
• Do not use commercial vaginal lubricants, as most reduce fertility by impairing sperm function 5