A man’s fertility test is a cup and a private room, a woman’s can be surgery. Yet women are still investigated first, longest and hardest, while sperm counts quietly halve. Cheek’s go-to GP, Dr Rebekah Hoffman, on the most lopsided workup in medicine.
Let’s consider two different fertility investigations. The first involves blood tests across the menstrual cycle, an internal often painful and invasive ultrasound, sometimes a procedure where dye is pushed through the fallopian tubes, or a laparoscopy under general anaesthetic. The second involves a specimen jar, a private room, and about twenty minutes. The first is what we routinely do to women. The second is a semen analysis and it is often the last thing anyone thinks to order.
This is the quiet scandal of fertility medicine: the burden of investigation, treatment and blame falls overwhelmingly on women, even though a male factor is involved in roughly half of all cases, and for a silent, unspoken group, sometimes no cause is found at all. But often the blame remains with the women, being “unable” to conceive. Australia’s government-funded men’s health body, Healthy Male, puts the breakdown plainly: in infertile couples, male infertility alone is the cause in 20–30 per cent of cases, and both partners contribute in around another 30 per cent.
The reality is, the cause of infertility is in neat thirds, a third female, a third male, a third both or unexplained. Infertility affects about one in six Australian couples. Men are not bystanders to it. Half the time, they’re central. You would not always know that from how the workup unfolds. Healthy Male itself acknowledges the problem, noting that some fertility services “focus more on females than the couple” when the fertility of both partners “should be investigated from the outset.”
The World Health Organization goes further, and names the cultural machinery behind it: women “are often perceived to suffer from infertility, regardless of whether they are infertile or not,” and it is women who disproportionately bear the social fallout, the stigma, the intrusive questions, sometimes the violence and divorce. The default assumption, still, is that a couple’s failure to conceive is the woman’s body to fix.
That’s not just unfair but clinically backwards, and I’ll explain why. The single most efficient, cheapest, least invasive test in the entire fertility workup is the one we do to men. A semen analysis is a fresh sample examined under a microscope, there is no anaesthetic, no theatre, no recovery. If you were designing a rational diagnostic pathway from scratch, you’d start there, every time, before you put a single woman through a blood test or an ultrasound, long before a laparoscopy. That we so often don’t is not medicine. It’s culture wearing a lab coat.
And it matters more than ever, because something is happening to sperm. The largest analysis of the evidence, pooling data from men across the globe including Australia, found that sperm concentration fell by around 52 per cent between 1973 and 2011.
The 2023 update was worse: a 51.6 per cent global decline through to 2018, with the rate of decline appearing to accelerate this century, the annual drop roughly doubling after the year 2000. We don’t fully understand why, and the figures are debated, but a trend of that size in male reproductive health should be front-page news. Instead it barely rates a mention, while the entire cultural conversation about fertility decline stays fixed on how old a women is. Calling them “geriatric” after the age of 37. Yes 37.
This is the other myth worth dismantling: the idea that only women have a biological clock. Men’s fertility declines with age too. Australian data shows that if a woman under 25 has a partner over 40, it takes, on average, around two years to conceive, compared with about five months if he’s also under 25; miscarriage risk rises when the father is older, and the risks of some developmental conditions in children tick up with paternal age. “He can father children into his seventies” is technically true and practically misleading. The clock is just quieter in men, because nobody’s been shouting about it.
The good news is that a lot of male fertility is modifiable, and this is where men can genuinely take on their share. Sperm take around three months to develop, so changes made now pay off within a season. Smoking, heavy drinking, obesity, heat, and importantly anabolic steroids and testosterone supplementation all reduce sperm quality, the last sometimes with lasting effects. That gym-bag testosterone or the “T clinic” script deserves a specific mention, because plenty of young men have no idea it can switch off their own sperm production. If you want to be a father, that vial is working against you.
So what should change? Practically, if a couple is struggling to conceive, both partners should see a doctor and be investigated together, from the start and if the bloke’s semen analysis hasn’t been done before his partner faces anything invasive, that’s a red flag about the care, not about her. Culturally, we need to let go of the idea that fertility is women’s work and infertility is women’s fault.
I’ll say something to the men reading, too, because I know male infertility carries a particular sting. Healthy Male is honest that men can feel a “sense of failure,” “emasculated,” a loss of self-esteem and that this shame is exactly why so many suffer in silence and skip the simple test.
But a low sperm count is a medical finding, not a verdict on your manhood, and it’s frequently treatable or workable-around. The bravest, most useful thing you can do for the woman you love is to put your hand up first. Get a referral for a test, a pathology jar, a private room, twenty minutes of your time.
Fertility is a two-person project. It’s well past time the medicine, and the blame, was shared like one.
About the author
Dr Rebekah Hoffman is a Sydney GP, practice owner, researcher and Chair of the RACGP NSW and ACT Faculty. She works across clinical practice, research and health advocacy, with a particular interest in preventive health, women’s health, healthcare access and translating complex medical evidence into practical, everyday advice. The views expressed are her own and do not necessarily reflect those of the organisations with which she is affiliated.
