They Tested Everything About Her. Nobody Tested Him.

By Dr. Georgine Nanos, MD, MPH — Founder & CEO, Kind Health Group, Encinitas, CA

Here's a scene I have watched more times than I can count.

A woman comes in and she has a folder. An actual folder. She's had the bloodwork and the day-three labs and the AMH and the thyroid panel, she's had the ultrasounds, she's had the dye study, she's been temping and tracking and peeing on things for fourteen months, and her chart is now three inches thick. And every single result has come back fine.

And she sits down and she says some version of, so I guess it's just me, something must be wrong with me and they can't find it.

And I ask the question I always ask now, which is: what did his semen analysis show?

And she looks at me. And most of the time, the answer is that nobody ever ordered one.

Fourteen months. Three inches of chart. And half the equation has never been looked at even once.

I had Dr. Kian Asanad on the podcast to talk about this, and he is exactly the right person for it. He's a fellowship-trained reproductive urologist and microsurgeon, he directs the Fertility and Men's Sexual Health Center at USC, he teaches urology at Keck, he's published more than forty peer-reviewed papers including one in JAMA. He does the half of fertility medicine that nobody talks about at brunch.

And he gave me the number that should end this whole pattern.

Half. It's half.

Male factor is involved in about fifty percent of infertile couples. And it is the sole cause in about twenty percent.

I want to be careful here because I say a lot of numbers on this show and I check them all, and I checked this one specifically, because it sounded high even to me. It's right. Male factor is present in roughly half of couples struggling to conceive, and in about one in five it's the only thing going on.

So one in five of those women with the three-inch folder didn't need any of it. Not the dye study, not the fourteen months. The answer was sitting in a test nobody ordered.

Kian's read on why this persists is generous, and probably correct. The old mental model was that women are born with all their eggs and the supply runs down, and men make sperm continuously and have millions of them, so the constraint must be on her side. Add the fact that egg quality genuinely does decline with age, and it becomes very easy for a tired clinician to reach for the explanation that's already sitting there.

But the sperm side has its own problems, and they're common, and they are frequently the easier thing to find.

The test takes a week and you can do it at home

This is the part that made me sit up, and I'll admit on the record that I did not know how far this had come.

You can order a semen analysis to your house. It ships to you, you produce the sample at home, you ship it back, you get a result. Kian uses mail-in and at-home testing routinely, and there are several validated companies doing it well now.

I'm not going to name brands, because I haven't personally vetted them and I'm not going to send you somewhere on a vibe. Ask your doctor or a urologist which one they trust. But know that the option exists, because the last time most people checked, this required an appointment, a referral, and a room at a clinic, which is a genuinely uncomfortable errand and a real reason men put it off for a year.

And Kian said something that reframed the timing for me entirely. He sees couples who aren't even trying yet. Newly married, want kids in a year or two, and they just want to know where they stand. A blood test, a semen analysis, a physical exam. A week, and you have a baseline.

A week. Set that against a year of one person being the only one investigated.

He also made the case for the physical exam, which I loved because it's such an old-fashioned point coming from a guy who does robotic microsurgery. He finds things with his hands. A large varicocele, which is a fixable cause. Or, occasionally, something much bigger: a completely healthy thirty-five-year-old man who has not seen a doctor since he aged out of his pediatrician, and on exam the vas deferens is missing on both sides.

That finding is not random. Congenital absence of the vas deferens is strongly linked to the cystic fibrosis gene, and in most series somewhere between sixty-eight and eighty-two percent of these men carry a CFTR mutation. Usually one copy, which makes them carriers rather than people with cystic fibrosis.

And here is the piece I want to add on top of what we discussed, because it matters and it didn't come up: if he's a carrier, she needs to be tested too. If both partners carry a mutation, the risk to a future child is real and it changes what you do next. So that exam didn't just explain the infertility. It changed the genetic counseling for the whole family.

That's what a fifteen-minute appointment can turn up in a man everybody assumed was fine.

When the answer is zero

About ten percent of men who get evaluated for infertility have no sperm in the sample at all. None. That's called azoospermia, and Kian's description of delivering it stayed with me, because these are usually completely healthy men with zero symptoms who came in expecting a formality.

There are two versions. Either the testicle isn't making sperm, or it's making sperm and there's a blockage somewhere in the plumbing. The blockage version is less common and generally more fixable. The non-obstructive version, where production itself has failed, is the harder one.

And this is where his actual craft comes in.

There's an operation called microTESE, microsurgical testicular sperm extraction, where the surgeon opens the testicle, puts it under a microscope, and searches the tissue directly for the rare pockets that are still producing. Not a blind biopsy. An actual hunt, at magnification, through the tissue.

And about half the time, in men whose semen analysis said zero, he finds sperm. Enough to fertilize an egg through IVF. Enough to have a biological child.

Published success rates run from around fifty percent up to seventy depending on the underlying cause, and Kian quotes his patients the conservative end, which I respect enormously. When you're the person delivering this news you should be quoting the low number, not the flattering one.

Going from "you have no sperm" to "there's a fifty-fifty chance we can still find some" is one of the more remarkable things medicine does quietly.

I'll also note, because he did, that essentially nothing has fundamentally changed in this field since 1999. That's when microTESE was first described. Twenty-plus years and no comparable breakthrough. There's early work on growing sperm from stem cells at Utah and elsewhere, and it's genuinely exciting, and I want to be clear that it is nowhere near your fertility clinic. That's a horizon, not an option.

How he tells people

I asked him what happens in the room when the odds aren't what a couple hoped, and how he keeps doing that without it hollowing him out.

His answer was that he can't promise a couple he'll find sperm, but he can promise them that if it's findable, today is the day. Everything optimized in advance, testosterone corrected if it's low, lifestyle factors addressed, best team, best facility. So that if they walk out without sperm, there is no what-if left. No "should we have tried something first." That door is closed, and it's closed cleanly.

Then he does the part that I think is the actual medicine.

He reframes the result as a stepping stone rather than an ending. Because the couple's real goal was never a biological child specifically. It was to be parents. And most couples, given time to grieve, do get there another way, through donor sperm or adoption. He said when he sees those same couples on the other side, they are happy. Not consoled. Happy.

I believe him, and I'd add one thing from my own chair: the grief in between is real and it deserves to be treated as real. You are allowed to mourn the child you pictured. That mourning is not disloyalty to the child you end up with. Rushing a couple past that stage is one of the least kind things medicine does, and it's usually done in the name of optimism.

The supplement question, and what honesty actually sounds like

Now I want to talk about the part of our conversation I've thought about the most since, and it isn't the science. It's how he handled a question he had every commercial reason to handle differently.

Kian built a fertility supplement company. He named it after his two kids. And a while after he launched it, friends and family started coming to him half-joking, asking whether he could make something that would help them have a girl, or a boy. Enough people asked that he took it seriously, and he built a product for it.

The idea, theoretically, goes like this. Sperm carrying a Y chromosome were long thought to be smaller and lighter and faster, and sperm carrying an X thought to be sturdier and more DNA-dense. So if that were true, you could imagine nudging the environment one way or the other. More alkaline conditions and better motility to favor the Y. Antioxidant support and DNA integrity to favor the X.

So I went and looked at the evidence, because that's my job and because you deserve to know before you spend money on anything.

Here's what I found, and I'm going to give it to you straight. The premise underneath all of this, which comes from the Shettles method that people have been passing around since the 1960s, has largely not held up. More recent work has not found the shape difference between X-bearing and Y-bearing sperm that Shettles described, and has not found evidence that Y sperm actually swim faster. And studies on timing intercourse to influence sex have mostly found no effect at all, with some pointing the opposite direction from what Shettles predicted.

There is some real signal on the maternal side, and I'll be fair about it. Preconception vitamin D status has been associated with a higher likelihood of a male birth in a study of over twelve hundred women. Mineral content of the diet shifts sex ratio in animals fairly reliably. But that's observational and mostly not in humans, and it is a long way from a supplement bottle and a promise.

So the honest summary is that the male-side theory is built on a foundation that hasn't survived testing very well.

And here's why I'm telling you all of this in an article that is otherwise fairly admiring of this man.

Because when I asked him about it directly, on the record, he did not do the thing that almost everyone in his position does. He didn't reach for a study. He didn't quote me a percentage. He said, plainly, that it has never been proven. And then he said the line I keep repeating to people: if somebody tells you they can improve your odds by thirty percent, they are literally lying to you, and he is not in the business of lying to his consumers.

That is a man describing the limits of his own product, out loud, on a podcast, while selling it.

I have been in medicine a long time and I cannot tell you how rare that is. The supplement industry is not regulated for efficacy, which means the marketing can say very nearly anything, and most of it does. To have someone stand in that space and volunteer that the evidence isn't there is genuinely unusual, and it made me trust everything else he told me more, not less.

So where does that leave you if you're a couple who wants a particular outcome.

My read, and it is only mine: these are multivitamins. The downside is mostly your money, and the upside on the specific promise is unproven and, if I'm honest with you, probably small to nonexistent based on what the evidence currently shows. Do not spend money you can't spare on this. Do not build hope on it. And if you have any medical condition or you're on any medication, run the ingredients past your own doctor first, because "natural" and "harmless" are not the same word.

But there's one thing in it I do think has real value, and it has nothing to do with chromosomes.

Kian said something in passing that I want to pull out. For years, all of this has been on her. She takes the supplements. She does the tracking. She's the one saying tonight's the night. He said men can carry a little of that load, that it's a team sport and it should feel like one.

And that part is true regardless of whether the mechanism does anything at all. A man who takes a daily vitamin because he and his partner are trying to have a baby is a man participating in something he was previously outside of. That changes how a couple experiences a hard, long, lonely process.

So if you do it, do it for that reason. Do it because you're doing it together. Not because someone promised you a number, and if anybody ever does promise you a number, you now know exactly what that tells you about them.

Before cancer treatment, ask about this

A short section, because it's the kind of thing that gets missed in the worst possible moment.

If you or someone you love is about to start cancer treatment and is past puberty, fertility preservation should be discussed before treatment begins. That is not a nice-to-have. American Society of Clinical Oncology guidelines direct clinicians to raise sperm banking with all pubertal and post-pubertal male patients before therapy starts, and the 2025 update goes further, adding surgical sperm extraction as a standard-of-care option for men who can't produce a sample.

Timing is the whole thing. Sample quality and sperm DNA integrity can be compromised after even a single round of treatment. Before is a completely different conversation from after.

Good centers have this on a checklist now, and some have navigators whose job is to make sure it happens. Plenty of places still don't. So if nobody has raised it, you raise it. Say the words "fertility preservation" out loud before the first infusion. It is one of the few things in that entire terrifying process that you cannot go back and do later.

The part every man in his thirties needs to hear

Okay. This is the section I would tape to the door of every gym in America.

Testosterone is a contraceptive.

That is not a warning about a rare side effect. That is what the drug does. And Kian said it's the thing men most consistently don't know until they're sitting across from him, at which point they've frequently been on it for two years.

I want to be precise about that word, because it cuts both ways and the second way matters. Testosterone was genuinely studied as contraception. The World Health Organization ran efficacy trials, weekly testosterone injections in 271 healthy fertile men across seven countries, and in the men whose sperm production fully shut down there was one pregnancy in nearly 1,500 months of exposure. That is a failure rate in the same neighborhood as the pill.

But it shut down fully in about sixty-five percent of them. Which means roughly one in three men kept making some sperm, and no man can tell which group he is in without a semen analysis. That is a large part of why it was never approved as a contraceptive anywhere.

So hear both halves of this. If you want children, assume testosterone will take that ability away from you. And if you do not want children right now, do not treat it as birth control, because for about a third of men it simply isn't. It is very good at making you infertile and not reliable enough to prevent a pregnancy, which is the worst possible combination to be wrong about in either direction.

The mechanism is simple and once you hear it you can't un-hear it. Your brain is monitoring how much testosterone is floating around. It has no way to tell whether your body made it or whether it came out of a vial. So when the level reads high from an outside source, the brain concludes that production is handled and switches off the signal it sends down. And the testicles don't only make testosterone off that signal. They make sperm off it too. Same switch. You turn one off, you turn both off.

The numbers, which I looked up because I wanted to hand you something exact rather than a vibe: about sixty-five percent of men with normal sperm counts go to zero sperm within roughly four months of starting testosterone. Mean time to zero, about a hundred and twenty days.

Zero. Four months.

Now, the good news is real, so let me give it to you properly. It's usually reversible. Between sixty-four and eighty-four percent of men recover, with a median of somewhere around a hundred and ten days after stopping. Roughly ninety percent are back to their baseline sperm concentration by twelve months, and essentially everyone by twenty-four.

But read that last bit again. Some men take the full two years. I have sat with couples in their late thirties for whom a two-year wait is not a minor inconvenience, it's the whole window.

And then Kian told me about the study that genuinely made me angry.

A colleague of his, Dr. Justin Dubin, ran a secret-shopper study that was published in JAMA Internal Medicine. A researcher posed as a thirty-four-year-old man with low energy and low libido, with normal testosterone levels, who explicitly said he was interested in future fertility. He contacted direct-to-consumer testosterone platforms.

Six of the seven offered him testosterone.

Normal levels. Said he wanted children. Offered it anyway, by six out of seven. And only about half of them asked about his fertility intentions at all.

I want to be fair here, because I'm not anti-testosterone and neither is Kian. There are men who are genuinely hypogonadal, who feel dramatically better on properly monitored therapy, and for whom it's the right call. That's real medicine and it helps people.

What I'm against is a thirty-two-year-old being sold a subscription by a platform that never asked whether he wants to be a father.

And Kian's answer to the broader mythology was the best line of the episode. The biggest myth in men's health, he said, is that testosterone is the answer to all of men's problems. He sees men whose level is 350, which is normal, who are convinced that getting to 1000 will fix how they feel. It usually doesn't. Low libido, erectile dysfunction, and depression all occur at perfectly normal testosterone levels, and blaming the number every time means the actual cause never gets found.

So, plainly, if you're a man who might want children:

Ask before you start. One sentence. "Will this affect my fertility, and how long does it take to come back?" A clinician who won't engage with that is telling you something important.

Get a baseline semen analysis first. You cannot get that information later. Once you've started, the baseline is gone.

Bank sperm if there's any chance at all. It's cheap relative to everything downstream, and it is the single highest-leverage thing on this entire list.

And if you're already on it and you want kids, don't panic and don't just quit into the void. This is very manageable, but it's managed with a reproductive urologist, not with a forum and not with the person who sold it to you.

What I actually want you to take from this

I asked him what he tells the nervous guy in his office, and his answer was so simple it's almost easy to miss: bring your partner.

He said men come in alone, get information, and lose most of it before they're back to the car, and then their wife has questions they can't answer and the whole thing needs doing again. So he invites her in. Fertility consults, vasectomy consults, all of it. And if she couldn't come, he tells the guy to have her message him directly.

That's such a small operational thing, and it says everything about how he practices.

Because here's the shape of the whole problem. We built fertility medicine so that she carries all of it. She takes the supplements, she does the tracking, she gets the ultrasounds, she absorbs the appointments and the grief and the logistics, and she is the one who ends up believing her body is the broken thing. And he stands slightly outside it, supportive, waiting to be told when.

Kian said it's a team sport and half the team has been sitting on the bench. And it isn't because those men don't care. It's because nobody ever handed them anything to do.

So here's the thing to do. One test. It takes a week and you can do it from your house.

To the women reading this with the three-inch folder, who have quietly decided that this is their fault: it was never only your chart. You were investigated thoroughly and he wasn't investigated at all, and then you concluded the problem was you. That's not evidence. That's just where everybody was looking.

Ask for his labs. Ask for the semen analysis. Ask before you spend another fourteen months on a workup that's only examining half the question.

You deserve the whole picture, and it's one test away.

It's all fixable. And even when it isn't fixable the way you first pictured it, there is almost always another way to end up a parent, and I have watched enough people get there to promise you that.

Dr. Georgine Nanos is a board-certified family physician and the founder of Kind Health Group in Encinitas, California, where she practices comprehensive concierge and preventive medicine for women and men who are tired of being told everything looks fine.

This conversation is from The Kind Revolution podcast with guest Dr. Kian Asanad, MD, reproductive urologist and microsurgeon, Director of the USC Fertility and Men's Sexual Health Center at Keck Medicine of USC. Also available on Apple Podcasts, Spotify, Amazon Music, and YouTube. Search "The Kind Revolution."

This article is for education and is not medical advice. Talk to your own physician about your situation.

Frequently Asked Questions

How much of infertility is caused by male factors?

Male factor is involved in approximately 50% of infertile couples and is the sole identified cause in about 20%. Despite this, the male partner is frequently evaluated later than the female partner, or not at all. A semen analysis is inexpensive, non-invasive, and produces results within days, which makes it one of the most efficient first steps in any fertility evaluation rather than a last resort after months of testing on the female partner.

Does testosterone therapy cause infertility?

Yes. Exogenous testosterone suppresses the hormonal signal from the brain that instructs the testicles to produce both testosterone and sperm, because the brain cannot distinguish testosterone made by the body from testosterone introduced from outside. Approximately 65% of men with normal sperm counts develop azoospermia, meaning no sperm at all, within about four months of starting testosterone. Men who may want biological children should obtain a baseline semen analysis and consider sperm banking before beginning therapy.

Is testosterone-related infertility reversible?

Usually, though recovery takes time. Between 64% and 84% of men recover sperm production after stopping testosterone, with a median recovery time of roughly 110 days. About 90% return to baseline sperm concentration within 12 months and essentially all within 24 months. Some men require the full two years, which can be significant for couples on a limited timeline. Recovery is best managed with a reproductive urologist rather than by stopping treatment without guidance.

What is a microTESE procedure?

MicroTESE, or microsurgical testicular sperm extraction, is a surgical procedure for men with non-obstructive azoospermia, meaning no sperm in the ejaculate because the testicle is not producing normally. The surgeon opens the testicle and examines the tissue under an operating microscope to locate small regions that are still producing sperm, then extracts them for use in IVF. Sperm are successfully retrieved in roughly half of cases, with published series ranging from about 50% to 70% depending on the underlying cause. The technique was first described in 1999.

When should a man get a fertility test?

Ideally before there is a problem. A baseline semen analysis, blood work, and physical examination can be completed in about a week and provide a clear starting point, and many couples now do this before they begin trying to conceive. Validated at-home and mail-in semen testing has made initial screening straightforward. An abnormal home result should be confirmed with a formal semen analysis and evaluated by a urologist, since some causes found on physical examination, such as a varicocele, are treatable.

Can a physical exam find causes of male infertility?

Yes, and some findings are significant. A varicocele, which is an enlargement of veins within the scrotum and a treatable cause of impaired sperm production, is identified on examination. In rarer cases, examination reveals congenital absence of the vas deferens, which is strongly associated with cystic fibrosis gene mutations, with CFTR mutations found in roughly 68% to 82% of affected men. Most of these men carry a single mutation and do not have cystic fibrosis, but the finding means the female partner should also undergo carrier testing before conceiving.

Should men bank sperm before cancer treatment?

Yes, and the timing matters greatly. American Society of Clinical Oncology guidelines direct clinicians to discuss sperm banking with all pubertal and post-pubertal male patients before cancer treatment begins, and the 2025 guideline update adds surgical sperm extraction as a standard-of-care option for patients unable to produce a semen sample. Sperm should be collected before treatment starts, because sample quality and sperm DNA integrity may be compromised after even a single round of therapy. Patients who have not had this conversation should raise it directly with their oncology team.

Do gender-swaying supplements work?

The evidence does not support them. The underlying premise, drawn from the Shettles method, holds that Y-bearing sperm are smaller, lighter and faster while X-bearing sperm are sturdier, but more recent research has not found the morphological difference Shettles described and has not found evidence that Y sperm swim faster. Studies of timing intercourse to influence sex have largely shown no effect. Some weak signal exists on the maternal side, including an association between preconception vitamin D status and male birth, but it is observational and far from establishing that a supplement can shift outcomes. Such products are generally low-risk multivitamins rather than harmful, but no reputable source can quote a success rate, and any seller who offers a specific percentage is making a claim the evidence cannot support.

Why do online testosterone platforms create fertility risk?

Because many do not ask whether the patient wants children. In a secret-shopper study published in JAMA Internal Medicine, a researcher posed as a 34-year-old man with normal testosterone levels who stated an interest in future fertility and contacted direct-to-consumer testosterone platforms. Six of seven platforms offered testosterone therapy anyway, and only about half asked about fertility intentions at all. Because testosterone suppresses sperm production, a patient who is not asked about family plans may begin a treatment that renders him temporarily infertile without ever being informed of it.