Male Fertility Worksheet

Since fertility problems are a shared concern, you and your partner should go to the first appointment together. Bring copies of your health records to your visit and have copies sent to your doctor ahead of time to avoid the hassle and expense of duplicating medical tests. Expect to be asked about your sexual history, whether you’ve ever had any sexually transmitted infections, how often you make love, and more. Not much about your private life will be private anymore, so you’ll want to feel comfortable with your doctor. (For details about what your doctor will ask your partner, see the female fertility worksheet.)

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Read this worksheet all the way through — it links to more detailed information. Then click here to print a clean worksheet you can fill out and give to your doctor.

Date of birth:
Partner’s name:
Partner’s date of birth:
Current medications:

Were you born with undescended testicles? (If one or both testicles remain inside the abdomen too long, body warmth can permanently affect sperm production.)

Have you had an illness accompanied by a high fever in the last six months? (Fevers, or elevated temperatures, can damage sperm production temporarily.)

Have you noticed swelling or pain in one or both testicles recently? Have you sustained any injuries to your testicles? Have you ever had a testicular torsion? (Torsion occurs when the testicle twists inside the scrotum. But a blow to the groin can also cause inflammation that can temporarily affect sperm quantity.)

Have you ever had a tumor or cyst in your testicles? (A past surgical procedure, say to remove a testicular cyst, can sometimes cause scarring that affects fertility.)

Have you had any X-rays to your groin area? (A shield is usually used to protect the testicles from exposure to radiation, but an accidental zap can cause sperm problems.)

Do you have chronic bladder or urinary tract infections? Is your urine cloudy, or do you feel a burning sensation when urinating? (Some sexually transmitted infections manifest as a burning sensation when men urinate. If such a disease is passed on to a woman, it could damage her fallopian tubes.)

Have you ever had cancer requiring chemotherapy or radiation therapy? (Cancer treatments, such as radiation therapy and chemotherapy, can kill sperm.)

Do you have any chronic illness such as diabetes or thyroid disease? (These conditions, and some of their treatments, have been linked to fertility problems.)

Do you take any medications? (Steroids and high blood pressure medication — especially calcium channel blockers — have been known to interfere with fertility.)

Have you had the mumps? How old were you when you caught them? (Having the mumps after puberty has been associated with low sperm production.)

Are you a Gulf War veteran? Were you ever exposed to any toxins such as Agent Orange? (These chemicals have been linked to fertility problems in men.)

Have you ever tested positive for a sexually transmitted infection? Which one? (If you pass them on to your partner, chlamydia and gonorrhea can cause inflammation that may block your partner’s tubes or harm her reproductive organs.)

Have you had a vasectomy? Or a reversal? (Reversing a sterilization procedure isn’t foolproof. Scar tissue can still prevent sperm from being ejaculated. And even when reversals work, patients often develop sperm antibodies that can kill or disable sperm.)

Do you have any difficulty getting or maintaining an erection?

Do you have any problems ejaculating?

Are you having any sexual difficulties? Please explain:

Have any members of your family had problems with abnormal births or stillbirths? (Some fertility problems are genetic. You may want to talk to your relatives — particularly childless couples or families with an only child — about their fertility history.)

(Some studies suggest that lifestyle factors may affect fertility.)

Do you drink alcohol? How many drinks do you have per week? (Several studies suggest that women and men who drink alcohol — any amount — lower their chances of conceiving.)

Do you smoke? How many packs of cigarettes do you smoke a week? (Some evidence has shown that the nicotine in cigarettes can lower sperm counts.)

Do you take hot baths or use hot tubs? (Heat can hamper sperm production — take showers instead, or keep your baths warm, not hot.)

Are you a frequent bike rider? How often do you ride? (Some early evidence suggests that pressure on the groin and heat around the scrotum from frequent bicycling can harm sperm production.)

Do you work with chemicals, radiation, or around high levels of heat? (Exposure to these elements can adversely affect sperm production.)


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