A questionnaire assessing factors that might cause an increase in scrotal temperature was completed by patients with reproducible oligoasthenoteratozoospermia of idiopathic nature or caused by varicocele. Evaluation by means of a grading scale revealed increased scrotal heat stress in oligoasthenoteratozoospermic patients compared with normozoospermic men (P < 0.01). In addition, long-term determination of 24 h scrotal temperature profiles showed that compared with semen donors, oligoasthenoteratozoospermic patients frequently had scrotal temperatures above 35.5 degrees C despite the same environmental temperatures (P < 0.05). In 88% of cases, maximum scrotal temperatures were measured during rest or sleep phases, whereas minimum values were recorded during physical activity or frequent change of position. Nocturnal scrotal cooling by means of an air stream resulted in a decrease in scrotal temperature of approximately 1 degrees C. Furthermore, a highly significant increase in sperm concentration (P < 0.0001) and total sperm output (P < 0.0001) was achieved after nocturnal scrotal cooling for 12 weeks together with a moderate decrease in factors leading to genital heat stress. A significant improvement in sperm motility (P < 0.05) and sperm morphology (P < 0.05) was also observed, but this improvement was markedly less pronounced than the changes in sperm concentration. This study shows the importance of genital heat stress as a cofactor in fertility impairment in men and indicates nocturnal scrotal cooling as a therapeutic option.