40w LaterGuide

Infertility is not only a female issue. Male factors can contribute to infertility on their own or together with female factors, so both partners should ideally be evaluated when pregnancy is not occurring as expected. Common male factors include problems with sperm production, sperm count, movement, shape, or semen delivery.

Checking sperm health: semen analysis

A semen analysis is one of the basic tests used to evaluate male fertility. It measures characteristics such as semen volume, sperm concentration, total sperm number, motility, and morphology.

For a diagnostic semen analysis, the WHO recommends approximately 2–7 days of ejaculatory abstinence before collecting the sample. Follow the specific collection instructions provided by the clinic or laboratory.

The current international laboratory reference is the WHO Laboratory Manual for the Examination and Processing of Human Semen, 6th edition, published in 2021. Approximate lower reference values from fertile men include semen volume 1.4 mL, sperm concentration 16 million/mL, total sperm number 39 million per ejaculate, total motility 42%, progressive motility 30%, and normal morphology 4%.

However, these figures are not a strict dividing line between fertile and infertile men. A result slightly below a reference value does not mean that natural pregnancy is impossible, and a result above the reference values does not guarantee fertility. The overall pattern of the semen analysis, the female partner’s age and fertility, and how long the couple has been trying to conceive all matter.

If the first semen analysis is abnormal, a repeat test is often considered because semen parameters can vary between samples.

What happens if the semen analysis is abnormal?

If abnormalities are mild, the next step depends on the couple’s overall fertility situation. In some cases, continued attempts at natural conception may be reasonable; in others, treatments such as intrauterine insemination (IUI) may be considered.

When sperm concentration or motility is severely reduced, or there are multiple significant abnormalities, in vitro fertilization (IVF) may be considered. In some cases, intracytoplasmic sperm injection (ICSI) is used, in which a single sperm is injected directly into an egg.

The choice between natural conception, IUI, IVF, and ICSI should not be made from one semen value alone.

What is azoospermia?

Azoospermia means that no sperm are detected in the ejaculate, including after appropriate laboratory examination of the sample. It does not have a single cause.

Azoospermia is broadly divided into:

1) Non-obstructive azoospermia

In this condition, sperm production in the testes is severely impaired. Causes can include genetic or chromosomal conditions, damage to the testes, certain cancer treatments, infections, or other testicular disorders.

In some men, small numbers of sperm can still be found in testicular tissue through surgical sperm retrieval procedures and may be used with ICSI. Whether this is possible depends on the underlying cause.

2) Obstructive azoospermia

Here, sperm are being produced but cannot reach the ejaculate because part of the reproductive tract is blocked or absent.

Sperm may sometimes be retrieved directly from the epididymis or testes using procedures such as PESA, MESA, TESA, or TESE, and the retrieved sperm can be used for IVF with ICSI.

3) Azoospermia caused by hormonal deficiency

In some men, the hypothalamus or pituitary gland does not provide enough hormonal stimulation for normal sperm production. This is known as hypogonadotropic hypogonadism.

In these cases, treatment with gonadotropin hormones may stimulate sperm production. This is different from giving an “ovulation injection” to a man; the hormones are being used to stimulate testicular function.

Men with azoospermia should be evaluated to distinguish obstruction from impaired sperm production, and additional hormonal or genetic testing may be recommended depending on the findings.

In summary

1. Semen analysis is a basic test for evaluating male fertility and should be interpreted using current WHO laboratory standards.
2. WHO reference values are not absolute cutoffs between fertile and infertile men.
3. Mild or severe abnormalities are managed differently depending on both partners’ fertility factors.
4. Even with azoospermia, pregnancy may still be possible in some cases through hormonal treatment, surgical sperm retrieval, and assisted reproductive technologies such as IVF with ICSI.