In a substantial proportion of couples we see, the woman has undergone months of investigation and treatment before anyone requests a semen analysis. That sequence is common in India and it is medically backwards.
Male factors are involved in roughly forty to fifty percent of cases, and the test that identifies them is the simplest in the whole fertility workup.
Why Men Get Tested Last
The reasons are cultural rather than clinical. Infertility is widely assumed to be a female problem, and a suggestion that the man be tested is often received as an accusation.
The practical consequence is delay. A couple may spend a year on ovulation induction when the underlying issue was a sperm count that a simple test would have identified in the first week.
Fertility is a couple's issue and the assessment should begin with both partners simultaneously. A normal result also removes a large question quickly, which is valuable in itself.
What a Semen Analysis Measures
A semen analysis assesses several parameters, and it is the combination rather than any single number that matters.
- Volume: normally at least 1.4 ml
- Concentration: at least 16 million per ml
- Total count: at least 39 million per ejaculate
- Motility: at least 42 percent moving, with 30 percent progressively moving
- Morphology: at least 4 percent normally formed
- Vitality and white cell count, which can indicate infection
The four percent morphology figure alarms men who see it as meaning ninety six percent abnormal. Sperm morphology is assessed by extremely strict criteria, and four percent is a normal result rather than a poor one.
How to Give an Accurate Sample
Results vary considerably with collection conditions, and a poor result from a badly collected sample causes needless alarm.
- Abstain for two to five days beforehand, no longer and no shorter
- Collect the complete sample, since the first portion contains most of the sperm
- Deliver it to the laboratory within an hour, kept close to body temperature
- Do not use ordinary lubricants or condoms, which are toxic to sperm
- Avoid collection during or soon after a fever or illness
Because sperm production takes about seventy four days, an illness two months earlier can affect today's result. Any abnormal result should be repeated after two to three months before conclusions are drawn.
The Common Causes
Several conditions reduce sperm production or delivery, and a number are treatable.
- Varicocele: dilated veins around the testis raising local temperature, the most common correctable cause
- Infections: past or present, including mumps orchitis after puberty
- Hormonal problems: low testosterone driven by pituitary or thyroid disorders
- Undescended testis in childhood, even if corrected
- Obstruction of the ducts, sometimes after hernia surgery or infection
- Genetic conditions such as Klinefelter syndrome or Y chromosome deletions
- Medications: some blood pressure drugs, and notably anabolic steroids and testosterone supplements
- Chemotherapy or radiation
Testosterone supplementation deserves emphasis. Taken for bodybuilding or energy, it suppresses the body's own sperm production, sometimes for a long period after stopping. Many men do not know this.
Lifestyle Factors That Genuinely Matter
Sperm production is unusually sensitive to environment, and the seventy four day cycle means changes made now show up in about three months.
- Heat: laptops on the lap, hot baths, saunas, tight underwear and prolonged driving all raise scrotal temperature
- Smoking: reduces count, motility and DNA integrity
- Alcohol: heavy intake reduces testosterone and sperm quality
- Obesity: raises oestrogen and impairs production
- Anabolic steroids: among the most damaging and most reversible on stopping
- Occupational exposure to pesticides, solvents and heavy metals
- Chronic stress and poor sleep
These are worth acting on for three months before repeating the test, since improvements are often meaningful.
Further Investigation
When a semen analysis is abnormal on two occasions, a male infertility assessment looks for the cause.
- Physical examination, which identifies varicocele and absent vas deferens
- Hormone profile including testosterone, FSH, LH and prolactin
- Scrotal ultrasound
- Genetic testing where the count is very low or absent
- Sperm DNA fragmentation testing in selected cases, particularly recurrent miscarriage or repeated IVF failure
The FSH level is particularly informative. A high FSH with a low count suggests the testis is not producing, while a normal FSH with no sperm raises the possibility of an obstruction, which may be surgically correctable.
Treatment Options
Treatment depends entirely on the cause, and it is not automatically IVF.
- Varicocele repair: can improve parameters over several months in selected men
- Hormonal treatment where a specific deficiency is identified
- Antibiotics for genital tract infection
- Stopping steroids or offending drugs
- IUI: for mild reductions, concentrating the best sperm and placing them in the uterus
- ICSI: requires only a single viable sperm per egg, and has transformed outcomes for severe male factor
- Surgical sperm retrieval: where no sperm appear in the ejaculate but production is occurring in the testis
ICSI means that even very low counts are now compatible with biological fatherhood, which was not the case a generation ago.
The Emotional Dimension
A diagnosis of male factor infertility is often experienced as a challenge to identity in a way that female factor is not, and men are markedly less likely to seek support.
Fertility and virility are not the same thing. Sperm production and sexual function are governed by different mechanisms, and a low count says nothing about masculinity.
Couples who go through this together, with both attending appointments, cope considerably better than those where the woman manages the process alone. Counselling is part of our fertility programme for both partners.
The most useful thing a couple can do at the start of fertility investigation is to test both partners at once. A semen analysis takes a day and can redirect the entire treatment plan.
Our fertility department at T. Nagar assesses both partners together, with andrology testing on site.
Related Topics
