When to seek help
After twelve months of trying without a pregnancy, if your partner is under 35. After six months if she is 35 or older, because time then starts to weigh on the treatment strategy.
Sooner if there are signs that justify not waiting: a history of undescended testicles (cryptorchidism) or testicular surgery, previous chemotherapy or radiation therapy, a varicocele that has already been diagnosed, a known hormonal disorder, sexual dysfunction that makes trying difficult, or an abnormal semen analysis done for some other reason.
Semen analysis: what a sperm test shows
A semen analysis, often simply called a sperm test, assesses sperm concentration, motility and morphology, as well as semen volume. It is the first test and the most informative one. But a semen analysis is not proof of fertility, and reading it correctly calls for three precautions that are often overlooked:
- One abnormal result is not a diagnosis
- Sperm production varies with a recent fever, the length of abstinence, stress and infections. An abnormal result is usually repeated a few weeks later before any conclusions are drawn.
- A normal result does not rule out a male factor
- Some functional problems go undetected by a standard semen analysis. One example is sperm DNA fragmentation, which is assessed with additional tests when it is suspected.
- Reference values are statistical, not a fertility cutoff
- Falling below the reference range lowers the chance of pregnancy per cycle; it does not make pregnancy impossible. Being above it does not guarantee a pregnancy.
What the workup includes beyond semen analysis
- Clinical evaluation and physical exam
- Testicular volume, whether a varicocele is present, and abnormalities of the reproductive ducts.
- Hormone testing
- Testosterone, FSH, LH and prolactin, which help tell whether the problem lies in sperm production or in sperm transport. See also Andropause and testosterone replacement therapy.
- Imaging
- Scrotal ultrasound and, in selected cases, MRI.
- Additional tests
- Sperm DNA fragmentation, genetic evaluation and karyotyping when results are severely abnormal.
Treatments
- Correcting identifiable causes
- A varicocele when there is a real indication for repair, hormonal disorders, infections, and current medications that interfere with sperm production.
- Medical and lifestyle optimization
- Weight control, quitting smoking, cutting back on alcohol, managing diabetes, and changing whatever habits can be changed. Antioxidant supplements have also been studied for their effect on semen parameters. I published a meta-analysis on this subject, and the honest conclusion is that there is a benefit for some outcomes, but supplements are far from the solution their marketing suggests.
- Sperm retrieval
- When there are no sperm in the ejaculate (azoospermia), surgical techniques can retrieve them directly from the testicle or the epididymis, making assisted reproduction possible.
- Assisted reproduction
- When it is indicated, treatment is carried out together with the fertility team. My role is to optimize the male factor before and during treatment, which improves the procedure's chances of success.
How the evaluation works
The first consultation can be done by telemedicine, including a review of any test results you already have. Couples often attend together, and that usually helps.
Frequently asked questions
Which of us has the problem?
That is not the most useful question. A male factor is present in about half of cases, often alongside a female factor, and in some couples no clear cause is found in either partner. Both partners are evaluated at the same time because treatment depends on the full picture, not on deciding whose fault it is.
Does an abnormal semen analysis mean I can't have children?
No. A semen analysis measures probability, not possibility. It is not proof of either fertility or infertility. Mild and moderate abnormalities are compatible with natural conception, and many have a treatable cause. An abnormal result is the start of the workup, not its conclusion.
How long does the male workup take?
It is usually quick. Semen analysis and hormone test results are ready within a few days, and the initial evaluation is completed in one or two consultations. Precisely because it is quick and inexpensive, the man's workup should start alongside his partner's, not after it.
Do supplements improve fertility?
There is evidence that some antioxidants benefit semen parameters, but the effect is modest and does not replace finding the cause. Taking supplements without a diagnosis often delays the treatment that would actually solve the problem.
