How do I assess male factor infertility, and what tests are appropriate for initial evaluation?

Assessment of male factor infertility begins with a detailed clinical history and physical examination focusing on previous genital pathology, urogenital surgery, sexually transmitted infections, varicocele, systemic illness, and any abnormal genital findings. This initial assessment helps identify known causes of infertility and guides further testing ¹.

The primary and most important initial test is semen analysis. The semen sample should be collected by masturbation into a clean, wide-mouthed plastic container confirmed to be non-toxic for spermatozoa, after 2 to 7 days of sexual abstinence. The sample should be kept close to the body to maintain temperature and delivered to the laboratory preferably within 30 minutes and no longer than 50 minutes after collection ¹.

Semen analysis results should be interpreted using the latest World Health Organization (WHO) reference values: semen volume ≥1.5 ml, sperm concentration ≥15 million/ml, total sperm number ≥39 million per ejaculate, total motility ≥40% motile or ≥32% progressive motility, vitality ≥58% live spermatozoa, and normal morphology ≥4% ².

If the first semen analysis is normal, no repeat test is needed. However, if abnormal, a repeat confirmatory semen analysis should be performed ideally 3 months later to allow for a full spermatogenesis cycle. If there is severe sperm deficiency (azoospermia or severe oligospermia), the repeat test should be done sooner, within 2–4 weeks ¹,².

Men with two abnormal semen analyses should be referred to secondary care for further assessment. Additional investigations may include microbiological tests (e.g., chlamydia screening), endocrine tests, imaging of the urogenital tract, and testicular biopsy if indicated ¹.

Screening for antisperm antibodies is not recommended as there is no evidence that treatment improves fertility ¹,².