Male infertility is a common problem, one that effects approximately 45% of couples having difficulties conceiving. It can be defined as any issue with the male’s biology that reduces the couple’s chances of conceiving. The good news is that with modern treatment techniques, even severe male factor patients can become fathers.
No matter the severity of the infertility in the men we treat, ORH has the knowledge and tools to help them become fathers.
The Diagnosis of Male Infertility
The initial diagnosis of male infertility is carried out primarily with a semen analysis. During a semen analysis we look at many different parameters, however, the three most important are:
- Sperm motility – The % of the sperm in the sample that are moving at room temperature. Having adequate motility in important to ensure the sperm can reach the egg to fertilize it. The reference range at our clinic is 40% or greater.
- Sperm morphology – a detailed look at the appearance of the sperm using a strict criteria. Abnormally shaped sperm are less likely to be able to successfully fertilize and egg. The reference range at our clinic is 15% or greater normal shapes.
- Sperm count – The total number of sperm in a milliliter (mL) of the sample. Having a lower count makes it harder for adequate sperm to reach the uterus in order to fertilize the egg. The reference range at our clinic is 20 million/mL or greater.
We also look at a variety of other less important characteristics that can effect how effective the sperm are such as: viscosity of the sample, forward progression of the sperm, and sperm agglutination (which can be an indicator that sperm antibodies are present).
While a semen analysis is the primary test to diagnosis male infertility, the truth is that each of the parameters above do not mean much by themselves. What our expert male fertility specialists look at is the big picture. Specifically, will the sperm be able to fertilize an egg. If the semen analysis comes back normal, it is very likely that sperm will function as it should. When one or more of the parameters come back abnormal then we can assume a problem may be evident based on the severity of the abnormality.
Other Semen Tests
In some cases, what we find in the original semen analysis can lead us to recommend additional testing.
- Sperm Antibody Screening – There are two tests that assess for sperm antibodies. The first is a simple test called a MAR Screen. The MAR screen is a test that rules out sperm antibodies, however it cannot confirm the presence of sperm antibodies. If the MAR comes back positive, then a more accurate Immunobead Test (IBT) will be ordered to conclusively confirm the presence of the antibodies. For reference, the presence of sperm antibodies can interfere the ability of sperm to fertilize an egg.
- Leucoscreen – This test is ordered for semen samples that contain a high round cell count. Round cells are commonly found in the ejaculate and can be a variety of different cells. A luecoscreen is ordered to determine if any of the round cells are white blood cells (leukocytes). The presence of white blood cells can be an indication of an infection, which should be treated as soon as possible after the initial diagnosis.
- Sperm Viability Testing – This test is for sperm samples that exhibit a very low motility and is used to assess what percentage of the sperm are alive. It is possible for sperm to still be alive and able to fertilize an egg, and exhibit zero motility.
Male Fertility Diagnoses
There are a variety of abnormalities that a semen sample can have. Below are some of the more common ones and the clinical criteria used at ORH to diagnose them. Other labs may use different criteria for each parameter as the methodologies used to measure each thing can vary widely. The information below is for educational purposes only, and should not be used to make any diagnostic decisions.
- Oligozoospermia – Reduced sperm count. At the ORH lab we consider a sample analyzed with less than 20 million sperm per milliliter to be abnormal.
- Asthenozoospermia – Reduced sperm motility. At the ORH lab any sample with less than 40% motile sperm at room temperate is considered abnormal.
- Teratozoospermia – Reduced sperm morphology. At the ORH lab any sample with less than 15% normal shapes are considered abnormal.
The above conditions can also be combined if a sperm sample exhibits multiple abnormalities. For example, a sample that exhibits all three conditions above will be labeled, Oligoasthenoteratozoospermic.
- Azoospermia – A more serious condition that can occur in some males where there is no sperm contained in the ejaculate. Any samples that exhibit azoospermia are carefully analyzed for sperm, then, if sperm are not seen, concentrated and reanalyzed. Often once a patient is suspected of azoospermia, the doctor will then assess for the presence of retrograde ejaculation (sperm in the urine) before moving to more aggressive recommendations.
Causes of Male Infertility
There are quite a few causes of male infertility and all of them can affect the quality, quantity, or both, of the sperm.
- There is a blockage in the sperm’s passage. Could be from birth, scarring from an infection, past vasectomy… etc.
- Sperm production is impaired in the testes. There are many things that could cause this, including hormonal abnormalities.
- Retrograde ejaculation. A condition where semen is ejaculated into the bladder.
- Other issues with the ejaculate, such as the presence of sperm antibodies, and/or white blood cells.
- Lifestyle factors: Smoking, drug use, being overweight and a variety of other factors can impact sperm production negatively.
Treatment for Male Infertility
Treatment varies depending on the cause, and severity of the male infertility. In mild cases use of intrauterine insemination (IUI) may be sufficient. During an IUI the semen sample is concentrated and cleaned in the laboratory and then injected directly into the uterus. If the cause is hormonal in origin then hormone treatments might be recommended. Some mild cases can also be treated through lifestyle changes. However, it is important to note that any lifestyle or medical intervention that a man goes through in order to improve their sperm count will take time to be effective. The male sperm production process is a lengthy one that takes about three months from start to finish. This means that it can take up to three months for any changes to make a noticeable difference.
In more severe cases, in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) may be indicated. Through the use of ICSI, we can achieve very high fertilization rates, even in severe male factor cases.
Even the most severe cases of male factor infertility, where there is no sperm in the ejaculate (clinically referred to as azoospermia) can be treated. If you have been diagnosed with azoospermia there is still a possibility that you have some degree of sperm production in the testes, but its delivery to the ejaculatory ducts has been blocked. In these cases, surgery can be used to determine if there is still sperm being produced in the testes, and if so to retrieve enough for fertility treatments. The most common type of surgical intervention is a testicular biopsy (sometimes called a testicular aspiration). This procedure can be used to further diagnose the issue and retrieve enough healthy sperm, if they are present, to be used in an IVF cycle paired with ICSI. It is also possible to freeze the sperm for use in a later IVF cycle, or to use one aspiration for multiple cases if enough sperm are found. However, this will vary depending on individual factors. We almost always recommend a fresh sample whenever possible as the freezing/thawing process is detrimental to sperm quality and, generally, only a small amount of sperm is obtained through these procedures.
Whatever the cause, our specialists at ORH have extensive training and experience with the diagnosis and treatment of male infertility. Please contact us if you have any questions or would like to schedule a consultation to discuss your options.
Male Infertility FAQs
Infertility is slightly more common in women. About 40-50% of couples with difficulty conceiving will have some sperm issues, ranging from mild to severe problems. Sometimes this is the only reason for a couple’s infertility, and sometimes male infertility problems and female infertility issues occur together in both partners.
Part of the reason that women have more infertility issues is that getting older often has more effect on female fertility than on male fertility, as a woman makes few, if any, new eggs in her lifetime, with a peak number of eggs at birth. The number and quality of eggs left (ovarian reserve or egg supply) declines in women in their 30’s and 40’s, and rarely in their 20’s. Men have less consistent effects of aging, as they make new sperm all the time, so some men in their 50’s or 60’s may have little or no sperm problems.
There are several different standards for morphology reporting. There is an older standard called WHO morphology, where 30% normal forms is a ‘perfect score’. The most common method of reporting nowadays is called Kruger or ‘strict’, where the ideal range is 15% or greater normal morphology.
To answer your original question: yes, low morphology means your husband may be ‘subfertile’ and it may be harder to conceive naturally. Dr Kruger’s group compared morphology with other numbers like count and motility, and all were helpful at identifying men with subfertility, with a value of under 5% for strict morphology being the suggested cutoff. More abnormal shaped sperm means he may have more sperm with genetic abnormalities.
Even if the abnormal morphology test was done at a fertility clinic using the Kruger or strict morphology, one repeat semen analysis 1-2 months after the first is still a good idea.
None of the sperm tests are 100% predictive, though – you may still get pregnant ‘easily’ as it only takes one good sperm to fertilize an egg.
I recommend seeing a Fertility specialist (Reproductive Endocrinology and Infertility or REI MD) for further testing and advice, if you aren’t already seeing one.
We can’t make your husband do a test he doesn’t want to but it’s a bad idea to ‘skip’ testing for him. In couples who aren’t getting pregnant after trying for a year or longer, almost half the time there is a sperm issue (40-50% of couples). It could be the only problem or occur along with problems on the woman’s side. A Semen Analysis is a good test to do early on. A Semen Analysis can be collected at home if you live less than an hour away. It is possible to start with your tests and do the Semen Analysis later if your husband is unwilling to be tested early on we can discuss the test with your husband at the first visit or at the second meeting, when we go through fertility testing results and make a treatment plan.
Men with low morphology (% of normal-shaped sperm) may have more genetically abnormal sperm. Morphology testing is far from a perfect test but may mean that you need more workup or can change fertility treatment recommendations. More genetically abnormal sperm increases the chance of miscarriage or chromosomally abnormal pregnancy, but does not cause common birth defects. Morphology has two different standards – the ‘strict’ or Kruger morphology standard, where 15% is a perfect score and < 5% is very low, is a more useful test than the older World Health Organization or WHO standard, where 30% is a perfect score, for men trying have a child â€“ this test should be done at a Fertility clinic.
I recommend getting a Semen Analysis ‘done right’ at a Reproductive Endocrinology and Infertility clinic rather than at a hospital or a general medical testing lab such as Labcorp or Quest. We have trained Andrologists, using the correct equipment and microscopes, and quality control standards to give you the most accurate results. A complete Semen Analysis looks at Sperm Count (the concentration of sperm per milliliter of semen), Motility (the percentage of moving sperm), Morphology (the % of normal-shaped sperm), and a screening test for Sperm Antibodies. Morphology has two different standards – the ‘strict’ or Kruger morphology standard, where 15% is a perfect score and < 5% is very low, is a more useful test than the older World Health Organization or WHO standard, where 30% is a perfect score, for men trying have a child.
We review his medical and lifestyle history, including alcohol, tobacco and prescription medication use, and recommend a Semen Analysis for fertility testing. When both partners attend fertility visits (preferred but not mandatory), the man may look bored, or nervous, or rarely embarrassed by the whole fertility thing. Some can find the humor in the situation which helps. Men with significant sperm issues benefit from a scheduling a physical exam with a Urologist at a later date; men with normal or near-normal sperm tests don’t need to get a physical exam, so the embarrassment factor should be fairly low. A Semen Analysis can be collected at home if you live less than an hour away.
Not right away. If only one sperm count was zero (azoospermia), he should repeat the test 1-2 months later – make sure it’s at a fertility clinic where if there are ‘no sperm’ they can centrifuge or ‘spin down’ the semen so that even a few sperm will be seen. If no sperm are seen again he will need hormonal testing, and genetic tests – karyotype and Y chromosome microdeletions (YCMD), and we will refer him to a Urologist for a physical examination. Most men have sperm that can be surgically retrieved, but certain YCMD mean that a testicular biopsy should not be done.
Absolutely. In all couples not getting pregnant after a year or more trying, the male partner should get a Semen Analysis; 40-50% of these men have a sperm issue, ranging from mild to severe sperm problems. About half the time the sperm issue is the only problem, and the other half have male and female factors together, like blocked tubes or low egg supply. If your sperm test is normal you don’t need much else in the way of testing. Men with abnormal sperm counts may need hormonal or genetic blood work.
Yes, it is very common. In couples trying to conceive without success we find a sperm issue about 40-50% of the time, ranging from mild to severe sperm problems. Semen analysis is an important part of infertility testing. Sometimes the sperm issue is the only problem we find when we test both partners, but often there are male and female factors together. Even if the man’s sperm is ‘normal’ it helps a lot if the male partner is supportive.
We may do hormonal tests, looking for low testosterone, high estrogen, thyroid or prolactin issues or abnormal LH or FSH hormone levels. Some men get better sperm with treatment of hormone problems. Some men need genetic tests, and/or a consultation with an Urologist. Mostly we treat mild to medium sperm problems with Intrauterine Inseminations (IUI) where washed sperm is placed inside the woman’s uterus; severe sperm problems need IVF with ICSI (In Vitro Fertilization with Intracytoplasmic Sperm Injection) or use of donor sperm. No sperm (azoospermia) or very severe sperm problems may need a surgical sperm retrieval procedure.
Unfortunately, there is no treatment for severe male infertility that is 100% guaranteed to work using your own sperm. Donor sperm is the closest thing for couples where the male partner has azoospermia as it’s sperm from healthy men without known fertility issues. Having said that, many men with azoospermia can have children using their own surgically-retrieved epididymal or testicular sperm, combined with IVF with ICSI (In Vitro Fertilization with Intracytoplasmic Sperm Injection). A genetic test identifies some men ahead of time who won’t get sperm at retrieval. Having Donor sperm as a backup is a good idea.
Azoospermia (no sperm or no living sperm) could be due to obstruction (blockage) or a sperm production issue. It should be confirmed by more than one semen analysis: a fertility clinic will ‘spin down’ a sample with no sperm so that we can find very low numbers of sperm. Many men still have some sperm production, so sperm can be surgically retrieved for IVF with ICSI (In Vitro Fertilization with Intracytoplasmic Sperm Injection), or donor sperm can be used for fertility treatment such as Intrauterine Inseminations (IUI) . See a Fertility MD (Reproductive Endocrinology and Infertility or REI) for help.
Azoospermia should be diagnosed by an Andrology lab at a Fertility clinic or a Urology clinic. More than one semen analysis is needed to confirm the diagnosis. If we see a semen sample with no sperm we use a centrifuge to ‘spin down’ the specimen so that we can find very low numbers of sperm. See a Fertility MD (Reproductive Endocrinology and Infertility or REI) for a complete Semen Analysis test. Even if you have a microscope at home I don’t recommend home testing for this condition.
A Semen Analysis through a fertility clinic is a good place to start for him. In couples who aren’t getting pregnant after trying for a year or longer, almost half the time there is a sperm issue (40-50% of couples). It could be the only problem or occur along with problems on your side. He should also quit tobacco use, cut down alcohol if he has moderate to heavy drinking habits, avoid using drugs, and aim for a normal weight.
The World Health Organization defines oligozoospermia as less than 20 million sperm per ml (milliliter). More recent studies show that in men with proven fertility, the lower limit of normal is around 15 million sperm per ml. Semen Analysis should be done through a Fertility clinic or a Urology lab not a general medical testing lab, and an abnormal result needs a second test 1-2 months later for confirmation.
Oligozoospermia means a low sperm count. Any abnormal Semen Analysis needs a second test 1-2 months later for confirmation, ideally through a fertility clinic. Hormonal testing may identify treatable problems, and tablets may improve sperm; hormone shots are needed very rarely. Mild to medium low sperm count is often treated with Intrauterine Inseminations (IUI), where washed sperm is placed inside the woman’s uterus. Severe sperm problems need IVF with ICSI (In Vitro Fertilization with Intracytoplasmic Sperm Injection) or the use of donor sperm.
An abnormal semen analysis, such as a low sperm count, always needs a second test 1-2 months later for confirmation. Based on how low the count is, and/or sperm quality tests like motility and morphology (the % of normal-shaped sperm) are, we may do hormonal or genetic blood work. In some guys taking tablets or rarely shots can increase count. Men who are overweight may get better sperm numbers and quality by losing weight, and men should cut down heavy alcohol use and quit using tobacco, avoid illegal drugs and anabolic steroids, and review any prescription drugs with their MD.
Men who are overweight may get better sperm numbers and quality by losing weight, and men should cut down heavy alcohol use and quit using tobacco, avoid illegal drugs and anabolic steroids, and review any prescription drugs with their MD. An abnormal semen analysis, such as a low sperm count, always needs a second test 1-2 months later for confirmation.
They should have no major effects on sperm count. I’m assuming you’re talking about ‘regular’ prescription corticosteroids like triamcinolone (Kenalog) – these have little to no effect on sperm, unlike anabolic steroids like testosterone or Dianabol, which can cause major reductions in sperm count. Some studies indicate that heavy use of Non-Steroidal Anti-Inflammatory Drugs or NSAIDs, including aspirin, may affect sperm motility and sperm morphology (the % of normal-shaped sperm) as well.
Get a Semen Analysis at a fertility clinic or a urology office rather than a general medical testing lab. Home sperm tests are not very useful, and you can’t tell by looking at your semen. If you’re not trying to conceive assume you’re fertile; if you and your partner are trying to conceive without success you should both see a fertility specialist (Reproductive Endocrinology and Infertility or REI) for testing and individualized treatment.