Male Factor Evaluation — half the picture, equally important.

Why this matters

Male factor infertility is statistically as common as female factor and is involved in nearly half of all infertility cases. Yet it's the most under-investigated and most often deflected piece of the workup. Couples spend months on female-focused interventions when a basic semen analysis would have changed the plan from the start.

In my practice, both partners are evaluated together. There is no "first we work on the woman and circle back to the man if things don't work" approach. The male workup happens in parallel from day one.

The basic workup — semen analysis

A semen analysis is the cornerstone test. It measures:

• Volume — the amount of ejaculate (normal: above 1.4 mL).
• Concentration — sperm count per mL (normal: above 16 million/mL).
• Total count — concentration × volume (normal: above 39 million total).
• Total motility — percentage of moving sperm (normal: above 42%).
• Progressive motility — sperm moving forward effectively (normal: above 30%).
• Morphology — percentage of normally shaped sperm (normal: above 4% using strict criteria).
• Vitality — percentage of live sperm (normal: above 54%).

These thresholds are WHO 2021 lower reference limits — the bottom of the fertile range, not optimal values. Pre-test preparation matters: 2–5 days of abstinence, sample collected in a clean container, analysed within 1 hour.

Beyond the basic — second-line tests

DNA fragmentation index

Measures the integrity of sperm DNA. High fragmentation is associated with lower natural conception, lower IUI success, more miscarriages, and sometimes lower IVF success. Worth testing in unexplained infertility, recurrent miscarriage, and failed cycles.

Hormonal profile

FSH, LH, testosterone, prolactin, sometimes oestradiol. Identifies hypogonadism, pituitary issues, hyperprolactinaemia. FSH is particularly useful: high FSH suggests primary testicular failure; low FSH suggests pituitary problem.

Scrotal ultrasound

Detects varicocele, testicular masses, vas deferens abnormalities. Indicated when the physical examination raises concern.

Karyotype and Y-microdeletion

In severe oligozoospermia or azoospermia. Klinefelter syndrome, Y-chromosome microdeletions, and balanced translocations can be identified.

Anti-sperm antibodies

Identifies immune-mediated infertility. Worth testing after vasectomy reversal, testicular trauma, or persistent unexplained findings.

Common findings and what they mean

• Oligozoospermia — low sperm count.
• Asthenozoospermia — low motility.
• Teratozoospermia — abnormal morphology.
• Oligoasthenoteratozoospermia (OAT) — combined deficits.
• Azoospermia — no sperm in semen (obstructive vs non-obstructive).
• Hypogonadism — low testosterone, treatable with appropriate management.

Treatable causes

• Varicocele — the most common identifiable, treatable cause. Varicocelectomy improves sperm parameters in 60–70% of cases.
• Hormonal imbalances — hypogonadism, hyperprolactinaemia, thyroid disorders.
• Infections — chronic prostatitis, epididymitis.
• Lifestyle factors — smoking, alcohol, obesity, heat exposure (saunas, tight clothing, laptops on lap).
• Medications — some hypertension drugs, steroids, certain antibiotics. Review and adjust where possible.
• Oxidative stress — antioxidants for 3 months can improve DNA fragmentation.

Many of these are reversible over 3–6 months. Sperm production cycle is 72 days, so any intervention takes about 3 months to show measurable change.

When IVF or ICSI is the right step

IVF with ICSI becomes the right path when:

• Sperm parameters are too low for IUI even after medical optimisation.
• DNA fragmentation index is very high and conservative measures haven't helped.
• Surgical sperm retrieval is needed (azoospermia).
• Previous cycles of conservative treatment and IUI have failed.

Surgical sperm retrieval — for azoospermia

• PESA (percutaneous epididymal sperm aspiration) — for obstructive azoospermia.
• TESA (testicular sperm aspiration) — for obstructive azoospermia or some non-obstructive cases.
• Micro-TESE (microsurgical testicular sperm extraction) — for non-obstructive azoospermia. Retrieves usable sperm in 40–60% of cases despite no sperm in the ejaculate.

Retrieved sperm is used immediately for ICSI or frozen for later cycles.

The emotional side — what often goes unspoken

Male factor infertility carries stigma that female infertility largely doesn't. Men often hear "you're fine" too quickly, or receive their abnormal semen analysis with little context or follow-up. Some men avoid the workup altogether out of fear of what it might find. None of that improves outcomes — and it makes the couple's overall experience harder.

In my practice, I evaluate both partners in parallel. The male workup is presented matter-of-factly, with clear next steps regardless of result. No deflecting.

How I work

From the first consultation, both partners are scheduled for parallel evaluation. The semen analysis happens in the first 2 weeks alongside the female workup. Results are reviewed together, not separately. If the male partner has identifiable findings, we move on treatment in parallel with female monitoring — not in series. Time matters.