Overview.
Male factor infertility accounts for approximately 50% of infertility cases in couples, yet male evaluation is frequently delayed until after female workup completes. The ASRM recommends simultaneous evaluation of both partners. The male fertility panel combines semen analysis (the foundational test) with a hormonal blood panel, and adds genetic testing when specific patterns are identified.
Semen analysis evaluates sperm count, concentration, motility, morphology, and vitality using WHO 6th edition (2021) reference values. The hormonal panel measures total testosterone, FSH, LH, prolactin, estradiol, and SHBG to identify gonadal dysfunction. Genetic testing (Y microdeletion, karyotype, CFTR) is added for severe oligozoospermia or azoospermia.
What's included.
- Sperm Concentration — normal: ≥16 million/mL · WHO 6th ed. lower limit; below = oligozoospermia
- Total Sperm Count — normal: ≥39 million/ejaculate · Concentration x volume; most clinically useful metric
- Progressive Motility — normal: ≥30 % · Sperm swimming forward; most important motility type
- Normal Morphology (Kruger strict) — normal: ≥4 % · Even fertile men have only 4-15% normal forms
- Total Testosterone — normal: 300-1000 ng/dL · Hypogonadism if <300; affects spermatogenesis
- FSH — normal: 1.5-12.4 mIU/mL · Elevated = impaired spermatogenesis or testicular failure
- LH — normal: 1.7-8.6 mIU/mL · Elevated LH + low T = primary hypogonadism
- Prolactin — normal: <15 ng/mL · Elevated = prolactinoma or medication effect
Preparation.
No fasting required.
When: No cycle timing needed (unlike female testing). Testosterone should be drawn in the morning for accuracy. Semen analysis requires 2-7 days abstinence — shorter reduces count, longer reduces motility.
- Semen analysis: 2-7 days of sexual abstinence before collection
- Deliver sample to lab within 30-60 minutes at body temperature
- If incomplete collection, note on form — major source of false abnormals
- Blood draw: testosterone ideally drawn 7-10 AM (peak levels)
- Prolactin: draw fasting and relaxed
- Two semen analyses minimum, 2-3 months apart, before drawing conclusions
When it's ordered.
- Partner has been trying to conceive for 12+ months (under 35) or 6+ months (35+)
- Should be ordered simultaneously with female partner's evaluation
- Known risk factors: undescended testes, prior chemotherapy/radiation, varicocele
- History of anabolic steroid or TRT use
- Sexual dysfunction or low libido
- Gynaecomastia or other signs of hormonal imbalance
- Recurrent miscarriages in partner
Interpretation.
What normal means
Sperm parameters meet WHO 6th edition reference limits, hormones support spermatogenesis, and no pattern suggests obstruction or gonadal failure. Normal results do not guarantee fertility — they indicate male factor is unlikely to be the primary cause.
Abnormal patterns
Low concentration + Normal hormones + Normal volume (Oligozoospermia)
Possible causes
- Varicocele (most common correctable cause)
- Environmental/lifestyle factors
- Idiopathic (no identified cause in ~50% of cases)
Next steps
- Repeat semen analysis in 2-3 months
- Scrotal ultrasound to evaluate for varicocele
- Lifestyle optimisation (heat avoidance, alcohol reduction)
No sperm + Normal hormones + Low volume (Obstructive azoospermia)
Possible causes
- Congenital bilateral absence of vas deferens (CBAVD)
- Ejaculatory duct obstruction
- Prior vasectomy
Next steps
- CFTR mutation testing for CBAVD
- Transrectal ultrasound
- Reproductive urologist referral
- Sperm retrieval (TESE/PESA) has >90% success
No sperm + Elevated FSH (>12) + Small testes (Non-obstructive azoospermia)
Possible causes
- Klinefelter syndrome (47,XXY)
- Y chromosome microdeletion
- Prior chemotherapy/radiation
- Maturation arrest
Next steps
- Karyotype analysis
- Y chromosome microdeletion testing
- Micro-TESE (sperm retrieval success 25-60%)
- AZFa/AZFb deletions = near-zero retrieval prognosis
Low testosterone + Low/normal FSH + Low/normal LH (Secondary hypogonadism)
Possible causes
- Pituitary disorder
- Hyperprolactinaemia
- Exogenous testosterone/steroids
- Obesity
- Opioid use
Next steps
- Check prolactin
- Pituitary MRI if prolactin elevated
- Discontinue exogenous testosterone
- Consider gonadotropin therapy (FSH + hCG)
Cost & access.
Semen analysis costs $50-200 without insurance. Hormonal panel adds $100-300. Genetic testing (if indicated) adds $200-500. Most fertility clinics offer bundled pricing. Insurance typically covers with infertility diagnosis.
FAQs.
One abnormal semen analysis — does that mean I'm infertile?
No. Semen quality varies substantially within the same individual. A febrile illness 2-3 months prior, stress, incomplete collection, or wrong abstinence window can all produce a below-reference result. At least two analyses, 2-3 months apart, are needed before drawing conclusions.
My morphology is only 3% — is that terrible?
It's below the WHO reference limit (4%), but even in fertile men, only 4-15% of sperm have normal morphology under strict criteria. Many men with 1-3% morphology father children naturally. Morphology is most relevant in conventional IVF; ICSI largely bypasses morphology as a barrier.
I'm on testosterone replacement — does that affect fertility?
Yes, significantly. Exogenous testosterone directly suppresses FSH and LH, shutting down sperm production. Azoospermia can develop within weeks of starting TRT. If fertility is desired, discuss switching to gonadotropin therapy (FSH + hCG) with a reproductive urologist. Recovery after stopping TRT can take 12-24 months.
How quickly can lifestyle changes improve results?
Spermatogenesis takes approximately 74 days. Any intervention needs at least 3 months before its effects appear in a semen analysis. Products claiming rapid improvement are not evidence-based.