Male infertility: semen analysis and varicocele

What does infertility mean?

The EAU and WHO define infertility as a couple having had 12 months of regular unprotected intercourse without a pregnancy. If there has never been a pregnancy it is called “primary” infertility; if there has been one before, “secondary.” WHO calls it a disease of the male or female reproductive system and says one in six people of reproductive age experience it in their lifetime. The NHS estimates that one in seven couples has trouble conceiving.

Whether the problem lies with the man or the woman cannot be told by guessing. The EAU writes that in about half of infertile couples a male factor is found, and in about 20 percent the problem is male alone. In 30 to 40 percent of cases no specific male cause is found. The NHS also says that in about a quarter of cases no cause is found at all. WHO points out that in many places the woman is considered infertile regardless of her actual condition, which brings shame and psychological stress to both people. So it helps to know from the start that this is a couple’s issue and both partners are evaluated together, as the EAU recommends.

When should we start an evaluation?

The EAU starts the evaluation after 12 months of regular unprotected intercourse and says the man should be assessed in every couple seeking help for fertility problems. The NHS says that when the woman is under 40, more than 8 in 10 couples conceive naturally within a year. If the woman is 36 or older, or you already know there may be a problem, see a doctor sooner.

How is the man assessed?

The EAU says the man should be seen by a urologist who is familiar with male reproduction. The assessment usually covers the following.

History and examination. Lifestyle, associated conditions such as obesity, diabetes and high blood pressure, past sexual infections, testicular surgery, and use of medicines or substances that harm the testicles, according to the EAU. WHO lists male causes as: problems with ejaculation, no or low sperm, abnormal sperm shape or movement, blockage of the passage, hormonal disorders, varicocele, chemotherapy, anabolic steroids, and factors such as smoking, heavy alcohol use, obesity and environmental pollution.

Semen analysis. The EAU says it should be done according to the sixth edition of the WHO manual (2021). If the result is normal, one test is enough. If it is abnormal, at least two analyses in a row are needed, and if it is abnormal twice, further specialist work-up is needed. MedlinePlus also says that because sperm counts vary from day to day, several samples may be taken over one to two weeks. How to give the sample is covered in the test preparation guide.

The WHO (2021) lower reference limits quoted by the EAU are: volume 1.4 mL, total number 39 million per ejaculate, concentration 16 million per mL, total motility 42 percent, progressive motility 30 percent, vitality 54 percent, normal shape 4 percent. The EAU stresses that these limits are not the boundary between fertile and infertile men. MedlinePlus gives close but slightly different numbers (for example a concentration above 15 million), because references differ between labs. Always interpret your result against the reference on the same report.

Further tests. The EAU says that in a man with a low sperm count or none at all, testosterone, FSH and LH should be measured. If the count is very low, genetic testing and genetic counselling are also recommended. If a blockage is suspected, a transrectal ultrasound is suggested.

Varicocele

A varicocele is a widening of the veins around the testicle. The EAU writes that it is seen in about 15 percent of normal men, 25 percent of men with an abnormal analysis and 35 to 40 percent of infertile men, which means it is common everywhere and its presence alone is not the reason for infertility. Diagnosis is mostly by examination; if the examination is not clear, a Doppler ultrasound helps. The EAU says a vein diameter above 3 mm and reflux lasting more than 2 seconds point to a clinically significant varicocele.

Treatment is not always needed. According to the EAU:

• In an infertile man with a normal analysis, or a varicocele seen only on ultrasound that cannot be felt on examination, treatment is not recommended.
• In a man with a clinical varicocele, an abnormal analysis and unexplained infertility, treatment is considered, provided the partner has a good ovarian reserve.
• In an adolescent whose testicle has stayed small (a size difference of more than 2 mL or 20 percent at two visits six months apart), surgery is considered.

Whether these conditions apply to you can only be known through an examination and an analysis.

Lifestyle

The NHS says a BMI of 30 or above reduces fertility. Smoking, even second-hand smoke, lowers the chance of pregnancy and reduces semen quality. Heavy alcohol use affects sperm quality, and severe stress may reduce desire and sperm production. The EAU says smoking and environmental pollution are linked to oxidative stress and sperm DNA damage, but the effect of antioxidant supplements and lifestyle change has not yet been confirmed by randomised trials. So lifestyle change is good for general health and does not give a firm promise of conceiving.

What does treatment depend on?

Treatment depends on the cause. The EAU says the partner’s fertility must be assessed at the same time, because it affects the timing and the choice between assisted reproduction and surgery. The NHS names assisted reproduction methods such as intrauterine insemination (IUI) and IVF, and says IVF has risks, for example transferring more than one embryo raises the chance of twins and the risk to mother and baby. MedlinePlus says that depending on the cause, referral to a fertility specialist may be needed too. The choice of method, its cost and its availability in Iran are matters for your doctor.

A reminder

This page is for general information and does not replace an examination and a semen analysis. An abnormal test result means “we need to look more closely,” not that the road ends.