Male Infertility


Male infertility is the inability of a man to cause pregnancy to a fertile woman.

It is a common reason for a man to see the urologist for this condition.

Based on the WHO (World Health Organization definition, infertility is the inability of a sexually active, non-contracepting couple to achieve pregnancy in one year. The male partner can be evaluated for infertility or subfertility using a variety of clinical interventions, and also from a laboratory evaluation of semen.

The causes of male infertility include:

  • Sperm disorders
  • Varicocele
  • Retrograde ejaculation
  • Immunologic infertility
  • Obstruction of the sperm passages
  • Hormonal disorders
  • Certain medications

The various causes include chronic illnesses like kidney failure, past childhood infections like mumps, and genetic / chromosome problems and hormonal disorders.


The diagnosis of this disorder require:

A thorough clinical history and examination by the urologist, including:


  • illness or injury affecting testes,
  • pubertal development
  • sexual performance
  • fertility exposures
  • occupation, habits

Physical examination:

  • general examination
  • virilization features
  • presence of enlarged breasts (gynecomastia)
  • body proportions and BMI
  • scrotal examination
  • testicular size assessment
  • examination of the epididymides, vasa (sperm tubes), and presence of varicoceles (dilated veins around the testicles)

Semen analysis

Imaging – Scrotal ultrasound, transrectal ultrasound of prostate and seminal vesicles, magnetic resonance imaging of pituitary may be required. Transrectal ultrasound may be required if an obstruction of the sperm passages are suspected

Hormonal testing – including Luteinizing hormone, follicle-stimulating hormone and testosterone. When indicated – prolactin

Testis biopsy – may be required if indicated, by needle aspiration or open technique

Semen Analysis

It is important to follow the proper sample collection:

  • The man is asked to abstain from sex/masturbation for 2–7 days before a semen sample is collected to maximize the quantity of the ejaculate and concentration of the sperm.
  • Abstinence should not be more than 7 days
  • Semen is collected after masturbation into a sterile container. It should not be collected in a condom as there will be spermicidal agents within the condom.
  • Semen analysis should be performed within an hour of sample collection. If done at home, the collection should be kept at body temperature closely held near the chest and brought immediately to the lab within the hour, during office-hours.

How do I collect the sample?

Samples are either produced on site in the dedicated sample rooms or at home in certain cases.

  • Ensure that you have been provided with a completed semen analysis request form from your doctor and they have indicated the test required is a post vasectomy semen analysis. Abstain from any sexual activity for two to five days but for no more than seven days.
  • Always provide the sample during office hours as it needs to be interpreted and reported immediately. Preferably give the semen sample on the morning of the working day. If not, the report may falsely show dead sperms and give an impression that there are no viable sperms in your semen.
  • Thoroughly wash, rinse and dry your penis, testicles and hands before you produce the sample
  • If producing the sample at home; masturbate and collect the sample into the container making sure you tightly cap it and place it in the self-sealing bag provided. Immediately transport the sample to the center keeping it close to the body for example in a jacket pocket during transportation. Avoid temperature extremes during transportation.
  • If producing at the center, masturbate and collect the sample into the container making sure you tightly cap it and give it to the laboratory.
  • Inform us if any of the sample is missed during production. Most of the sperm in the ejaculate are contained in the first part. If you do miss some of the sample we may ask you to repeat the test to ensure an accurate result can be provided.

Your semen specimen obtained at home can be brought by yourself to the hospital only if:

  • It can be in the laboratory within half hour of collection, and
  • It is kept at room temperature during that time.

It is still the best that you produce your semen specimen while you are at the hospital itself.

Please note that masturbation is the only recommended method for collecting the sample ‘cleanly’ for analysis. The withdrawal method (vaginal, oral or anal) is not recommended as it is likely that some of the sample will be lost and may in any case be contaminated. The first part of the ejaculate contains most of the sperm so this is particularly important.

Ordinary condoms cannot be used for collection during masturbation as these contain a spermicide which will kill any sperm in the ejaculate.

Please note the following important instructions and guidelines for semen collection:

  • The sample should be collected after a minimum of 2 days, and a maximum of 7 days, of sexual abstinence.
  • If you choose to collect the specimen at home, it must be collected in a clean specimen container with a secure lid, such as one with a screw-on cap. If you do not have the proper container, please contact the Urology clinic to obtain a sterile container for collection. Do not bring the specimen in a bag, or a condom, etc.
  • The specimen must be collected by masturbation directly into the container. Avoid use of lubricants as they are toxic to sperm. It is important to collect an entire specimen and it is critical that you notify the lab if any of the semen was lost.
  • Because sperm are very sensitive to temperature changes that might be encountered during transport, the best place to collect the specimen is here in the hospital.
  • If you perform the semen collection at home, please make certain that you bring it to the lab within 30 minutes and kept at body temperature.

How will my sample be tested?

We examine the sample under the microscope to determine if any sperm are present in the sample and carry out the following tests:

  • Sperm volume.
    We record the actual volume in millilitres of the semen sample you provided. We do not expect you to fill the container; an average ejaculate will be around 2.5 ml but some men will produce more or less semen.
  • Sperm concentration (sperm count).
    Reported as millions per millilitre of semen. We use a microscope to identify if sperm are present in a droplet of your sample and if any are, we count the number of sperm in the sample using a special counting chamber and report this finding to your doctor.
  • Sperm motility
    If sperm are present in the sample, the sperm are grouped into four groups with the strongest swimmers (grade ‘a’) being the most fertile. If there are motile sperm in your sample we cannot grant you clearance as just a single motile sperm could fertilize an egg.
  • Sample centrifugation
    If no sperm are seen from the droplet of sperm examined we load the whole sample into a test tube and spin it in a machine called a centrifuge which causes any cells in the sample (including sperm) to form a concentrated ‘pellet’ in the bottom of the tube. This can then be harvested and examined under the microsope to confirm whether or not there are sperm present in your sample.

The following are the normal characteristics of the semen analysis:


Normal findings


1.5 – 5 mL


Whitish, opalescent


Complete within 30 minutes


Basic 7.2–8.0

Total number of sperm per ejaculate

> 39 million per ejaculate

Sperm concentration per mL

> 15 million per mL

Vitality (percentage of live sperm)

> 58% live sperm

Morphology (percentage of normal forms)

> 4% sperm are morphologically normal.

Total motility (progressive and non-progressive sperm)

> 40%

Progressive motility

> 32%

Fructose in seminal plasma

> 13 μmol/L

Leukocytes per mL of semen

< 1 million


The following is the WHO range of normal semen analysis:


WHO reference range

Total sperm count in ejaculate

39–928 million

Ejaculate volume

1.5–7.6 mL

Sperm concentration

15–259 million per mL

Total motility (progressive and non-progressive)

40–81 percent

Progressive motility

32–75 percent

Sperm morphology

4–48 percent

The various terms used for the abnormalities of the semen analysis are:

  • Oligospermia or oligozoospermia – decreased number of spermatozoa in semen
  • Aspermia – complete lack of semen
  • Hypospermia – reduced seminal volume
  • Azoospermia – absence of sperm cells in semen
  • Teratospermia – increase in sperm with abnormal morphology
  • Asthenozoospermia – reduced sperm motility
  • Necrozoospermia – all sperm in the ejaculate are dead
  • Leucospermia – a high level of white blood cells in semen
  • Normozoospermia or normospermia – It is a result of semen analysis that shows normal values of all ejaculate parameters by WHO but still there are chances of being infertile. This is also called as unexplained Infertility


The following are the definitions of the abnormal conditions in semen parameters:




No ejaculate


Low ejaculate volume (< 1.5 mL)


No spermatozoa in the ejaculate


< 1 million spermatozoa/mL of ejaculate


< 15 million spermatozoa/mL of ejaculate


< 32% of spermatozoa show progressive motility (category PR)


Increased amorphous spermatozoa


(OAT syndrome)

Signifies disturbance of all three variables:

Low concentration, insufficient motility, and increased amorphous spermatozoa

Urological treatment

The urological treatment of male infertility would be based on the cause of the infertility and various other factors.

It is best to see a urologist and discuss these issues with them.

Coital disorders (improper or failed sexual intercourse)

They include erectile dysfunction, failure of ejaculation, premature ejaculation and retrograde ejaculation. The urologist will be able to discuss these treatment options.


If your semen has no sperm (azoospermia), investigations will be done to find out if this is due to obstruction (blockage) or not. If there is an obstruction, there are various surgical choices which will be discussed.

Ejaculatory duct obstruction

This will require transurethral resection of the ejaculatory duct (TURED)

In this, a scope is passed into the urethra (the tube inside the penis) and a small resection is made in the ejaculatory duct. The success rates for this is about 60-70%.


Varicocele treatment in infertility needs further discussions, and it is best to discuss this with the urologist concerned. Surgical options involve ligation of the varicocele.

Treatment of unknown causes and non-specific treatment of male infertility

These include the various Assisted Reproductive Techniques (ART) which includes Intrauterine Insemination (IUI), In-vitro fertilization (IVF), Intracytoplasmic sperm injection (ICSI) and various other techniques done by the gynecologists specialized in infertility.

There are still other options available when all the above fails, including the option of adopting a child.