How to Proceed with an Abnormal Semen Analysis Report

Case 1

Q1. Diagnosis & WHO Guideline Edition

Oligoasthenozoospermia — a reduced sperm concentration with reduced motility, in the setting of a normal ejaculate volume — assessed against the WHO 6th Edition (2021) manual for the examination and processing of human semen.

Q2. Limitations of the WHO 5th Edition

The reference ranges in the 5th edition were considered of limited value for distinguishing fertile from infertile men. They were derived from a large cohort of fertile men with defined confidence intervals based on time-to-pregnancy (TTP) data, rather than true diagnostic thresholds. WHO itself never intended these as absolute reference values — only as suggested acceptable levels.

Further limitations included substantial day-to-day variation in parameters, and an inability to capture the functional ability of sperm.

Decision Limits (6th Edition)

Reference ranges were replaced with decision limits, classified as:

Q3. Interpreting an Abnormal Report

Before acting on an abnormal result, confirm the abstinence period observed and the completeness of the collection. Repeat testing should then follow severity:

Q4. Terminology for Abnormal Semen Analysis

Additional Terminology

Guidelines for Semen Collection

• 2–7 days of sexual abstinence before collection
• Two separate samples, at least 7 days apart, should be analyzed
• The duration of abstinence should remain constant across samples
• Masturbation in a clinical setting is the recommended method
• Collection in a private room at the same center where analysis occurs
• Container: pre-warmed (21°C), sterile, non-toxic, wide-mouthed

Q5. Precautions to Advise

• Pass urine before collection
• Wash hands with soap and dry
• Clean glans and penis with a wet paper towel (avoid soap)
• Avoid lubricants — they interfere with motility
• Collect the entire sample — ~70% of sperm is in the first part of the ejaculate

Alternative Collection Methods

• Coitus interruptus
• Condom collection — polyurethane, not latex (spermicidal)

Q6. Inadequate Erection or Ejaculation

• Phosphodiesterase type 5 (PDE5) inhibitors — 30–60 minutes before collection
• Cavernosal or subcutaneous prostaglandin injections
• Vacuum erection devices
• Vibratory stimulation — useful in spinal cord injury
• Rectal probe electro-stimulation — via efferent fibers of the hypogastric plexus

Q7–Q8. Labeling & Timing of Analysis

On the sample

• Patient name, age, clinic/doctor name

On the laboratory form

• Period of abstinence (days)
• Date & time of collection
• Mode of collection, complete or incomplete
• Time interval from collection to analysis

Timing

Incubate at 37°C for 30 minutes. Examine ideally within 30 minutes, and absolutely within 1 hour — motility drops significantly after 2 hours.

Q10. Grading of Oligozoospermia (WHO 2021)

WHO lower reference limit for normal sperm concentration: 16 million/mL

Q11. Principles of Management

Management is guided by the severity of oligozoospermia, female partner's age and fertility status, duration of infertility, presence of reversible causes, hormonal abnormalities, genetic factors, and lifestyle or environmental contributors.

Q12. Evaluation Before Treatment

Workup: Repeat semen analysis (minimum 2 reports, 2–4 weeks apart)

History

Smoking, alcohol, heat exposure, anabolic steroids, obesity, stress, occupational toxins

Examination

Varicocele, testicular size, vas deferens

Hormonal Profile

FSH, LH, testosterone, prolactin, estradiol (selected cases)

Q13. Lifestyle Modification & Drug Therapy

• Weight optimization — BMI normalization improves testosterone and semen quality
• Smoking cessation — reduces oxidative stress and DNA fragmentation
• Alcohol reduction — avoid heavy intake
• Sleep — 7–8 hours recommended
• Exercise — moderate, regular; avoid excessive endurance training
• Avoid heat exposure — tight underwear, laptop on lap, sauna/hot baths
• Stop gonadotoxic drugs — testosterone injections, anabolic steroids, certain chemotherapeutics
• Diet — Mediterranean-style: fruits, nuts, fish, olive oil, vegetables

Drug Therapy (Selected Cases)

Clomiphene citrate — for low-normal testosterone or secondary hypogonadism. Dose: 25 mg daily or alternate day, for 3–6 months.

Aromatase inhibitors (anastrozole/letrozole) — indicated with elevated estradiol or a low testosterone-to-estradiol ratio.

Antioxidant Therapy

Oxidative stress is implicated in many cases of idiopathic oligozoospermia. Commonly used preparations, alone or in combination:

Some studies suggest benefit in reversing oxidative-stress-related sperm dysfunction and improving pregnancy and live-birth rates, with no evidence of increased miscarriage risk (mild GI upset reported). Overall evidence remains inconclusive given heterogeneity across study designs and the multifactorial nature of infertility.

Case 2 — Secondary Infertility with Varicocele

Q2. What is Oligo-Astheno-Teratozoospermia (OAT)?

OAT describes a combined semen abnormality in which sperm concentration, motility, and morphology are all reduced below WHO decision limits simultaneously.

Q3. Common Causes of OAT

Q4. Effect of Increasing Age on Semen Parameters (Age 30→50)

Kidd et al., Fertil Steril 2001

Q5–Q8. Key History Points

General history: ethnic origin, duration of cohabitation, duration trying to conceive, previous marriage, primary vs secondary infertility, coital frequency and sexual dysfunction (including spermicidal agent use), prior fertility evaluation/treatment, occupation, weight/obesity, habits (smoking, alcohol, drug use), environmental toxin exposure.

Medical history to rule out: diabetes mellitus, hypertension, pituitary dysfunction, tuberculosis, inflammatory bowel disease, thyroid disorder, hyperprolactinemia, chronic respiratory disease (RTI/bronchiectasis), parasitic disorders, cystic fibrosis. A recent fever can suppress semen quality for up to 3 months.

Past infections: UTI, STI, mumps, tuberculosis, leprosy.

Medications affecting spermatogenesis:

Previous surgery to note: vasectomy/reversal, orchidectomy, orchidopexy, varicocelectomy, torsion, trauma, tumour, hernia, hydrocele, appendectomy.

Also relevant: family history of infertility/genetic causes (e.g., CF), sauna/steam/tight underwear use, stress, irregular diet, heavy smoking (>10/day), excess alcohol, marijuana/recreational drug use.

Q9–Q10. Examination of the Male Partner

General: build, weight/obesity; abnormal secondary sex characteristics may indicate a congenital endocrine disorder (e.g., eunuchoid appearance in Klinefelter syndrome). Gynaecomastia suggests an estrogen/androgen imbalance or prolactin excess. Situs inversus raises suspicion for Kartagener syndrome (immotile cilia → immotile sperm).

Local examination: penis (rule out hypospadias); scrotum examined with the patient standing in a warm room to relax the cremaster muscle; testes assessed for consistency and intratesticular mass, measured with calipers, an orchidometer, or sonography — decreased testicular size correlates with impaired spermatogenesis (Lipshultz and Corriere, 1977); epididymis palpated for induration/cystic dilation (possible obstruction); vas deferens checked to rule out CBAVD.

Q11. Role of Ultrasound and Colour Doppler (CDU)

Routinely used to evaluate the testes and ductal system. TRUS with CDU is particularly useful in obstructive azoospermia when a block at the ejaculatory duct or seminal vesicle level is suspected, and enables accurate diagnosis of congenital/acquired lower urogenital tract anomalies. CDU is the single most useful tool to detect subclinical varicocele.

EUA, 2018; ASRM/AUA, 2020

Scrotal ultrasonography in varicocele shows dilatation of the pampiniform plexus (>2–3 mm diameter), a serpiginous appearance, and flow reversal with Valsalva.

Q12. Grading of Varicocele

Options Going Forward

• Repeat the test promptly and investigate in detail
• Direct ICSI with self sperm
• Donor IUI
• Antioxidants/medical therapy for 3–6 months
• Varicocelectomy

Q13. Indications for Varicocele Surgery (EUA 2018)

• Grade 3 varicocele
• Ipsilateral testicular atrophy
• Abnormal semen parameters
• No other fertility factor in the couple

In couples pursuing ART, varicocele repair may improve semen parameters and reduce the level of ART needed. Varicocelectomy was performed in this patient.

Q14. When to Repeat Semen Analysis

NICE, 2013; EUA, 2018; ASRM, 2020 — repeat HSA was done 6 months after surgery in this patient.

Q15. What is TMSC?

Total Motile Sperm Count (TMSC) = sperm concentration × total semen volume × total motility (%). Thresholds of >5/10/20 million are used clinically.

In this case: sperm concentration ~8 million/mL × semen volume 1.8 mL × total motility 40% = TMSC 5.76 million.

Q16. Choosing IUI, IVF, or ICSI by TMSC

Hamilton et al., 2015

The final choice also depends on tubal factor, ovarian reserve, duration of infertility, and the female partner's age.

Q17–Q18. Is IUI Appropriate Here, and What Predicts Its Success?

Threshold levels associated with successful IUI outcomes include: total motility ≥30%, total motile count (TMC) 5–10 million, morphology ≥4% normal forms, and inseminating motile count (IMC, post-wash) 0.8–5 million/mL.

Case 3 — Azoospermia with Suspected Klinefelter Syndrome

Semen analysis: normal-volume azoospermia.

Endocrine evaluation:

Q1. Differentiating Obstructive (OA) vs Non-Obstructive Azoospermia (NOA)

Q2. Common Causes of Normal-Volume Azoospermia

A. Non-obstructive azoospermia (NOA) — the most common association; the problem lies in intratesticular sperm production. Examples: Sertoli-cell-only syndrome, maturation arrest, hypospermatogenesis, Klinefelter syndrome, testicular failure after mumps/chemotherapy/radiation. Typical findings: normal volume, fructose positive, FSH often elevated, small/soft testes.

B. Proximal obstruction (before the seminal vesicles) — examples: epididymal obstruction, vas deferens obstruction after infection, post-vasectomy status. Typical findings: normal volume, fructose positive, normal FSH, normal testicular size.

Q3–Q4. Fructose-Positive vs Fructose-Negative Azoospermia

Fructose is produced mainly by the seminal vesicles; its presence indicates the ejaculatory ducts and seminal vesicles are likely functioning normally, but on its own it does not fully distinguish obstructive from non-obstructive azoospermia — it helps localize the level of pathology. With normal fructose, the key remaining question is whether sperm production is absent, or there is proximal obstruction.

Q5–Q6. Exceptions and Guideline Guidance

Fructose may be absent despite an apparently normal volume with partial ejaculatory duct obstruction (residual prostatic secretions maintain near-normal volume while seminal vesicle contribution is markedly reduced), seminal vesicle dysfunction/hypoplasia, or incomplete collection/technical error.

Both ESHRE and ASRM recommend interpreting seminal fructose together with semen volume, pH, hormonal profile, and imaging — not in isolation.

Q7–Q9. Further Work-up and Genetic Testing

Next steps to consider: testicular FNAC, imaging, IUI with donor sperm, and genetic testing/counseling.

Indications for genetic testing (EUA 2018; ASRM/AUA 2020): sperm concentration <5 million/mL, azoospermia, testicular atrophy, elevated FSH — tests include karyotyping and Y-chromosome microdeletion (YMD) analysis.

• 47,XXY (Klinefelter syndrome) — ~10% of men with azoospermia
• Chromosomal translocations/deletions may be hereditary and can cause habitual abortion or congenital malformation
• AZF region deletions on the Y chromosome — ~5% incidence in azoospermia/OAT
• CBAVD — ~85% of cases are CFTR-gene positive

Q10. Role of FNAC (ASRM/AUA 2020)

TESA in an indeterminate case is generally considered not necessary given these predictors.

Q11. Sperm Retrieval by Micro-TESE (If FNAC Was Unfavourable)

Schwarzer, 2013

Q14–Q15. Can Surgical Sperm Retrieval Be Refused?

In this patient: testicular volume 6 cc each side, serum FSH 25.21. Per EUA 2018 and ASRM/AUA 2020, FSH, testicular size, or other markers cannot be used to predict retrieval success or to refuse surgical sperm retrieval outright. No reliable positive prognostic factor guarantees sperm recovery in NOA; the only recognized negative prognostic factor is the presence of AZFa or AZFb microdeletions.

Case 4 — Low-Volume, Fructose-Negative Azoospermia

Diagnosis: fructose-negative azoospermia with an ejaculate volume of 0.8 mL — low-volume, fructose-negative azoospermia.

Role of Clinical Examination

Imaging & Work-up in This Patient

• TRUS: a 3.4 cm midline prostatic cyst with internal echoes, and marked bilateral seminal vesicle dilatation
• MRI: confirmed the midline/retrovesical cyst with mildly dilated seminal vesicles
• Post-ejaculate urinalysis: no sperm seen (retrograde ejaculation ruled out)
• Transrectal cyst aspiration: 80 mL of turbid fluid; contrast filling on X-ray demonstrated the vasa and seminal vesicles
• Vasogram: dilated bilateral vas deferens and seminal vesicles, with the ejaculatory duct ending in a blind cyst-like cavity beneath the prostatic urethra (vasal obstruction ruled out)

Surgical Management in Obstructive Azoospermia — When to Refer

• Vasovasostomy
• Vasoepididymostomy
• Transurethral resection of ejaculatory ducts (in EDO)

A patent tract does not guarantee conception (Baker and Sabanegh, 2013).

CBAVD — Work-up

Findings: semen volume <1.5 mL, pH <7.0, fructose negative. Next steps: TRUS, renal ultrasound, CFTR mutation testing, and partner testing if the man is a carrier.

EUA, 2018; ASRM/AUA, 2020. Indian prevalence of CBAVD: 1:10,000–1:40,000 (Kapoor et al., 2006; Prasad et al., 2010) — CBAVD is not uncommon.

Case 5 — Cryptorchidism, Motility & Advanced Sperm Testing

Bilateral Cryptorchidism in Adults

• A palpable undescended testis in adulthood should not be removed, as it still produces testosterone
• Correcting bilateral cryptorchidism, even in adulthood, can restore sperm production in previously azoospermic men
• Testicular biopsy at the time of adult orchidopexy is used to detect germ cell neoplasia in situ

EUA, 2018

Important clinical clue: low semen volume with fructose-negative status strongly suggests ejaculatory duct obstruction or CBAVD, often linked to CFTR gene mutations.

Sperm Motility

Motility is the most important predictor of the functional aspect of spermatozoa, reflecting normal axoneme development and epididymal maturation. WHO grading:

Limitations: motility is usually assessed by simple visual estimation across several fields — this is subjective and prone to technical error, and in-vitro motility may not reflect true motility within the female reproductive tract.

Viability

Assessed when motility is reported below 5–10%, to differentiate immotile from dead sperm.

• Staining method (standard): Eosin Y with Nigrosin counterstain — viable sperm have intact membranes and exclude the dye, remaining unstained
• Hypo-osmotic swelling test (HOST) (alternative): exposes sperm to hypo-osmotic fluid; viable sperm (intact membranes) show swelling of the cytoplasmic space and tail curling, while non-viable sperm show no effect. Reproducible and inexpensive; useful for selecting viable sperm for IVF/ICSI.

Non-Sperm Cells in Semen

Bacteria and protozoa such as Trichomonas vaginalis are uncommon in semen, but their presence suggests possible reproductive tract infection.

Limitations of Semen Analysis

• A normal semen analysis may not reflect true fertility status
• Men with poor parameters can still father spontaneous pregnancies; men with good parameters can still be subfertile
• Only about 50% of subfertile men have a recognizable cause detectable by semen analysis
• Semen analysis remains only a surrogate measure of fertility potential

Sperm Function & Advanced Testing

Testing for Antisperm Antibodies (ASA)

• Direct ASA testing detects sperm-bound immunoglobulins (preferred)
• Indirect testing detects circulating ASA biologic activity
• Sperm MAR (mixed antiglobulin reaction) is an economical, widely available screening test
• Immunobead test (IBT, measures IgG/IgA/IgM) may be added if screening is positive

Clinical Implications of ASA in Male Infertility

• Present in ~10% of subfertile men vs ~2% of fertile men
• Present in 34–74% of vasectomized men; persists in 38–60% after vasectomy reversal
• Does not affect the decision to perform vasectomy reversal; routine testing is not recommended
• In immunologic infertility with impaired zona pellucida binding, ICSI is the procedure of choice over IVF

References

1. Smits RM, Mackenzie-Proctor R, Yazdani A, Stankiewicz MT, Jordan V, Showell MG. Antioxidants for male subfertility. Cochrane Database Syst Rev. 2019;3(3):CD007411.
2. Kidd SA, et al. Effects of male age on semen quality and fertility. Fertil Steril. 2001.
3. Hamilton JA, et al. Total motile sperm count as an indicator for treatment selection. 2015.
4. Schwarzer JU. Sperm retrieval outcomes by histopathological diagnosis. 2013.
5. Lipshultz LI, Corriere JN Jr. Testicular consistency and spermatogenesis. 1977.
6. Takihara H, et al. Testicular volume measurement techniques. 1983.
7. Baker K, Sabanegh E. Obstructive azoospermia — reconstructive outcomes. 2013.
8. Kapoor V, et al.; Prasad R, et al. CFTR mutations and CBAVD prevalence in Indian men. 2006; 2010.
9. European Association of Urology (EAU). Guidelines on Male Infertility. 2018.
10. ASRM/AUA. Guidelines on the Diagnosis and Treatment of Infertility in Men. 2020.
11. NICE. Fertility Problems: Assessment and Treatment (CG156). 2013.