Male Infertility Diagnosis: Tests and Evaluation Explained

In short: The diagnosis of male infertility starts with the couple’s medical history and a physical examination, followed by a semen analysis, which may need repeating because results vary. Hormone, immune and infection tests may then be requested, and a testicular biopsy when no sperm are found. Not every test is needed: the doctor chooses those each case requires.

Diagnosis of Infertility in Men

Understanding the cause of male infertility usually starts with a thorough, respectful conversation and a few simple steps. Here is how Dr. Najeeb Layyous and his team typically approach the evaluation.

A. Medical History

Taking a detailed medical history from both partners is an important first step. Couples are usually asked about any medical illnesses such as diabetes, episodes of high fever, long-term use of certain medications, mumps, any previous genital disease, and any past surgery — especially involving the female pelvis or the male genitourinary system. Other helpful details include how long the couple has been trying to conceive, any previous miscarriages, earlier marriages and whether pregnancy occurred in them, frequency of intercourse, age of puberty, and any past exposure to chemotherapy, radiation, or very high temperatures. Many other questions may also help identify the underlying cause of infertility.

Men are also asked about any use of testosterone or anabolic steroids, including some bodybuilding products, because these can stop sperm production

B. Physical Examination

A general examination is usually done first (head, neck, chest, abdomen, upper and lower limbs), followed by a more focused examination of the genital area.

C. Diagnostic Procedures and Tests

1. Seminal Fluid Analysis (SFA)

It’s worth noting that one abnormal semen test result is not enough on its own to confirm a problem. Because many factors — including a man’s general health at the time — can affect semen quality, the test is often repeated 2–3 times for a more reliable picture.

The following instructions are usually recommended before giving a sample for SFA:

• Abstinence for 2–7 days (ideally 3–5 days).
• Avoid taking a hot shower before giving the sample.
• Wash your hands with soap, then rinse with water.
• Wash the genital area several times.
• Make sure to close the collecting tube carefully, without losing any part of the sample.Collect the whole sample, without using any lubricant or a condom.
• The time between giving the sample and bringing it to the lab shouldn’t exceed one hour; keep it in the palm of your hand or close to your body to maintain its temperature around 37°C.
• Normal values (WHO, 2021) — these are the lower limits of normal: volume 1.4 ml; concentration 16 million per ml; total sperm count 39 million per ejaculate; total motility 42%; progressive motility 30%; vitality 54%; normal forms 4%. A result below these limits does not mean pregnancy is impossible, and a result above them does not guarantee it. Terms you may see on the report: oligozoospermia (low count), asthenozoospermia (low motility), teratozoospermia (too many abnormal forms) and azoospermia (no sperm in the ejaculate).

2. Evaluating the Sperm’s Ability to Fertilize

Since a standard semen analysis doesn’t fully assess the functional ability of sperm, several additional tests have been developed:

a. Testing the sperm’s ability to move inside the female body

- Post-coital test (explained further below).

- In-vitro mucus penetration test (the sperm’s ability to pass through cervical mucus).

- Sperm survival tests (the sperm’s ability to keep moving over a certain period of time).

b. Acrosome reaction: This test uses a special dye to identify the presence of the acrosome in sperm and assess its functional ability.

c. Hyposmotic swelling test:

This test identifies the percentage of sperm with a healthy, functioning membrane.

d. Ability of the sperm to penetrate the oocyte:

- Hamster ovum penetration test.

- Hemizona assay.

- In-vitro fertilization of a human oocyte.

Older tests such as the hamster ovum penetration test and the hemizona assay are rarely used today, because when fertilization is likely to be difficult, ICSI overcomes most of these problems. A sperm DNA fragmentation test may be offered in selected cases, for example after repeated miscarriage or several unsuccessful IVF cycles.

Does sperm DNA fragmentation affect fertility, and can it be treated?

Each sperm carries half of the baby’s genetic material (DNA). Sometimes this DNA is damaged or broken. This does not show on a routine semen analysis, so the analysis can look normal even when the damage is there.

Its effect: it can affect how the embryo develops and raise the risk of miscarriage, and it is linked to repeated IVF failure and implantation failure.

Common causes: the man’s age (especially after 40–45), smoking, obesity and oxidative stress in the body, and varicocele.

Yes, it can be treated. Your doctor chooses the right steps for you from the following:

1.     Stop smoking in every form, including shisha. DNA damage takes about 3–6 months to improve after quitting, as our article on [smoking and fertility](/smoking-and-fertility/) explains.

2.     Reach a healthy weight, and avoid heat on the testicles and exposure to toxins.

3.     Antioxidants when needed, on your doctor’s advice.

4.     Treat a varicocele that can be felt on examination when DNA fragmentation is high. Our article on [varicocele and male infertility](/varicocele-effect-on-infertility-and-its-management/) explains when repair is advised.

5.     In the laboratory: select sperm with less DNA damage, for example with [microfluidic sperm sorting](/microfluidic-innovation-for-sperm-sorting-mfssi/) together with ICSI. The evidence that this raises birth rates is still limited.

6.     Use sperm taken directly from the testicle when DNA fragmentation is high.

3. Immunity Tests

These check for the presence of anti-sperm antibodies through blood tests, seminal plasma, or the sperm itself.

4. Microbiological Tests

These are performed when there is a genital tract infection or a high level of white blood cells in the semen.

5. Hormonal Tests

FSH, LH, prolactin, and testosterone levels can all be measured through blood tests.

6. Examination of the Testes

Testicular Biopsy

This is performed when there is azoospermia (no sperm found in the semen), to assess the testis’s ability to produce sperm and help guide the treatment plan.

If there is an obstruction in the seminal ducts, surgical intervention may be needed, or a biopsy may be performed to retrieve sperm for use in ICSI (Intracytoplasmic Sperm Injection) procedures.

Testicular Sperm Aspiration (TESA)

- Vasography, if there is suspicion of a seminal duct obstruction.

- Tests to diagnose varicocele (dilated, tortuous veins around the testis).

Testicular ultrasound

- Doppler blood flow analysis.

- Thermography. Vasography and thermography are rarely needed today.

7. Tests for Disorders of Ejaculation or Intercourse

For example, a urine analysis after ejaculation may be done to check for retrograde ejaculation.

- Electric ejaculator.

8. Genetic and Chromosomal Tests

- Recommended if there is suspicion of Klinefelter’s syndrome or cystic fibrosis.

A karyotype (chromosome test) and a test for Y-chromosome microdeletions are advised when there is no sperm in the semen or the count is very low (below 5 million per ml); these detect conditions such as Klinefelter’s syndrome. Testing for cystic fibrosis gene (CFTR) mutations is advised when the vas deferens is absent on both sides, and the female partner is then tested too.

It’s important to know that not all of these tests are necessary for every patient — your treating physician will decide which ones are most relevant to your individual situation. If you have concerns about male fertility, the team at Dr. Najeeb Layyous’s clinic can help guide you through the right evaluation steps.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist