Male Infertility Work-up: A Practical Guide for Clinicians

When a couple struggles to conceive, the evaluation too often focuses on the woman first. Male factor contributes to a significant share of infertility, so evaluating the male partner early and properly saves time, avoids unnecessary treatment and points couples to the right option sooner.

Start early, assess both partners together

Best practice is to evaluate both partners at the same time. A semen analysis is simple and non-invasive, and should never be postponed until the female work-up is complete.

1. History

Key points to cover:

• Duration of infertility and previous fertility, including pregnancies with any partner
• Sexual function and frequency of intercourse
• Childhood conditions such as undescended testes, and any testicular surgery or injury
• Infections, including mumps after puberty
• Medical conditions, medications and previous treatments such as chemotherapy
• Occupational and lifestyle exposures: heat, smoking, alcohol, anabolic steroids

2. Examination

Examination should include general features, signs of hormonal problems, and a scrotal examination assessing testicular size and consistency, the vas deferens and the presence of a varicocele.

3. Semen analysis

The semen analysis is the cornerstone of the male work-up. It must be performed using standardised methods, ideally following the WHO 6th edition laboratory manual, with:

• Clear collection instructions, including the abstinence period
• Analysis within the recommended time
• Assessment of volume, concentration, motility and morphology

Because results vary from sample to sample, an abnormal result should usually be repeated before drawing conclusions. Read our article on semen analysis according to the WHO 6th edition.

4. Further tests, when indicated

Depending on the findings, further evaluation may include:

• Hormonal tests (for example FSH, LH and testosterone) when counts are low
• Scrotal ultrasound
• Genetic testing in men with very low counts or absent sperm
• Tests for antisperm antibodies or infection in selected cases

Advanced tests such as sperm DNA fragmentation are best used selectively, where they will change management.

5. Matching findings to treatment

The work-up guides the next step:

• Lifestyle changes and treatment of reversible causes
• IUI for selected cases of mild male factor
• IVF with ICSI for more severe male factor
• Surgical sperm retrieval, with specialist urology input, for men with azoospermia

Why laboratory quality matters

A poorly performed semen analysis can send a couple down the wrong path. Standardised methods, internal quality control and trained staff are essential.

Train with ReproNest

ReproNest's Andrology & Semen Analysis Course provides hands-on training in WHO 6th edition methods, sperm preparation and cryopreservation. Read about careers in the andrology lab, or contact us.