From the Guidelines
A semen analysis indicating low normal sperm morphology and high abnormal morphology implies reduced fertility potential, and men with this finding should consult a reproductive urologist or fertility specialist for a complete evaluation. According to the most recent guidelines from the American Urological Association (AUA) and the American Society for Reproductive Medicine (ASRM) 1, the World Health Organization reference limits for human semen characteristics are as follows:
- Semen volume: 1.4 mL (one-sided lower reference limit)
- Total sperm number: 39 million per ejaculate
- Sperm concentration: 16 million/mL
- Vitality: 54% live
- Progressive motility: 30%
- Total motility: 42%
- Morphologically normal forms: 4.0%
Given the provided semen analysis results:
- Volume: 1.4 mL (within the normal range)
- Total sperm concentration: 243.6 million/ejaculation (above the normal range)
- Liquification time: 60 min (normal)
- pH fluid: 8.7 (normal)
- Viscosity: 4 (normal)
- Progression: 3 (below the normal range)
- Speed: 4 (normal)
- Normal % sperm morphology: 21% (below the normal range)
- Abnormal percent: 79% (above the normal range)
- Sperm count: 174/mL (above the normal range)
The low normal sperm morphology and high abnormal morphology suggest teratozoospermia, which can make natural conception more challenging. Initial steps may include lifestyle modifications such as quitting smoking, reducing alcohol consumption, avoiding excessive heat to the testicles, maintaining healthy weight, and taking antioxidant supplements (such as a combination of vitamin C, vitamin E, zinc, selenium, and CoQ10) for 2-3 months, as suggested by previous studies 1. The specialist might recommend additional testing including hormone levels, genetic testing, or ultrasound to identify underlying causes. Treatment options depend on the severity and underlying causes but may include varicocele repair if present, addressing hormonal imbalances, or assisted reproductive technologies like intrauterine insemination (IUI) or in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI).
Key considerations for the initial evaluation of male factor infertility include:
- A physical exam (PE) performed by an examiner with appropriate training and expertise
- A reproductive history
- At least one properly performed (high-quality) semen analysis, as recommended by the Human Reproduction Update study 1 A full evaluation by an urologist or other specialist in male reproduction should be carried out if the initial screening evaluation demonstrates an abnormal PE, an abnormal male reproductive or sexual history, or an abnormal semen analysis is found.
From the Research
Semen Analysis Interpretation
The provided semen analysis results indicate:
- Volume: 1.4 mL
- Total sperm concentration: 243.6 million/ejaculation
- Liquification time: 60 min
- pH fluid: 8.7
- Viscosity: 4
- Progression: 3
- Speed: 4
- Normal % sperm morphology: 21%
- Abnormal percent: 79%
- Sperm count: 174/mL
Implications for Fertility
The low normal sperm morphology (21%) and high abnormal morphology (79%) may imply reduced fertility, as studies have shown correlations between the percentage of normal forms and functional sperm abnormalities, as well as correlations with the ability to conceive in vivo and the success of intra-uterine insemination (IUI) or conventional IVF 2. However, the sensitivity and specificity of sperm morphology assessment in the diagnosis of infertility are poor, except in cases of specific sperm defects linked to genetic disorders.
Clinical Relevance and Diagnostic Workflow
Semen analysis is a fundamental test in the diagnosis of male infertility, and its results should be interpreted by experienced clinicians 3. A diagnostic flowchart can be proposed based on the results of the semen analysis to orient towards specific diagnoses that can be confirmed by further ad-hoc tests.
Treatment Options
Clomiphene citrate is a commonly prescribed empiric medical therapy for male infertility, but its outcomes and response rates remain incompletely understood 4, 5. Some studies have shown that clomiphene citrate can increase sperm parameters, but its effectiveness in treating male infertility is still debated. In vitro studies have also shown that clomiphene citrate can improve sperm parameters and fertilization rate in IVF protocols 6.
Key Points to Consider
- Sperm morphology assessment has poor sensitivity and specificity in the diagnosis of infertility, except in cases of specific sperm defects linked to genetic disorders 2.
- Semen analysis should be interpreted by experienced clinicians, and a diagnostic flowchart can be proposed based on its results 3.
- Clomiphene citrate may be a treatment option for male infertility, but its effectiveness is still debated, and more research is needed to understand its outcomes and response rates 4, 5, 6.