What are the treatment options for a man with low semen volume and thick semen?

Treatment of Low Semen Volume and Thick Semen

The primary approach is to identify and treat the underlying cause through systematic evaluation, as treating the symptom alone is ineffective. 1

Initial Diagnostic Evaluation

Physical Examination Priorities

• Palpate for bilateral vas deferens to rule out congenital bilateral absence of vas deferens (CBAVD), which can be diagnosed by physical examination alone and requires no surgical correction 1, 2
• Assess testicular size and consistency: normal-sized testes suggest obstruction while atrophic testes indicate primary testicular failure 1, 2
• Examine for palpable varicoceles, as only clinical (palpable) varicoceles warrant treatment and improve semen parameters 1, 2
• Perform digital rectal examination to evaluate prostate size, consistency, and tenderness, as tenderness suggests prostatitis/chronic pelvic pain syndrome 2

Critical Laboratory Tests

• Check semen pH: acidic semen (pH <7.0) with low volume strongly suggests ejaculatory duct obstruction or CBAVD 1, 2
• Measure serum testosterone and FSH: low testosterone with low/normal FSH indicates hypogonadotropic hypogonadism, while elevated FSH (>7.6 IU/L) suggests primary testicular failure 1, 2
• Perform post-ejaculatory urinalysis when volume <1 mL (except in bilateral vasal agenesis or hypogonadism) to diagnose retrograde ejaculation 1, 2
• Order at least two semen analyses at least one month apart with 2-3 days abstinence to confirm findings 3

Imaging When Indicated

• Reserve transrectal ultrasound (TRUS) or pelvic MRI for cases with clear clinical suspicion of ejaculatory duct obstruction: low volume, acidic semen, azoospermia or severe oligospermia, normal testosterone, and palpable vas deferens 1, 2
• Avoid routine scrotal ultrasound for varicocele diagnosis, as only palpable varicoceles benefit from treatment 1

Treatment Based on Specific Etiology

For Ejaculatory Duct Obstruction

Transurethral resection of ejaculatory ducts (TURED) is the definitive treatment when TRUS or MRI confirms dilated seminal vesicles and ejaculatory ducts 1, 2

For Congenital Bilateral Absence of Vas Deferens

• No medical or surgical treatment restores ejaculatory volume; proceed directly to sperm retrieval (TESE/MESA) with intracytoplasmic sperm injection (ICSI) for fertility 1, 2
• CFTR gene testing for the female partner is mandatory before proceeding with assisted reproduction 1

For Clinical Varicocele

• Varicocelectomy is indicated for palpable varicoceles with abnormal semen parameters, as it improves semen parameters and may restore sperm in ejaculate for men with azoospermia 1, 2
• Do not treat subclinical (non-palpable) varicoceles, as this does not improve semen parameters or fertility rates 1, 2

For Semen Hyperviscosity (Thick Semen)

The thick semen component warrants specific attention, as hyperviscosity affects 12-29% of infertile men and impairs sperm movement in the female reproductive tract 4:

• Hypofunction of the prostate or seminal vesicles is the primary cause of abnormal viscosity 4
• Infection and high levels of seminal leukocytes may result in hyperviscosity development 4
• Treatment options include:
  • Mechanical disruption with hypodermic needle 4
  • Mucolytic enzymes 4
  • Antibiotics and anti-inflammatory agents when infection/inflammation is documented 4, 5

For Chronic Epididymitis/Genital Tract Infection

When chronic epididymitis is suspected (which may present with thick semen and reduced volume):

• Consider additional markers of inflammation such as granulocyte elastase, pro-inflammatory cytokines (interleukin-6 or 8), or reactive oxygen species, as leukocyte count may be below 10⁶/mL threshold 6
• Anti-inflammatory or antibiotic treatment has shown improvements in sperm parameters and leukocytospermia, though data on conception rates are limited 5
• Avoid antibiotics in the absence of symptoms or microbiological infection 5

Mandatory Genetic Testing Before Assisted Reproduction

• Karyotype testing is mandatory for azoospermia or severe oligospermia (<5 million/mL) 1, 2
• Y-chromosome microdeletion analysis is required for azoospermia or sperm concentration <1 million/mL 1, 2
• Genetic counseling should precede ICSI, as genetic abnormalities may be transmitted to offspring 1

Critical Pitfalls to Avoid

• Never prescribe testosterone to men desiring fertility, as it suppresses spermatogenesis and worsens fertility 2
• Do not perform TRUS/MRI as initial evaluation—reserve for cases meeting specific criteria for ejaculatory duct obstruction 1, 2
• Do not hunt for subclinical varicoceles with ultrasound—only palpable varicoceles warrant treatment 1, 2
• Do not delay genetic testing—results impact counseling and treatment decisions before proceeding with assisted reproduction 1

When to Consider Assisted Reproductive Technology

• For couples with low total motile sperm count (<5 million motile sperm after processing), IUI success rates are reduced, and IVF/ICSI should be considered 2
• ART allows fertility where natural pregnancy has not occurred, though it does not correct the underlying condition 2