What can I do if I have oligospermia (low semen volume) on more than 2 occasions?

Approach to Low Semen Volume on Repeated Testing

If you have documented low semen volume (<1.4 mL) on more than 2 occasions, you need a systematic evaluation to identify the underlying cause—which determines whether treatment can restore normal ejaculation or whether assisted reproduction is necessary. 1

Step 1: Physical Examination to Narrow the Diagnosis

Your physician must check specific anatomical features that immediately point to certain diagnoses:

• Palpate for bilateral vas deferens: If both are absent, you have congenital bilateral absence of vas deferens (CBAVD)—this can be diagnosed by exam alone without imaging 1, 2
• Assess testicular size: Normal-sized testes suggest obstruction somewhere in the ductal system, while small/atrophic testes indicate the testicles themselves aren't producing sperm properly 1, 3
• Check for palpable varicoceles: Only varicoceles you can feel (not ones found only on ultrasound) benefit from surgical treatment 1, 2
• Digital rectal exam: Evaluates prostate size and consistency, with tenderness suggesting prostatitis 2

Step 2: Critical Laboratory Tests

Three tests determine the next steps:

• Semen pH: If your semen is acidic (pH <7.0) combined with low volume, this strongly suggests ejaculatory duct obstruction or CBAVD 1, 2
• Serum testosterone and FSH: Low testosterone with low/normal FSH indicates your pituitary isn't signaling properly (hypogonadotropic hypogonadism—potentially treatable), while elevated FSH (>7.6 IU/L) means primary testicular failure 1, 3
• Post-ejaculatory urinalysis: Required when volume is <1 mL to check for retrograde ejaculation (sperm going backward into the bladder) 1, 2

Step 3: Treatment Based on What's Found

If You Have Ejaculatory Duct Obstruction

Transurethral resection of ejaculatory ducts (TURED) is the definitive surgical treatment when imaging (TRUS or pelvic MRI) confirms dilated seminal vesicles and blocked ducts 1, 2. This only applies if you have: low volume, acidic semen, normal testosterone, and palpable vas deferens 1.

If You Have CBAVD

No surgery or medication restores ejaculatory volume. Proceed directly to sperm retrieval (testicular sperm extraction) with ICSI for fertility 1, 2. Your female partner must undergo CFTR gene testing before proceeding, as CBAVD is associated with cystic fibrosis gene mutations 1.

If You Have a Palpable Varicocele

Varicocelectomy improves semen parameters and may restore sperm in the ejaculate if you have abnormal semen analysis 1, 2. Do not pursue treatment for varicoceles found only on ultrasound—these subclinical varicoceles don't improve fertility outcomes 1, 2.

If You Have Hypogonadotropic Hypogonadism

Treatment with human chorionic gonadotropin (hCG) can normalize testosterone, sperm concentration, and semen volume 4. This is a treatable cause that can restore natural fertility.

If You Have Retrograde Ejaculation

Post-ejaculatory urinalysis will show sperm in the urine 1, 2. Treatment options include medications to tighten the bladder neck or sperm retrieval from urine for assisted reproduction.

Step 4: Genetic Testing Before Assisted Reproduction

Before proceeding with any fertility treatment involving your sperm:

• Karyotype testing is mandatory if you have azoospermia or severe oligospermia (<5 million sperm/mL) 1, 2
• Y-chromosome microdeletion analysis is required if sperm concentration is <1 million/mL 1, 2
• These genetic abnormalities can be passed to offspring, making counseling essential before ICSI 1

Critical Pitfalls to Avoid

• Don't get imaging (TRUS/MRI) as your first test: Reserve these only for clear suspicion of ejaculatory duct obstruction (low volume + acidic + azoospermic semen with normal testosterone and palpable vas) 1, 2
• Don't hunt for varicoceles with ultrasound: Only palpable varicoceles warrant treatment; treating subclinical ones doesn't improve outcomes 1, 2
• Don't take testosterone if you want fertility: Testosterone replacement suppresses sperm production and worsens fertility 2
• Don't delay genetic testing: Results impact counseling and treatment decisions before assisted reproduction 1

Natural History Warning

If you have severe oligospermia, be aware that 12.8% of men progress to azoospermia (no sperm) over time, and 17.9% decline to levels detectable only after centrifugation 5. If follow-up semen analyses show declining sperm counts, consider sperm cryopreservation before counts drop further, as sperm retrieval success decreases once azoospermia develops 5.