Male Fertility Testing: Essential Evaluation Protocol
All men in couples unable to conceive after 12 months of unprotected intercourse (or 6 months if female partner >35 years) require a focused fertility evaluation consisting of medical/reproductive history, physical examination, semen analysis, and hormonal assessment. 1, 2
Core Initial Testing
Semen Analysis - The Cornerstone Test
Obtain at least two semen analyses at least one month apart if the first shows abnormalities. 1, 2, 3 A single normal test is sufficient, but abnormal results require confirmation due to biological variability. 1
Critical collection requirements:
- Abstain from sexual activity for 2-3 days before collection (inadequate abstinence invalidates results) 3
- Examine within one hour of collection (delayed analysis compromises motility assessment) 3
- Collect by masturbation or specialized semen collection condoms 3
WHO 2021 reference values (lower limits): 2, 3
- Volume ≥1.4 mL
- pH >7.2
- Sperm concentration ≥16 million/mL
- Total sperm number ≥39 million per ejaculate
- Progressive motility ≥30%
- Total motility ≥42%
- Normal morphology ≥4.0%
- Vitality ≥54% live spermatozoa
Critical pitfall: Semen analysis alone cannot distinguish fertile from infertile men—25% of infertility cases remain unexplained despite normal parameters. 3, 4 Laboratory quality varies significantly, as many facilities don't adhere to WHO standardized methods. 3
Physical Examination - Required Components
Assess the following specific findings: 1, 2, 3
- Testicular size and consistency (normal volume ≥15 mL)
- Presence and consistency of vas deferens and epididymides
- Varicocele presence
- Penis examination
- Secondary sex characteristics (body habitus, hair distribution)
- Digital rectal examination
Medical and Reproductive History - Essential Elements
Document these specific factors: 1, 2, 3
- Frequency and timing of intercourse
- Duration of infertility and prior fertility
- Sexual history including erectile/ejaculatory function
- Childhood illnesses (cryptorchidism, mumps orchitis)
- Systemic illnesses and medications
- Environmental/occupational exposures
- Anabolic steroid use
- Smoking, alcohol, and recreational drug use
- Family history of infertility or genetic conditions
Mandatory Additional Testing Based on Initial Findings
Hormonal Evaluation - When Required
Order serum testosterone and FSH in these situations: 1, 2, 3
- Sperm concentration <10 million/mL (oligozoospermia)
- Azoospermia (no sperm)
- Impaired libido or erectile dysfunction
- Clinical findings suggesting endocrinopathy
If abnormalities detected, also measure LH and prolactin to distinguish primary testicular dysfunction (elevated LH) from secondary hypogonadism (low/normal LH). 5
Genetic Testing - Specific Indications
Order karyotype and Y-chromosome microdeletion testing when: 2, 3
- Severe oligospermia (<5 million/mL)
- Azoospermia
This testing is mandatory before assisted reproductive technology, as genetic abnormalities may be transmitted to offspring. 3
Post-Ejaculatory Urinalysis
Order when ejaculate volume <1 mL (except in bilateral vasal agenesis or hypogonadism) to detect retrograde ejaculation. 3
Advanced Testing - Selected Cases
Men with persistent abnormalities require referral to a male reproductive specialist for: 1, 2
- Transrectal ultrasonography (if ejaculatory duct obstruction suspected)
- Testicular ultrasound (if physical examination abnormal or azoospermia)
- Sperm DNA fragmentation testing (controversial—not routinely recommended by current guidelines, but may be considered in recurrent pregnancy loss or failed IVF) 1
Important caveat: Routine measurement of reactive oxygen species is not recommended, as no standardized testing methods exist and validation in high-quality trials is lacking. 1
Critical Health Counseling
Associated Health Risks
Counsel all men with abnormal semen parameters about increased health risks: 2
- Higher rates of testicular cancer
- Increased overall cancer risk
- Increased mortality compared to fertile men
This makes the fertility evaluation an opportunity for broader health screening.
Lifestyle Modification - Specific Interventions
Address these modifiable factors: 2, 3
- Smoking cessation (oxidative stress damages sperm DNA)
- Weight optimization (obesity impairs spermatogenesis)
- Discontinue anabolic steroids (suppress spermatogenesis)
- Avoid excessive heat exposure (hot tubs, saunas, laptops on lap)
- Medication review (many drugs impair fertility)
- Limit alcohol consumption
Advanced Paternal Age
Counsel couples when male partner ≥40 years about increased risks in offspring, including de novo gene mutations, sperm aneuploidy, and chromosomal aberrations. 2
Simultaneous Partner Evaluation
Both partners must be investigated concurrently—this is a strong recommendation, as male factors contribute to 50% of infertility cases. 1, 6 Delaying male evaluation while focusing solely on the female partner wastes time and resources.
Home Sperm Tests - Limited Role
Home tests serve only as initial screening tools to determine whether formal laboratory evaluation is warranted, particularly for men facing barriers to clinic-based testing. 3 They cannot replace comprehensive semen analysis, as they don't assess morphology and lack quality control. 3 If abnormal, formal laboratory evaluation with two properly performed analyses is mandatory. 3