What If Your Semen Analysis Results Are Abnormal?

Additional Testing and Treatment Options for Semen Analysis

Human sperm, artwork
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You've had a semen analysis, and your results are considered abnormal. Maybe your sperm count is low, or maybe your test results have found poor sperm motility or morphology. What does this mean? What's next?

One Abnormal Result Doesn't Mean Male Infertility

The most important thing to know is that one poor result doesn't necessarily mean you're infertile. "It is important to know that an abnormal test result can actually be normal as sperm can fluctuate," explains Dr. Jennifer Hirshfeld-Cytron, Director of Fertility Preservation at Fertility Centers of Illinois. "A semen analysis needs to test abnormal twice to truly be abnormal."

Your semen analysis can be affected by recent illness, anxiety over the exam, and other various factors. Not abstaining from ejaculation for the three to four days before your test can also alter the results. Your doctor will likely order one or two follow-up tests about two to three months after the first, to see if the abnormal results repeat.

It's also important to remember that the semen analysis results need to be considered together. In other words, if the only abnormal finding is a high white blood cell count, but other semen parameters are normal, and there are no other signs of infection, then your results may, in fact, be considered normal.

"If a second follow-up test returns poor results, it’s time to see a reproductive urologist and reproductive endocrinologist to discuss options for treatment," says Dr. Edward Marut of Fertility Centers of Illinois. "Men with very poor semen quality are at an increased risk for testicular disease as well. In most cases, there is more emphasis on treating the sperm than treating the man—it’s important to look at the whole picture."

Types of Abnormal Sperm and Poor Semen Analysis Results

Before you experienced infertility, you may have only been familiar with sperm count. You likely knew that having a low sperm count is a problem. You may not have been aware of the many other ways sperm or semen can be abnormal.

You may hear these terms used to describe male infertility or semen analysis results:

Normozoospermia

This is when all measured sperm and semen parameters are normal. 

Normal semen analysis results are...

  • Semen volume: 1.5 ml or more (or between 1.4 and 1.7 ml)
  • Total sperm count: 39 million (or between 33 and 46 million)
  • Sperm concentration: 15 million per ml (or between 12 and 16 million per ml)
  • Total motility: 40 percent or more (or between 38 and 42 percent)
  • Progressive motility: 32 percent or more (or between 31 and 34 percent)
  • Vitality: 58 percent or more (or between 55 and 63 percent)
  • Sperm morphology: 4 percent or more (or between 3 and 4 percent)

Aspermia

This is when there is no ejaculate and no sperm. This is not the same as azoospermia (discussed below) where there is semen but no sperm. In aspermia, there’s no semen at all. The man may experience an orgasm, but there may be no ejaculate released. This is sometimes called “dry orgasm.”

Aspermia may occur because of retrograde ejaculation, a genetic disorder (like with Klinefelter syndrome or cystic fibrosis), congenital abnormalities of the reproductive tract, hormonal imbalance, diabetes, post-testicular cancer treatment, or severe sexual dysfunction.   

Aspermia severely affects male fertility. However, having a genetic child may still be possible. In some cases, the cause of aspermia can be treated. When that isn’t possible, testicular biopsy may be able to retrieve immature sperm from the testes. These sperm can be matured in the lab and then used with IVF-ICSI treatment.

If these options aren’t possible, a sperm donor may be considered.

Hypospermia

This is when the total ejaculate is low, or less than 1.5 milliliters of fluid. That's less than a third of a teaspoon. 

Hypospermia may be caused by many of the same things that cause aspermia. Most commonly, though, hypospermia is caused by retrograde ejaculation. Retrograde ejaculation is when semen goes backward into the bladder instead of going out the urethra.

Azoospermia

Azoospermia is when there are zero sperm in the ejaculate. Also referred to as having “no sperm count,” this is a severe form of male infertility. The semen may appear completely normal otherwise. This can only be diagnosed with the help of semen analysis.

The most common causes of azoospermia include genetic disorders, congenital anomalies of the male reproductive tract, and obstruction of the seminal tracts. Some untreated sexually transmitted infections can cause obstructions that lead to azoospermia. Azoospermia can also occur post-testicular cancer treatment.

Azoospermia may also be caused by a hormonal imbalance, severe sexual dysfunction, or an infection of mumps orchitis, but these cases are rare.

Oligozoospermia

Oligozoospermia is when sperm count is lower than normal. It may be further described as being mild, moderate, severe or extreme oligozoospermia. Extreme oligozoospermia is sometimes called cyrptozoospermia.

Frequently, when sperm count is low, other problems with sperm health are also present, including problems with sperm movement and sperm shape. (More on these sperm factors below.)

There are many possible causes of low sperm count, including the presence of a varicocele, hormonal imbalance, reproductive tract abnormalities, undescended testicles, untreated diabetes or celiac disease, an underlying infection of the reproductive tract, previous cancer treatment, and genetic disorders. Some medications can impact sperm count.

Environmental conditions, work-related exposure, and lifestyle choices can also cause low sperm count. For example, overheating of the testicles (like from frequent hot tub use), exposure to toxic chemicals at work, smoking, obesity, or recreational drug and alcohol use can reduce sperm counts. In some cases, lifestyle changes may improve sperm count enough to improve fertility.

That said, in the vast majority of cases, a specific cause for low sperm count is never found. When a cause can’t be identified, it is called idiopathic oligozoospermia.

Oligozoospermia is the most common reason for subfertility in men. Men with mild or moderate oligozoospermia may still be able to father a child naturally. However, the lower the sperm count, the less likely it is that the couple will have pregnancy success without the help of fertility treatments. It may also take longer to get pregnant.  

Asthenozoospermia

Asthenozoospermia is when a large percentage of sperm movement is not normal, otherwise known as abnormal sperm motility. Normal sperm should move in a progressive direction. A progressive direction is defined as in a straight line or very larger circles.

Usually, poor sperm motility goes along with low sperm count. Many of the things that can cause low sperm count also may lead to asthenozoospermia. Possible causes include exposure to toxins, poor nutrition, illness, recreational drug use, excessive alcohol intake, or smoking. Some medications can cause poor sperm motility. 

Even though the World Health Organization defines poor sperm motility by the percentage of properly moving sperm, research has found that the total number of motile sperm is a better measure of fertility. According to this research, men with less than 5 million motile sperm would be considered having severe male infertility, those with 5 to 20 million would be regarded as moderately infertile, and those with over 20 million motile sperm would be considered normal.

Teratozoospermia

Teratozoospermia is when a large percentage of sperm have an abnormal shape. Sperm morphology is the shape of the sperm. Normal sperm should have an oval head with a long tail. Abnormal sperm may have an oddly shaped head, more than one head, or more than one tail. If the sperm are not of normal shape, they may be unable to fertilize the egg.

Sperm shape is essential to the ability of the sperm to move or swim. For this reason, it’s not uncommon for poor sperm morphology to go along with poor sperm movement.

Poor sperm morphology may be caused by a variety of genetic causes. In rare cases, some specific genetic causes will lead to all the sperm to be the same abnormal shape. For example, globozoospermia is a specific kind of teratozoospermia where the sperm head is round instead of oval in shape. This is caused by a specific genetic mutation.

Also, many of the things that cause poor sperm shape can also cause poor sperm motility or low sperm count. (See above.)

Oligoasthenoteratozoospermia (OAT)

Oligoasthenoteratozoospermia (OAT) is when all sperm parameters are abnormal. In other words, sperm count, movement, and shape are all problematic. This is the most common cause of male infertility.

OAT can be mild, moderate, or severe. The severity of the situation will determine prognosis and possible treatments.

Necrozoospermia

A rare cause of infertility, necrozoospermia is when all the sperm are dead. This is not the same as severe asthenozoospermia, which all the sperm are non-moving but still alive. The treatments are different.

When the sperm are non-moving but still viable, treatments like IVF with ICSI are available. ICSI is when a sperm cell is directly injected into an egg, to hopefully allow for fertilization. If the sperm is dead, however, like it is with necrozoospermia, this treatment is not an option.

This doesn’t mean treatments aren't available. While the causes of necrozoospermia are not well understood (because it is so rare, it’s difficult to study), when a cause can be determined, treating the cause can resolve or improve the situation. In other cases, testicular biopsy with IVF-ICSI may be possible. In this case, your doctor will remove immature (but viable) sperm cells directly from your testicles, mature them in the lab, and then use them for IVF-ICSI.

Leukocytospermia

Leukocytospermia is when there is a high count of white blood cells in the semen. This is also known as pyospermia.

With leukocytospermia, the sperm are not necessarily abnormal, but the semen may be a problem. That said, high levels of white blood cells may lead to sperm damage, which can decrease fertility.

High white blood cell count can indicate possible infection or, in some cases, an autoimmune disease. Many of the causes of low sperm count can also cause leukocytospermia as well. 

Semen Analysis Results and Potential Fertility

Semen analysis normal and abnormal ranges are based on percentiles. In other words, what percentage of men had this particular result and went on to father a child within a year. Your semen health may be considered subpar, but you may still be able to conceive with those subpar numbers.

In fact, normal results on a basic semen analysis don't necessarily guarantee fertility.

Semen analysis is not a test of fertility, but a tool used to investigate possible causes of infertility. Low sperm count, for example, is not a diagnosis itself, but a symptom that can be only discovered through semen analysis. There are a variety of causes for low sperm count, and sometimes, a cause is never found. If your semen analysis shows low sperm count, your doctor's next goal will be to investigate why this may be occurring, and what can be done to help you and your partner have a baby.

Further Male Fertility Testing

As stated above, your doctor will want to repeat the semen analysis again. If you had trouble producing a sample, your doctor may suggest doing so via intercourse, using a specialized condom meant for the collection of semen samples. (Don't use a regular condom! It can kill sperm, even without added spermicide.)

Beyond the basic semen analysis, depending on testing results, your doctor may also order:

  • A general exam by a urologist.
  • Blood work, specifically to check hormone levels including follicle stimulating hormone (FSH), testosterone, luteinizing hormone (LH), estradiol, and prolactin.
  • More advanced semen analysis testing, which may include Computer Assisted Semen Analysis (CASE), anti-sperm antibodies testing, sperm DNA testing, hypo-osmotic swelling testing, and others.
  • Post-coital testing (PCT), a test that evaluates the woman's cervical mucus after intercourse, to check for live, moving sperm.
  • Genetic testing, to check for chromosomal disorders that can cause male infertility
  • Genetic karyotyping, especially if recurrent miscarriage is occurring
  • Transrectal, scrotal, or renal ultrasonography
  • Pelvic or cranial Magnetic Resonance Imaging (MRI)
  • Post-ejaculatory urinalysis (urine testing), to check for retrograde ejaculation
  • Testicular biopsy
  • Vasography

What If Poor Results Repeat

After additional testing, your doctor may recommend treatment to improve your semen health. This may include lifestyle changes, medications, or surgery. Your doctor may also recommend fertility treatments, like IVF or IVF with ICSI. Another possibility is that your doctor will recommend considering a sperm donor.

"The treatment of ICSI has allowed us to treat the majority of male infertility issues and achieve pregnancy," says Dr. Hirshfeld-Cytron. "I view ICSI as the great equalizer of abnormal sperm and if there is one problem to have, abnormal sperm is it! Sperm regenerates every three months while we are born with our entire supply of eggs. If a positive action is made—ceasing cannabis use, losing weight, halting excess alcohol intake—we will see a benefit from that action."

It's also possible that your doctor will recommend trying one thing, and if that doesn't work, recommend something else. Treatment is not always as straightforward and quick as we'd like. Your partner's fertility will also be taken into account when devising a treatment plan.

"The value of waiting for the sperm to improve versus doing fertility treatments [right away] is often dependent on the woman’s testing," says Dr. Hirshfeld-Cytron. "Before making any treatment decisions, it is important to evaluate the fertility potential of both partners through testing. Infertility testing and treatment is truly a team sport!"

If you'll be trying out medication, lifestyle changes, or surgery, it's important to know that your semen health will take time to improve. While sperm may seem to be produced at the moment of ejaculation, in actuality, it takes weeks for sperm to develop within the male reproductive system. This is why your doctor may recommend a follow-up semen analysis three to four months after a treatment plan has been put into action.

"The reversible changes to semen quality can be effected over two to three months by quitting smoking (tobacco and marijuana), reducing alcohol intake to one to two drinks a day (no binging), cutting out high fat/high calorie foods, following a Mediterranean diet, reducing weight, and assessing the effects of medications that have been prescribed," recommends Dr. Marut. "Motility and morphology both vary the most, and the use of antioxidants like Coenzyme Q10 have been shown to be helpful over time in some men, but not all."

"Stopping any use of steroids or testosterone will also make an improvement," adds Dr. Hirshfeld-Cytron.

A Word From Verywell

Receiving a diagnosis of male infertility can be emotionally distressing. Speak to your doctor about his recommended treatment plans. Don't be afraid to ask questions. The more you know, the easier it will be for you and your partner to make informed decisions on moving forward. 

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