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. 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."

— Dr. Edward Marut, Fertility Centers of Illinois

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. Here are the ranges for normal semen analysis results.

  • 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% or more (or between 38 and 42%)
  • Progressive motility: 32% or more (or between 31 and 34%)
  • Vitality: 58% or more (or between 55 and 63%)
  • Sperm morphology: 4% or more (or between 3 and 4%)

Aspermia

Aspermia is when there is no ejaculate and no sperm. This is not the same as azoospermia, where there is semen but no sperm. In aspermia, there is no semen at all.

With aspermia, a man may experience an orgasm, but there may be no ejaculate released. This is sometimes called “dry orgasm.”

Aspermia can have several causes, including 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.   

Male fertility is severely affected by aspermia. However, having a genetic child might still be possible. In some cases, the cause of aspermia can be treated. If treatment is not possible, a testicular biopsy might be able to retrieve immature sperm from the testes. These sperm can be matured in a lab, then used with IVF-ICSI treatment.

If these options are not possible, a sperm donor may be considered.

Hypospermia

This is when the total ejaculate is low (less than 1.5 milliliters of fluid or less than a third of a teaspoon). Hypospermia can be caused by many of the same things that cause aspermia, but it is most commonly 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 is zero sperm in the ejaculate. It is also referred to as having “no sperm count" and is a severe form of male infertility. The semen may appear completely normal otherwise, so the condition can only be diagnosed through semen analysis.

The most common causes of azoospermia include:

  • Congenital anomalies of the male reproductive tract
  • Genetic disorders
  • 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. Rarely, the condition can be caused by a hormonal imbalance, severe sexual dysfunction, or an infection of mumps orchitis.

Oligozoospermia

Oligozoospermia is when the sperm count is lower than normal. The condition can be further characterized as being mild, moderate, severe, or extreme. Extreme oligozoospermia is sometimes called cyrptozoospermia.

Frequently, when the sperm count is low, other issues related to sperm health are also present, such as problems with sperm movement and sperm shape.

There are many possible causes of low sperm count, including:

  • Celiac disease
  • Certain medications
  • Genetic disorders
  • Hormonal imbalances
  • Presence of a varicocele
  • Previous cancer treatment
  • Reproductive tract abnormalities
  • Underlying infection of the reproductive tract
  • Undescended testicles
  • Untreated diabetes

Environmental conditions, work-related exposure, and lifestyle choices can also cause low sperm count. For example, overheating the testicles (e.g. from frequent hot tub use), toxic chemical exposure 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.

In the majority of cases, a specific cause for low sperm count is never found. When a cause cannot be identified, it is called idiopathic oligozoospermia.

Oligozoospermia is the most common reason for subfertility in men. Men with mild or moderate oligozoospermia might 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 can also take longer to conceive.

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 (defined as "in a straight line" or "very larger circles").

Poor sperm motility usually goes along with low sperm count. Many of the things that can cause low sperm count also may lead to asthenozoospermia.

Possible causes of poor sperm motility include:

  • Excessive alcohol intake
  • Exposure to toxins
  • Illness
  • Poor nutrition
  • Recreational drug use
  • Smoking
  • Some medications 

Even though the World Health Organization (WHO) 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.

For example, according to a 2015 study, less than 5 million motile sperm would be considered to severe male infertility, 5 to 20 million would be moderately infertile, and over 20 million motile sperm would be considered normal.

Teratozoospermia

Teratozoospermia is when a large percentage of a man's sperm has an abnormal shape. Sperm morphology is the shape of the sperm. Normal sperm 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.

Sperm shape is essential to the ability of the sperm to move or swim. Therefore, it’s not uncommon for poor sperm morphology to go along with poor sperm movement. If the sperm are not of normal shape and cannot move well, they might not be able to fertilize an egg.

Poor sperm morphology can have a variety of genetic causes. In rare cases, some specific genetic causes lead to all the sperm being the same abnormal shape. For example, globozoospermia is a specific kind of teratozoospermia where the sperm head is round instead of an oval shape. The condition is caused by a specific genetic mutation.

Many causes of poor sperm shape can also lead to poor sperm motility or low sperm count.

Oligoasthenoteratozoospermia (OAT)

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

OAT can be mild, moderate, or severe. The condition's severity will determine the treatment and prognosis.

Necrozoospermia

Necrozoospermia is when all the sperm are dead. This is not the same as severe asthenozoospermia, in which all the sperm are non-moving but still alive. Necrozoospermia is a rare cause of infertility.

The treatment options for necrozoospermia differ from those for other conditions related to sperm health. For example, when sperm are non-moving but still viable, treatments like IVF with ICSI (when a sperm cell is directly injected into an egg to, hopefully, allow for fertilization) are available.

However, if the sperm is dead (as with necrozoospermia) these types of treatment are not an option. However, this does not mean there are no treatments available.

The causes of necrozoospermia are not well understood (because it is so rare, it’s difficult to study). When a cause can be determined, hopefully, treatment will resolve or improve the situation.

In some cases, testicular biopsy with IVF-ICSI might be possible. During this procedure, your doctor removes immature (but viable) sperm cells directly from your testicles, matures them in the lab, then uses them for IVF-ICSI.

Leukocytospermia

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

With leukocytospermia, the sperm is not necessarily abnormal, but the semen might be a problem. High levels of white blood cells may lead to sperm damage, which can decrease fertility.

A high white blood cell count can indicate an infection. In some cases, it can be a sign of an autoimmune disease. Many causes of a low sperm count can also cause leukocytospermia.

Semen Analysis Results and Potential Fertility

The normal and abnormal ranges for semen analysis are based on percentiles. Percentiles are based on the percentage of men who had a particular result and went on to father a child within a year.

Your semen health might be subpar, but you may still be able to conceive. Likewise, normal results on a basic semen analysis do not necessarily guarantee fertility.

Semen analysis is not a test of fertility; rather, it's a tool to investigate the possible causes of infertility. For example, a low sperm count 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. Sometimes, a cause is never found. If your semen analysis shows that you have a low sperm count, your doctor's goal will be to find out the cause and determine what can be done to help you and your partner have a baby.

Further Male Fertility Testing

Your doctor will usually want to repeat the semen analysis. If you had trouble producing a sample the first time, your doctor might suggest that you do so via intercourse.

For this process, you use a specialized condom that is meant for the collection of semen samples. You should not use a regular condom for collection, as it can kill sperm—even without added spermicide.

Beyond basic semen analysis, your doctor might also want to perform other tests depending on your results.

Other tests your doctor might order to assess fertility include:

  • 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 might include Computer Assisted Semen Analysis (CASE), anti-sperm antibodies testing, sperm DNA testing, hypo-osmotic swelling testing, and others.
  • Post-coital testing (PCT), which evaluates a woman's cervical mucus after intercourse to check for live, moving sperm.
  • Genetic testing, which checks 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 evaluate for retrograde ejaculation
  • Testicular biopsy
  • Vasography

What If Poor Results Repeat

After additional testing is performed, your doctor might recommend treatment to improve your semen health. This could include lifestyle changes, medications, or surgery. Your doctor might 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. 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."

—Dr. Hirshfeld-Cytron

Treatment is not always straightforward or quick. It's possible that your doctor will recommend one treatment and, if it does not work, recommend that you try another. 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 might seem to be produced at the moment of ejaculation, it actually takes weeks for sperm to develop within the male reproductive system. Therefore, your doctor may want you to have a follow-up semen analysis three to four months after a treatment plan is put in place.

"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, but there are tests and treatments you can explore. Talk to your doctor about testing your sperm health and finding a possible cause for your infertility.

Don't be afraid to ask questions. The more you know, the more empowered you will be to make informed decisions about your treatment and fertility options.

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