Male infertility and Evaluation

Usually, the first step in evaluating for male infertility is a semen analysis. This is an analysis for the assessment of morphology, sperm count, motility, and total motile sperm. Two samples may be required to establish the diagnosis of male infertility. An abnormal semen analysis will usually prompt further investigation. Additional tests may include hormonal evaluation, testicular examination, and in some instances, a chromosome analysis. Types of hormone problems that can lead to male infertility include, but are not limited to, high prolactin levels, abnormal testosterone levels, or abnormal FSH/LH (the hormones that regulate sperm production. An examination for physical abnormalities can be conducted by a urologist.

Normal parameters for a semen analysis:

Total Sperm Count

> 39 million

Morphology (WHO)

> 04% normal shape


> 1.5 milliliters

Morphology (Kruger)

> 14% normal shape


> 40% motile


complete by 60 min

Total motile sperm count is the amount of moving sperm in the entire sample. This value is also used as an indicator of the overall assessment of the semen. Generally, total motile sperm above 20 million are not associated with significant problems with fertilization as long as the other parameters are not significantly low. Many couples will still consider ICSI in the setting of a borderline semen analysis. Fertilization is the biggest concern with borderline counts. The lower the semen analysis parameters, the higher likelihood of encountering fertilization failure. Fertilization failure is the situation where there are fewer than expected fertilized eggs. This is often avoided by performing ICSI which is a process of injecting a single sperm into an egg. Fertilization rates are often higher with ICSI so women with low numbers of eggs may also elect to do ICSI to maximize the number of fertilized eggs.

When no spermatozoa is found in the ejaculate it is called azoospermia. Usually sperms are present in the testes if there is no testicular failure. ICSI can be done by testicular spermatozoa. But before recruiting the patient for the procedure it is to be ensured that there are spermatozoa in the testes. Following are the procedures for detection of spermatozoa in the testes.

  • Microsurgical Sperm Aspiration (MESA) or Percutaneous Epididymal Sperm Aspiration (PESA) are procedures where sperm is retrieved from the epididymis. Epididymal sperm usually contains more mature sperm .
  • Testicular sperm aspiration (TESA):  Testicular sperm is aspirated by a wide bored needle
  • Testicular sperm extraction (TESE) or Testicular biopsy – This is a procedure where a portion of testicular tissue is collected. This can serve as a diagnostic tool in the setting that testicular tissue is abnormal. It can also be one of the last remaining sources of sperm for some men. There is a higher likelihood of immature sperm and the sperm retrieved will likely be in low numbers. ICSI is essential following most biopsy and aspiration procedures.

These maneuvers can be done under general or local anaesthesia. It is easy to perform and not so invasive for the patient.

When spermatozoa found by these procedures it can be frozen for future use and no need of repeat maneuver on the day of ICSI procedure.