Lab result explainedHormonesLast updated November 11, 2026

Semen analysis: how to read your results, normal sperm count, motility and morphology, and what low values mean

Semen analysis · Stand-alone test (ordered in a fertility work-up, after vasectomy, or before sperm banking); often followed by FSH, LH, testosterone and prolactin · reported in Volume in mL; concentration in million/mL; total count in million per ejaculate; motility, vitality and morphology in percent; pH; round cells and white cells in million/mL

A semen analysis is the laboratory examination of a semen sample for the number of sperm it contains, how well they move, what proportion are normally shaped, and the volume and chemistry of the fluid they are carried in. It is the first and most informative test for the male side of a couple's fertility, and it is also used to confirm that a vasectomy has worked and to assess a sample before freezing. About 40 to 50 percent of couples who have difficulty conceiving have a male factor contributing, and a semen analysis finds it in the majority of those cases.

Results are compared with the World Health Organization's 2021 reference limits, which are the 5th percentile of values from men who fathered a child within a year of trying: 1.4 mL of semen, 16 million sperm per milliliter, 39 million sperm in the whole ejaculate, 42 percent of sperm moving (30 percent moving forward), 54 percent alive, and 4 percent with normal shape by strict criteria. These are not pass or fail lines. One in twenty fertile men falls below each of them, and men well above them can still have fertility problems. A result below a limit means the chance of conceiving per month is lower and the finding deserves a repeat test and an explanation.

A single sample is only a snapshot. Sperm take about 74 days to form and a further 2 weeks to mature, so a fever, an illness, a course of medication or a stretch of heavy drinking in the preceding 3 months shows up in the result, and the same man's counts commonly vary by 30 to 50 percent between samples. Guidelines therefore ask for two analyses, at least 2 to 4 weeks apart (ideally a few months apart if the first was abnormal), each after 2 to 7 days without ejaculation, produced by masturbation into a sterile container and examined within an hour. Only when two samples agree is a diagnosis made, and the diagnosis then points to the next tests: hormones, a physical examination for a varicocele or missing vas deferens, and sometimes genetic tests.

Semen analysis at a glance

What it is: a microscopic and chemical examination of semen for sperm count, movement, shape, volume, pH and white cells; the core male fertility test.
WHO 2021 lower reference limits: volume 1.4 mL; concentration 16 million/mL; total count 39 million per ejaculate; total motility 42 percent; progressive motility 30 percent; vitality 54 percent; normal morphology 4 percent (strict criteria); pH 7.2 or above.
Below a limit does not mean infertile: 5 percent of men who fathered a child within a year are below each cut-off. Two samples 2–4 weeks or more apart are needed before any label is applied.
Terms on the report: oligozoospermia (low count), asthenozoospermia (low motility), teratozoospermia (low normal forms), azoospermia (no sperm seen, about 1 percent of men and 10–15 percent of infertile men), cryptozoospermia (sperm found only after spinning the sample).
Collect after 2–7 days of abstinence (not longer), by masturbation into the lab's sterile cup, catching the whole sample; deliver within 30–60 minutes kept at body temperature. Fever or illness in the past 3 months lowers results.
Next step after an abnormal repeat: FSH, LH, total testosterone and prolactin; examination for varicocele; genetic testing (karyotype, Y-chromosome microdeletions, CFTR) if the count is under 5 million/mL or zero.

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What Semen analysis measures

The sample is first left to liquefy, which normally takes 15 to 30 minutes (up to 60) as prostatic enzymes break down the gel from the seminal vesicles. The technician records the volume, which comes about 65 percent from the seminal vesicles, 25 percent from the prostate and only around 5 percent from the testes and epididymis; a very low volume therefore points to a blocked or absent duct, retrograde ejaculation or a lost fraction rather than to the testes. The pH (normally 7.2 to 8.0) and viscosity are noted, and the appearance: normal semen is gray-opalescent, and a yellow or reddish tinge suggests infection or blood.

Sperm concentration is counted in a hemocytometer chamber under the microscope and multiplied by the volume to give the total count, which is the more meaningful number because it reflects the testes' total output. Motility is graded by watching at least 200 sperm: progressive (moving forward in a line or large circle), non-progressive (moving but not advancing) and immotile; WHO 2021 reintroduced a split of progressive into rapid and slow. Vitality (the proportion alive, by dye exclusion) is checked when motility is low, to distinguish dead sperm from live but immotile ones, which matters for assisted reproduction. Morphology is assessed by strict (Tygerberg or Kruger) criteria on a stained smear, which classify any sperm with the slightest head, midpiece or tail defect as abnormal, so a normal result is only 4 percent or more; older, looser criteria gave much higher 'normal' percentages and should not be compared.

Round cells are counted and, if more than 1 million/mL, stained to tell immature germ cells from white cells; more than 1 million white cells per milliliter (leukocytospermia) raises the question of infection or inflammation. Additional tests ordered selectively include a mixed antiglobulin reaction (MAR) or immunobead test for antisperm antibodies (significant when 50 percent or more of motile sperm are coated), semen fructose when volume is low and sperm absent (absent fructose means the seminal vesicles are blocked or missing), semen culture, and sperm DNA fragmentation, where an index above about 25 to 30 percent is associated with lower natural and IUI pregnancy rates and more miscarriages. Computer-assisted semen analysis (CASA) systems are used in many labs for count and motility, but morphology still relies on a trained observer, which is one reason results vary between laboratories.

Normal range for Semen analysis

Reference ranges vary between labs and by age, sex and pregnancy. Use the range printed on your own report.

Group	Typical range (Volume in mL; concentration in million/mL; total count in million per ejaculate; motility, vitality and morphology in percent; pH; round cells and white cells in million/mL)	Notes
Semen volume	1.4 mL or more (WHO 2021 lower limit; WHO 2010 used 1.5 mL)	Typical range 1.5–5 mL. Below 1 mL suggests incomplete collection, short abstinence, retrograde ejaculation or obstruction; above 6 mL is usually just long abstinence.
Sperm concentration	16 million/mL or more (WHO 2010: 15 million/mL)	Median in fertile men is about 66 million/mL. Under 5 million/mL is severe oligozoospermia and prompts genetic testing; zero is azoospermia and the sample is centrifuged to look for any sperm.
Total sperm count	39 million per ejaculate or more	Concentration multiplied by volume; the better measure of testicular output. Median in fertile men about 200 million.
Total motility (progressive plus non-progressive)	42 percent or more (WHO 2010: 40 percent)	Assessed within 1 hour of collection; motility falls with every hour of delay and with cooling.
Progressive motility	30 percent or more (WHO 2010: 32 percent)	Sperm actively moving forward; the fraction most relevant to natural conception and intrauterine insemination.
Vitality (live sperm)	54 percent or more (WHO 2010: 58 percent)	Checked when motility is below about 40 percent; many live but immotile sperm point to a structural tail defect, many dead sperm to epididymal or oxidative damage.
Normal morphology (strict criteria)	4 percent or more	By Kruger/Tygerberg strict criteria. Most fertile men score 4–15 percent; values of 0–3 percent reduce but do not abolish natural fertility. Not comparable with older, looser criteria.
pH	7.2 or above (typically 7.2–8.0)	Acidic pH (under 7.0) with low volume and no sperm suggests absent or blocked seminal vesicles; pH above 8 can accompany infection.
Round cells and white cells	Round cells under 1 million/mL; peroxidase-positive white cells under 1 million/mL	More than 1 million white cells/mL is leukocytospermia, a trigger for culture and examination for prostatitis or epididymitis.

High or abnormal values: white cells, round cells, viscosity, volume, DNA fragmentation and antibodies

Most of a semen analysis is read for low values, but several parameters are flagged when they are high. A white cell count above 1 million/mL (leukocytospermia) is found in 10 to 20 percent of men being evaluated for infertility and signals inflammation somewhere along the reproductive tract, most often the prostate, seminal vesicles or epididymis. White cells release reactive oxygen species that damage sperm membranes and DNA, so leukocytospermia often comes with reduced motility and higher DNA fragmentation. A culture identifies a bacterial cause in only a minority; many cases are sterile inflammation, and treating the sample result with antibiotics in the absence of a proven infection does not reliably improve fertility. A raised round cell count on its own, without confirmed white cells, usually reflects immature germ cells shed early from the testis, which goes with disturbed sperm production rather than infection.

High viscosity (semen that forms threads longer than 2 cm when dropped from a pipette) and failure to liquefy within an hour are usually a prostate or seminal vesicle secretion issue, sometimes with infection or dehydration; they trap sperm and lower measured motility, and are managed in the lab by enzyme treatment if the sample is for insemination. A high volume (above about 6 mL) is almost always long abstinence or large seminal vesicle output and dilutes the concentration without changing the total count, which is why the total count is the number to look at. A pH above 8.0 is a soft sign of infection. Agglutination, with motile sperm sticking to each other head-to-head or tail-to-tail, suggests antisperm antibodies, confirmed by a MAR or immunobead test showing 50 percent or more of motile sperm coated; these antibodies arise after vasectomy, testicular injury or infection, impair movement through cervical mucus, and are bypassed by intrauterine insemination or ICSI rather than treated directly.

Sperm DNA fragmentation is reported as the percentage of sperm with broken DNA strands, and an index above about 25 to 30 percent (depending on the assay) is associated with lower natural and IUI conception rates, lower embryo quality in IVF and a higher risk of miscarriage, even when the standard parameters are normal. It is raised by varicocele, smoking, obesity, older age, heat exposure, infection, chemotherapy and long abstinence, and it is the one parameter that is relatively quick to improve: a shorter abstinence interval of 1 to 2 days, treating a varicocele, stopping smoking and antioxidant intake have each been shown to lower it in trials. Guidelines consider it a useful add-on in recurrent pregnancy loss and unexplained IVF failure rather than a routine test.

Common causes

Prostatitis, epididymitis and sexually transmitted infection
Chlamydia, gonorrhea, Mycoplasma and Ureaplasma, and bacterial prostatitis raise white cells and pH and lower motility; chronic epididymitis can also block the duct. Culture and STI testing are done when white cells exceed 1 million/mL, especially with urinary symptoms or pain.
Sterile inflammation and oxidative stress
Many men with leukocytospermia have no culturable organism; the white cells reflect inflammation from varicocele, smoking, obesity or a past infection, and generate reactive oxygen species that damage sperm membranes and DNA.
Long abstinence
More than 7 days without ejaculation raises volume and count but lowers motility and raises DNA fragmentation and dead sperm, because aged sperm accumulate in the epididymis. The 2–7 day window, and 1–2 days when DNA damage is the concern, gives the best quality.
Varicocele
Dilated veins around the testis raise scrotal temperature and oxidative stress; present in about 15 percent of men overall and 35–40 percent of men with primary infertility. It raises DNA fragmentation and lowers count, motility and morphology; repair improves semen parameters in most trials.
Antisperm antibodies
Arise when sperm (normally sealed behind the blood-testis barrier) meet the immune system after vasectomy, testicular trauma, torsion, biopsy or infection. Cause agglutination and poor cervical mucus penetration; significant when 50 percent or more of motile sperm are bound on MAR or immunobead testing.
Immature germ cells (high round cells, low white cells)
Spermatids and spermatocytes shed early into semen indicate disturbed spermatogenesis, as in varicocele, heat exposure, hormonal problems or after chemotherapy; they are counted as round cells but are not white cells.
Heat, smoking, obesity and age
Each raises DNA fragmentation independently: scrotal heating from hot tubs, saunas, laptops and tight clothing; smoking by about a third in meta-analyses; obesity through scrotal fat and inflammation; and age over 40–45 through accumulated oxidative damage.
Dehydration and prostate secretion problems
High viscosity and delayed liquefaction reflect prostatic enzyme deficiency or concentrated seminal vesicle fluid; better hydration and treating any prostatitis help, and the lab can liquefy the sample enzymatically for assisted conception.

Symptoms that can go with it

Usually none; most abnormal semen findings produce no symptoms and are discovered only when a couple has trouble conceiving
Pain or burning on urination, pelvic or perineal pain, or painful ejaculation with prostatitis or urethritis
A tender, swollen epididymis or testis with epididymitis
A dragging ache or visible 'bag of worms' veins in the scrotum, usually on the left, with a varicocele
Blood-tinged or yellowish semen with infection or inflammation
A history of vasectomy reversal, testicular injury, torsion or mumps orchitis in men with antisperm antibodies

Low sperm count, motility or morphology

A low sperm count (oligozoospermia, under 16 million/mL or under 39 million in total) is the commonest abnormal finding and spans a wide range of meaning. Counts just under the limit on one sample are often normal on the next, because month-to-month variation is large and a febrile illness, heavy drinking, a new medication or a hot tub habit 2 to 3 months earlier can halve a count temporarily. Counts persistently between 5 and 16 million/mL lower the monthly chance of conception, and the time to pregnancy lengthens progressively as the count falls, but natural conception remains common. Counts under 5 million/mL (severe oligozoospermia) and azoospermia (no sperm at all, found in about 1 percent of men and 10 to 15 percent of men with infertility) change the approach: hormones and a physical examination separate a production problem in the testes (usually with a high FSH above about 7.6 IU/L and small, soft testes) from an obstruction (normal FSH, normal-sized testes, and often a missing vas deferens or a history of infection or surgery), and genetic testing is recommended, because 10 to 15 percent of men with severe oligozoospermia or non-obstructive azoospermia carry a chromosomal abnormality such as Klinefelter syndrome (47,XXY) or a Y-chromosome microdeletion, and congenital absence of the vas deferens is usually due to CFTR (cystic fibrosis gene) mutations with implications for the couple's children.

Low motility (asthenozoospermia, total motility under 42 percent or progressive under 30 percent) is often the first parameter to suffer from anything that stresses sperm after they are made: long abstinence, delay or cooling between collection and analysis, infection, antisperm antibodies, varicocele, smoking and oxidative stress. Motility that is almost zero with normal vitality suggests a structural defect of the sperm tail (primary ciliary dyskinesia, in men who may also have chronic sinus and chest problems), while near-zero motility with mostly dead sperm (necrozoospermia) points to epididymal dysfunction, infection or toxin exposure. Low normal morphology (teratozoospermia, under 4 percent by strict criteria) is the parameter most men worry about and the one that matters least in isolation: it is highly observer-dependent, most fertile men score only 4 to 15 percent, and studies show that values of 1 to 3 percent reduce natural and IUI success modestly but have little effect on IVF with ICSI. A uniformly abnormal population of sperm (all round heads, or all pin heads) is the exception and has specific genetic causes.

In practice the three parameters are read together with the total count, and combinations are more informative than any one value. Low count with low motility and low morphology (OAT syndrome) suggests a testicular problem such as varicocele, hormonal deficiency, heat, toxins or a genetic cause. Low volume with low count suggests retrograde ejaculation (confirmed by sperm in a post-ejaculation urine sample) or partial obstruction. Normal count with isolated low motility suggests a post-testicular problem (abstinence, infection, antibodies, delay in analysis). After a vasectomy, the goal is the opposite: no motile sperm, and ideally no sperm at all, on a sample 8 to 16 weeks and at least 20 ejaculations after the procedure; rare non-motile sperm under 100,000/mL are accepted by most guidelines.

Common causes

Varicocele
The most common correctable cause, found in 35–40 percent of men with primary infertility. Raised testicular temperature and oxidative stress lower count, motility and morphology; surgical repair improves parameters in about two thirds of men and modestly improves pregnancy rates when the semen analysis is abnormal and the varicocele is palpable.
Testosterone therapy and anabolic steroids
External testosterone shuts down LH and FSH and therefore sperm production, often to zero within months; recovery takes 6–24 months after stopping and is incomplete in some men. This is among the commonest preventable causes in men under 40 and is why testosterone is never prescribed to a man who wants to conceive.
Hormonal causes: hypogonadotropic hypogonadism, hyperprolactinemia, thyroid disease
Low LH and FSH (pituitary tumors, Kallmann syndrome, opioids, severe illness) starve the testes of signal and are treatable with gonadotropins; a high prolactin suppresses the same axis; untreated hypothyroidism and hyperthyroidism both impair semen quality.
Genetic causes
Klinefelter syndrome (47,XXY, about 1 in 600 men) causes small firm testes, high FSH and azoospermia or severe oligozoospermia; Y-chromosome microdeletions (AZFa, b, c) cause production failure, with AZFc deletions still allowing sperm retrieval; CFTR mutations cause congenital absence of the vas deferens with low-volume, acidic, sperm-free semen.
Heat, medications and toxins
Fever, hot tubs, saunas and occupational heat lower counts for 2–3 months; chemotherapy and pelvic radiation can cause permanent azoospermia (bank sperm beforehand); sulfasalazine, ketoconazole, cimetidine, spironolactone, long-term opioids, SSRIs (motility and DNA damage), 5-alpha-reductase inhibitors (finasteride) and heavy cannabis use each reduce one or more parameters reversibly.
Obstruction and retrograde ejaculation
Prior vasectomy, hernia repair with mesh, epididymitis from chlamydia or gonorrhea, and ejaculatory duct cysts block sperm transport, giving azoospermia with normal hormones and testes. Retrograde ejaculation (diabetes, prostate or bladder neck surgery, alpha-blockers such as tamsulosin) sends semen into the bladder and gives low volume and count.
Undescended testes, torsion, mumps orchitis and testicular cancer
A history of undescended testis (even if corrected) roughly doubles the risk of a low count; torsion and mumps orchitis after puberty can destroy tubules; testicular cancer and its treatment impair the other testis as well, and men are offered sperm banking before orchiectomy.
Smoking, heavy alcohol and obesity
Smokers have about 13–17 percent lower concentration and 10 percent lower motility in meta-analyses; more than 14 drinks a week lowers testosterone and sperm quality; a BMI over 30 is associated with a higher rate of oligozoospermia and azoospermia and higher DNA fragmentation, improving with weight loss.
Systemic illness and recent infection
Diabetes, celiac disease, kidney and liver failure, HIV, sickle cell disease and any febrile illness (including COVID-19 and influenza) lower semen parameters, usually with recovery over 3–6 months once the illness is controlled.
Collection problems and idiopathic
Losing the first, sperm-rich fraction of the ejaculate, a short abstinence, condom collection with spermicide, or a long delay before analysis all produce artificially low results. After full evaluation, 30–40 percent of men with abnormal semen have no identifiable cause (idiopathic male infertility).

Symptoms that can go with it

Usually none; a low sperm count is discovered through testing, not felt
Small or soft testes, which suggest a production problem (and firm, very small testes in Klinefelter syndrome)
Low libido, erectile difficulty, reduced facial and body hair, breast tissue or low energy when testosterone is also low
Scrotal heaviness or visible veins with a varicocele
A dry or very small ejaculate, or cloudy urine after sex, with retrograde ejaculation or obstruction
Absent sense of smell with low LH and FSH (Kallmann syndrome), or chronic sinus and chest infections with immotile sperm (primary ciliary dyskinesia)
Headaches, visual field loss or milky nipple discharge with a pituitary tumor raising prolactin

Read it alongside

FSH — the key hormone when the count is low: above about 7.6 IU/L with small testes indicates failed sperm production (non-obstructive), normal FSH with azoospermia suggests obstruction.
LH and total testosterone — low testosterone with low or normal LH points to a pituitary or hypothalamic cause (or external testosterone use); low testosterone with high LH to testicular failure. Draw between 7 and 10 am.
Prolactin — a high level suppresses LH and FSH and can be the whole explanation; above 100–200 ng/mL suggests a pituitary adenoma.
Estradiol — raised in obesity and with some testicular tumors; a testosterone-to-estradiol ratio under 10 is used by some clinicians to guide aromatase inhibitor treatment.
TSH — hypothyroidism and hyperthyroidism both impair semen quality and are easily corrected.
A1C and fasting glucose — diabetes causes retrograde ejaculation, erectile dysfunction, lower testosterone and higher DNA fragmentation.
Post-ejaculation urinalysis — sperm in the urine confirms retrograde ejaculation when volume is low; semen fructose and scrotal or transrectal ultrasound locate obstructions.
Karyotype, Y-chromosome microdeletion and CFTR testing — recommended when the concentration is under 5 million/mL or zero, and before surgical sperm retrieval or ICSI, because findings affect the couple's children.

What usually happens next

If one parameter is below a reference limit, repeat the analysis at the same laboratory after 2 to 7 days of abstinence, at least 2 to 4 weeks later and ideally 3 months after any fever, illness or heavy exposure; a normal repeat usually ends the matter.
If the abnormality is confirmed, expect a morning FSH, LH, total testosterone and prolactin, and a physical examination of testicular size and the scrotum for a varicocele, the vas deferens and the epididymis; this separates production problems from obstruction and hormonal causes.
A concentration under 5 million/mL or azoospermia leads to karyotype, Y-chromosome microdeletion and (for absent vas or low-volume acidic semen) CFTR testing, and a referral to a reproductive urologist to discuss varicocele repair, hormonal treatment or surgical sperm retrieval.
Review every medication and supplement with the clinician, particularly testosterone, anabolic steroids, finasteride, opioids, SSRIs, sulfasalazine and alpha-blockers; several cause reversible changes that recover over 3 to 12 months.
Ask how the result changes the couple's options: mild abnormalities may need only time and lifestyle changes (count the time in 3-month blocks), moderate ones often lead to intrauterine insemination, and severe ones to IVF with ICSI, which needs only a handful of live sperm.
If you are about to start chemotherapy, radiation, testosterone or have testicular surgery, ask about sperm banking first; a single analysis with freezing can preserve the option of children later.

Diet, lifestyle and natural levers with evidence

What can move Semen analysis once the cause is known. Nothing here replaces finding the cause.

Stop smoking, cannabis and heavy drinking

Strong evidence

A meta-analysis of 20 studies in about 5,900 men found smokers had lower sperm concentration (about 13 to 17 percent), motility (about 10 percent) and normal morphology, with a dose effect and partial recovery within 3 months of stopping; smoking also raises DNA fragmentation by around a third. Regular cannabis use is associated with 28 to 29 percent lower concentration and total count in a large cohort, and more than 14 alcoholic drinks a week lowers testosterone and semen volume. These are the most consistently supported lifestyle changes, and they take one spermatogenic cycle (about 3 months) to show.

Keep the testes cool and the abstinence interval short

Moderate evidence

Sperm production needs a temperature 2 to 4 °C below core body temperature. Avoiding hot tubs, saunas and prolonged laptop or seat heating has reversed severe oligozoospermia in small case series (in one, 5 of 11 men more than doubled their counts within 3 to 6 months of stopping hot baths), and trials of scrotal cooling devices and loose underwear show modest gains in count and motility; a large cross-sectional study found men wearing boxers had 25 percent higher concentration than those in tight underwear. Separately, ejaculating every 1 to 2 days rather than abstaining for a week lowers DNA fragmentation and improves motility, and the 2 to 7 day window applies only to the test sample itself.

Weight loss and regular moderate exercise if overweight

Moderate evidence

Obesity is associated with roughly a 40 percent higher risk of oligozoospermia and azoospermia, lower testosterone and higher DNA fragmentation. In intervention studies, diet-induced weight loss of about 10 percent in men with obesity increased total sperm count by around 40 percent and improved motility and DNA integrity over 8 to 12 weeks, with gains maintained in men who kept the weight off; randomized trials of 3 to 6 months of moderate aerobic exercise (three to four 50-minute sessions a week) improved count, motility and morphology in sedentary men. Very high-volume endurance training and anabolic steroid use have the opposite effect.

Rapid weight loss after bariatric surgery can transiently worsen semen quality for 6–12 months before improving; plan conception timing with your clinician.

Coenzyme Q10

Moderate evidence

Meta-analyses of randomized trials in men with idiopathic infertility found that 200 to 300 mg of CoQ10 a day for 3 to 6 months increased sperm concentration by around 5 million/mL and progressive motility by roughly 4 to 5 percentage points, with improvements in seminal antioxidant markers, but no clear increase in live births has been shown. It is the single antioxidant with the most consistent effect on measured parameters; broad antioxidant combinations were tested in the large MOXI trial (2020) and did not improve semen parameters or live birth, and the 2022 Cochrane review rates the evidence for antioxidants as low quality.

Generally well tolerated; may slightly reduce the effect of warfarin. Reassess after 3 to 6 months rather than continuing indefinitely.

Omega-3 fatty acids and a Mediterranean-style diet

Preliminary evidence

Sperm membranes are rich in docosahexaenoic acid (DHA). A meta-analysis of three randomized trials found omega-3 supplementation (about 1 to 2 g of EPA plus DHA a day for 3 months or more) increased sperm concentration, motility and DHA content, and a Danish cross-sectional study of 1,700 young men found fish-oil users had higher semen volume and total count. Observational studies link Mediterranean-style eating (fish, vegetables, nuts, whole grains, less processed meat and sugar-sweetened drinks) with better count and motility, but no randomized trial has tested the diet directly. Zinc with folic acid, by contrast, did not improve semen quality or live birth in the 2,370-man FAZST trial.

Fish-oil doses above 3 g a day can increase bleeding tendency; choose products tested for contaminants.

When to see a clinician promptly

Sudden severe pain and swelling of one testicle, with or without nausea: testicular torsion is an emergency that can destroy the testis within 6 hours; go to an emergency department immediately.
A painless lump, hardness or change in size of a testicle, which needs an ultrasound within days to exclude testicular cancer, a cancer that is highly curable when found early and that itself lowers sperm counts.
Azoospermia or a count under 5 million/mL on a repeat sample, which warrants hormonal and genetic evaluation and a reproductive urology referral rather than waiting.
Fever with a painful, swollen scrotum or pain on urination and ejaculation: epididymitis or prostatitis, which needs same-day assessment and treatment to prevent duct scarring.
No pregnancy after 12 months of regular unprotected intercourse (6 months if the female partner is 35 or older), or earlier if there is a known risk factor such as undescended testes, chemotherapy or testosterone use.
Headaches with visual disturbance, milky nipple discharge, loss of sense of smell or hot flushes together with a low count, which point to a pituitary or hormonal cause.

Frequently asked questions

What is a normal sperm count?

By the WHO 2021 reference limits, a concentration of 16 million sperm per milliliter or more and a total of 39 million per ejaculate or more is within the normal range; the median in fertile men is around 66 million/mL and about 200 million in total. These limits are the 5th percentile of men who fathered a child within a year, so 1 in 20 fertile men is below them. Counts under 16 million/mL are called oligozoospermia, under 5 million/mL severe oligozoospermia, and zero azoospermia.

How do I read my semen analysis results?

Look first at total sperm count (concentration times volume) against 39 million, then progressive motility against 30 percent and total motility against 42 percent, then strict morphology against 4 percent. Check the volume (1.4 mL or more), pH (7.2 or more), the abstinence time recorded, the time from collection to analysis (should be under an hour) and any note of white cells over 1 million/mL or agglutination. A value just under a limit on one sample means repeat; several low values together, or very low values, mean an evaluation.

What is a normal sperm morphology percentage?

Four percent or more normal forms by strict (Kruger/Tygerberg) criteria. That sounds low because strict criteria classify any sperm with the slightest imperfection as abnormal; most fertile men score between 4 and 15 percent. Values of 1 to 3 percent modestly lower the chance of natural conception and IUI success but matter little for IVF with ICSI. Morphology is also the most observer-dependent parameter, so a single low morphology with normal count and motility is rarely acted on by itself.

What causes a low sperm count?

Varicocele is the commonest correctable cause; testosterone or anabolic steroid use is the commonest preventable one. Others include hormonal problems (low LH and FSH, high prolactin, thyroid disease), genetic conditions (Klinefelter syndrome, Y-chromosome microdeletions, CFTR mutations), heat exposure, fever or illness in the previous 3 months, medications (finasteride, sulfasalazine, opioids, SSRIs, chemotherapy), infections, obstruction after vasectomy or infection, smoking, heavy drinking and obesity. In 30 to 40 percent of men no cause is found after full evaluation.

How long should I abstain before a semen analysis?

Two to seven days, and most labs suggest 2 to 4. Shorter than 2 days lowers volume and count; longer than 7 days raises count slightly but lowers motility and increases dead sperm and DNA damage, so a 'long saving up' does not improve the result. Record the exact interval on the form, use the same interval for the repeat test, collect by masturbation into the lab's sterile container without lubricant, catch the whole sample (the first portion holds most of the sperm), and deliver it within 30 to 60 minutes kept close to body temperature.

Can a semen analysis be wrong, and why do results vary so much?

Results commonly vary by 30 to 50 percent between samples from the same man because sperm production responds to fever, illness, medication, heat, stress and alcohol over the previous 3 months, and because collection (lost fraction, short abstinence, delay, cooling) and the laboratory (manual counting, observer-dependent morphology) add variation. That is why guidelines require two samples before any conclusion, repeated at the same lab, and why a borderline first result is not a diagnosis.

How long does it take to improve sperm quality?

At least one full spermatogenic cycle: about 74 days to make sperm plus 2 weeks to mature, so roughly 3 months after any change (stopping smoking, correcting a hormone problem, varicocele repair, recovering from a fever). Recovery after stopping testosterone or anabolic steroids takes 6 to 24 months. Repeat testing sooner than 3 months after a change mostly measures sperm that were already in production.

What does azoospermia mean, and can I still have children?

Azoospermia means no sperm were found in the ejaculate, even after centrifuging the sample. It affects about 1 percent of men and 10 to 15 percent of infertile men. About 40 percent of cases are obstructive (normal production, blocked transport, as after vasectomy or with absent vas deferens), where sperm can almost always be retrieved from the epididymis or testis for ICSI. The rest are non-obstructive (production failure, usually with high FSH), where microsurgical testicular sperm extraction finds usable sperm in roughly half of men. Genetic testing is recommended before treatment.

References

WHO laboratory manual for the examination and processing of human semen, sixth edition. World Health Organization (2021)View source
Semen analysis. MedlinePlus, US National Library of Medicine (2022)View source
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Campbell MJ, Lotti F, Baldi E, et al.. Semen analysis and the WHO 2021 reference limits: the distribution of semen examination results from men whose partners conceived within 12 months. Andrology (2021)
Sharma R, Harlev A, Agarwal A, Esteves SC. Cigarette smoking and semen quality: a new meta-analysis examining the effect of the 2010 World Health Organization laboratory methods for the examination of human semen. European Urology (2016)
Steiner AZ, Hansen KR, Barnhart KT, et al.. The effect of antioxidants on male factor infertility: the Males, Antioxidants, and Infertility (MOXI) randomized clinical trial. Fertility and Sterility (2020)
de Ligny W, Smits RM, Mackenzie-Proctor R, et al.. Antioxidants for male subfertility. Cochrane Database of Systematic Reviews (2022)
Schisterman EF, Sjaarda LA, Clemons T, et al.. Effect of folic acid and zinc supplementation in men on semen quality and live birth among couples undergoing infertility treatment: a randomized clinical trial (FAZST). JAMA (2020)
Lafuente R, González-Comadrán M, Solà I, et al.. Coenzyme Q10 and male infertility: a systematic review and meta-analysis. Journal of Assisted Reproduction and Genetics (2013)
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