How Is Male Infertility Diagnosed? Tests Every Man Should Know About

How Is Male Infertility Diagnosed?

If you and your partner are having difficulty conceiving, understanding how male infertility is diagnosed is an important first step.

Male fertility problems can have many different causes. Some affect sperm production, while others involve hormones, sperm transport, the testicles, or sexual and reproductive function.

For this reason, a proper male fertility assessment is not based on a single test.

A specialist usually combines your medical history, physical examination and semen analysis with additional tests when they are clinically appropriate.

The European Society for Sexual Medicine (ESSM) has addressed many of these areas within its scientific programme, including male infertility, hormonal factors, varicocele, sperm retrieval, oxidative stress and sperm DNA damage. ESSM 2014 Scientific Programme

Current European Association of Urology (EAU) guidance also recommends a structured evaluation of men presenting with fertility problems, rather than relying on semen analysis alone. EAU Male Infertility Guidelines

When Should a Man Have a Fertility Assessment?

A fertility assessment is generally recommended when a couple has been unable to achieve pregnancy after 12 months of regular, unprotected intercourse.

However, waiting 12 months is not always necessary.

Earlier assessment may be appropriate if a man has:

• A history of testicular problems

• Previous testicular or reproductive surgery

• A known varicocele

• A history of undescended testicles

• Previous chemotherapy or radiation

• Very low sperm count

• Azoospermia

• Erectile dysfunction

• Ejaculation problems

• Known hormonal abnormalities

• Previous fertility problems

Both partners should be assessed when appropriate because fertility is a couple-based issue.

What Happens During a Male Fertility Assessment?

A typical evaluation may involve several stages.

1. Medical and Fertility History

The first step is usually a detailed discussion about your medical and reproductive history.

Your specialist may ask about:

• How long you have been trying to conceive

• Previous pregnancies

• Previous fertility investigations

• Childhood testicular problems

• Undescended testicles

• Testicular injuries

• Previous infections

• Previous surgeries

• Medications

• Testosterone or anabolic steroid use

• Chemotherapy or radiation

• Chronic medical conditions

• Family history of infertility

• Smoking, alcohol and other lifestyle factors

This information can provide important clues about the potential cause of reduced fertility.

For example, previous testicular surgery or trauma may suggest a structural problem, while testosterone or anabolic steroid use can suppress sperm production.

2. Physical Examination

A physical examination is an important part of male infertility diagnosis.

The specialist may examine:

• Testicular size

• Testicular consistency

• Epididymis

• Vas deferens

• Scrotum

• Presence of a varicocele

• Other abnormalities of the reproductive system

Testicular size can provide information about sperm-producing capacity, while examination of the vas deferens may identify findings that could suggest obstruction or certain genetic conditions.

A physical examination can also identify a clinically significant varicocele.

The EAU recommends physical examination as part of the diagnostic assessment of men with infertility. EAU Male Infertility Guidelines

3. Semen Analysis

A semen analysis is one of the most important initial tests in male fertility assessment.

It examines the semen and provides information about several sperm parameters.

These may include:

Sperm concentration

How many sperm are present in a given volume of semen.

Total sperm number

The overall number of sperm in the ejaculate.

Sperm motility

How effectively sperm move.

Sperm morphology

The shape and structure of sperm.

Semen volume

The amount of semen produced during ejaculation.

Depending on the laboratory and clinical situation, additional parameters may also be assessed.

Does One Abnormal Semen Analysis Mean Male Infertility?

Not necessarily.

Semen parameters can vary from one sample to another.

A single abnormal result should therefore be interpreted carefully and, when appropriate, confirmed with a repeat test.

Current EAU guidance recommends at least two consecutive semen analyses when the initial analysis shows abnormal parameters. EAU Male Infertility Guidelines

More importantly, semen analysis does not provide a simple yes-or-no answer to fertility.

A man with abnormal semen parameters may still be able to father a child naturally, while a man with parameters within reference ranges can still experience infertility.

The result needs to be considered alongside the couple's fertility history and the rest of the clinical evaluation.

4. Hormonal Testing

Hormones are essential for normal sperm production.

When there is a significant sperm abnormality, reduced libido, erectile problems, small testicular volume or other signs suggesting a hormonal problem, blood tests may be recommended.

Depending on the situation, testing may include:

• Testosterone

• Follicle-stimulating hormone (FSH)

• Luteinizing hormone (LH)

• Prolactin

• Other hormones when clinically indicated
  

Why Are Hormones Important?

Sperm production depends on communication between the brain, pituitary gland and testicles.

If this hormonal pathway is disrupted, sperm production may be reduced.

The ESSM 2014 programme included a dedicated male infertility session addressing testosterone supplementation and male infertility, highlighting the relationship between hormonal treatment and reproductive function. ESSM 2014 Scientific Programme

An important point for men trying to conceive is that testosterone replacement is not a fertility treatment. External testosterone can suppress the hormonal signals required for sperm production.

Current EAU guidance recommends against using testosterone therapy to treat male infertility in men who wish to become fathers. EAU Sexual and Reproductive Health Guidelines

5. Genetic Testing

Genetic testing is not necessary for every man with fertility problems.

However, it may be recommended when sperm production is severely impaired.

For example, genetic investigations may be considered in men with:

• Azoospermia

• Severe oligozoospermia

• Certain physical findings

• A family history suggesting a genetic condition

Depending on the clinical situation, testing may include chromosome analysis or specific genetic tests.

Identifying a genetic cause can be important for both diagnosis and treatment planning.

It may also help determine whether a genetic condition could have implications for assisted reproduction or potential transmission to offspring.

Current EAU guidance recommends genetic evaluation in selected men with severe sperm-production abnormalities. EAU Male Infertility Guidelines

6. Scrotal Ultrasound

A scrotal ultrasound is not automatically required for every man undergoing a fertility assessment.

It may be useful when the physical examination identifies an abnormality or when further evaluation of the testicles or scrotum is clinically indicated.

Ultrasound can help assess:

• Testicular structure

• Testicular volume

• Varicocele

• Other scrotal abnormalities

However, imaging should complement—not replace—a proper history and physical examination.

7. Testing for Azoospermia

When no sperm are found in the ejaculate, the evaluation becomes more detailed.

The specialist first needs to determine whether the problem is:

Obstructive azoospermia

Sperm production may be preserved, but sperm cannot reach the ejaculate because of an obstruction.

Non-obstructive azoospermia

The main problem is impaired sperm production.

This distinction is extremely important because the treatment pathway can be very different.

Further evaluation may include:

• Hormonal testing

• Genetic testing

• Physical examination

• Testicular assessment

• Imaging when appropriate

The ESSM programme included several presentations related to micro-TESE and sperm retrieval, reflecting the importance of determining whether sperm can be retrieved in selected men with severe sperm-production problems. ESSM 2014 Scientific Programme

8. Sperm DNA Fragmentation Testing

Standard semen analysis evaluates basic sperm characteristics, but it does not provide a complete picture of sperm DNA integrity.

In selected patients, a sperm DNA fragmentation test may provide additional information.

It may be considered in situations such as:

• Unexplained infertility

• Recurrent pregnancy loss

• Repeated assisted reproduction failure

• Selected cases where conventional evaluation does not explain the fertility problem

The ESSM 2014 programme included discussion of oxidative stress and sperm DNA damage, demonstrating the growing interest in sperm quality beyond conventional semen parameters. ESSM 2014 Scientific Programme

However, this is an advanced test and is not necessarily appropriate as part of the initial fertility assessment for every man.

9. Advanced Sperm and Reproductive Testing

Depending on the individual case, a specialist may recommend additional investigations.

These could include:

• Advanced sperm testing

• Genetic testing

• Hormonal investigations

• Imaging

• Tests for reproductive tract obstruction

• Testicular assessment

• Sperm retrieval assessment

The important principle is targeted testing.

Not every man needs every fertility test.

The appropriate investigation depends on the results of the initial assessment.

How Do Doctors Find the Cause of Male Infertility?

The diagnosis is usually built step by step.

Step 1: Medical history

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Step 2: Physical examination

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Step 3: Semen analysis

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Step 4: Repeat semen analysis if abnormal

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Step 5: Hormonal testing when indicated

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Step 6: Genetic testing when indicated

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Step 7: Imaging or advanced testing when necessary

This approach helps avoid unnecessary investigations while ensuring that important causes are not overlooked.

What Happens If the Tests Find a Problem?

The next step depends on the diagnosis.

For example:

Low sperm count→ Investigate the underlying cause and consider appropriate medical, surgical or reproductive options.

Varicocele→ Assess whether treatment could be beneficial based on the clinical situation.

Azoospermia→ Determine whether it is obstructive or non-obstructive and evaluate potential sperm retrieval options.

Hormonal abnormality→ Identify the underlying endocrine problem and treat it appropriately.

Sexual or ejaculation disorder→ Address the specific sexual or reproductive problem.

Severe sperm-production impairment→ Consider genetic assessment and, in selected cases, surgical sperm retrieval or assisted reproduction.

This is why male infertility diagnosis should always come before choosing treatment.

Can Male Infertility Be Diagnosed With a Semen Analysis Alone?

No.

A semen analysis is an essential investigation, but it is only one part of the assessment.

Two men can have similar semen results but completely different underlying causes.

For example:

• One man may have a hormonal disorder.

• Another may have a varicocele.

• Another may have an obstruction.

• Another may have a genetic condition.

Their treatments may therefore be completely different.

A specialist assessment brings these pieces together to determine the most likely cause and the most appropriate next step.

When Should You See a Male Fertility Specialist?

You should consider a specialist assessment if:

• You have been trying to conceive for 12 months without success.

• Your partner has fertility concerns and you want to assess the male factor as well.

• You have previously been told that your sperm count is low.

• No sperm were found in a semen analysis.

• You have a known varicocele.

• You have a history of testicular surgery or injury.

• You have had chemotherapy or radiation.

• You have erectile or ejaculation problems.

• You have previously used testosterone or anabolic steroids.

• You have a known hormonal or genetic condition.

Early assessment may be particularly important when there is a known risk factor rather than waiting for the full 12-month period.

Final Thoughts

Male infertility diagnosis is not based on one test.

A complete assessment combines medical and reproductive history, physical examination and semen analysis, followed by hormonal, genetic, imaging or advanced investigations when they are appropriate.

The purpose is to identify the underlying cause—not simply to label a semen analysis as normal or abnormal.

Once the cause is understood, treatment can be tailored to the individual, whether that involves medical management, treatment of a varicocele, correction of an obstruction, management of a hormonal disorder, sperm retrieval or assisted reproductive treatment.

If you are experiencing difficulty conceiving, a specialist male fertility assessment can help determine why fertility may be reduced and what options are available to you.

Book a Consultation

Book a consultation with Professor Amr Raheem to discuss male infertility, abnormal semen analysis, azoospermia, varicocele or other male reproductive concerns.

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References

1. European Society for Sexual Medicine (ESSM). 16th ESSM Congress Joint with the 12th EFS Congress – Final Programme, Istanbul, 2014. The programme includes scientific sessions covering male infertility, testosterone supplementation, obesity and metabolic syndrome, micro-TESE, varicocele surgery, sperm retrieval, oxidative stress and sperm DNA damage. ESSM 2014 Congress Programme

2. European Association of Urology (EAU). EAU Guidelines on Sexual and Reproductive Health – Male Infertility. Current recommendations for the evaluation and management of male infertility. EAU Male Infertility Guidelines