Semen Analysis (Spermogram)

The current reference is the WHO Laboratory Manual for the Examination and Processing of Human Semen, 6th edition. The lower reference limits correspond roughly to the bottom 5th percentile of men whose partners conceived naturally within 12 months. These values do not separate fertile from infertile men. A value below one reference limit does not mean inability to conceive, just as a value above all limits does not guarantee fertility.

Motility is classified as: progressive motility (sperm moving effectively forward), non-progressive motility (movement without effective forward progress), and immotility. Total motility includes progressive plus non-progressive movement and should not be confused with progressive motility alone — two different numbers with different clinical meaning.

• Vitality: percentage of live sperm; especially useful when motility is very low.
• pH: contributes to assessing accessory gland function, but on its own does not confirm prostatitis, infection, or ductal obstruction.
• Liquefaction/viscosity: ejaculate initially coagulates and normally liquefies; delayed liquefaction or increased viscosity can make laboratory assessment harder, without being on its own a diagnosis of infertility.
• Leukocytes: can be quantified, but leukocytes in semen do not automatically mean bacterial infection — they may reflect inflammation without a positive culture.
• Round cells: include leukocytes but also immature germ cells — not all "round cells" are pus cells.
• Agglutination: may be noted occasionally, without on its own proving the presence of antisperm antibodies.

• Azoospermia: absence of sperm in the ejaculate after appropriate laboratory examination (often including centrifugation) — a single "zero sperm" finding needs confirmation before being considered definitive.
• Obstructive vs. non-obstructive azoospermia: in obstructive azoospermia, sperm production may be preserved but the outflow tract is blocked, whereas in non-obstructive azoospermia production itself is impaired — this distinction is not made from semen analysis alone, but requires history, examination, hormones, and often genetic testing.
• Cryptozoospermia: a very small number of sperm detected only after specialized examination/centrifugation — different from complete azoospermia.
• Necrozoospermia: a high percentage of non-viable sperm; vitality testing helps distinguish "immotile" from "dead".
• Aspermia: absence of ejaculate — this is not the same as azoospermia, where ejaculate is present but no sperm are found.

Collection is usually by masturbation into a suitable sterile/non-toxic container. Key points:

• Collect the entire ejaculate and report any loss, especially of the first fraction — this often contains a large proportion of sperm, and losing it can produce a falsely abnormal result.
• Do not use a standard condom — most contain substances that affect sperm motility/viability; if condom collection is needed, only a special non-toxic collection condom recommended by the laboratory should be used.
• Avoid ordinary lubricants, unless the laboratory has explicitly approved a specific product as sperm-safe.
• Collection near the laboratory is preferred when feasible; if home collection is permitted, follow the laboratory's transport protocol precisely — in general, testing ideally begins around 30 minutes and no later than about 60 minutes after collection.
• Avoid extreme cooling or heating during transport; keep the sample close to body temperature as instructed by the laboratory.

Semen parameters can vary considerably between samples due to abstinence, incomplete collection, recent illness, medications, lifestyle, and normal biological variability. An abnormal result should generally not be treated as a permanent diagnosis. If the initial result is normal by WHO criteria, one test is often sufficient; if abnormal, at least two consecutive semen analyses are usually recommended. The exact timing of the repeat test depends on the severity of the finding, a possible reversible cause, recent illness, clinical urgency, and partner age — there is no single interval for everyone.

Investigation often begins after 12 months of regular, unprotected intercourse without conception. Earlier evaluation may be appropriate given partner age, a known male or female risk factor, a history of undescended testis, testicular surgery, chemotherapy, or a severe ejaculatory disorder — there is no single rule for every couple. A persistent semen analysis abnormality often leads to hormonal testing (FSH, LH, total testosterone and others as appropriate, not every hormone in every man), assessment for varicocele or a clinical picture consistent with orchitis/epididymitis, and a history of testicular cancer or undescended testis. A normal FSH does not guarantee normal spermatogenesis, just as an elevated FSH alone does not prove complete absence of sperm production.

One or more abnormal findings lead to a structured pathway, not automatic treatment: repeat testing → history/physical examination → hormonal testing → assessment for varicocele or another organic cause → genetic testing where indicated → targeted treatment. In confirmed non-obstructive azoospermia, micro-TESE may be discussed as a sperm retrieval option — not as an automatic next step for every man with azoospermia. In confirmed clinical varicocele with a consistent semen analysis abnormality, microsurgical varicocelectomy is one option, not mandatory for every varicocele. Men with low testosterone are evaluated for hypogonadism — without giving exogenous testosterone with the goal of improving fertility.

A common misconception: "16 million/ml is good, 15 million/ml means infertility". Reference distributions are continuous. A man at 15 and one at 16 million/ml are not biologically split into two different categories by a one-unit difference. A reference limit is not a biological cliff edge. The same applies to morphology: 3% versus 4% should not be read as "infertile versus fertile" — interpretation always happens in the context of the whole profile and the couple's history.