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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Semen analysis and male-factor infertility

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Recognise testicular emergencies and malignancy

An abnormal semen result is not an emergency, but acute testicular pain may be torsion and a hard intratesticular mass may be cancer; both take priority over routine fertility work-up.

Action: Arrange immediate surgical assessment for suspected torsion and use the urgent suspected-cancer pathway for a testicular mass, while coordinating fertility preservation early if cancer treatment is likely to impair fertility.

Synopsis

Obtain and interpret semen analysis correctly, confirm genuine abnormalities, identify endocrine, obstructive and genetic patterns, and direct evidence-based treatment without stigma or unsupported add-ons.

  • Semen analysis is a sample-based estimate of fertility potential, not a binary fertile-infertile verdict; biological and pre-analytical variation is substantial.
  • Current WHO lower reference values used by NICE include volume 1.4 mL, concentration 16 million/mL, total number 39 million per ejaculate, total motility 42%, progressive motility 30%, vitality 54% and normal morphology 4%.
  • These reference values are valid only when the WHO laboratory methods are used; falling below one value does not prove sterility and being above all values does not guarantee conception.
  • Repeat an abnormal first test, ideally after about 3 months to cover spermatogenesis, but repeat azoospermia or severe oligozoospermia as soon as possible.
  • After at least two abnormal analyses, offer scrotal and testicular examination and consider testosterone and gonadotrophins.
  • Do not routinely test antisperm antibodies or sperm DNA fragmentation, and do not offer antioxidants or supplements to improve sperm DNA integrity under NG257.
  • Test for Y-chromosome microdeletion in idiopathic azoospermia or persistent concentration below 1 million/mL; test karyotype in idiopathic azoospermia and consider it below 5 million/mL.
  • Treat the cause where possible: hypogonadotrophic hypogonadism responds to gonadotrophins; for someone trying to conceive spontaneously, a clinically detected varicocele with reduced parameters may merit repair after accounting for the other partner's fertility factors; and azoospermia may require reconstructive or sperm-retrieval pathways according to cause.

    • Key red flags

    Sudden severe unilateral scrotal pain, nausea, a high-riding testis or absent cremasteric reflex requires immediate assessment for testicular torsion.

    A hard intratesticular lump, unexplained progressive enlargement or persistent focal abnormality requires urgent ultrasound and suspected-cancer referral.

    Azoospermia or severe oligozoospermia should be confirmed promptly and triggers focused endocrine, physical and genetic assessment rather than a routine three-month delay.

    Headache, visual-field symptoms, galactorrhoea or multiple pituitary hormone deficits with hypogonadism suggest a sellar disorder requiring expedited endocrine review.

    Planned chemotherapy, radiotherapy or gonadal surgery should prompt urgent sperm-preservation discussion before treatment whenever feasible.

    Investigation priorities

    01
    WHO-method semen analysisFirst step

    Quantify volume, pH, concentration, total number, motility, vitality and morphology.

    Management branches

    First sampleValidate before interpreting

    A semen report is received during fertility assessment.

    1. Confirm laboratory method, collection completeness, abstinence and processing history, recent fever and exposure to exogenous testosterone or gonadotoxins.
    2. Compare the complete profile with current WHO reference values and explain that the result modifies probability rather than assigning fertility status.
    3. If abnormal, plan a confirmatory sample at about 3 months unless azoospermia or severe oligozoospermia makes an earlier repeat appropriate.

    Key medicines

    Gonadotrophin therapyIndividualised specialist regimens use hCG activity, with FSH added according to response; products and doses vary and require endocrine and semen monitoring.Confirm the central diagnosis, exclude pituitary pathology where indicated and counsel that response takes months; this is not empirical treatment for idiopathic abnormal semen.
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    Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE NG257 male-factor testing and management
    • WHO laboratory manual for semen examination, sixth edition
    • NICE NG257 recommendations PDF
    • HFEA intracytoplasmic sperm injection
    • NHS infertility diagnosis

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom