Male History- A history of having offspring within the previous 2 years is reassuring although sperm quality can change over time. A careful history can suggest potential problems in the male:

1. Prior male reproductive surgery- such as varicocele repair, hernia repair, and vasectomy reversal can lead to development of antisperm antibodies. Sperm are considered as foreign by the immune system. Surgeries can cause a break of the semen-blood barrier to allow sperm to enter the vascular system and be recognized by the immune system. Antisperm antibodies can bind to the head of the sperm to prevent fertilization or bind to the tail to impair motility.

2. Prior male reproductive infections- that involve the prostate, the epididymis, and the testes can lead to production of antisperm antibodies. In addition, pus in the semen can lower sperm viability.

3. History of diabetes or hypertension- can make a man susceptible to erectile dysfunction and sexual difficulty. Antihypertension drugs such as the calcium channel blockers can impair sperm motility and fertilization potential by impeding the movement of calcium ion. Alternative medications should be used if possible.

4. Decreased libido- may suggest a hormonal imbalance. Abnormal release of pituitary hormones can lead to suboptimal production of testosterone, leading to abnormal sperm production.

Semen analysis- The semen analysis is routinely ordered during the initial evaluation. To be valid the test needs to be performed at a competent laboratory. Non-specialized laboratories (such as Labcorp or Quest) performed semen analysis according to the World Health Organization (WHO) criteria, which will miss subtle but clinically significant sperm abnormalities. Most quality fertility centers employ the strict criteria (Kruger) to rigorously analyze the sperm structure (morphology). A complete semen analysis has the following parameters:

1. Volume- The normal semen volume is 2-4 ml. Low volume can result from dehydration or faulty collection technique. Persistent low volume (≤ 1 ml) can indicate retrograde ejaculation, a condition in which the semen flows backward into the bladder during ejaculation.

2. Concentration- The normal sperm concentration is ≥ 20 million per ml of semen. Concentration less than 15 million/ml usually requires in vitro fertilization (IVF) with sperm injection (ICSI). Sperm concentration is a critical factor.

3. Motility- At least 50% of sperm must be motile in order for the sample to be normal. However, motility ≥ 30% is usually sufficient for intrauterine insemination, provided that the sperm count is adequate. Motility < 30% usually requires IVF with ICSI. Sperm motility is a critical factor.

4. Morphology- Using the Kruger strict criteria, the structure of the sperm can be rigorously evaluated. Normal semen has at least 7% of sperm with perfect morphology. Morphology values of 3%-6% are 'subnormal' but can still lead to pregnancy without requiring IVF. Morphology of ≤ 2% usually requires IVF/ICSI.

5. Progression- assesses the ability of sperm to move forward. Sperm have to move forward in order to reach the egg and to successfully penetrate the shell of the egg for fertilization. The grading system for progression varies among laboratories.

6. Direct anti-sperm antibody screen- checks for the presence of antibodies in the semen. Antibodies that attach to the tail can impair sperm motility while those bound to the head can prevent fertilization. The presence of significant antisperm antibodies usually means IVF and ICSI as treatment.

Special Male Testing- If the first semen analysis is abnormal, a second analysis is required to confirm. The patient can then be referred to a reproductive urologist for further evaluation. Occasionally, certain male infertility patients will be asked to have the following tests:

1. Cystic fibrosis screening- Cystic fibrosis is a genetic disease that impairs the ability of the body to make secretions. Affected individuals produce thick mucus in the lungs and gastrointestinal tract making them susceptible to serious infections. Men who have no sperm in the semen due to occlusion or absence of the vas deferens have 1 in 4 risk of having the mutations and should be tested.

2. Chromosomal analysis- Some men with severely low sperm count (<3 million/ml) may have abnormal chromosomes and their sperm should not be used.

3. Y deletions mutation- In men with severely low sperm count (<3 million/ml) certain regions within the Y chromosome that are responsible for sperm production may be missing. Although pregnancy can result by IVF with ICSI, these mutations can be passed to the male offspring.

4. Sperm Chromosome Structural Assay- This test measures the prevalence of DNA fragmentation within the sperm head. Studies have shown that if a man has 30% or more of sperm with damaged DNA, he has less than 5% chance of having a biological child even with IVF and ICSI.