As a reproductive endocrinologist, I spend a great deal of time trying to answer a deceptively simple question: Why is not this couple getting pregnant? Male factor infertility contributes to at least 40 percent of cases, and most reproductive endocrinologists recognize the importance of evaluating both partners early. In practice, however, the path to that evaluation is not always straightforward. In heterosexual relationships, patients may understandably focus first on the female partner, particularly when menstrual irregularities or known gynecologic conditions are present. At times, a semen analysis may be deferred, whether due to logistics, discomfort with collection, or a desire to “start somewhere.”
But fertility is inherently a couple-based diagnosis, when relevant, and the most efficient care comes from evaluating all contributing factors in parallel. Although sometimes awkward, a semen analysis is not an advanced or burdensome test. It is foundational. And it belongs at the very start of any fertility workup.
What we are actually measuring
A semen analysis evaluates three key parameters: count, motility, and morphology. Count tells us how many sperm are present. Motility reflects how well they move. Morphology assesses their shape. Together, these factors help us estimate the likelihood that sperm can reach and fertilize an egg. Clinically, I think about sperm in three functional categories:
- Sperm that are sufficient for unassisted conception
- Sperm that may work with intrauterine insemination (IUI): typically a total motile count under 20 million, or poor sperm morphology
- Sperm that require in vitro fertilization (IVF), often with intracytoplasmic sperm injection (ICSI): typically a total motile count under 5 million, or three or more prior unsuccessful IUIs
This framework helps guide patients toward the most appropriate and efficient treatment pathway. But without that initial semen analysis, we are navigating blindly.
The cost of waiting
One of the most difficult conversations I have in clinic is with a patient who has spent months undergoing treatment for ovulatory dysfunction, often related to polycystic ovarian syndrome, only to later discover severe male factor infertility. Could that time have been better spent pursuing IVF? In many cases, yes. Fertility care works best when we evaluate all contributing factors in parallel. Delaying the semen analysis creates an artificial bottleneck in care, one that can prolong time to diagnosis and treatment. Additionally, if sperm quantity and/or quality can be improved, delaying diagnosis wastes precious time that could be spent optimizing the sperm.
Not all abnormalities are equal
An abnormal semen analysis does not immediately define a diagnosis. It defines a need for further evaluation. The first step is always to repeat the test. Sperm production is dynamic, and temporary factors, such as illness, fever, or even collection issues, can affect results. Two abnormal analyses, however, warrant deeper investigation. From there, we consider hormonal testing, including testosterone, estradiol, follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone, as well as referral to a reproductive urologist. These specialists play a critical role in identifying correctable conditions, such as varicoceles, or more complex diagnoses like obstructive or non-obstructive azoospermia.
Importantly, sperm quality is not fixed. Lifestyle factors, such as tobacco use, marijuana exposure, certain medications, and environmental toxins, can significantly affect sperm parameters. And because spermatogenesis takes approximately three months, meaningful improvements require both intervention and patience.
When numbers do not tell the whole story
Semen analysis results must always be interpreted in context. I have seen patients with poor parameters who have achieved pregnancies, and others with “normal” values who have not. Prior reproductive history matters. So does the distinction between inability to conceive and recurrent pregnancy loss. Fertility is not a single data point. It is a clinical narrative.
The gray zones in modern fertility care
Patients are increasingly aware of emerging technologies: sperm sorting devices, DNA fragmentation testing, and various adjunctive techniques designed to optimize fertilization. These tools are appealing, particularly when prior treatments have failed. But many remain outside the standard of care, with limited or inconclusive data supporting their routine use. Take DNA fragmentation testing, for example. While high fragmentation may be associated with impaired embryo development, it is not always clear how the result should change management. In some cases, testicular sperm extraction may be considered. In others, lifestyle modification may be advised. But these decisions are nuanced and highly individualized. Similarly, sperm selection technologies may offer theoretical advantages, but their real-world impact on outcomes remains uncertain. In an emotionally charged field like fertility, it is easy to reach for the newest option. But as physicians, our responsibility is to anchor care in evidence, not just possibility.
A call for earlier, more complete evaluation
Male factor infertility is not an afterthought. It is nearly half the equation. As reproductive endocrinologists, we are trained to think comprehensively, and to integrate hormonal, anatomical, and embryologic factors into a cohesive plan. That approach must include early and thoughtful evaluation of sperm, not only as a number on a report, but as a meaningful contributor to embryo development. Sperm quality plays a critical role beyond fertilization. While the male genome is not fully expressed until the early stages of embryo development, its integrity can influence progression from day 3 to day 5, an interval where we often see embryos either thrive or arrest. In select cases, particularly when there is poor blastocyst development, DNA fragmentation testing may offer additional insight and help guide management.
The earlier we understand the factors affecting sperm, whether related to lifestyle, hormonal signaling, or underlying pathology, the sooner we can intervene. This may include targeted lifestyle modifications, appropriate laboratory evaluation, and referral to a reproductive urologist for specialized assessment. Importantly, not all patients will require in vitro fertilization. In some cases, identifying and addressing male factor contributions can open the door to less invasive, more efficient treatment pathways. Fertility care is most effective when it is both comprehensive and individualized. This begins with recognizing the full contribution of sperm, not just to fertilization, but also to the development of a healthy embryo, and ultimately a successful outcome.
Erica Bove is a double board-certified obstetrician-gynecologist and reproductive endocrinology and infertility (REI) specialist at the University of Vermont Medical Center, where she also directs the REI fellowship program. She is the founder and CEO of Love and Science: Thriving Through Infertility, a platform dedicated to guiding individuals and couples through the challenges of fertility with evidence-based medicine, coaching, and community.
Dr. Bove is passionate about supporting women physicians in building their families with confidence and compassion, blending science with intuitive, whole-person care. She extends her work beyond the clinic through her podcast and outreach on LinkedIn, Instagram, and Facebook.
Her academic contributions include studies on physician wellness and burnout, fertility preservation in oncology patients, and reproductive outcomes in complex medical contexts, with publications in Obstetrics and Gynecology, Journal of Graduate Medical Education, Endocrinology, and American Journal of Clinical Oncology.
Through clinical care, teaching, and advocacy, Dr. Bove is committed to advancing reproductive medicine, supporting healers, and creating a legacy of connection, empowerment, and compassion.
