Semen Analysis Testing
When, Where, Why and How
The semen analysis is the single most effective predictor of male fertility potential that is currently available. The American Society of Reproductive Medicine recommends that all men should have semen analysis testing done at the same time as initiating testing from the female side in couples having trouble conceiving a child.
We know that the semen analysis is not a perfect test. Some men with low sperm counts and poor sperm quality can achieve pregnancies without assistance, while others who have completely normal semen parameters are unable to establish a pregnancy with their partner. In general, though, men with better semen parameters have an easier time initiating a pregnancy, and so it’s beneficial to try and optimize these parameters as much as possible.
When to Get a Male Fertility Evaluation
The “official” guidelines are that the male should have fertility testing if the couple has been unsuccessful at establishing and maintaining a pregnancy after one year of trying. There are exceptions to this general rule, of course. If the man has a known history of risk factors that can impact his fertility (for example, previous scrotal surgery, chemotherapy, or genetic problems), then earlier testing would be a good idea. Also, the updated AUA/ASRM guidelines published in 2020 now recommend semen analysis testing after 6 months of trying in couples where the woman is thirty-five years of age or older. [Farooq S. AUAUpdate 2022] Some couples just choose to check semen testing earlier in the fertility process, or want to evaluate the man’s fertility potential before they even start trying for a child. There is no problem with these approaches if it makes the couple feel more comfortable with the process.
How Many Semen Analyses Should Be Performed?
Normal Semen Parameters
The standard recommendation is a single semen analysis is adequate if all of the parameters are in the normal range. However, a normal semen analysis does not mean that a man is not sub-fertile, so there a few caveats to consider:
#1) Semen analysis testing only gives us a rough indication of a man's true fertility capabilities and may miss other otherwise hidden biochemical and/or genetic abnormalities that can negatively impact a man's fertility potential. Therefore, even if a man has normal semen analysis testing, he may benefit from some basic lifestyle-related interventions that can increase his chances of successfully establishing a healthy pregnancy. These interventions are reviewed in the "Sperm Boot Camp" section of this website.
#2) If a man has normal semen analysis testing but the couple is still not able to establish a pregnancy after a subsequent reasonable period of time trying (e.g. 6 to 12 months), then repeat semen analysis testing (and possibly other tests, such as hormonal testing) may be indicated.
Abnormal Semen Parameters
When abnormalities are present on semen analysis testing, then at least two semen analyses should be performed. The official AUA/ASRM guidelines recommend that these be performed at least 1 month apart. [Schlegal PN. FertSteril 2021] However, I prefer to have the semen analysis testing about 8-10 weeks apart (see below). If the first analysis is abnormal, then the next step can be to have a male infertility evaluation, after which the second semen analysis can be performed following some basic testing and interventions have been undertaken.
Why a 8-10 Week Interval Between Semen Analyses?
Ten weeks is the length of a spermatogenic cycle, which is the time that it takes for a spermatic precursor cell to become a fully mature sperm. Any activities that can have a negative impact on sperm quality (such as sitting in a hot tub, smoking, etc.) can damage all of the sperm in the body at that point in time. It takes approximately ten weeks to get the damaged batch of sperm completely out of the body and replace it with a new, healthier set of sperm. Therefore, to get a more accurate picture of a man’s fertility potential, it is best to sample semen parameters from two separate batches of sperm if abnormalities are found on the initial testing. Also, any interventions that are performed to improve semen parameters generally take at least 8-10 weeks to be fully reflected in subsequent semen analysis testing.
Where to Get Semen Testing
The accuracy of a semen analysis depends on the skill and training of the laboratory technicians who perform it. I have seen semen analysis results from more than a hundred labs over the years, and the variability in quality is striking. Therefore, it makes sense to find a lab in your area that can offer a quality semen analysis, which is going to provide you with the most accurate information possible.
There are two main types of labs that you can choose to perform your semen analysis: hospital-based labs and fertility-specific labs. Hospital-based labs carry out a wide range of general medical testing. I would also include in this category large regional or national laboratories (such as Quest Diagnostics) that sometimes offer semen testing. While these general labs are good at other fertility-related testing such as blood hormone levels, I have found the quality of their semen analyses to be highly variable.
Accurate semen analysis requires highly trained technicians to perform specialized testing, including determining sperm density (numbers of sperm present), motility (how well they are swimming), and morphology (whether they have normal shapes). Accuracy depends greatly on how the specimen is handled and processed as well as on the skill of the technician making the measurements.
Fertility-specific labs are devoted only to fertility-related testing and treatments. These labs are associated with an IVF group, and therefore their staff are quite knowledgeable and experienced. The semen analyses they perform usually utilize the latest diagnostic criteria, and the results are generally more consistent and accurate than those from hospital-based labs.
In addition, most fertility-specific labs are set up to have private collection rooms with locking doors (something not generally available in hospital-based labs). Collecting the specimen at the lab eliminates travel time and transport issues, which can affect the outcome. Some fertility-specific labs do allow home collections, but under very strict timing and transport guidelines.
How to Find a Fertility-Specific Lab
You can Google local IVF doctors and then call to find out whether they are associated with a fertility-specific lab. You can also go to the website of the Society for Assisted Reproductive Technology (www.sart.com) and click on “IVF Success Rates” which has a drop-down tab where you can select "Find a Clinic". You can then search by Zip Code, State, or Region to find a list of the IVF programs located near you. You can then choose a local lab and get its contact information.
Once you have located a local IVF group, call the clinic and ask to be transferred to the lab, which can schedule you for a semen analysis.
What If There Is No Fertility-Specific Lab Nearby?
All large cities (and most medium-sized ones as well) will have an IVF lab nearby. However, for couples living farther from an urban center, a hospital-based lab may be their only choice. But such couples should keep in mind that if the results of the analysis do not seem to match up with their clinical situation, then they might want to try another nearby lab or make a road trip to the nearest large city to get more accurate testing.
Companies that Provide At Home Collection Options
Another potential option for couples without a local fertility-specific lab are a number of companies which have developed technology to provide high quality test results to patients who prefer or need to collect their semen analysis specimen at home. The patient collects his specimen and then sends it back by overnight shipping back to the company which then performs standard semen analysis testing. All of the collection and shipping matierals are provided by the company beforehand. Through certain technological innovations in specimen stabilization, extremely accurate results are able to be obtained which closely match those from a fertility-specific lab. The cost is generally a little higher for these home-based testing options due to the extra shipping costs, but this is a good option for couples who do not have access to a nearby quality semen analysis lab. It is also an option for men who are able to collect a specimen in the comfort of their own home, but are unable to effectively collect a specimen in the artificial environment of the semen analysis lab (and live too far from the lab to be able to get a home-collected specimen there within the necessary 30 minute time window for accurate results testing). Currently available options for good quality home collection evaluations include:
ReproSource @Home Collection Kit (www.reprosource.com)
Legacy (www.givelegacy.com)
Fellow (www.meetfellow.com) – my only issue with the Fellow test is that their motility evaluation only provides total motility (not progressive motility or motility grade). Therefore you know how many sperm are swimming but not how well they are swimming.
Other Optional Semen Parameters
A standard semen analysis generally checks the ejaculate volume, sperm density, motility, and morphology (though in some labs the morphology is an optional add-on). Many labs will also generally check a semen pH (and sometimes fructose) and look for the presence of elevated numbers of white blood cells. Optional tests can also be added on to the standard semen parameters when the clinical situation dictates. These include:
1) Post-Ejaculatory Urinalysis
The post-ejaculatory urinalysis (PEU) involves the man providing a urine specimen collected in a separate collection cup after ejaculation. PEU testing looks for the presence of retrograde ejaculation and is generally checked in the presence of persistently low ejaculate volumes (<1.4cc). The Ejaculatory Dysfunction section of this website reviews retrograde ejaculation in more detail.
2) Immunobead Testing / Antisperm Antibody Testing
This measures for the presence of antisperm antibodies, which is often accompanied by clumping (called "agglutination") of sperm on the semen analysis. See the Antisperm Antibody section of this website for more detailed information.
3) Sperm Washing
A test sperm wash is used to prep the sperm like it would prior to an intrauterine insemination (IUI). A test wash calculates a post-wash total motile sperm count which can be used as an indicator of the relative success rates of any subsequent IUI cycles.
4) Sperm Cryopreservation
Sperm can be frozen and stored by the lab. There are several potential reasons for sperm freezing and storage. Some men who are diagnosed with cancer choose to bank sperm if they are planning on undergoing treatments (such as chemotherapy and/or radiation) which have the potential to permanently impair sperm production. Men with very low sperm counts can freeze sperm as back-up in anticipation of an upcoming IVF cycle, in case they have no usable sperm on the day of their wife/partner's egg retrieval. Men with known ejaculatory and/or erection problems also sometimes bank sperm in case they are not able to produce a specimen on the day of their wife/partner's female fertility treatment. In addition, some soldiers who are getting ready to be deployed freeze sperm for use in female fertility treatments that can be used by their wife/partner when they are gone.
The Cost of Semen Analysis
The exact cost is going to vary between laboratories, but it generally falls in the $100 to $200 range. Depending on your state’s insurance coverage laws as well as the specifics of your insurance plan, the testing may or may not be covered. Sometimes a certain lab is covered by your insurance plan but another is not, so doing some research beforehand can potentially save you some money. However, if you have a fertility-specific lab in your area but find that the semen analysis is either cheaper or covered by insurance at a local hospital lab, I would still recommend getting the testing performed at the fertility-specific lab, since the results will likely be more accurate and useful.
See "Cost Guide" Section for more specific pricing information
Proper Collection of the Semen Specimen- Patient instructions
Collecting a semen specimen for analysis can be an embarrassing and stressful endeavor for some men. Here are some recommendations for making this process as smooth and accurate as possible. Always check with the fertility lab that you are working with for specific instructions, as they may vary somewhat from lab-to-lab.
Step #1: Schedule the appointment
Unlike blood testing labs, which often allow patients to simply drop in, fertility labs almost always require an appointment. Because semen analysis is generally performed manually by a technician, the lab needs to set aside the proper amount of time. Most labs need a signed order from a medical provider for a semen analysis test.
Step #2: Coordinate where the specimen is going to be collected
Each semen analysis lab is going to have its own recommendations on specimen collection. Many fertility-specific labs have designated collection rooms at their facilities, with locking doors for privacy. Other labs prefer specimen collection at home, but only if the specimen can be delivered to the lab within thirty minutes. If you are going to do a home collection, you still need to have scheduled an appointment time for specimen drop-off. You also need to stop by the lab beforehand to pick up the recommended collection cup (generally a wide-mouthed sterile container with a tight-fitting lid). After collecting the specimen, seal the container, tuck it into a pocket (to keep the specimen near body temperature), and take it straight to the lab.
Step #3: Determine the number of days of abstinence
It is generally recommended that you abstain from ejaculation for two to five days prior to semen analysis. The WHO normal values are based on collections from this abstinence timeframe so it is important to use these guidelines so that you can accurately compare your results with what is considered normal. The male reproductive system needs some time to replenish the semen supply between ejaculations, so if you abstain for less than two days, the sample can contain inadequate amounts of fluid and sperm. If you wait longer than five days, the sperm can get old and start to die off, so the sperm quality can appear inaccurately decreased. I tell my patients to aim for three or four days of abstinence prior to testing, so that if there are last-minute timing issues, there’s an extra day of cushion on either side.
Troubleshooting Collection Problems
Missing Part of Specimen
Trying to collect a semen specimen in a rather small cup is usually a new experience for most men, and it is quite common for men to miss collecting part of the specimen, especially the first time or two they try. I therefore recommend that men “practice” once or twice at home prior to the actual week of their semen analysis, using a similar type of wide-mouth cup. If a patient still misses a part of the specimen on the day of testing, he should not try to scoop up the missed part into the collection cup—you don’t want to introduce outside bacteria or foreign matter into the specimen. Instead, when he turns in the specimen cup, he should just let the lab know that part of the collection was missed, and an estimate of what percentage of the specimen he felt was lost so that this can be reported and taken into consideration when evaluating the results.
Need for Lubrication
Many lubricants can damage sperm quality if they come into contact with the semen. However, masturbation without lubrication can be unpleasant (and sometime not possible) for some men. There are isotonic lubricants, such as Preseed, which do not seem to have a negative impact on sperm quality. If a patient thinks that he is going to have a problem with collecting a specimen without lubrication, then he can ask the lab if he can use an isotonic lubricant (which can be purchased without a prescription and found online.
See "Lubricants" section for more detailed information on this topic.
Inability to Collect a Specimen
Sometimes men are unable to collect a specimen at all, and there can be many reasons for this. Some men just cannot collect in a strange environment (such as a fertility lab’s collection room), while others have a mental block about collecting a specimen for fertility testing. Other reasons include religious beliefs that discourage masturbation or medical problems that impact a man’s ability to get an erection and/or ejaculate. Some common causes of sperm collection problems are reviewed below:
1) Known erectile dysfunction/ejaculatory problems
Some of these men have a long-standing history of erectile dysfunction or ejaculation problems, and for them the difficulties with specimen collection can be anticipated beforehand. For these types of issues, please see the sections “Erectile Dysfunction” and “Ejaculatory Problems”
2) Inability to Collect a Specimen in a Strange Environment
Most men find the prospect of providing a semen specimen for evaluation a stressful and embarrassing undertaking. Some men just cannot “perform” in a collection room at the lab, whether due to problems with achieving and/or maintaining an erection, or due to difficulty reaching climax.
If the problem is primarily one of achieving or maintaining an erection, sometimes taking an erection-enhancing medication prior to a planned collection may be helpful. For transient sperm collection difficulties in men who normally have fairly good erections, taking 100 mg of Viagra, 20 mg of Levitra or Staxyn, or 20 mg of Cialis one hour prior to the scheduled collection time, or 10 mg of Stendra fifteen to thirty minutes beforehand, may be of benefit. See “Erectile Dysfunction” section (link above) for details on the proper use of these medications, as well as information about side effects and contraindications to taking them.
If collection-related erection problems persist despite use of these medications, or if the primary problem is an inability to reach climax and orgasm in an unfamiliar environment, then collecting a specimen in the comfort of one’s home may be helpful. As noted earlier, home collections must be closely coordinated with the lab. Specimens must be kept warm (around body temperature, so keeping them tucked into a pocket is fine) and must make it to the lab within thirty minutes. Also, a proper sterile collection cup must be obtained from the lab prior to specimen collection. As described above, several companies (Reprosource, Legacy, Fellow) offer high quality home semen analysis evaluations for men who are only able to collect a specimen at home but who live more than 30 minutes away from the fertility lab.
3) Inability to Effectively Masturbate in Any Location to Collect a Specimen
Some men who have masturbated normally in the past just have a mental block when trying to collect a specimen for evaluation and cannot reach orgasm even in the comfort of their own home. In these situations, sometimes the man’s partner needs to get involved to help with collection of the specimen; however, be careful to follow the lab’s guidelines regarding allowed lubrication and no use of saliva. Coitus interruptus (having intercourse and then pulling out right before ejaculation) is not recommended: it can be difficult to collect the full specimen, and there is potential for picking up contaminants from the normal flora microorganisms found in the vagina. A better option is using a special collection condom, which can be then given to the lab technician. Regular condoms cannot be used; you must obtain a specially made collection condom beforehand. Ask the lab if it will provide one or if you will need to purchase one on your own. An example of a commercially available collection condom is the Male Factor Pak, which costs around $20 at Amazon.com. Always check with the lab before using a collection condom to make sure that this is okay with them.
4) Lack of Experience with Masturbation
Although most men begin masturbating with the onset of puberty, some men make it to adulthood without ever having masturbated. While sociological studies have shown that the vast majority of men (at least 95 percent) masturbate, certain religious groups officially discourage masturbation, and some men from these religious communities may be unwilling or unable to produce a semen specimen for analysis. Depending on the individual’s particular beliefs, a special collection condom (mentioned above) could potentially be used in these circumstances. Working with a local sex therapist can be an effective approach in some situations. Post-coital testing can also be used with some couples to see if decent numbers of motile sperm are reaching the cervical mucus, although exact semen parameters cannot be measured.
See "Uncommonly Used Sperm Testing" for more information on post-coital testing
Planning for IVF with a History of Transient Sperm Collection Problems
If a man has had collection difficulties in the past and his partner is scheduled for an upcoming IVF procedure, it is strongly recommended that he collect and freeze sperm well prior to egg retrieval. IVF labs are able to freeze eggs (if the man cannot produce a specimen on the day of egg retrieval) but they prefer not to if possible due to concerns of potentially marginally lower success rates.