Understanding Your Semen Analysis: A Complete Guide to Male Fertility Testing

By Dr (TCM) Attilio D'Alberto | Traditional Chinese Medicine Practitioner, Wokingham

Male factor infertility contributes to approximately 50% of all infertility cases when both partners are considered — yet semen analysis is still frequently treated as an afterthought in fertility investigations, often performed only after extensive female testing. This is a significant oversight. Sperm quality is as important as egg quality in determining the outcome of conception, and in cases where both natural conception and IVF are failing, male factor — including sperm DNA fragmentation that does not appear in standard analysis — is frequently part of the explanation.

Understanding your semen analysis results is an important first step. The numbers can be alarming if you do not know what they mean or what the options are — and reassuring normal results can be misleading if the analysis does not include all the relevant parameters. This guide walks through each measurement in a semen analysis report, explains what it tells you, and describes what can be done when results fall outside normal ranges.

As noted in My Fertility Guide, sperm count in the Western world has declined by approximately 60% over the past 40 years — one of the most striking trends in reproductive health. Diet, lifestyle, environmental toxins, and psychological stress are all implicated, and the same factors that drive this population-level decline affect individual fertility outcomes.

On this page

1. WHO 5th edition parameters
2. Semen volume
3. Sperm count and concentration
4. Sperm motility
5. Sperm morphology
6. Sperm vitality and other parameters
7. Sperm DNA fragmentation
8. TCM understanding of male fertility
9. Acupuncture for male fertility
10. Improving semen analysis naturally
11. My Fertility Guide
12. References

1. WHO 5th edition parameters

The World Health Organization (WHO) publishes reference values for semen analysis based on analysis of fertile men in the general population. The current standard is the 5th edition (2010), with updated guidance in the 6th edition published in 2021. The reference values represent the lower 5th percentile of fertile men — meaning that 95% of men who successfully conceived within a year had values at or above these thresholds.

Key reference values (WHO 5th edition, 2010):

• Volume: ≥1.5 mL
• Total sperm number: ≥39 million per ejaculate
• Concentration: ≥15 million per mL
• Total motility (progressive + non-progressive): ≥40%
• Progressive motility: ≥32%
• Morphology (normal forms, strict Kruger criteria): ≥4%
• Vitality (live sperm): ≥58%
• pH: ≥7.2
• Leucocytes: <1 million per mL

It is important to note that "within normal limits" on a semen analysis does not guarantee fertility. These are minimum thresholds, not optimal values. A man with 4% normal morphology, 32% progressive motility, and 15 million/mL concentration is technically normal but at the lower end on every parameter — a combination that may significantly reduce natural conception probability, particularly in women with age-related egg quality decline.

2. Semen volume

A normal ejaculate volume is 1.5–5 mL. Volumes outside this range can indicate problems:

• Low volume (<1.5 mL): May indicate partial retrograde ejaculation (where some semen enters the bladder rather than being expelled), obstruction of the ejaculatory ducts, partial agenesis of the seminal vesicles, or androgen deficiency. Can also reflect incomplete collection of the sample.
• Very low volume with azoospermia: If very low volume combines with no sperm, consider congenital bilateral absence of the vas deferens (CBAVD) — associated with CFTR mutations (the cystic fibrosis gene).
• High volume (>6 mL): Sometimes associated with infection or inflammation of the accessory glands; less clinically significant than low volume.
• Retrograde ejaculation: Can be confirmed by post-ejaculation urinalysis — if sperm are found in the urine, retrograde flow is occurring. Causes include diabetes, spinal cord injury, prostate surgery, and certain medications.

3. Sperm count and concentration

Sperm concentration (millions per millilitre) multiplied by volume gives the total sperm count per ejaculate. Both are reported on standard semen analysis. Terminology:

• Normozoospermia: Normal sperm count
• Oligozoospermia: Low sperm count (below 15 million/mL or 39 million total)
• Severe oligozoospermia: Below 5 million/mL
• Cryptozoospermia: Rare sperm found only after centrifugation
• Azoospermia: No sperm in ejaculate — may be obstructive (blocked vas deferens) or non-obstructive (failure of sperm production in the testes)

Common causes of low sperm count include: varicocele (dilated veins in the scrotum — the most common identifiable cause), previous infection (orchitis from mumps, chlamydia, gonorrhoea), heat exposure, hormonal imbalance (hypogonadism), genetic causes (Klinefelter syndrome, Y chromosome microdeletions), previous surgery or trauma, and lifestyle factors (smoking, alcohol, anabolic steroid use).

4. Sperm motility

Motility describes the percentage of sperm that are moving. The analysis distinguishes between:

• Progressive motility: Sperm moving forward in a straight line or large curves — the most important type for fertilisation. Target ≥32%.
• Non-progressive motility: Sperm moving in circles or with minimal forward progression.
• Immotile: Sperm not moving at all.

Low motility (asthenozoospermia) is one of the most common semen abnormalities. Causes include: oxidative stress (the most important modifiable cause), varicocele, infection, antisperm antibodies, structural defects in the sperm tail, and chromosomal abnormalities. Lifestyle factors — smoking, alcohol, heat exposure, sedentary behaviour, and nutrient deficiencies (particularly selenium, zinc, and CoQ10) — are major contributors to poor motility.

Sperm with poor progressive motility cannot swim effectively through cervical mucus, up the fallopian tube, and to the egg. This reduces natural conception probability significantly, though IVF with ICSI (intracytoplasmic sperm injection — where a single sperm is injected directly into the egg) overcomes motility issues for assisted conception.

5. Sperm morphology

Morphology describes the proportion of sperm with normal shape. Sperm are assessed under strict Kruger criteria — a stringent set of measurements applied to head shape, mid-piece, and tail. Only sperm that conform precisely to the normal shape criteria are counted as morphologically normal. Under strict criteria, only ≥4% of sperm need to be normal-shaped to meet the minimum threshold — which means that even in a "normal" semen analysis, 96% of sperm may be abnormally shaped.

Common morphological abnormalities include: large heads, small heads, round heads (globozoospermia — associated with fertilisation failure even with ICSI), double heads, coiled tails, midpiece defects, and pin heads. High rates of abnormal morphology (teratozoospermia) are associated with increased chromosomal abnormality in the sperm, higher DNA fragmentation, and reduced fertilisation rates.

6. Sperm vitality and other parameters

Vitality (also called viability) measures the percentage of live sperm — important to distinguish from motility, as some live sperm may be temporarily immotile. When motility is very low, vitality testing helps determine whether the immotile sperm are alive (good ICSI prognosis) or dead (poor prognosis).

Other parameters reported may include:

• Leucocytes: White blood cells above 1 million/mL (leucocytospermia) suggest infection or inflammation of the genital tract, which generates reactive oxygen species that damage sperm DNA.
• Agglutination: Sperm clumping together, suggesting antisperm antibodies.
• pH: Low pH suggests obstruction or absent seminal vesicles; very high pH may indicate infection.
• Liquefaction: Semen should liquefy within 60 minutes of ejaculation. Delayed liquefaction may indicate prostate or seminal vesicle dysfunction.

7. Sperm DNA fragmentation

Sperm DNA fragmentation (SDF) measures the integrity of the DNA packed within the sperm head. Standard semen analysis does not assess DNA fragmentation — a man can have normal count, motility, and morphology while having high DNA fragmentation that severely impairs fertility. This is one of the most important limitations of standard semen analysis as a fertility screening tool.

High SDF is associated with:

• Reduced natural conception rates
• Reduced fertilisation rates in IVF
• Poor embryo development and blastocyst conversion
• Recurrent miscarriage — particularly when embryos appear morphologically normal but fail to implant or develop
• Repeated IVF failure with good-quality embryos

SDF testing methods include the SCSA (Sperm Chromatin Structure Assay) and TUNEL assay. A DNA fragmentation index (DFI) above 15–25% (depending on the laboratory) is generally considered elevated. High SDF can be significantly reduced within 3 months through antioxidant supplementation, lifestyle changes, and addressing oxidative stress — making it an important target for pre-conception preparation in men with a history of IVF failure or recurrent miscarriage.

8. TCM understanding of male fertility

In TCM, male fertility is primarily governed by Kidney Jing (Essence) — the foundational constitutional substance that determines the strength and quality of sperm. Kidney Jing is influenced by constitutional endowment (genetics), lifestyle, diet, and the ageing process. Supporting Kidney Jing is therefore the central therapeutic aim in TCM male fertility treatment.

Common TCM patterns in men with abnormal semen analysis include:

• Kidney Qi and Jing deficiency: Low count, poor motility, reduced libido, lower back weakness, fatigue, frequent urination. Corresponds broadly to hypogonadal or constitutional causes of oligospermia.
• Kidney Yang deficiency: Low motility (cold slows movement), reduced sexual function, cold extremities, pale complexion. Corresponds to impaired testicular temperature regulation and reduced testosterone production.
• Kidney Yin deficiency: High percentage of abnormal forms, elevated body temperature, poor sleep, restlessness. May correspond to oxidative stress-driven DNA damage.
• Damp-heat in the Lower Jiao: Elevated leucocytes, varicocele, scrotal heaviness, burning urination, history of genital infection. Corresponds to inflammatory or infectious causes of sperm damage.
• Blood stasis: Poor motility with clumping, history of varicocele or groin surgery. Poor circulation in the genital vessels creates a suboptimal environment for sperm maturation.

9. Acupuncture for male fertility

Acupuncture for male fertility has been studied in several randomised controlled trials and observational studies. Findings include significant improvements in sperm motility, concentration, and morphology following a course of treatment. Mechanisms include:

• Reduction of oxidative stress in the testicular environment
• Improvement of testicular blood flow and hormonal microenvironment
• Regulation of hypothalamic-pituitary-testicular axis hormone secretion
• Reduction of sperm DNA fragmentation
• Anti-inflammatory effects relevant to leucocytospermia and damp-heat patterns

Treatment typically involves weekly sessions for a minimum of three months — the time required for a complete spermatogenic cycle — to achieve meaningful improvement in semen parameters.

10. Improving semen analysis naturally

The three-month sperm maturation window provides a genuine opportunity to improve semen analysis results through targeted intervention:

• Antioxidants: The most evidence-based intervention for improving sperm quality. A combination of vitamin C (1000mg), vitamin E (400 IU), selenium (200mcg), zinc (25mg), and CoQ10 (ubiquinol 200–400mg) addresses oxidative damage across multiple pathways.
• Omega-3 fish oil (2g DHA+EPA daily): DHA is the predominant fatty acid in sperm cell membranes. Supplementation improves membrane fluidity and motility.
• Vitamin D (2000–4000 IU): Improve serum levels to 75–100 nmol/L. See vitamin D and fertility.
• Walnuts (75g daily): Clinical trial evidence of improved motility, vitality, and morphology.
• Eliminate smoking: Smoking significantly impairs all semen parameters and increases DNA fragmentation. Quitting produces measurable improvement within months.
• Limit alcohol: Even moderate alcohol consumption reduces testosterone and impairs semen quality. Aim for none during preparation.
• Avoid heat: Hot baths, saunas, tight underwear, and laptops on the lap all raise testicular temperature — maintain cool temperatures to optimise sperm production.
• Reduce stress: Psychological stress elevates cortisol, which suppresses testosterone and impairs spermatogenesis. Active stress reduction is beneficial.
• Exercise moderately: Regular moderate exercise improves testosterone levels and semen quality. Excessive endurance training and anabolic steroid use have opposite effects.

11. My Fertility Guide

12. References

• WHO. WHO Laboratory Manual for the Examination and Processing of Human Semen. 5th ed. Geneva: WHO; 2010.
• Carlsen E, et al. Evidence for decreasing quality of semen during past 50 years. BMJ. 1992;305(6854):609–613.
• Agarwal A, et al. Oxidative stress and its implications in female infertility — a clinician's perspective. Reprod Biomed Online. 2005;11(5):641–650.
• Pei J, et al. Quantitative evaluation of spermatozoa ultrastructure after acupuncture treatment for idiopathic male infertility. Fertil Steril. 2005;84(1):141–147.
• Afeiche MC, et al. Walnut intake and sperm quality. Biol Reprod. 2012;87(4):101.