Male infertility: semen analysis, investigation, and GP referral

Male infertility in general practice

Male factor infertility is among the most common, and most underestimated, reproductive health problems in Australian general practice. Roughly half of couples who struggle to conceive have a male-factor contribution — about 30% as the primary cause and a further 20% alongside female-factor issues — yet the male partner is frequently investigated late or not at all (Healthy Male; Your Fertility). Couple infertility affects approximately one in six Australian reproductive-age couples.

The good news for GPs is that the initial workup is straightforward and largely rebatable under Medicare: two semen analyses, a targeted history and examination, and a hormone panel when results are abnormal. Most of what is found is actionable — through lifestyle modification, referral for varicocele repair, hormonal correction, or assisted-conception pathways.

A. Core clinical — the AU general-practice framework

Definition and timing

ESHRE (2024) and ASRM (2023) define infertility as failure to conceive after at least 12 months of regular unprotected intercourse when the female partner is under 35, or after six months when she is 35 or older. Earlier investigation is appropriate when a contributing cause is already known — prior anabolic steroid use, history of orchidopexy or orchidectomy, mumps orchitis, chemotherapy or radiotherapy, or a palpable varicocele.

Both partners should be investigated simultaneously. Sequencing — investigating the female partner first, then the male — delays diagnosis and is not supported by current guidelines.

History

A targeted history identifies the probable mechanism before any test is ordered:

• Duration and prior fertility — has the couple conceived before, including with other partners?
• Anabolic steroids and exogenous testosterone — ask directly and non-judgementally; ask about “test”, “tren”, “deca”, “var”, and online purchases. Both suppress pituitary LH/FSH, shutting sperm production down; recovery typically takes 6–24 months (Krzastek, J Urol 2019), sometimes permanently.
• Testicular risk factors — cryptorchidism and orchidopexy (note age and side); mumps orchitis after puberty; prior torsion or trauma; inguinal hernia repair (vas injury risk).
• Medications — opioids (suppress GnRH), sulfasalazine (reversible oligozoospermia), alpha-blockers (retrograde ejaculation), 5-alpha-reductase inhibitors (reduce semen volume), SSRIs (delayed ejaculation), chemotherapy.
• Lifestyle — smoking (dose-dependent reduction in count and motility), alcohol (>10 standard drinks/week impairs spermatogenesis), cannabis, occupational heat exposure (welders, bakers, professional drivers), hot tubs and saunas, BMI.
• Family history — cystic fibrosis carrier status is relevant if congenital bilateral absence of the vas deferens (CBAVD) is suspected (RACGP Genomics guideline).

Examination

• Testicular volume — measure with a Prader orchidometer; normal adult volume is 15–25 mL; below 12 mL suggests spermatogenic impairment.
• Varicocele — examine standing with Valsalva; Grade 1 palpable on Valsalva only; Grade 2 palpable at rest; Grade 3 visible. Left-sided predominance.
• Vas deferens — palpate the spermatic cord; absent or attenuated vas suggests CBAVD.
• Secondary sexual characteristics — gynaecomastia, eunuchoid proportions, and small firm testes (below 5 mL) raise concern for Klinefelter syndrome (47,XXY).

First-line investigations

Semen analysis × 2, at least three weeks apart, assessed against WHO 6th-edition (2021) reference values. Both samples require 2–7 days abstinence and delivery to the laboratory within one hour. A single abnormal result is insufficient for diagnosis — spermatogenesis is a 74-day cycle, and febrile illness, alcohol, or heat exposure in the prior three months distorts individual results.

Parameter	WHO 2021 lower reference limit
Volume	≥1.4 mL
Concentration	≥16 million/mL
Total count	≥39 million/ejaculate
Progressive motility	≥30%
Total motility	≥40%
Normal morphology	≥4%
Vitality	≥54%

When either semen analysis is abnormal, add morning fasting bloods: total testosterone (8–10 am), LH, FSH, prolactin, TSH, ± SHBG and oestradiol. Also check hepatitis B and C, HIV, and HbA1c if not already current.

Scrotal ultrasound when a varicocele is suspected clinically or when testicular asymmetry or a mass is found.

B. Evidence appraisal — three key clinical controversies

Varicocelectomy for clinical varicocele

The Cochrane 2019 systematic review (Wang) and the ESHRE 2024 guideline support varicocelectomy — ideally microsurgical sub-inguinal — when three criteria are met: a palpable (Grade 2–3) varicocele, an abnormal semen analysis, and a couple who have been trying for at least 12 months. Evidence for improvement in semen parameters and natural pregnancy rates is moderately strong. Subclinical varicoceles detected only on ultrasound, in the absence of semen abnormality, are not an indication for surgery — older trials that showed null effects predominantly included subclinical cases.

Antioxidant supplements

Multiple supplements — CoQ10, vitamin C and E, zinc, selenium, L-carnitine — are marketed for male infertility. The Cochrane 2019 review (Smits) found modest improvements in semen parameters across pooled trials, but the landmark FAZST/FOLFOL RCT (Schisterman, JAMA 2020) showed that folic acid plus zinc supplementation had no effect on live-birth rates. Supplements are a reasonable adjunct during the three-month lifestyle optimisation window but should not be presented as a reliable treatment, and specialist referral should not be delayed while awaiting their effect.

Testosterone and anabolic steroids as a fertility hazard

This is among the most important counselling points in men’s reproductive health. Exogenous testosterone — whether prescribed for androgen deficiency or used non-medically as part of bodybuilding — suppresses pituitary LH and FSH, shutting down testicular testosterone production and spermatogenesis. Recovery after stopping takes 6–24 months and is not guaranteed (Krzastek, J Urol 2019). Anabolic steroids carry the same risk. Testosterone must never be prescribed to a man who intends future fertility without a documented discussion of this consequence. The alternative for fertility-seeking men with hypogonadotrophic hypogonadism is clomiphene (off-label) or hCG ± FSH, both of which stimulate endogenous sperm production rather than suppressing it.

C. Management pathway

Lifestyle optimisation — the three-month window

Because spermatogenesis takes 74 days, lifestyle changes implemented now improve semen quality approximately three months later — making this a meaningful pre-conception intervention:

• Smoking cessation — dose-dependent reduction in count, motility, and DNA integrity; Quitline 13 78 48 plus pharmacotherapy (NRT, varenicline).
• Alcohol reduction to ≤10 standard drinks per week, or abstinence in the three months before a fertility attempt.
• Weight optimisation to BMI 20–30 — obesity-related aromatisation lowers testosterone and impairs semen parameters.
• Cease anabolic steroids and exogenous testosterone — recovery is not guaranteed; refer to endocrinology or fertility specialist for clomiphene or hCG bridge.
• Heat avoidance — hot tubs, saunas, prolonged hot baths, laptops on the lap.
• Cannabis and recreational drug cessation.
• Coital timing — every one to two days through the cycle, including the five-day fertile window before ovulation; sperm-friendly lubricants (Pre-Seed, canola oil).

Pharmacological options (specialist-initiated)

• Clomiphene 25–50 mg daily/alternate days — off-label for male hypogonadotrophic hypogonadism in fertility-seeking men; raises endogenous LH/FSH and testosterone without suppressing spermatogenesis (Krzastek, J Urol 2019). Specialist-initiated in Australia; privately funded in most cases.
• hCG ± recombinant FSH — Section 100 Authority, specialist-initiated; for hypogonadotrophic hypogonadism failing clomiphene.
• Dopamine agonist (cabergoline) — for hyperprolactinaemia.

Assisted reproductive technology

• IUI — for mild male factor (total motile count >5–10 million post-wash) with a partner who has patent tubes.
• IVF — moderate male factor or co-existing female factor.
• ICSI — moderate-to-severe male factor, severe oligozoospermia, prior fertilisation failure; around one in 16 Australian babies is born via ART (Fertility Society of Australia and New Zealand).
• Donor sperm — non-obstructive azoospermia with failed sperm retrieval; severe genetic conditions; same-sex couples.

D. Australian operations

MBS-rebatable pathways

• Standard GP consultations — MBS items 23/36/44; a new male-infertility presentation with comprehensive history, examination, and investigation planning warrants a Level C or D consultation.
• Semen analysis — pathology items 73450–73464 for diagnostic infertility workup; rebate is partial in many labs, with a private co-payment of $80–150 per test common. Two tests are required.
• Hormone panel — FSH, LH, testosterone, prolactin, TSH — pathology coning rules apply under item 66719.
• Scrotal ultrasound — MBS 55059.
• Genetic testing — karyotype, Y-microdeletion, and CFTR in the MBS 73289 range for eligible indications; out-of-pocket costs are common for fertility-only indications.
• Mental Health Care Plan — MBS 2715; fertility distress and AAS-related dysmorphia are well-recognised triggers.
• GPCCMP — MBS 965/967; eligible where chronic comorbidities (obesity, T2DM, OSA, opioid dependence) are driving infertility.

PBS

• Clomiphene — PBS for female ovulation induction; off-label and privately funded for male hypogonadotrophic hypogonadism (low cost, ~$20–40/month).
• hCG (Pregnyl) and recombinant FSH — Section 100 Authority, specialist-initiated.
• Testosterone — PBS Authority Required for confirmed androgen deficiency; pre-prescription fertility counselling is mandatory in any man of reproductive age — document explicitly that the contraceptive/fertility implications were discussed.

ART access in Australia

Private fertility clinics (Monash IVF, IVF Australia, Genea, City Fertility, Newlife IVF) provide most ART; out-of-pocket per fresh cycle is approximately $4,000–6,000 post-rebate. Public IVF pathways exist in VIC, QLD, ACT, and WA with variable eligibility and waitlists. The Fertility Society of Australia and New Zealand accredits ART providers nationally.

E. Special populations

Aboriginal and Torres Strait Islander men — limited population data; the standard workup applies; telehealth via Healthy Male is accessible nationally. ATSI Health Assessment MBS 715 provides an opportunity to integrate sexual and reproductive health screening.

Cancer survivors — chemotherapy (especially alkylating agents and platinum) and pelvic or testicular radiotherapy are gonadotoxic. Semen cryopreservation before treatment is the standard of care and should be discussed at diagnosis. GPs managing post-treatment men should check FSH, LH, and testosterone, and refer early to a fertility specialist. DVVA Gold and White card holders are fully covered.

Men with CBAVD or CFTR mutation — congenital bilateral absence of the vas deferens causes obstructive azoospermia with normal FSH and testicular volume. CFTR testing and partner carrier screening are essential before ART, as the CFTR variant can be passed to offspring (RACGP Genomics).

Men on opioids or antipsychotics — opioid-induced hypogonadotrophic hypogonadism is under-recognised; switching to opioid-sparing analgesia or a naltrexone bridge may restore sperm production.

When to escalate

Refer urgently (same-day urology) for a new testicular mass — this is a suspected cancer pathway regardless of fertility concerns. Refer semi-urgently for hyperprolactinaemia with visual field changes (pituitary macroprolactinoma).

Routine referral to a fertility specialist or reproductive urologist/andrologist is indicated when:

• Two abnormal semen analyses with no obviously reversible cause
• Clinical varicocele plus abnormal semen analysis plus couple infertility
• Non-obstructive azoospermia or severe oligozoospermia (below 5 million/mL) — genetic workup and sperm retrieval planning required
• Female partner aged 35 or older with any male factor — refer after six months
• Hypogonadotrophic hypogonadism (low testosterone + low LH/FSH) in a fertility-seeking man

Send both semen analyses, the full hormone panel, scrotal ultrasound result, a complete medication and AAS history, and the female-partner workup status with every referral.

What this article is and is not

This is general health information based on current Australian guidelines — Healthy Male, Your Fertility, eTG, AMH, ESHRE 2024, and the RACGP Genomics guideline. It is not personal medical advice and does not create a doctor–patient relationship. Assessment, investigation, and treatment decisions are made with your own GP and specialist team.

For Australian consumer resources: Healthy Male, Your Fertility, HealthDirect — male infertility, Better Health Channel — male fertility, ACCESS Australia — fertility support.

For crisis support: Lifeline 13 11 14 · Beyond Blue 1300 22 4636.

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Sources cited

1. Healthy Male — male infertility and fertility
2. Your Fertility — National Health Promotion Program
3. Fertility Society of Australia and New Zealand
4. RACGP — Genomics in General Practice
5. Therapeutic Guidelines (eTG) — Endocrinology
6. Australian Medicines Handbook (AMH)
7. NHMRC — Ethical guidelines on the use of assisted reproductive technology
8. WHO Laboratory Manual for Semen Examination, 6th edition (2021)
9. ESHRE Guideline on Male Infertility (2024)
10. EAU Guidelines on Sexual and Reproductive Health — Male Infertility (2024)
11. Wang J et al. — Surgical treatment of varicocele for couple infertility. Cochrane Database Syst Rev 2019
12. Smits RM et al. — Antioxidants for male subfertility. Cochrane Database Syst Rev 2019
13. Schisterman EF et al. — FAZST trial: folic acid + zinc on live birth. JAMA 2020;323:35-48
14. Krzastek SC et al. — Clomiphene citrate for male hypogonadism. J Urol 2019;202:1029-35
15. HealthDirect — male infertility
16. Better Health Channel — male fertility
17. ACCESS Australia — fertility support
18. MBS Online — items 23, 36, 44, 715, 965, 967, 2715, 55059, 66719, 73289, 73450
19. PBS Schedule
20. Quitline — 13 78 48