SA Men: What a Semen Analysis Actually Measures

You asked for the test. You collected the sample. You got a report back — and now you’re staring at words like “oligozoospermia” and numbers that mean nothing without context. You’re not alone. Male factor infertility accounts for roughly half of all fertility problems in couples, yet semen analysis results are rarely explained well at the point of care. This guide changes that.

The misconception worth naming first

A wave of social media posts and news headlines over the past decade have used studies on global sperm count decline to suggest that a single low result is a fertility death sentence. The most cited of these — a 2017 meta-analysis led by Hagai Levine — found a 59% decline in sperm concentration among men in Western countries between 1973 and 2011. The 59% figure was real, but it was widely misapplied: it described a population trend, not an individual prognosis. A single below-reference result does not confirm infertility, and one normal result does not confirm fertility. Both points matter equally.

What the test actually measures

A semen analysis is a laboratory examination of a semen sample, usually collected by masturbation after two to seven days of abstinence. The South African Society of Reproductive Medicine and Surgical Conception (SASRM) recommends using WHO 2021 reference values as the benchmark. Here is what each parameter means.

Volume

The lab measures how many millilitres of fluid you produce. The WHO 2021 lower reference limit is 1.4 ml. Low volume (hypospermia) can point to ejaculatory duct obstruction, retrograde ejaculation (semen entering the bladder instead of exiting the urethra), or hormonal problems. Very high volume can dilute sperm concentration, which affects the total count.

Sperm concentration

This is the number of sperm per millilitre of semen. The WHO 2021 lower reference limit is 16 million sperm per ml. Below this threshold the condition is called oligozoospermia. Severe oligozoospermia is generally defined as fewer than 5 million per ml. To put this in perspective: a man with 15 million sperm per ml is just below reference but may still conceive naturally; a man with 1 million per ml faces a much steeper challenge. Concentration alone does not tell the full story — that is why labs also calculate total motile count.

Total sperm count

Multiply concentration by volume and you get the total number of sperm in the ejaculate. The WHO 2021 lower reference limit is 39 million per ejaculate. This figure is often more clinically useful than concentration alone, because a man who produces 3 ml at 15 million per ml has a total count of 45 million — above the reference threshold despite a borderline concentration.

Motility

Sperm that cannot swim cannot reach the egg. Motility is divided into two categories:

• Progressive motility (PR): sperm moving forward in a straight or large-circle path. WHO 2021 lower reference: 30%.
• Total motility (PR + non-progressive): WHO 2021 lower reference: 42%.

Poor motility is called asthenozoospermia. A common cause in the South African context worth noting: untreated genital tract infections — including those associated with sexually transmitted infections (STIs), which carry a significant burden in SA — can damage sperm motility directly.

Morphology

This is the most misunderstood parameter. Morphology describes the percentage of sperm with a normal shape. Using WHO 2021 (Kruger strict criteria), the lower reference limit is just 4% normal forms. Yes — a result of 4% normal is considered reference-range. This number shocks men because it sounds like nearly everything is “broken,” but the human reproductive system has never relied on morphology alone. Below 4% is called teratozoospermia. Severely low morphology (under 1%) is associated with reduced IVF success rates, but sperm shape is assessed alongside every other parameter, not in isolation.

Other parameters

The report may also include:

• pH (normal: 7.2–8.0): Very low pH can suggest ejaculatory duct obstruction or absence of seminal vesicle fluid.
• Vitality (viability): The percentage of sperm that are alive. WHO 2021 lower reference: 54%. Relevant when motility is very low — dead sperm cannot be made to swim.
• White blood cells: More than 1 million white blood cells per ml (pyospermia) suggests infection or inflammation and warrants further investigation.

Why one result is never the final word

Semen parameters vary significantly from sample to sample in the same man, depending on recent illness (a fever three months earlier can affect sperm produced during that window), alcohol intake, stress, and abstinence period. SASRM guidelines, in line with WHO guidance, recommend that any abnormal result be confirmed with a second analysis at least four weeks later. A single normal result also does not rule out male factor infertility — what the test measures is quantity and movement, not the sperm’s genetic integrity. DNA fragmentation testing is a separate, specialised assay not captured in a standard semen analysis.

No local SA data exists on the average rate of result variability between tests; the figures cited above draw on WHO 2021 reference data.

What the next steps look like in SA

Public sector pathway

If you are in the public system, your first point of contact is a primary healthcare clinic or community health centre (CHC). A basic semen analysis is available at most public sector andrology or reproductive health units attached to district or regional hospitals, though waiting times and equipment availability vary by province. From the clinic you will be referred upward — to a district hospital for initial workup, and potentially to a tertiary academic hospital (such as Charlotte Maxeke, Tygerberg, or Inkosi Albert Luthuli) if surgical intervention or assisted reproduction is needed. Public sector assisted reproduction services are extremely limited; most IVF is delivered privately.

A known barrier in the public system is load-shedding: samples must be processed within 60 minutes of collection, and power outages at collection points can compromise results. If you are collecting at a public facility, ask the nursing staff whether the lab has backup power.

Private sector costs

In private practice, a standard semen analysis typically costs between R400 and R900, depending on the laboratory and location. A full andrological consultation with a urologist or reproductive medicine specialist adds R1,000 to R2,500 for an initial appointment. Advanced testing — including DNA fragmentation analysis or anti-sperm antibody testing — can add R1,500 to R3,000 per test. These figures are indicative averages; confirm costs directly with the provider before booking.

Medical aid and PMBs

Male infertility investigations do not fall under Prescribed Minimum Benefits (PMBs), which means your medical aid is not legally required to cover semen analysis or fertility workups. Coverage varies widely by scheme and plan. Some open schemes cover basic diagnostic tests under their savings benefits. Contact your scheme directly before testing to avoid unexpected out-of-pocket costs. If your scheme does cover fertility benefits, get pre-authorisation in writing.

Understanding your total motile count (TMC)

Clinicians often use the total motile count (TMC) — calculated as total sperm count multiplied by percentage total motility — to guide treatment decisions rather than any single parameter. A TMC above 20 million is generally associated with a reasonable chance of natural conception. Between 5 and 20 million, intrauterine insemination (IUI) is often considered. Below 5 million, IVF with intracytoplasmic sperm injection (ICSI) is usually recommended. These thresholds are used as clinical guides, not rigid rules.

When to see a doctor

See your GP or a urologist if:

– You and your partner have been trying to conceive for 12 months (or six months if your partner is over 35) without success.

– Your report shows azoospermia (no sperm detected).

– Your report shows severe oligozoospermia (fewer than 5 million sperm per ml).

– You have a history of testicular injury, undescended testes, or previous STI treatment.

– You have pain, swelling, or a lump in the testes — see a doctor immediately regardless of fertility concerns.

Bottom line

• Check every parameter together — count, motility, morphology, volume, and vitality each add information the others miss.
• Confirm any abnormal result with a second test at least four weeks later before drawing conclusions.
• Ask your lab or doctor for your total motile count; it is the single most clinically useful number on the report.
• Male infertility investigations are not PMB-covered — confirm medical aid benefits before testing.
• A below-reference result is a starting point for investigation, not a diagnosis of permanent infertility.