Male Factor Infertility Checklist for GPs

Male factors contribute to infertility in up to half of couples having difficulty conceiving. Current Australian and international guidance recommends assessing the male partner early and in parallel with the female partner, rather than waiting for the female assessment to be completed.[1–3]

For GPs, the initial work-up can usually be kept simple: focused history, examination where appropriate, semen analysis and targeted blood tests.

1. When should male fertility assessment start?

Consider assessment after 12 months of regular unprotected intercourse, or earlier when time matters or a male risk factor is present.[1,3]

Consider earlier assessment when the female partner is ≥35 years, there is a known female fertility factor, or the man has:

• Previous undescended testis, torsion, testicular trauma or surgery

• Chemotherapy or radiotherapy

• Previous vasectomy or pelvic/retroperitoneal surgery

• Erectile or ejaculatory dysfunction

• Testicular atrophy, scrotal mass or significant asymmetry

• Current or previous testosterone/anabolic-steroid use

See: Male Infertility & Reproductive Urology

2. First-visit GP checklist

Ask about:

• Duration trying and previous pregnancies

• Sexual function, ejaculation and intercourse frequency

• Cryptorchidism, infections, torsion, trauma and reproductive surgery

• Significant febrile illness in recent months

• Medications and supplements—particularly testosterone or anabolic steroids

• Smoking/vaping, cannabis, alcohol and relevant occupational exposures

Where appropriate, examine testicular size and consistency and assess for a clinically palpable varicocele. A hard intratesticular mass requires prompt investigation rather than routine fertility follow-up.[1]

3. Order semen analysis early

Semen analysis is the key first-line investigation and should use current WHO laboratory methods.[1,4]

Importantly, a semen analysis does not provide a simple “fertile” or “infertile” result.

If the first semen analysis is abnormal, Australian guidance recommends repeating it approximately 6 weeks later, or longer when clinically appropriate.[1] However, do not delay referral simply to obtain another sample when azoospermia or severe abnormalities are present.

GPs and patients can use the Semen Analysis Interpreter to understand commonly reported parameters.

4. When should GPs order hormones?

If semen parameters are abnormal or there are features suggesting androgen deficiency or endocrine disease, consider morning:

• Total testosterone

• FSH

• LH

• Prolactin when clinically indicated[1–3]

Results should be interpreted alongside the semen analysis, examination and clinical history.

5. What should not be ordered routinely?

Routine initial testing generally does not require:

• Scrotal ultrasound in every patient

• Antisperm antibodies

• Sperm DNA fragmentation testing[1]

Genetic testing is important in selected men with azoospermia or significant oligozoospermia but is usually best targeted after specialist assessment.[1,2]

6. Refer earlier when you find:

• Azoospermia

• Severe or persistent oligozoospermia

• Markedly abnormal semen parameters

• Small or abnormal testes

• Clinical varicocele with abnormal semen analysis

• Significant endocrine abnormalities

• Infertility after testosterone/anabolic-steroid exposure

• Significant ejaculatory dysfunction

• Recurrent pregnancy loss or repeated assisted-reproduction failure where male reassessment may be relevant[1–3]

Men with azoospermia require assessment to distinguish obstructive from non-obstructive azoospermia, as investigation and treatment pathways differ.

Useful resources: Azoospermia | Fertility After Testosterone

What should you include in the referral?

Attach semen-analysis reports, hormone results, medication history, previous fertility/IVF records and relevant operative reports where available.

Patients can also complete the Male Fertility Assessment Checklist before review.

For patients outside Brisbane, initial assessment and record review may sometimes be undertaken before travel. See Interstate & International Patient Information.

A specialist assessment does not automatically mean treatment or surgery. The aim is to clarify the likely cause, identify potentially reversible factors and help determine an appropriate pathway based on both partners' circumstances.

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References

1. Katz DJ, O'Donnell L, McLachlan RI, Moss TJ, Boothroyd CV, Jayadev V, et al. The first Australian evidence-based guidelines on male infertility. Med J Aust. 2025;223(11):653-663. doi:10.5694/mja2.70080.

2. Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, Lamb DJ, et al. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part I. Fertil Steril. 2021;115(1):54-61. doi:10.1016/j.fertnstert.2020.11.015.

3. European Association of Urology. EAU Guidelines on Sexual and Reproductive Health: Male Infertility. Arnhem: EAU Guidelines Office; 2026.

4. World Health Organization. WHO laboratory manual for the examination and processing of human semen. 6th ed. Geneva: World Health Organization; 2021.

5. Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, Lamb DJ, et al. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part II. Fertil Steril. 2021;115(1):62-69. doi:10.1016/j.fertnstert.2020.11.016.

Medical Disclaimer

This article provides general educational information for health professionals and patients and is not a substitute for individual medical advice. Investigation, treatment and referral should be tailored to the individual patient, partner factors, local laboratory standards and clinical circumstances.