Tokuda Hospital Sofia


Reduced sperm counts

One of the most common reasons for a couples inability to conceive is male reduction of procreativity. The most important 

examination is the semen analysis (analysis of a semen sample). If a man conducts this analysis in the beginning of a treatment, this could possibly spare his partner some unnecessary, as well as stressful tests and treatments.

The sperm maturation takes place in the testicles at around 35°C. The whole development cycle takes three months. If the temperature in the testicles is too high, the production stops or the sperm cells are destroyed. Even a low temperature has inhibitory effects, although the sperm cells are not destroyed.

The sperm maturation starts in puberty and continues until an advanced age. During this time span, the sperm quality can vary strongly. Therefore, it is necessary to do at least two sperm analyses over a three months period, in order to estimate the semen quality. Infections and fever, as well as prolonged sunbathing, sauna and solarium usage have negative effects on sperm maturation.

Analysis of a sperm sample: the spermiogram

One of the most important tests for a couple with difficulties conceiving is the spermiogram, the analysis of a sperm sample.

The partner delivers a sperm sample after an abstention period of 3 to 5 days. After liquefaction the volume of the sample, the amount of sperm cells per milliliter, the percentage of sperm cells which move fast or slow and the percentage of sperm cells with normal morphology are identified. With this examination a slight or severe infertility can be determined. If the partner has this test conducted at the beginning of the fertility treatment he can spare his wife unnecessary and stressful treatments.

Preliminary remark: The standard values have been defined by the World Health Organisation (WHO). We would like to point out again that a poor result alone is not significant. We recommend a repetition of the examination 6 to 12 weeks later. If no second test has been conducted one cannot speak of infertility. The analysis should occur at the latest 60 minutes after ejaculation. 


Important: The semen analysis can strongly vary, so one analysis is therefore not significant.

The image shows how the amount of sperm cells per milliliter can vary over several weeks.







The following parameters should appear on your result:

General parameters

Standard values (WHO)

Reasons for conspicuous results

Date of the result

Not older than 6 months


Abstention period

3 - 5 days

less than 3 days: the result may be falsified

Volume of the sample

2 ml or more

prostate problems, spillage of sample, stress during delivery

Liquefaction time

within 60 minutes

high discrepancy - clarification!

pH - value

7,2 to 8,0

prostate problems, infection


less than 1 mio/ml

infection, urological check-up recommended

Specific parameters

Ref. Values WHO 5 (after 2010)

Ref. values WHO 3-4

(1992- 2010)

Concentration / density of sperm cells per ml

≥ 15 mio SCs/ml        ≥ 39 Mio. SCs/Ej.

≥ 20 mio SCs/ml

Mobility of sperm cells in %



a. fast moving (progressive)

a+b ≥ 32 %

a ≥ 25%

b. slow moving (progressive)

a+b ≥ 32 %

a+b ≥50%

c. non-progressive

c + d < 68%

c + d < 50%

d. immotile

c + d < 68%

c + d < 50%

Morphology in %

Normal SCs ≥ 4%

Normal SCs  ≥  30% / 15% **


* We need an up-to-date test result which should not be older than 6 months. Please ask whether all the parameters required are on your test result. We cannot give a definitive statement if parameters are missing!

** Depending which criteria are used.

Usually the results are summarized by the following terms: (definitions of the World Health Organization):

Summary of results (definition by the WHO)

Normozoospermia: normal ejaculate
Oligozoospermia: too few sperm cells
Asthenozoospermia: percentage of moving cells too few
Teratozoospermia:   percentage of regularly formed cells too small
Oligoasthenoteratozoospermia:   syndrome combination of all three disorders
Kryptozoospermia: very few sperm cells present within the seminal fluid
Azoospermia:  no sperm cells present within the seminal fluid
Aspermia: no seminal fluid 





What is important to consider for the sperm delivery?

  • 3 - 5 days abstention period should be observed
  • the bladder should be empty before ejaculation
  • hands and penis should be washed before the delivery
  • no check-up necessary for an inconspicuous test result (normozoospermia)
  • for conspicuous test results a check-up 6 to 12 weeks later is recommended
  • in the case of kryptozoospermia or azoospermia the check-up can be conducted already after 4 to 6 weeks
Azoospermia and aspermy 

Some men do have no sperm cells in their seminal fluid. This condition is called azoospermia. If there are a few sperm cells present, this is referred to as kryptozoospermia. It is absolutely necessary to repeat the semen analysis after approximately 6 weeks, as there might be natural variations. Should the second analysis show no sperm cells there is still hope of conceiving a child.

There are three causes of azoospermia:

The spermatic cords are closed or missing. Hence, the sperm cells from the testicles, resp. the epididymis cannot reach the seminal fluid.

Very few sperm cells are formed. They are degraded on the way from the testicles through the epididymis to the seminal cords, i.e. before they reach the seminal fluid, which is released by the prostate during ejaculation.

No sperm cells are formed in the testicles.

The urologist/andrologist is the first person to be contacted in case of diagnosed azoospermia. They conduct a clinical examination and give advice on the possibilities. Sperm cells can be obtained directly through a testicle biopsy (Testicular Sperm Extraction (TESE) or from the epididymis (Microepididymal Sperm Aspiration (MESA). In some patients, the obtained material is very suitable for treatment, because it contains large amounts of sperm cells. This gives the possibility to freeze and store a part of them. Sometimes, however, there are no sperm cells to be found. An alternative would be to use semen from a third party. This procedure is regulated differently in individual countries.           

IMPORTANT: Very few sperm cells can be obtained through TESE and MESA. Therefore it is always necessary to treat the female partner with in vitro fertilization (IVF), since this is the only way to achieve fertilization of the ovum with very few sperm cells.

Aspermia is the condition where no seminal fluid is ejected from the urethras despite muscle contractions. This dry orgasm is normal prior to puberty. Afterwards, it is most likely caused by a nerve disorder in the urogenital system, e.g. through paraplegia.



The severing of the testicular ducts is a very reliable form of contraception. It prevents the sperm cells from reaching the seminal fluid. This severing has no effect on the seminal fluid volume during ejaculation or on the potency.


1. Small incision

2. Severance of the testicular ducts

3. Blood vessels

4. Testicular ducts

5. Epididymis

6. Testicles


While this method is very reliable it has the disadvantage that it can only be reversed in certain conditions. If a desire for pregnancy occurs after a vasectomy the man has two alternatives:

The urologist can attempt to repair the severance through a reconstruction of the testicular ducts. If the operation is successful the man can achieve a pregnancy via intercourse.

The sperm cells are obtained directly from the epididymis or the testicular tissue. In this case, the amount of obtained sperm cells is usually very small. A treatment with in vitro fertilization (IVF) is necessary to achieve a pregnancy.


Paraplegia can often cause problems with erection and ejaculation. There are several options to obtain sperm cells in such cases.

The sperm cells can sometimes be obtained from the bladder. Moreover, an ejaculation can be triggered via electrostimulation. Another possibility is to gain sperm cells surgically through a testicle biopsy or epididymal aspiration.

The urologist can elaborate on the alternatives in special cases. Furthermore, andrology specialists familiar with the mentioned methods are available for consultations.     

The couple should be advised by a good team which is experienced in consulting paraplegics with a desire to have children of their own. Fortunately, nowadays there are good chances for a paraplegic man can to become a father.



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Hospital location

51B "Nikola I. Vaptsarov" blvd. (if you drive, the entrance is from "At. Dukov" str.), "Hladilnika" distr., 1407 "Lozenets".

The hospital has a parking lot. The first 30 min. are free of charge, then a fee of 3 bgn/hours applies.

Public transport:
Buses: №88, 120
Shuttle bus: 32

Subway: Getting off at "James Bourchier" station, after that walking through "Lozenets" distr., or tram №10, taking off at "Nikola I. Vaptsarov" stop. or a bus №88, taking ff at "Tokuda Hospital" stop.


From the Central Railway Station

Bus line №305 getting off at "Romanian embassy" stop
From "Romanian embassy" stop – Bus line №120 getting off at "Tokuda Hospital" stop.
(after the traffic lights at "Atanas Dukov" str.

With a subway, from "Central Railway Station" station, getting off at "James Bourchier" station, after that walking through "Lozenets" distr., or tram №10, taking off at "Nikola I. Vaptsarov" stop. or a bus №88, taking ff at "Tokuda Hospital" stop.