If you are looking for answers from this article, it is possible that you may have concerns after receiving a semen analysis report indicating a sperm count below the standard threshold, leading to the questions: For those with a low sperm count, should they choose ICSI or IVF? And how do the two methods differ?
This article will delve into all questions to ensure you receive comprehensive information, because we believe you deserve the true facts before making a decision.
What is a low sperm count, and how is it classified?
Before answering whether to do ICSI or IVF, what you first need to know is what level your low sperm count falls into, because the word “low” does not have just a single meaning.
The World Health Organization (WHO) specifies that a normal sperm count must not be lower than 16 million per mL (or 39 million per ejaculate)[cite: 8]. If it is lower than this, it is called oligospermia, or a low sperm count, which is clearly categorized into the following severity levels[cite: 8]:
| Category | Sperm concentration | What it may mean for treatment |
| Mild low sperm count | 10–15 million/mL[cite: 8] | Natural conception or conventional IVF may still be possible[cite: 8] |
| Moderate low sperm count | 5–10 million/mL[cite: 8] | Other semen results and the couple’s circumstances need reviewing before deciding on ICSI[cite: 8] |
| Severe low sperm count | Below 5 million/mL[cite: 8] | ICSI is commonly recommended in the circumstances described here[cite: 8] |
| Azoospermia | No sperm detected in semen[cite: 8] | Sperm retrieval, such as TESE or PESA, may be needed before ICSI[cite: 8] |
The lower the sperm count, the higher the likelihood that physicians will recommend ICSI[cite: 8], but numbers alone are not always the final answer.
What is the difference between IVF and ICSI?
This question is asked very frequently because many people hear these two terms often until they are familiar, but they are not sure how they truly differ.
With conventional IVF (in vitro fertilisation), eggs and prepared sperm are placed together in a laboratory dish[cite: 8]. Sperm must swim towards an egg and enter it for fertilisation to occur[cite: 8]. This approach can work when enough sperm are present and their movement and other characteristics are suitable[cite: 8].
With ICSI (intracytoplasmic sperm injection), an embryologist selects a sperm and injects it directly into an egg using a fine needle[cite: 8]. This avoids relying on sperm to travel to and penetrate the egg on its own, which can be particularly useful when sperm numbers or quality are reduced[cite: 8].
In summary, IVF allows natural fertilisation in a controlled environment, whereas ICSI involves selecting a single, most perfect sperm to directly assist in fertilisation.
How low does sperm count need to be before ICSI is considered?
This is the core of the article and the question Gift Fertility specialists are asked most often, but in reality there is no single fixed number, though there are principles physicians use for consideration, as follows:
Below 5 million sperm/mL: ICSI is usually recommended
When sperm count is this low, the chance of sperm successfully swimming to the egg on their own in an IVF dish is very low[cite: 8]. Therefore, ICSI is clearly a more suitable choice because it reduces the risk of obtaining no embryos at all[cite: 8].
Between 5 and 15 million sperm/mL: other findings matter
At this range, the answer does not depend solely on sperm count[cite: 8]. Physicians will look at additional factors, including[cite: 8]:
- Female partner’s age The older she is, the less advisable it is to risk a method with a lower success rate[cite: 8].
- Sperm morphology and motility If the sperm count is already low and high morphological abnormalities are present, the chance of fertilisation in IVF drops even further[cite: 8].
- Previous treatment Has a previous IVF cycle failed[cite: 8]?
- Number of eggs collected If few eggs are available, taking a risk with IVF where no embryos might result may not be worthwhile[cite: 8].
Above 15 million sperm/mL: conventional IVF may be sufficient
In cases where the sperm count is mildly low and quality remains adequate, conventional IVF may yield good results without necessarily requiring ICSI[cite: 8]. However, physicians will still review the complete overall picture before making a decision[cite: 8].
Summary table: Review your sperm count to find the answer
| Situation | Sperm concentration | Morphology / motility | Initial option discussed |
| Very low sperm count | < 5 million/mL[cite: 8] | Any result[cite: 8] | ICSI[cite: 8] |
| Moderate low count with poor quality | 5–15 million/mL[cite: 8] | Less than 4% normal forms[cite: 8] | ICSI[cite: 8] |
| Moderate low count with suitable quality | 5–15 million/mL[cite: 8] | At least 4% normal forms[cite: 8] | IVF or ICSI, considering the female partner’s age[cite: 8] |
| Mild low count with otherwise suitable findings | 10–15 million/mL[cite: 8] | Good quality[cite: 8] | Conventional IVF may be sufficient[cite: 8] |
| Azoospermia | No sperm in semen[cite: 8] | Not applicable[cite: 8] | Sperm retrieval (TESE/PESA) followed by ICSI[cite: 8] |
This table is an initial guide only; actual diagnosis must always involve testing and direct consultation with a physician[cite: 8].
Is ICSI always better than IVF when sperm count is low?
This question can be answered directly: No, not always. ICSI is not automatically superior to IVF; rather, it is a tool suited to specific situations[cite: 8].
In cases where sperm count and quality are sufficient, conventional IVF achieves comparable results, and in some instances, allowing sperm to naturally select the egg may even yield better-quality embryos[cite: 8].
However, when sperm count is low or quality is poor, ICSI is an aid that removes the need for the entire process to rely on sperm luck[cite: 8].
Can you wait to improve sperm count before starting ICSI?
Yes, but careful consideration is required, particularly regarding these factors[cite: 8]:
Waiting may be considered when:[cite: 8]
- The female partner is under 35 and other fertility findings are favourable[cite: 8].
- Sperm count is only mildly reduced, with a potentially treatable cause such as varicocele or a hormone deficiency[cite: 8].
- The fertility specialist considers that waiting around three to six months is unlikely to compromise the couple’s treatment prospects[cite: 8].
Earlier treatment may be preferable when:[cite: 8]
- The female partner is 37 or older and age-related changes are an important consideration[cite: 8].
- Severe low sperm count has persisted and no clear treatable cause has been identified[cite: 8].
- The couple has already experienced infertility for more than two years[cite: 8].
What if there is no sperm in the semen sample?
For couples where the male partner has a sperm count so low that no sperm are detected in the semen (azoospermia), there is still a way forward[cite: 8].
PESA (percutaneous epididymal sperm aspiration) uses a fine needle to collect sperm from the epididymis, usually where a blockage prevents sperm from entering the semen[cite: 8].
TESE (testicular sperm extraction) involves taking a small tissue sample from the testicle to look for sperm[cite: 8]. It may be considered in some cases where sperm production is severely reduced, as well as certain other causes of azoospermia[cite: 8].
Once sperm are retrieved, both methods are always used in conjunction with ICSI because the quantity of retrieved sperm is usually very small.
What are the success prospects for ICSI with a low sperm count?
Data from Gift Fertility shows that the success rate of ICSI in cases of low sperm count depends on multiple factors that must be evaluated together, including the female partner’s age, the quality of retrieved eggs, the number of developing embryos, and previous pregnancy history[cite: 8].
Overall, ICSI for male-factor infertility (including low sperm count) has an average successful fertilisation rate of 70–80% per egg collected[cite: 8]. However, the successful pregnancy rate per cycle varies according to individual factors[cite: 8].
Gift Fertility physicians will be able to assess your chances more clearly after examination and complete review of your information[cite: 8].
Low sperm count: which method is considered?
| Semen findings | Recommended Approach |
| Fewer than 5 million sperm/mL[cite: 8] | ICSI[cite: 8] |
| 5–15 million/mL with poor sperm quality[cite: 8] | ICSI[cite: 8] |
| 5–15 million/mL with suitable quality and a younger female partner[cite: 8] | IVF or ICSI, after assessment[cite: 8] |
| More than 15 million/mL with suitable quality[cite: 8] | Conventional IVF may be sufficient[cite: 8] |
| No sperm detected in semen[cite: 8] | TESE/PESA with ICSI, where sperm retrieval is possible[cite: 8] |
The final answer does not depend solely on numbers, but on the overall picture of both partners. Direct discussion with a physician is the most crucial step.
Frequently Asked Questions (FAQ)
Can we try conventional IVF first and change to ICSI if it does not work?
Sometimes. Where sperm count is severely reduced, a fertility specialist may recommend ICSI from the outset because conventional IVF carries a concern about complete fertilisation failure[cite: 8]. Previous results and the sperm assessment help guide this choice[cite: 8].
Can ICSI fail because sperm count is low?
A low count alone does not determine whether ICSI will succeed, because a sperm is injected directly into each suitable egg[cite: 8]. Egg quality, embryo development and uterine factors also affect the outcome[cite: 8]. Poor sperm quality may still matter even when enough sperm are available for injection[cite: 8].
Is it possible to have a child with a very low sperm count?
It may be possible[cite: 8]. Even when no sperm are detected in the semen, retrieval procedures such as TESE may find sperm that can be used for ICSI in selected cases[cite: 8]. The likelihood of retrieval depends on the cause of the problem[cite: 8].
How does Gift Fertility decide between ICSI and IVF?
The fertility specialist reviews the latest semen analysis, the female partner’s age and ovarian reserve tests, including AMH and AFC, previous treatment and the couple’s goals[cite: 8]. These findings are discussed before agreeing on a fertilisation method[cite: 8].
What does the male partner need to do before providing sperm for ICSI?
The preparation guidance recommends avoiding ejaculation for two to five days before semen collection, limiting alcohol and excess heat exposure, and following the clinic’s instructions about anything that could affect sperm quality[cite: 8]. The sample is collected on the date arranged by the treatment team[cite: 8].
Ready to know a clearer answer than this?
Numbers in a semen analysis report can only tell part of the story; what will tell you whether a low sperm count makes ICSI or IVF more suitable for you is testing and discussing directly with an expert physician.
The fertility specialists at Gift Fertility are ready to provide consultation and join you both in planning the treatment approach, because we believe success in building a family begins with mutual understanding.