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Male Fertility

Self-Assessment Questionnaire

This questionnaire helps assess male fertility and determine if basic semen analysis or advanced assessments are needed. Please answer the following questions honestly.

Male Fertility Assessment Questionnaire

Male Fertility Assessment Questionnaire

1. How long have you and your partner been trying to conceive?
2. Have you fathered a child in the past?
3. Is this your second or subsequent marriage?
4. Has your current partner had a successful pregnancy with a previous partner?
5. Has your partner undergone any fertility testing?
6. Have you or your partner had any pregnancies that ended in miscarriage?
7. Have you or your partner undergone any abortions?
8. Are you aware of any genetic disorders or baby malformations in your family history?
9. What is your current age?
10. Do you have any history of sexually transmitted infections (STIs)?
11. Do you experience any sexual dysfunction (e.g., erectile dysfunction, premature ejaculation)?
12. 12. Do you have a history of urological surgeries or conditions (e.g., varicocele, undescended testicle)?
13. Have you been exposed to any known environmental or occupational hazards (e.g., radiation, toxins)?
14. Do you smoke or use recreational drugs?
15. Do you consume alcohol frequently (more than 3 drinks per week)?
16. Do you exercise regularly (at least 30 minutes, 3 times a week)?
17. Do you maintain a healthy diet with a balanced intake of nutrients?
18. Do you experience high levels of stress in your daily life?
19. How many hours of sleep do you get on average per night?

Scoring Instructions:

Add up the points based on your responses:

  • Fertility History: 1 point for each “Yes” except for questions 4 and 5 (no points for these).
  •  Sexual Health and Risk Factors: 1 point for each “Yes”.
  •  Lifestyle and Health: 1 point for each “No” in questions 16 and 17, and 1 point for each “Yes” in questions 18 and 19.
  • Age: 1 point for each category (e.g., 1 point for “30-39 years”).

What is your score?

0-6 Points: Low Risk – Basic semen analysis is recommended to assess fertility. Advanced testing may not be necessary at this time.

7-13 Points: Moderate Risk – Basic semen analysis is necessary. Depending on the results, advanced assessments might be considered.

 14-20 Points: High Risk – Comprehensive fertility assessment including advanced tests like DNA Fragmentation Index (DFI), Reactive Oxygen Species (ROS), Acrosin Activity, and Annexin V tests is highly recommended.

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