The aim of this study was to determine characteristic malformations of sperm ultrastructure in patients with severe subfertility undergoing intracytoplasmic sperm injection (ICSI). Although light microscopy (LM) can reveal major abnormalities of the three parts of the spermatozoon (head, mid-piece and flagellum), the various cell organelles of the spermatozoon and their fine structure remain unevaluated by LM. Insight into the submicroscopic organization of the spermatozoon and its complex organellar system may contribute to a better understanding of the preconditions for success or failure of fertilization. An in-depth evaluation of semen quality by transmission electron microscopy (TEM) can improve the diagnosis of male subfertility and can give substantial information about the fertilizing competence of spermatozoa. Thus, in this study 56 ejaculated sperm samples from patients with severe male subfertility or previous failed attempts at in-vitro fertilization were assessed by LM and TEM prior to ICSI to evaluate the most important sperm defects causing extreme subfertility. LM analysis was performed according to World Health Organization criteria. It could be confirmed that severe head defects are mostly involved in long-term infertility and fertilizing failure in classical IVF treatments. The most frequent head defects are disorders of the nuclear membranes and the acrosomal cap and disorganization of the chromatin structure. These defects of sperm fine structure seem to be associated with dysfunctional sperm-oocyte recognition, binding and fusion with the oolemma. Chromatin alterations and signs of decondensation or karyolysis are frequently associated with a deterioration of the nuclear membranes and may be due to impaired spermiogenesis. However, our results and the success of ICSI proved that severe sperm defects have no predictive value and do not impair the fertilization process, and also that the maturity of spermatozoa does not play an important role. Fine structure analysis revealed the pleiomorphology and heterogeneity of human spermatozoa.