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The Male Factor
Semen Analysis
Difficulty conceiving is related to some compromise of the sperm count or sperm function in as many as forty percent of all couples. Therefore, a semen analysis should be one of the very first tests done. A semen analysis is easy (ignoring the embarrassment some men may feel), inexpensive and noninvasive. Evaluation of the sperm is a point of discrimination: The sperm count will dictate which options are reasonable for a couple to pursue in their attempts to conceive. A severely compromised sperm count may, for example, mean that only rather sophisticated procedures are worthwhile, whereas a normal count would allow consideration of much more conservative procedures.
Obtaining and Delivering the Sample
A semen sample is usually obtained by masturbation with collection of the ejaculate into a sterile specimen container. No lubricants should be used. There are also specially designed condoms that can be worn during intercourse to collect a semen sample. (These do have to be special condoms, which are available through your physician.) Two to three days of abstinence is suggested before obtaining a sample for analysis. Longer periods of abstinence may increase the count, but the percentage of sperm that are actively motile will decrease. Conversely, shorter periods of abstinence may result in some decrease in the number of sperm present. Two to three days of abstinence before a semen analysis provides the most accurate results.
The sample should be submitted for analysis as soon as possible after collection. It is preferable to collect the sample at the office or laboratory where the analysis will be performed. Specially designed rooms just for this purpose are usually available. If you are going to collect the sample at home, keep it at body temperature while transporting it to the laboratory. Placing the container under your arm, inside your pants, or in your bra will accomplish this. The sooner the sample is provided to the laboratory after collection the better.
Interpreting Semen Reports
Examples of two reports of semen analysis results are provided below. It is easy to see that there is much more detailed information available in the second report.
The first is a report fairly typical of a laboratory that does not really specialize in evaluating semen samples.
Clinical Laboratory - Community General Hospital
Any City
Date: ___________ Patient Name: ___________________
SS#: ___________ Physician: ___________________
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Test Result Expected Range Units
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Semen analysis - Fertility
Semen Volume 2.5 2.0 - 5.0 mL
Sperm Motility 65 60-100 %
Sperm Count 89 60-150 M/mL
There is nothing wrong with this type of analysis, and often for a first test, this is fine. If it is perfectly normal, it's probably pretty reliable but this information is obviously limited. If there is any question at all about the normalcy of the results from this type of laboratory, the second test should be done by a laboratory that can do a more detailed analysis.
There is obviously far more information and detail provided by the second sperm analysis. This test was analyzed by a laboratory that specializes in evaluating sperm samples. Following is an explanation of the information obtained and what the results mean.
Coagulum present: The ejaculate normally "coagulates" into a jellylike blob within a few minutes of ejaculation.
Liquefied in: The coagulum should begin to break down and liquefy within thirty to sixty minutes of ejaculation.
Volume: Two to four cc's is normal. Larger or smaller volumes may present a problem in getting enough sperm to the cervix either because there is not enough seminal fluid to protect the sperm in the vagina or because the sperm present are diluted in too large a volume.
Viscosity: This is a measure of the overall stickiness of the sample.
Motility: This is the measure of the rate at which the sperm move. Good sperm motility is vital to their ability to fertilize an egg. Only those sperm with rapid progression can reach and fertilize an egg. Sperm may also be slowly progressive (moving, but not moving well, or moving in very erratic patterns), non-progressive (alive and shaking, literally, but not moving), and immotile (alive but not moving at all). Some distinction about grade of motility is important and sometimes missing from more cursory evaluations.
Viability: The percentage that are alive regardless of their motility.
Agglutination and aggregation: Measures of the extent to which the sperm are stuck to each other or stuck to material within the ejaculate.
pH: The pH of the seminal fluid must be within the range of 7.2 to 8.0 to protect the sperm from the very acidic environment of the vagina until they can reach the cervix.
Sperm concentration: The number of sperm present in one cc.
Total count: The sperm concentration multiplied by the volume.
Fructose: Fructose is the sugar present in the seminal fluid. It functions as an energy source for the sperm and is produced in the seminal vesicle. Absence of fructose suggests an obstruction in the path of the sperm from the testicles to the penis.
Leukocyte concentration: Leukocytes are white blood cells, and their presence suggests an infection, often of the prostate gland. This is reported as the number of white cells per 100 sperm present.
Morphology: This is the microscopic assessment of the appearance of the sperm. There are two techniques for evaluating morphology. The "standard technique" is done much more superficially and with this technique, most laboratories use sixty percent normal sperm as their cut-off point for a normal semen analysis. The second technique uses the "strict criteria." With this technique, the sperm are much more critically assessed, and a sperm must be perfectly normal to be so considered. Under these criteria, more than fourteen percent normal-appearing sperm is outstanding, and more than four percent is probably normal. The use of the "strict criteria" for evaluating morphology is validated by the good correlation between normal appearance by these criteria and the fertilizing capacity of a sperm. Most labs specializing in semen analyses will use the "strict" criteria.
Total motile normal sperm (also known as TMNS):This is the "bottom line" of the semen analysis. This is the number of sperm that are normal by strict criteria and possess rapid progressive motility. In other words, this is how many sperm in the sample are capable of fertilizing an egg. The TMNS provides the physician with a number that he or she can use to determine which treatment alternatives will offer a couple an acceptable chance of conception.
Other Tests Of Sperm Function
Sperm penetration assay: A test in which sperm are incubated with specially prepared hamster eggs (actual fertilization cannot occur). The ability of the sperm to bind to the eggs and penetrate them is measured. The results of this test correlate moderately well with the ability to penetrate a human egg: If there is good penetration in this assay, there is a very good chance the sperm are capable of penetrating a human egg.
Sperm antibody tests: These tests check for the production of antibodies by either the male or female. Antibodies are substances that can either immobilize or even kill the sperm before the sperm can reach the egg. In order to detect antibodies, a tube of blood is drawn from the woman and incubated with a sperm sample in the laboratory and examined microscopically.
Mannose test, acrosome reaction test: Before a sperm can attach to and fertilize an egg, it must undergo a process known as capacitation. Capacitation involves changes in the membrane of the head of the sperm that are necessary to allow attachment to, and penetration of, the egg. These tests measure the ability of the sperm to undergo capacitation and allow identification of sperm that may not be able to fertilize an egg in spite of an otherwise normal semen analysis. These tests can be particularly useful in cases of unexplained infertility or prior to an ART procedure. These are also known as sperm function tests (SFTs).
Sperm washing or Percoll gradient: Techniques used to isolate the healthiest and most motile sperm. A semen sample is subjected to one of these procedures prior to, for example, inseminations.
Testicular biopsy: A technique in which a small piece of the testicle(s) is surgically removed and microscopically evaluated. The value of this procedure in terms of suggesting ways to improve the sperm count is questionable at best. With the availability of microinsemination techniques such as ICSI (intracytoplasmic sperm injection), a testicular biopsy may be worthwhile in that if it demonstrates the presence of even a few very immature sperm, these can now be used to achieve fertilization and pregnancies.
Causes of Abnormal Sperm Counts
Heat: Sperm production is sensitive to heatso sensitive, in fact, that placing the testicles at normal body temperature on a chronic basis stops sperm production altogether. The temperature in the testicles is about four degrees lower than body temperature. Anything that tends to keep the temperature in the testicles elevated for long periods of time will likewise have a negative effect. Excessive use of hot tubs or saunas or maybe even prolonged and heavy exercise may decrease sperm production and motility. One example often cited of an occupational exposure to excessive heat is truck drivers or farmers who often work long, hot hours in heavy clothing such as blue jeans.
Cigarettes, Alcohol, and Nonprescription Drugs: Cigarette smoking and alcohol abuse adversely affect sperm counts and sperm function. This is not to imply that having a beer or two on the weekend needs to be avoided, but significant alcohol intake can have a very significant effect. In short, if you drink, do so in moderation. If you smoke, QUIT.
Illicit drugs definitely affect sperm counts. Marijuana and cocaine are the prime examples of drugs that interfere with sperm production. Anabolic steroid use is also well known to decrease sperm production.
Prescription Drugs, Infections and Illnesses: Certain medications may also have a negative effect. Sulfasalazine (used for ulcerative colitis), cimetidine (used for ulcers), and calcium-channel blockers (used for high blood pressure) alter sperm production and function. The use of any medication on a chronic basis should be brought to the attention of your physician. Prenatal exposure to DES (diethylstilbestrol, a hormone used in the past to help prevent miscarriage) can dramatically decrease sperm production.
Certain infections, such as mumps contracted after puberty, have been clearly shown to dramatically affect sperm counts. Others, such as the presence of white cells in a semen analysis in a man who is otherwise asymptomatic are less clear, but treatment is probably indicated and may result in some improvement.
Chronic illnesses, such as diabetes, are important. Prior treatment for cancer by surgery, radiation or chemotherapy can also be significant.
Other causes: Obviously, a history of a prior vasectomy is important. There may be increased antibody production in men who have had a prior vasectomy and a reversal. The same may be true in individuals who have experienced significant injuries to the testicles.
Finally, does chronic stress have a negative impact? Maybe! Long-term, high-stress situations can lead to a decrease in testosterone production, and possibly in sperm production.
Treatment Options For Sperm Problems
There are ways to improve sperm counts, and we will detail those in the next few paragraphs. However, the treatment of male infertility and improvement of sperm counts has been a frustrating problem for both the patient and the physician for a long time. The process of spermatogenesis is an extremely complex one that occurs over the course of about seventy days. Our understanding of this remarkable process is rudimentary, at best, and our ability to define where a problem exists and to correct it is almost nonexistent. Until recently, we could do nothing for many cases. Now, however, with the advent of laboratory techniques such as IVF and ICSI, we have the ability to take the most compromised of sperm samples and achieve fertilization in the laboratory. Men with even just a few sperm can achieve pregnancy. The bottom line when it comes to treating male fertility is this: Much of the focus in the treatment of male infertility has shifted from trying to improve sperm production and quality to finding ways to work with whatever sperm are present.
Schedule Wisely
It's important to realize that it takes about seventy days for the testicles to produce a sperm that is fully mature and ready to achieve fertilization. Any significant insult during that seventy-day period can significantly affect the sperm count for two to three months. For example, if you have a very high fever today as the result of the flu or an infection, it may be three months before your sperm count will fully return to normal. Keep this in mind when scheduling your sperm countsif you have any reason to think there may have been some event that could interfere with sperm production, it may be wise to wait a while between sperm counts and see if the count improves.
Remember to avoid toxinsit's that simple. You don't necessarily have to abstain from drinking alcohol, but be reasonable. And, if there is any evidence of infection, treat it. It's straightforward, inexpensive, non-invasive, and it may help.
Urologist Evaluation
Evaluation by a urologist, particularly one who has a special interest in male fertility, is usually the first step in evaluating abnormal semen analyses. There are several problems that urologists treat effectively.
1. Varicocele: A varicocele is a dilated vein or veins around the testicles. It is thought that these dilated veins increase the heat of the testicle and thereby impair sperm production and the motility of the sperm that are produced. This effect of a varicocele can be progressive over time. Significant varicoceles can usually be appreciated on a simple physical exam. Correction of a varicocele requires a minor surgical procedure and can result in dramatic improvements in sperm numbers and function if the varicocele is large. Smaller varicoceles may or may not be important, and correction of small varicoceles is not likely to result in clinically significant improvements in the sperm count.
2. Obstruction: Most obstructions of the male reproductive tract are due to prior vasectomies, although they may occur as a result of infection, prior surgery (e.g., hernia repair), or may even be congenital. Microsurgery in the hands of one experienced in this technique can be very successful in reversing obstruction. The chances of successfully reversing an obstruction decrease the longer the obstruction has been present.
3. Failure of ejaculation: There are medications available that can remedy this problem for a large number of individuals. In others (for example, men who have suffered a spinal cord injury) electroejaculation has been very successful.
4. Retrograde ejaculation: In some individuals, the sperm are actually ejaculated backward into the bladder rather than out through the penis. This can be a congenital abnormality, or it may occur as the result of surgery, illness (e.g., diabetes) or medications. This can often be corrected through the use of medications, but if this does not work, the sperm can be isolated from the urine and used for insemination.
5. Testicular cooling: The testicles don't work well if they are too hot. Taking steps to keep the testicles cool is a very reasonable thing to do. Wear boxer shorts instead of jockey shorts. Avoid long or frequent saunas or hot tubs. Sleep naked. Finally, there is some suggestion that actually placing a small ice pack in a sock and then sitting on it for a while in the evening may be worthwhile.
Medical Therapies
Clomiphene citrate (Clomid, Serophene): Clomiphene citrate is an orally administered medication often used in women because it leads to an increased production of FSH by the pituitary, stimulating the ovaries. The rationale behind the use of clomiphene in men is that it will result in increased levels of FSH stimulating the testicles to produce more sperm. There is no good evidence that the use of clomiphene in men results in improved sperm production or better pregnancy rates.
Human menopausal gonadotropins: These medications are actually preparations of the hormones FSH and LH (Pergonal, Humegon), or FSH alone (Metrodin, Fertinex, Gonal-F, Follistim). They must be administered by injections, usually on a daily basis, and they are very expensive. In the rare individual whose pituitary does not produce LH and FSH, these preparations can be quite effective. In individuals whose pituitary gland functions normally but the sperm count is decreased, the value of these medications is much more questionable.
Human chorionic gonadotropin (hCG): Although this was a popular form of therapy in the past, it has not been found to be of value and is rarely used anymore.
Vitamins: There have been reports touting everything from vitamin E to vitamin C to zinc as the cure for decreased sperm production. I would suggest that everyone take some nice multivitamin, not megadoses, and leave it at that.
The Male Algorithm
This chart demonstrates the algorithm for the evaluation and management of the male. It will allow a couple to understand the steps involved and follow along with the evaluation. This same chart is reproduced in the back of the book in a form that allows a couple to record and chart the findings as they are obtained.
Semen Analysis
Semen analyses were discussed in detail above. If the semen analysis is abnormal, it should be repeated. Before repeating it, eliminate any of the possible causes of abnormal evaluations as listed above. Also be sure to repeat it after an adequate period of time has elapsed to allow improvement to occur. Remember, it takes seventy days to produce a mature sperm.
Postcoital Test
If the semen analysis is normal, the next step should be a post-coital test. The postcoital test (also known as the Huhner Test) is an excellent means of assessing the interaction of the sperm and the cervical mucus. In order to reach the fallopian tube and fertilize an egg therein, the sperm must first migrate through the cervical mucus. There are many factors that can impair the ability of the sperm to survive and traverse the cervical mucus, including faulty intercourse (e.g,. premature ejaculation), infection, prior surgery on the cervix and production of antibodies (substances that can kill or immobilize the sperm).
During a normal menstrual cycle, there are only a couple of days during which the sperm can survive in the cervical mucus. At other times of the cycle, the mucus is a very effective barrier. Around the time of ovulation, the cervical mucus becomes very thin and watery, and probably even somehow assists the sperm as they migrate through to the uterus and on to the fallopian tubes. The timing of this test is, therefore, crucial. If a woman's cycles are regular, an ovulation predictor test can be used. If she is on medication or has very irregular cycles, the timing of this test should be discussed with your physician, but must always be just prior to ovulation.
Have intercourse the morning of the post-coital test. Do not use lubricants or douche or take a bath after intercourse (showers are fine). Note the approximate time of intercourse since that is important in evaluating the results. Although some authors state that this test must be done within two hours of intercourse, this is not important. Simply note how long it has been and notify your physicianthey can adjust their interpretation based on the length of time.
In the office, a speculum exam is performed. A small amount of cervical mucus is withdrawn from the cervix (this is painless). This is then examined under the microscope. The quality of the cervical mucus as well as the number of sperm present and their motility will be assessed. You should be able to know the results right away.
If the post-coital test is abnormal, it should be repeated. This test is very dependent on proper timing in the cycle. If the test remains abnormal, there are a couple of possibilities:
1. Poor cervical mucus: Is there infection or prior surgery on the cervix, or is the woman on medications ( e.g., clomiphene) that might account for poor cervical mucus. Inseminations (see below) may be suggested as a means of dealing with this problem.
2. Poor sperm motility: This can suggest the presence of sperm antibodies. Sperm antibody testing should be considered. The presence of sperm antibodies would suggest that either inseminations or an ART procedure such as IVF or ZIFT be considered.
If the post-coital test is normal, evaluation of other possible factors should proceed. Sperm function testing should be considered before initiating treatments such as superovulation , or an ART procedure.
Alternatives
If the semen analyses are repeatedly abnormal, sperm function testing and urologic referral should be obtained. If no significant improvement in the semen analysis is obtainable, then the TMNS should be calculated, the results of the sperm function testing taken into account, and the appropriate interventions or treatments considered. The number of TMNS that is adequate for each intervention will vary from lab to lab and physician to physician, but the alternatives include the following:
1. Inseminations (also known as AIH): A semen sample is collected (preferably by masturbation although intercourse with a special condom is an option) and provided to the laboratory in a sterile specimen container. The semen sample obviously contains much more than just the sperm, including proteins, sugars and prostaglandins. The laboratory will treat the semen sample in such a fashion that a pure sperm sample suspended in a specially designed buffer is obtained. This sample is then placed in a small syringe to which is attached a small plastic tube, or catheter. A speculum is placed in the vagina, the catheter is directed through the cervix and into the uterus, and the sperm preparation is slowly injected. While this procedure may cause slight cramping, it is generally painless. This procedure allows a far greater number of sperm to reach the uterine cavity and fallopian tubes than would normally occur with intercourse.
2. ART (assisted reproductive technologies): These procedures will be discussed in detail in Chapter 13, but far fewer sperm are needed for these procedures to be successful than is the case even with inseminations, let alone intercourse.
3. ICSI (intracytoplasmic sperm injection): In short this procedure involves injecting a single sperm into an egg using a microscope and micromanipulation instruments. Fertilization and pregnancies can be achieved even if only a few sperm are present.
4. Donor sperm: If there is complete absence of sperm (azoospermia), this may be the only option for achieving conception. Some couples will also opt to use donor sperm rather than resorting to some of the more high-tech procedures, often because of cost considerations.
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