The Semen Analysis
The parameters of the semen analysis evaluated include the volume, viscosity, concentration (sperm count), motility (the percentage of sperm moving and the progression of the motile), morphology (shape of the sperm) and presence of cellular contaminants such as red or white blood cells. The normal parameters of the sample are as follows:
pH: slightly alkaline
Volume: 2.0 to 5.0 ml of semen
Concentration: > 20 million/ml
Motility: >50% moving, >25% rapid forward
Morphology: >14% normal forms (based upon Kruger criteria)
Additionally, the sample should liquefy in 30 minutes or less. Samples which remain highly viscous may have impaired motility and may be representative of an infection in the prostate. The presence of some white blood cells in the semen is normal but many white blood cells might indicate the presence of an infection within the urogenital tract.
Abnormalities in any of the semen parameters may compromise the fertility potential of the sample. However, since spermatogenesis occurs in waves, a secondary analysis after 4 to 6 weeks is recommended.
Factors affecting the semen analysis
Many factors may influence the results of the semen analysis. Since many of which involve specimen transport it is important to adhere to the specimen collection policy defined by the laboratory.
Collection technique: Failure to collect the sample by masturbation, failure to collect the entire sample and the use of lubricants may effect results. Additionally, the specimen container itself may not be a friendly environment for sperm, therefore a laboratory approved container should only be used during collection.
Time of collection: Motility and viability may be compromised in samples that are analyzed more than 1 hour from time of collection. It is important to follow the instruction for transport should you need to collect outside of the facility.
Abstinence period: Too short or too lengthy a period of abstinence may impact the concentration or motility of a specimen. It is important to adhere to the guidelines for abstinence as outlined in the specimen collection policy.
Recent illness: Recent severe systemic illness in the last three months may affect the semen analysis.
Medications: Several medications may affect the results of the analysis.
Semen cultures: Semen cultures are acquired on some patients when an infection is suspect due to the presence of bacteria or a high concentration of white blood cells.
Fructose analysis: Fructose analysis is performed on azoospermic samples, or samples that are completely absent of sperm. Fructose, a component of the seminal plasma, is necessary for sperm survival and function after ejaculation. The absence of fructose may indicate a blockage in the pathway of ejaculation or in many cases the complete absence of the seminal vesicles and vas deferens, a congenital anomaly afflicting approximately 1% of infertile couples.
Sperm viability testing: The sperm viability or sperm survival test provides crude information on the functional potential of the sperm and its ability to survive in vitro for an extended period. The test is not very informative if survivability is in normal range however if sperm survival is poor following the incubation period this has very poor projection on functionality.
Sperm vitality testing: Samples demonstrating <30% motility are automatically stained for viability. An immotile sperm may still be viable, therefore it is important with severely impaired motility, that the % of viable sperm is established.
Hormone analysis: An analysis of pituitary derived hormones such as LH and FSH, can used to determine the pathophysiology of repeated ejaculates demonstrating poor concentration of or complete absence of sperm. Sperm concentration below normal may indicate a problem in the stimulation of the testicle by the brain, via the pituitary gland, or an injury to the testicle itself.
Testicular biopsy: A testicular biopsy is performed to determine whether sperm production exists in the testis. This procedure has particular importance with patients demonstrating a complete absence of sperm. The biopsy is a relatively simple surgical procedure which can be performed under local anesthetic in the physician’s office. If the biopsy reveals that sperm are indeed present in the testicle, then the use of advanced reproductive technology can be utilized in a very successful manner. The most important issues with regard to testicular biopsy include the presence or absence of sperm production and, if present, the stage of development. Maturational arrest, a condition where sperm arrest in their development, has been associated with abnormal hormone concentrations, such as testosterone.
Mastography: Mastography is another surgical test in which a dye is injected into the vas deferens, the duct through which the sperm travels in order to visualize possible blockages.
Karyotype/genetic testing: One of the other tests performed for severely compromised sperm production is a chromosomal analysis (Karyotype). Some men bear an extra chromosome, as in Klinefelter’s syndrome, (47 XXY), which is the reason for the absence of sperm. Congenital bilateral absence of the vas deferens (CBAVD) warrants testing for the gene mutation causing cystic fibrosis. Compromised sperm parameters can also be observed in men carry the CF mutation.
What Are the Most Common Reasons for Male Infertility?
Reduction in any one or more of the semen analysis parameters can significantly reduce the fertility potential of any given specimen. The natural fluctuations in sperm production warrant multiple semen analyses in compromised samples. Many factors can contribute to male infertility, including:
Varicocele: A varicocele is the presence of swollen varicose veins in the scrotum. A varicocele may go unnoticed for a significant period without inducing any chronic aches or pains. It is one of the most common reasons for low sperm motility, or the ability of the sperm to demonstrate forward progressive movement. The effects on motility are due to increasing shifts in temperature due to blood accumulation around the testicle.
Blockages: Blockages of the vas deferens can be observed at birth or may result because of surgery or insult from an accident. Surgical repair can be technically complicated simply due to the size of the vas, however repair is successful in fifty percent of the cases, meaning that sperm can be identified in the semen after surgery. In the first few months following repair, sperm may be of poor quality but improvements may be seen as time progresses. Secondary to the blockage, sometimes there is damage to the functional lining of the epididymis (the sperm warehouse) either as a result of infection or increased pressure.
CBAVD: Congenital bilateral absence of the vas deferens. For patients born without the vas deferens, the conventional treatment is sperm aspiration directly from epididymis. This is performed by microsurgical techniques in order to find the location of sperm storage.
Vasectomy: Following vasectomy, sperm are still produced and stored, but are not released in the ejaculate but rather absorbed. Microsurgical repair of the tube is possible to reverse the effects of the vasectomy. The vasovasostomy is the reveral surgery which is a very delicate procedure, which, in the most skillful hands, can be successful approximately eighty percent of the time.
Immunity: Many controversies exist with regard to sperm antibody production in the male or in the female tract. We suggest that each case be evaluated on its merit and treated appropriately.
Hormonal imbalance: Hormonal imbalance in the male may occur following head injury or result from a tumor in the pituitary gland or in the hypothalamus, the base of the brain. Additionally, since the adrenal is the site where most of the male hormones are produced, malfunction of this gland could have significant impact on male fertility.
Pituitary dysfunction, cirrhosis of the liver, thyroid dysfunction, hyperprolactinemia production, and certain enzyme deficiencies influence hormone production in the testes. Mainly, imbalances are due to improper pituitary stimulation of the testes, which fails to support sperm production. Treatment of hypogonadotropic hypogonadism consists of gonadotropin therapy using hCG, LH and FSH. Although this is a somewhat lengthy and costly therapy, it can be effective in enhancing sperm production.
Substance abuse: Sustained elevated levels of alcohol can damage the liver and decrease the level of male hormones. Liver cirrhosis and alcohol suppress sperm production directly. Drug abuse can also influence the morphology (shape) and motility of the sperm in a negative fashion. Drug misuse also alters the hormonal balance causing impotence and problems achieving erections.
Undescended testes: It is not uncommon for newborns to demonstrate undescended testes, however, failing to descend from the abdominal cavity to the scrotum by 2 years of age can result in testicular destruction. An undescended testis requires surgical intervention and in some instances its removal is warranted because of risks of developing cancer.
Torsion: One of the testicles can undergo torsion, which is described as the twisting around its neck. Damage occurs because of the cessation of blood supply. The signs of torsion are excruciating pain and swelling of the testicle. Once diagnosed, untwisting of the testicle is immediately necessary, since a delay in time will cause permanent functional damage.
Infections. Viral infections such as smallpox, mumps, and TB have been related to abnormal sperm production. Additionally, gonorrhea, chlamydia, syphilis, and other sexually transmitted diseases may influence spermatogenesis or sperm function.
Medications. Some medications can play an important role in sperm production and sex drive. These can include drugs for high blood pressure such as Methyldopa, cortico steroids and anabolic steroids for muscle building. Other treatments for Hodgkin’s disease, lymphoma or leukemia, which are called chemotherapeutic agents as well as radiation, can destroy sperm production rendering the man sterile. If the potential for sterility due to surgery, chemotherapeutic or radiation therapy exists, sperm can be banked and stored in our long term storage facility for as many as ten to twenty years.
Increased temperature: The testicles are located within the scrotum because the core body temperature can alter sperm production and function. The temperature in the testicle is about 0.8 degrees cooler than in the body. Clothes such as tightly fitting jeans or briefs cause the testicles to be pressed back into the warmth of the body and when combined with hot tubs, bath and sauna can cause significant abnormalities in sperm production. Wearing loosely fitting cotton pants and boxer shorts can prevent this damage.
Occupational hazards: Dangerous chemicals including exposure to heavy metals, nickel, mercury, insecticides, pesticides, benzene, xylene, acids and x-rays can impact sperm production and function. Patients who have experienced exposure to microwave radiation (such as around radar equipment) have a diminished capacity for sperm production.
Ejaculation problems: Sexual dysfunction can be related to infertility either because of the inability to ejaculate or due to circumstances that make intercourse very difficult. Usually psychological evaluation and treatment of these conditions is both successful and rewarding.
Retrograde ejaculation. In some cases during ejaculation the semen travels back into the bladder instead of exiting through the penis. One of the most common indicators of retrograde ejaculation is the presence of cloudy urine following intercourse. Patients with this problem usually suffer from diabetes, or have had prostrate surgery, spinal injury, congenital problems, or take medication to control blood pressure. The simplest way to diagnose retrograde ejaculation is to examine the urine following ejaculation. The diagnosis is confirmed if sperm are found in the urine. Extraction of the sperm from the urine is possible. Unfortunately the recovered sperm are usually of poorer quality and result in diminished pregnancy rates. The combination of IVF with intracytoplasmic sperm injection (ICSI) can provide better results.