A Sperm

Male infertility usually has no outward signs. The first step, indeed the single most important test in any fertility evaluation, is a semen analysis (SA.) Even if a child has been fathered or a previous semen analysis has been reported as normal, this is still necessary.

Several years ago, an IVF laboratory director in a reasonably well-known program complained that a couple was having in vitro fertilization because the woman had blocked tubes. At the time the eggs were obtained, there were no sperm in the husband’s semen sample. No semen sample had ever been obtained before. Their doctor was quoted as saying he “had not wanted to stress the male partner.” What about the stress of a $7500 bill for an IVF procedure and nothing to show for it? There have been too many instances where female partners have undergone surgery or aggressive medical therapy when a semen sample had never been examined. Luckily, these cases are becoming increasingly scarce.

Do men feel differently about infertility?

There is always considerable performance anxiety before the first semen sample is produced and great pride when it is discovered to be normal. For a man to be told of an abnormal semen analysis is equivalent to a woman being told that she cannot carry a child. Men equate sperm counts with potency, potency with virility and virility with manliness. Men may not wake up each morning and go to bed at night thinking about infertility, but they certainly carry the burden with them. Infertility attacks the male self image as strongly as the female.

The male infertility inventory (The Ten “I”s)

Infection
Illness
Incision (surgical injury)
Injury
Impotence (erectile dysfunction)
Environment* (toxins and stress) *Ok, so we fudged! But this e sounds like an i!
Intoxicants (smoking, alcohol, illicit drugs)
Ingestants (medications, diet)
Inheritance
Idiopathic (unknown cases)

Who evaluates male infertility?

If the semen sample is abnormal, referral to a urologist is common, but not necessarily the best option. Urologists, while very capable of a thorough exam, unfortunately are often are not interested or trained in complete evaluation and treatment of the infertile couple. Probably the best route is a relatively quick referral to a fertility center. The reproductive endocrinologist (RE) receives training in both male and female infertility and may be the best individual to explain options and coordinate efforts. A question you should ask when selecting a facility is whether the team includes an andrologist and reproductive urologist. The andrologist may be either a scientist or a clinician specifically skilled in male reproductive biology and infertility. The reproductive urologist has an interest in andrology, as well as surgical treatment of male infertility, and is a valuable member of the comprehensive care team. Unfortunately there are too few of these professionals around.

Looking at and understanding the numbers

Sperm count, motility, and morphology are the big three in analysis of semen. The chances of pregnancy fall as the number of problematic factors in a semen sample increase from one to two and from two to three. Often there are abnormalities in all three categories (oligoasthenoteratospermia.)

Standard recommendation is that semen samples should be analyzed after three to four days of abstinence in order to have the maximum chance of a satisfactory evaluation. In reality, it may be more appropriate to produce a sample at your natural intercourse interval. Regardless, it is most important that the days of abstinence be recorded. If there is a good sample after twelve hours of abstinence—that’s real good. Semen quality among men of proven fertility can vary considerably between samples. Do not be alarmed with a single bad report. It may be a one-time occurrence. Sometimes the semen analysis can be performed as a part of a natural or clomiphene cycle, adding therapy to diagnosis.

Withdrawal sex should not be used for producing a sample for analysis. The best sperm may be lost in the first several drops of semen. Artificial lubricants may lower motility and viability. If successful masturbation is not possible, many fertility clinics have condoms especially designed for this purpose.

General guidelines for interpretation of semen samples

The normal volume of semen is 2-5 milliliter (ml) (1 ml = 1 cc, these units are used interchangeably.) Less semen may be seen when there was recent intercourse. Lack of seminal fluid is a sign of obstruction or retrograde ejaculation. Low volume could indicate partial obstruction or infection.

Concentration is expressed as the number of sperm in each ml of ejaculate. Often a SA is read as abnormal because only total sperm count is considered rather than the count per ml. If there are no sperm, the condition is called azoospermia. Causes of azoospermia can be genetic factors, an obstruction, and/or hormonal problems. To exclude retrograde ejaculation (passage of the sperm into the bladder instead of out the urethra) a second semen analysis with evaluation of urine sample after ejaculation should be performed. Endocrine testing should also be performed. Unless the cause is immediately obvious, genetic studies may be needed.

If the count is under 20 million per ml, the individual is said to have oligospermia. It is not really a diagnosis, but a finding, and virtually every source of male infertility has the finding of oligospermia. It shows the likelihood of pregnancy, not what is wrong.

Motility (movement of the sperm) is very seldom above about 80%. Samples under 10% should be scrutinized for lab or collection errors. Labs differ in what they consider normal motility. Normal ranges are probably about 40-70%. Be aware of the sample that looks too good on paper. Problems with motility are referred to as asthenospermia.

Morphology refers to the shape of the sperm. There are two different classification systems in use. According to the traditional World Health Organization classification, normal forms (shape) should be over 30%. Using a more refined classification including the “strict” criteria developed by Kruger, fertilization after IVF was 37-47% when there are less than 14% normal forms and 85-88% when there are over 14% of normal shape.

Be aware of the laboratory that is performing the semen analysis. Hospital labs are notorious for letting the sample sit too long before analysis, and too often technicians interpret semen samples with little formal training in semenology. The quality of the semen may be much better than reported. Often when white blood cells (WBC’s) are reported, these are actually immature sperm cells. The distinction between WBC’s and immature sperm can save unnecessary treatment with antibiotics. The results of the semen analysis may also overestimate sperm quality, but generally a sample reported as too good is much less worrisome for everyone.

If one semen analysis is abnormal, it should be repeated. If two semen analyses are normal, male factor cannot be excluded but becomes much less likely.

What is too low?

The most useful parameter in evaluation of a semen sample is total motile sperm. Too often a sample is judged good or poor by looking at only one of the above parameters. The correct formula for use to judge a sample is Total motile = (Volume of sample) X (Concentration of sperm) X (motility.)

When there are more than 20 million total motile sperm, the chances of fertility are good. When in vitro fertilization (IVF) is used, there is little difference in fertilization rates with samples above five million. Every fertility specialist has been surprised with a pregnancy that occurred with counts so low as to border on sterility.

In the past, the prognosis for men with very low sperm counts was very poor and often donor sperm became the most viable option for achieving pregnancy in the female partner. We are now in a new era of male infertility therapy. We can not absolutely predict the limits of male fertility and it truly may take only one good sperm. It may mean assisted reproduction, but virtually all-male factor infertility is now treatable with relatively good success. Direct injection of sperm into the egg, intracytoplasmic sperm injection (ICSI) has dramatically changed the boundaries of male fertility. The confines of male infertility have been pushed even farther back with the technique of removal of sperm directly from the testicles.

Are there other fertility tests for him?

If a repeat semen analysis is also low, the next step is hormone testing. The basic evaluation includes blood tests for luteinizing hormone (LH,) follicle stimulating hormone (FSH,) and testosterone. If FSH levels are high, there is reduction in sperm production, while low FSH and LH indicates a “stress” pattern or communication problem within the endocrine system. Normal levels may be seen with obstruction of the sperm ducts. This is only a basic guide and there is considerable variation. The advisability of more extensive testing of sperm and sperm function, such as sperm penetration assays, antibody testing, and sperm viability studies should be highly questioned on a cost benefit basis. These tests may be valuable experimental tools, but truly offer very little to alter course of therapy and are best performed and read only by highly specialized clinics.

What can he do to improve his fertility?

One major area in which change for the better can occur is in lifestyle. Individuals with PCOS often share many lifestyle evils with their partner. There is no better way than to work on the problems together. There is a clear relationship between male obesity and decreased testosterone and decreased libido. Smoking has been clearly linked with decrease in sperm function. This relationship is very clear and very real. Additionally, smoking frequently leads to difficulty in establishing an erection in men over 40. Caffeine has the effect of temporarily exciting sperm, but then they don’t live as long. It is unclear if the occasional alcoholic beverage affects sperm counts or function, but chronic and heavy use is clearly dangerous. A survey of any medications used is important. For example, calcium channel blockers, which are excellent drugs for hypertension, have also been shown to block fertilization. Too much of a good thing can also have negative consequences. For example, running over twenty miles a week reduces fertility.

In many cases of couples with both PCOS and male factor infertility, if one were more fertile than the other was, that one might not be seen in a fertility clinic. Sometimes if we can improve the female fertility by increasing the number or quality of eggs, this alone will overcome the male factor.

Boxers or Briefs?

There is probably no male undergoing a fertility investigation in the United States today who is still wearing briefs. While based on the sound theory that increased heat reduces sperm count, there is clearly no evidence that the type of underwear worn makes a difference. The famous lover Casanova was said to have used long hot baths as a contraceptive, but this story, as well as a recommendation, is suspect. Fertility seems to go down in the summer months, and men in certain occupations subject to long periods of high heat are possibly affected, but the risks have been exaggerated

Should a varicocele be repaired?

A varicocele is a varicose vein of the scrotum. It has been theorized that this dilation of the veins increases scrotal temperature and reduces semen quality. There are some very positive scientific reports on improvement in sperm after the veins have been closed (ligated, occluded) or removed. Sperm counts may rise somewhat after surgery, but the hard evidence is completely lacking in relation to varicocele repair having any positive effect on fertility. If a surgeon finds a varicocele, there is a good a chance the opportunity to “have it fixed” will be offered. There would seem more effective alternatives than surgery, especially if there is the combined problem of PCOS.

So, what are my chances?

Our new technologies of assisted reproduction have dramatically affected the success with treatment of male infertility. Couples that in the past were relegated to use of donor sperm, or adoption, often have excellent chances of pregnancy with IVF or IVF and sperm injection(ICSI). See our info sheets on these subjects.

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