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The most important test for assessing male fertility is semen analysis. It needs to be done by experts and analyzed in detail.
Semen Analysis - All you ever wanted to know about Sperm and Infertility
The man's only contribution to making a baby is producing healthy motile sperm, and depositing it in the vagina at the right time. But what is sperm? And how does your doctor check whether your sperm is fine or not?
Sperm are the male reproductive cells - the man's gametes. They are the smallest cells in the human body and are produced in the testes. They find their way out through the male reproductive tract and are ejaculated in the semen.
The most important test for assessing male fertility is the semen analysis. The fact that it is so inexpensive can be misleading because many patients (and doctors ! ) feel that it must be a very easy test to do if it is so cheap, which is why they get it done at the neighborhood lab. However, its apparent simplicity can be very misleading, because in reality, it requires a lot of skill to perform a semen analysis accurately. However, it is very easy to do this test badly (as it often is by poorly trained technicians in small laboratories), with the result that the report can be very misleading - leading to confusion and angst for both patient and doctor. This is why it is crucial to go to a reliable andrology laboratory, which specializes in sperm (Sperm Video) testing, for your semen analysis, since the reporting is very subjective and depends upon the skill of the technician in the lab.
View a sample SEMEN ANALYSIS REPORT
Some men try to judge their fertility by the thickness of their semen. It's not possible to do this, so don't worry if you think your semen is too "thin" or too fluid!
For a semen analysis, a fresh semen sample, not more than half an hour old is needed, after sexual abstinence for at least 3 to 4 days. The man masturbates into a clean, wide-mouthed bottle which is then delivered to the laboratory.
Providing a semen sample by masturbation can be very stressful for some men - especially when they know their counts are low; or if they have had problems with masturbation "on-demand" for semen analysis in the past. Men who have this problem can and should ask for help. Either their wife can help them to provide a sample _ or they can see sexually arousing pictures or use a mechanical vibrator to help them get an erection. Some men also find it helpful to use liquid paraffin to provide lubrication during masturbation. For some men, using the medicine called Viagra can help them to get an erection, thus providing additional assistance. If the problem still persists, it is possible to collect the ejaculate in a special silicone condom (which is non-toxic to the sperm and is available from our online store) during sexual intercourse, and then send this to the laboratory for testing.
The semen sample must be kept at room temperature; and the container must be spotlessly clean. If the sample spills or leaks out, the test is invalid and needs to be repeated. Except for liquid paraffin, no other lubricant should be used during masturbation for semen analysis - many of these can kill the sperm. It is preferable that the sample is produced in the clinic itself - and most infertility centers will have a special private room to allow you to do so - a "masturbatorium".
How is the test performed in the laboratory?
After waiting for about 30 minutes after ejaculation, to allow the semen to liquefy, the doctor will check the semen.
The volume of the ejaculate: While a lot of men feel their semen is "too little or not enough", abnormalities of the volume are not very common. They usually reflect a problem with the accessory glands - the seminal vesicles and prostate - which are what produce the seminal fluid. Normal volume is about 2 to 6 ml. A low volume (less than 1 ml) is an uncommon problem and is often due to incomplete ejaculation (which is not rare because of the stress of producing a sample in the lab !) or spillage. Since the major portion of the ejaculate is produced in the seminal vesicles, a persistently low volume is because of a problem with seminal vesicle function - either an absence of the seminal vesicles or an ejaculatory duct obstruction. A very high volume surprisingly will also cause problems, because this dilutes the total sperm present, decreasing their concentration.
During ejaculation, the semen spurts out as a liquid which gels promptly. This should liquefy again in about 30 minutes to allow the sperm free motility. If it fails to do so, or if it is very thick in consistency even after liquefaction, this suggests a problem most usually one of infection of the seminal vesicles and prostate.
Normally the pH of semen is alkaline because of the seminal vesicle secretion. An alkaline pH protects the sperm from the acidity of the vaginal fluid. An acidic pH suggests problems with seminal vesicle function, and is usually found in association with a low volume of the ejaculate and the absence of fructose.
Presence of a sugar called fructose:
This sugar is produced by the seminal vesicles and provides energy for sperm motility. Its absence suggests a block in the male reproductive tract at the level of the ejaculatory duct.
The most important test is the visual examination of the sample under the microscope. What do sperm look like ? Sperm are microscopic creatures that look like tiny tadpoles swimming about at a frantic pace. Each sperm has a head, which contains the genetic material of the father in its nucleus; and a tail that lashes back and forth to propel the sperm along. The mid-piece of the sperm contains mitochondria, (the powerhouse of the sperm) which provide the energy for sperm motion.
Ask to see the sperm sample for yourself under the microscope - if normal, the sight of all those sperm swimming around can be very reassuring. You are likely to be awestruck by the massive numbers and the frenzy of activity. If the test is abnormal, seeing for yourself gives you a much better idea of what the problem is! A good lab should be willing to show you and to explain the problem to you.
First, the doctor checks to see if there are enough sperm. This is done using a specially calibrated counting chamber. If the sample has less than 20 million sperm per ml, this is considered to be a low sperm count. The new WHO criteria suggest that even a sperm count of more than 15 million per ml is normal and men with this count should be considered as being fertile. Less than 10 million is low - and less than 5 million per ml is very low. The technical term for this is oligospermia (oligo means few). Some men will have no sperm at all and are said to be azoospermic. This can come as a rude shock because the semen in these patients looks absolutely normal it is only on microscopic examination that the problem is detected.
(whether the sperm are moving well or not ). The quality of the sperm is often more significant than the count. Sperm motility is the ability to move. Sperm are of two types - those which swim, and those which don't. Remember that only those sperm which move forward fast are able to swim up to the egg and fertilize it - the others are of little use. Motility is graded from a to d, according to the World Health Organisation (WHO) Manual criteria, as follows. Grade a (fast progressive) sperm are those which swim forward fast in a straight line - like guided missiles. Grade b (slow progressive) sperm swim forward, but either in a curved or crooked line or slowly (slow linear or non-linear motility). Grade c (nonprogressive) sperm move their tails but do not move forward (local motility only). Grade d (immotile ) sperm do not move at all. Sperm of grade c and d are considered poor. Why do we worry about poor motility? If motility is poor, this suggests that the testis is producing poor quality sperm and is not functioning properly - and this may mean that even the apparently normal motile sperm may not be able to fertilize the egg.
(whether the sperm are normally shaped or not - what is called their form or morphology. Ideally, a good sperm should have a regular oval head, with a connecting mid-piece and a long straight tail. If too many sperms are abnormally shaped (round heads; pinheads; very large heads; double heads; absent tails) this may mean the sperm are abnormal and will not be able to fertilize the egg. Many labs use Kruger "strict " criteria ( developed in South Africa ) for judging sperm normality. Only sperm which is "perfect" is considered to be normal. A normal sample should have at least 15% normal forms (which means that even up to 85% abnormal forms is considered to be acceptable!) Some men are infertile because most of their sperm are abnormally shaped. This is called teratozoospermia (terato=monster).
Sperm clumping or Agglutination:
Under the microscope, this is seen as the sperm sticking together to one another in bunches. This impairs sperm motility and prevents the sperm from swimming up to through the cervix towards the egg.
Putting it all together, one looks for the total number of "good" sperm in the sample - the product of the total count, the progressively motile sperm, and the normally shaped sperm. This gives the progressively motile normal sperm count which is a crude index of the fertility potential of the sperm. Thus, for example, if a man has a total count of 40 million sperm per ml; of which 40% are progressively motile, and 60% are normally shaped; then his progressively motile normal sperm count is: 40 X 0.40 X 0.60 = 9.6 million sperm per ml. If the volume of the ejaculate is 3 ml, then the total motile sperm count in the entire sample is 9.6 X 3 = 28.8 million sperm.
Whether pus cells are present or not:
While a few white blood cells in the semen is normal, many pus cells suggest the presence of seminal infection. Many labs will misreport round cells seen in the semen as being pus cells and doctors will then try to treat this "infection" with antibiotics! While a few white blood cells in the semen is normal, many pus cells suggests the presence of seminal infection. Unfortunately, many labs cannot differentiate between sperm precursor cells ( which are normally found in the semen) and pus cells. This often means that men are overtreated with antibiotics for a "sperm infection" which does not really exist !
Some labs use a computer to do the semen analysis. This is called CASA, (computer-assisted semen analysis). While it may appear to be more reliable (because the test has been done "objectively" by a computer), there are still many controversies about its real value, since many of the technical details have not been standardized, and vary from lab to lab.
A normal sperm report is reassuring, and usually does not need to be repeated. If the semen analysis is normal, most doctors will not even need to examine the man, since this is then superfluous. However, remember that just because the sperm count and motility are in the normal range, this does not necessarily mean that the man is "fertile". Even if the sperm display normal motility, this does not always mean that they are capable of "working" and fertilizing the egg. The only foolproof way of proving whether the sperm work is by doing IVF (in vitro fertilization)!
Overtreating a semen analysis report
Sadly, we see many men with completely normal semen analysis reports who have taken months of futile treatment! Some doctors will "treat" a few pus cells in the semen with antibiotics - claiming that the pus cells suggest an infection! Others will even try to treat a normal sperm count with medicines, claiming that their treatment will help to "boost" the sperm count and thus the man's fertility !
Azoospermia (no sperm in the semen)
About 10% of infertile men will have no sperm at all in the semen. This is called azoospermia. The conditions which cause azoospermia can be classified into 3 groups - pre-testicular, testicular, and post-testicular. An example of azoospermia because of pretesticular disease is hypogonadotropic hypogonadism, where the testis does not produce sperm because of the absence of production of gonadotropins by the pituitary. Consequently, even though the testes are normal, no sperm are produced because of the absence of the needed hormonal stimulation. In testicular conditions, the testis does not produce sperm because of testicular failure (end-organ damage). In these men, the testicular damage is so severe that no sperm are found in the semen. This is also called non-obstructive azoospermia, and an example of this is Klinefelter's syndrome. In post-testicular conditions, even though sperm are being produced normally in the testes, the outflow passage is blocked (ductal obstruction or obstructive azoospermia)
If a semen report shows azoospermia, then it needs to be rechecked. The lab should be instructed to centrifuge the sample in order to look carefully for sperm. A close analysis of the report will often help the doctor to differentiate between non-obstructive and obstructive azoospermia. Thus, if the semen volume is low, the pH is acidic and the fructose is negative, then this is likely to be due to an obstruction at the level of the ejaculatory duct. If sperm precursor cells (immature sperm cells) are seen in the sample on careful microscopic examination, then this clearly means that the problem is not because of an obstruction.
We request men with azoospermia to provide a sequential ejaculate for semen analysis - two samples produced 1-2 hours apart. Occasionally, in men with non-obstructive azoospermia, the second sample may show a few sperm, because it is "fresher".
An FSH level test in the blood ( as described in the next chapter) is also helpful in differentiating between obstruction and testicular failure. If the FSH level is high, it means the problem is a testicular failure. If, on the other hand, the FSH level is normal, then a testis biopsy is needed to come to the correct diagnosis.
Rarely, some men will not be able to ejaculate at all. This is called aspermia, and their semen volume is zero. While this is sometimes because of a psychological problem (because the man cannot achieve an orgasm in spite of being able to get an erection), the commonest reason for this is condition is retrograde ejaculation.
Poor sperm tests can result from incorrect semen collection technique if the sample is not collected properly, or if the container is dirty too long a time delay between providing the sample and its testing in the laboratory too short an interval since the previous ejaculation recent systemic illness in the last 3 months (even the flu or a fever can temporarily depress sperm counts)
If the sperm test is abnormal, this will need to be repeated 3-4 times over a period of 3-6 months to confirm whether the abnormality is persistent or not. Don't jump to a conclusion based on just one report - remember that sperm counts do tend to vary on their own! It takes six weeks for the testes to produce new sperm - which is why you need to wait before repeating the test. It also makes sense to repeat it from another laboratory to ensure that the report is valid.
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