Are you and your partner having troubles conceiving? Learn how to identify and manage male infertility.
What Is Semen Analysis?
As many as 40 percent of all couples have difficulty conceiving due to some compromise of the sperm count or sperm function; therefore, a semen analysis should be one of the very first tests done for couples having trouble conceiving.
A semen analysis is easy (aside from the embarrassment some men may feel), inexpensive, and noninvasive. 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.
How Do You Obtain a 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 are 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. On the other hand, shorter periods of abstinence may result in some decrease in the number of sperm present.
The sample should be submitted for analysis as soon as possible after collection. It is best to collect the sample at the office or laboratory where the semen will be analyzed. (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.
How Are Samples Analyzed?
Semen analysis results can vary from clinic to clinic. In a laboratory that does not really specialize in evaluating semen samples, you’d be likely to receive the following report.
Clinical Lab – Community Hospital, Any City
There is nothing wrong with this type of analysis, and often for a first test, this is fine. If it is perfectly normal, it is probably reliable, but this information is obviously limited. If there is any question about the normalcy of the results from this type of laboratory, a second test should be done by a laboratory that can do a more detailed analysis.
A laboratory that specializes in evaluating sperm samples will provide far more information and detail in its semen analysis. Measurements they would be likely to analyze include the following (with explanation):
- 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 30 to 60 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 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 most laboratories use 60 percent normal sperm as their cut-off point for a normal semen analysis. The second technique uses stricter 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 14 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.
What Other Sperm Tests Are Available?
- 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 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.
What Can Cause Abnormal Sperm Counts?
Several factors can have a hand in inadequate sperm production from outside influences to genetic predispositin.
- Heat: Sperm production is sensitive to heat—so 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, 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 you can’t have a beer or two on the weekend, but heavy alcohol intake can have a very significant effect. In short, if you drink, do so in moderation. If you smoke, quit. (See the American Society for Reproductive Medicine’s fact sheet on smoking and fertility.) 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 such as 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.
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:
- Poor cervical mucus: Is there infection or prior surgery on the cervix, or is the woman on medications (for example: clomiphene) that might account for poor cervical mucus? Inseminations (see below) may be suggested as a means of dealing with this problem.
- 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 assisted reproductive technology (ART) procedure such as IVF or zygote intrafallopian transfer (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.
What Happens if We Still Have Trouble Conceiving?
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:
- 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.
- ART (assisted reproductive technologies): Far fewer sperm are needed for these procedures to be successful than is the case even with inseminations, let alone intercourse.
- 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.
- 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.