Semen Analysis Part 2

In the last blog post, I discussed why someone would need a semen analysis, how sperm is made, male and female similarities, and low testosterone. Now I will discuss the process of the semen analysis and more..

What is the process?

For the semen analysis, you will come into the clinic for collection and masturbate into a sterile cup. Then the semen will get analyzed in a lab. Before you come in, you will receive a few instructions. The standard instruction is no masturbation or intercourse for at least 2-3 days before the analysis. One mistake some men make is they choose to wait even longer thinking more is more. Then we end up seeing a lot of dead sperm in the analysis which is not a true reflection of what is going on. You want to clear the pathway, wait a few days, and then give your sample.

What are you looking for?

During a sperm analysis, we are looking for concentration, motility, and morphology. The guidelines we have give the 95% lower limit, so I am going to go over what is normal. The first thing we look at when we receive the sperm is the color, pH, thickness and viscosity of the sperm. However, the first measurable metric is the volume.

Volume
1.5 mL is the lower end of normal to make sure you have enough of a sample. If for some reason you didn’t catch all of the semen in the cup, it’s important to tell your provider. Having a smaller amount will affect the other parameters as well. If the volume is low, it may signal that something else is off. Sometimes low volume could mean something called retrograde ejaculation. This is when the some sperm gets pushed back up and into the bladder during ejaculation. The urethra for the male is for both urine and the ejaculation system. You can check a post-ejaculation urinalysis and find sperm in the urine. So if the volume is less than a milliliter and you did not miss the cup, yu should be doing a urinalysis to see if sperm is found.

Concentration
Concentration is simply the number of sperm per milliliter of ejaculate. The lower end of normal is 15 million sperm per milliliter, and the average is closer to 73 million per milliliter. I like to think of sperm as an army because I hear people frequently say, “It just takes one.” That is true. Kind of. Truly, you need that whole army of millions of sperm putting pressure on the egg to exert enough force to crack it open and let that one sperm in. Conception rates with severely low sperm called oligospermia are very low. They are not zero unless it is something called azoospermia which means no sperm at all. This happens in about 1% of all men and about 15% of infertile men. Azoospermia can happen for two different reasons. The first reason is the body is not making sperm which can be caused by taking testosterone or something is off on your hypothalamic pituitary axis. The other reason is because there is an obstruction blocking your sperm. This can happen post-vasectomy reversal if there is scarring. It can also happen with congenital bilateral absence of the vas deferens, which is often seen in cystic fibrosis carriers. We want to know if it is obstructive or no-obstructive. Concentration is a very important value. The lower it is, the harder it is to get pregnant. IVF is often recommended in this case. For mild levels, IUI may be an option but not for severe levels. If the total motile sperm is over 10 million, an IUI may be suggested.

Motility
Motility tests the movement of the sperm. The lowest end of normal motility is 40% and over 60% is more average. The probability of getting pregnant increases when the percentage of motile sperm increases. Poorly motile sperm can be seen for many reasons. A prolonged abstinence period, infection, environmental exposures, or an obstruction like a varicocele. Motility is often impacted by environment whether it’s the physical environment or the actual environment like infection exposures. Motility is developed as the sperm are matured.

Morphology
Morphology is the shape of sperm. Those of us in science love morphology because we are taught that structure equals function. If the structure of the sperm is off, the function is expected to be off as well. A sperm’s function is to swim through the reproductive system, fertilize an egg, and keep the DNA in tact. It keeps DNA in it’s head. Morphology is saying “If our structure is off, do we really think we function the way we are supposed to?” Sperm can look very different. They can have two heads, a pear shaped head, two tails, a small tail, and other abnormalities. All of these can impact how well the sperm can move and do their job. Something that can be confusing for patients is that different labs use different grading criteria to determine morphology. The best labs use Kruger Strict criteria, and you want to have at least 4% there. However, some labs use an old WHO mechanism. What may be low on that scale could be different than a lab using Kruger. We see decrease in pregnancy rate with men who have abnormally shaped sperm between 0 and 4%. 4% is the lowest end of normal and average is 15% even on the Kruger Strict morphology. Sometimes IUI is suggested in this scenario when based on the whole parameter. However, IVF is going to give you the highest success rates. Morphology is either just how the sperm is developed or environmental. So you will sometimes see recommendations for vitamins like Vitamin E, Vitamin C, Zinc, Selenium, L-Carnitine, and L-Arginine, and COQ10. We often see excess exposure to heat to testes area like prolonged outdoor cycling, motorcycle riding, frequent hot tub or sauna usage as some of the top reasons for low sperm parameters. Environmental exposures like smoking cigarettes, marijuana use, alcohol consumption, and high sugar in the diet can also impact sperm parameters. We cannot ignore the environmental factors that play a role in your sperm quality.

Round Cells can either be a high prevalence of immature cells or germ cells. They can also be white blood cells. You will frequently see recommendation for anti-inflammatory medication and anti-biotics if this is reported.

Male age also plays a role in male fertility. We usually see this begin to impact fertility when a man gets closer to age 45 or 50. Increased paternal age is associated with increased chromosomal abnormalities, increase in DNA fragmentation, birth defects, genetic mutations, and things like a higher presence of schizophrenia and autism. We also see that men start to go through a male menopause at some point where the body isn’t making as many androgens or testosterone.

What are the next steps?
If the semen analysis comes back abnormal, a few things need to be discussed and asked. What do these abnormalities mean? Are there lifestyle changes that can be made? Are there medications or supplements that can be taken? What are the treatment options for that particular factor? We have to remember that IVF is the gold standard for most male factor infertility. That is not the only treatment though. Even in some cases, IVF is not a choice, and donor sperm is the only option to get pregnant.

If your doctor is recommending the semen analysis, that means they are doing the right thing. It is important that the results are explained to you and next steps should be discussed.