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Male Infertility

One of the reasons for not having a baby can be male infertility as well. Just as female infertility there are ways to deal with male infertility as well.

  1. Male Infertility : Preventing Male Infertility, Male Reproductive System
  2. The Man with a Low Sperm Count Oligospermia : Cause & Treatment
  3. Semen Analysis & Sperm Analysis

Male Infertility : Preventing Male Infertility, Male Reproductive System

Male Infertility is more common than is popularly believed. In fact, it is the cause of half of all infertility cases. The man's fertility can be easily tested by Semen Analysis, and there are many treatments including the advanced ICSI (Intracytoplasmic Sperm Injection) that can remedy the situation in most cases.


One of the most amusing books I have read on infertility is: A Few Good Eggs : Two Chicks Dish on Overcoming the Insanity of Infertility by Julie Vargo and Maureen Regan.

The book is targetted towards infertile women living in the US, and is written in the currently fashionable "chick-lit" style. It's amusingly written; and is a breath of fresh air , if you are the sort of person who finds a sense of humour helps you cope better with infertility.

The book has lots of Top-10 lists, and here's their list of Top Ten Misconceptions About Infertility.


Information on Male Infertility : Male Infertility Cure

Fatherhood has always been important in Indian society, but Male Infertility is surprisingly common . 1 in 6 couples is infertile , and in 50% of these, the problem is with Male Infertility . To put this in perspective, remember when you are watching the Indian cricket team playing the next time , that at least one of the men on the field is likely to have a Male infertility problem , whether they know it or not!

Most young men are obsessed with their virility, but few worry about their Male infertility. Most Indian men still believe that making babies is a woman's job, and expect that if they can have sex, they can also get their wives pregnant. However, this is simply not true ! While it is true that you need to be able to perform sexually in order to get your wife ( or girl friend) pregnant, this is not enough ! You also need to have enough active sperm in your semen to be able to fertilise her eggs, and there is no relationship between your sperm count and anything else - your sexuality, virility , your performance in the bed, or the size of your penis. What this effectively means is that you can never be sure of your fertility, Male Infertility - until you have actually got your wife pregnant !

Some men may suspect they have a Male infertility problem. Thus , men who have low levels of testosterone (poorly developed secondary sexual characters ; an effeminate appearance; scanty hair; decreased libido) may have a male infertility problem; as may men whose testes are small or absent. Men who have had testicular inflammation ( a swollen and painful swelling of the testis called orchitis) after an attack of mumps; and those whose testis have been injured are also at risk for infertility. Children who have had hernia surgery in childhood are also at risk; as are young men who have chemotherapy for treating leukemia and lymphoma. Men who have erectile dysfunction may also need male infertility treatment; as may those with diseases such as diabetes, which cause them to have problems with ejaculating semen properly.

Isn't there a test for measuring male fertility?

The basic test for Male Infertility is a semen analysis, which allows the doctor to measure the number of sperm ( sperm count) you have, how active they are ( motility) and whether they look normal ( morphology). However, while it is true that a man with no sperm ( a condition called azoospermia) cannot get his wife pregnant, many men ( and even many doctors ) still do not appreciate the limitations of the semen analysis. After all, the sperm count is not like a bank account, and the key question is not - What is the sperm count, or motility ? They key question is - are the sperm capable of working ? are they capable of fertilizing the egg ? And there really is still no test which can answer this reliably for the individual man. While it is true that men with a low sperm count have lower fertility, there are also men with an absolutely perfect sperm count who cannot get their wives pregnant, because their sperm do not work properly - in effect, they are shooting "blanks".

What if the sperm count is zero ? This is called azoospermia, and requires evaluation by a specialist, so that the doctor can determine if the problem is a result of the failure of the testes to produce sperm properly; or if the passageway is blocked or absent.

Men with a low sperm count present the most frustrating problem in reproductive medicine today. This condition is called oligoasthenospermia ( low sperm count with weak sperm) and in the vast majority of cases, we simply cannot determine what the reason for the low sperm count is. This is labeled as being idiopathic , which is just a Latin term to disguise our ignorance ( or as my patient poetically phrased it, means that the doctor is an idiot and the condition of the man is pathetic !) In many cases, we are now learning that the reason for the low sperm count is genetic, and is due to a microdeletion on the Y-chromosome. These men typically have a very low sperm count, because some of the genes on their Y-chromosome which code for sperm production are absent. Since we cannot determine the reason for the low sperm count in many men, it is hardly surprising that we have very little effective therapy to offer them. This is the reason why there are hundreds of medicines to treat men with low sperm counts - because none of them work ! We do know that a low sperm count is not related to physique, general state of health, diet, sexual appetite or frequency. While not knowing the cause can be very frustrating, medicine still has a lot to study and understand about male infertility, which is a relatively neglected field today.

The good news is that modern assisted reproductive technology can help practically every man to have a baby with his own sperm, using an advanced technique called ICSI( intracytoplasmic sperm injection), in which the doctor injects a single sperm into each egg to fertilise it. However, because this is so expensive, many men end up wasting a lot of time and money on ineffective treatment options in a futile attempt to improve their fertility.

The diagnosis of a low sperm count can be a major blow to a man's ego. It is so totally unexpected, because it is not associated with other symptoms or signs. Men react differently to Male Infertility - but common feelings include anger with the wife and the doctor; resentfulness about having to participate in infertility testing and treatment since they feel having babies is the woman's "job"; loss of self-esteem; and temporary sexual dysfunction such as loss of desire and poor erections. Many men with Male Infertility also feel very guilty that because of "their" medical problem, they are depriving their wife the pleasures of experiencing motherhood. Unfortunately, social support for the infertile man is practically non-existent, and he is forced to put up a brave front and show that he doesn't care. Since he is a man, he is not allowed to display his emotions. He is expected to provide a shoulder for his wife to cry on - but he needs to learn to cry alone. However, remember that the urge for fatherhood can be biologically as strong as the urge for motherhood - and we should stop treating infertile men as second class citizens.

Male Infertility - Male Reproductive System - Male Infertility guided tour

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Even though a man's reproductive system hangs out in the open, most men are so obsessed with their penis, that they know surprisingly little about their own reproductive organs. The male reproductive system begins in the scrotum, the sack behind the penis. This contains two testicles, which make men's sex cells, called sperm; and the male sex hormone, called testosterone. The testicles feel solid, but a little spongy, like hard boiled eggs without the shell. They hang from a cord called the spermatic cord. It's normal for one testicle to hang lower than the other; and for one testicle to feel slightly larger than the other. The testicles make sperm best at a temperature a few degrees cooler than normal body temperature. This is why nature designed a scrotum - so that the testes can hang outside the body to keep them cool.

The testicles start making sperm when a young man reaches puberty. This is in response to the male sex hormone, testosterone , which starts being produced at this time. The testes keep making sperm for the rest of the man's life. Most of the testis is composed of the tightly coiled microscopic seminiferous tubule, which if uncoiled would reach a length of 70 cm. The sperms are produced inside the seminiferous tubule, from where they are carried to the outside through the male reproductive passage, which consists of the epididymis , a finely coiled tubule, which leads to the vas deferens , - a thin cord like muscular tube, which is part of the spermatic cord and which ends at the ejaculatory duct in the prostate. Here is joined by the seminal vesicle ducts and they all open into the urethra . During ejaculation, the epididymis and vas deferens muscles contract to propel the sperm into the ejaculatory duct. Here the sperm is joined with the secretions of the seminal vesicles and prostate gland (which contribute the bulk of the seminal fluid) to form the semen. The powerful muscles surrounding the base of the urethra then cause the semen to squirt out of the penis at the time of orgasm.

Mature sperm take about 75 days to develop in a process called spermatogenesis which takes place in the seminiferous tubules. This can be a very "temperamental" assembly line - things often go wrong, causing low sperm counts. When the sperm leave the testis, they are not yet able to swim on their own. They acquire the capacity to do so in their passage through the epididymis - which is like a swimming school for the sperm.

During ejaculation, about one teaspoon of semen spurts out of the penis. Semen is a milky white color, the consistency of egg white. Sperm account for only about 2 to 3% of semen. Most of it consists of seminal fluid - the secretion of the seminal vesicles and the prostate gland, which provide a vehicle for the sperm into the vagina.

A normal ejaculation contains 200 to 500 million sperm. Sperms are the smallest living cells in the human body , while their female counterpart , the egg , is the largest. Basically, sperms are designed so that they can deliver their contents - the male genetic material - to the egg. This is why they are designed like projectiles - the male DNA is in the chromosomes in the sperm head nucleus, and the tail propels the sperm up towards the egg.

What happens to the sperms if you don't have sex for many days? Unfortunately, you cannot "store up" sperms. If ejaculation does not occur for many days, the sperms in the reproductive ducts simply die. But just like you cannot store your sperm, you cannot run out of sperm either - masturbation and sex cannot use sperm up. The body keeps making sperm as long as a man has even one normal testicle.

Male Infertility - Preventing Male Infertility

Often preventing Male infertility is much easier and better than treating it! What can you do to reduce the risk of being infertile ? The biggest preventable danger to male fertility is due to uncontrolled sexually transmitted diseases (STDs) such as syphilis, gonorrhea and chlamydia which can cause irreparable damage to the reproductive tract . Another important preventable cause of testicular damage in men is uncorrected undescended testes. Undescended testes should be surgically treated at an early age to prevent damage - preferably before the age of 2 years. This requires educating mothers of young boys; and doctors as well. It may also be a good idea to immunise boys against mumps in childhood, thus preventing the ravage which mumps can cause to the testes in later life.

Male Infertility - Drugs - including alcohol, cocaine and marijuana - are all poisons. They can reduce sex drive; damage sperm production; and interfere with ovulation - and sometimes this damage is irreparable. Smoking tobacco also affects reproductive function - by depleting egg production; increasing the risk of PID; and lowering sperm counts. Often, the adverse effect is temporary, so that when these are stopped, the harmful effects on reproductive function are likely to be reversed. However, since abstinence is easier than moderation, the best option is not to smoke, drink or use drugs!

Occupational hazards can also decrease sperm counts. Many toxic drugs - including radiation, radioactive materials, anesthetic gases, and industrial chemicals such as lead, the pesticide DBCP and the pharmaceutical solvent ethylene oxide can reduce fertility by imparing sperm production. Intense exposure to heat in the workplace (for example, long-distance truck drivers exposed to engine heat; and men working in furnaces or in bakeries) can cause long-term and even permanent impairment of sperm production. You should be aware of these hazards and may need to control your exposure if fertility is a concern.

Interestingly, many researchers have observed that sperm counts the world over are declining. Whether this is due to exposure to toxic chemicals such as dioxins ( formed as a result of environmental pollution) , which cause disruption of the endocrine system; or to the stresses of modern day life remains unclear.

Male Infertility - What can you do to improve your sperm count ? Stop smoking, drinking or abusing drugs. Most doctors will advise that you take vitamins ( such as Vitamin E, Vitamin C); and others prescribe antioxidants and selenium, though the effect of these on male fertility is still a contentious issue. Traditional advise included taking cold water showers and wearing loose underwear, to help keep the testicular temperature low and " sperm friendly ", but the results can be unpredictable. Certain drugs ( for example, salazopyrine which is used for treating ulcerative colitis) can suppress sperm counts, so if you are taking prescription medicines, ask your doctor about what their effect on sperm counts it. One simple way of increasing your chances of getting your wife pregnant is to have sex frequently - the more the sperm you deposit, the better your chances of hitting the jackpot !



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The Man with a Low Sperm Count Oligospermia : Cause & Treatment

The diagnosis and treatment of oligospermia or low sperm count is not straight forward. Most men are not keen on semen testing in the first place, and a diagnosis of low sperm count puts extra pressure on him. Since there is no guaranteed treatment to remedy this condition, it is preferable to try alternative solutions like such as IVF and ICSI.


Many infertile men are obsessed about their low sperm count - and this seems to become the central concern in their lives. Remember that the real question the man with a fertility problem is asking is not: What is my sperm count or what is my motility ? But - are my sperm capable of working or not? Can I have a baby with my sperm? Since the function of the sperm is to fertilize the egg, the only direct way of answering this question is by actually doing IVF for test fertilization. This is, of course, too expensive and impractical for most people which is why the other sperm function tests have been devised.

The major problem with all these tests, however, is that they are all indirect --- there is no very good correlation between test results, pregnancy rates, and fertilization in vitro for the individual patient. This is why offering a prognosis for the individual patient based on an abnormality in the sperm test result is so difficult, and why we find that different doctors give such widely varying interpretations based on the same sperm report. You can see what a normal sperm count looks like here !

This is really not surprising when you consider how abysmal our ignorance in this area is - after all, we do not even know what a "normal" sperm count is! Since you only need one "good" sperm to fertilise an egg, we do not have a simple answer to even this very basic question! While the lower limit of normal is considered to be 10 million progressively motile sperm per ml, remember that this is a statistical average. For example, most doctors have had the experience of a man with a very low sperm count (as little as 2-5 million per ml) fathering a pregnancy on his own, with no treatment. In fact, when sperm counts are done for men who are undergoing a vasectomy for family planning, these men of proven fertility have sperm counts varying anywhere from 2 million to 300 million per ml. This obviously means that there is a significant variation in "fertile" sperm counts, and therefore coming to conclusions is very difficult for the doctor (leave alone the patient!)

In order to make sense of this, you need to understand two important concepts - "trying time" and "fertility potential of the couple". If your sperm count is low, but you have been trying to have a baby for less than 1 year, it still makes sense to keep on trying for about 1 year, since 10% of men with low sperm counts will father a pregnancy in this time. If however, you have already tried for more than 2 years with no success, you need to move on and do something more - the chances of a spontaneous pregnancy are now very low. Remember, that a doctor does not treat just a "low sperm count report" - he treats patients!

So what does the man with a low sperm count do? Most men go to their doctor and expect that their doctor will prescribe a medicine which will help them to increase their sperm count, and fix their problem. After all, they expect that if medical technology has become so advanced, then there must be some treatment available to correct such a common problem !

The problem with the medical treatment of a low sperm count is that for most people it simply doesn't work. After all, if the reason for a low sperm count is a microdeletion on the Y-chromosome, then how can medication help ? The very fact that there are so many ways of "treating" a low sperm count itself suggests that there is no effective method available. This is the sad state of affairs today and much needs to be learnt about the causes of poor production of sperm before we can find effective methods of treating it.

However, patients want treatment, so there is pressure on the doctor to prescribe, even if he knows the therapy may not be helpful . When most patients go to a doctor, they expect that the doctor will prescribe a medicine and treat their problem. Since most people still believe there is a "pill for every ill", they expect that the doctor will give them a medicine ( or an injection) which will increase their sperm count. No patient ever wants to hear the truth that there is really no effective treatment available today for increasing the sperm count.

Since most doctors know this, they are pressurised into prescribing medicines for these patients, because they do not want the patient to be unhappy with them. They are worried that if they do not fulfill the patient's expectation of a prescription, the patient will desert them, and go elsewhere, which is why they often do not tell the patient the complete truth. The doctor also remembers the occasional anecdotal successes (who come back for followup , while the others desert the doctor and are lost to followup) is why patients with low sperm counts are put on every treatment imaginable - with little rational basis - clomiphene, HMG and HCG injections ( using the rationale that what's good for the goose must be good for the gander !) proxeed, testosterone,Vitamin E, Vitamin C, anti-oxidants, high-protein diets, hoemeopathic pills , ayurvedic churans and even varicocele surgery. However, the very fact that there are hundreds of medicines itself proves that there is no medicine which works ! ( After all, if one medicine worked, then all doctors would prescribe this, so there would be no need for so many different medicines !)

Many doctors justify their prescriptions by saying - " Anyway it can't hurt - and in any case, what else can we do? " However, this attitude can be positively harmful. It wastes time, during which the wife gets older, and her fertility potential decreases. Patients are unhappy when there is no improvement in the sperm count and lose confidence in doctors. It also stops the patient from exploring effective modes of alternative therapy - such as IVF and ICSI . Today empiric therapy should be criticised unless it is used as a short term therapeutic trial with a defined end-point.

A word of warning. Medical treatment for male infertility does not have a high success rate and has unpleasant side effects, so don't take it unless your doctor explains his rationale. The treatment is best considered "experimental" and can be tried as a therapeutic trial. Make sure, however, that semen is examined for improvement after three months and then decide whether you want to press on regardless.

What about surgery to treat a varicocele ? Remember that many men with large varicoceles have excellent sperm counts , which is why correlating cause (varicocele) and effect (low sperm count) is so difficult. It is possible that the varicocele may be an unrelated finding in infertile men - a "red herring" so to speak. This means that surgical correction of the varicocele may be of no use in improving the sperm count - after all, if the varicocele is not the cause of the problem, then how will treating it help? In fact, controlled trials comparing varicocele surgery with no therapy in men who have varicoceles and a low sperm count have shown that the pregnancy rate is the same - so that it does not seem to make a difference whether or not the varicocele is treated !

Because surgery for varicocele repair is simple and straightforward , many doctors still repair any varicoceles they find in infertile men, following the dictum that it's better to do something, rather than do nothing ! However, keep in mind that varicocele surgery will result in an improvement in sperm count and motility in only about 30% of patients - and it is still not possible for the doctor to predict which patient will be helped. Of course, just improving the sperm count is not enough - and pregnancy rates after varicocele repair alone are in the range of 15%. However, one danger of doing a varicocele repair is that when it doesn't help, patients get frustrated, and refuse to pursue more effective options, such as the assisted reproductive techniques.

The sad fact of the matter is that there is no method of increasing a low sperm count today! This is why modern management of a low sperm count uses assisted reproductive technology extensively. The modern protocol for managing male infertility is based on the man's motile sperm count; and on a simple test, called a sperm survival test. The sperm are washed, and their recovery assessed; the washed sperm are then kept in culture medium in the incubator for 24 hours and then rechecked. If there are more than 3 million motile sperm per ml, this is reassuring. If, however, none of the sperm is alive after 24 hours, this suggests that they may be functionally incompetent. Treatment depends upon how low the count is. If it is only moderately decreased (total motile sperm count in the ejaculate being 20 million), it makes sense to try to improve the fertility potential of the wife, and the easiest treatment for men with moderately low sperm counts is superovulation plus intrauterine insemination. If after doing this and trying for 4 treatment cycles (the reason 4 is the "magic" number is that most patients who are going to become pregnant with any method will usually do so within 4 cycles) no pregnancy ensues, you need to go on and explore further alternatives, such as IVF or ICSI.

Unfortunately, we find that many doctors still offer IUI ( intrauterine insemination) treatment for men with oligospermia. The hope seems to be that washing the sperm will help the doctor to recover the "best sperm"; and since only one sperm is needed to fertilise the egg, then IUI will improve the chances of achieving a pregnancy. Unfortunately, IUI is a terrible treatment for oligospermia, with a very low pregnancy rate. The problem is that oligospermic men have sperm which are functionally incompetent, which is why washing the sperm and doing IUI does not help.

So what is the right treatment ? For men with a motile sperm count of more than 5 million in the ejaculate, logically IVF would be the first treatment offered. This would allow us to document if the sperm can fertilize the eggs or not. If fertilisation is documented, then the patient has a good chance of getting pregnant. However, if the motile sperm count is less than 5 million, or if there is total failure of fertilisation in IVF, then the only treatment available is ICSI(intracytoplasmic sperm injection, pronounced "eeksee") or microinjection. ICSI has revolutionised our approach to the infertile man, and it promises the possibility for every man to have a baby, no matter how low his sperm count.

We personally prefer offering ICSI treatment directly to all men with oligospermia, to bypass the risk of total fertilisation failure with IVF. This allows us to guarantee that we will be able to make embryos in the lab, no matter how poor the sperm.

What about the answer to the million dollar question: --- Why do I have a low sperm count? Unfortunately, nine times out of ten, the doctor will not be able to answer that question, and no amount of testing will help us to find out - this is labelled as "idiopathic oligospermia" which is really a wastepaper basket diagnosis for "god only knows!". Modern research has shown that the reason some men have a low sperm count maybe because of a microdeletion on the Y-chromosome. This is an expensive test, which is available only in research laboratories at present, and does explain why we have little effective treatment for this common problem! We do know that a low sperm count is not related to physique, general state of health, diet, sexual appetite or frequency. While not knowing the cause can be very frustrating, medicine still has a lot to study and understand about male infertility, which is a relatively neglected field today.

The major cause of male infertility usually is a sperm problem. However, do remember that this is no reflection on your libido or sexual prowess. Sometimes men with testicular failure find this difficult to understand (but doctor, I have sex twice a day! How can my sperm count be zero?). The reason for this is that the testis has two compartments. One compartment, the seminiferous tubules, produces sperms. The other compartment, the "interstitium" or the tissue in between the tubules (where the Leydig cells are) produces the male sex hormone, testosterone, which causes the male sexual drive. Now while the tubules can be easily damaged, the Leydig cells are much more resistant to damage, and will continue functioning normally in most patients with testicular failure.

This is why the diagnosis of a low sperm count can be such a blow to one's ego --- it is so totally unexpected, because it is not associated with other symptoms or signs. Men react differently - but common feelings include anger with the wife and the doctor; resentfulness about having to participate in infertility testing and treatment since they feel having babies is the woman's "job"; loss of self-esteem; and temporary sexual dysfunction such as loss of desire and poor erections. Many men also feel very guilty that because of "their" medical problem, they are depriving their wife the pleasures of experiencing motherhood. Unfortunately, social support for the infertile man is practically non-existent, and he is forced to put up a brave front and show that he doesn't care. Since he is a man, he is not allowed to display his emotions. He is expected to provide a shoulder for his wife to cry on - but he needs to learn to cry alone. However, remember that the urge for fatherhood can be biologically as strong as the urge for motherhood - and we should stop treating infertile men as second class citizens.



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Semen Analysis & Sperm Analysis

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Though Semen Analysis is inexpensive, it is the most important test for assessing male fertility and requires highly skilled technicians. We recommend you use a reliable Andrology laboratory rather than the neighborhood lab.


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 neighbourhood 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 specialises 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.

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 centres 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 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 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.

The viscosity. 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.

The pH. 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.

The 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.

Microscopic examination The most important test is the visual examination of the sample under the microscope. What do sperm look like ? Sperm are microscopic creatures which 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 which lashes back and forth to propel the sperm along. The mid-piece of the sperm contains mitochondria, (the power house 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.

Sperm count ( concentration) . 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. Less than 10 million 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.

Sperm motility ( 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 fertilise 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 fertilise the egg.

Sperm shape ( 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; pin heads; very large heads; double heads; absent tails) this may mean the sperm are abnormal and will not be able to fertilise the egg. Many labs use Kruger "strict " criteria ( developed in South Africa ) for judging sperm normality. Only sperm which are "perfect" are considered to be normal. A normal sample should have at least 15% normal forms (which means that even upto 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 upto 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 times, the lab technician sees many round cells under the microscope. He mis-reports them as pus cells and the doctor may then jump to the wrong conclusion you have an infection, which he then treats with antibiotics. However, often these round cells are sperm precusor cells ( spermatids and spermatogonia) which are quite normal !The lab needs to do special stains to differentiate between the two possibilities ( but most labs do not have the expertise to do so)

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 standardised, and vary from lab to lab.

A Sperm Analysis 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 fertilising the egg. The only foolproof way of proving whether the sperm work is by doing IVF (in vitro fertilization) !

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".

A 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 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 psychologic problem ( because the man cannot achieve an orgasm inspite 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 a 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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