The most
important test for assessing male fertility is semen analysis. It needs to be
done by experts and ananlysed 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 are sperm ? And how
does your doctor check whether your sperm are 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 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.
View a sample
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.
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.
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.
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.
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. 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 millipn 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.
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 orAgglutination:
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 labs will mis-report round cells seen in the semen
as being pus cells and doctors will then try to treat this
"infection" with antibiotics !
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 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
fertilising 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".
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.
Related
Searches: Semen Analysis Infertility, SEMEN ANALYSIS REPORT, Infertility Sperm Viscosity, Sperm Ananlysis Fructose, Sperm Count,
Azoospermia Infertility, Sperm Motility,
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.
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
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