Why is the semen analysis so important?
Together with the evaluation of the female’s ovarian reserve, confirmation of ovulatory status and normalcy of uterus and tubes (by hysterosalpingography), the assessment of the male by the semen analysis constitute the more critical tests to be performed by a couple trying to conceive. Keep in mind that:
- Male infertility is present in 30-50% of couples.
- It is truly unacceptable that females undergo diagnosis and treatment without a prior thorough examination of the semen.
- The semen analysis therefore must be performed as an initial test, in order not to delay proper diagnosis and undergo unnecessary and inefficient treatments.
- The male partner should receive a complete semen evaluation by a properly accredited and experienced laboratory. The routine evaluation consists of the so-called “basic semen analysis”. At the Sher Fertility Institute New York this analysis is performed microscopically by trained technicians, is also computer-aided as appropriate, and is supervised by a CAP and ABB Board-Certified Laboratory Director.
The analysis of the semen consists of the evaluation of (a) the characteristics of the semen, and (b) various sperm parameters.
Semen characteristics: these are important features as they can provide valuable clinical information, i.e., volume of the semen (normal > 1.4 mL, with a low volume suggesting presence of male tract obstruction or ejaculation problems), viscosity (if excessive pointing out to dysfunctions of accessory glands, particularly of prostate), agglutination (may be specific, indicative of presence of anti-sperm antibodies. or non-specific, due to excessive bacterial contamination of semen), changes in pH (suggestive of infections or obstructions), and presence of bacteria and other non-sperm cells (such of excessive immature forms indicative of spermatogenesis disorders) or leukocytes (indicating need for cultures to rule out infection).
Sperm parameters: the most critical parameters that can direct clinical management are sperm viability, concentration, motility, and morphology. The World Health Organization (2010) has recently established new reference values based on lower limits (95% confidence intervals or C.I.) compatible with successful natural pregnancy following recent large population studies.
Viability (% alive/total sperm) 58% (C.I.= 55-63)
Concentration (millions/ml) 15 x 106/mL (C.I.= 12-16)
Total motility (progressive + non-progressive, %) 40% (C.I.= 38-42)
Progressive motility (%) 32% (C.I= 31-34)
Morphology (% normal shape by strict criteria) 4% (C.I.I=3-4)
We rely on the following definitions for clinical management:
- Low count or oligozoospermia: <20 million sperm/mL
- Low motility or asthenozoospermia: <50% progressive motility
- Low morphology or teratozoospermia: <4% normal forms
Occasionally significant temporal variations in semen parameters may be observed. That is why we recommend a repeat analysis for semen samples with abnormal parameters to determine if the abnormality(ies) are persistent.
Abnormalities of sperm shape (morphology) are frequently observed. It should be noted that low or poor morphology is defined in the range of 0-4% normal forms. Based on a New England Journal of Medicine report (2001), the odds ratio for infertility for the patients with the single abnormality of sperm morphology can reach as high as 3.7 (over 3 times higher chance of infertility). Although some factors such as infections, high fever, usage of illicit drugs, excessive alcohol consumption, varicocele, exposure to environmental toxins and organic solvents as well as smoking have been reported as causative, no definite known etiology for poor sperm morphology has been found nor have specific remedies to improve the abnormality been established.
In the absence of medically (hormone deficiencies, infections) or surgically treatable conditions (varicocele, some obstructions) couples with one or more abnormal sperm deficiencies can be successful using intrauterine inseminations (IUIs). In our experience IUI therapy is significantly more efficient when the motile sperm per ejaculate (total motile count) is greater than 10 million sperm. IUIs should be limited to 3-4 cycles. If not successful, or if the male factor is more severe from the onset, or if there are associated female factors, then IVF augmented with intracytoplasmic sperm injection (ICSI) is the treatment of choice.
Cases of complete absence of sperm in the ejaculate (azoospermia, of obstructive or non-obstructive origin) can be successfully treated by a combination of testicular sperm aspiration or biopsy and ICSI.
Nowadays attention has also focused on the analysis of DNA fragmentation in sperm. Our laboratory can test for this abnormality with the Halotest. An increased rate of DNA fragmentation may be associated with poor sperm function, resulting in low fertilization or abnormal embryo development. Our laboratory uses PICSI to separate sperm with no DNA fragmentation at the time of ICSI, to try to enhance results.
At the Sher Fertility Institute, New York, we will help you achieve your goal of starting a family. For further information please Request An Appointment or call us at (646) 792-7476.
Recommended references to review
Guzick DS, Overstreet JW, Factor-Litvak P, Brazil CK, Nakajima ST, Coutifaris C, Carson SA, Cisneros P, Steinkampf MP, Hill JA, Xu D, Vogel DL; National Cooperative Reproductive Medicine Network. Sperm morphology, motility, and concentration in fertile and infertile men. N Engl J Med. 2001 Nov 8;345(19):1388-93.
Kruger TF, Acosta AA, Simmons KF, Swanson RJ, Matta JF, Oehninger S. Predictive value of abnormal sperm morphology in in vitro fertilization. Fertil Steril. 1988 Jan;49(1):112-7.
Morshedi M, Duran HE, Taylor S, Oehninger S. Efficacy and pregnancy outcome of two methods of semen preparation for intrauterine insemination: a prospective randomized study. Fertil Steril. 2003 Jun;79 Suppl 3:1625-32.
World Health Organization. WHO laboratory manual for the examination and processing of human semen (5th ed.). Geneva (2010)
Int J Androl. 2011 Oct;34(5 Pt 2):e319-29
Oehninger S. Sperm DNA fragmentation testing: ready for prime time? Transl Androl Urol. 2017 Sep;6(Suppl 4):S385-S388.