Swimming Toward Conception: The Semen Analysis

Nothing’s more basic to sexual reproduction from the male’s perspective than the sperm. Ya gotta have ‘em and they’ve got to be able to swim, penetrate the egg, and deliver their payload of genetic material. Figuring out what’s in your semen is the first step to understanding the male’s contribution to a couple’s reproductive efforts.

That insight is especially critical if you’ve been trying to have a baby for a year (six months if your partner is over 35) and nothing’s happened. As squeamish as it makes most men, this basic test may save you a lot of time, money, and emotional investment by helping both of you decipher whether or not you need an assist from reproductive medicine. And if you do, it may also point to the medical technology that’s most likely to give you what you want - a genetically linked child.

“There’s almost no such thing as male infertility. There are people with 5 sperm who have kids,” remarks Dr. Mark Licht of Boca Urology in Boca Raton, FL. “Pure Kleinfelter’s people (men with no sperm in their semen) are having their own kids. Technology has caught up with male infertility so that almost all of it is treatable or by-passable.”

And in the last few years, as social consciousness has caught up with the advances in reproductive medicine, men are finding far more understanding from their spouses, their peers and their doctors.

“Men are more than just the providers of sperm - they’re whole people and should be treated as patients, and people,” says Dr. Eric Seamen of Associates in Urology in West Orange, NJ and Surgeon in urology at St. Barnabas Medical Center in Livingston, NJ. The environments in which you live and work, and how you are feeling each day, can affect your semen and your sperm. “Often, there’s so much anxiety surrounding the test that it will affect your output and results.” We’ll give you enough information here so that you can take charge of the semen analysis and understand what the report is telling you.

Basically Speaking
First, here are some fundamental facts. Sperm take about two months to develop, and can be affected by what happens to you during their development, up until ejaculation. “I always ask for a second semen analysis, and often a third,” says Dr. Philip Werthman, Director of the Center for Male Reproductive Medicine in Century City, CA. “You never hang your hat on one or two. Even men with a semen analysis showing no sperm can turn out to have normal semen a month or two later.” A cold or a fever that knocked you out a few months ago may be the culprit in a poor sperm sample. The physical environment or anxiety can have a negative effect.

“We know there’s enormous variability. There was a study of one guy in his 20s and he provided two samples a week for two years. And his output varied. It’s not precise but, from that one kid we know there’s enormous variability, he’d drop from 45 million per ml to 15 within a week. And swing back up again,” said Dr. Sarah Girardi of Urology Associates in Manhasset, NY.

Second, don’t rush into assisted reproductive techniques without a full evaluation of the male. What if you were planning to use a poor sample for an IVF (in vitro fertilization) procedure? “Using that sperm to do IVF probably wouldn’t work because the sperm in that sample wouldn’t work,” says Dr. Werthman. “It’s better to take time, and not rush a couple into IVF.”

Often, there is a condition that can be treated by medication or surgery, and then some people can conceive on their own.

In preparation for the collection of your semen, you’ll have to refrain from ejaculating for 2 to 3 days prior to the test. Any shorter, and your volume of ejaculate may be low. Any longer, and the sperm’s swimming ability may be compromised. Follow all the instructions for collection down to the last detail. If you are at home, be careful as you collect the ejaculate making sure you use a sterile container to catch every last drop --volume is one of the critical indicators that will be measured. The analysis must be done within two hours of collection, so you may be asked to go to a lab to provide a sample, or even to provide the sample in the doctor’s office. The office will have a private, comfortable space, with accoutrements to help you get in the mood, if you need them.

Over the course of figuring out what’s up with you and your partner, you can expect to be asked to repeat the semen analysis two or three times. If you don’t provide a sample from home, you’re likely to find yourself in a commercial laboratory, especially if your insurance-as most insurance does --covers the test.

If you do go to a commercial lab, be prepared to shed your modesty. You’re often in a waiting room with lots of people waiting to have their blood drawn when “someone calls out,’ hey, who’s here for the semen analysis?’” observes Dr. Mark Licht at Boca Urologists in Florida. “It’s not very discreet and often, these labs don’t have an appropriate room for collection.”

Moreover, many commercial labs may not be as effective at performing the qualitative parts of analyzing the sample. They simply may not have the depth of experience to properly interpret your results. While they are usually dependable when it comes to volume and concentration, commercial labs generally don’t look at the more complicated assays, the subtler issues such as forward progression of the sperm.

Remember that semen samples are highly variable, both from person to person and from a single person over a period of time. So investigate the lab’s history of performing this type of analysis.

It’s worth going to a fertility clinic even if it’s an extra cost. You’ll have a more comfortable space called a masturbatorium (yes, it’s really called that) in which to provide the sample, and the results will be read by experienced technicians and the analysis will be considerably more reliable.

The lab report of the semen analysis will evaluate several different things, including volume and content of the ejaculate, sperm count, sperm motility (swimming ability), and the shape and structure of the sperm. Bear in mind that because of the great variability, average ranges are very wide. Large differences from the average will suggest further avenues for you and your doctors to explore.

Also be aware that there are two different classification systems for analyzing sperm. One, called “minimal adequacy,” consists of benchmarks below which pregnancy tends to become increasingly difficult. These values are based on statistical data specialists have compiled over the years. The other classification system - and the one used by most andrology labs-is World Health Organization For Semen Values because, explains Dr. William W. Lin of the Department of Urology, Feinberg School of Medicine at Northwestern University in Chicago, “The WHO values seem to correlate better with pregnancy.”

So familiarize yourself with the system used by the lab you have chosen and make sure the technicians are well trained and use it consistently.

The Outcome
There will be a lot of information doctors derive from the analysis. Here are some facts to help you understand the results:

Volume: Normal volume ranges from 1.5 to 5.0 milliliters (a milliliter is roughly equal to a teaspoon). The WHO threshold is 2 mL. Dr. Girardi says “Volume is often very low on the first semen analysis, and the low volume is often related to stress. Most of the time volume corrects on its own.” If it doesn’t, says urologist Eric Seaman, “Low volume may indicate obstruction of the ejaculatory ducts. Sometimes low volume is a sign of retrograde ejaculation (in which semen go back into the bladder, not out of the body).”

Semen Content: Some semen samples show round cells that may be either immature sperm or white blood cells. The contents may affect the alkalinity of the semen (normal pH is 7.2 to 7.8). Researchers are constantly learning more about the content and makeup of semen. Dr. Werthman, says, “We now know that free radicals (leftover byproducts of antibodies produced to fight infection) damage sperm once they’ve left the testicle. (With) treatment that helps scavenge free radicals, neutralize them, or stop the body from producing them, we can expect better sperm.” Any of these findings suggest more blood tests be performed to look for infections.

Sperm Count: The sperm count measures how many sperm appear in the sample. What is normal? This is the place where there is the widest variability. The “normal” count is approximately 70 to 80 million sperm/mL. But this is an average, and pregnancy rates decline only after the sperm density drops below 20 million sperm/mL. Moreover, remarks Dr. Lin, “Men with high quality sperm may be very fertile even with a very low sperm count.” (In fact, natural pregnancies have been documented with sperm concentrations as low as 1 million sperm/mL.)

However, says Dr. Seaman, “A lower sperm count is a sign that something may be happening in your body.” It gives the doctor a clue, but only something to follow up in an evaluation including a physical exam, ultrasound, and a history. Remember, a low sperm count is not definitive.”

Also, observes Dr. Lin, a sperm count below 10 million signals the urologist to look for genetic anomalies you may be carrying that you could pass along to your offspring, including karyotype abnormalities (anomalies on the chromosome itself) that might cause such conditions as Kleinfelter’s Syndrome and cystic fibrosis.

Genetic testing also checks for microdeletions on the Y chromosome. “If a male is missing certain areas of Y chromosome, conventional treatments such as ICSI (intracytoplasmic sperm injection) or IVF aren’t going to be successful so there’s no point in going forward,” according to Dr. Peter Schlegel, Chairman of Dept of Urology, Weill-Cornell Medical Center and Cornell Institute for Reproduction. “Once the problem is defined, it provides us with an opportunity for the future to design new treatments that can effectively replace or repair what is not functioning in these men.”

Sperm motility: Motility is the sperms’ ability to move. It suggests something about the sperms’ ability to swim, wiggle, or fight their way through the cervix, uterus, and fallopian tubes to an egg. The lab technician will observe what percentage of sperm demonstrate any motion. Motion by 50% of the sperm is considered normal. The lab technicians should also examine how the sperm move, that is, whether they are able to progress forward, at what speed, and in a straight line, more or less. This is a qualitative assessment. You should check to see that your lab does this analysis, and find out how much experience it has. Obviously, the greater the experience, the more reliable the readings tend to be.

The standard for normal quality of motion also varies. Generally, though, between 50 and 60% of the moving sperm should be making forward progress.

Any number of things can affect sperm motility. Dr. Seaman says, “agglutination - sperm sticking to sperm - would drive motility down. Two common reasons include presence of anti-sperm antibodies, or free radicals. Free radicals can be caused by infection or inflammation. Anti-sperm antibodies seem to be some kind of immune system response - they may be a latent response to testicular injury or infection,” according to Dr. Seaman.

In your physical exam, the doctor will want to do a complete physical with a detailed history, and will be looking for signs or symptoms of infection.

Sperm morphology (shape): Sperm should have smooth oval heads with straight tails. Shape is important because it can reflect development - misshapen sperm may reflect exposure to toxins or other chemicals affecting reproduction, or other issues. A normal count will show approximately 50% of the sperm have the usual shape using the WHO parameters.

The Future Is Coming
Naturally the more we know, the more complex -and possible—things become. With sperm, there’s a lot that is being done but each discovery opens up new avenues of understanding that gamete’s role. “In part, the sperm information has lagged because people have assumed that once sperm fertilized an egg it was done,” said Dr. Schlegel. “But ICSI and IVF allow us to get a better insight into what’s going on after fertilization, a process we were never able to directly observe before.”

It seems the sperm’s DNA is likely to play a greater part in achieving a successful pregnancy than previously thought. Using what are called DNA integrity tests, researchers are beginning to look in more detail at the genetic material that’s inside the sperm. Dr. Schlegel reports that there are several tests, each of which “refers to individual sperm or populations of sperm to determine whether they’re undergoing the process of dying, or if there are breaks in the DNA or how DNA is organized.” Some research suggests that even a very abnormal sperm can fertilize an egg but embryo growth and implantation may be significantly affected. That is of great importance for couples with Intracytoplasmic Sperm Injection (the preferred treatment for male factor infertility) IVF cycles.

“Recurrent miscarriages may be attributable to sperm DNA, even though those sperm look normal on semen analysis,” says Dr. Schlegel. “We are just learning how and if sperm contribute to embryo development.preliminary results are that abnormal DNA in sperm does affect embryo growth and implantation. Results aren’t as absolute as other groups have reported so far. But we’re working on it.”

In The Final Analysis
The semen analysis is the beginning of the story, not the end. Often, the semen analysis, together with the physical exam, blood analysis, and a history, will suggest a comparatively simple treatment for the male. And even if the issues are more complex, a constantly evolving array of fertility technologies is helping more men-even those who only a decade ago had no chance—to father their own genetic children.

For more information about fertility and infertility diagnosis and treatment, visit http://www.focusonfertility.org, http://www.theafa.org
or contact The AFA directly at 1-888-917-3777. This fact sheet is part of the Focus On Fertility campaign (http://www.focusonfertility.org)
and is sponsored by OrganonUSA (http://www.organonusa.com).