Semen Analysis in the diagnosis of Male infertility

Doctors will often conduct two or three separate sperm analysis tests to get a good idea of your sperm’s health. Your doctor may order this test for [3]

• Evaluation of male fertility: when couples are having problems getting pregnant even after trying for at least 12 months
• Confirmation of sterility after vasectomy: To confirm the absence of sperm in the semen sample, and to know whether your vasectomy procedure is successful or not. A vasectomy is a surgical procedure for male sterilization to prevent pregnancy by blocking the release of sperm during sex.
• The success of ART: For the selection of good quality sperm for assisted reproductive technology (ART) procedures like invitro-fertilization, gamete intrafallopian transfer techniques.
• Selection of Donor: To select a healthy donor for the process of artificial insemination (IUI)
• Other medico-legal issues like proving paternity

For the semen test, you have to collect a fresh semen sample into a sterile container on the day of the test. You have to avoid sexual activity, including masturbation, for 2–5 days before the semen sample collection. It ensures your sperm count is highest on the day of sample collection, and your results are accurate. You can collect the semen sample by masturbation at your home or the clinic. You will be provided privacy in a separate room of the clinic to stimulate and come up with sample collection.[4] Talk to your doctor if you have questions or concerns about providing your semen sample. You need to provide two or more additional semen samples within a week or fifteen days. That's because sperm count and semen quality can vary on a day to day basis.

In preparation, the doctor will suggest you avoid ejaculation for at least 48 hours before the test, stay away from alcohol, smoking, and consuming any other illicit drugs for at least five days before giving a sample for a test. Also, inform your doctor about any other medicines that you are taking, as they may affect the test results. Doctors may ask you to stop taking hormonal medication, herbal supplements, Ayurvedic or homeopathic pills, and any steroids before giving a sample.[5]

Routine semen analysis results vary from lab to lab, and your doctor can interpret the cause of infertility by looking at the following parameters in-depth,

Sperm count: In general, the semen specimen contains about 20 million sperm per milliliter or more. A semen sample that has only 10 million per milliliter or less sperm is known as low sperm count semen. If you have low sperm count, you may get problems conceiving a child.

Semen volume: This is the measurement of your semen sample collected in a container in milliliters (ml). The normal volume of semen is 1.5 to 5 milliliters per ejaculation.

Sperm motility: It determines what percentage of the sperm in the sample are motile or moving. Sperm motility should be at least 40% in a given semen analysis. Low sperm motility is one factor that can lead to infertility in males.

Total motile sperm count: In a semen sample, there should be more than 20 million motile sperm.

Sperm morphology: The appearance, shape, and size of sperm; are studied under a microscope. More than 50% of sperm cells should have a smooth covering, oval head, a mid-piece connecting head to tail. The presence of abnormal sperms represents fertility issues.

Liquefaction time and viscosity: Viscosity describes how thick or thin your semen sample is. Usually, fluid present in semen has a low to moderate thickness. Semen should be thick after ejaculation, and then naturally, it will turn into water-like consistency within 15 to 20 minutes; this is known as liquefaction time. If your semen remains thick for a longer time, sperm will get stuck in a gel-like substance, and their movement will be affected, decreasing your fertility.

Appearance: Normal appearance of your semen is whitish-grey and opalescent. Hematospermia (presence of blood in sperms) makes semen look reddish-brown. Yellow-colored semen is during jaundice, or infection, or sexually transmitted disease. If you eat foods that contain food dyes, then your semen will have an unpleasant smell and be seen in yellow color.

The pH of semen: This will tell about the alkaline or acidic factor of the semen. The lower the pH, the more acidic your semen, and the higher the pH, the more alkaline is the semen. Normal pH is 7.2 to 7.8. If it is more than 8.0, it indicates you have an infection, and if less than 7.0, would tell there is a blockage in ejaculatory ducts or urine contamination.

Vitality: It is the percentage of live sperms in the given semen sample and also called as viability. It identifies live non-motile sperms from dead sperms when a larger number of your sperms are not moving during the motility test. Using a special stain that can enter only the sperm with damaged membranes or outer part, healthcare personnel will differentiate live sperms from the dead ones. If the stain enters sperms, they are said to be dead ones and vice versa. Viability of at least 50% or more is normal.

Fructose level: Normal fructose level should be more than 150 milligrams per deciliter of semen. This fructose level helps to determine the energy level that is available for the sperm that helps in its movement. If the fructose level is below the normal range, there may be problems with seminal vesicles.

Leukocytes (WBC): The presence of more than one million white blood cells (WBC) per milliliter of semen may be a warning sign of infection or inflammation. Usually, such conditions are easy to treat.

Sperm Agglutination: The amount of sperms (in %) that are stuck together in the given sample is called sperm agglutination. The healthy sperms swim freely, straight, and forward direction. Sperm are not supposed to stick together, as they will not be able to swim. The main reason for the clumping of sperm is the presence of sperm antibodies, which is seen in bacterial infections. About 4 out of 5 men are said to develop sperm antibodies after they have undergone a vasectomy surgery [6]

If there is any problem with the above parameters of if the test shows that the sample was not normal then you may be asked to repeat the testing process. When repeating the semen analysis test, it is advisable to wait for at least three months (approximate 12 weeks), because our body needs a minimum of three months' time to make a new cycle of sperm. When your doctor does not find the cause for your infertility from the above test parameters, he may order for further tests like blood work to check hormones, MRI of the pelvis, ultrasound for scrotum, testicular biopsy, and post-ejaculatory urinalysis to know if there is retrograde ejaculation. Sometimes, severe infertility may be due to sperm DNA damage which lowers the chances of making a healthy embryo and a live-born baby.

The table below is the estimated reference range of semen parameters [7]

Healthy sperm is essential to fertilize the female egg, which is the first step of pregnancy. Once fertilized, the egg will move towards the uterus and implant itself into the uterine lining. Good sperm volume and quality improves your chances of natural pregnancy. However, sometimes your semen test results may show abnormal test results, which may be a cause of concern. Semen analysis test is the first step to identify male factor infertility.[8] Abnormal test results usually show either low sperm count, poor motility, or unusual shape and size of sperm. The abnormal shape and size of sperm, known as sperm morphology, affect the sperm’s ability to fertilize the egg in women. A low sperm count is called oligospermia, and no sperm in a semen sample is called azoospermia. Men with oligospermia have fewer than 15 million sperm per milliliter of semen. While despite having low sperm count, it would be possible to impregnate the women, it might take longer. Whereas, if semen analysis is showing no sperm, natural pregnancy will not be possible, and the male will be diagnosed infertile. The absence of sperm in a semen sample is an important criterion for diagnosing male infertility.[9]

Other problems with sperm, like, low sperm motility, abnormal pH balance, and presence of white blood cells (WBC) in semen might also make it difficult for sperm to travel and penetrate a woman’s egg. Before confirming your test results and coming to a final diagnosis, the doctor may suggest one or more follow up tests. Even after checking two or three times if the results are the same, then your doctor will order other tests and recommend medications with a change in lifestyle. In the case of repeated abnormal test results, it is better to consult a fertility specialist who can better interpret your report and suggest you with the best available infertility treatment. Some of the common abnormalities of sperms are:

Depending on the type and cause of sperm defect, your fertility expert may suggest you fertility treatments such as,

Intrauterine insemination (IUI): IUI treatment is suitable for males suffering from low sperm count with normal sperm motility and sperm morphology.

In vitro fertilization (IVF): If a semen analysis reveals a very low concentration of normal sperm, then the doctor will recommend IVF for male infertility. It is because the chances of IVF success in this condition is much better than with timed intercourse or IUI.

Intracytoplasmic sperm injection (ICSI): ICSI is an option for you if you have nil or low sperm count or abnormal sperm morphology, where sperm cannot swim actively (such as previous vasectomy, problems with antibodies against sperm, and in testicular cancer). During ICSI, the doctor will inject a single sperm with the help of a tiny needle, into the cytoplasm of the female egg to promote fertilization. The fertilized egg (now called an embryo) is then grown in a laboratory for 1 to 5 days before getting transferred to the woman’s uterus (womb).

PESA or Percutaneous Epididymal sperm aspiration: Is suggested for you if you have no sperm count. Here, the doctor will insert a small needle into the head of the epididymis through the scrotum, and fluid is aspirated. From this collected fluid, sperm cells will be retrieved and prepared for fertilization.

TESA or Testicular sperm aspiration technique: Is used if your sperm count is less. Here, your sperms are retrieved by inserting a needle directly into the testes and by aspiring fluid and tissue with negative pressure. The tissue is then processed in a lab to extract sperm cells that will then be used to fertilize the egg.

Micro-TESE (Microsurgical Testicular Sperm Extraction): Micro-TESE (Microdissection Testicular sperm extraction) is a surgical method for sperm retrieval. It is advised in cases where sperm production is hindered, and the man is unable to produce sperm even after the testosterone hormone level is normal.

Semen Analysis can be used to diagnose the actual reason for male infertility. You can get information on your sperm count, sperm motility, the shape of your sperm, and many more.