The work up for the evaluation of male infertility and the diagnosis male infertility includes clinical examination and investigations. The latter include semen analysis and other semen tests, urine and prostatic expressate tests, blood sample for genetic tests and measuring hormone levels, imaging, among others.
Evaluation of male infertility by Clinical Examination:
Clinical examination is necessary for the diagnosis of male infertility and its cause, to check for the structure and function of the male genitalia. Examination can help conclude the cause of infertility in many cases, such as cases with varicocele, congenital absence of the vas, undescent of the testis. However accurate the examination is, investigations are still necessary to confirm the cause of infertility.
Evaluation of male infertility by Laboratory Tests:
Before providing the Semen Analysis sample, one must have waited 3-5 days without ejaculation. If one ejaculates (at sexual intercourse, masturbation or wet dreams), one must wait again for another 3-5 days before Semen Analysis.
The sample must be provided by masturbation, AND NOT sexual intercourse, to avoid mixing the sample with the lady’s secretions, possibly altering the results.
Ejaculating the Semen Analysis sample straight into the special container, without touching the container from inside, or using any foreign material such as gel, soap or water upon masturbation. The container must be immediately closed and transferred to the laboratory within 30 minutes at most, without exposing it to heat, vibration or direct sun light.
All the ejaculate must reach the container (no spills).
Conventional Semen Analysis:
Interpretation: How to read a semen report:
Sperm concentration vs Sperm count:
Sperm concentration in a normal Semen Analysis should be 20-50 million sperm per cubic millimeter (ml) of ejaculate.
This is totally different from “total sperm count” which is the sperm concentration per ml, multiplied by the number of millimeters (volume) of the seminal fluid. The volume of fluid has no relation to the function of the testis. It is related to sexual desire and mental relaxation. The more one is relaxed and willing to have sex, the higher the volume is.
Therefore, specialists evaluate fertility potential by checking sperm concentration in a Semen Analysis rather than the total count.
It must be noted that normally, sperm concentration fluctuates within narrow limits, day to day. Only severe permanent drops are considered abnormal. Temporary mild drops are not.
Sperm has a tail that moves side to side to push the sperm forwards. The motility (motion) is necessary for sperm to reach the ovum, noting that sperm travel a long distance from the vagina to the fallopian tube to reach her. A special type of very fast motility (forward progressive) is necessary for the sperm to the ovum.
After one hour of ejaculation, examining the percentage of motile sperm under the microscope should reveal at least 60% of sperm being motile, and at least 25% showing “forward progressive motility”.
For proper judgment of motility, the sample should be ejaculated after 3-5 days of abstinence (no ejaculation) no more and no less, since further delay decreases motility. In addition, the sample should not be contaminated with foreign materials such as gel, soap or water.
Normal semen contains a certain percentage of abnormal forms. Upto 40% is acceptable. Abnormal forms higher than 40% of sperm may result in infertility. Normal sperm form is described in here. Abnormal forms include round head, small head, double tail..etc.
This is when sperm tails are entangled with each other. This may hinder their motility.
Semen Pus cells / White blood cells:
These cells belong to the immune system and are normally present within a certain concentration to guard the testis. Normal values are less than one million cells per cc, or 305 per high power field (HPF).
When pus cells increase in concentration, this is a sign that the testis or its accessory glands are infected with a microbe.
This is the amount of fluid in which sperm are present. The fluid id not secreted by the testis, but rather secreted by a gland called “seminal vesicle”. Normal volume is 2-5 cc.
Semen volume decreases in case of high obstruction of the seminal tract (ejaculatory duct obstruction), in congenital absence of the vas deferens, in atrophy of the seminal vesicles or in cases of retrograde ejaculation.
However, the reason for decreased semen volume may be much more trivial , such as spilling of part of the ejaculate outside the collection cup, or unfavorable psychological conditions, since semen volume is related to the power of ejaculation, which in turn is related to the emotional and psychological status. So, if a man is trying to ejaculate in a laboratory and is uncomfortable with that, his semen volume will be low, despite being normal when upon normal sexual intercourse.
Semen Viscosity and Liquefaction Time:
Semen is ejaculated in a coagulated and thick. It should liquefy totally within 30 minutes following ejaculation. Upon liquefaction, its viscosity should be light. If liquefaction time or viscosity increase, this may lead to infertility. This may occur in diseases of the prostate or seminal vesicles.
On the contrary, absent ejaculation may be a sign of ejaculatory duct obstruction
Normally, semen is greyish white. It may turn yellow in infections or jaundice, red in cases of haemospermia (blood in semen).
Semen Culture and Sensitivity
When infection occurs, antibiotics are necessary to cure it. However, in many instances, bacteria can escape the effect of some antibiotics but remain sensitive to others. Culture and sensitivity is when an infected sample (semen, prostate, urine..etc) are examined in the laboratory for the effect of various antibiotics on the bacteria within, to determine which antibiotic is more effective in treating the infection.
Computer Assisted Semen Analysis (CASA)
When semen is examined under the microscope, the results are vulnerable to human errors. This is where computer assisted analysis comes handy. CASA spots the sperm by comparing the cells in the sample to preset video images. CASA is very accurate in determining motility and morphology, more than it is at determining sperm concentration.
Sperm Swim up
This test examines the actual number of highly motile sperm by getting rid of the semen fluid, microbes and pus cells that may be a cause of weak motility, and placing the sperm concentrate underneath a motility compatible medium. The set is incubated in suitable conditions for one hour, after which the medium is examined for the number of sperm that has left the concentrate and invaded the medium. The number is proportional to the forward progressive motility. Swim up determines if the sample is suitable for normal conception, IUI or if IVF is necessary.
Sperm Function Tests
Sperm count, motility and morphology can be deducted from semen analysis. However, its actual capability for penetrating the ovum, the consistency of its content of genetic material and acrosomal enzymes can only be examined by sperm function tests such as “Hamster penetration assay” and “Acrosin test”. In addition , if sperm are absolutely immotile (do not move), they are either dead or live static. Differentiation between the the states is via sperm function tests such as “hyper osmotic swelling test” or “eosin test”
Antisperm Antibody Test
Antisperm antibodies are normally absent. If present, they can decrease or prevent sperm movement, They can examined in semen, cervical mucous of the female and in blood samples in both partners. The latter is of no clinical significance. Examination is preferably by the indirect MAR test.
Sperm Freezing “Cryopreservation”
Whenever sperm concentration drops the great extent, it is advisable to store sperm by freezing just in case concentration drops to zero. Sperm preserved by cryopreservation can be used for IVF / ICSI within 3 years following storage.
For sperm to be stored, it is purified by getting rid of seminal fluid, microbes and pus cells. A nutrient and special preservative is added. The sample is mixed and inserted in a special tube on which the name and code of the owner is printed. The tube is preserved in 179°C, achieved by immersion in liquid nitrogen.
Semen Markers of Obstruction
These are special chemicals secreted by the epididymis (alpha glucosidase) and seminal vesicles (fructose). Their absence in semen can denote obstruction of the vas deferens and help deduct its site.
Genetic tests are necessary in the following conditions:
1-Suspicion of a genetic cause of infertility:
Abnormalities in chromosomes may lead to infertility. An example is “Klinefilter” (KF) syndrome, where an extra “X” chromosome leads to complete arrest of spermatogenesis (sperm formation) and the testis becomes small and firm. Another condition is cases of congenital absent vas deferens.
The value of genetic analysis in these cases is determination of the most suitable way of treatment (KF requires ICSI from testicular sperm if any), as well as prevention of transmission of the same defect to the upcoming children (congenital absence of the vas).
Genetic tests include karyotyping and PCR, analysis of AZF micro-deletions and CFTR mutations.
Is secreted by the pituitary gland (in the brain)to stimulate the testis to produce sperm. Its level is regulated by the activity of the testis. If activity is weak, FSH level rises to activte the testis further. If activity is fine, the level becomes within normal. If FSH is too low, this indicated failure of the pituitary gland.
Increased prolactin levels leads to decreased activity of the testis, infertility and erectile dysfunction (impotence). Prolactin level changes through the day. The sample must be taken in the morning considering the biological clock of the human body. Prolactin level must be elevated at least double fold on repeated samples for the elevation to considered of value. Extreme elevation in prolactin level may be related to benign brain tumors and an x-ray or CT of the skull are then necessary.
Is the hormone responsible for mmasculinity. It is secreted by the testis under influence of “LH”, a hormone produced by the pituitary gland present in the brain. Decreased testosterone level may lead to infertility and impotence. This decrease may be due to failure of the testis (in which case LH level is high) or failure of the pituitary (LH level is low).
Testosterone must be measured in the morning (9-11AM) as it is highest in the morning. Two forms of testosterone should be measured: Free and Total.
Estradiol is related to femininity, but is nevertheless present in every man’s blood. If its level rises above the normal values, it can result in infertility and impotence. Some testicular tumors may result in a rise in estradiol level. It is therefore important to check for the source of this rise, particularly by tumor markers and ultrasound.
Urine and Prostate Examination
Examination of urine and prostatic expressate are important in cases of infection. The prostatic secretions contribute approximately 20% of semen volume. Their analysis determines the degree of infection by counting pus cells, and culture sensitivity can be performed to determine the best antibiotic for treating the infection.
Prostatic expressate is obtained by massaging the prostate by a finger in the anus. Though it sounds painful and embarrassing, it is not so if performed gently, slowly and with experienced hands. It should be restricted for indicated cases. Repeated massaging of the prostate is of no clinical value and should not be performed.
Evaluation of male infertility by Imaging
o Scrotal Duplex
Is important for diagnosing varicocele, hydrocele, accurately determining testicular size and checking the testis for tumors. Duplex ultrasound for varicocele is much more accurate than clinical examination by the hand. To diagnose varicocele, the diameter of the scrotal veins should be more than 1.7mm, and preferably be associated with “reflux on Valsalva”, which is reversal of the direction of blood flow in the vein upon straining.
o Trans Rectal Ultrasound (TRUS)
Is necessary for diagnosing ejaculatory duct obstruction , congenital absence of the vas deferens, tumors of the prostate and senile prostatic enlargement. It is performed by inserting a detector (probe) into the anus by using a lubricant that decreases discomfort to a great extent.
Is necessary for determining the presence and position of the testis in case of undescent of the testis. It is also useful for checking the renal system (Kidney, ureter and bladder) for stones in case of infection, and abnormalities in cases of congenital absence of the vas deferens. It has to be noted that in cases of undescended testis, the most accurate diagnosis is by laparoscopy (abdominal endoscopy).
-Roentgenogram (X ray)
§ Skull Xray
Is useful for diagnosis of brain tumors in cases of increased prolactin level and decreased FSH/LH/Testosterone which contribute to sperm concentration.
§ Renal System (Kidney, ureters and bladder):
A dye is used to check these organs for stones and abnormalities.
Is xray of the vas deferens with injection of a dye to determine the site of obstruction. It should not be done except during surgery for correction of obstruction, since office vasography carries a risk of occluding the vas at the site of needle entry ( a needle is used to inject the dye)
In cases of severe decrease of sperm or total absence of sperm in semen ( azoospermia ), a biopsy is necessary to check whether the decrease/absence is due to low activity of the testis, or due to obstruction of the vas deferens in the presence of normal activity of the testis.
Testicular biopsy is extraction of a tiny bit i the testicular tissue and its examination. This tiny bit is extracted through a 3-5mm long incision, under local anesthesia. The incision is closed by one or two sutures that dissolve spontaneously after a while. The procedure takes around ten minutes and the patient is discharged from hospital after 1 or 2 hours.