Male Factor Infertility – The Sperm Test
Hi, everyone. Sorry for the delay in the videos. We’ve been getting quite busy back at Cape Fertility. So, I’ve managed to take this moment out just to start shooting some more videos. Today, I thought perhaps we should be looking at male infertility and some of the options that are available for the male partner. Most of our videos have been concentrating on the females. So, it is to give the men a bit of love with these videos. Let’s start off with addressing how big of a problem male infertility is.
So, when we look at the reasons that couples come to see us between 30 and 40% of the time, there will be a male factor involved, whether it’s only the male factor or male factor, as well as a female factor that can vary. And most of the time we say 40% male, 40% female, and 20% combination or a reason we can’t really identify. The bottom line is. Just remember that when you present us a couple of full fertility treatment, you’re coming as a couple. So, it doesn’t help to say it’s a male or female problem, but rather a couples problem to overcome together and rather not assign blame.
Whenever we talk about male factor infertility, the first thing that comes to mind is always the sperm sample and what those parameters in that test tell us. That’s how we often decide which treatment options are a good idea and where we need to investigate further. But it is important to remember that there are other factors that can contribute to male fertility, not only the sperm test. One factor that men are often quite embarrassed to bring up in a consultation is difficulty with sexual performance. Remember the sperm does need to get where it needs to be and in order for that to happen you need ejaculation.
So, if your partner is struggling with erectile dysfunction, which has difficulty in either obtaining or maintaining an erection or ejaculatory dysfunction, there are medications and different therapies that can help for this. There might be some very obvious reasons for male factor infertility, such as vasectomies. So, if your partner’s had a male sterilization previously, and we do have options to get around this. Something else to bear in mind is this is also speaking to the men who have spinal cord injuries. And we do have many patients with spinal cord injuries, unable to produce a sample, we can also assist with this.
So, what are some of the things that we want to know about when we taking a medical history from the male partner? We obviously want to know about any medical conditions, any medication that your partner may be taking that could be affecting his ability to either have an erection, ejaculate, or affect the sperm quality. We wants to know about any previous surgery, especially in the groin area. We want to know about any previous injuries, such as a torsion, which can happen with contact sports, when someone is kicked in the groin. The testicle itself might actually twist and cut of blood supply.
So, if your partner has a history of this, and it’s not just a simple kick in the groin, where he may have had to go and see a doctor or even had surgery to untwist the testicle. This can cause some damage, and this can be an underlying problem. Another thing that we always think about is a previous mumps infection in men, as well as any STDs. We also need to think about lifestyle factors; we know that being overweight smoking, drinking excessively, not living a healthy lifestyle can affect your sperm parameters. While this might not add up to the difference between fertile and infertile, it can make a massive difference in the quality of the sperm.
Another thing men are never too comfortable to admit in a consultation is the use of steroids or testosterone. So, if your partner has been using any of these or has previously used these, it’s important to talk to him about telling us about these. It’s important because that extra, what we call exogenous testosterone, so that testosterone that he’s injecting, it’s actually giving a signal to not make his own testosterone. And this is going to affect your sperm production. This is very important because he needs to stop using any steroids and it’s not going to be an immediate recovery. It does take a little while, but it’s important that we know, so we can try and expedite this.
So, before we jump into the sperm test, it’s important to understand that sperm isn’t produced today and ejaculated today. This is a process that takes on average roundabout three months we usually say, but it’s usually closer to about 80 days. So, whatever happened to three months ago is what’s going to be affecting his sperm quality now. So, if he makes a lifestyle change now that’s excellent and we do support that, but you’re not going to see an instant improvement. Sometimes men will say, I don’t understand I’ve made such good lifestyle changes and I’m looking after myself, but remember, this does take a little while. So, whatever happened a few months ago can affect what’s happening now. For example, in the time of COVID-19, if your partner has been ill and has been affected by it and has had a very high temperature that extra temperature can affect the sperm production. And that can be something that lingers for the next two to three months.
So, let’s get into the nitty gritty with a sperm sample; how do you get a spam sample? Obviously, masturbation, some men are not comfortable with this, as a partner you’re welcome to assist him. But the important things is we don’t want any disinfectants, any soaps, or any lubricants. When the sample is being created, you can’t use a normal condom at home and bring in the sample. Unfortunately, the condoms have spermicide in it, but we do have laboratory grade condoms that do not have spermicide that we’re able to provide so that you can produce a sample via intercourse, if he’s not comfortable with masturbation.
So, some important facts about producing the sperm sample, what we need is two to five days of abstinence: so, no masturbation and no intercourse. He’s welcome to produce the sample in the clinic, we do have two rooms that are available to be used. Or he can produce the sample at home. We will provide a container if you prefer to produce the sample at home. The time duration between production of sample and arriving at the clinic should be ideally less than one hour. Remember it’s important to not use any soaps, any spermicides, any lubricants, any disinfectants as this can kill the sperm and give us an inaccurate reading. When you are trying to transport the sperm sample from home to the clinic, keep it body temperature. So, tuck it into the pants and keep it nice and warm. Please do not put it in a freezer or a cooler bag as this will kill the sperm.
So, what are some of the factors we look at when we’re looking at the semen analysis report that our lab will then generate? Well, the first thing we look at is always just to make sure that everything has been adhered to, so at the time of abstinence, the time before it got to the clinic. We always do a triple check to make sure that the details match, that we are providing you with the correct information and not somebody else’s results. You will know that when you get to the clinic, you will have to check all of your information with the lab before you hand over the sample.
Just a brief note on male anatomy, just so we know what’s happening in the testicle, that’s the point where you’re making the actual sperm. The sperm is then stored in the epididymis, which is like a holding area. The sperm there needs to travel up through a long pipe, which has caught the vas deferens and this is the thing that is obstructed when we do have a vasectomy. Once it travels through the vas deferens, it will then meet closer to the bladder with our bunch of glands that will create some fluid and that’s how the sperm is transported. The fluid is very important for protecting the sperm inside of the vaginal environment and providing it with some nutrition.
So, the first thing that we look at with the sperm sample is what is the volume? Normal volume is at least 1.5 mils, if the volume is much lower than this, then we will always be concerned that there’s an obstruction at some point from the sperm creation all the way to ejaculation, so this is very important first step to look at. We then consider the concentration of the sprint. So, one way that we look at this. Is to look at how much sperm there is per mill of sample. So, for example, if the sample is three mills, we will then look at one ml of that sample and figure out how many sperm are in that sample. Now the testes are going to be making millions of sperm, and what we would usually take as normal is 15 million sperm. This is a good point where we should go through how the sperm test parameter is actually made and so you can understand this is a fluctuating situation.
So very briefly, how did we decide what is normal and what should constitute concern? These studies have been done and they’ve been updated as we go along with new guidelines and the criteria is actually gotten more and more strict as we go along. But essentially what happened was we took a huge sample of men and we looked at those men whose partners fell pregnant within one year of trying to conceive. We looked at their sperm samples and we were able then to see what is compatible with fertility and what should cause concern. So, this is not a diagnosis of fertile or infertile, this is saying the sperm sample is compatible with fertility, so we would expect a pregnancy. So, if your values do not fall completely with a normal, this doesn’t mean that you are in fertile, this does not mean that your partner will never fall pregnant.
So back to the sperm sample interpretation, now we’ve discussed what we expect of one mil, 50 million sperm per mil, but we will also look at how much sperm is in the entire sample. And for this be considered 14 million sperm, a normal amounts of sperm, why the difference? Well the difference comes in if you only produce one mil of sperm or whether you are producing three or four mils of sperm, obviously the amount of sperm in the sample will change. We then move on to motility; now what motility is, is how much of the sperm is moving, and this would be grade in a percentage. Now it doesn’t help a sperm is moving, but it’s not actually making any progress in its movement. So, if the sperm is moving from point A to point B, that we call progressive motility. If it is moving, but not really actually getting anywhere sort of twitching around or perhaps even swimming in circles that we just considered general motility, and that sperm is not going to be very helpful.
So, what are our cut offs for these values? Well, we consider 42% for total motility to be the aim and 32% for rapidly progressive sperm, so sperm that is moving from point A to point B. The next thing we look at is morphology and men are often horrified to hear they’ve only got four or 5% normal looking sperms, so morphology refers to how the sperm looks. Remember the testicle is making millions and millions of sperm is bound to make quite a few errors. So, when we’re looking at what is normal, what we take as normal is 4%. So yes, we only expect 4% of the sperm to actually look normal.
A few other things we might look at are the pH of the sperm. This can give us some information about what’s happening with the ejaculatory ducts, so the ducts there make fluid to support the sperm. We might look at the vitality, so how many of the sperm are actually alive. This becomes important when a lot of the sperm are not moving, so they’re not very motile. Then we need to make sure that they are not actually dead, and this might then reflect a problem with how the sample was produced. We might also check for antibodies if you’ve had a previous vasectomy and a reversal, sometimes there can be antibodies. And if this is the case that might hinder the sperm from moving normally.
So, this then covers the routine sperm tests that we do. There are more advanced tests, such as DNA fragmentation that we can do that looks at the DNA integrity of the sperm. So, at the time we might start thinking about doing something like that is when the semen analysis parameters are normal, but we think perhaps it might be something else underlying. This is a test that we can offer at CAPE Fertility, it is a bit more involved and it tells us how much of the sperm actually has intact DNA. There’s a whole spectrum of different tests that can also be done to see whether the sperm can actually penetrate an egg and whether it can do what it’s supposed to do in this process. A lot of these have sort of been left to the side simply because IVF and ICSI is so advanced, these tests are a bit more expensive to do, and they don’t necessarily change your management. But there are a variety of sperm function tests out there.
So, once we have your semen analysis report, we can make recommendations for treatment. This will obviously depend on what we find, so if the sample is completely normal, this is compatible with fertility. If there is an abnormality, it will completely then depend on how severe that abnormality is. So, there is a difference between someone who’s got five to 10 million sperm and very good motility and someone who’s only got one or 2 million sperm based on this, we will decide whether inseminations are an option. So, whether we think after the whole washing procedure, which we extract the sperm that is motile to put inside of the uterus, the womb at the time of ovulation. Whether we think that is a viable option and we will have enough sperm to make that treatment worthwhile, whether we need to actually convert to IVF or ICSI, where we take the egg and we take the sperm and the sperm is actually injected into that egg.
We can only determine this once we’ve seen the semen analysis, but sometimes if it’s a bit borderline and it’s more difficult to decide, we might recommend a diagnostic wash. What this is, is the lab will then take the sperm sample, they will run it through the system that we would usually use to get the sample ready for an insemination and look at the final results. From this, then we can see, do we think we will have a good enough sperm sample to be able to use for an insemination? Or do we think we need to go down to IVF?
So, we’ve covered what we can do when there is a slightly reduced semen analysis, such as inseminations or when we have to go to ICSI, because there’s a severe limitation on the amount of sperm that is there. But what happens when there’s absolutely no sperm in the sample, well the first step is we’re going to ask you to repeat that sperm test because we can never rely on a single sperm test. But as for what we do next, I will cover that in the next series of videos on Azoospermia, means no sperm in the sample. And we’ll run through what the medical and surgical options offered this, and if those options are not there, we can chat a bit about sperm donation. Until the next video stay safe.