Male Infertility: The Formula for Male Fertility The day that Michael T. heard that he had no sperm in his semen, he almost stormed out of my office. Hearing the news didn't do much for Shelley either: "A year of tests for nothing!" she said. "Don't be so hasty. They weren't exactly for nothing," I assured her. "You did find out you have endometriosis, which impairs your fertility. Only now we know that we must treat both of you. You may have that baby yet." Many couples overreact to the results of a single semen analysis, just as Michael and Shelley T. did. However, since many factors can "spoil" or influence a single test result--errors in collection, errors in handling the specimen, and errors at the laboratory I'll always advise performing a second semen analysis in a month or so. Convincing Michael and Shelley of this wasn't easy. "The semen analysis is only a screening test," I explained. "It does not provide a definitive diagnosis. It tells me the quality and quantity of your sperm, the motility or movement of your sperm, the volume of your semen, and the concentration of your sperm. In plain English it tells me if you are producing the right amount of good quality sperm and semen." "What did my test show?" "I found almost no sperm and very little semen or fluid. This can mean a number of things: You do not produce much semen and sperm. You produce semen and sperm but due to an obstruction they do not come out when you ejaculate. Or, perhaps even more simply, you didn't collect the sample correctly. That's what I need to find out first." Semen Analysis If the semen analysis suggests that the man is fertile and free from infection, no further fertility testing is usually needed of him. Other factors that might impair his sperm are incompatibility between his semen and his wife's cervical mucus or an inability to bind to the egg and fertilize it. Problems with sperm-mucus interaction can be checked by doing a postcoital test which I'll describe. Hamster-egg penetration tests, zona binding tests or in vitro fertilization can tell me if the sperm can function properly when it reaches the egg. However, if his semen analysis indicates a fertility problem, further evaluation is necessary. Collecting the Semen Sample Before I could evaluate the validity of Michael's semen analysis results, I needed to find out how he and Shelley had collected the sample. (To collect semen, a man must ejaculate into a sterile cup.) I asked them these questions: "When you collected the sample, how long had it been since the last time you ejaculated?" Each ejaculation affects your sperm supply, so specimen collection timing should be as close to your normal ejaculation frequency as practical. (When figuring this interval, you need to consider both sex and masturbation.) Having this information is vital for correctly interpreting semen analysis findings. For example, if you ejaculate infrequently, your sample will contain a higher than expected number of dead sperm and sloughed-off cells. If you ejaculate very frequently (for example, once a day), you may not have time to replenish your sperm supply between emissions. Altering your normal pattern just to perform the test either sooner or later can distort the results. Michael reported that he produced the specimen at his normal frequency of ejaculation. "How long did it take you to get the specimen to our laboratory for testing?" Normally I suggest collection at our laboratory site in our specially prepared soundproof room. However, a number of men have difficulty masturbating on demand in the doctor's office. It's at best embarrassing, and some even refuse for moral and religious reasons. I try to circumvent these obstacles as best as possible without seriously jeopardizing the integrity of the test. If the specimen is collected at home and delivered within one hour, we should be able to evaluate sperm quality. If the "home" results are abnormal, the test must be repeated to determine whether the sample was damaged in transit. If the couple wishes, the wife can help with the collection. Using on-site facilities ensures that you collect the sample in a sterile container, that you do not expose your sample to temperatures above 80 degrees Fahrenheit, and that your sperm don't deteriorate from remaining in seminal plasma for more than an hour. By testing your sample immediately, we can also examine how it changes consistency. Normally your semen coagulates after ejaculation to prevent spillage. It should begin to liquefy within twenty minutes to one hour. If the semen remains coagulated, it traps your sperm and prevents them from swimming to the egg. Once identified, I can easily solve coagulation problems. Michael assured me that he had brought the specimen to the office within an hour: "Your nurse suggested that since we live so far away we get a motel room down the street. You should have seen the motel clerk," Michael said, "when they saw we had no luggage." "How did you collect the sample, and did you save the entire ejaculation?" The best way to collect your semen is by masturbating into a sterile wide-mouth jar. I don't recommend using jars washed in a dishwasher, since they contain harmful soap residue. It's extremely important that you collect the entire specimen because the concentration of sperm varies in different portions of your ejaculate. For 90 percent of the male population, the first squirt (ejaculate fraction) contains more sperm than later portions. Subsequent squirts contain primarily semen (seminal vesicle secretions). For these reasons, you cannot collect a good sample by withdrawing your penis during sex and taking a sample of remaining squirts. You cannot withdraw in time to save the first drop of sperm-rich semen. Since Michael T.'s religious beliefs forbade masturbation (that's actually why he refused testing with their previous doctor), I provided him with a Mylex condom to fit around his penis during sex. I cautioned him not to use an ordinary condom or lubricants, since they often contain sperm-killing chemicals. Although Shelley complained of some discomfort with the loose-fitting plastic pouch, they both found this procedure more acceptable and were able to collect a complete sample. Where religious beliefs forbid the use of contraceptive devices, inserting a small hole near the top of the collection pouch will satisfy the patient's objections and provide an adequate specimen. Substituting the Postcoital Examination If a man is unable or unwilling to collect a semen sample, I can examine the wife's cervical mucus several hours after unprotected intercourse. If I find living, mobile sperm, the chances of the man's being fertile are pretty good. Under ordinary circumstances, however, the postcoital test does not give me as much information as the semen analysis, because I cannot evaluate the percentage of deformed sperm or take a white blood cell count to test for infection. Repeating the Semen Analysis "Michael, I feel pretty confident that the results of your semen analysis are correct. However, I want you to repeat the test in four to six weeks. "I never jump to conclusions from a single negative test result. And you shouldn't either. Too many things can influence the results." I glanced at his medical history form. "I see you're diabetic. I want to do a physical and also evaluate your hormones. You aren't down for the count yet. You and Shelley have many options we haven't even discussed." I closed his file and leaned back in my chair. "I frequently find a condition called retrograde ejaculation in diabetics. It's possible that your bladder sphincter muscle, which normally directs your semen out through your penis, is not closing. Your sperm may be squirting back into your bladder instead." "Can you do something for it?" Shelley asked hopefully. "Yes. But first, we need to find out exactly what we're dealing with." "Okay, let's do it." Michael turned toward Shelley and said, "We'd better reserve that motel room again." What Is Semen Quality? To fertilize an egg (ovum), your sperm must be able to perform these critical tasks: Your sperm must be able to swim to the egg with a vigorous straight motion (motility, forward progression). Your sperm must be able to penetrate the egg to deliver your genes for fertilization (sperm penetration). The semen analysis tells me if your sperm meet the first criteria. The sperm penetration assay (hamster test) or acrosin test will tell me if your sperm can penetrate the egg for fertilization. I'll discuss egg penetration tests in later chapters. Sperm Count World Health Organization guidelines say a normal sperm count consists of 50 million sperm per ejaculate with 50 percent motility and 60 percent normal morphology (form). we know that concentrations must be under 20 million sperm per milliliter of ejaculate in order to actually impair fertility. Provided your sperm show adequate forward motility and good egg penetration, concentrations as low as 5 to 10 million can produce a pregnancy. It's interesting to note that only twenty-five years ago counts of 100 million sperm per ejaculate were the norm. With time, the effects of our toxic environment and/or lifestyle seem to be gradually degrading male sperm counts. Low Semen Volume Your total semen volume also influences your fertility. If the volume is too small, say under one milliliter, you may not have enough fluid to bring the sperm in contact with your wife's cervix (the entrance of her womb). In addition, an insufficient quality of protective semen will expose your sperm to the acid, sperm-killing environment of her vagina. I remember one couple who had been trying to have a baby for over three years. When I checked the husband's semen, I found a low semen volume and a depressed sugar (fructose) level. Since the seminal vesicles (glands that produce most of the seminal fluid) produce this sugar, I suspected an obstruction or infection. When I examined him further, I found evidence of infection. After several rounds of antibiotics, his semen volume doubled to normal levels. When semen volume cannot be increased, artificial insemination (AIH) provides excellent results by delivering concentrated sperm to the womb. High Semen Volume If your ejaculate averages more than 3.5 milliliters, your sperm concentration may be too low; that is, your sperm are diluted by excess seminal fluid. We know that for 90 percent of men, the first portion of their ejaculate is richest in sperm. So if you produce too much semen, I'll suggest that you collect an ejaculate by masturbation. I can then concentrate the sperm and place them inside the uterus, intrauterine insemination (IUI). Semen Viscosity Semen viscosity (liquid flow) also affects your fertility potential. If your coagulated semen does not liquefy within an hour of ejaculation, your sperm may be trapped in the cottage cheese-like jelly. I remember one man whose semen did not liquefy. Since the prostate gland secretes the chemical required for liquifaction, I did a rectal examination to check his gland. He just about jumped off the table when I pressed on the swollen tissue. Fortunately his infected prostate responded to antibiotic therapy. The most common way of dealing with persistent coagulation or high viscosity is collecting your sperm through masturbation, washing the semen from them, and using your sperm for artificial insemination (AIH). I'll discuss these procedures in more detail. Sperm Agglutination A microscopic examination will tell me if your sperm are clumping together (agglutinating). I've seen a number of semen samples where the sperm orient themselves tail-to-tail or head-to-head instead of swimming in a straight line. This clumping prevents them from swimming through the cervical mucus to the egg and attaching if they get there. This finding may indicate a problem with sperm antibodies or the presence of a bacterial infection. I'll discuss how we can solve these problems. Sperm Morphology A normal-looking sperm has an oval head and a tail seven to fifteen times longer than the head. You can identify defective sperm by their large heads or strange tails - kinked,, doubled, or coiled. The World Health Organization says good quality semen should contain 60 percent normal sperm morphology. (See figure 6.1 Sperm Morphology) A closer evaluation called a strict morphology (Kruger morphology) is more time consuming and usually predicts normal sperm function when more than 15% are normal. The reason all men produce abnormal sperm (up to 40 percent) is not known. However, considering the rate at which your production line operates ten million to fifty million new sperm per day some attrition should be expected. We do know that toxins such as lead have been linked to reduced motility; cigarette smoke to abnormal morphology, organic solvents to coiled tails; and excessive scrotal heat to coiled tails in animal sperm. When you lower your exposure to these agents, abnormal morphology levels usually decrease. I remember one man who transferred to a different job at his company so he could avoid exposure to heat from a blast furnace and began taking 1000 mg of vitamin C each day. Within a few months his sperm motility and morphology showed definite improvement. Debris and Infection Too many underdeveloped or immature sperm (germinal cells) in your semen indicate testicular stress from illness or infection. I remember one young athlete who had recently recovered from a case of the flu where he'd run a 104-degree temperature for three days straight. His sperm count, revealing many dead and immotile sperm, nearly blew his mind. "Don't worry," I told him. "Your fever probably caused all the damage." I retested him three months later and found him fully recovered. If I find white blood cells (leukocytes) in your semen, I suspect an infection. I will want to check both you and your wife for infection, since these diseases are easily passed back and forth between sexual partners. Sexually transmitted infections such as gonorrhea and ureaplasma respond to doxycycline, a tetracycline derivative. Prostate infections, which can be especially stubborn to treat, may take a month or more to clear up. Asthenospermia (Low Sperm Motility) with Adequate Concentration and Morphology Low motility may be a sign of infection or exposure to toxic substances. If your semen contains white blood cells and other cellular debris, you probably have an infection, which should respond well to antibiotic therapy. I will also ask if you are using medications or "street" drugs like marijuana, which can impair sperm motility. Changing medications or stopping drug usage will usually improve motility. Low motility is also quite common in the presence of a varicocoele. If other causes have been eliminated, I may recommend that the varicose vein be repaired. Nearly half the men who have this surgery impregnate their wives. If I find small testicles, scant pubic hair, or a thinning beard, I will run blood tests to confirm a hormonal deficiency. Chapter 8 discusses when varicocoele repair or hormone replacement therapy is a waste of time and money and when it will work wonders. Sperm-Mucus Interaction (the Postcoital Test) Your sperm must be: able to survive heir journey through your wife's reproductive system. The first barriers your sperm encounter are her highly acidic vaginal fluids and cervical mucus The vaginal environment does a good job of keeping bacteria under control, so in that way it's beneficial. However, the sperm must be specially equipped to make the journey intact. The postcoital test will tell me if your sperm are getting to your wife's uterus in good shape and in adequate members. I perform the postcoital test war the middle of your wife's monthly cycle (when she should be most fertile). At the time of ovulation her cervical mucus, which normally seals her womb from the outside, becomes thin and watery to allow your sperm to swim through the cervix toward her waiting egg. If the test is done 'at the "wrong" tine of her cycle, the results will be abnormal, since before rand after ovulation the mucus becomes impervious to sperm. This is why I use a urine LH kit to predict when she is about ready to ovulate. A few drops of urine are placed on the test stick. When a color change is noted, ovulation will usually occur within 24 hours. So, I recommend having intercourse that evening and checking the cervical mucus early the next morning. When I examine her cervical mucus, I look for three things: (1) if you delivered good quantities of sperm to her cervix, (2) if your sperm are vigorously swimming through the mucus in one direction, and (3) if white blood cells are present, indicating infection in either partner. Assuming your semen analysis was normal, if I find immotile, clumped, or dead sperm in the mucus, I'll suspect that your sperm and your wife's mucus are incompatible. If I find no sperm at all, I may suspect a problem with the way you're having sex. Even though the postcoital test provides very valuable information, I cannot substitute this test for a semen analysis, which gives me a better picture of morphology 'and the presence of infection (white blood cell count). Normal Semen Analysis with Poor Postcoital Test If I find no sperm in the cervical mucus, as I did with Michael and Shelley T., I suspect a deliverer problem. Perhaps, the husband is ejaculating prematurely and not depositing the sperm near her cervix. Maybe he is not actually ejaculating at all. Or maybe she is douching immediately after sex. I can often identify the problem by talking with the couple. I remember one man who had a great sperm count but no sperm at all showed up in their postcoital test. After counseling with him, I discovered that when he had sex he faked his climax and did not ejaculate. After several months of counseling (costing far less than fertility treatment), he and his wife returned for another postcoital evaluation and all looked well. "It's only a matter of time now," I told them. "Just let nature take its course." If I find agglutinated (coagulated) semen that contains shaking sperm instead of actively swimming sperm, I suspect that something in the mucus is attacking the sperm. Vaginal lubricants or allergic responses to the sperm can also cause this toxic reaction; for example, the woman's immune system may be producing antibodies that are attacking the sperm. In some situations the man himself may be making antibodies in his own sperm. I find this among men with frequent genital infections and with men who have undergone a vasectomy reversal. Overcoming Sperm Antibodies Using a condom during sex can sometimes reduce a wife's sensitivity to her husband's sperm. If she avoids all contact with her husband's sperm - hands, her mouth, her genitals, and so forth - for three months or so, her antibodies may decrease in numbers. A repeat postcoital test at three-month intervals will tell me if this procedure is working. Once her antibodies stop attacking his sperm, they can swim to her egg and make a baby. Some people do not want to wait as long as a year for the possibility that her antibodies will decrease. So usually I use artificial insemination with the husband's sperm to bypass sperm-mucus interaction problems. This is the route Steven and Kathy S. eventually took. AIH often works quite well. I will discuss these procedures in greater detail in Chapter 21. Concentrating Your Sperm Sometimes I can improve the quality of your semen without having to diagnose and treat an underlying fertility problem. Concentrating your sperm by natural means or in the laboratory may improve your semen quality enough so that your wife can get pregnant without expensive medications and surgeries. Centrifuging Semen for AIH Centrifuging your semen and using the more concentrated Portion for AIH may also improve your semen quality. Sometimes this technique is used with in vitro procedures. Freezing Multiple Semen Samples for AIH Unfortunately, collecting and freezing several sperm samples will not increase sperm quantity and concentration. The freezing and thawing processes damage the sperm so severely that semen quality actually diminishes. It's interesting, however, that sperm from a fertile donor does not deteriorate from freezing as much as that from an infertile donor. Other Methods of Sperm Preparation Many methods are available to separate the sperm from the semen and concentrate them before performing an insemination. Techniques such as percoll, swim-up, swim-down and sedimentation procedures are helpful for in vitro fertilization, they are usually not necessary for insemination. Most of these procedures select only a small percentage of the moving sperm so I usually have many fewer sperm than after a simple centrifuging sperm procedure. If sperm concentration techniques do not work, I have to look for underlying causes. Chapters 7 and Chapter 8 explain how I can identify the causes of your problem and outline a fertility treatment plan. Hit or-Miss Male Fertility Treatment In the past the understanding and treatment of male fertility lagged far behind that of female fertility. Infertile men were treated empirically. Without ever undergoing a thorough diagnosis, most men received a random series of treatments. Many times I've heard my patients say, "I had a low sperm count, so the doctor gave me Serophene. He said if that didn't work, we'd try Metrodin." When I asked them if their doctor ran tests to find out why the sperm count was low, more often than not they said no. This type of treatment consumes a lot of precious time as well as your energy and money. Therefor, you should insist on getting an accurate diagnosis and treatment for a known problem. Evaluating male fertility can be time-consuming and frustrating because sperm take approximately ninety days to form and mature. So if your doctor does something today to enhance your sperm production, it may be ninety days before the improved sperm show up in your semen sample. With the advent of inn vitro fertilization techniques, we're seeing rapid advances in male fertility, diagnosis and treatment. Doctors now know how to direct therapy to the source of your problem. Today we can correctly diagnose 80 percent of our male fertility patients. And we can successfully treat over half of those. These results are pretty impressive when you consider the aim—the creation of a new human life. Click here to read Chapter 7, Evaluating Male Fertility or go to the Miracle Babies Online Table of Contents For more information on your initial visit to your physician read the INCIID Routine Fertility Workup or IVF.com Homepage. Miracle Babies and Other Happy Endings for Couples with Fertility Problems Copyright © 1986 Mark Perloe M.D., and Linda Gail Christie. Return to the IVF Homepage This page, and all contents, are Copyright © 2005 by IVF.com, Atlanta, GA, USA.