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 their 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 towards 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 and 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:
- if you delivered good quantities of sperm to her cervix
- if your sperm are vigorously swimming through the mucus in one
direction
- 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.
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. Chapter
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. Therefore, 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 in 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.
