Investigations in Male Infertility

Semen Analysis – Male Infertility

Semen analysis is the first and foremost investigation ordered while evaluating a man for infertility.

Semen analysis – If normal

Additional specialized sperm functional tests may be done to assess the fertility potential of the sperm. However if the facility is available in the clinic this can also be utilized as a routine test at the initial evaluation itself.

Semen analysis – If abnormal

Evaluation for reproductive hormones
Doppler evaluation of the testis
Additional transrectal ultrasound may be required

Treatment of infertility involves comprehensive evaluation of both male and female to find an ideal solution to the couple’s problem.

What is semen analysis?

Semen analysis is the first test ordered in the management of male infertility. In this preliminary assessment we look at certain physical characteristics like volume or quantity of the ejaculate, pH, time taken to liquefy & levels of fructose. Microscopic examination helps us to measure the count or the concentration, motility of the sperm (forward), morphological characteristics of the sperm (size and shape) & concentration of white blood cells. This basic analysis guides the clinician to proceed further and manage accordingly.

What are the pre-requisites and precautions for this test?

This is a simple test which does not involve any painful injections. Following are instructions and precautions to be followed:

• A sexual abstinence of 3-7 days is a must for semen analysis
• Ideally the sample should be collected in the hospital, but patients having issues with hospital collection can collect it at home
• All home collected semen samples should be transported to the Andrology lab within 45 min of collection
• Never use a jelly, lubricant, vasaline, spit or a condom for collecting the semen sample, they alter the quality
• There are special condoms available for semen collection (speak to your specialist for more information)
• Make sure that all the semen collection containers are properly labeled with your identity to avoid mixing of samples

Normal Values of various Semen parameters as per WHO

Volume >/= 1.5 – 6 ml
PH 7.2 – 8.0
Sperm concentration >/= 20 million/ml
Total sperm count >/= 20 million/ml
Motility >/= 50% with forward progression (Grade a + b) or >/= 25% with rapid progression (Grade a)
Morphology >/= 30% with normal forms or if using Kruger’s strict criteria 15% normal forms
Vitality >/= 75% live
White blood cells < 1-3 cells/hpf

Will semen analysis alone tell me about my fertility potential?

Traditional semen analysis tells us about the capacity of the sperm to swim to the site of fertilization, but it fails to tell us the fertilizing ability of the sperm. However sperm concentration, motility and morphological assessment are adequate for initial management. Patients who do not respond to the initial management or in patients where we cannot find an underlying cause need advanced testing.

What are the drawbacks of semen analysis?

Traditional semen analysis or the WHO (World Health organization) method of semen analysis has the following drawbacks:

• Only limited parameters are assessed
• Doesn’t give an idea of the fertilizing ability of sperm
• It is associated with inter-observer variation

Few of these shortcomings have been addressed by a new method of analysis called CASA – Computer Assisted Semen Analysis.

CASA – Computer Assisted Semen Analysis (CASA)

Computer Assisted Semen Analysis (CASA) is a catch-all phrase for automatic or semi-automatic semen analysis techniques. It provides fast, accurate and objectively repeatable results. The Inter-observer bias can be eliminated using this technique. It analyzes the sperm basing on image analysis and tracking cell movement on a digitizing tablet. The system provides immediately and objectively detailed results of motility and concentration in a complete report. A precise morphological and morphometric analysis of each spermatozoid is provided in real time. This equipment can also perform certain specialized tests like sperm vitality & sperm DNA fragmentation index.

DNA Fragmentation Index

Sperm has an equal contribution in human reproduction. Apart from the DNA the sperm has certain other important organelles which are crucial in fertilization and child birth. Centrosome present in the neck of the sperm is crucial to initiate the process of fertilization in humans. The DNA of sperm is necessary for fertilization. It also influences the embryo development and the placental formation in pregnancy. Hence, a fragmented DNA can adversely affect the pregnancy outcome. Diagnosing DNA fragmentation is crucial in management of male infertility.
Oasis is one among the very few centers in India offering DFI testing on a routine clinical basis.

ROS – Reactive Oxygen Species

Reactive oxygen species (ROS) known as free radicals are oxidizing agents generated as a result of metabolism of oxygen and have at least one unpaired electron that make them very reactive species. Normally, free radicals attack the nearest stable molecule, which becomes a free radical itself, beginning a cascade of chain reaction. These can very rapidly oxidize biomolecules that they encounter in their vicinity thus exerting either a positive or a negative influence on normal cell function.

Normal aerobic metabolism is related to optimal levels of ROS because a balance exists between ROS production and antioxidants activity. Oxidative stress (OS) is the term applied when oxidants outnumber the antioxidants due to excessive generation of reactive oxygen species and when antioxidants cannot scavenge these free radicals. Such phenomena cause pathological effects, damaging cells, tissues and organs.

Reactive Oxygen Species (Ros) And Male Infertility

Excessive generation of ROS in semen can cause damage to spermatozoa due to its exclusive structural composition. Seminal ROS levels, when present in excess, possess potentially toxic effects on both sperm quality and function. Elevated seminal ROS production has been associated with decreased sperm motility, defective acrosome reaction, and loss of fertility. These findings suggest an explanation why patients with normal semen parameters can experience idiopathic infertility. Given the major role of oxidative stress in the pathogenesis of male infertility, treatment strategies include prescribing antioxidants like L-carnitine, Lycopene, CO-enzyme Q10, Selenium and Zinc.