Semen Analysis and Other Male Infertility Procedures

When a couple is unable to conceive, the problem may be due to a malfunction of the female reproductive system or the male reproductive system, or a combination of both. Even if a woman has a known condition, it is still important to check her partner for contributing sources of infertility. To screen for male infertility problems, a semen analysis is performed at our Chicago, Illinois-area practice. If the results indicate that problems are present, additional tests may be necessary to pinpoint the condition and determine the course of treatment.

• Semen Analysis (SA)
• Common Problems
• Treatment Options
• Types of Azoospermia and Treatment Options

Semen Analysis (SA)

The first test in the assessment of male infertility is the semen analysis. This relatively simple screening procedure can provide a wealth of information about the health and function of the male reproductive system and the fertilization potential of sperm.

The semen analysis is conducted by first collecting a semen sample. A sterile, labeled container will be provided by our lab for this purpose. To ensure accurate results, the sample must be delivered to our lab within one hour of being produced and kept close to room temperature during transport. Once received, the sample will be examined for volume, consistency, pH, and the presence of fructose (a sugar that sustains the sperm). The sperm will be analyzed for concentration, motility (movement), and morphology (shape).

Because there are many factors that may temporarily affect sperm production, a single semen analysis is often not sufficient to provide the information we need to diagnose male infertility, unless it is perfectly normal. Occasionally two semen analyses may need to be scheduled, with at least one month between them. If the results are inconclusive or abnormal, additional analyses or tests may be scheduled.

Pending the semen analysis results, a referral to a urologist or a male fertility specialist (andrologist, fellowship trained urologist) may be recommended.

Sperm Function Test

As part of the semen analysis at FCI, we routinely do a sperm function test in order to assess the man’s ability to fertilize an egg. The “strict morphology” of the sperm predicts a man’s fertility potential (fertilizing capacity) even in cases where the sperm count, motility and/or regular morphology of the sperm analysis are normal. The strict morphology takes a critical look at many individual sperm according to a very strict set of criteria. Only specialized andrology laboratories have trained technicians who can analyze the sperm according to these strict criteria. The sperm are stained and examined under oil at 1000X power for normal size and shape of the head, mid piece, tail, and for any other abnormalities. Even a minor defect in any category rates the sperm as abnormal. Therefore, relatively few sperm are rated as “normal” or perfect (near-perfect) during the strict morphology test, as compared to the “estimated crude morphology” done during a regular semen analysis (WHO criteria).  

The strict morphology score is a result that indicates and predicts the sperm’s potential for fertilization: 

• A strict morphology score over 14 percent normal is considered normal and fertilizing capacity is excellent
• A strict morphology score of 4-14 percent normal is considered abnormal with possibly decreased or impaired fertilizing capacity
• A strict morphology score of 0-3 percent normal is considered abnormal with severe impairment or probable inability to fertilize without IUI or IVF

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Common Problems

Among the most common causes of male infertility are physical problems that either affect sperm production or inhibit the movement of sperm through the reproductive system. This includes a varicocele, which is a varicose vein in the scrotum that causes overheating of the testicles. A blockage in the vas deferens or epididymis is another physical problem that can cause infertility. Both of these are generally diagnosed through a combination of semen analysis and physical examination.

Environmental and lifestyle causes of male infertility include anything that a man consumes or is exposed to that negatively impacts sperm production. Smoking, certain medications, frequent use of hot tubs, and exposure to certain hazardous substances (solvents) can all cause or contribute to male infertility. Fortunately, the effects are usually temporary and can be reversed by avoiding exposure to the substances causing infertility.

To learn more, read this article about diet, lifestyle changes, and male fertility (PDF)

Hormonal imbalances are another source of male infertility. There are many factors that can cause hormones to be out of balance, including obesity, a disorder of the hypothalamus, or other endocrine glands, and prolonged stress. Results from the semen analysis, along with other indications, may suggest a hormonal problem. If so, blood tests will be taken to measure the amount of testosterone, follicle stimulating hormone (FSH), and other hormones in the body. Hormonal imbalances are usually treated with medication or by addressing the underlying cause of the imbalance.

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Treatment Options

There are many treatments for male infertility, depending on the cause and severity of the problem and whether or not the female partner has any conditions contributing to infertility. Although not all types of infertility can be treated, most can be overcome through assisted reproductive technologies such as in vitro fertilization.

Surgery

Blockages and other physical fertility problems can often be addressed with surgery. Generally, these are outpatient procedures that can be performed under local or general anesthesia and require only short recovery periods. If the blockage being treated is the sole source of infertility, the chances of conceiving naturally after surgery are usually excellent. If there is major impairment of sperm production, after surgical removal of the sperm, IVF with ICSI is performed.

Learn more about surgical options in the section on azoospermia below.

Lifestyle Changes

When male infertility is the result of obesity or environmental factors, the best treatment option is usually to make lifestyle changes that eliminate the problem. These changes, such as losing weight, quitting smoking, and avoiding exposure to harmful chemicals, as these will not only improve fertility, but also overall health. Several nutritional products (Conception XR - ConceptionXR.com; COAST Male Fertility Supplement - CoastReproductive.com) containing antioxidants such as Vitamin C, Zinc, and Carnitine, may also improve sperm production and function.

To learn more about lifestyle changes, read the article above under the environmental and lifestyle causes section.

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Medication

Some hormonal imbalances and certain other conditions may be treatable with medication. If the source of male infertility is an infection, medications can help to treat the infection, but it will take two to three months before the effects will be detectable through a semen analysis, as sperm cells must mature over time.

Occasionally, Clomid® (by stimulating FSH production) may be utilized to improve sperm production.

Assisted Reproductive Technologies (IUI and IVF)

Intrauterine insemination (IUI) can often overcome male factor problems by significantly increasing the number of motile sperm that can enter the fallopian tubes after placement in the uterus.

In vitro fertilization (IVF) is a highly effective method of bypassing many types of infertility. If sperm production is particularly low or if there is a high number of abnormal sperm cells, intracytoplasmic sperm injection (ICSI) may be used. ICSI is an advanced IVF technique that can improve the chances of successful pregnancy by increasing the number of eggs that are fertilized by microscopically placing normal appearing sperm into each egg. Certain causes of male infertility prevent sperm from being carried out of the testicles, despite adequate production. In these cases of obstructive azoospermia, a Percutaneous Epididymal Sperm Aspiration (PESA) can be performed to collect sperm cells directly from the epididymis for use in IVF. In cases involving non-obstructive azoospermia with impaired sperm production, TESE may be performed to obtain sperm for IVF/ICSI.

To learn more, read this article about azoospermia and sperm retrieval techniques (PDF)

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Types of Azoospermia and Surgical Treatment Options

Azoospermia is a condition where no sperm are found in the ejaculated semen. In cases with low ejaculatory volume (less than 1 ml) retrograde ejaculation should always be ruled out. Azoospermia may be caused by obstruction of the epididymis or vas deferens (called obstructive azoospermia or OA) or there may be problems associated with defective spermatogenesis (called non-obstructive azoospermia or NOA). A urologist or andrologist can usually distinguish between the two types by measuring testis size, FSH hormone levels, and occasionally a biopsy of the testis is necessary.

Obstructive azoospermia (OA) may be associated with congenital defects such as congenital bilateral absence of the vas deferens (CBAVD), often associated with cystic fibrosis or may also be due to injury, infection or elective vasectomy. If the obstructive azoospermia can be corrected surgically, this is often a more cost-effective option. If surgical repair or reconstruction is not possible, or is ultimately not successful, then sperm must be extracted from either the testis or epididymis. The extracted sperm can then be utilized with in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI). In these cases, extraction of sperm from the epididymis is often easier, yielding abundant sperm. For obstructive azoospermia, MESA, (microscopic epididymal sperm aspiration) or PESA (percutaneous epididymal sperm aspiration) are usually successful due to abundant sperm. MESA will often yield a better sample however.

Non-obstructive azoospermia (NOA) associated with defects in spermatogenesis may also be congenital or can be acquired later in life due to injury or infection. In some cases, pre-treatment with medications such as clomiphene citrate to stimulate spermatogenesis may help as adjunctive therapy prior to sperm retrieval. In cases of severe oligospermia, (sperm count less than 5 million/ml) and especially with azoospermia, genetic screening may be very helpful. For example, the chance of finding sperm in men with NOA is essentially 0 percent if they have a genetic microdeletion of the Y chromosome at the AZF A or B locus. On the other hand, cases caused by mumps, torsion, cryptorchidism or idiopathic causes may be associated with a 50-70 percent chance of finding sperm. In cases of non-obstructive azoospermia, sperm are generally extracted from the testis by various methods. In approaching an NOA patient, it is very important to determine a) who has sperm? and b) where is it? Microdissection TESE (testicular sperm extraction) is often successful due to the concept that the seminiferous tubules containing sperm are “thicker” than those that don’t. General anesthesia and 25 times magnification are required. Another successful technique involves office FNA mapping (fine needle aspiration) followed then by directed TESE. This can often be done with local anesthesia and no need for an operating microscope.

In cases of OA and NOA involving both epididymal and testicular sperm extraction, the IVF/ICSI pregnancy rates appear to be essentially the same with fresh or frozen sperm. Since IVF/ICSI is far less than 100 percent successful, it behooves the reproductive urologist or andrologist to utilize sperm retrieval techniques that are reliable, associated with low morbidity, but also have the potential to harvest sufficient sperm in order to enable cryopreservation for future IVF/ICSI attempts.

In obstructive and non-obstructive azoospermia, a urologist or andrologist can use many different methods for extracting sperm from the testis and/or epididymis including open surgical extraction, microsurgery, as well as needle aspiration. With obstructive azoospermia, since larger numbers of sperm are present all choices are possible, but extraction of sperm from the epididymis is often easier. However, with non-obstructive azoospermia, in order to obtain enough sperm from the testis, open surgery, microsurgery and/or directed multiple needle punctures are required.

For Male Infertility and Semen Analysis Information, Contact Our Chicago, Illinois Practice

Contact our practice for more information about male infertility or semen analysis. We serve Chicago, Illinois and all of the surrounding communities.

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• The IVF Process
• Micromanipulation
• Using A Donor
• Surrogacy
• Cryoperservation
• IUI & Other Infertility Treatments

For additional information about male infertility or semen analysis, contact our Chicago, Illinois-area offices.

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