SEMEN ANALYSIS : A carefully performed semen analysis is the most important test that needs to be performed to start the investigation of the infertile couple. There are three important variables that one looks at when evaluating the sperm:
- Sperm should be collected after 3 to 5 days of abstinence. Longer than 7 days can result in lower motility. The semen should be evaluated within 45 minutes of collection; otherwise the result could be false and misleading.
- Count: The number of sperm present in the ejaculate.
- Motility: The ability and percentage of the sperm moving in a forward direction.
- Morphology: The shape of the sperm head and tail.
- Ejaculate volume > 2.0 ml
- Sperm concentration >20 million/ml
- Motility > 50% forward progression
- Morphology > 4% normal forms (Kruger’s criteria)
- HORMONAL EVALUATION: Routine hormonal evaluation is not warranted in most cases, unless the sperm concentration is severely depressed. Hormones that are commonly tested are FSH, LH and Testosterone levels. Very elevated levels of FSH and LH indicate testicular failure. This condition is not treatable since the testicles have lost the ability to produce sperm.
- TESTICULAR BIOPSY: In men with total absence of sperm but with normal hormone levels, a testicular biopsy is indicated to document the presence of sperm. This is important since new advances in reproductive medicine allow us now to recover sperm directly from the testicles (TESE) for use during IVF with Intracytoplasmic Sperm Injection (ICSI). Testicular biopsy is done under anesthesia whereby a small piece of testicular tissue is taken after exposing the testicle through the scrotum. Some post-biopsy pain is common especially if swelling occurs.
To determine the cause of male infertility, we can perform an in-depth semen analysis, examining the shape, motility and number of sperm present.
- SCROTAL OR TRANSRECTAL ULTRASONOGRAPHY: This is currently the best test to evaluate the seminal vesicles and ejaculatory ducts. It is also valuable in visualizing and grading varicoceles.
- POST-COITAL TEST: It assesses the quality of cervical mucus at the time of ovulation, with special emphasis on the survival of sperm in the mucus. The test involves microscopic evaluation of a sample of cervical mucus 2-8 hours after intercourse. The predictive value of this test does not add much to a simple semen analysis. Because of the inconvenience it causes to couples, this test should rarely be performed.
- SPERM PENETRATION ASSAY: Often called the Hamster egg penetration test, it involves measuring the ability of the sperm to fuse a Hamster egg. It is supposed to predict the fertilizing capability of sperm. Unfortunately and because of methodical problems and inadequate standardization, this test has a very poor prognostic value and is very difficult to interpret.
- SPERM ANTIBODY TEST : Sperm antibodies are often the only possible explanation of male factor infertility. Commonly present in men with previous vasectomies or genital surgeries, these antibodies (protein molecules secreted by the immune system) can bind to the sperm head or tail and interfere with fertilization. The best test is called the Immunobead Assay, that detects antisperm antibodies bound to the surface of sperm.
- SEMEN CULTURES : Any genital infection should be immediately treated to prevent damage to the delicate testicular tubules and ducts. Most common infections involve Gonorrhea and Chamydia that can be diagnosed by taking a swab culture of semen or the tip of the penis. Another common infection that is associated with causing abnormal sperm morphology, is Ureaplasma urealyticum.
- CHROMOSOMAL ANALYSIS : Recent evidence shows that a significant percentage of men with severely depressed sperm counts (severe oligospermia) have abnormalities in their chromosomes such as Klinefelter’s syndrome where an extra X chromosome exists instead of only one (XXY instead of XY).