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Semen Analysis  |   Sperm Count Variability  |   Morphology  |   Round Cells  |   Hamster Penetration Assay

Semen Analysis

Case: 28 year old male with a history of subfertility, an unremarkable medical history, no prior pregnancies, and a semen analysis revealing oligospermia (a concentration of 12 million sperm per mL, 60% motile, 50% normal forms by World Health Organization criteria).

Question: What diagnostic or treatment options should be suggested if this is the only abnormal finding after a routine infertility evaluation?

Answer: I generally suggest repeating the semen analysis if the sperm concentration is found to be low, since there is a normal variability in the concentration of sperm. Therefore, I only consider the sperm concentration to be low if the count is repeatedly found to be decreased.

If the sperm concentration is repeatedly found to be less than 20 million sperm per mL, then I consider this to be decreased (as per the World Health Organization parameters). I also understand that the sperm concentration may not be as important a parameter (in terms of assessing the reproductive potential of the sperm) as the percentage of sperm motility or the percentage of normal sperm morphology (shape). The basis of the 20 million sperm per mL cutoff is from a study published in 1950 that compared 1,000 army men with children to 1,000 army men without children, with very little attention to potential confounding variables. Therefore this cutoff may not relate to a change in sperm function or ability to fertilize an egg. There are also quite a few recent studies suggesting that the sperm counts in the world appear to be decreasing, and suggest making the lower limit of normal 10 million sperm per mL.

If the sperm concentration is consistently a little decreased, then I would suggest that the couple consider intrauterine inseminations (IUIs) to treat a probable mild male factor. The IUIs could be performed in natural (spontaneous) cycles or in cycles of controlled ovarian hyperstimulation (using menotropins to promote the maturation of multiple eggs per cycle).

Case: 33 year old male with a history of 2 children in a prior marriage, an unremarkable medical history, and a semen analysis revealing asthenospermia (a reduction in the percentage of motile sperm, with a concentration of 62 million sperm per mL, 30% motile, and 50% normal forms by World Health Organization criteria). The sperm was “produced” by manual ejaculation into a clean container at home, brought to a large laboratory “patient service center” (that collects specimens and draws blood which are then brought to the reference laboratory at the end of the day), and read by the laboratory technician about 13 hours after ejaculation.

Question: What should be considered given this information?

Answer: Large reference laboratories often have negotiated contracts with many insurance companies (especially the managed care insurance products). In these agreements, the payment for each particular laboratory test that is performed is discounted in lieu of an increased volume of laboratory tests that are performed. To perform a very large number of tests, the laboratories collect samples at one of many “patient service centers” in a geographic region, and then the samples are transported to a central reference laboratory during the day for processing.

In the situation of large reference laboratories, specialized tests that require special conditions for accurate results may be subjected to standard (less than ideal) conditions. A lack of attention to the details that are required for the proper handling of some specimens may thereby lead to abnormal results. Sperm should be stored at a temperature a few degrees lower than core body temperature, or about 35-36 degrees centigrade, until read. The test should ideally be completed about 1-2 hours after producing the specimen (ejaculation). If the temperature conditions for the storage of the sample or the time interval prior to the completion of the test are suboptimal, the sperm motility appears to be affected first. The concentration of sperm per mL and their shape are less subject to change due to these transient factors.

If the initial semen analysis reveals asthenospermia and it was performed at a laboratory in which I might suspect that the test conditions were not ideal (for semen analysis), then I would suggest a repeat semen analysis preferably at another laboratory. I run my own laboratory in my office, where I have control over the test conditions and I can see the sperm myself. In other small laboratories, a similar attention to the relevant details may result in quite different results (compared to the large reference laboratories).

Case: 39 year old male with a history of proven fertility (a child in a prior marriage), an unremarkable medical history, and a semen analysis revealing isolated teratospermia (a reduction in the percentage of normal shaped sperm, with a concentration of 62 million sperm per mL, 70% motile, and 20% normal forms by World Health Organization criteria).

Question: What should be considered given this information?

Answer: The sperm morphology (shape) is generally thought to be less subject to change (due to transient variables) than either the sperm concentration (which continuously varies widely) or sperm motility (which may be affected by temperature, infection, lubricants, and time since ejaculation).

All laboratories that perform morphologic assessments of sperm during semen analysis must be certified by CLIA (USA), in an attempt to maintain a certain standard of quality. However, the morphologic assessments at any two laboratories still vary widely when compared to one another. Therefore, when I get a semen analysis reporting teratospermia I suggest that the semen analysis is repeated at another lab (a lab run by an In Vitro Fertilization (IVF) center or my own lab where I can look at the sample myself). IVF center embryologists look at many different sperm samples regularly and can often correlate sperm sample quality to fertilization rates seen during IVF. Infertility specialists who look at sperm regularly also can often correlate the appearance of the sperm to fertility rates using different treatment options (such as intrauterine insemination or IVF).

Case: 34 year old male with a history of high semen volume (6.5 mL volume, a concentration of 30 million sperm per mL, 50% motile, and 50% normal forms by World Health Organization criteria), an unremarkable medical history, and no prior pregnancies.

Question: What further testing or treatments should be considered?

Answer: Semen volume is normally 2-5 mL per ejaculate.

If the volume of the semen is greater than 5mL, the concentration of sperm may be lower than normal since the sperm are “diluted” by the large volume. A normal number of sperm is greater than 40 million per ejaculate (normally greater than 20 million per mL with at least 2 mL volume). If the volume is 6.5 mL and the total ejaculate contained 40 million sperm then the concentration of sperm would be only 6.15 million per mL (40 million divided by 6.5 mL).

If a normal number of sperm are released at ejaculation but the sperm concentration is low, then the sperm may have difficulty passing into the cervical mucus. During (or shortly following) intercourse, it is absolutely necessary for the sperm to swim through the semen into the mucus in order for them to have a chance to fertilize the egg within the fallopian tube.

A postcoital test can be useful in determining whether a “normal” number of sperm are present within the cervical mucus several hours after intercourse. If the postcoital test is abnormal, there is a known benefit for intrauterine inseminations (IUIs). If the postcoital test is normal, I generally do not suggest IUIs based solely on the finding of an elevated semen volume.

Case: 43 year old male with a history of unproven fertility (no prior pregnancies), an unremarkable medical history, and a semen analysis revealing very viscous semen (with a concentration of 132 million sperm per mL, 60% motile, and 80% normal forms by World Health Organization criteria). The sperm was “produced” by manual ejaculation into a clean container about 90 minutes prior to evaluation in the andrology laboratory.

Question: What should be considered given this information?

Answer: Viscoscity is a term that describes the consistency of semen. Generally, semen will turn from a gel into a liquid (undergo liquifaction) within 60 minutes (at room temperature). The presence of mucus streaks or globs in the semen suggests incomplete liquifaction.

Once semen has had time to complete liquifaction the consistency of the semen can be assessed. This assessment may be performed by gently aspirating a sample of the test semen into a pipette or syringe and then allowing the semen to drop from the pipette. Normally, semen will drop in small round drops. If the viscosity is high, then a thread of semen that is greater than 2 cm in length may drop.

Sperm may have difficulty swimming through highly viscous semen. If this is so, the ability of the sperm to transfer from the semen to the cervical mucus at intercourse may be compromised. Therefore, I (strongly) encourage a postcoital test if the semen is found to be viscous.

Sperm Count Variability

Case: 51 year old male with a history of 3 children in a prior marriage, an unremarkable medical history, and several (four) semen analyses that have revealed considerable variability in terms of sperm concentration (12 million per mL, 26 million per mL, 31 million per mL, and 94 million per mL). The semen collections were all thought to be complete and the other variables assessed in the semen analysis (including motility and morphology) were entirely normal.

Question: What should be considered given this information?

Answer: There is a normal variability in sperm concentration for a normal fertile man. The sperm concentration occasionally is decreased even in the normal fertile male population. Therefore, the fact that most of the semen analyses report a normal concentration is encouraging. Also, the fact that this gentleman has proven fertility in the past is encouraging.

There does seem to be considerable inter-assay variability with respect to sperm concentration. This is especially true if the same semen sample is brought to several different laboratories, where the range of results that are reported is often great.

Case: 26 year old male with a history of unproven fertility (no prior pregnancies), an unremarkable medical history, and a semen analysis generally revealing mild oligospermia (reduction in sperm concentration). Intrauterine inseminations are performed in natural (spontaneous) cycles on back to back days (two IUIs per cycle on consecutive days) with the second semen sample seemingly much lower in concentration than the initial semen sample.

Question: What should be considered given this information?

Answer: In the year 2000, there were several research reports published in the literature that suggest 2 IUIs per cycle have a somewhat better reproductive success rate than 1 IUI per cycle. Therefore, when (an expensive and highly monitored cycle such as) controlled ovarian hyperstimulation (with menotropins) is used to stimulate the maturation of several eggs per IUI cycle many infertility specialists now recommend 2 IUIs on consecutive days to optimize pregnancy rates. One can also consider 2 consecutive IUIs in natural (spontaneous) cycles.

Generally, semen analyses are performed after 2 to 7 days of abstinence. The data on which this suggestion was formulated is not so clear, but a popular rationalization is that (a) sperm ejaculated after greater than 7 days of abstinence may have reduced motility, while (b) sperm ejaculated after less than 2 days of abstinence may not have had adequate time to reaccumulate.

Sperm takes about 74 days to mature within the testes and then is stored within the epididymis for about 12-14 days prior to release at ejaculation. Thus, if it really does take two days to fully replenish the sperm in the epididymis and if a man usually ejaculates less often than every other day then there should be adequate reserve within the epididymis if he (infrequently) needs to ejaculate on two consecutive days.

In the situation where a reduced amount of sperm is normally produced (which would result in oligospermia) then ejaculation on 2 consecutive days may result in (further unmask) a noticeable reduction of sperm on the second day (since the reserve in the epididymis may be reduced).

Fresh sperm at the time of ovulation appears to be important for reproductive success. Therefore, I would think that the second IUI in a case like this is valuable even if the concentration were reduced. The “minimal” number of sperm required for IUI to have a reasonable chance of success is not clear, but often is thought to be greater than 1 million motile sperm per mL.


Case: 41 year old male with a history of unproven fertility (no prior pregnancies), an unremarkable medical history, and a semen analysis revealing normal sperm morphology by World Health Organization (WHO) criteria but only 2% normal forms (an abnormal result) using the Kruger Strict Morphology criteria.

Question: What should be considered given this information?

Answer: The WHO criteria for assessment of sperm morphology are widely accepted (USA) by Reproductive Endocrinologists (REs). The Strict Morphology criteria are also used by many REs and In Vitro Fertilization (IVF) centers but remain controversial and lack widespread acceptance. I use the Kruger Strict Morphology criteria during IVF cycles to assess the desirability of assisted fertilization (ICSI) since it is (generally) very difficult to predict when a particular sperm sample will result in an unexplained lack of fertilization. During IVF cycles I generally suggest ICSI if there is any abnormality in the appearance of the sperm, including the morphologic assessment of the sperm by Strict Morphology criteria. I generally use the WHO criteria alone to assess sperm morphology. One exception would be when I am deciding on a method of in vitro fertilization during IVF. If the WHO criteria suggest a normal sample in terms of sperm morphology, then I would consider a trial of timed intrauterine inseminations if suggested by either a mild male factor or an abnormal postcoital test. The advisability of these treatment alternatives would not be changed by the results of an assessment of the sperm by Strict Morphology criteria. Many couples in my own infertility practice have a severe abnormality when the sperm morphology is assessed by Strict Morphology, a normal morphology by WHO criteria, and achieve pregnancies with IUI alone.

Case: 45 year old male with a history of 3 children with his current partner (aged 19, 22 and 24 years old), an unremarkable medical history, and a semen analysis revealing teratospermia (a reduction in the percentage of normal shaped sperm) with a concentration of 125 million sperm per mL, 70% motile, and 25% normal forms by World Health Organization criteria.

Question: What treatment options should be discussed given this information?

Answer: Sperm morphology is generally stable from year to year for a particular man. When looking at sperm concentration, sperm motility and sperm morphology (shape) the variable that is least likely to change over time is the sperm morphology. The particular abnormality(ies) in the shape (morphology) of the sperm that is seen in this man?s semen specimen has an increased importance since it (they) may suggest treatable pathology. For example, if a high percentage of tapered forms are seen then this may suggest the presence (or increase in size) of a varicocele. If the abnormalities were widely varied for this man, then I would tend to think that they have most likely been present for a long period of time. In this case, I would consider simple intrauterine inseminations for a possible mild male factor if the remainder of the infertility evaluation on the female partner were normal.

Case: 36 year old male with a history of unproven fertility (no prior pregnancies), an unremarkable medical history, and a semen analysis revealing oligoteratospermia (reduction in the concentration of sperm and the percentage of normal shaped sperm). The man?s wife has had a bilateral tubal ligation in the past (in another relationship).

Question: If In Vitro Fertilization (IVF) is planned due to the (patient?s previous) surgical ligation of the fallopian tubes, how should this information from the semen analysis further guide treatment?

Answer: At the time of IVF, a decision needs to be made regarding the utility of assisted fertilization (generally ICSI). If standard microdroplet IVF (egg placed into a small amount of culture media generally with 50,000 or more sperm) is planned and there is no fertilization of the available eggs on the day after egg (oocyte) retrieval, then assisted fertilization (ICSI) can be performed on these day old eggs. The pregnancy rates following ICSI on day 1 eggs are not encouraging. It is also very difficult to predict which sperm will result in an unexplained lack of fertilization. The Kruger Strict Morphology was developed in conjunction with an IVF program and reportedly can fairly reliably predict whether a specific sperm sample will be able to fertilize an egg under the conditions present at IVF. If there is any abnormality (less than 14% normal forms) on Strict Morphology then I encourage a liberal use of assisted fertilization. If the sperm sample has any abnormality on semen analysis including teratospermia using WHO criteria, I suggest considering assisted fertilization if IVF is planned. If IVF were otherwise not necessary, then I would certainly consider intrauterine inseminations for a few cycles if there were a reasonable amount of motile sperm present.

Case: 26 year old male with a history of unproven fertility, an unremarkable medical history, and a semen analysis revealing teratospermia using Strict Morphology criteria. The remainder of the basic infertility evaluation (including a hormone evaluation (wife), hysterosalpingogram (wife) and postcoital) has been normal. In Vitro Fertilization has been suggested by the IVF center performing the initial evaluation.

Question: On second opinion, what alternative diagnostic and treatment options should be considered given this information?

Answer: The reliability of the Strict Morphology to predict reproductive potential of sperm has been challenged (is not clearly understood). The initial articles proposing these test criteria suggest that the criteria indeed have a high level of reliability. Since the initial research on the Strict Morphology criteria (1980s) there has been a great deal of controversy about their true reliability. In my own clinical infertility practice, I have seen many couples seeking a second opinion since they were told elsewhere that they need IVF in order to conceive. In a significant number of these situations, this conclusion was apparently based solely on the (morphologic) assessment of the sperm using Strict Morphology criteria. If this is the only abnormality that is seen in the semen analysis, I generally suggest re-assessment of the semen using the World Health Organization (WHO) criteria. If the morphology is normal using WHO criteria, I consider the man to have a potential mild to moderate male factor which I usually treat with intrauterine inseminations (with good results). The cost of IUIs is a few hundred dollars compared to 10,000 to 20,000 dollars for IVF, which is a considerable (significant) savings for most couples.

Case: 44 year old male with a history of one child in a prior marriage, an unremarkable medical history, and three different semen analyses revealing mixed results with respect to teratospermia when using the Strict Morphology criteria. The reported percentage of normal forms (for this particular gentleman) using Strict Morphology criteria is from 2% normal (suggesting very poor ability to fertilize an egg, at least in vitro) to 18% normal (suggesting a very good ability to fertilize an egg, at least in vitro).

Question: What should be considered given this information?

Answer: The range of results that occurs for a semen analysis between two different laboratories or even within the same laboratory can be staggering. With criteria that are as specific as the Strict Morphology criteria, one would suspect that different morphology assessments of the same sperm samples would yield similar results. Unfortunately, this is simply not the case. I have used the proficiency testing service of a highly reputable Association of Bioanalysts to confirm the accuracy of my laboratory?s test results. This testing service has been available since 1949 and the surveys are approved by the Clinical Laboratory Improvement Amendments of 1988 (CLIA), Commission on Office Laboratory Accreditation (COLA), Health Care Financing Administration (HCFA), Joint Commission on Accreditation of HealthCare Organizations (JCAHO) and most state agencies. The test kits from this proficiency testing service (available at the end of the year 2000) reported a percentage of normal forms (for sperm morphology assessments) within 3 standard deviations of the mean to be considered acceptable. Two sperm samples were provided to each laboratory undergoing proficiency testing, over 175 of the labs assessed the sperm sample with the Kruger Strict Morphology criteria, and the range of acceptable answers (+/- 3 standard deviations from the mean for all participating laboratories) for the first sample was 0-29% and for the second sample was 0-14%. This means that one lab could report a 3% normal forms result while another lab could report a 14% normal forms result and both were considered within the acceptable range. This further means that there was an incredible range of answers provided to the proficiency testing service from the participating laboratories. In the example presented here, it should be noted that sperm with greater than 14% normal forms is considered totally normal by Strict Morphology criteria while sperm with less than 4% normal forms is considered severely compromised using these same criteria. Therefore, the range of reported values that are considered to be acceptable may range from normal to severely compromised. In my own office I generally perform all semen analyses myself since over time (through clinical experience) one acquires a lot of information that is potentially valuable. In particular, one begins to get a sense for what types of sperm seem to be able to result in a pregnancy and what sperm appears to have more compromised reproductive potential. In my opinion, IVF embryologists (who perform a semen analysis, inseminate eggs in vitro with the sperm, and later identify the rate of fertilization of these eggs) and infertility specialists who perform their own semen analyses (then inseminate women with the sperm and determine which of these couples achieve a pregnancy) are in the best position to see correlations between sperm appearance and function.

Round Cells

Case: 24 year old male with a history of one pregnancy in a prior relationship, an unremarkable medical history, and a semen analysis revealing 3-5 round cells per high power field (otherwise normal).

Question: What should be considered given this information?

Answer: Round cells in semen analysis are of unclear reproductive significance. A special stain should be considered to distinguish immature sperm cells (sperm heads without tails) from white blood cells (WBCs). If there is an elevated concentration of WBCs in the semen, this is termed pyospermia or pyosemia. Generally, less than 10% of semen samples examined during an infertility evaluation are found to contain excess WBCs. The reproductive significance of pyospermia (pyosemia) is also not clearly understood. There are no well recognized associations between pyospermia and semen quality (number, motility, morphology of sperm). An association (of unknown reproductive importance) between pyospermia and certain infectious agents has been described in the literature, including Gardnerella Vaginalis and Ureaplasma Urealyticum. Despite the controversial nature of any relationship that may exist between pyospermia and reproductive potential, I generally suggest antibiotic treatment since pyospermia does suggest an inflammatory (or infectious) process that is not normal.

Case: 38 year old male with a history of 2 children, an unremarkable medical history, and a semen analysis that has revealed persistent pyospermia (an excess number of WBCs in the semen) despite a 6 week course of (broad spectrum) antibiotic treatment.

Question: What should be considered given this information?

Answer: Pyospermia is often quite difficult to treat adequately, partially due to the relatively small blood supply to the prostate gland (making delivery of the antibiotic to the most common site of infection less efficient). If the pyospermia has been adequately diagnosed (immature sperm cells ruled out) then I would generally suggest a Urologic evaluation (with a Urologist who has an active interest in fertility), which would generally include a culture of prostatic fluid that is expressed during the examination. If the prostatic fluid culture does not isolate an organism (s) then sterile pyospermia is identified and may not require treatment. There is at least one article in the literature that found clamydia in cultures men with a diagnosis of sterile pyospermia.

Hamster Penetration Assay

Case: 36 year old male with a history of unproven fertility, an unremarkable medical history, a normal semen analysis and a sperm penetration assay revealing a lack of decondensed sperm heads (fertilization) within the hamster eggs.

Question: What should be considered given this information?

Answer: The sperm penetration assay (SPA) uses zona (egg shell) free hamster eggs and human sperm in an attempt to assess the reproductive function (ability to fertilize an egg) of the human sperm. The ability of this testing (SPA) to reliably predict sperm function (or a lack of reproductive function) is highly controversial. Many infertility specialists have abandoned use of the test due to significant problems with its positive and its negative predictive values. The SPA test is highly dependent on specific laboratory conditions. If a decision is made to perform the test, it is therefore very important to perform the test in a facility that is familiar with it. Quality control should always be determined when the SPA test is performed. Generally, an intra-assay coefficient of variation should be established by repeating the analysis of a sperm sample at least 10 times in one assay. This intra-assay (within assay) coefficient of variation should not exceed 10-15%. The inter-assay coefficient of variation should also be determined and should be found to be less than 25%. This between assay coefficient of variation can be determined by used a (frozen stored) sample of sperm with a known ability to penetrate the hamster eggs. I do not change my clinical recommendations based on the results of the SPA test. Therefore, I do not suggest the testing for my own patients. If the couple has had the test before arriving at my office for consultation, I discourage relying on the results of the test to accurately predict sperm function. In one research report, it was found that about 15% of men with no egg fertilization during the SPA test subsequently achieved a human pregnancy.

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