Infertility affects many couples worldwide, with male factors contributing to approximately half of all cases. When a couple experiences difficulty conceiving after one year of regular, unprotected intercourse, it is crucial to evaluate both partners. In the case of a male, it should include a complete reproductive history checkup and analysis of at least two semen samples. If any abnormality is detected, further thorough medical and physical examination should be carried.
There are multiple tests to assess various aspects of male infertility. We will discuss these tests, along with other important information about male factor infertility and potential treatments that can be effective in such cases.
Initial Evaluation
During the initial assessment, the healthcare provider will typically inquire about several key areas, including:
Past Medical History - A review of previous medical conditions, surgeries, and medications used by the patient.
Family History - Discussion about any family history of infertility or birth defects that may have a genetic component.
Social History - A careful examination of the patient's social habits and occupational risks to assess potential exposure to substances that could adversely affect fertility.
Semen analysis
A key component of male fertility testing is semen analysis. Semen samples can be collected by masturbating and ejaculating into a special container. The evaluation encompasses several critical aspects of sperm quality, including sperm motility (movement), sperm morphology (shape) and maturity, ejaculate volume, sperm count, and ejaculate liquidity. Each of these factors play a crucial role in male fertility. The semen is also checked for signs of infections or other problems. If the semen analysis is normal, the focus may shift to testing the female partner.
Usually, sperm counts can fluctuate. Therefore, to ensure precision, the specimen should be collected through masturbation into a sterile container after abstaining for 2-3 days to maximize sperm count and quality. Each additional day of abstinence typically boosts semen volume by 0.4 mL and sperm density by 10-15 million sperm/milliliter, but abstinence for more than several days can not make any changes in sperm and can even have negative effects. Therefore, abstinence is recommended only for several (3-4) days. Ideally, the sample should be evaluated within one or two hours of collection for optimal accuracy.
Sperm shape
A normal result for sperm shape is that more than 50 percent of sperm are normally shaped. If a man has greater than 50 percent of sperm that are abnormally shaped, this reduces his fertility. A laboratory may identify abnormalities in the sperm’s head, midsection, or tail.
These abnormalities can hinder the sperm's ability to move effectively towards the egg and penetrate its protective outer layer. Immature sperm may also be observed during analysis. These immature sperm cells lack the necessary structures and characteristics to successfully fertilize an egg, contributing to infertility issues.
Sperm motility
Achieving normal fertility requires that more than 50% of sperm exhibit normal movement, known as motility, within one hour after ejaculation. Motility is crucial as it enables sperm to travel towards and fertilize an egg successfully.
To assess sperm motility accurately, automated systems analyze sperm movement and assign scores ranging from 0 to 4. A score of 0 indicates immobile sperm, while scores of 3 or 4 indicate vigorous and effective movement, essential for reaching and penetrating the egg.
pH
pH, or potential hydrogen, refers to the acidity or alkalinity level of semen. In the context of fertility testing, a normal pH level typically falls between 7.2 and 7.8. This range is considered optimal for maintaining sperm viability and function.
A pH level higher than 8.0 may suggest the presence of infection in the male reproductive system, such as prostatitis or seminal vesiculitis. Infections can alter the pH balance of semen, making it more alkaline.
On the other hand, a pH level below 7.0 could indicate contamination of the specimen, possibly from urine, or it may indicate blockage in the ejaculatory ducts, preventing the normal secretion of alkaline fluids into semen.
Sperm Volume
The volume of semen refers to the amount of fluid expelled during ejaculation. In fertility assessments, a normal semen volume typically exceeds 2 milliliters. This volume is considered sufficient to transport and nourish sperm as they travel through the female reproductive tract towards the egg.
A low semen volume may indicate a reduced quantity of sperm available for fertilization which can potentially impact fertility because a smaller amount of sperm may not adequately reach and penetrate the egg.
Conversely, an excessive fluid volume in semen could dilute the concentration of sperm present. Although in that case, the total volume may be higher, the actual number of sperm per milliliter of semen is lower, which reduces the chances of successful fertilization.
Sperm Liquefaction
Sperm liquefaction refers to the process where semen changes from a thick, gel-like consistency immediately after ejaculation to a more watery consistency over time. This transformation is crucial for sperm motility - the ability of sperm to move effectively through the female reproductive tract towards the egg.
Normally, semen should liquefy within 15 to 30 minutes after ejaculation. If liquefaction does not occur within this time frame, it may indicate an issue with fertility. Delayed or absent liquefaction can hinder sperm movement, hence its ability to reach and fertilize the egg.
Sperm count
The sperm count, also referred to as sperm density, indicates the concentration of sperm present in a given volume of semen. In a normal semen analysis, the sperm count typically ranges from 20 million to over 200 million sperm per milliliter (mL) of semen. When the sperm count is low — below the normal range — conceiving can be more challenging.
Sperm Appearance
The appearance of semen in a normal state should typically be whitish to gray and opalescent. This color and opacity indicate normal levels of various proteins and other substances present in semen.
However, deviations from this norm in color can indicate potential health issues or external factors:
Red-brown tint - This may indicate the presence of blood in the semen, which could result from infections, trauma to the genital tract, or other underlying conditions that affect the reproductive system.
Yellow tint - A yellowish color may suggest jaundice, a condition where there is an excess of bilirubin in the blood. It can also be a side effect of certain medications or indicate the presence of substances like urine in the semen due to improper collection techniques.
Monitoring the color and appearance of semen during a semen analysis is important in diagnosing potential health issues that may affect male fertility. Any unusual colors or appearances should be discussed with a healthcare provider to determine the underlying cause and appropriate management.
Infection
An elevated presence of white blood cells (WBCs) in semen can indicate infections or inflammation within the genital tract. White blood cells and germ cells both appear as round cells under microscopic examination, making it challenging to distinguish between them visually.
To differentiate between white blood cells and germ cells accurately, immunohistochemical stains are employed. These stains target specific markers on cells, allowing for precise identification and classification. Immunohistochemical staining is typically performed when more than 5-10 round cells per high-power field (HPF) are observed in semen analysis.
This approach helps healthcare providers diagnose and differentiate between infectious or inflammatory conditions affecting the male reproductive system, guiding appropriate treatment strategies
Antisperm antibody test
Sperm contain unique antigens that are not recognized as self by the body's immune system because of the blood-testis barrier. However, this barrier can be breached due to factors like infection, vasectomy, testicular torsion, cryptorchidism (undescended testicles), or testicular trauma. When this happens, the immune system may produce antisperm antibodies.
Antisperm antibodies are antibodies that recognize sperm antigens as foreign and can bind to sperm cells. This binding can impair sperm function by reducing their ability to move effectively (motility), penetrate cervical mucus, and bind to the zona pellucida (outer layer of the egg).
After a vasectomy, approximately 60% of men may develop antisperm antibodies, although the clinical significance of this is not fully understood. In cases of Congenital Bilateral Absence of the Vas Deferens (CBAVD), about 35% of patients may have these antibodies. The presence of antibodies bound directly to sperm cells (rather than in serum or seminal plasma alone) is more indicative of potential fertility issues.
Signs that may indicate the presence of antisperm antibodies include abnormal clumping or agglutination of sperm, reduced motility without an obvious cause, or abnormal results from a postcoital test (test done after sexual intercourse to assess sperm viability).
Various methods are available to detect antisperm antibodies, including radioimmunoassay and enzyme-linked immunosorbent assay (ELISA). However, the most specific test is the immunobead test, where more than 15-20% of sperm bound by antibodies is considered a positive result. These tests can help healthcare providers give a proper diagnosis.
Hormonal analysis
Around 3% of male infertility cases are believed to stem primarily from hormonal factors. During the initial evaluation for infertility, specific serum hormone levels will be checked. This typically involves assessing levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, and prolactin.
Abnormalities in these hormone levels can indicate underlying issues originating from the hypothalamus, pituitary gland, or testes themselves. For instance, low levels of testosterone or high levels of FSH and LH may suggest dysfunction in the testes, whereas elevated prolactin levels could indicate a pituitary gland problem.
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