Infertility is defined as when couple fails to conceive after 1 year of unprotected intercourse. 30-35% chances are due to female infertility. 35% can be due to male infertility 30% due to both and in 10%causes is not known. In males disruption can occur at testicular level,intratesticular or post testicular level. In some patients it can be at immunological or genetic level.Proper evaluation of all factors is required for specific management of the cause.
Male reproductive system consists of center’s in brain which regulates pituitary release of gonadotropins and sexual behavior, pair of testis which controls sperm production,ductal system consisting of vas-deferens and epidydimis which stores and transports sperms and accessory glands compromising of seminal vesicle , prostate and bulbo uretheral gland. Due to pulsatile release of Gnrh it stimulates secretion of LH and FSH by anterior pituitary which binds to leydig cells and sertoli cells respectively and helps in spermatogenesis. Testosterone regulates spermatogenesis and also maintains primary and secondary sexual characters. Spermatogenesis is a continuous process and it takes 72-74 days for individual germ cells to mature. Optimum temperature required for spermatogenesis is around 34 degree Celsius.
– Hypothalmopitutiary disorder which contributes to 1-2% of the cause. It can be congenital or acquired.Congenital causes can be due to Kallaman syndrome. In acquired it can be due to pituitary tumor, use of steroids, head injuries, chronic illness like diabetes mellitus, infections, obesity etc
.-Primary gonadal disorder which can be due to congenital or acquired causes. Congenital causes consisting of Klinefilter syndrome, y chromosome micro deletion, single gene polymorphism, chronic illness like cancer, drugs used in treatment of cancer or environmental causes.Acquired causes can be due to varicocele, infections like tuberculosis, mumps.
-Defective sperm transport which can be due to ejaculatory failure or at the level of epididymis and ejaculatory ducts.Congenital causes can be due to cabvd, kartgeners syndrome, young’s syndrome.Acquired causes can be due to vasectomy, ejaculatory dysfunction,infections like tuberculosis, Chlamydia or gonorrhea.
-Unexplained infertility is responsible for 10-20% of cases where semen analysis is normal, ovulation and uterine cavity is normal with at least one tube functional.
*SPERM AND ITS ROLE IN FERTILIZATION
Sperm is a male gamete which can fertilize female gamete. They are produced in semniferous tubules of testes. Sperms are not visible to naked eye but can be viewed under the microscope. They have round head and long tail. Head contains nucleus which carries 23 chromosomes and tail enables the sperm for movement. In process of fertilization mature oocytes meet the spermatozoa in the Fallopian tube. Sperms bind to oocyte surface and penetrates zona pellucida. Once it penetrates zona pellucida the 23 chromosomes in sperm head join with 23 chromosome in eggs nucleus and forms embryo with 46 chromosomes and this ends the process of fertilization.
*WHAT IS SEMEN ANALYSIS AND WHY IS IT DONE
Semen analysis is required for infertility testing of male partner. It helps us to find out if sperm production from male side is normal or not. Complete quantity and quality of semen can be analyzed during the process. It is very important to do semen analysis as it tells about the quality of sperm, low sperm count or nil sperms. Secondly it is done to check for success of vasectomy i.e to check if sperm is present in the semen or not. Thirdly it could be done to check reversal of vasectomy to see if good quantity of sperm present in ejaculate post reversal.
*SEMEN ANALYSIS PROCEDURE AND PARAMETERS
Semen analysis is done on freshly ejaculated sperms. After this range of tests are performed under microscope. Reference ranges are compared with WHO parameters. Appearance: it should be whitish to grey in color.It is yellow in case urine is mixes with semen or in jaundice. It can some times be red or pink in color due to presence of RBCs.
Ph: it checks the acidity level of seminal fluid.It is checked by ph paper. Normal values should e 7.2-7.8 but if more than 8 it indicates infection and if it’s low it indicates ejaculatory duct blockage.
Volume: volume is measured by pipette. It should be in range of 2-5 ml. Men with lower volume can have blockage, retrograde ejaculation or hormonal problem. Low volume cannot neutralize acidity in vagina. In case where volume is high sperms get diluted.
Count: Sperm count should be more than 15 million for women to get pregnant.
Motility: Sperm motility is important for its travelling from cervix to Fallopian tube for fertilization. Depending on movement it can be progressive motility, non progressive motility or immotile. Total motility is sum of progressive ad non progressive motility.
Morphology: Shape of sperm is assessed. Head, mid-piece,tail is assessed. Every male has certain percentage of abnormal sperms . 200 sperm should be examined for abnormality. Presence of white blood cells indicates infection.
Fructose level: Determines the energy level. Its absence indicates problem with seminal vesicles.
Viability: It indicates live sperm in semen sample. Viability should be at least 58%.
Liquefaction: Ejaculated semen is thick gel like and it takes 15-30 minutes to liquefy. Liquefaction helps sperm motility, if liquefaction doesn’t happen in given time, its movement gets restricted.Agglutination can also be seen in which motile sperm stick to each other at head, tail or in mixed way. Its presence suggests presence of anti sperm antibody.
*PREPARATION FOR SEMEN ANALYSIS AND WHEN AND HOW SHOULD IT BE COLLECTED
Best way to collect sample for semen analysis is by ejaculation, but those men who are not able to ejaculate there are surgical and electro stimulation technique which helps in recovering sperm.
Before giving semen sample certain instructions need to be followed:
-Avoid ejaculation 1-3 days before semen analysis
.-Avoid alcohol or caffeine 3-5 days before analysis
-Avoid any medication, drinking or alcohol few days prior to seen analysis.
Semen sample should not be given in case of infections.
Semen sample can be collected by various methods:
-Sexual intercourse with condom but no spermicide should be present in condom as it can kill sperms.
-Having sex with withdrawal before ejaculation(coitus interrupts) but it leads to loss of seminal fluid which contains more sperm of better DNA quality.
-Masturbation: This is the best way as sample remains uncontaminated by vaginal fluid and contains semen of best quality.
-Semen sample can also be collected by using simulators. Ejaculation is stimulated by stimulating ejaculatory reflexes.When other retrieval fails there are surgical methods which can be adopted like MESA, PESA,TESA,TESE.
Home collection of sample could be done for men who find it difficult to ejaculate in clinic. The sample should be available in lab within 30 mins to maximum one hour of collection.
Semen analysis report should be compared with reference value of WHO
Normal report needs no repeat testing.
WHO PARAMETER OF SEMEN ANALYSIS (2010)
Semen volume : ≥ 1.5ml
Sperm count : ≥15 million/ml
Total sperm count : ≥39 million
Total motility ≥40%
Progressive motility ≥32%
Sperm Viability : ≥ 58%
Sperm Morphology : ≥ 4%Semen
ph : 7.2-7.8
Sperm Antibodies : ≤ 50% motile sperm showing antibody activity
Abnormal report may show low count, decreased motility and morphology. Increase in ph and presence of WBC may also affect fertility. One semen analysis abnormal report doesn’t mean man is infertile,two or more follow up test should be done to confirm the report.
Semen Analysis Abnormality
Aspermia – absence of sperms
Azoospermia – absence of sperm in semen
Hypospermia-low semen volume
Hyperspermia-high semen volume
Oligozoospemia-very low sperm count
Polyzoospermia: abnormal high sperm count in ejaculate
Asthenozospermia: Poor semen motility
Teratozospermia: Sperm that have morphologicaldefects
Necrozospermia: All sperms in ejaculate are dead
Leucospermia: High level of WBC present in semen.
Hematospermia: Presence of RBC in ejaculate
Semen can be yellow colored due to STD, jaundice,WBC or presence of urine and sometimes semen sample can also green in color due to pro-static infections.
If there is any abnormality in semen report your fertility specialist will get your semen sample repeated again after 6 weeks. If report is still not within normal limits than other tests will be conducted to find out the underlying cause and accordingly appropriate action will be taken!!!