Male Fertility Evaluation
One unusual aspect of this field of medicine is that it involves two patients who may each need to be evaluated. In many cases, both also need to be treated. When it comes to evaluating the man, once you know the four basic parameters of male sexual health — semen, sperm, testosterone and erections — it’s relatively easy to get a fix on a man’s sexual biological age.
What to Expect in a Male Fertility Evaluation
In a visit to his doctor for a fertility evaluation, a man can expect to have a thorough physical examination with emphasis on the genitalia. In addition there may be laboratory tests ordered for hormones and semen analyses and, most importantly, a discussion of any questions and concerns. A man’s partner is strongly encouraged to join him for his fertility evaluation. The doctor will discuss a man’s concerns with him privately and with his partner.
Following are more details on what to expect in a fertility evaluation.
Semen and sperm evaluation
The most commonly used initial test of a man’s ability to conceive children is the semen analysis. Optimally, the man produces semen by masturbation in a private room in the semen analysis laboratory. If that’s not possible, a man may bring semen collected at home into the laboratory. Because men with low sperm numbers may deplete their sperm reserve by ejaculating too frequently, it is best for a man to wait two to three days after his last ejaculation before he performs a semen analysis. Semen analysis results vary widely from sample to sample and throughout the year. This is why a doctor requests that a man provide two semen samples to judge his fertility.
How Sperm are Made
Sperm production is a complex affair, a process referred to as “spermatogenesis.” At the beginning of this process, round, nondescript cells in the testes duplicate. These copies then divide twice to form cells that contain half of the man’s chromosomes. A sperm half cell will ultimately join with the half cell that is the egg to make an embryo. But first, a sperm must dramatically change in shape to become the elegant submarine that swims upstream in the female reproductive organs to penetrate the egg.
The complicated manufacturing of a single sperm requires two to three months to complete, yet the testis produces hundreds of millions to billions of sperm each day. A result of the months-long production of sperm is that, should a man require treatment to improve spermatogenesis, he must wait two to three months before therapy’s effects may be seen.
Sperm Test Limitations
While a semen analysis is the most commonly used initial test for male fertility, it’s not a complete representation of a man’s fertility. Many men with a “normal” semen analysis have problems conceiving children (and sometimes men with an abnormal semen analysis successfully impregnate their partners).
How Semen Analysis Works
The semen analysis measures average aspects of sperm, whereas male fertility is characterized not by the average, but the most exceptional sperm. The most exceptional sperm travels through the entire female reproductive tract, penetrates and fertilizes the egg. No test currently exists that can characterize this extraordinary sperm. As the exceptional sperm is more likely found in a larger number of good sperm, the better the results of the semen analysis, the better a man’s chances, and the shorter time it should take to impregnate his partner.
The World Health Organization publishes the criteria most widely used for semen analysis. However, as described above, the reference value does not guarantee fertility. The main parts of the semen analysis include the items shown in the chart below:
Counting the Sperm
Sperm counts are given as the number of sperm in each milliliter of semen. Healthy men have between 40 million and 300 million sperm per milliliter; the average sperm count is between 60 million and 80 million. Counts below 15 million per milliliter are considered poor, with counts between 15 million and 40 million considered marginal, although possibly fine if other aspects of the sperm are good. Men with counts below 15 million may still be fertile, but it may take longer to initiate a pregnancy and the chances are greater than a pregnancy will not occur. Men with high counts are not guaranteed to be fertile, particularly if an infection or other abnormalities that affect morphology and motility have occurred.
Interpreting a sperm count correctly requires knowing the total volume of semen in a sample. For example, if a man has 15 million sperm per milliliter of semen, it might be considered low. But if he ejaculates 5 milliliters of semen, his total number of sperm is 75 million, which would be considered perfectly adequate.
A low sperm count is almost always the result of some underlying health problem, which can be serious. A low sperm count can be a clue that something is wrong. A low sperm count is like a high fever: The best approach is to find the underlying problem that’s causing the symptom and to treat that underlying problem. Some of the most common underlying problems are:
- hormonal irregularities,
- use of over-the-counter steroids,
- distended veins in the testicles,
- pituitary tumors, and
- testicular cancer.
Morphology: The Shape of the Sperm
Sperm shape is determined by examining semen under a microscope and counting how many appear normal in the area in view. Sperm are made in such vast quantities that semen from even the healthiest man contains many dead or misshapen sperm. It’s considered normal to have as high as 90% of the sperm in a sample be abnormal or dead, though obviously the fewer such sperm, the better for fertility.
To make morphology a more precise measurement, a standard called “strict” criteria were devised. Although the number may vary, laboratories often use 4% as the cutoff for strict morphology. That means if up to 96% of sperm are oddly shaped by strict criteria, the semen is considered normal.
Scientific studies do not agree on the ability of strict morphology to predict sperm function, and even highly trained laboratory personnel may disagree on how many sperm are normal by strict morphology in a single sperm sample. As a result, a strict morphology result may or may not be meaningful in assessing a man’s fertility. Two good rules of thumb are:
- If all of the sperm are abnormally shaped in the same way (for example, they all have perfectly round instead of oval heads), there’s a problem.
- If the abnormal shape is associated with an identified condition such as a varicocele (varicose veins in the scrotum), the condition is likely a problem.
Detects whether there is an infection in the semen. Ejaculates into container (same as semen analysis), drop is cultured in lab to see if bacteria is growing in the semen. Indication of UTI, which causes infertility.
Several infections can lead to problems with the health of your sperm. These include infection of the prostate, epididymitis (inflammation of the epididymis), orchitis (inflammation of the testicles) and gonorrhea. Infections such as these can disrupt sperm count and distort the shape and size of the sperm, which can also interfere with conception.
A sperm’s basic job is to transport its genetic cargo to the egg. The quality of the DNA contained within the sperm may affect egg fertilization and early embryo development. There are two categories of DNA testing: Semen DNA testing which is accomplished through a laboratory analysis of the semen and may show promise in predicting embryo development and pregnancy; and chromosomal DNA testing which looks for abnormalities that may contribute to male infertility.
There are two basic ways to test DNA for Male Infertility
Chromosomal DNA Testing
DNA is organized in cells in chromosomes. Two currently available ways of testing chromosomes are the karyotype, in which a picture is made of the 23 pairs of human chromosomes and missing or extra areas are identified, and the Y-chromosomal microdeletion assay, where specific regions of the Y chromosome are determined to be missing. These tests screen only a fraction of the many genes that contribute to male fertility. While recommended for men with very low sperm counts or no sperm in the ejaculate, a doctor will balance the costs of these tests and the chance of discovering a genetic condition in each man.
Sperm DNA Testing
One commercial test of DNA quality is the sperm chromatin structure assay, or SCSA. The SCSA measures DNA melting in acid, called denaturation. Studies in the scientific literature disagree over whether DNA denaturation as measured by the SCSA predicts embryo development and pregnancy. Other tests of DNA quality include the Comet and the terminal uridine deoxynucleotidyl transferase nick end labeling (TUNEL) assays, both commonly performed in molecular biology laboratories for scientific studies of cells. In scientific journals, researchers have reported correlation between Comet and TUNEL results and embryo quality and in vitro fertilization (IVF) outcomes. Although not yet widely available, Comet and TUNEL may be promising tests to measure sperm DNA quality.
Testosterone levels are checked by drawing a blood sample, usually from the arm. Blood samples should be taken in the morning, since that’s when testosterone levels are highest. If the levels are below or near 300 nanograms per deciliter, another one or two samples may be taken on other days, since testosterone levels fluctuate daily and seasonally.
Whether or not a man has erectile dysfunction is something he and his partner judge for themselves based on their personal experience. All men occasionally can’t achieve an erection; the question is how often it happens. These days a man complaining of erectile dysfunction is usually given a trial prescription for an erection-enhancing pill, unless he can’t take the pill because of other risk factors such as being on a nitrate-containing medication. If the pill fails to work, more elaborate tests can be done to try and pinpoint the problem. Such tests can include injection of erection-producing drugs to check the health of the man’s penile arteries and veins, and the use of devices that detect the presence and quality of night-time erections.