Advanced Reproductive Medicine & Gynecology of Hawaii, Inc.

John L. Frattarelli, MD

Reproductive Endocrinology & Infertility

LeighAnn C. Frattarelli, MD, MPH

Gynecology & Reproductive Medicine

Male Infertility - Evaluation and Testing

Dr Frattarelli has evaluated and treated many couples in Hawaii and elsewhere for male infertility. Dr. Frattarelli's research on male infertility has allowed many to receive male infertility treatment in his Oahu fertility clinic, in Honolulu and windward Oahu (Kailua)

The Male Reproductive System

The male reproductive system is also under the influence of hormones and is responsible for producing sperm. The same hormones that regulate female reproductive functions also regulate the production of sperm in the male. FSH stimulates sperm production, and LH stimulates the production of the hormone testosterone. Testosterone helps maintain sperm production, sexual desire, and male characteristics such as hair growth.

Sperm is produced by the testes (or testicles). The scrotum protects the testes and maintains a constant temperature, which is somewhat lower than normal body temperature, to help sperm develop properly. As sperm are produced, they pass from the testes through the coiled channels of the epididymis, which is an organ that stores and nourishes sperm as they mature.

Once sperm are completely mature (spermatozoa), they move into the vas deferens. This tubal structure connects the epididymis with the seminal vesicles, which are two pouchlike glands that store mature sperm. The entire process of sperm formation to maturation takes about 72 days. However, this is an ongoing process, and sperm are being manufactured all the time.

When a man ejaculates (releases fluid from his penis during intercourse), the sperm from the seminal vesicles combine with a thick fluid from the prostate gland to create semen. The fluid (ejaculate) is deposited into the woman’s vagina. Sperm can live 48 –72 hours with the female reproductive tract, retaining the ability to fertilize an egg. This is why sexual intercourse around the time of ovulation is necessary for conception to occur.

The sperm’s ability to fertilize an egg

Several factors determine whether a man’s sperm can fertilize an egg. Semen quality and quantity may affect the ability of sperm to fertilize the egg successfully. The ability of sperm to move referred to as mobility, appear to be one of the most important factors in determining the fertilizing capability of sperm. Even with a low sperm count, men with highly motile sperm may still be fertile. The shape of the sperm referred to as morphology, may also affect its ability to fertilize an egg. In addition, the sperm must live long enough to reach the egg, characteristics know as viability.

Semen Analysis and Anti-Sperm Antibodies

Infertility is a couples’ problem. Most studies suggest that problems with the male account for about 40 % of all infertility, while couples with problems with both partners’ account for another 20%. The basic test to evaluate fertility in the male is the Semen Analysis.

The purpose of the semen analysis is to:

  1. evaluate the seminal plasma for abnormalities in its density, volume and biochemical characteristics
  2. look at the sperm under the microscope for abnormalities in number, shape and movement

Based on the results of the semen analysis, recommendations on further evaluation and/or therapy may be made.

How to Schedule a Semen Analysis

  1. Call the office to schedule the semen analysis.
  2. An appointment is absolutely necessary so that the specimen may be evaluated in an appropriate and timely manner.
  3. If you are unable to make the appointment, please call the scheduling number to cancel, so that another patient may be scheduled.
  4. All specimens should be produced by masturbation. Never use over-the-counter condoms meant for contraception: they are toxic to sperm. If collection is by other than masturbation, you will be given a special sterile condom by our office, along with special directions on how to use it.

Specimen Collection Instructions

  1. Refrain from any sexual activity that would result in ejaculation of semen for at least 2 days, but not longer than 5 days prior to the specimen collection.
  2. The specimen will be collected by masturbation in a private room in the office complex or at home.
    • a. You will be provided a sterile container from the laboratory.
    • b. No lubricants (except mineral oil) are to be used because they are bad for the sperm.
    • c. Wash your hands prior to producing the specimen to minimize the chances for contamination.
    • d. Remove the lid from the container.
    • e. Produce the specimen.
      • i. Avoid touching the inside of the container with your fingers or penis.
      • ii. Replace the lid immediately after completing the collection.
      • iii. Interrupted intercourse is not an acceptable method of collection for infertility purposes.
    • f. Please deliver your sample directly by handing it to a lab representative.

Home Collections

The most accurate semen analysis is the one that has been produced at the lab and evaluated promptly. We strongly urge you to produce the specimen at our facility if at all possible. However, we understand that this is not feasible for all couples. Please follow the instructions below for home collections:

  1. Obtain a sterile collection container from the office.
  2. This specimen should also be produced by masturbation.
  3. Follow the collection instructions above.
  4. Make sure the specimen is properly labeled.
  5. The specimen should be delivered to the laboratory within one hour of ejaculation.
  6. Care should be taken to maintain the specimen at body temperature (carried upright in an inside pocket, close to the body).
  7. DO NOT refrigerate the specimen or place it in hot water.
  8. If there are problems with the collection, please let the lab personnel know, as this will aid in interpretation of the specimen.

Interpreting the Results of the Semen Analysis

At its most basic level, the infertility work-up is trying to determine which is the optimal method to deliver the sperm to the egg. There are 4 ways to deliver the sperm to the egg: (1) intercourse, (2) artificial insemination, (3) in vitro fertilization (IVF), and (4) IVF using intracytoplasmic sperm injection (ICSI).

The semen analysis results are interpreted within the context of the couple’s entire evaluation to provide the most efficient and effective means of sperm delivery for a given situation.

sperm_analysis

Semen Analysis Normal Values

Volume:
2.0-5.0 cc

If the volume is too small, there may not be enough to get to the cervix, if there is too much, it may dilute the sperm.

Concentration: >20 million/cc

Sperm concentrations may vary widely from within the same individual. Among the factors that can effect the concentration include frequency of ejaculation, environmental factors, surgery/trauma, heat and ingestables (drugs, alcohol, recreational drugs). About 20-25% of fertile men actually have counts below 20 million.

Motility:
50%

This is the proportion of sperm that are swimming.  They may swim very fast, moderately fast or slow.  The sperm may also wiggle in place or not move at all.

Morphology:

The overall appearance of the sperm.  The normal range of morphology depends on the laboratory analysis.  Please consult with your physician concerning the result.

White Blood Cells:
< 1 million/cc

The presence of WBC suggest that an inflammatory process is ongoing in the male reproductive tract. They can secrete factors that inhibit a sperm’s ability to move and fertilize an egg. White blood cells may be markers for infection, which can be treated with antibiotics.

Antisperm Antibodies in Men

Antibodies are large proteins that are produced by a type of white blood cell known as plasma cells. Antibodies can bind to the outer cell membranes of cells that the body recognizes as foreign. This process marks the cell they are bound to for destruction by white blood cells. It has been known for a long time that experimental animals could be made infertile by immunizing them with sperm. The sperm are normally isolated from the rest of the body in the seminiferous tubules. If there is disruption of the tubules and sperm are exposed to the immune system, they are recognized as foreign and elicit an antibody response. Anti-sperm antibodies can be found in 8-10% of men. In men with a history of infection, trauma or surgery, the antibodies can be found in up to 60% of the men. Often, however, there is no known cause for their presence. When the antibody binds to the sperm, they may alter the sperm’s ability to swim (if bound to the tail) or fertilize an egg (if bound to the head). When there are a large percentage of sperm with antibodies bound to them, there is a good chance for fertilization failure, even with IVF. ICSI is very effective in overcoming this.

Antibodies to Sperm

Anti-Sperm Antibody Testing

Anti-sperm antibody testing is done directly on the sperm. In some cases, the test can also be performed on the female partner’s blood. Your doctor will decide if female partner testing is warranted. The male partner simply has to produce a specimen according to the directions give above. In the laboratory, the sperm are then exposed to latex beads that have antibodies attached to them. The antibodies on the latex beads will allow the latex beads to attach to the antibodies on the sperm. This is done because the antibodies are not visible, but the latex beads are visible under the microscope. The number of sperm with beads attached to them is counted. If more than 50% of the sperm have beads attached to them, the test is considered to be clinically significant.

Negative Environmental Factors and Sperm Function

Men have the benefit of being able to continuously produce sperm (in contrast to a woman being limited to 300-400,000 oocytes that she is born with). This allows men to make behavioral changes that might improve sperm quality. A variety of chemicals are used by men that can adversely affect sperm production and/or function. These include alcohol, marijuana, cocaine, cigarette smoke, and narcotics. For the occasional user of these substances, stopping their use can result in improved semen parameters in 3-6 months for some men.

However, long-term use can result in permanent impairment. A number of drugs also contribute to problems with sperm. These include calcium-channel blockers (anti-hypertensives, see list below), cimetidine, spironolactone, nitrofurantion, sulfasalazine, erythromycin, tetracycline, and anabolic steroids. Other drugs that can be problematic include chromium picolinate, DHEA, ansdrostendione, colchicines, methotrexate and niradazole. Calcium –channel blockers are particularly important to know about, as the sperm can appear normal, but not be able to fertilize an egg because of changes induced in the sperm cell membrane by the medicine.

Chemical exposures by other means can affect sperm production/function. These include heavy metals (lead, mercury, boron), organic solvents (acetone, ethylene glycol, benzene, toluene, etc) and pesticides (dibromochloropropane, ethylene dibromide, carbaryl, chordecone,). Other physical factors that have been associated with sperm abnormalities or reduced fertility include, heat, vibration (truck driving, bike riding), electromagnetic fields and microwave radiation. Therapeutic interventions might include the use of artificial insemination, donor insemination, in vitro fertilization or intracytoplasmic sperm injection with IVF.

Calcium Channel Blockers.  Below are listed the calcium channel blockers that are listed below from the 2001 PDR. If you are on one of these drugs, it is important to tell your doctor and nurse. Calcium channel blocker can alter the sperm cell membrane so that they cannot fertilize an egg, despite being normal in every other way. If you are not sure about one of your medications, please ask your doctor or nurse.

Generic Name Brand Name
Amlodipine Norvasc
Bepridil   Vascor
Diltiazem  Cardizem, Tiazac
Felodipine Plendil
Nicardipine      Cardene
Nifedipine Adalat, Procardia
Nimodipine    Nimotop
Nisoldipine  Sular
Verapamil    Calan, Covera, Isoptin, Verelan

In approximately 40% of infertility cases, abnormalities of the sperm are found. These can include decreased numbers of sperm (oligospermia), decreased sperm motility (asthenospermia) or an unusually high number of abnormally shaped sperm (teratospermia). Some of the common causes of infertility include:

Previous Cancer Treatment:  Chemotherapy and radiation can cause abnormal sperm or sterility.

DES (diethylstilbestrol) exposure prior to birth:  Synthetic estrogen used in the 50’s and 60’s used by women to prevent miscarriage. Can cause low sperm counts, decreased sperm motility, and abnormal sperm forms, small penises, undescended testicles (risk factor for testicular cancer) abnormal testicles.

Hormonal imbalances:  Hormone problems affecting sperm count include thyroid problems, low testosterone levels, elevated FSH, and excess prolactin (see next entry).

Immune problems: Immune reactions to sperm in the man (autoimmune) can be a problem post-vasectomy, but may also have other causes. Anti-sperm antibodies can “attack” the sperm, thus preventing it from being able to fertilize the egg.

Impotence/ Sexual Dysfunction:  There are a variety of medical causes that can contribute, including diabetes mellitus, medications such as antidepressants, etc. Viagra, according to the manufacturer, does not appear to have any negative impact on sperm. Up to 20% of men may have decreased sexual desire, inability to maintain an erection, and premature ejaculation. This could result from low testosterone or performance anxiety.

Infection:  Mumps contracted after childhood and, occasionally, venereal diseases such as gonorrhea and chlamydia can harm male fertility. Also, recurrent infections of the prostate can lower sperm count and motility.

Genetic Abnormalities:  A small percentage of infertile men have Klinefelter's Syndrome; they have two X chromosomes and one Y chromosome, rather than the normal one X and one Y. They are generally tall and thin, with small testicles.

Lifestyle factors:

Obstruction/Blockage:  due to prior surgery or infection the vas deferens may be damaged.

Previous Vasectomy:  Vasectomies can often be reversed. However, the more time has passed, the more likely it is that the man will have an immune reaction to his own sperm and the lower the chance of being able to produce a pregnancy. Retrograde ejaculation: Can be caused by certain medications, surgeries, and nerve damage (for example, from diabetes mellitus). Sperm goes in the wrong direction and is ejaculated into the bladder.

Trauma to testicles:  Severe injury to the testicles can result in decreased sperm production.

Varicocele:  An enlarged vein in the scrotum, which causes pooling of blood and an elevated temperature. Although controversial, some argue it is one of the most common and readily treatable causes of male infertility. Others say that varicocele is also common among fertile men, and question the connection with infertility and the need for treatment. In general, very large or painful varicoceles that go untreated can cause permanent damage to the testicles. This can lead to should be treated. The options are either surgery to close it off, or balloon insertion to block the blood flow.

TREATMENT:

Intrauterine Insemination

Sperm is carefully washed and prepared so that the most motile and viable sperm are concentrated into a very small volume to be injected into the uterine cavity. Searching through about a dozen medical journal articles and a number of web sites resulted in a rather wide-range of statistics. Basically the odds of success are reported to be just under 8% and as high as 26% per cycle. The low statistics are with one follicle, while multiple follicles resulted in as high as 26% success. Another influencing factor is sperm count. Higher sperm counts increase the odds of success, however, there was little difference between success with good-average counts and those with high counts. The overall success rate seems to be between 15-20% per cycle based on the current literature. The rate of multiple gestation pregnancies was 23-30%.

Donor Insemination (DI)

The option of donor sperm has been available to those couples with severe male infertility for a long time. Now with the addition of ICSI almost all-severe male factor infertility is treatable. However some couples may choose to use donor sperm from one of many certified sperm banks across the country due to concerns of genetic disorders that effect sperm production (like Cystic Fibrosis). Once a donor is chosen, the sperm is washed and prepared in a similar fashion to that of an IUI.