Semen analysis

Semen analysis
Diagnostics
Human sperm stained for semen quality testing in the clinical laboratory.
HCPCS-L2	G0027

A semen analysis (plural: semen analyses) evaluates certain characteristics of a male's semen and the sperm contained in the semen. It may be done while investigating a couple's infertility or after a vasectomy to verify that the procedure was successful. It is also used for testing donors for sperm donation, in stud farming and farm animal breeding. Many men, especially if they are older, have a semen quality analysis, testing for common STIs, and perhaps testing for genetic defects done as part of routine pre-pregnancy testing, though this is decisively not the norm, as most doctors will not test the semen and sperm (and the man's genome and his STI status) unless specifically requested or there is a strong suspicion of a pathology in one of these areas discovered during the medical history or during the physical examination. Such testing, especially at that kind of comprehensive level, is very expensive and time-consuming, and may not be adequately covered by most insurance plans unless the insurance company, within the parameters of the plan and its coverage, accepts the medical evidence that there is a very valid reason for doing so.

Relation to fertility

The characteristics measured by semen analysis are only some of the factors in semen quality. One source states that 30% of men with a normal semen analysis actually have abnormal sperm function.^[1] Conversely, men with poor semen analysis results may go on to father children.^[2]

Collection methods

Further information: Semen collection

The most common way to collect a semen sample is through masturbation, directing the sample into a clean cup.^[2]

A sample may also be collected during intercourse in a special type of condom known as a collection condom. Collection condoms are made from silicone or polyurethane, as latex is somewhat harmful to sperm. Many men prefer collection condoms to masturbation, and some religions prohibit masturbation entirely. Adherents of religions that prohibit contraception may use collection condoms with holes pricked in them.^[3]

A third option for collecting a sample is through coitus interruptus (withdrawal). With this technique, the man removes his penis from his partner near the end of intercourse and ejaculates into a cup.

Finally, if a blockage in the vas deferens is suspected to impede fertility, semen can be taken directly from the epididymis. Such a collection is called per cutaneous epididymal sperm aspiration (PESA). Alternatively, the testicular tissue itself, instead of the sperm produced can be investigated. Then, the collecting method is called TESE.^[4]

Parameters

Examples of parameters measured in a semen analysis are: sperm count, motility, morphology, volume, fructose level and pH.

Sperm count

Approximate pregnancy rate varies with amount of sperm used in an artificial insemination cycle. Values are for intrauterine insemination, with sperm number in total sperm count, which may be approximately twice the total motile sperm count.

Sperm count, or sperm concentration to avoid mixup, measures the concentration of sperm in a man's ejaculate, distinguished from total sperm count, which is the sperm count multiplied with volume.^[5] Over 15^[6] million sperm per milliliter is considered normal, according to the WHO in 2010. Older definitions state 20 million.^[1][2] A lower sperm count is considered oligozoospermia. A vasectomy is considered successful if the sample is azoospermic. Some define success with rare non-motile sperm are observed (fewer than 100,000 per millilitre).^[7] Others advocate obtaining a second semen analysis to verify the counts are not increasing (as can happen with re-canalization) and others still may perform a repeat vasectomy for this situation.

The average sperm count today is around 60 million per milliliter in the Western world, having decreased by 1-2% per year from a substantially higher number decades ago.^[8]

Chips for home use are emerging that can give an accurate estimation of sperm count after three samples taken on different days. Such a chip may measure the concentration of sperm in a semen sample against a control liquid filled with polystyrene beads.^[9]

Total sperm count

Total sperm count, or total sperm number, is the total number of spermatozoa in the entire ejaculate. By WHO, lower reference limit (2.5th percentile) is 39 million per ejaculate.^[6]

Motility

Regarding sperm motility, WebMD defines normal motility as 60% of observed sperm, or at least 8 million per millilitre, showing good forward movement.^[2] The World Health Organization has a similar value of 50% and this must be measured within 60 minutes of collection. WHO also has a parameter of vitality, with a lower reference limit of 60% live spermatozoa.^[6] A man can have a total number of sperm far over the limit of 20 million sperm cells per milliliter, but still have bad quality because too few of them are motile. However, if the sperm count is very high, then a low motility (for example, less than 60%) might not matter, because the fraction might still be more than 8 million per millilitre. The other way around, a man can have a sperm count far less than 20 million sperm cells per millilitre and still have good motility, if more than 60% of those observed sperm cells show good forward movement.

A more specified measure is motility grade, where the motility of sperm are divided into four different grades:^[10]

• Grade a: Sperm with progressive motility. These are the strongest and swim fast in a straight line. Sometimes it is also denoted motility I.
• Grade b: (non-linear motility): These also move forward but tend to travel in a curved or crooked motion. Sometimes also denoted motility II.
• Grade c: These have non-progressive motility because they do not move forward despite the fact that they move their tails. Sometimes also denoted motility III.
• Grade d: These are immotile and fail to move at all. Sometimes also denoted motility IV.

Morphology

Regarding sperm morphology, the WHO criteria as described in 2010 state that a sample is normal (samples from men whose partners had a pregnancy in the last 12 months) if 4% (or 5th centile) or more of the observed sperm have normal morphology.^[6]

Morphology is a predictor of success in fertilizing oocytes during in vitro fertilization.

Up to 10% of all spermatozoa have observable defects and as such are disadvantaged in terms of fertilising an oocyte^[11].

Also, sperm cells with tail-tip swelling patterns generally have lower frequency of aneuploidy.^[12]

Volume

WebMD advises that semen volumes between 1.0 mL and 6.5 mL are normal;^[2] WHO regards 1.5 ml as the lower reference limit.^[6] Low volume may indicate partial or complete blockage of the seminal vesicles, or that the man was born without seminal vesicles.^[1] In clinical practice, a volume of less than 2 mL in the setting of infertility and absent sperm should prompt an evaluation for obstructive azoospermia. A caveat to this is be sure it has been at least 48 hours since the last ejaculation to time of sample collection.

Fructose level

Regarding the level of fructose in the semen, WebMD lists normal as at least 3 ^mg/_mL.^[2] WHO specifies a normal level of 13 μmol per sample. Absence of fructose may indicate a problem with the seminal vesicles.^[1]

pH

WebMD lists a normal pH range of 7.1-8.0;^[2] WHO criteria specify normal as 7.2-7.8.^[1] Acidic ejaculate (lower pH value) may indicate one or both of the seminal vesicles are blocked. A basic ejaculate (higher pH value) may indicate an infection.^[1] A pH value outside of the normal range is harmful to sperm.^[2]

Liquefaction

The liquefaction is the process when the gel formed by proteins from the seminal vesicles is broken up and the semen becomes more liquid. It normally takes less than 20 minutes for the sample to change from a thick gel into a liquid. An abnormally long liquefaction (more than 30 minutes at 37 24°C) time may indicate an infection.^{[citation needed]} In the NICE guidelines, a liquefaction time within 60 minutes is regarded as within normal ranges.^[13]

MOT

MOT is a measure of how many million sperm cells per ml are highly motile,^[14] that is, approximately of grade a (>25 micrometer per 5 sek. at room temperature) and grade b (>25 micrometer per 25 sek. at room temperature). Thus, it is a combination of sperm count and motility.

With a straw ^[15] or a vial volume of 0.5 milliliter, the general guideline is that, for intracervical insemination (ICI), straws or vials making a total of 20 million motile spermatozoa in total is recommended. This is equal to 8 straws or vials 0.5 ml with MOT5, or 2 straws or vials of MOT20. For intrauterine insemination (IUI), 1-2 MOT5 straws or vials is regarded sufficient.^[16] In WHO terms, it is thus recommended to use approximately 20 million grade a+b sperm in ICI, and 2 million grade a+b in IUI.

Total motile spermatozoa

Total motile spermatozoa (TMS)^[17] or total motile sperm count (TMSC)^[18] is a combination of sperm count, motility and volume, measuring how many million sperm cells in an entire ejaculate are motile.

Use of approximately 20 million sperm of motility grade c or d in ICI, and 5 million ones in IUI may be an approximate recommendation.

Others

The NICE guidelines also include testing vitality, with normal ranges defined as more than 75% of sperm cells alive.^[13]

The sample may also be tested for white blood cells. A high level of white blood cells (over 1 million per milliliter) may indicate an infection.^[1]

Abnormalities

• Aspermia: absence of semen
• Azoospermia: absence of sperm
• Hypospermia: low semen volume
• Oligozoospermia: low sperm count
• Asthenozoospermia: poor sperm motility
• Teratozoospermia: sperm carry more morphological defects than usual

Factors that influence results

Apart from the semen quality itself, there are various methodological factors that may influence the results, giving rise to inter-method variation.

Compared to samples obtained from masturbation, semen samples from collection condoms have higher total sperm counts, sperm motility, and percentage of sperm with normal morphology. For this reason, they are believed to give more accurate results when used for semen analysis.

If the results from a man's first sample are subfertile, they must be verified with at least two more analyses. At least 2 to 4 weeks must be allowed between each analysis.^[19] Results for a single man may have a large amount of natural variation over time, meaning a single sample may not be representative of a man's average semen characteristics.^[20] In addition, sperm physiologist Joanna Ellington believes that the stress of producing an ejaculate sample for examination, often in an unfamiliar setting and without any lubrication (most lubricants are somewhat harmful to sperm), may explain why men's first samples often show poor results while later samples show normal results.

A man may prefer to produce his sample at home rather than at the clinic. The site of semen collection does not affect the results of a semen analysis.^[21]

Measurement methods

Volume can be determined by measuring the weight of the sample container, knowing the mass of the empty container. Sperm count and morphology can be calculated by microscopy. Sperm count can also be estimated by kits that measure the amount of a sperm-associated protein, and are suitable for home use.^[22]

Computer Assisted Semen Analysis (CASA) is a catch-all phrase for automatic or semi-automatic semen analysis techniques. Most systems are based on image analysis, but alternative methods exist such as tracking cell movement on a digitizing tablet.^[23][24] Computer-assisted techniques are most-often used for the assessment of sperm concentration and mobility characteristics, such as velocity and linear velocity. Nowadays, there are CASA systems, based on image analysis and using new techniques, with near perfect results, and doing full analysis in a few seconds. With some techniques, sperm concentration and motility measurements are at least as reliable as current manual methods.^[25]

See also

• Semen quality
• Artificial insemination for more details of how semen parameters affects pregnancy rate

References

1. ^ ^{a b c d e f g} "Understanding Semen Analysis". Stonybrook, State University of New York. 1999. http://www.uhmc.sunysb.edu/urology/male_infertility/SEMEN_ANALYSIS.html. Retrieved 2007-08-05. 
2. ^ ^{a b c d e f g h} Essig, Maria G.; Edited by Susan Van Houten and Tracy Landauer, Reviewed by Martin Gabica and Avery L. Seifert (2007-02-20). "Semen Analysis". Healthwise. WebMD. http://www.webmd.com/infertility-and-reproduction/guide/semen-analysis?page=1. Retrieved 2007-08-05. 
3. ^ Kippley, John; Sheila Kippley (1996). The Art of Natural Family Planning (4th addition ed.). Cincinnati, OH: The Couple to Couple League. pp. 306–307. ISBN 0-926412-13-2. 
4. ^ Fertility Center, Stockholm (translated from Swedish)
5. ^ sharedjourney.com - Male Infertility Testing
6. ^ ^{a b c d e} Cooper TG, Noonan E, von Eckardstein S, et al. (2010). "World Health Organization reference values for human semen characteristics". Hum. Reprod. Update 16 (3): 231–45. doi:10.1093/humupd/dmp048. PMID 19934213. http://www.who.int/reproductivehealth/topics/infertility/cooper_et_al_hru.pdf. 
7. ^ Rajmil O, Fernández M, Rojas-Cruz C, Sevilla C, Musquera M, Ruiz-Castañe E (2007). "Azoospermia should not be given as the result of vasectomy" (in Spanish; Castilian). Arch. Esp. Urol. 60 (1): 55–8. PMID 17408173. 
   Dhar NB, Bhatt A, Jones JS (2006). "Determining the success of vasectomy". BJU Int. 97 (4): 773–6. doi:10.1111/j.1464-410X.2006.06107.x. PMID 16536771. 
8. ^ The sperm count has been decreasing steadily for many years in Western industrialized countries: Is there an endocrine basis for this decrease? The Internet Journal of Urology TM. ISSN: 1528-8390
9. ^ New Chip Provides Cheap At-Home Sperm Counting By Stuart Fox Posted 01.26.2010 in Popular Science
10. ^ Shared Journey: Semen Analysis
11. ^ Sadler, T. (2010). Langman's medical embryology. (11th ed. ed.). Philadelphia: Lippincott William & Wilkins. pp. 30. ISBN 978-0-7817-9069-7. 
12. ^ Pang MG, You YA, Park YJ, Oh SA, Kim DS, Kim YJ (June 2009). "Numerical chromosome abnormalities are associated with sperm tail swelling patterns". Fertil. Steril. 94 (3): 1012–1020. doi:10.1016/j.fertnstert.2009.04.043. PMID 19505688. 
13. ^ ^{a b} [1] Fertility: Assessment and Treatment for People with Fertility Problems. London: RCOG Press. 2004. ISBN 1-900364-97-2. 
14. ^ Cryos International - What does MOT mean?
15. ^ Cryos International - What is a straw?
16. ^ Cryos International - How much sperm should I order?
17. ^ Merviel P, Heraud MH, Grenier N, Lourdel E, Sanguinet P, Copin H (November 2008). "Predictive factors for pregnancy after intrauterine insemination (IUI): An analysis of 1038 cycles and a review of the literature". Fertil. Steril. 93 (1): 79–88. doi:10.1016/j.fertnstert.2008.09.058. PMID 18996517. 
18. ^ Pasqualotto EB, Daitch JA, Hendin BN, et al. (October 1999). "Relationship of total motile sperm count and percentage motile sperm to successful pregnancy rates following intrauterine insemination". J. Assist. Reprod. Genet. 16 (9): 476–82. doi:10.1023/A:1020598916080. PMID 10530401. http://www.kluweronline.com/art.pdf?issn=1058-0468&volume=16&page=476. 
19. ^ Weschler, Toni (2002). Taking Charge of Your Fertility (Revised ed.). New York: HarperCollins. pp. 189. ISBN 0-06-093764-5. 
20. ^ "Adequate Analysis Frequency". Kokopelli Technologies. 2007. http://www.fertilityformen.com/info_why.php#frequency. Retrieved 2007-08-11. 
21. ^ Shetty Licht R, Handel L, Sigman M (2007). "Site of semen collection and its effect on semen analysis parameters". Fertil Steril. 89 (2): 395. doi:10.1016/j.fertnstert.2007.02.033. PMID 17482174. 
22. ^ dailyprogress.com > Charlottesville company sends out its home male sterility tests By Brian McNeill. Published: May 14, 2009
23. ^ Mortimer ST (1 July 2000). "CASA--practical aspects". J. Androl. 21 (4): 515–24. PMID 10901437. http://www.andrologyjournal.org/cgi/reprint/21/4/515. Retrieved 2007-08-05. 
24. ^ Hinting A, Schoonjans F, Comhaire F (1988). "Validation of a single-step procedure for the objective assessment of sperm motility characteristics". Int. J. Androl. 11 (4): 277–87. doi:10.1111/j.1365-2605.1988.tb01001.x. PMID 3170018. 
25. ^ Testing of Accubead in: Tomlinson MJ, Pooley K, Simpson T, et al. (April 2010). "Validation of a novel computer-assisted sperm analysis (CASA) system using multitarget-tracking algorithms". Fertil. Steril. 93 (6): 1911–20. doi:10.1016/j.fertnstert.2008.12.064. PMID 19200972. 

External links

• Geneva Foundation for Medical Education and Research - complete list of parameters.