Of patients presenting for fertility evaluation for their first pregnancy, 15% will fail to achieve pregnancy. Over 50% of all infertility cases can be ascribed to male factor involvement. Of these cases, the breakdown is as follows:
Male factor only 33%
Combined male and female factors 20%
The appropriate evaluation of the male partner is therefore very important.
The evaluation of the male partner should include the following:
1. Historical review.
|BOX 1. Factors in Male Infertility History|
|History of Infertility|
|Evaluation and treatment of wife|
|Timing of intercourse|
|Frequency of intercourse|
|Frequency of masturbation|
|Childhood and Development|
|Undescended testicles, orchiopexy|
|Y-V plasty of bladder|
|Onset of puberty|
|Systemic illness (e.g., diabetes mellitus, multiple sclerosis)|
|Previous or current therapy|
|Orchiectomy (testis cancer, torsion)|
|Pelvic, inguinal or scrotal surgery|
|Y-V plasty, transurethral prostate resection|
|Tuberculosis, smallpox (rare)|
|Drugs (chemotherapeutic, cimetidine, sulfasalazine, nitrofurantoin,alcohol, marijuana, androgenic steroids)|
|Androgen receptor deficiency|
|Review of Systems|
|Impaired visual fields|
The evaluation of the subfertile male
a. Childhood illnesses
b. Existing medical disease review
c. Prior surgeries
d. Family history
e. Sexual development
f. Exposure to toxins
(4) Toxic fumes
(5) Tobacco use
(6) Drug and recreational drug use (marijuana, cocaine, hallucinogens, etc.)
2. Physical examination: A “fertility-focused” examination should seek to identify physical characteristics within organ systems that may contribute to or identify the male factor in a couple’s infertility (Table 6-1).
|Table 6-1 Focal Points of the Mate Physical Examination|
|1. Habitus||Eunuchoid proportions||Klinefelter^ syndrome|
|2. Vital signs||Orthostatic hypotension||Autonomic insufficiency|
|3. Head, eyes, and nose||Diminished beard||Androgen deficiency|
|Bitemporal hemianopsia||Pituitary tumor|
|4. Neck||Thyromegaly||Hypothyroidism or hyperthyroidism|
|5. Lungs||Wheezes, rhonchi, rales||Cystic fibrosis|
|Inguinal hernia||Prior cryptorchidism|
|a. Penis||Decreased length*||Hypospadias|
|Occluded||Partial urethral obstruction|
3. Tests. ,
a. Urinalysis and postejaculate urine: Rule out urinary tract infections, retrograde ejaculation, and medical renal diseases.
b. Chlamydia and gonorrhea cultures (optional and where indicated).
c. Endocrine evaluation: Knowledge of the hypothalamic—pituitary— gonadal (H—P—G) axis is important in the evaluation of the sub-fertile and infertile male. The H—P—G axis is a negative-feedback loop; the entire system is directed by pulsatile release from the hypothalamus of GnRH, which causes pituitary release of FSH and LH. The FSH acts on the Sertoli component of the testis with the release of inhibin, whereas the LH stimulates the Leydig cell component to release testosterone. The combination of high intratesticular levels of testosterone plus the effect of FSH on Sertoli cells is responsible for spermatogenesis. Both enter into the systemic circulation and, through negative feedback, inhibit the release of GnRH. The endocrine evaluation allows for the categorization of male patients as follows1:
(a) Normal FSH
(b) Normal LH
(c) Normal testosterone
(2) Hypogonadotropic (hypogonadotropic hypogonadism)
(a) Low FSH
(b) Low LH
(c) Low testosterone
(3) Hypergonadotropic (hypergonadotropic hypogonadism)
(a) Elevated LH -» Leydig cell dysfunction —> gonadal failure
(b) Decreased testosterone Leydig cell dysfunction —| gonadal failure
(c) Elevated FSH —> spermatogenic dysfunction —i gonadal failure
(4) Only in conditions associated with obstructive azoospermia or retrograde ejaculation are all hormonal levels within normal limits.
d. Semen analysis: Normal semen, as defined by the World Health Organization, is an admixture of spermatozoa suspended in secretions from the testes and epididymes, which are mixed at the time of ejaculation with secretions from the prostate, seminal vesicles, and bulbourethral glands. The final composition is a viscous fluid that comprises the ejaculate.
(1) Requirements are as follows:
(a) 48 to 72 hours of abstinence.
(b) Multiple analyses (minimum of three recommended) separated by 2-week to 4-week intervals.
(c) A specimen: Generally obtained through masturbation and delivered to the laboratory within 2 hours in a wide-mouth container (usually silicone); should be kept as close to body temperature as is possible.
(d) Postejaculate urine: Tested to rule out retrograde ejaculation and possible retention of semen in the urethra secondary to obstruction.3
(e) Collecting jar: Cap or top must not have a rubber lining because this will kill whatever spermatozoa are present.
(f) Collection, avoid the following:
(i) Ordinary condoms: interfere with sperm Viability
(ii) Coitus interruptus: high potential loss of first part of the ejaculate, a possibility of cellular and bacterial contamination, and acid vaginal pH affects sperm motility
(g) Safe handling: Semen may contain harmful agents (e.g., human immunodeficiency virus, hepatitis viruses, herpes simplex viruses, Chlamydia, gonorrhea) and must be handled with care.
(2) Box 6-2 shows the differential diagnosis based on sperm count.
|BOX 6-2 Differential Diagnosis Based on Sperm Count in the Infertile Male|
|(1) Hypogonadotropic hypogonadism|
|(5) Hypothalamic and pituitary sarcoidosis|
|(1) Klinefelter’s syndrome and variants|
|(2)> Noonan’s syndrome (XX male)|
|(3) Ring Y chromosome mosaicism|
|(3) Primary hypogonadism secondary to orchitis|
|(4) Other causes|
|(a) Germ cell dysfunction|
|(b) Androgen resistance syndromes|
|(c) Germ cell aplasia|
|(e) Sertoli cell—only syndrome|
|d. Obstruction or aplasia of the ductal system|
|(a) Aplasia of vas deferens|
|(b) Aplasia of the epididymis|
|(3) Vas deferens occlusion|
|(b) Young’s syndrome|
|e. Retrograde ejaculation|
|(1): Autonomic insufficiency|
|(2) Ganglionic blockers|
|(1) Hypogonadotropic hypogonadism|
|(2) Hypothalamic and pituitary sarcoidosis|
|(5) Hyperprolactinemiab. Other causes(1) Selective germ cell dysfunction
(3) Androgen resistance syndromes
(4) Germ cell aplasia
(6) Sertoli cell—only syndrome
1 3. Normospermia I a. Immunoinfertility I b. Varicocele
1 c. Unrecognized female factors j d. “Normal but infertile”
(3) Macroscopic examination.
(a) pH of semen
(i) The pH of normal semen should be measured at a uniform time, usually within 1 hour of ejaculation, and should be in the range of 7.2 to 8.0.
(ii) If the pH is less than 7.0 in a sample with azoospermia, dysgenesis of the vas deferens, seminal vesicles, or epididymis may be present.
(i) Opaque to opalescent is normal.
(ii) Clear or translucent is oligospermia.
(iii) Rust or red is hematospermia.
(iv) Yellow, creamy, or milky is pyospermia.
(v) In jaundice, the semen is bright yellow.
(4) Liquefaction: In humans, semen forms a gel-like clot after ejaculation, but within 15 to 20 minutes liquefaction of this clot has occurred. Coagulation of the human semen depends on the presence of a fibrinogen-like substance that is manufactured by the seminal vesicles and that is acted on by the enzyme vesiculase produced by the prostate. Breaking down of the clot and the associated fibrin takes place as a result of the activities of a series of proteolytic enzymes secreted by the prostate. These include proteases, pepsinogen, amylase, and even hyaluronidase. Concomitant release of transaminase enzymes can cause further peptide breakdown. Therefore, both clotting and liquefaction are induced by prostate secretions. Liquefaction of semen usually occurs within 10 to 20 minutes after ejaculation.
(a) Liquefaction is usually assessed visually.
Grade 1: Semen that fails to liquefy forms a gel-like coagulum.
Grade 2: Partially liquefied semen will contain many small gel’like clots.
Grade 3: Fully liquefied semen has no gel-like clots and the semen is completely fluid,
(b) Treatment of liquefaction defects includes the following:
(a) Viscosity is defined as the quality of semen that allows it to be poured drop by drop out of a container.
(i) The viscosity of the seminal fluid can vary from sample to sample.
(ii) Increased viscosity may be associated with infertility.
(b) Treatment of hyperviscous semen includes the following:
(i) Passage through a wide-bore needle
(ii) Mixing viscous semen with sperm-firee seminal fluid from another patient
(a) There is a large variance in the normal sperm count.
(b) Often cited are 20 million/mL to 200 million/mL.
(c) The World Health Organization established a count of 20 million/mL as the line between “normal” and “abnormal or infertile.”
(d) The sperm concentration takes no account of total number of sperm in the overall ejaculate, because volumes can and do vary.
(e) It is known, too, that in a single individual, counts per milliliter can vary from some number less than 20 million/mL or exceed 200 million/mL.
(f) For that reason, at least three analyses, done at least 1 week or more apart, with 2 days of abstinence are recommended.
(g) Sperm counts can vary with the type of counting chamber used (Table 6-2). With respect to accuracy and using 35 million beads per milliliter as a standard, the following chambers were tested for their accuracy:
(i) Cell VU: mean count 35.1 ± 2.5
(ii) Microcell: mean count 36.2 ± 9.3
(iii) Neubauerhemacytometer: mean count 51.4 ± 12.8
(iv) Makler: mean count 51.2 ± 7.4
(h) Nomenclature for semen variables
(i) Normozoospermia: normal ejaculate
(ii) Oligozoospermia: sperm concentration less than 20 million/mL
(iii) Azoospermia: no spermatozoa in the ejaculate
(iv) OligoAsthenoTeratozoospermia: disturbance of all three variables—count, motility, and morphology
(v) Teratozoospermia: fewer than 30% spermatozoa with normal morphology
(vi) Asthenozoospermia: fewer than 50% spermatozoa with forward progression of 3 or 4
(vii) Aspermia: no ejaculate
(viii) Polyzoospermia: sperm concentration in excess of 250 million/mL
(ix) Necrospermia: dead sperm (7) Motility.
(a) Sperm must be able to move in such a manner as to demonstrate forward progression. This type of movement is necessary for a sperm to enter and pass through the female genital tract and also for it to achieve fertilization.
(b) Sperm movement is evaluated both quantitatively and qualitatively.
(c) Quantitation motility (viability) is defined as the average percentage of sperm moving in 10 random high-power microscopic fields.
(d) Qualitative assessment of sperm movement is based on the pattern displayed by the majority of motile spermatozoa.
(i) 0 is none. No forward progression.
(ii) 1 is poor. Sluggish forward progression.
(iii) 2 is moderate. Definite forward progression.
(iv) 3 is good. Good forward movement with progression.
(v) 4 is excellent. Vigorous rapid forward progression.
(e) If motility is under 50%, a viability stain is done using eosin with nigrosin as counterstain. Greater than 50% of sperm should be viable. Abnormalities in motility and quality of movement can be seen with the following :
(ii) Antisperm antibodies
(iii) Partial ejaculatory duct obstruction
(iv) Gonadotoxin exposure
(vi) Protein—carboxyl methylase deficiency (induced byradiation exposure or environmental toxin)
(vii) Immotile cilia—Kartagener’s syndrome
(a) According to the World Health Organization, a morphologically normal semen sample contains 50% normal forms, defined as sperm with oval heads and no neck or tail abnormalities (Figs. 6-1 and 6-2).
Diagrammatic representation of Diff-quick stained spermatozoa. a, Normal form, b, Slightly amorphous forms: 1, head slightly elongated, loss of oval shape, 2, thick neck but normal-shaped head, c, Severely amorphous forms: 1 and 2, abnormally small acrosome; 3, no acrosome; 4, acrosome greater than 70% of head.
Basic components and morphologic characteristics of the normal spermatozoa.
(b) The advanced technology of in vitro fertilization has made it necessary to. redefine sperm morphologic criteria that may correlate with fertilization outcomes.
(i) According to “strict criteria” established by Kruger et al„ a normal spermatozoon has an oval configuration with a smooth contour; an acrosome comprising 40% to 70% of the distal part of the head; no abnormalities of the neck, midpiece or tail; and no cytoplasmic droplets of more than half of the sperm head,
(ii) Borderline forms are abnormal.
(c) Kruger et al. grouped together the normal and borderline forms to obtain the “morphology index”; they proposed that more than 4% morphologically normal sperm and a morphology index greater than 30% predict a good fertilization outcome. Fertility rates per oocyte with a strict criteria score of under 4% was 7.6% compared to a fertility rate per oocyte of 64% with strict criteria score of greater than 4%.
(a) Simply put, motile spermatozoa stick to each other. These agglutinates can be as follows:
(i) Head to head
(ii) Tail to tail
(iii) Midpiece to midpiece
(b) The adherence of immotile sperm to each other or of motile sperm to mucus threads, cells other than spermatozoa, or debris is considered to be “nonspecific aggregation” rather than agglutination.
(c) The presence of agglutination is suggestive of, but not sufficient evidence for, an immunologic cause of infertility.
(d) Sperm tend to agglutinate spontaneously with fairly high frequency. This phenomenon is observed in sperm of both fertile and infertile men.
(e) Agglutination can occur with exposure of sperm to the following:
(iv) Steroids: testosterone tail to tail agglutination; progesterone head to head agglutination
(f) The severity of agglutination can be approximated as follows:
(i) + – fewer than 33% of sperm agglutinated
(ii) ++ = 33% to 66% of sperm agglutinated
(iii) +++ = greater than 66% of sperm agglutinated
(g) Furthermore, clinicians should endeavor to describe the nature of the agglutination (i.e., head to head, etc.). (10) Antibody-agglutination testing (Box 6-3) should be done for the following3:
|BOX 6-3 Tests for Agglutination and Antisperm Antibody2,4,6|
|1. Gel agglutination test (Kibrick): detects IgG or IgM|
2. Sperm microagglutination test (Franklin-Dukes): detects clumping of motile sperm (>10% is considered positive for sperm antibodies); IgG, IgM, IgA
3. Sperm immobilization test (Isojima/SIT): detects those antibodies that interact with the surface of sperm, are complement dependent, and cause sperm immobilization; IgM and IgG; IgA does not activate complement
4. Mixed agglutination reaction (MAR test): detects IgA and IgG
5. Immunobead test: detects IgG and IgA
6. Indirect immunofluorescence: detects IgG and IgA
7. Sperm—cervical mucus contact test (SCMC or Kremer): IgA and
occasionally IgG within cervical mucus
8. Spermocytotoxicity tests: detect IgM and IgG
9. Enzyme-linked assay (ELISA)
(a) Agglutination of spermatozoa
(b) Agglutination of motile dimers
(c) Idiopathic infertility
(d) Abnormal postcoital tests
(e) Historical factors that increase the risk of antibody formation:
Vasectomy – Testicular biopsy
Infection – Trauma
Obstruction – Torsion
Cryptorchidism – Cancer
Varicocele – Genetic predisposition
(11) Cellular components of semen.
(a) White blood cells (WBCs) and pyospermia
(i) White blood cells are present in small numbers in normal semen. As a general guide, the normal ejaculate should not contain more than 5 to 10 WBCs per HFF.
(ii) An abnormal number of WBCs in the semen is called pyospermia. The presence of WBCs lying together in aggregates is diagnostic of infection. Any sample demonstrating these findings must be cultured.
(iii) Increased numbers of WBCs in the semen may also be the result of prostatic abnormalities.
(iv) The four main sites for infection in the male genital tract are: epididymis, seminal vesicles, prostate, and urethra and periurethral glands. By doing split ejaculate analysis and culture, the site of infection can he localized using the physiology of the emission and ejaculation process4:
Emission: derived from the accessory or periurethral glands.
Ejaculation: The first part of the ejaculate derives from the testicular component, followed by secretions from the prostate; the last part derives from the seminal vesicles.
(v) Another method for detecting infection in the prostate is prostatic massage for expressed prostatic secretions (EPS). The sample can be examined under the microscope as well as sent for culture. A microscopic count of ± greater than or equal to 10 WBCs per HPF is indicative of prostatitis.
(vi) Infection alters semen quality in the following ways: Ductal damage with resultant obstruction, interference with accessory gland secretion, and impaired motility of spermatozoa.
(vii) The most common organisms associated with pyospermia are as follows:
Escherichia coli – Mycobacterium tuberculosis
Enterococci – Chlamydia trachomatis
Staphylococci – Trichomonas vaginalis
Neisseria gonorrheae – Candida albicans
Mycoplasmas – Viruses
(b) Epithelial cells
(c) Red blood cells
(ii) Can be a manifestation of infection and malignant disease or can be idiopathic
(d) Germ cells
(i) Germ cells are generally considered normal in the semen.
(ii) The exact number of these immature cells felt to be abnormal has yet to be defined.
(f) Particulate matter
(i) Spermine crystals
(ii) Prostatic calculi
e. Tests of sperm function. Of the many tests of sperm function available, none unequivocally identify functional spermatozoa. These tests are not performed as a matter of routine examination of the subfertile male. They are highly selective.
(1) Sperm penetration assay (SPA): This test uses the golden hamster egg, which is unusual in that removal of its zona pellucida results in loss of all species specificity to egg penetration. It is used to yield information relative to sperm fertilization potential.
(a) The SPA measures are as follows:
(ii) The acrosome reaction
(iii) Sperm oolemma fusion
(iv) Sperm incorporation into the ooplasm
(v) Decondensation of chromatin
(b) The SPA does not test for the following:
(i) Penetration of the zona pellucida
(ii) Normal embryonic development
(c) The positive SPA test cannot therefore do the following:
(i) Guarantee fertilization of intact human eggs
(ii) Guarantee embryonic development of fertilized human eggs
(d) The negative SPA test has not been found to correlate with poor fertilization in human IVF.
(2) The acrosin assay: This test measures acrosin, which is thought to be responsible for penetration of the zona pellucida and for triggering the acrosome reaction.
(3) The hemizona assay.
(a) This test measures the binding of sperm to the zona pellucida of human eggs.
(b) In the human hemizona assay, unfertilized oocytes obtained through donation are bisected and the number of sperm tightly bound to the outer surface is counted.
(c) The major advantages are as follows:
(i) Using the two halves of the hemizona allows for controlled comparisons of binding.
(ii) The limited number of human oocytes is amplified.
(d) The results of this test show good correlation with Kruger “strict” morphology criteria and IVF fertilization rates.
(4) The hypoosmotic swelling test.
(a) This test measures the membrane integrity of sperm, important for metabolism but also for the successful union of male and female gametes.
(b) When viable sperm are exposed to hypoosmotic conditions, water enters the sperm, resulting in swelling. This places the tail fibers under tension, causing curling of the tails.
(5) Cervical mucus penetration.
(a) This test quantitates the sperm—mucus interaction and yields information regarding the motility of the spermatozoa.
(b) The PCT is done at midcycle when the cervical mucus is less of a barrier to sperm. A good PCT done within 12 hours after coitus is defined as greater than 10 motile sperm per HPF.
(c) Female factors affecting the PCT are as follows:
(i) Inadequate estrogen priming
(ii) Deficient endocervical tissue
(iii) Previous surgery to the cervix
(d) Male factors affecting the PCT are as follows:
(i) Anatomical abnormality (i.e., hypospadias, resulting in inadequate delivery of sperm)