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Archive for January 2019

WHO standards of Semen Analysis

Semen Analysis

What is Semen Analysis?

Semen Analysis is an important diagnostic tool for the evaluation of male fertility, by examining the male semen and the sperms present within. The test is necessary for those wanting to conceive or for those verifying the success of vasectomy.

This investigation is carried out according to WHO guidelines, focusing more on the concentration, morphology and motility of the sperm(s).

Indications for Semen Analysis

  • Infertility
  • Follow up after Vasectomy
  • Hypogonadism
  • Prior to donations for artificial insemination
  • Storage of semen before radiotherapy

Semen Analysis explained according to WHO criteria:

A complete semen analysis should include ejaculate volume, sperm count, concentration, motility and morphology.

Ejaculate volume; A semen volume of 2 to 5 milliliter is considered normal, according to WHO the lower limit is 1.5 mL. A decreased ejaculate volume maybe seen in congenital bilateral absence of the vas deferens, ejaculatory duct obstruction, primary testicular dysfunction and retrograde ejaculation. These conditions cause a low volume of ejaculate with no sperms.

Ph; the pH of an ejaculate as stated by WHO should be between 7.2 – 7.8.  any pH value not falling in this range is considered harmful to the sperms, affecting their motility and hence their ability to penetrate the egg. An acidic pH (<7.2) of the semen is most commonly due to a blockage of the seminal vesicles, which functions to provide an alkaline solution (fructose) to the ejaculate. In the absence of which the acidic prostatic fluid predominates.

Total sperm count and Sperm concentration; if there is a complete absence of sperm on standard microscopic semen analysis after centrifugation of the semen sample then a repeat test should be done. If no sperm is detected on both the tests, then it is labeled as azoospermia.

A sperm concentration of less than 20 million per milliliter is labeled as oligospermia and a concentration of less than 5 million per milliliter is labeled as severe oligospermia.

However recently WHO revised this criterion and the following concentrations that divide oligospermia into three classes are also considered now;

  • MILD: concentrations between 10 million – 15 million sperm per mL
  • MODERATE: concentrations between 5 million – 10 million sperms per mL
  • SEVERE: concentrations less than 5 million sperm per mL

Motility of sperms; WHO has a cut off value of 50% for sperm motility. The sperms are graded according to their motility;

  • Motility IV or Grade A: Sperms that fall in this category are the ones with progressive motility, they move fast in a straight line and are the strongest.
  • Motility III or Grade B: These sperms move in a non-linear direction, they do move forward but in a curved or crooked motion.
  • Motility II or Grade C: These move in a non-progressive manner, which means they do move their tails but do not progress forward.
  • Motility I or Grade D: Sperms in this category fail to move at all and are labeled immotile.

Morphology of sperms; according to WHO a semen sample with at least 30% or more with normal morphology can be considered normal. While WHO standard for Kruger strict is 4% or more.

In Vitro Fertilization (IVF), uses morphology of sperms to predict the success rates of fertilization.

Fructose level; fructose is an important carbohydrate produced by seminal vesicles, its function is to provide energy to the sperms for swimming. WHO verifies the normal value for fructose level as 13 mmol per sample. Since fructose is provided by seminal vesicle, an absence of it would indicate an abnormality in the seminal vesicle.

Semen Analysis

Summary of WHO Criteria for a Normal Semen Analysis;

According to WHO, an ejaculate is considered normal if at least 1.5ml of ejaculate contains more than 15 million sperms per milliliter of semen. Out of these at least 32% should swim in a forward direction, and at least 4% should have a normal shape. Given that these criteria are met, a man is considered fertile.

In order to be certain, the ejaculate should be evaluated twice.

Apart from the findings of semen analysis, an ejaculate should not contain more than 1 million white blood cells and microorganisms per mL ejaculate.

If the semen analysis is abnormal and does not meet the WHO criterion, then further intervention is required.

The WHO criteria changes at times however the sperm concentration criteria have been the same for a long time now, which is; there should be at least 15 million sperm cells per mL and the ejaculate volume should be at least 1.4 mL.

Semen Analysis

By – Dr. Alvina Arslan Meer

ART Coordinator (MBBS) & Online Counselor 

 

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Difference Between Azoospermia and Oligospermia

 

In simple words and in a lay man’s language this could be explained as; azoospermia meaning ‘no sperm’ and oligospermia meaning ‘not much sperms’.
However, in medical language it is explained as follows;

Azoospermia:

Azoospermia is a medical condition where there is a complete absence of sperms in the semen sample of a male, given the sample is centrifuged. At least two semen samples should be studied before diagnosing a male with azoospermia. It affects about 1% of male population and accounts for 20% of male infertility cases.

Oligospermia:

Oligospermia is a condition where the amount of sperms required in a male’s ejaculate to conceive is less than the minimum level for conception. This condition is also called oligozoospermia. The cut off value, according to WHO is 20 million sperms per milliliter, any sperm count less than this value is labeled as oligospermia. It is the most common cause of decreased chances of conception and infertility in men.

CAUSES : 

Both these conditions are caused by a vast majority of factors, both congenital and acquired.

Causes of Azoospermia:

Congenital absence of the Vas Deferens

Epididymitis

Ejaculatory duct obstruction

Undescended testes at birth

Young syndrome

Trauma or surgery of the scrotum

Vasectomy

Primary testicular failure (Klinefilter syndrome)

Chromosomal abnormality causing genetic infertility; this condition requires karyotyping

Micro deletion of the Y chromosome

Unexplained genetic infertility

Secondary testicular failure (Kallman syndrome)

Pituitary/Hypothalamic tumor

Hyperprolactinemia; high level of prolactin in males

Unexplained gonadotropic hormones deficiency, these hormones are required for spermatogenesis

Cancer treatment; which includes chemotherapy, radiation and surgery

Drug induced pituitary suppression; drugs like glucocorticoids, anabolic steroids and alcohol

Testosterone supplements

Congenital adrenal hyperplasia

Varicocele

Organ failure due to severe illness (kidney or liver failure)

Sickle cell anemia

Hemochromatosis

Diabetes mellitus

Pesticide/toxin exposure; for example in hot tubs and baths

Sperm autoimmunity

Causes of Oligospermia:

Certain medical conditions leading to oligospermia include:

Varicocele: This is caused by dilatation of testicular veins which increases testicular temperature and further disrupts spermatogenesis. For sperm production to take place the temperature of the testicles should not rise because if it rises then it affects the production of testosterone, the male hormone required for sperm production and the high temperature also causes damage to the sperm’s DNA.

Sexually transmitted diseases; it leads to infections and hence the sperm count

Medications; some medicines like beta blockers, blood pressure control medicines and antibiotics cause ejaculation problems and decrease the sperm count

Problems with ejaculation; retrograde ejaculation or those caused by cancer, injuries, past surgeries, tumors

Hormonal imbalance: gonadotropic releasing hormone, FSH, LH and Testosterone, all are required for healthy sperm production

The lifestyle of a male also accounts for a few factors responsible for Oligospermia, these include:

High testicular temperature: most often caused by placing laptop on the lap/near the genitals, sitting frequently and wearing tight clothing

Obese males; being overweight or obese has negative effects on sperm production as well as on hormonal production

Substance abuse and alcohol: drugs like cocaine and marijuana cause decreased sperm production. Excessive alcoholism and smoking cigarettes have the similar negative effects.

Environmental exposure; exposure to some chemicals and metals causes decreased sperm production, these include cleaning agents, pesticides, painting material and heavy metals like lead.

TREATMENT

Treatment of azoospermia:
The treatment depends mainly on the cause of azoospermia.

Blockage: if the sperms are absent due to blockage then microsurgery is the option given to patients, it involves removing the obstruction for example in vas deferens or by passing it, allowing the sperms to pass through.

Hormonal imbalance: if the cause of absent sperms is lack of hormones then administration of the required hormones is the option given to patients.

However for men who have unexplained infertility and other issues are advised to undergo In Vitro Fertilization process in which the sperm(s) if any present in the testes are extracted directly using sperm retrieval procedures. The sperm is then used, to be injected directly into the female oocyte (egg) in a lab, a process called ICSI (Intra Cytoplasmic Sperm Injection)
These procedures are used depending on the infertility diagnosis and are as follows;

TESE: Testicular sperm extraction.

Micro TESE.

MESA: Microscopic Epididymal Sperm Aspiration.

PESA: Percutaneous Epididymal Sperm Aspiration

Testicular Biopsy.

Treatment of Oligospermia:
Oligospermia is much easier to treat as compared to azoospermia, but again the treatment depends on the cause of oligospermia;

Varicocele: the treatment involves surgically ligating the dilated spermatic veins.

Infections: the treatment involves an antibiotic course to get rid of the urinary or reproductive tract infections.

Hormonal imbalance: medications and hormonal replacement treatments are given to fix the hormonal imbalance.

If the couple still fails to conceive, they should visit an infertility specialist and discuss their options of assisted reproductive techniques like IUI (Intra Uterine Insemination), IVF (In Vitro Fertilization), and ICSI (Intra Cytoplasmic Sperm Injection). Further more if the cause is mainly male infertility due to no sperm in the ejaculate or due to low sperm count then the options of testicular sperm retrieval should be considered, where the sperms are aspirated or extracted from the testes and used in assisted reproductive techniques to fertilize an egg.

 

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