ADVANCED MALE FERTILITY TESTING
We define Advance Fertility Testing as a comprehensive evaluation of a semen specimen using state-of-the art technology to give information required for diagnosis and treatment options.
The comprehensive semen analysis is considered by many reproductive specialists to be the cornerstone of the male fertility evaluation. This noninvasive test examines specific characteristics of your semen and provides information on the ability of your testes to produce healthy sperm and the ability of other organs termed male accessory glands to produce the components of seminal fluid which bath and nourish the sperm and provide the optimal conditions for sperm function.
A semen analysis is actually a collection of many individual tests that evaluate the macroscopic, microscopic, and physiologic characteristics of your ejaculate. The macroscopic parameters that are assessed are volume, pH, color, viscosity, and coagulation/liquefaction. Normal volume should be between 2 and 4 mL. A volume that is less than 2 mL could indicate partial retrograde ejaculation or a problem with the male accessory glands (eg, prostate, seminal vesicles) producing the seminal fluid. Semen pH should be between 7.2 and 7.8. A pH less than 7 can suggest ejaculatory duct obstruction or retrograde ejaculation. A pH of 8 or greater indicates infection. Semen should be white. Yellow semen suggests jaundice or use of certain drugs. Reddish brown semen often indicates the presence of blood. Viscosity or thickness od semen should measure 4 mm of stretching of the semen called threading. Viscosity measurements greater than 6 mm indicate a problem with the glands producing the seminal fluid. Normal semen should coagulate upon ejaculation and liquefy within 20 minutes at room temperature. Failure to liquefy might indicate infection or absence of certain essential components of semen.
Direction and path of sperm movement is represented by color and directional pattern.
The physiological evaluation assesses sperm motility and sperm viability. Proper motility is required to enable sperm to traverse the female reproductive tract and fertilize an egg. The best method for assessing motility is the progressive motility grading system. Training and practice are required to effectively perform this evaluation.
Viability testing is typically done when a semen sample has a low percentage of motile sperm. Viability testing determines if sperm cells are dead (red) or alive (blue). The semen sample is stained with a dye. The cell membranes of dead sperm no longer function, so allow the dye to enter and stain the sperm cell.
Live sperm fluoresce blue and dead sperm fluoresce red.
The microscopic examination of your semen will evaluate sperm count and concentration, sperm agglutination, sperm morphology, and the presence of non-sperm cells. Sperm concentration is the number of sperm per mL of semen. Sperm count is the total number of sperm in your semen sample. Sperm concentration should be greater then 20 million sperm per mL of semen, and total count should be at least 40 million sperm per semen sample. A concentration less than 20 million per mL could indicate impaired sperm production by the testes or an obstruction. Agglutination occurs when sperm clump together. It is not normal. Agglutination might be an indication of infection or the presence of antibodies that attack sperm. Sperm morphology is an assessment of the shape and structures (ie, acrosome, head, midpiece, tail) of a sperm cell. Sperm morphology is an important predictor of fertility potential, and the most subjective and difficult to standardize part of a semen analysis
White blood cells (leukocytes) stain brown with a peroxidase stain.
Leukocytes (cells produced in increased number with infection), immature sperm cells, and epithelial cells are the most common non-sperm cells found in semen. Leukocytes are indicative of infection or a high level of reactive oxygen species which, when present, impairs the sperm membrane and affects fertility. To differentiate leukocytes from immature sperm cells requires the use of peroxidase stain. With this stain the leukocytes are brown.
Morphology is the most subjective of all measurements. In addition, measurements of other macroscopic parameters such as concentration and motility (ie, movement of sperm) require exceptional training of the technologists performing the examination. Advanced motility measurements of linear and angular velocity can only be obtained by sophisticated imaging and motion detection systems. Although trained technologists can provide a reasonable estimate of semen parameters they are no match for the accuracy and precision provided by a computer assisted semen analyzer (CASA).
This sophisticated computer system has resulted in meaningful results and therapeutic options for patients. We feel that use of this advanced technology is the current standard for semen analysis and is essential for providing meaningful results to referring physicians. The results using a CASA system are both verifiable and reproducible and provide objective data required for treatment decisions. There is much literature that supports this view.
A normal sperm has an acrosome (yellow) which covers 40 to 60% of the sperm head.
Not always understood by the patient having a semen analysis is the need for non-standard tests to be performed during a semen analysis. For example, if no sperm is found in the specimen a Fructose test needs to be done to confirm that the fluid obtained is part of the ejaculate and not urine that might have been given or analyzed as a semen specimen by mistake. If round cells are found in the semen a test needs to be (termed a peroxidase test) to determine whether these cells are wbc’s (ie infection cells) or immature sperm cells. We feel it is essential to perform these tests on the original semen specimen being provided. Many laboratories might not include these tests and many do not even have the ability to perform these tests.
With the halosperm assay as shown in this figure, normal sperm have a halo while sperm without a halo have fragmented DNA
There are also additional tests that might be requested on your semen specimen. These tests are most often sent out to a reference laboratory. These outside laboratories will bill you separately for these tests. These might include:
- Sperm Chromatin Assay: The Sperm DNA Fragmentation Assay (SDFA)™ uses acridine orange staining and flow cytometry to quantify the tendency for sperm DNA to fragment under stress. The SDFA provides both a DNA fragmentation index (DFI) and a high DNA stainability score (HDS). The DNA fragmentation index (DFI) has been shown to be a useful predictor of couples who are more likely to be unsuccessful with natural conception and IUI. The HDS score provides supplementary information regarding the percent of cells with highly-staining DNA, and can be abnormal when high levels of immature sperm cells are present.
- Oxidative Stress Evaluation: The OSA™ test directly measures sperm damage from oxidative stress by quantifying the presence of “adducts,” molecules in semen covalently modified by free radicals/reactive oxygen species.
Semen can be exposed to oxidative stress for a variety of reasons such as an infection or inflammation in which there is an over production of reactive oxygen species (ROS) such as free radicals that cause permanent, damaging structural changes to the sperm. Previously, this damage was only indirectly measured by assessing the capacity of semen to absorb or buffer ROS. The OSA test, however, measures ROS damage of sperm directly.
- Semen Culture: When an increased number of wbcs or bacteria is found on semen analysis or when the referring physician suspects a sub-clinical (ie an infection that does not give symptoms) infection a semen culture may be requested. Positive results might be treated with antibiotics.
- Cryopreservation: there are many reasons to cryopreserve sperm (ie Sperm Bank). A low sperm number, prior to procedures or therapy that might affect sperm production or transport of sperm or simply because the patient elects to store sperm are all possibly reasons. Sperm banking must be scheduled since our laboratory will only cryopreserve one specimen at a time ensuring the security of the specimen processing and storage.
PREPARATION FOR THE EXAM
Preparing for a semen analysis is easy, just follow the steps listed below:
- Call the lab and make an appointment 516-487-2700.
- Please abstain from ejaculating for 48-72 hours prior to specimen collection. Thus is the period of abstinence that will give the best representative specimen. It is also the period of abstinence recommended by most fertility experts to have when a couple is trying to conceive.
- Specimen can be collected at home or in the office.
- Collection in the office is required for patients considering cryopreservation of their specimen in addition to an analysis to assure proper handling and the best cryopreserved specimen. In general, it is always better to produce in the office however, if produced at home please make sure the specimen is to our office within an hour and is kept as close to body temperature as possible.
- Specimen collection instructions:
- Empty your bladder by urinating in the toilet.
- Collect the specimen by ejaculating into a sterile wide-mouthed container (obtain from local pharmacy or stop by our office).
- Please bring the sample to the office within one hour of collection to insure that the best possible specimen will be examined. Please keep the specimen at body temperature.
- DO NOT URINATE after giving the specimen. When you arrive at the office (or if producing in the office) we will ask you to collect all the urine in your bladder by urinating (to completion) into a sterile container that we will provide.
If you have any questions about these instructions please call us at 516-487-2700. It is extremely important to have a properly collected specimen for proper evaluation of your fertility.