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Male Infertility
Laboratory Assessment of Male Infertility – A Guide for the Urologist
a report by
Ashok Agarwal, Frances Monette Bragais and Edmund S Sabanegh, Jr
Center for Reproductive Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic
The assessment of a male’s fertility starts with a thorough history-taking duct obstruction or retrograde ejaculation. High-volume semen (>8ml) is
and at least two separate sperm analyses. For the past 50 years, this often associated with poor-quality semen.
2
inexpensive test has been the first ancillary procedure ordered when a
man undergoes fertility assessment. Microscopic Variables
The microscopic parameters assess spermatogenesis and are said to be the
Proper collection of semen must be emphasised to patients as it is often most technically difficult part of the semen analysis. Inter-patient variation
the cause of error in the semen analysis. The semen samples must be is present in even the most ideal conditions of collection and testing. The
collected with a minimum interval of seven days while observing sexual WHO laboratory manual is the most widely used resource for normal
abstinence of two to seven days per collection.
1,2
The fertility physician results, and is used for infertility and andrology work-up purposes.
4
must bear in mind that inter-patient variability exists and multiple
collections may be required to obtain an accurate assessment. Other The microscopic examination starts with the creation of a wet smear (a
factors, such as well-equipped and well-trained laboratory personnel, drop of semen on a slide covered with a cover slip) visualised under x1,000
play a hidden but significant role in the delivery of accurate results.
3
magnification. Sperm agglutination, sperm presence and subjective motility
can be assessed using this method. A small degree of agglutination is
Macroscopic Variables normal.
4
Excessive agglutination is suggestive of the presence of antisperm
Macroscopic variables are volume, pH, coagulation, liquefaction, colour antibodies and subsequent work-ups for this should be requested. After
and viscosity. The normal values – based on the World Health liquefaction, assessment of sperm concentration (number of sperm/ml) and
Organization 1999 manual – are listed in Table 1.
4
Variations in these sperm count (number of sperm/ejaculation) is conducted. Oligozoospermia
parameters are relatively common and may be of little clinical significance; (<20 million sperm/ml) may be indicative of incomplete collection or a short
however, this may also be indicative of accessory gland malfunction. The abstinence period. It may also indicate partial duct obstruction and other
specifics of the tests can be found in the WHO manual.
2
The most medical conditions that affect sperm production such as varicocele,
common condition that may give rise to abnormalities in the macroscopic cryptorchidism, diabetes, primary testicular failure and medications such as
variables is ductal obstruction and/or vas/epididymal abnormalities. The nitrofurantoin. Febrile illnesses may cause transient oligozoospermia (and,
semen is often low in volume and non-coagulating with acidic pH. Volume rarely, azoospermia). A repeat semen analysis should be requested after
variation is of value when it is consistently low and may indicate partial two to three months, bearing in mind that a complete spermatogenesis
cycle lasts for 74 days. Azoospermia (absence of sperm) is observed when
the genital tract is obstructed, as well as severe sperm testicular pathology
Ashok Agarwal is Director of the Center for Reproductive
such as Sertoli cell only syndrome or hypogonadism. Hormonal tests
Medicine and Director of the Clinical Andrology Laboratory
and Reproductive Tissue Bank at the Cleveland Clinic’s (follicle-stimulating hormone (FSH) and testosterone), karyotyping and
Glickman Urological and Kidney Institute. Cleveland Clinic’s
Y chromosome microdeletion testing are requested when severe
Reproductive Center is recognised internationally for its
innovative research into the pathophysiology of male and
oligozoospermia or azoospermia are seen. Deletions in the AFZa or AFZb
female infertility. (versus AFZc) regions of the Yq chromosome are indicative of markedly
E: Agarwaa@ccf.org
impaired spermatogenesis with poor sperm retrieval even with testicular
Frances Monette Bragais completed her urology residency at
biopsy, and these deletions may be passed on to the male offspring
the National Kidney and Transplant Institute in the conceived with intracytoplasmic sperm insertion (ICSI).
5
Philippines and has been a Visiting Urology Consultant in
the same institute since her graduation in 2004. She was an
Observer in Male Infertility at the Cleveland Clinic’s Center
Sperm morphology can also be a significant predictor of pregnancy in
for Reproductive Medicine from June to August 2007.
subfertile couples when deciding which assisted reproduction technology
(ART) procedure to employ. Couples with teratozoospermia (<15%
normal morphology) by WHO standards, and with no other male factor
Edmund S Sabanegh, Jr, is Head of the Section of Male
infertility, may be recommended to proceed with ICSI versus intrauterine
Fertility for the Glickman Urological and Kidney Institute at
the Cleveland Clinic. He is the Program Director for the
insemination (IUI).
6,7
Male Infertility Fellowship, leading one of the few male
infertility fellowship programmes in the US that combines
Leukocytes are the most significant non-sperm cellular elements in the
basic research with extensive clinical experience.
semen, and are a frequent finding in patients with unexplained infertility.
8,9
In the initial microscopic analysis, the immature spermatozoa may be
confused with leukocytes. Additional tests such as immunocytochemistry
106 © TOUCH BRIEFINGS 2008
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