Understanding Semen Analysis and Options to Boost Male Fertility

Sheldon Marks, MD and Peter Burrows, MD
February 9, 2005

The opinions expressed herein are the guest's alone. If you have questions about your health, you should consult your personal physician. This chat is meant for informational purposes only. The following chat transcript has been edited.
 

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[RESOLVE] Hello to everyone who has joined us this evening! RESOLVE's chat on Understanding Semen Analysis and Options to Boost Male Fertility is being hosted by Sheldon Marks, MD. Dr. Marks is a microsurgical specialist and diplomat of the American Board of Urology. Dr. Marks practices with the International Center for Vasectomy Reversal Arizona.

[Dr. Marks] I'd like to introduce J. Stan Grossman, affectionately called Stan the Sperm Man. He spent over 12 years with Larry Lipshultz at Baylor and has now been with us for three years.

[RESOLVE] Could you explain the various terminology associated with a semen analysis: morphology, vitality, etc.?

[Dr. Marks] RESOLVE, morphology is the percentage of normal appearing sperm. This varies from lab to lab and format to format. Vitality is the percentage of sperm that are actually alive, whether motile or nonmotile.

[Rita] Hello! White blood cells were found in my husband's semen in all three of our IUIs. What could cause this? No bacteria were ever found and he has no pain or discomfort.

[Dr. Marks] Rita, White Blood Cells are a normal part of any semen specimen. It is only a concern when they are excessive, such as more than 15 per high power field. I know many Reproductive Endocrinologists like to cover their patients with antibiotics if there are any questions, such as Doxycycline.

[Sheila] Hi Dr. Sheldon. My husband and I are about to do our first IUI with Follistim in March. His semen analysis showed: great count (100 Million), good motility (close to 50%), good survival, but poor morphology (3% using Kruger). He went on a one month course of antibiotics in January, was examined by an Urologist to rule out a varicocele and he went off his antidepressant medication (Effexor) in January as well. He is still on cholesterol lowering medication (Crestor). Besides taking a regular multivitamin, he also increased his antioxidants (vitamin C & E) and B-complex vitamins. Is there anything else we should be doing to improve morphology? Are there other male factor tests to consider such as a Karyotype test? Do you think IUI is the right path for us now?

[Dr. Marks] Shelia, according to Dr. Grossman, your numbers are good enough for normal conception. If you are eager to get pregnant or have been trying for a while, then an IUI with a gradient wash will improve his morphology percentage. The trick with IUI is to find a good technician who knows how to do washes correctly to keep the numbers good. Remember that most men function with quantity, not quality so a low morphology is okay if there are high numbers.

[LMS] How long should I hold off ejaculation in order to get the maximum results on a sperm analysis?

[Dr. Marks] LMS, most experts suggest that you get peak motility after three days of abstinence. I suggest to my patients 48 hours if counts are low just to be sure that the Fallopian tubes are filled with some sperm when the egg goes rolling past.

[ckd] Can we still get pregnant naturally with morphology of 3.2? If so, what are our chances each month?

[Dr. Marks] ckd, this depends on your total motile count- the number of sperm that are healthy enough to get to the egg. This is calculated from the volume times the count times the percent motility in a decimal form. I have seen pregnancies with very low numbers. It is just a probability thing. The more you have the better your chances. Dr. Grossman says if you have a total motile above 15 million then morphology of 3.2 should give you a 10 percent chance each month.

[aphillips6] What does the sperm count, motility, and morphology need to be in order to conceive without IUI or IVF?

[Dr. Marks] aphillips6, the goal is 15 million total motile with a "normal" morphology which varies from 5 to 30 % depending on the methodology.

[CnR] We have been diagnosed with moderate male factor. I am trying to educate myself on the criteria levels. Color = WNL and Viscosity = WNL. My first question is: What does WNL stand for? Thanks.

[Dr. Marks] CnR, WNL stands for Within Normal Limits.

[LMS] I recently was diagnosed with epididymitis and was treated with antibiotics. Can this affect my sperm and for how long?

[Dr. Marks] LMS, usually most antibiotics do not harm sperm. Each one is different and you should ask your doctor this question - whether you should hold off on conception until the medications are out of your system or not. In my experience, though, most cases of epididyistis are not infectious- they are from trauma of sterile reflux of urine causing a chemical burn. It is important to be on anti-inflammation medications as well.

[Becky1] When azoospermia is diagnosed, what are the possibilities for "fixing" the problem?

[Dr. Marks] Becky1, this depends on the cause. Is he making the sperm and they are not getting through or is he not even making sperm. Even with the worst news, nowadays, with testicular mapping and skilled lab guys like Dr. Grossman, you have a 40% chance of finding sperm good enough for ICSI with in-vitro. Most men do not have a simple problem like a scar at the ejaculatory ducts that can be fixed restoring normal counts.

[Becky] What is involved in a semen analysis and how much do they usually cost?

[Dr. Marks] A semen analysis costs anywhere from $65 to over $200, and often the cost has nothing to do with the quality. Big coastal cities charge more.

[Mel] Is there anything that can be done to "boost" count, motility and morphology?

[Dr. Marks] Mel, yes, usually. First, avoid all heat- no hot tubs, hot showers, jacuzzis or hot saunas. Stay well hydrated. Eat beef. Take anti-oxidants such as Vitamins C, E, coenzyme Q 10, folic acid, B complex a multivitamin and selenium each day, get sunshine and sleep in total darkness.

[Becky1] What is ICSI?

[Dr. Marks] Becky1, ICSI stands for Intra-cytoplasmic sperm injection, where they take one sperm and inject it into the egg, which causes the egg-sperm combination to begin reproducing into an embryo and then they evaluate the quality, some are frozen and then replace back into one's uterus after priming to make babies.

[RESOLVE] If you are interested in receiving more information on Male Factor Infertility, RESOLVE offers various pieces of literature on the subject which is available to order either online, www.resolve.org or by contacting our business office which is staffed Monday through Friday 9am-5pm ET.

[KatieW] Can antidepressants affect sperm?

[Dr. Marks] KatieW, not usually. These medications usually reduce a man's interest (libido) and or his ability to reach climax.

[negerber] What is proxeed (proseed?)

[CnR] What is your take on Proxeed?

[Dr. Marks] negerber and CnR, Proxeed is an Italian blend of nutritional supplements that some believe may help improve sperm quality and motility. All the studies that support this are from Italy and so we tend to be a little suspect until we can duplicate these studies here in the States. I use it though explain that it is very expensive. Some have told me that eating beef several times a week is as good.

[LMS] Is it normal for my husband's morphology to go from 6% to 2 % in one month's time and how long should we wait before re-testing?

[Dr. Marks] LMS, the semen analysis is an ever changing momentary snapshot of a actively fluctuating dynamic process. This means that each and every one is just a frame of a perpetual movie and so the information must be taken with a grain of salt and used with the big picture. A semen analysis is not a measure of fertility. It is a measure of sperm production and sperm delivery.

[Traci] We have morphology issues (2% Kruger) Can you recommend a change in diet to improve on this? Varicocele repair was completed six months ago with no improvement in morphology.

[Dr. Marks] Traci, I would suggest the above diet, primarily a good balanced diet, sleep, fluids, vitamins, moderate regular exercise, regular sex and an old urologist many years ago suggested to his patients that they put an ice water soaked washcloth on his scrotum twice a day for 20 to 30 minutes. This has not been tested scientifically, but can't hurt.

[aphillips6] Does caffeine affect motility?

[Dr. Marks] aphillips6, yes, caffeine actually has been shown to improve sperm motility, and keeps husbands less tired in the afternoons.

[Jim] I did a semen analysis six months back and it was through WHO method. The motility is 33%. Can I improve the motility through medications?

[Dr. Marks] Jim, you can try Proxeed and the nutritional approach. My first thought is to repeat the semen analysis. If your hubby is overweight, then this ups his estrogen levels and he may benefit from three months of aromatase inhibitors such as Femara or Arimidex, with aggressive exercise to get rid of that oh so evil gut fat.

[KatieW] My husband has 6% normal forms and 35% motility. I will start Clomid on my next cycle. Should we go straight to IUI or do you think we have a shot at success the "natural" way (plus Clomid)? Thanks.

[Dr. Marks] Traci, try normal conception for a while. This should work. If after a few months you are just too anxious or eager or you are older and worried about your age then go to IUI, again with a good wash.

[Becky] My husband says that he does not need a semen analysis because he has a five year old and his sperm is fine. Could his sperm count have diminished over time?

[Dr. Marks] Becky, yes, five years is enough time for almost anything to happen. He does need a semen analysis if you have been trying without success. Tell him to quit whining and just do it.

[Josey] Can abnormal morphology (round heads) be genetic? My husband has uncles without children.

[Dr. Marks] Josey, yes, this can be a genetic problem passed on. This is where the magic of IVF with ICSI can get you a baby.

[kpavlovic] Is it true that Clomid therapy for a male with normal Testosterone levels can actually decrease sperm count?

[Dr. Marks] kpavlovic, on occasion I have seen that. More often, though, it does boost intratesticular testosterone and sperm numbers. If you are not sure, nothing lost trying it for three months.

[Michelle] Hello Doctors. We recently completed a failed IVF cycle and all of our embryos were showing significant fragmentation. The Reproductive Endocrinologist said it could be due to a DNA fragmentation issue in the sperm as "male factor" is our only known issue. What is your opinion on the role of male factor infertility on embryo fragmentation?

[Dr. Marks] Michelle, there can be problems with DNA problems with sperm, measured with a SCSA test. Get the test to see if the sperm are indeed damaged.

[Josey] You mentioned vitamins to possibly improve morphology. What do you recommend and in what amounts? Also for how long? I am under the impression that most changes take 90 days?

[Dr. Marks] Josey, yes, it takes 74 days to make a sperm so anything you do now won't be seen for 74 days. This is why it is essential to avoid heat for months before conception is attempted. I like to suggest Vitamin C at 500 mg three times a day, Vitamin E of the d-alpha, not dl-alha, at 400 IU a day, selenium at 200 micrograms a day, a standard B complex and standard multivitamin and zinc at 30 to 50 mg a day and coenzyme Q 10 at 30 to 50 mg a day.

[bbu] Thank you taking my question. I have been trying to get pregnant for 2 ? years. The last year I have had three IUIs and two miscarriages. I was reading on INCIID about sperm DNA fragmentation. They had done a study called metanalysis (I'm not sure what kind of study that is. It said that if your sperm DNA fragmentation was less than 30% your chances of pregnancy was about seven times more. What do you think? Could this be the reason for us not getting pregnant? The doctors have not found anything wrong with me and my husband's semen analysis is normal.

[Dr. Marks] bbu, yes, if the DNA damage is high, then those sperm cannot make healthy embryos that last. This is where taking anti-oxidants has been shown to be very effective in correcting DNA damaged sperm over time.

[Dr. Marks] Does anyone want to ask about antibodies?

[CnR] What are antibodies?

[Dr. Marks] CnR, thank you. Antibodies are the body's way of attacking what it sees as a foreign protein- sperm. They rarely are a problem. When they are a problem, it is because they are very sticky and hold the sperm together so they cannot swim individually and find the egg.

[Lee and Pam] My wife and I have been trying to conceive for one year. My most recent semen analysis showed volume 3.3 ml, pH 8.5, Concentration 4, motility 50, WHO Normal Morphology 14. Specifically, there were 74% head, 9% neck/midpiece, and 9% tail defects. I have been on Fertile One for 40 days. Before that I was taking L-Carnetine and Acetyl L-Carnetine for 30 days. Now, along with Fertile One I take Pycnogenol (30 mg 2xday), L-Carnetine (500 mg 2xday), Acetyl L-Carnetine (250 mg 2xday), Vitamin C (500 mg 2xday), and a Centrum Performance (1 tablet/day). I have been going to an acupuncturist who has recently prescribed herbs (taken in the form of a tea). I have a mild varicocele that my urologist said surgery would not help. Now, we are about to go through our second IVF cycle. My wife is a breast cancer survivor (that was estrogen receptor positive) and just turned 41 this past January. The team at our clinic, CRMI, has told me repeatedly that my wife's age is a much larger factor than my counts, and have therefore suggested we begin an IVF cycle now rather than waiting another month for the Fertile One to take effect. What are your thoughts?

[Dr. Marks] Lee and Pam, I am not sure that Fertile One is your answer. I think you are doing all you can do nutritionally. I do think that fixing small varicoceles does help but it may take a few sperm cycles to get your counts up a bit and I don't think you have that time. I suggest that you go ahead and get a baby as quick as you can any way you can, including IVF, only if that is safe for her with her history of breast cancer.

[RESOLVE] The RESOLVE toll-free Helpline is available to answer your questions during business hours Monday, 9am - 4pm ET, Tuesday though Friday 1pm-4pm ET and Monday and Tuesday evenings from 7pm - 10pm ET at info@resolve.org or 1-888-623-0744. Members have the opportunity to contact our Medical Call-In Helpline, also 888-623-0744, Wednesdays 1-4pm ET.

[Michelle] If the SCSA test shows high DNA fragmentation, is there anything that can be done to improve it?

[Dr. Marks] Michelle, yes, take a long course of anti-oxidants; avoid heat and other stresses such as x-ray exposure, toxin or chemical exposure, etc.

[Michigan Couple] My husband's count is 284, but he has 1% morphology, so what are our chances of success with IUI, and how many do you think we should do?

[Dr. Marks] Michigan Couple, the count is great. His morphology is not. If his motility is decent and is volume is good, then a gradient wash will be good for him for IUI and improve his morphology. It all comes down to the skill and expertise of the andrologylab technician doing the wash. Be sure to get your own copies of the wash numbers before and after the wash.

[CnR] How would I know if antibodies are a problem? Would this be discovered in a semen analysis?

[Dr. Marks] CnR, yes, antibodies can be discovered if they see motile sperm clumping or agglutination on the semen analysis.

[Guest b] Dr. Marks. Please tell me if 3.2 morphology is too low to conceive naturally.

[Dr. Marks] Guest b, no. It depends on the normal range for that lab and the skill and expertise of the lab tech reading the morphology. It may just take longer to get pregnant. Also, do repeat semen analyses over several months as again this can vary widely.

[negerber] Can low motility or morphology hurt the chances of a successful IVF cycle by hurting the chances of the egg successfully fertilizing even if you use ICSI?

[Dr. Marks] nergerber, low motility is not a problem for ICSI as they will select the best looking sperm and grab it and inject it into the egg. The morphology just reduces their selection of a happy healthy sperm.

[bbu] Where do you get the SCSA test? Is it part of the usual sperm tests?

[Dr. Marks] bbu, no, the SCSA must be sent to a special lab. Contact your lab and ask them to find out about this and they can find out the nearest lab that does SCSA. Also, most andrologists and Reproductive Endocrinologists know where to do this. There are not a lot of places that do SCSA.

[Sb9] Dr. Marks, thank you for your time. Is there another way to test for antibodies besides semen analysis?

[Dr. Marks] Sb9, yes, you can do an antisperm antibody test if there are questions on the semen analysis. You should check for IgG, IgA and IgM for head, midpiece and tail attachment.

[kpavlovic] Do you have any thoughts on TESE with IVF (risk/benefits)? My husband has a 3.5mil/ml count and no found cause of infertility. Our urologist mentioned it for us to consider.

[Dr. Marks] kpavlovic, this is called a pooled IUI. Why not use the ejaculated sperm for IVF? The other option is to store up ejaculated specimens, freeze them and when you have enough banked thaw them and do IUI.

[negerber] What is the significance of the PH factor?

[Dr. Marks] negerber, almost no value for 99% of men. If it is very high or low, then I repeat it. It may be a sign of infection, but I would be looking at the white cell count primarily.

[Michigan Couple] On our latest semen analysis, it showed 65% total head defects, 16% tail defects, and 18% midpiece defects. Is there any hope that these numbers will change, and how long would it take? Also, how long does it take for White Blood Cells in semen to go away? My husband took tetracycline and had three White Blood Cells per unit?

[Dr. Marks] Michigan Couple, I would give it a cycle or two (74 days each sperm production cycle). He should do the vitamin thing, no heat, lots of fluids, lots of sex and give it time and recheck a count in several months. Doxycycline is a great drug for this, though I suspect that infection is not his problem with such a low White Blood Cell count.

[RESOLVE] Dr. Marks, thank you for your time and ongoing support of RESOLVE and your dedication to this family building issue. We also send a special thank you to everyone for your participation and all of your great questions.

[RESOLVE] Do you have any final comments you would like to share?

[Dr. Marks] It has been a lot of fun. I hope Dr. Grossman and I have been able to help out. I think getting accurate information is the biggest hurdle. We would love to come back and do this as often as needed.

[Rossin Canada] Thanks Dr. Marks! :)

[Guest b] Yes, thank you very much!

[kpavlovic] Thank you so much for your time. I will ask my Reproductive Endocrinologist about pooled IUI. A possibility I've never considered.

[Lee and Pam] Thank you.

[RESOLVE] Providing the chat on Understanding Semen Analysis and Options to Boost Male Fertility is being hosted by Sheldon Marks, MD has been our pleasure. We hope you have found this information to be helpful. If you have further questions, please contact the RESOLVE Helpline at 888-623-0744, Monday, 9am - 4pm ET, Tuesday though Friday 1pm-4pm ET and Monday and Tuesday evenings from 7pm - 10pm ET at info@resolve.org or 1-888-623-0744. Members have the opportunity to contact our Medical Call-In Helpline, also 888-623-0744, Wednesdays 1-4pm ET.

[LMS] Thank you.

[kpavlovic] Many thanks! :)

[Traci] Thank you for your time, it was very informative!

[Josey] Thank you!

[Michigan Couple] Thanks very much, doctors :)

[Dr. Marks] Good luck to you all. You must keep the faith.

[aphillips6] Thank You.

[drum] Thank you doctors.

[CnR] Thanks!

[Rossin Canada] Thanks to Dr. Grossman.

[Becky1] Thank you.