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Infertility Assessment – Male

Male Factors

A male factor is estimated to be the sole cause in about 20% of infertile couples and a contributor in another 20%-30%. The presence of a male factor is typically suggested by an abnormal semen analysis but there can be challenges defining male subfertility more

Defining male subfertility accordingly to the sperm parameters in a basic semen analysis can be problematic unless the sperm concentration or motility are consistently in the extremely low ranges. The reason is that there are wide overlaps in the values of sperm parameters between fertile and subfertile men. The assessment of normal sperm morphology (appearance) using Tygerberg “strict criteria” has added additional confusion more

The strict criteria for assessing sperm morphology was originally used to estimate the chance of in vitro fertilization before ICSI was introduced. Since then, it is one parameter considered when deciding if ICSI is needed for couples going through IVF treatment. However, the same method is now used to score sperm morphology in the general population. While this has standardized the method of assessing sperm morphology, it may inadvertently increase the false positive rates for some men with good sperm concentration and sperm motility, creating unnecessary anxiety and concerns. Hence, a low % sperm morphology needs to be interpreted appropriately and not in isolation.

 

There are circumstances that early or immediate assessment of male fertility should be considered, e.g.:

  • History of undescended testes
  • History of chemotherapy
  • Question about the male’s fertility potential
  • More advanced female age (over 35)
  • Lifestyle factors, e.g., use of recreational drugs, including testosterone

 

Early evaluation of the male partner is important to:

  • Prevent unnecessary added delays, since many couples are now postponing parenthood.
  • Screen for modifiable practices or lifestyle elements that might be affecting male fertility.
  • Identify treatable causes of male infertility.
  • Screen for medical conditions that may contribute not only to male infertility but general health.

There can be many causes for male infertility. Therefore, we advocate a systematic approach which begins with a detailed history and if appropriate, a physical examination, followed by a semen analysis. Depending on the results of the initial semen analysis, a more detailed evaluation may follow depending on clinical indications:

  • Hormone tests
  • Repeat semen analyses
  • Sperm function assessment
  • DNA fragmentation more

    The sperm chromatin dispersion test measures the integrity of sperm DNA, the genetic material contained in the sperm head that will be passed onto the embryo. The test uses acid to denature the DNA protein. Sperm with DNA breaks and sperm without DNA breaks are identified by observing the difference in the size of halos formed around the sperm core. The halos represent expansion of DNA loops. Undamaged sperm will have large or medium halos and damaged sperm will have small or no halos. Sperm DNA fragmentation has been suggested as a cause of infertility and has been linked to unexplained infertility, repeated IVF failure, and recurrent miscarriage although controversies exist.

  • Genetic evaluation
  • Urology consultation

The goal is to optimize overall fertility potential and maximize chances of natural or assisted conception.

Sperm Functional Assessment (SFA)

A routine screening semen analysis provides basic information on the semen volume, the presence of sperm and their number (sperm concentration), their movements (sperm motility), and the proportion with normal shape (% normal sperm morphology). However, because the sperm has to overcome a few important steps before it can reach and fertilize the egg, more detailed assessment and sometimes, additional specialized tests are needed to assess its fertilizing potential.

 

What does the Sperm Functional Assessment (SFA) evaluate?

  • Detailed breakdown of the different grades of sperm motility, particularly sperm with rapid progression
  • Mean number of defects per abnormal sperm to provide another dimension of looking at the % of normal sperm morphology
  • Recovery of sperm, with rapid progression, from the semen sample available for potential assisted conception.

 

Other tests included in the Sperm Functional Assessment (SFA) provides additional information on

  • how well the sperm will swim through mucus secreted by the cervix, the initial barrier to entry to the uterine cavity and the fallopian tube to reach the egg
  • whether there are antisperm antibodies coating the surface of the sperm that might impede this process
  • if the sperm can penetrate the egg.

After excluding other female factors this information helps your physician tailor your fertility treatment, which can range from

  • timed intercourse
  • intrauterine insemination (IUI)
  • in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI).

According to the most recent criteria of the World Health Organization and other international standards includes evaluating the concentration, motility and movement patterns (particularly those with rapid progression), and appearance of the sperm (morphology). The procedures to analyze these criteria are highly standardized to ensure that the results are accurate and reliable. In addition we perform an extra in-depth evaluation of sperm morphology that provides more information of possible problems with sperm function.

After intercourse the ejaculated semen is deposited in the vagina near the opening of the cervix (the entrance to the uterus). Sperm then swim out of the semen into the cervical mucus and into the fallopian tube where one sperm will fertilize the egg. This sperm has to undergo certain final maturation changes before it is capable of fertilizing the egg.

One of the most important challenges the sperm faces naturally is to swim through the cervical mucus into the uterus. A particular swimming pattern is required to achieve this. The Diagnostic Lab at Grace Fertility Centre has a computer-aided sperm analysis (CASA) machine calibrated carefully to analyze the swimming pattern of hundreds of sperm in just a few minutes. If there are not enough sperm that show the correct swimming pattern then the chance of pregnancy by intercourse, even if carefully timed, is reduced. In this case, your physician can recommend intrauterine insemination.

A few men produce antibodies that react against their own sperm and these anti-sperm antibodies can block sperm fertilizing ability. There are several causes of anti-sperm antibodies, ranging from testicular injury, vasectomy, having had mumps, or just an infection with certain bacteria. Anti-sperm antibodies bind to the surface of the sperm and interfere either with their swimming through the cervical mucus, their binding to the egg, or the fertilization process itself. Although there is no effective treatment for anti-sperm antibodies, the SFA at Grace Centre includes a comprehensive screen for them so your physician can avoid fertility treatments that are known to be ineffective in the presence of certain types of anti- sperm antibodies, and select treatments that can bypass this problem.

Sperm must be separated from the liquid part of the semen before they can complete their final maturation and be able to fertilize the egg. In the natural situation this happens when they swim through the cervical mucus. For assisted conception procedures this is done using a special washing technique, and doing a “trial wash” as part of the SFA gives important information on the number of likely competent sperm in a man’s ejaculate. Using this information, your physician can advise the most appropriate forms of treatment for the man’s sperm.

Before a sperm can fertilize an egg, it has to develop a special swimming pattern (called “hyperactivation”) as part of the final process of sperm maturation. After incubating the sperm in the same solution (culture medium) in which we perform IVF, the CASA machine is used to determine the proportion of sperm that show this special swimming pattern, and if indeed there are too few of them, then ICSI can be recommended.

Treatment recommendations

Together, these results give your physician not just an indication of the likely fertilizing ability of the sperm in a man’s semen sample, but it can also identify specific risks of sperm function failure. However, the SFA Lab Report can only identify issues directly related to the man’s sperm and not other medical aspects of a couple’s infertility. Using the detailed information from the SFA, your physician will be better able to recommend treatments that are more likely to succeed in bypassing the problem(s) causing your infertility. However, sometimes on the day of treatment, the semen sample might not be not as good as the one tested in the SFA and your physician may advise a different form of treatment.

SFA Results

Due to the extensive testing performed within an SFA, it can take up to 10 days to complete the results and prepare the final report. Your physician then reviews the SFA report with you, along with your history and other investigations to recommend the appropriate fertility treatment option.