Editing Infertility: Diagnosis and Evaluation (section)

==== Secondary Semen Analyses ====

===== DNA fragmentation =====
* Negatively associated with pregnancy rates and positively associated with miscarriages
**Patients with high sperm DNA fragmentation can be counseled that there is a possible association with infertility and compromised outcome after ART
*'''Direct measures of sperm DNA fragmentation include (2):'''
**Terminal deoxynucleotidyl transferase dUTP nick end labeling '''(TUNEL) assay'''
**'''Comet assay'''
* '''<span style="color:#ff0000">Indications</span>'''
**'''<span style="color:#ff0000">Not recommended in the initial evaluation of the infertile couple</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**May be useful in couples undergoing IVF with repeated IVF failure
*Management
**Currently no effective therapy to correct an abnormal DNA fragmentation result
**If high sperm DNA fragmentation, consider'''[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
***Using surgically obtained sperm in addition to ICSI
****In a prospective cohort study of over 100 couples with high DNA fragmentation, testicular sperm yielded substantially higher live birth rates than ejaculated sperm.[https://pubmed.ncbi.nlm.nih.gov/28865546/]
***Antioxidant administration
***Varicocele repair
***Frequent ejaculation
****Decreased abstinence may be an intervention to limit sperm DNA damage.[https://pubmed.ncbi.nlm.nih.gov/29043697/]
***Donor sperm

===== <span style="color:#ff0000">Semen WBC staining</span> =====
*'''<span style="color:#ff0000">Increased levels of round cells in the semen may result from</span>''' 
*#'''<span style="color:#ff0000">Presence of elevated levels of white blood cells in the semen (pyospermia)</span>'''
*#*White blood cells in the semen may result from infection or inflammation in the proximal or distal male genital tract.
*#'''<span style="color:#ff0000">Spermatogenic problem where immature germ cells</span>''' (spermatocytes and/or round spermatids) '''<span style="color:#ff0000">are present in the ejaculate</span>''' 
*#*No evidence that elevated levels of immature sperm in the semen is deleterious to fertility, and they may be present in semen of infertile men and fertile men with high sperm counts.
*#'''<span style="color:#ff0000">Idiopathic</span>'''
*#*Most common cause
*'''Important to know whether men with elevated levels of round cells in the semen have immature germ cells or an infectious or inflammatory etiology for subsequent management (see below)'''
*'''Leukocytes and immature germ cells are not differentiable with light microscopy'''
**'''Papanicolaou staining may be used'''
***Immunocytochemical staining provides more information to aid in distinguishing between inflammation and those subtypes involved in fighting off infection
*'''<span style="color:#ff0000">Indications</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**'''<span style="color:#ff0000">Increased round cells on semen analysis (>1million/mL)</span>''' 
***'''Upper limit of normal as <1 million white blood cells/mL of semen'''
*'''<span style="color:#ff0000">Management</span>'''
**'''<span style="color:#ff0000">If staining suggestive of</span>'''
***'''<span style="color:#ff0000">Pyospermia, evaluate for the presence of infection</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
****'''<span style="color:#ff0000">Sexual transmitted infections can also lead to leukocytes in semen and this needs to be ruled-out</span>''' 
****'''Chronic prostatitis due to bacterial infection may require long courses of antibiotic treatment''', and some cases of elevated levels of white blood cells may result from chronic nonbacterial prostatitis.
****Leukocytes can occur with UTIs, but unless urine is in the semen, this is an unlikely source.
****Inflammation may be medically treated with anti-inflammatory drugs.
***'''<span style="color:#ff0000">Immature germ cells is a condition that cannot be treated</span>'''

===== Anti-sperm antibodies =====
* '''Can result in sperm agglutination in the semen'''
**Anti-sperm antibodies may be present without sperm agglutination and, conversely, agglutination may be present due to other factors, such as the presence of E.coli in the semen
* '''Can impair sperm-ova penetration'''
*'''Associated with events such as trauma, mumps orchitis, testis malignancy, vasal obstruction, vasectomy that disrupts the blood-testis barrier, or the patency of the male genital tract allowing sperm antigens or genital tract infections to generate anti-sperm antibodies.'''
** Vasectomy disrupts the blood-testis barrier, resulting in detectable levels of serum antisperm antibodies in 60% to 80% of men.
* IgA and IgG antibodies are the predominant antibodies found in semen, while IgM is rarely found[https://pubmed.ncbi.nlm.nih.gov/33295257/]
*Tests used (2):
**Mixed antiglobulin reaction test
**Immunobead (IB) test
***Gives information about the type and presence of the immunoglobulins and their localization specifically on the sperm head, midpiece or tail or covering the entire sperm
*'''Indications'''
**'''Should not be done in the initial evaluation of male infertility'''
**'''Should only be considered if it will affect management of the patient.''' 
***'''For couples planning on ICSI, ASA testing should not be performed since it will not change management.'''
*'''Management'''
**'''IUI after specific semen processing or ICSI'''
***Some have reported improved IUI pregnancy rates with specific semen processing protocols for couples with anti-sperm antibodies compared to standard sperm washing, although the data are limited
***In those with anti-sperm antibodies, ICSI yields higher pregnancy rates per cycle than IUI with semen processing designed to disrupt the bound antibodies.

===== Sperm aneuploidy testing =====
*Involves the use of fluorescent molecular probes for chromosomes 13, 18, 21, X, Y because the presence of an extra chromosome for these specific chromosomes is consistent with a potentially viable but affected offspring. Aneuploidy of all other human chromosomes is not consistent with a viable offspring.[https://pubmed.ncbi.nlm.nih.gov/33295257/]
*'''Indications'''
**'''Recurrent pregnancy loss'''

===== Sperm penetration assay =====

*Most closely models incubational in vitro fertilization

===== Sperm culture =====

*'''Limited seminal concentrations of the majority of bacteria including E. Coli have minimal or no effects on sperm motility in vivo'''

===== Fructose =====
*'''Produced in the male reproductive tract by the seminal vesicles and is released into the semen during ejaculation'''
*Energy source for spermatozoa[https://pubmed.ncbi.nlm.nih.gov/11554980/ §]
*Mean concentration of fructose in human semen is 2–3 mg/mL (11–16 μmol/mL)[https://pubmed.ncbi.nlm.nih.gov/11554980/ §]
**'''Low semen fructose may suggest ejaculatory duct obstruction'''