Editing Infertility: Diagnosis and Evaluation (section)

=== Semen analysis ===
* '''<span style="color:#ff0000">Generally, results cannot precisely distinguish fertile from infertile men except</span>'''
**'''<span style="color:#ff0000">Individual sperm parameters diagnostic of infertility (4):'''
**#'''<span style="color:#ff0000">Azoospermia</span>'''
**#'''<span style="color:#ff0000">Necrozoospermia</span>'''
**#'''<span style="color:#ff0000">Complete asthenozoospermia</span>'''
**#'''<span style="color:#ff0000">Some types of teratozoospermia (e.g., complete globozoospermia)</span>'''
*'''<span style="color:#ff0000">Should be examined under the microscope within one hour of collection</span>''' 
*'''<span style="color:#ff0000">Should be given after 2-3 days of abstinence</span>'''
*'''<span style="color:#ff0000">Number of samples</span>'''
**'''<span style="color:#ff0000">At least two semen analyses obtained a month apart are important to consider, especially if the first SA has abnormal parameters[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]</span>'''
***'''If azoospermia, a second SA should be performed at least one to two weeks later.'''

==== <span style="color:#ff0000">WHO semen parameter percentiles</span> ====
* '''<span style="color:#ff0000">Derived from men whose partners became pregnant (fertile population) within 1 year of discontinuation of contraceptives.</span>'''
* '''<span style="color:#ff0000">The 5th percentile is used to describe infertility cut-offs for 7 semen parameters</span>'''
** '''Values falling above or below the lower limit do not by themselves predict either fertility or infertility;''' '''males with''' '''abnormal semen parameters have contributed to a prior successful pregnancy through natural conception'''
***The odd ratio for infertility increases as the number of abnormal parameters increases.
#'''<span style="color:#ff0000">Volume <1.5mL</span>'''
#* '''See [[CUA: Azoospermia (2015)|2015 CUA Azooospermia]] Guideline Notes'''
#* '''<span style="color:#ff0000">Causes (6)</span>'''
#**'''<span style="color:#ff0000">Obstruction or hypoplasia (severe androgen deficiency, CBAVD) of the prostate and seminal vesicles</span>'''
#**'''<span style="color:#ff0000">Alpha blockers</span>'''
#**'''<span style="color:#ff0000">Retrograde ejaculation</span>'''
#***'''<span style="color:#ff0000">Definition: semen with sperm are released into the prostatic urethra but travel backward (retrograde) into the bladder</span>'''
#****Distinguished from aspermia (absence of antegrade ejaculate; dry ejaculate)
#***'''<span style="color:#ff0000">Causes</span>'''
#****'''<span style="color:#ff0000">Diabetes</span>'''
#****'''<span style="color:#ff0000">RPLND</span>'''
#****'''<span style="color:#ff0000">Spinal cord injury</span>'''
#**'''<span style="color:#ff0000">Multiple sclerosis</span>'''
#* '''Hypervolemia (>5 mL), dilutes sperm therefore interferes with reproduction.'''
#** '''IUI can be used to concentrate sperm'''
#'''<span style="color:#ff0000">Total number <39 million/ejaculate</span>'''
#* '''<span style="color:#ff0000">Most important semen analysis parameter</span>'''
#*'''<span style="color:#ff0000">Definition of azoospermia: no sperm in the ejaculate</span>'''
#*'''<span style="color:#ff0000">If semen analysis shows azoospermia, laboratory should then centrifuge the ejaculate and re-suspend the pellet in a small volume of seminal plasma and examine under wet mount microscopy for the presence of rare sperm.</span>''' 
#**'''If no sperm are present, a second semen analysis should be performed at least one to two weeks later. If the sample is azoospermic, then another pellet analysis should be performed.[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
#**'''Further investigations for azoospermia depend on if it is associated with low-volume (obstructive) azoospermia or normal-volume azoospermia'''
#*'''Azoospermic patients with[https://pubmed.ncbi.nlm.nih.gov/15363709/ §]'''
#**'''Normal ejaculate volume may have either obstruction of the reproductive system or abnormalities of spermatogenesis'''
#**'''Low semen volume and normal sized testes may have ejaculatory dysfunction or ejaculatory duct obstruction'''
#'''<span style="color:#ff0000">Concentration <15 million/mL</span>'''
#* Visual assessment under microscopy
#*
#*'''<span style="color:#ff0000">Definition of oligospermia: <15 million/mL</span>'''
#'''<span style="color:#ff0000">Total motility <40%</span>'''
#* '''Visual assessment under microscopy'''
#* '''<span style="color:#ff0000">Asthenospermia is when total motility <40% or progressive motility <32%'''
#** '''Causes of asthenospermia[https://www.pulsus.com/scholarly-articles/evaluation-and-treatment-of-oligoasthenospermia-in-the-era-of-assisted-reproductive-techniques.html §]'''
#**# '''Sperm structural defects'''
#**# '''Prolonged abstinence periods'''
#**# '''Genital tract infection'''
#**# '''Anti-sperm antibodies'''
#**# '''Partial ductal obstruction'''
#**# '''Varicocele'''
#'''<span style="color:#ff0000">Progressive motility <32%</span>'''
#* '''Progressive motility: moving actively, linearly or in large circle, regardless of speed'''
#* '''Nonprogressive motility: all other patterns with absence of progression'''
#'''<span style="color:#ff0000">Normal forms <4%'''
#* '''Teratozoospermia: normal forms <4%'''
#* '''Globospermia''': '''failure of acrosomal head to form small, round heads'''.
#** Without the acrosome, fertilization with sperm in the natural setting or with incubational in vitro fertilization will not be successful. '''Intracytoplasmic sperm injection is required'''.
#*** Ejaculated sperm is available in this patient, and therefore surgical sperm extraction is unnecessary.
#* '''Higher rates of aneuploidy with many abnormal forms.'''
#** '''Conditions associated with aneuploidy:'''
#*** Aging
#***Cytotoxic agents
#***Environmental exposures (smoking)
#** '''Consider aneuploidy in patients with recurrent pregnancy losses'''
#** '''intracytoplasmic sperm injection with biological gametes is not recommended with sperm associated with macrocephaly and multiple tails due to the high rate of aneuploidy'''
#* '''Strict morphology is not a consistent predictor of fertility, and for this reason, the AUA states that strict morphology “should not be used in isolation to make prognostic or therapeutic decisions"'''
#'''<span style="color:#ff0000">Vitality <58%</span>'''
#*Metabolically active living cells
#*'''Necrospermia: reduced vitality'''
#**'''Cannot evaluate in complete asthenospermia since assay relies on association of moving particles proximal to motile sperm'''
#***'''To rule out necrospermia when motility is 0%, consider vital stain'''
#**'''In the complete absence of motility and necrospermia has been ruled out, electron microscopy can identify if ultrastructural tail defects are present in the immotile cilia syndrome'''
#***In immotile cilia syndrome is confirmed, patients can subsequently be counselled to undergo IVF
#'''<span style="color:#ff0000">Viscosity, coloration, pH</span>'''
#*In spinal cord injury, a brown hue can be noted in the semen
#*'''<span style="color:#ff0000">pH should be 7.2-7.8 (alkaline due to seminal vesicle contribution)</span>'''
#**'''<span style="color:#ff0000">If low volume with</span>'''
#***'''<span style="color:#ff0000">Acidic pH, azoospermic ejaculate can be indicative of obstruction in the genital tract</span>''' 
#***'''<span style="color:#ff0000">Normal pH (>7.2), azoospermic ejaculate can be indicative of incomplete collection, retrograde ejaculation, or partial obstruction</span>''' 

* '''The presence of abnormal semen parameters suggests the presence of a male factor in an infertile couple which should prompt further evaluation of the male'''

==== 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'''