Editing Infertility: Diagnosis and Evaluation (section)

==== <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'''