Chapter 4a
Testing the Man - Semen Analysis

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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In the past, infertility was blamed wholly and solely on the woman. This may have been to protect the fragile male ego, was because the male psyche equates fertility with virility, and views failure to father a child with shame. Studies today however show that 40% of infertility is because of a medical problem with the man.

The vast majority of men have simply no way of judging their fertility before getting married (unless, of course, they have had a premarital affair and fathered a pregnancy - the ultimate proof of male fertility !). Rarely, however, some men may know they have a fertility problem - for example, a sexual problem of impotence, which prevents consummation of the marriage; or one of hypospadias (in which the urethra is located at the base of the penis and the semen cannot be put in the vagina); or undescended testes ( in which both the testes are not in the scrotum).

When testing a couple for infertility, the man must always be tested first. Tests for the woman are far more complicated, invasive and expensive - it is much simpler to find out if the man has a problem.

The most important test is an inexpensive one - the semen analysis. The fact that it is so inexpensive can be misleading, because many patients ( and doctors ! ) feel that it must be a very easy test to do if it is so cheap, which is why they get it done at the neighbourhood lab. However, its apparent simplicity can be very misleading, because in reality it requires a lot of skill to perform a semen analysis accurately. However, it is very easy to do this test badly (as it often is by poorly trained technicians in small laboratories) , with the result that the report can be very misleading – leading to confusion and angst for both patient and doctor. This is why it is crucial to go to a reliable andrology laboratory , which specialises in sperm testing , for your semen analysis, since the reporting is very subjective and depends upon the skill of the technician in the lab.

For a semen analysis, a fresh semen sample, not more than half an hour old is needed, after sexual abstinence for at least 2 to 4 days. The man masturbates into a clean, wide mouthed bottle which is then delivered to the laboratory.

Providing a semen sample by masturbation can be very stressful for some men - especially when they know their counts are low; or if they have had problems with masturbation "on demand" for semen analysis in the past. Men who have this problem can and should ask for help. Either their wife can help them to provide a sample - or they can see sexually arousing pictures or use a mechanical vibrator to help them get an erection . Some men also find it helpful to use liquid paraffin to provide lubrication during masturbation. For some men, using the medicine called Viagra can help them to get an erection, thus providing additional assistance. If the problem still persists, it is possible to collect the ejaculate in a special silicone condom (which is non-toxic to the sperm but is not available in India ) during sexual intercourse, and then send this to the laboratory for testing.

The semen sample must be kept at room temperature; and the container must be spotlessly clean. If the sample spills or leaks out, the test is invalid and needs to be repeated. Except for liquid paraffin, no other lubricant should be used during masturbation for semen analysis – many of these can kill the sperms. It is preferable that the sample is produced in the clinic itself - and most infertility centres will have a special private room to allow you to do so - a "masturbatorium".

How is the test performed in the laboratory?

After waiting for about 30 minutes after ejaculation, to allow the semen to liquefy, the doctor will check the semen.

• The volume of the ejaculate. While a lot of men feel their semen is "too little or not enough" , abnormalities of volume are not very common. They usually reflect a problem with the accessory glands - the seminal vesicles and prostate - which are what produce the seminal fluid. Normal volume is about 2 to 6 ml. A very low volume will cause problems, because too little semen may mean that the sperm find it difficult to reach the cervix. A very high volume surprisingly will also cause problems, because this dilutes the total sperms present, decreasing their concentration.
   
• The viscosity. During ejaculation the semen spurts out as a liquid which gels promptly. This should liquefy again in about 30 minutes to allow the sperm free motility . If it fails to do so, or if it is very thick in consistency even after liquefaction, this suggests a problem - most usually one of infection of the seminal vesicles and prostate.
   
• The pH. Normally the pH of semen is alkaline. An alkaline pH protects the sperms from the acidity of the vaginal fluid. An acidic pH suggests problems with seminal vesicle function – either absence of the seminal vesicles, or an ejaculatory duct obstruction.
   
• The presence of a sugar called fructose. This sugar is produced by the seminal vesicles and provides energy for sperm motility. Its absence suggests a block in the male reproductive tract at the level of the ejaculatory duct.

The most important test is the visual examination of the sample under the microscope.

What do sperm look like ? Sperm are microscopic creatures which look like tiny tadpoles swimming about at a frantic pace. Each sperm has a head, which contains the genetic material of the father in its nucleus; and a tail which lashes back and forth to propel the sperm along. The mid-piece of the sperm contain mitochondria, or the power house, which provide the energy for sperm motion.

Ask to see the sperm sample for yourself under the microscope - if normal, the sight of all those sperms swimming around can be very reassuring . You are likely to be awestruck by the massive numbers and the frenzy of activity. If the test is abnormal, seeing for yourself gives you a much better idea of what the problem is! A good lab should be willing to show you, and to explain the problem to you.

Fig 1. Sperm as seen under a microscope

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