Preseed.com Blog

A physical exam by a fertility urologist or male specialist is an important part of evaluating the man for fertility issues.  A general physical exam needs to be done to make sure there are no underlying issues that might impact his health and sexual function.  This includes making sure his blood pressure is normal and he doesn’t have diabetes. In addition, a careful exam of his “parts” (genitalia) should be done. 

The physician should evaluate: the penis, including where the urethra opens; the size, shape and consistency of the testicles, the vasa (or cords) and the epididymides;  if a varicocele is present; any signs of hormone disruptions; and a digital rectal exam for the prostate and internal organs.   Remember TWO semen analyses one month a part are required for adequate review of the man’s semen.  This is because many men are nervous with their first sample, and the quality can be quite poor even with normal men The clinic that does the semen analysis should adhere to World Health Organization guidelines for the analysis 

If they don’t use these standards, it suggests they may not be very experienced at male factor  work ups and you may not be given good information.  Abstinence should be 2 days, longer than this can be counterproductive. Semen can be collected by masturbation or during intercourse using a special semen collection condom. Pre~Seed or Pre’ can be used to lubricate the collection process.  Remember here, the better the experience feels for the man, the more sperm he can produce.  So do every thing you can to make collection enjoyable.  For many men, this means not doing it at the clinic. 

As long as you can get the sample to the clinic so they can begin examination in less than one hour, and you can protect it from temperature extremes, there is nothing wrong with collecting the sample at home, or even in a local hotel, near the clinic. If it is very hot or cold out, and/or you have travel, which traffic and life’s delays push that 1 hour time frame, then go ahead and make the best of the clinic’s “men’s room”.   If you are transporting samples, wrap them in a good sized towel to protect them from temperature changes during transit.  The laboratory should have a quality control program with standards set by CLIA.  Again it is good to ask if they use WHO guidelines and if they conform to CLIA standards. 

A semen analysis provides information.  It can not tell you (in general) if a man is fertile or not. Men can have a normal semen analysis and still not be fertile.  But most of the time, a semen sample that doesn’t meet the reference range suggests a male factor fertility issue and indicate a need for further evaluation. 

Failing to meet the reference range doesn’t mean this man is “sterile” or will never cause a conception (unless he is not making any sperm). It can mean that his chances of fathering a child are, in general, less than a man with results in the reference range.   Semen analysis Reference Values are:

1. Ejaculate volume
   1.5 to 5 ml
2. pH
   > 7.2
3. Sperm concentration
   > 20 million/ml
4. Total sperm number
   > 40 million/ejaculate
5. Percent Motile
   > 50%
6. Forward Progression
   > 2 (0-4 scale)
7. Normal Morphology
   >30% WHO 1992  or >14% Kruger/Tygerberg Strict Criteria WHO 1999
8. Sperm agglutination
   < 2 (Scale 0-3)
9. Viscosity
   <3 (Scale 0-4)   
    

Inseminating sperm directly into the uterus (intrauterine insemination or IUI) is often used in male factor infertility, either with or without giving medication to stimulate the ovaries.  There have been a couple of papers this year of interest to me on this topic.  Many couples don’t fully realize how low the per cycle pregnancy rate with IUI can be, especially in conditions as noted below, or in clinics that aren’t very experienced in dealing with male factor patients (read more of my FAQs to learn about this).

Specifically, Badawy et al., 2008 showed declining pregnancy rates following IUI with  male factor if: the female partner was over 35 yrs old; the number of motile sperm inseminated was less than 5 million ( a 5.5%, pregnancy rate versus 24% if there were more than 5 million motile sperm); or if normal sperm morphology  (WHO guidelines) was under 30%.    Another recent study (Dovey et al., 2008) with over 4,000 couples found pregnancies from women under 35 years of age at 11.5% per cycle.  Women 35-37 had a pregnancy rate of 9% , which declined down to 1.8% in women over 42.  

This is why we recommend if you are 35 or older, do not wait for one year without conceiving to get assistance!

Many people do not believe that a doctor’s intervention is the right thing to do in conceiving, or perhaps they just can’t afford it.  It is interesting to note that although the percentage of women having a baby tends to be higher following intra-uterine insemination,  it has not been able to be proven to be more effective in clinical studies versus well timed natural intercourse (Cochrane Database Syst Rev., 2007 ).  This is likely due to the lack of well designed studies, rather than an ineffectiveness of IUI (done by experienced clinicians), BUT it does suggest that good old, natural love making at least every other day throughout your ovulation time, can be effective even after a long time of trying!  So even if you can’t or won’t do IUI, keep timing your ovulation and keep love making  “that time” as enjoyable as you can! Sometimes miracles do happen

Dr. E

PS: I will continue my male work-up series later this month!