​What tests can be done to check sperm quality? ​

When you come to the fertility clinic, the first thing that’s done is a semen analysis. So, we obtain sperm from the patient then, we check the sperm: the volume, the pH, the count, the motility, progression and also normal forms. This is the norm in the majority of the clinics that actually do the test. Some labs actually do further testing of the same sample, for example, they look at the sperm antibodies and they look at for example in more detail on the velocity of the sperm and so on. So this is what a general semen analysis is about. However, if we see anything that concerns us in this semen sample, then we could suggest to the patient to do further testing of the sperm. The further tests that can be done are, for example, either survival test of the sperm which we will look at on how well it survives within 24 hours 48 hours and so on. We could also look at the DNA fragmentation which is a more detailed look at the DNA structure of the sperm. We know from research that high DNA fragmentation can lead to infertility. We could also do further tests of the sperm chromosome aneuploidy so, looking further into the chromosomes of the sperm and see if we could be normal ourselves as a man but the sperm we produce could actually chromosomally be abnormal. So depending on what we see in the first test, we can then build on those tests and do further analysis.

Our semen analysis will look at the volume of sperm so making sure there’s at least one and a half milliliters – that’s a normal value according to the World Health Organization. We’ll then take small samples of it and look at the amount of sperm that’s there so according to the again, the World Health Organization, a normal sperm current is 15 million sperm per mil or higher and then out of that sperm that’s there we’ll look at the motility and how well it’s moving and at least 32% of that sperm should be moving forwards in a good progression (so a good speed) or 40% of the sperm as a progression so what that means is a combination of forward moving sperm or sperm that’s moving slower and so 40% that way. So those are the most important ones and then we look at sperm morphology which should be in a normal sample would be glasses 4% and above but the most important ones for us are the amount of sperm that’s there and the movement of the sperm.

There is a general consensus that we should either diagnose normality or abnormality not on the basis of a single sperm test but ideally on the basis of two sperm tests which are completed at different times. The recommendation is to abstain for 2 to 5 days but not more than 5 days as the majority of the sperm then start to die and no less than 2 days. The sperm sample should be assessed as quickly as possible and ideally on site. Two sperm analyses a few months apart is the standard and recommendation.

The first test that has been used for many many years and it is considered the main test for assessing male fertility is the spermodiagram. It is the test where the male has to produce sperm after a period of abstinence of two or three days and then the sperm is set under microscope after liquefaction and the parameters that are checked are mainly the sperm count, the sperm motility and sperm morphology. We do have the guidelines from WHO, that guides us on how to correctly and in a standardized way to assess sperm quality in an effort to have a solid diagnosis for the male fertility stages. A very important recommendation is to absolutely have more than two sperm tests available before finalizing our diagnosis for the male. There is quite a fluctuation in the sperm count and sperm quality of the time so, that’s why we should never base our diagnosis and our clinical decisions based on one test and only. Apart from the spermodiagram over the last years there have been another test that has entered our clinical practice and has become part of our investigation routine and this is the DNA fragmentation index which goes beyond the numerical and the quantitative characteristic of the sperm and enters into the sperm cells and assess the structure of the DNA, of the sperm’s DNA. With these tests, we have increased our diagnostic efficiency because we have another parameter of the sperm cell this time to assess and improve if there is a need.

Important test is the standard semen parameters that all patients coming to clinics will have because that’s the test that’s most used in terms of comparing you to people who have conceived normally. So we look at sperm concentration, we look at how well the sperm moves – particularly how well or how large numbers are of sperm that are moving in a good direction at a reasonable speed. Also we look at things like the sperm appearances – this is a little bit more subjective really and in fact most people are surprised to find out that by the kind of strict criteria that labs use, four percent will be a normal value so, the overwhelming majority of sperm seen under the microscope will be abnormal. If your result comes back as your center of normal sperms is 30 or 40% it’s probably a lab issue rather than anything else. The test also looks at other things, it looks at the acidity of the sebum sample, looks at the volume. The volume can be very important too, it could indicate a problem with ejaculation so that’s the most important test. Other tests that can be used include things like DNA fragmentation; some clinics use that. Sometimes if there’s a suggestion that there’s an infection in the male genital tract, a sample scene might be sent to the laboratories to look for bacteria after growing it in an incubator. Sometimes an ultrasound scan might be carried out to look for the nature of any lumps that might be found on examining the scrotum and that’s most of the tests I think will be carried out.

To investigate male infertility, we can perform spermiogram, a basic spermiogram where we can assess concentration – so how many sperm there are, motility – how many spermatozoa are motile and also morphology – how spermatozoa looks if there are some defects in its head, neck or tail. However, in order to understand also the quality of the spermatozoa it is important to assess DNA fragmentation of the spermatozoa. This can be done with two techniques: one is TUNEL and the other one is SCAS. In case the patient has high DNA fragmentation is spermatozoa it is important to apply some techniques that can select the spermatozoa that do not present any damage, for example, microfluid sperm selection or PICSI technique.

The basic test that we will perform to assess sperm quality would be the spermiogram where we will assess concentration, motility and morphology. If that it’s not enough, we have extra tests like DNA fragmentation, apoptosis or other extra tests that your Andrologist can ask you if the cycle it hasn’t been successful.

So, what is the semen analysis? Semen analysis is a procedure to examine the quality of the sample that is produced during ejaculet in an ivf clinic or a diagnostic andrology clinic. What we look for in this is a number of characteristics, a number of qualities that will determine the quality of their sample. So, for instance, the ejaculate volume (usually between two and five mils), the concentration or the count of sperm (should be around 39 million, anything between 39 million and above is considered a good sperm count), concentration (will be the 15 million sperm per ml, that’s your concentration of sperm), the motility is the ability of the sperm to swim so, how well the sperm swim (we would measure the motility of the sperm) and the morphology. Basically what the sperm looked like in terms of its morphology, it’s various parts of the sperm, the head, midpiece and tail and their quality is good. Anything above 4% is considered normal. In those cases these are the basic macro examinations of sperm quality. There are other aspects. We can look if there’s repeated failed fertility which we’ll look at DNA and you can look at DNA fragmentation that would be to determine the quality of the sperm head, it’s quality of how well the sperm packs the DNA and maintains the quality of that DNA as well. So, there are other parameters to look at as well but mainly it’s the basic concentration, count, morphology and motility of sperm within the ejaculate.

Until recently it has been thought that the main test for a male patient to do it would be the classic semen analysis test and this is not the necessarily the case, yes, the semen analysis test it is the first step that’s been being followed to investigate the basic parameters of the sperm, such as the sperm count (so the number of sperm being present in the ejaculate), the amount of motile sperm and the type of progression that those sperm have and also their morphology. But we need to bear in mind that further tests, more sophisticated tests, need to be combined with the semens analysis such as a DNA fragmentation test. DNA fragmentation although it is still a controversial issue whether it is of clinical significance or not, we have more data to start believing that by investigating the levels of DNA fragmented sperm, it can help us also investigate further what we call the male factor. In my opinion, I’d say when we’re talking about sperm quality and one test needs to be followed, I would say we always start with a semen analysis, a basic semen analysis that would be ideally be combined with the sperm DNA fragmentation test, in that way with those tests, not only we investigate the basic semen parameters, so we answer the questions: either is there a sperm, if yes, how much sperm, what type of motility is it, does the sperm look healthy under the microscope (so in terms of morphology) but also what is the quality of that DNA that exists and on those spermatozoa and also something else that we need to bear in mind it’s not just the lab test itself, a man who’s a consistently show us a reduced semen volume, that patient they need to see a urologist or an uro-andrologist where they can be referred for a scrotal ultrasound, for example, or a transrectal ultrasound (more importantly) to investigate the obstruction of any of the ejaculatory ducts, for example. Everything starts with semen analysis but then further tests need to be followed.

The first test that a man should have for his sperm is a semen analysis and of course that’s very important because that tells him how many sperm he has, his sperm count, what they look like, are they well formed and what’s the structure or the morphology and then, the third one is the motility: how fast can they swim and can they swim in a straight line. Those are very very important factors for a man to know but there are other tests which are also really important such as DNA (which I was talking about earlier) and how much oxidative stress the sperm have. You wouldn’t believe that we can get stressed as people but I’m sure you didn’t know that your sperm can get stressed and that’s true as well.

In order to assess the semen quality, the cornerstone of male infertility is testing semen analysis. This is the first test that should be done for the male partner. Semen analysis is a standard test which analyses different characteristics, for example the appearance, the volume, pH of the sample, the viscosity and also some microscopic features of sperm, such as concentration, motility and morphology which is also important and the vitality rate of sperm. This is a standard test but there are other types of tests considered to be more advanced such as the evaluation of seminal fructose which is a marker of obstructive azoospermia and also acts as tests for seminal oxidative stress and sperm DNA fragmentation. Both conditions have been associated with male infertility so it is very important to identify this condition and analyze if a man has high levels of seminal oxidative stress or a high rate of sperm DNA fragmentation. This can be done through different tests, for example seminal oxidative stress has a large variety of tests which analyse the level of oxidants or the level of antioxidants in semen. There is one test that has been recently developed called oxidative reductive potential, which analyses the rates of oxidant and antioxidant molecules in a semen sample. It has been really important recently as it is easy to perform and standardise. At the same time, even for sperm DNA fragmentation there are several tests such as TUNEL, comet, SED, SCSA which all identify the presence of breaks in sperm DNA and this is important because high rates of sperm DNA fragmentation has been associated with lower reproductive potential.

Sperm quality in the routine analysis begins with the count of the spermatozoa, we have tables for normality and we usually follow the WHO criteria for a minimum amount number of spermatozoa per ml which is presently at 15 million. And there are also tests for the quality of the sperm, which is charged by motility, morphology, DNA fragmentation index, and various other less frequently done tests such as mucus penetration. Motility is meant to be the way we count the forward movement of the spermatozoa which gives them the ability to approach and fertilize the egg. Morphology refers to the way the head of the spermatozoon is shaped up; it has to be normal in order to carry on the function and I must mention that the DNA that the sperm carries in the head will be joining the female DNA after it penetrates the egg. DFI is the measurement of the DNA of the spermatozoa; a very important measurement and something that’s becoming more popular. And finally, the mucus penetration has to do with the ability of the sperm to penetrate the mucus and reach the target which is of course the egg to fertilize.