Sperm analysis or tests are a critical part of finding out what why a couple may not be conceiving. Male low fertility is usually involved about 60% of the time, with 40% of the time the man being the main cause and 20% of couples having shared male and female issues.

First of all the results of a sperm analysis are your medical records and you have the right to them, and the right to a good conversation of what was found. I am surprised how often people don't get reports back or how poorly the material is reported back. YOU need to be aggressive about talking to your doctor and understanding what they found. YOU also have the responsibility of making sure your clinic is using state of the art methods to look at DH's (darling husband’s) sperm. If not, find another clinic! One recent study showed that showed only 30% OF ALL CLINICS doing sperm tests in this study had accurate readings of motility and morphology.

That said it is important to understand that there is NO sperm test that can tell you if a couple will conceive or not - except if there are no sperm in a man's semen- then of course the chance is zero.

There have been thousands of studies with every one wanting a magic bullet that says "this ejaculate can make a baby, this one can not". NO SUCH Test exists.

What we do have is studies relating various quality sperm to various levels of fecundity (this means the chance of conceiving). Men with normal sperm parameters in regards to count, motility, and morphology (shape) tend to have normal chances of impregnating their wives (20-30% chance each month). Although other things can be wrong with sperm that appear normal at sperm analysis. The chromatin (DNA) can be damaged, there can be antibodies etc... Meaning that just b/c DH has a normal basic sperm analysis does NOT guarantee he is "fertile". Many couples with unexplained infertility have stopped evaluating the man because he has normal parameters on a semen analysis. This is not good medicine.

Infertility with normal sperm counts: If your DH has a normal sperm analysis, but you have been trying over 12 months, or 9 months and the woman is 35 or older & there are no obvious female factors...you need to see a Clinical Andrologist- a male sperm specialist- NOT an RE to look deeper into more subtle sperm defects.

On the other side, an abnormal sperm count does not mean your husband is sterile- sterile means NO functional sperm in the ejaculate. It truly does only take one normal sperm and we have all heard of couples that could not conceive for years and years due to male factor, who suddenly do become pregnant. Lower quality sperm, meaning outside of average, means your fecundity or chance of conceiving each cycle drops. There is one recent study with Dr. Kruger as an author (i.e. Kruger's strict morphology criteria) that studied all the other studies and basically said that you can break ejaculate quality into "fertile" or "subfertile" based on "thresholds of <5% normal sperm morphology, a concentration <15 x 10(6)/ml, and a motility <30% should be used to identify the subfertile male”.

You will note that this study used the strict criteria for morphology - Other forms of looking at sperm shape are not as accurate or predictive of subfertility.

Subfertile doesn't mean sterile- it means your chances are less and as you move to worse and worse quality the chances continue to decline somewhat.

Infertility with abnormal sperm analysis: If you have this situation you need to repeat the sperm analysis to confirm accuracy. I NEVER use a first sperm sample even in my totally normal young volunteers in my studies- b/c the first time a guy performs in a cup- the sperm are usually bad!!!! A recent study showed that sperm motility, and counts differed AMAZINGLY for monthly sampling over a year from the same guy. Four times, even 17 times! the number of sperm in an individual ejaculate. The only parameter that did not vary was the percent of morphologically normal sperm - the shapes. The one caveat here is that these guys all collected into a cup - probably dry handed (without lubricant). Numerous other studies have shown that you can improve the normal morphology % using collection into a condom during intercourse based on the man being more stimulated.

It is also important to note that sperm counts and quality decrease as your DH ages over 45 yrs...see below. Another study has shown that sperm DNA quality also goes down after age 45. SO... if your DH is older for sure really stimulate him for any semen collection. Try to make it as exciting as possible and think about using that collection condom.

Also, many, many studies have suggested the benefit of antioxidants in men that are trying to conceive. I have posted one here that looked at it the other way - instead of an effect of vitamins on sperm quality- they looked at fertile versus infertile guys and found that the fertile guys had more antioxidants in their semen. So any man with a poor semen analysis should be put on fertility vitamins with antioxidants such as FertilAid.

Good luck-
Dr. E

Using a Sperm Collection Condom?

Q: A friend told me about using a condom to collect sperm for our IUI. What does this require and why would you use choose this message?

A: Here is a copy of a newsletter that I wrote on this subject:

Semen Collection by Masturbation vs. Intercourse with a Condom

Millions of sperm samples are processed each year for both diagnostic procedures (to determine sperm quality in a man) and therapeutic interventions, such as intrauterine insemination (IUI) and in vitro fertilization (IVF). The majority of these samples are collected manually by masturbation. However, this method can cause a great deal of stress in men, and it can lead to production of inferior sperm samples, with lower sperm counts and motility resulting. Whether men morally object to masturbation to collect semen, or if the whole process of performance "on demand" is too much to allow for good sample collection, numerous studies have shown that collecting sperm in a condom during intercourse is an excellent alternative to masturbation.

Data Supporting Sperm Collection Using Condoms at Intercourse:  Studies over the last three decades, have shown that sperm quality can be strongly impacted by collection method, especially in oligospermic men (men with low sperm counts). A review of the published literature shows that total sperm counts, sperm motility, and the percentage of sperm with normal morphology are often 2-3 times higher in samples collected in condoms at intercourse than by masturbation in the same men (Sofikitis & Miyagawa, Journal Andrology, 1993). Sperm function tests like hamster zona penetration or membrane swelling are also significantly improved for sperm from condom collection versus masturbation. In fact, in one study (Zavos, Fertility & Sterility, 1985), 38% of the patients that were classified as having low sperm counts based on masturbated sperm samples, were reclassified as normal after semen collection at intercourse in a condom. Furthermore, in this study, the total functional sperm fraction (numbers of normally shaped motile sperm in the sample) increased by 190% in oligospermic patients, and 69% in normospermic men.

In these studies sexual satisfaction at collection is also greatly increased, lessening the stress of the collection process. In fact in one study, patients preferred condom use so much over masturbation that the scientists had to stop randomizing collection method and only have men collect at intercourse AFTER the masturbation collections were done, or the men would stop participating in the study!

In general, all studies comparing masturbation to condom collection of sperm have found that those sperm parameters historically associated with and related to fertility show improved outcomes when collected into condoms at intercourse. Sperm samples collected by masturbation, therefore, do not represent the optimum quality sample a man can produce and may lead to diagnostic mistakes and/or lowered success rates in assisted reproduction.

This is especially important for sperm samples to be used in assisted reproduction techniques such as IUI, where total motile sperm count critically impacts successful outcomes. For men with borderline sperm sample quality, using a condom at intercourse instead of masturbation could provide significant clinical benefit by increasing the potential fecundity rate (the chance of conceiving per cycle) as the number of motile sperm inseminated is increased.

These previous studies have lead one clinician to write "It appears that for cervical cap insemination, intrauterine insemination, and IVF coitus condomatus (collection into a condom) is preferable to regular masturbation" (Gerris, Human Reproduction Update,1999). He further concludes, that for "artificial reproductive technology, masturbation as a method for semen collection should not be recommended".

Specially Designed Condoms for Sperm Collection

Almost all commercially available condoms are made of latex. Latex condoms have been shown to be toxic to sperm and never should be used for sperm sample collection. In contrast, two types of condoms are approved for sperm collection. These include polyurethane condoms manufactured by Apex Medical Technologies (San Diego, CA), called the "Male Factor Pak".

Previous Problems with Sperm Collection Condoms

In spite of all of the studies discussed above, many people are unaware of the possibility of using a special condom during intercourse with their partner for sample collection. Part of the reason for this, is that many doctors became discouraged with these condoms due to patient frustration with them. In the past, patients had a difficult time using the condoms due to vaginal dryness and lack of lubrication, leading to pain and performance issues. Previously available vaginal lubricants harm sperm and could not be used with the condoms. This made both intercourse and removal of the condom difficult and at times painful. I am aware of numerous couples who tried the semen collection condoms, only to have to stop during intercourse because of pain from the lack of lubrication.

A Solution to Non-lubricated Semen Collection Condoms

Pre' Lubicant has been specially formulated to not harm sperm while providing lubrication. It can be applied to both the vulva and penis, and inside the condom to facilitate intercourse and sample collection. The Pre' formula has been tested and is compatible with the Apex condoms. 

Couples who plan to use condoms to enhance sperm quality for assisted reproduction procedures such as IUI should practice at least once with the condom and Pre’ to learn how to best use the system, without the stress of the procedure hanging over them. Additionally, a new (but very small) study has suggested that it is best if couples can get their semen sample to the laboratory 30 minutes after collection. For couples who live a distance from their clinic, renting a hotel room may offer a more romantic and enjoyable experience for condom collection, than having to rush out the door at home. Finally, individuals need to make sure their laboratory has experience with sperm samples in condoms. They will need to rinse the condom in order to optimize sperm recovery. It is perfectly acceptable for any one to ask to have this done!

Assisted reproduction procedures, such as IUI, all have tremendously variable outcomes based on the clinic and technique used. In general, cumulative pregnancy rates for 3 cycles of IUI should equal rates of an IVF cycle at around 25%. Three cycles of IUI is actually more cost effective for couples with unexplained infertility and moderate male factor infertility, than IVF. The most important thing a couple can do to optimize their chances for conception is to increase the number of motile sperm in the ejaculate. The best option for doing that is likely through condom collection of sperm at intercourse - where the couple can function as a team, the way it was meant to be!

Dr. E

What is good IUI Technique?

Q: In an earlier post you wrote: "If your clinic doesn't have good stats with IUI find another- it has one of the most variable success rates of any fertility procedure based on techniques. Many couples go thru several cycles of poorly done IUI and this isn't helping anyone"

How do I know if my clinic is using good technique? What is good technique? Are you talking about the sperm preparation technique, the actual insemination technique, the timing of the IUI, or all of the above?

A: In response to that question the answer has to be "all of the above". But to provide a bit more explanation:

Sperm preparation technique There are several methods for "washing" sperm, and many variations upon them. Differences in outcome can even be caused by using lower quality products – so always insist on knowing whether the lab uses cleared products such as media. According to the world experts in sperm preparation technology, the best method is a simple 2-step density gradient centrifugation, followed by a single centrifugal wash step. This allows separation of the sperm from the seminal plasma (which must never enter the uterine cavity) quickly and efficiently. But before the sperm can be washed the semen specimen must be produced and delivered to the lab. If the sperm spend more than 30 minutes in the seminal plasma (i.e. there is a delay of more than 30 minutes between the man collecting his semen specimen and the lab starting the washing procedure) then their functional potential can be irreversibly compromised. And of course the sperm must be protected against hot and cold (i.e. temperatures above body temperature and below room temperature) during that time.

Insemination technique How the insemination is performed can also have great impact on the chance of conceiving. It must be as simple and a traumatic as possible. And the catheter used must be cleared for that purpose. There are cheap catheters out there that have been used for IUIs for many years, but they are known to be toxic to sperm (with great between and within batch or lot variability), and if a clinic uses one of these then the results could be compromised.

Timing of the IUI Obviously the insemination must be performed at the right time of the cycle. How this is determined varies between clinics and doctors, but the plan is to have the sperm inseminated a few hours before, or very soon after the time that the egg will reach the site of fertilization in the oviduct (fallopian tube). If the sperm are there too early then they might become exhausted or even die while waiting for the egg, and if they're inseminated too late then the egg may have become unfertilizable. Judging this is a skill that has to include not only knowledge of the ovulation process, but also the performance dynamics of the particular method being used to predict ovulation. Some studies suggest that two inseminations are better than one (see study below).

What's a good success rate? This will depend to some extent on whether any ovarian stimulation is used in the IUI cycle. But great care must be taken not to use too much, or too powerful drugs, as that runs a very high risk of multiple pregnancy: not just twins, but triplets, quadruplets or more! Always ask about success rates specific for the EXACT treatment that you'll be receiving, and also ask about the risk of multiple pregnancy, and whether the clinic uses "selective reduction" in cases where multiple embryos implant after IUI in "stimulated" cycles. Working hard to get pregnant and then having to choose to kill one or more of the embryos that has implanted in your womb is surely not the best way to handle TTC!

With no stimulation, or perhaps just some Clomid, a fecundity rate (pregnancy rate per cycle of trying) of 8 to 12% should be achievable. Although I believe Clomid is over used in IUI and other stimulation meds offer a better per cycle pregnancy rate (see article below). With some mild stimulation the fecundity rate should be in the range of 16 to 24% per cycle or so. Of course, if a clinic treats a lot of patients by IUI who have a poor prognosis then these results will be lowered. Clinics where patients are screened carefully as to their suitability for IUI treatment report fecundity rates of 25% per cycle in those patients for whom IUI is deemed appropriate. Patients with lower chances are better channeled towards IVF, although the higher cost of IVF might cause them to remain in an IUI treatment population (and hence lower the apparent overall success rate).

The bottom line: If a clinic can't or won't explain just what they'll be doing, or give you the answers to your questions, you should exercise your right as a patient to seek a second opinion or go to another doctor or clinic.

Fertil Steril. 2005 May;83(5):1510-6. Related Articles, Links

Women with ovulatory dysfunction undergoing ovarian stimulation with clomiphene citrate for intrauterine insemination may benefit from administration of human chorionic gonadotropin.

Vlahos NF, Coker L, Lawler C, Zhao Y, Bankowski B, Wallach EE.

The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA. nvlahos@jhmi.edu 

OBJECTIVE: To investigate factors that may affect pregnancy outcome following ovarian stimulation with clomiphene citrate (CC) combined with intrauterine insemination (IUI). DESIGN: Retrospective cohort study. SETTING: University teaching hospital. PATIENT(S): Three hundred and twenty women who underwent 691 ovarian stimulation cycles with CC for IUI. INTERVENTION(S): Ovarian stimulation with CC followed by a single IUI either 24 hours after a spontaneous serum LH surge (>25 mIU/mL) or 36 hours after intramuscular human chorionic gonadotropin (hCG) administration (10,000 IU) when the largest follicle had reached a diameter of 17 mm. MAIN OUTCOME MEASURE(S): Clinical pregnancies. RESULT(S): Women with ovulatory dysfunction who received hCG had significantly higher pregnancy rates (24.6%) compared with women with other types of infertility. There were no differences in pregnancy rates between the LH surge group and the hCG group (14.3% vs 12.4%). A spontaneous LH surge was noted in a variety of follicular sizes (14 to 35 mm). There was no correlation for age, body mass index, follicular diameter, number of mature follicles, other sperm characteristics, and pregnancy outcome in either group. CONCLUSION(S): After ovarian stimulation with CC, IUI is equally effective 24 hours after a spontaneous LH surge or 36 hours after administration of hCG. Spontaneous LH surges were observed at a variety of follicular sizes with comparable pregnancy rates. In women with ovulatory dysfunction, hCG administration before insemination may be beneficial.

Fertil Steril. 2004 Dec;82(6):1638-47.
Related Articles, Links:

Intrauterine insemination (IUI) pregnancy outcome is enhanced by shorter intervals from semen collection to sperm wash, from sperm wash to IUI time, and from semen collection to IUI time.

Yavas Y, Selub MR.
Florida Institute for Reproductive Sciences and Technologies, Weston, Florida 33326-3257, USA. DrYavas@yahoo.com 

OBJECTIVE: To determine whether IUI pregnancy was affected by [1] place of semen collection (home vs. clinic), and [2] intervals from collection to sperm wash (C-SW), from sperm wash to IUI (SW-IUI), and from collection to IUI (C-IUI). DESIGN: Retrospective study. SETTING: Infertility clinic. PATIENT(S): Sixty-two couples in 132 cycles. INTERVENTION(S): Clomiphene citrate (CC) or hMG, plus hCG, and IUI. MAIN OUTCOME MEASURE(S): Ultrasonographic detection of fetal heart beat(s). RESULT(S): Semen collection at clinic resulted in a higher pregnancy rate than collection at home in hMG-treated (44% vs. 18%; P=.03) but not in CC-treated women (9% vs. 9%; P=.93). Intervals of C-SW, SW-IUI, and C-IUI were shorter in pregnant than in nonpregnant hMG-treated women (27 vs. 41 minutes, 42 vs. 85 minutes, and 99 vs. 156 minutes, respectively; P< or =.01) but not in CC-treated women (28 vs. 38 minutes, 51 vs. 63 minutes, and 109 vs. 131 minutes, respectively; P> or =.19). Semen processed within 30 minutes after collection resulted in a higher pregnancy rate than that processed 31-60 minutes after collection in hMG-treated (48% vs. 18%; P=.02) but not in CC-treated women (10% vs. 8%; P=.81). Intrauterine insemination performed within 90 minutes of collection resulted in a higher pregnancy rate than IUI performed at 91-120 minutes or >120 minutes after collection in hMG-treated (99% vs. 22% and 7%, respectively; P<.0001) but not in CC-treated women (11%, 4%, and 10%, respectively; P> or =.46). CONCLUSION(S): For i.u.i. with hMG but not CC, semen collection at the clinic is more effective than, and should be chosen over, collection at home. Delaying semen processing from 30 minutes up to 1 hour and/or delaying IUI from 90 minutes up to 2 hours after collection compromises the pregnancy outcome in hMG-IUI cycles. Semen specimens should be processed as soon as just after liquefaction and within 30 minutes of collection, and IUI performed as soon as just after processing and within 90 minutes of collection.

1: Fertil Steril. 2005 Sep;84(3):678-81. Related Articles, Links

Effect of ejaculatory abstinence period on the pregnancy rate after intrauterine insemination.

Jurema MW, Vieira AD, Bankowski B, Petrella C, Zhao Y, Wallach E, Zacur H.

Department of Obstetrics and Gynecology, Women and Infants' Hospital, Providence, Rhode Island 02905, USA. mjurema@wihri.org

OBJECTIVE: To determine the optimal interval of ejaculatory abstinence for couples undergoing IUI. DESIGN: Retrospective analysis. SETTING: Reproductive endocrinology and infertility center. PATIENT(S): Infertile couples undergoing ovulation induction and IUI with partner's semen. INTERVENTION(S): Ovulation induction with clomiphene citrate and a single IUI procedure per cycle. MAIN OUTCOME MEASURES(S): Clinical pregnancy rates as a function of abstinence intervals. RESULT(S): Four hundred seventeen women underwent 929 cycles from June 1999 to October 2002 for a median of 4 IUI attempts per couple. The median ejaculatory abstinence interval was 4 days (range 0-30) with an overall pregnancy rate of 12% per cycle. Abstinence correlated positively with inseminate sperm count but negatively with motility. Variations in inseminate parameters did not correlate with pregnancy rates. However, abstinence intervals significantly affected pregnancy rates. The highest pregnancy rate was observed with an abstinence interval of 3 days or less (14%) and the lowest pregnancy rate seen with an abstinence interval of 10 days or more (3%). CONCLUSION(S): An abstinence interval of 3 days or less was associated with higher pregnancy rates following IUI. Prolonged abstinence decreases pregnancy rates, independent of other sperm parameters, perhaps as a result of sperm senescence and functional damage not readily identified by standard semen analysis. Abstinence intervals should be controlled for in studies examining pregnancy outcome in assisted reproduction.

Dr. E

When DH isn't "in" to TTC

Q: Lately my husband seems to be not interested in having sex, especially when I am ovulating. It is causing a lot of friction between us, and I keep feeling something must be wrong with me.

Last week we had a big fight and didn't even end up having intercourse during my fertile time. I am so angry. Is this normal? I have no idea what to do!

TIA

A: TMI answer so stop if you are shy....

It is much more common than many couples realize for sex to become a source of friction between TTC couples. This has many reasons:

1) Some times we gals become like generals with military precision on where and when, and suddenly something that was fun (sex), begins to feel like his Mom is involved... Couples who continued to enjoy making love even during the fertile time had a lower divorce rate and a higher pregnancy rate than couples who found TTC intercourse at less enjoyable in one study (see our Reference Library).

2) Fear of failure or indecision about having kids. Couples often have different views of TTC, maybe he isn't sure if he wants kids... or maybe he wants them so bad he can't stand the stress of disappointing you if it doesn't work out. In either case you two have to talk about how important it is to you, and what you plan to do if it doesn't work out. Again couples with really differing views of what potential childlessness meant tended to have high rates of marriage failure, in studies. If you find you have divergent views get into counseling and make sure you have consistent life goals BEFORE you become pregnant. Many couples fail to really talk about what all this means and how far they are willing to go- Having a plan (if this then this...) decreases everyone's stress.

3. As men age (and we are talking mid 30's here) their libido declines, this can often manifest as ejaculation failure, and not necessarily erection failure as most people think of. Drinking, job stress and antidepressants can also decrease sexual libido.

What happens with many men is that after a few days of BD-fest they begin to feel numb and aren't able to finish (ejaculate)-- this can often happen right when you are ovulating!!!! And women get crazy when this happens!!!!

Face it- our entire reproductive potential as women is not tied up in whether or not we orgasm at a certain time!!! It is for our DH's - so be gentle!

Some things to try if BD when TTC has become a bore- or if DH is feeling numb and frustrated.

a) Make sure at least one of your BD events close to ovulation is a real steamer b/c the more turned on he feels the more sperm he can make. If you two don't normally do magazines or movies together - this would be a good time to try them. These could range from looking at Victoria's Secret together to more steamy fare like Penthouse or Hustler. I think couples can enjoy sharing what pictures they think are sexy and why. Remember, he isn't wanting you to "be" these women, anymore than when you read a "trash" novel, you want DH to "be" the hero in the books (Ok maybe for a second but same goes!).

Movies can be fun, and if you are new to them try Candida Royalle's line, or Adam and Eve-- both are shops that cater to couple enjoyable products. It is fine to try a variety and give each other the feedback until you find a director or product line you both like (too soft, too hard etc..). I think many women end up either not enjoying movies, or just tolerating them b/c the couple hasn't experimented enough with different types, and the right to say "This is NOT OK with me", without everyone freaking. Keep shopping and talking. Adam and Eve as well as other sites have products you can buy in 15 min. increments which allows you to check things out!

b) New moves! When BD gets boring try some new moves on DH...these are all aimed at applying more pressure to his "parts" and helping him ejaculate.

Use Pre~Seed to make this all sexy slippery fun!

You can try having him come in you from behind (doggie-style). Reach your hand behind you, and make a V outside of your vulva, so that when he thrusts he is going in and out of both your fingers (which are squeezing down on him on each side of his penis) and your vagina. This also allows him to thrust harder in this position without hitting your tonsils!

Cut your nails off for this next fun step! In this same V position, you can also use your thumb to stroke along the ridge of his penis by pressing on it as he thrusts.

Another great position is with you both lying on your side facing each other. Put your leg over the top of his and again reach behind yourself. Use your fingers (again no nails) in a flat position to push against his penis as he thrusts in and out of you. It should feel like you are pushing him down into you as he moves in and out. If you like he can also introduce a well lubricated finger into you anally at this time and he will be able to feel this pressure on his penis when he is in you as well.

Taken together- all these techniques can be used to help raise the "dead". We know b/c we had a stressful time when we had to figure out what worked to keep us both from getting really fed up with the whole process as well!

Let me know how these techniques work for you- Good luck and keep making love even if you are making a baby!

Dr. E

Q. Do Antidepressants Impact Sperm Function?

A. A recent study presented at the Reproductive Medicine meeting this year (Tanrikut et al., 2008), suggested that an SSRI antidepressant significantly increased sperm DNA damage to levels that have been well associated with poorer reproductive outcomes (over 30% damaged sperm). This study mirrored the results from a 2005 study that my group presented. In our study, men who smoked saw a dramatic increase in the percent of sperm with damaged DNA, while taking SSRIs.

It is my opinion that the potential impact of SSRIs on men who are trying to conceive, is a hugely under-discussed issue. Approximately 4-6 million men
of reproductive age in the US are on SSRIs. These medications can cause 1/3 - 1/2 of men to have sexual dysfunction including erectile dysfunction and delayed ejaculation, which can also interfere with TTC.

The cause of this is most likely disruption of the hypothalamic-pituitary-gonadal axis. These medications can elevate prolactin, which due to a cascade, suppresses testosterone production in the testicles and disrupts sperm production. Although, the sperm damage may also be caused by increased levels of oxidative stress on the sperm from the SSRIs.

There are other types of antidepressants that can be discussed with your physician if you are trying to conceive. Another option would be to have a sperm chromatin test done if you are taking SSRIs and TTC. This way, you can find out if your sperm's DNA has been impacted. Please read my FAQ about sperm chromatin testing to better understand what this involves.

Take care-
Dr. E