Infertility evaluation- semen analysis

Semen analysis
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

MODERATORS:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai.
2

INTRODUCTION
 Infertility impacts one of every six couples
attempting pregnancy.
 Male partner contributes in 30 – 50 % of
cases, and is a sole factor in upto 20 % .
 Semen analysis still remains THE test which
defines the fertility status of a male
3

What is the purpose of the test?
 Investigating male infertility
 Identify treatment options
 Surgical treatment.
 Medical treatment.
 Determine the suitability of semen for ICSI/IVF
 Pre and Post vasectomy – Confirmation.
 Following vasectomy reversal.
4

Human sperm cell is about 70 µm long.
The head size: 4-5µm
Nucleus - contains the 23 chromosomes.
Acrosome
Mid-piece: 4-5µm
Contains mitochondria.
The energy for motility is generated.
Tail: 55µm
contains axoneme for motility..
5

FRACTION OF SEMEN CONTRIBUTED
BY VARIOUS GLANDS
- Prostate: 20-30% of the ejaculatory volume, the secretion
contains citrate, zinc, acid phosphatase and proteolytic
enzymes for liquefaction of the semen.
- Seminal vesicles: 60-80 % of the ejaculatory volume, have an
alkaline ph, and contain antioxidant enzymes, fructose,
vitamin C, prostaglandin, and semenogelin ( for semen
coagulation ) & other substances, which nourish and activate the
sperm.
- Small contribution from bulbouretheral glands and
epididymis.
6

SEMEN HAS TWO MAJOR COMPONENTS
 Total no of spermatazoa: - total sperm produced by
testis
- is a marker of testicular
function.
 Total fluid volume : - produced by accessory glands,
- is a marker of the secretory
activity of the glands..
7

Standard guidelines for the collection of semen
 Collection – Private/ clean room in the same centre where
the semen will be analyzed. ( limits the exposure of semen
to fluctuations in temperature)
 Abstinence – routinely ( min) 2 to 5 ( max ) days of sexual
abstinence before collection.
Recent studies- single day abstinence is optimal for assessing
bulk seminal parameters.
 Clear consent and spoken instructions regarding method of
collection stating that semen sample should be complete
and any loss of volume of sample must be reported.
8

Method of collection – mostly by self stimulation/ masturbation,
- ejaculated into a clean, dry, presterile
( 21 * c ), nontoxic, wide mouthed container made up of plastic
/ glass .
- then container should kept between 20
to 37 *c .
Other method of collection – collection in condom,( coitus
interruptus method ), for this special nontoxic( poly urethane )
condoms should be used. Ordinary latex condoms should not
used as they are spermicidal.
9

Persons unable to achieve adequate erection and
ejaculation.
Phosphodiesterase type 5 inhibitors - 30 to 60 min before
collection.
Cavernosal and subcutaneous injections of prostaglandins
Vacuum erection devices
Vibratory stimulation
Rectal probe electro-stimulation induces ejaculation by
stimulation of the efferent fibers of the hypogastric plexus.
10

GENERAL PRECAUTIONS
Abstinence for 2-7 days.
Pass urine.
Wash hands with soap and dry.
Glans and the penis should be cleaned with a wet paper towel
(avoid soap).
Lubricants should be avoided - interfere with motility.
Collect the entire sample -70% of sperms is in the first part of
the ejaculate.
To establish baseline semen quality , atleast two semen
samples are needed.
11

Sample labelling
Patient name
Age
Clinic or Doctor name
Laboratory analysis form:
 The period of abstinence (in days).
 Date &Time of collection.
 Mode of collection.
 Complete or incomplete.
 The time interval from collection to analysis
Container should be then kept between 20 and 37*c
12

STORAGE AND TIMING OF ANALYSIS
Semen is placed in a incubator at 37° C for 30 minutes,
to allow liquifaction.
Then semen sample should be examined,
Ideally within 30 mins ( after liquefaction )
Absolutely within 1 hour of collection.
Motility decreases significantly after 2 hours.
13

WHO 2010
14

Parameter 1992 Lower Reference Limit 2010
Semen volume 2 ml 1.5 ml
Sperm concentration 20 M 15 x 106/ml
Total sperm number 39 x106/ejaculate
Progressive motility >50 % 32 % A
Total motility 40 % A+B
Vitality (live sperms) 58 %
Sperm morphology >15 % 4 %
pH >/=7.2 >/=7.2
Leucocyte <1M <1 x106/ml
MAR/Immunobead test <10 % <50 %
WHO 2010
15

SEMEN ANALYSIS CHARACTERISTICS
 MACROSCOPIC ASSESSMENT
 MICROSCOPIC ASSESSMENT
 SPERM FUNCTION ASSESSMENT
 ADVANCED SPERM TESTING
16

MACROSCOPIC ASSESSMENT OF SEMEN
 Liquefaction and appearance of the semen
 Semen volume
 Semen viscosity
 Semen ph
17

MACROSCOPIC ASSESSMENT
 Appearance – normally whitish to grey opalescent
- yellow – jaundiced, infection.
- pink/ reddish / brown – indicate RBCs
 Liquefaction - usually occurs within 15 to 30 mts.
- if doesnot liquify , we can wait for another 30
mts/ continous shaking either in room temperature or in an
incubator at 37 * c .
- still lumpy >60 mts – lack of prostatic protease
and sign of prostatic infection.
18

 Viscosity – normally smooth and watery.
- assessed by either introducing glass rod
into the sample / by pipetting the sample, and allow
the semen to drop by gravity and observing the lenght
of thread formed.
- when lenght of the thread exceeds 2cm it is
recorded as abnormal.
19

 SEMEN VOLUME
- measured either directly in a commercially available
modified graduated glass cylinder or weighing the sample in a
pre weighed container.
 WHO/ 2010 lower reference limit is 1.5 ml.
Low semen volume / seminal hypovolemia ( threshold value 1.0ml)
- short period of abstinence/ spillage of sample.
- CBAVD,/obstruction of ED
- erectile dysfunction/ retrograde ejaculation,
- androgen deficiency/ infection.
- DM, multiple sclerosis, spinal cord injury.
Needed semen fructose testing and post ejaculatory urine
analysis. 20

SEMINAL FRUCTOSE TESTING
 INDICATIONS: Men with low ejaculatory volumes and
no sperms.
 Absence of fructose – seminal vesicle agenesis or
obstruction.
POST EJACULATORY URINE ANALYSIS- microscopic
inspection of first voided urine after ejaculation
INDICATIONS : men with low semen volume and sperm
counts
? Retrograde ejaculation- DM
- H/O pelvic, bladder, retroperitoneal sx
- alpha blockers for BPH, antidepressants.
21

 If no .of sperm in urine equals or exceeds than
antegrade/ pre ejaculatory urine specimen –
Retrograde ejaculation is clinically significant.
High semen volume : - active exduation due to
inflammationof accessory organs.
- prolonged abstinence
- contaminated with urine
Needed semen culture/ sensitivity
22

SEMEN PH
 Usually measured after semen liquefied
 Ph paper of range 6 to 10 is used.
 A drop of semen is put evenly onto the ph paper, wait for colour of
semen drop area to change uniformly, and then match with ph
paper.
 WHO/2010 reference criteria is 7.2
 Low ph <7, with low volume and low sperm count – seen in
obstruction of ED / CBAVD
 High ph – is not of much significance.
23

MICROSCOPIC ASSESSMENT OF SEMEN
Sperm agglutination
Count and concentration
Motility
Morphology
Vitality
Prsence of Nonsperm cells
24

FOR MICROSCOPY-WET SMEAR
PREPARATION
Normally 10 ul semen to 190 ul water = 20x
dilution.
In cases of very low sperm count = 4x dilution
In cases of azoospermia = no dilution
 Add 10 ul of mixture to the neubauer chamber
 Then place a Cover slip
 Wait 2-3 min to settle.
 PHASE CONTRAST MICROSCOPE is
recommended.
25

 Initially 100 x magnification used ( 10 x objective lens
with a 10 x ocular lens )- this will detect any mucus
strands, sperm agglutination, cells other than
spermatozoa like epithelial cells, round cells, and isolated
sperm heads or tails.
 Then examination done at higher magnification 200 /
400 x – helps the assessment of sperm motility and
determination of dilution required for assessment of
sperm number.
26

27

 Lower reference limit for sperm concentration/density ( WHO
2010) is 15 million spermatazoa / ml
 Lower reference limit for total sperm number/count ( WHO
2010) is 39 million spermatazoa / ejaculate
CLINICAL SIGNIFICANT:
- sperm number directly correlates with fertility potential in terms
of both pregnancy rates and prediction of pregnancy.
- Sperm number is a direct measure of testicular function.
28

Azoospermia (absence of sperm)
Abnormal spermatogenesis, ejaculatory dysfunction,CBAVD, young s
syndrome, klinefilter ,vasectomy, chemotherapy, radiation
Oligospermia (abnormally lower sperm concentration/density)
Idiopathic ( most common),infection, UDT, Tobacco/alcohol, soya.
Cryptozoospermia – very low sperm difficult to measure.
Polyzoospermia (abnormally elevated sperm concentration) - rare.
May be caused by a long period of abstinence - associated with sperm of
poor quality.
29

SPERM MOTILITY
Most important predictor of the functional aspect of spermatozoa.
Sperm motility is a reflection of the normal development of the
axoneme and normal maturation within the epididymis.
WHO Sperm motility grading:
PR(progressive motility)- spermatozoa moving actively, either
linearly or in circles, regardless of speed.
NP( non progressive motility)- all patterns of movement but no
forward progression.
Immotility- no movement.
30

WHO REFERENCE LIMIT (2010):
 lower reference limit for total motility (PR+NP)- 40%
 lower reference limit for PR- 32%
clinical importance:
 Sperm motility directly associated with fertility and pregnancy
rates.
 ASTHENOSPERMIA – low motility.( toxins – pesticides, lead ,
carbon disulfide
31

Limitation of sperm motility assessment
- The method most commonly employed is the simple
estimation of the motility of sperm on several fields.
 Assessment of this parameter is subjective - potential for
technical mistakes.
 In-vitro motility of sperm may not reflect the true motility
within the female reproductive tract.
32

HABITUAL FACTORS AFFECTING SPERM DENSITY /
MOTILITY
 High intake of soya – decrease sperm density.
 High consumption of tobacco – decrease sperm density /
motility.
 Consumption of cocaine / Marijuana – decrease sperm
motility.
 Vaginal lubricants – decrease sperm motility.
 Alcoholism – affects all semen parameters.
33

SPERM VITALITY- PORTION OF SEMEN WITH
METABOLICALLY ACTIVE LIVING CELLS
• Tool to assess whether asthenospermia is a result of cell death
or dysfunction of molecular process involved in sperm motion.
• Tool for assessing the membrane integrity of the sperm cell.
 Tests used for assessing the membrane stability:
 Dye exclusion /Staining method (commonly used)
 Hypo-osmotic swelling test (HOST) (alternative
34

 DYE EXCLUSION METHOD;
- Eosin Y followed by counter staining with Nigrosin
- based on the principle that damaged plasma membranes
allow entry of membrane impermeant stains.
- viable sperm have intact cell membranes- Do not take up
the dye and will remain unstained.
- test is purely diagnostic / sperm are not to be used in IVF
35

HYPO-OSMOTIC SWELLING TEST (HOST)
 Semen sample is mixed to hypotonic fluid.
- Principle is that viable sperm have intact cell membranes, this
Cause swelling of the cytoplasmic space and curling of the sperm
tail.( swollen cells)
-Whereas Nonviable sperm - will not exhibit this
effect.( unswollen cells )
 Reproducible and relatively inexpensive test.
 Nondestructive method , amenable to subsequent use of sperm
in IVF
36

37

 WHO LOWER REFERENCE LIMIT/ 2010 – is 58 %
 Clinical significance :
- presence of vital but immotile cells are indicative of
structural defects in the flagellum.
- high percentage of immotile and non viable cells
suggests epididymal pathology.
- Helps in selection of viable sperm - IVF or ICSI.
Necrospermia – large no of non living sperm.
38

SPERM AGGLUTINATION
Wet smear
Sperm form clumps within semen
Sperm-to-nonsperm elements (nonspecific agglutination) -
accessory gland infection.
Sperm-to-sperm agglutination (site-specific agglutination) -
antisperm antibodies.
When agglutination is observed - semen cultures and
antibody assessment.
39

SPERM MORPHOLOGY
 Smear of semen is air dried, fixed with stain
(papanicolau, shorr, diff quik ).
 Then slide is examined at 1000 x magnification with
oil immersion.
 Approx 200 spermatozoa assessed for % of normal
and abnormal forms by assessing exact dimensions
and shape characteristics of sperm head, midpeice,
tail.
 Lower reference limit for normal forms is 4 % ( WHO
2010 )
40

41

 Total no of morphologically normal spermatozoa in the
ejaculate is of biological significance.
 This is obtained by = the total number of spermatozoa in
the ejaculate * the percentage of normal forms.
 Clinical significance;
- percentage of normal sperm morphology directly
corelated to pregnancy rates in both in vitro and in vivo.
Teratozoospermia- abundance of abnormal morphology
forms.( epididymal causes, increased scrotal temp,
smoking, systemic illness, varicocele, radiation)
Globozoospermia- sperm with small , round
heads( acrosome fails to form )
42

PRESENCE OF NON SPERM CELLS
 Suggestive of testicular damage or inflammation of
accessory glands or efferent ducts.
 It includes epithelial cells, round cells, leukocytes and
isolated sperm head / tail.
 Leukocytes: normally (1-4/HPF)
-Leukocytospermia/ pyospermia - above 1millionWBC/mL-
infection.
- detected by pyospermia assay- where pap stain/ peroxidase
stain used to diff leukocytes from immature germ cells based
on nuclear morphology. ( without staining, leukocytes are
indistinguisable from immature germ cells )
43

Spermatocytes: (Immature germ cells) 1-2/HPF- presence of
immature cells is common and not of pathological signifance.
Epithelial cells: normally (1-2/HPF)
Erythrocytes: (1-2/HPF). Increased number may indicate a
reproductive tract infection or damage to a small capillary during
sample production.
Bacteria and protozoan such as Trichomonas vaginalis are
uncommon in human semen but their presence is indicative of
possible male reproductive tract infection
44

OTHER ANALYSIS PARAMETERS
1) Multiple sperm defect indices
2) Pan leukocyte CD45 IHC staining
3) Computer aided semen analysis / CASA
4) Assessment of acrosome reaction
5) Assessment of sperm chromatin/ ROS.
45

Multiple sperm defect indices- for morphologically
abnormal spermatozoa defects.
three indices - multiple anomalies index / MAI,
teratozoospermia index / TZI,
sperm deformity index / SDI.
Panleukocyte CD45 IHC staining –
detection of peroxidase negative PML, also
differentiates between leukocytes and germ cells.
46

COMPUTER - ASSISTED SPERM ANALYSIS
Computer-assisted sperm analysis (CASA) is a
semiautomated technique that provides data on
Sperm density, Motility, morphology (straightline and
curvilinear velocity, linearity, average path velocity,
amplitude of lateral head displacement, flagellar beat
frequency, and hyperactivation)
Advantages:
High precision
Quantitative assessment of sperm kinetics.
Disadvantages:
Expensive equipment and still requires the subjective
participation of a technician.
47

SPERM FUNCTION ASSESSMENT
 Sperm- mucus interaction assay
 Acrosome reaction testing
 Sperm penetration assay
48

49

 - Progressively motile sperm > 10 to 50 per HPF is designated
as normal.
 Only Rotatory movements –antisperm antibodies in cx mucus
 Advantages:
-cervical mucus can be studied for estrogenic effect.
- - Tells mucus characteristics favourable to Sperm penetration
- - Antisperm antibodies.
50

Abnormal test - advised to proceed with IUI.
 Inappropriate timing testing / intercourse,
 Anatomic abnormalities,
 Due to antisperm antibodies,
 Abnormal sperm.
CONRAINDICATION ; cervical infections.
51

ACROSOME REACTION
The Acrosome is a membrane-bound organelle covers the anterior
2/3 of the sperm head.
 Acrosome reaction is an important prerequisite for
successful fertilization.
 ZP3
 Involves fusion of acrosomal membrane and sperm plasma
membrane.
 Acrosin and Hyaluronidase – required to digest the oocyte
cumulus cells and ZP
Acrosome reaction testing - not widely practiced in laboratories -
research interest.
Unexplained infertility
52

SPERM PENETRATION ASSAYS
The sperm penetration assay (SPA) or the hamster egg
penetration assay (HEPT)
It address the functional ability of sperm to to undergo
capacitation process, penetration and to fertilize the egg..
Done in Unexplained infertility / IVF failure cases.
.
53

 Incubating zona-free hamster oocytes in sperm droplets for 1
to 2 hours.
 The oocytes are examined microscopically for sperm
penetration.
 Penetrations are indicated by swollen sperm heads within
the oocyte cytoplasm.
 Normally, 10% to 30% of ova are penetrated.
54

 Oligozoospermic and severely teratospermic men – negative
testing
 Advantage - good SPA result – favours IUI
- poor SPA result – favours IVF
 Sperm capacitation index (SCI) is a variant of the SPA test,
assessing the mean number of penetrations per ovum.
-ICSI has been recommended –if SCI less than 5 instead of
standard IVF procedures.
55

ADVANCED SPERM TESTING
 Antisperm antibody testing( immuno assays)
 Electron microscopy
 Oxidative stress test
 Sperm DNA damage assay
56

Antisperm Antibody Testing
- 2 classes of ASA found in 3 locations: semen, seminal fluid,
spermbound IgG, IgA .
This cause:
Sperm agglutinating,
Sperm immobilizing,
Spermotoxic.
Normally the tight Sertoli-cell junctions provide the testis with a
barrier that prevents the immune system from coming in contact
with the post-meiotic germ cells( spermatozoa).
This unique barrier can be violated,
Testicular torsion, Vasectomy, Testicular trauma, testicular
surgeries
57

INDICATIONS ; -semen analysis shows agglutination.
- low sperm motility with H/O testicular injury or
surgery.
- un explained infertility
- presence of increased round cells are leukocytes.
Testing of ASA
 Direct ASA test - directly measure immunoglobulins on the
surface of sperm/ sperm bound. (preferred)
Because AB in serum/ seminal fluid don’t corelate to
sperm surface binding.
 Indirect test- measure circulating ASA in serum/ seminal
fluid.
58

 Two types of direct immunoassays :
- immunobead assay
- sperm MAR test
Sperm MAR test- recommended screening tests - economical and
readily available.
- latex beads coated with bridging antibody ( anti IgG / anti IgA) is
incubated with sperm- lead to formation of mixed agglutinates b/n
particles and motile spermatozoa.
Immunobead Test (IBT)- directly measures antisperm antibodies on
sperm – more accurate/ time consuming.
Prerequisite for test: some amount of sperm motion needed.
In Complete asthenospermia- this test cant be performed..
59

 REFERENCE VALUE :
- 50% or more motile spermatozoa with adherent particles is
diagnostic of immunological infertility.
60

Clinical implications of ASA on male infertility.
10% of subfertile men.
2% of fertile men.
ASA are present in 34% to 74% of vasectomized men.
Persist in 38% to 60% after vasectomy reversal.
Does not affect the decision to do a vasectomy reversal.
Routine tessting is not needed
In Immunologic infertility – IVF/ ICSI recommended.
.
61

ELECTRON MICROSCOPY
-Ultrastructural details of the sperm – studied only by EM.
-MSOME/ motile sperm organelle morphology examination- non
destructive method of assessing sperm head morphology .
-Sperm motility is dependent on ultrasturctural arrangement of
microtubules in tails ( 9+2)- studied by EM.
-Semen with < 10 % motility and vitality – can be tested by EM.
- Mitochondrial & Microtubular defects- not visible under the usual
Papanicolaou smear can be detected.
Selection of sperm for ICSI
62

Reactive Oxygen Species
Excessive production (ROS) is related to abnormal semen
parameters and sperm damage.
Oxidative stress test by chemiluminescence assay may
accurately discriminate between fertile and infertile men
Better than routine semen analysis
Currently not included in the routine evaluation of subfertile
men.
63

 Lack of equipment,/ standardization
 Lack of normal range of ROS in semen,
 Lack sufficient evidence ROS – infertility.
 ROS level for healthy donors – normal semen parameters is 1.5 ×104
cpm/20 M sperm/mL.
Oxidative stress positive (>1.5 × 104 cpm/20 million sperm/mL)
Oxidative stress negative (≤1.5 × 104 cpm/20 million sperm/mL),
 Under investigatory level.
64

SPERM DNA DAMAGE:
 - sperm DNA contains protamines (85% of nuclear proteins
predominant) and histones ( 15%).
 -sperm chromatin is tightly bound.
 -when this compact chromatin structure disturbed
( increased histones >15% / due to protamine deficiency),
makes nuclear DNA vulnerable to damage .
65

 In infertile men - increased sperm histone to protamine
ratio seen..
 Mech of DNA damage- defective chromatin condensation
due to mutations, oxidative stress and apoptosis.
 INDICATION FOR TESTING: - prolonged idiopathic infertility,
- repeated abortions,
- implantation failure following IVF,
- bad quality embryos in IVF
- advanced age,
- varicocele and cancer patients..
66

TEST FOR CHROMATIN CONDENSATION DEFECTS
 Aniline blue staining:
- Histone rich immature sperm cells- stains blue.
- Protamine rich mature sperm cells- dont take up the stain.
CHROMOMYCIN A 3 ( CMA3):
-CMA3 is guanine cytosine specific flurochrome.
- CMA3 competes with protamines for association with DNA.
-higher intensity of CMA3 staining indicate lesser amount of
protamine in sperm nucleus
67

TEST FOR SPERM DNA DAMAGE
 Sperm chromatin condensation defect tests :
- aniline blue staining
- chromomycin A3 ( CMA3) staining.
 Sperm DNA integrity tests :
- TUNEL assay
- COMET assay/ single cell electrophoresis.
- sperm chromatin sturcture assay /SCSA
- sperm chromatin dispersion test/ SCD
68

TESTS FOR SPERM DNA INTEGRITIY
 COMET( single cell gel electeophoresis):
principle- fragmented DNA moves rapidly towards anode in
agarose gel electrophoresis.
advantage - sensitive test, requires only few number of cells,
degree of DNA damage in individual cells can be tested.
 TUNEL ASSAY/term deoxynucleotidyltransferase mediated
deoxyuridine triphospate( d UTP) nick end labelling:
Principle- quantifies incorporation of dUTP at ds DNA breaks
in a reaction catalysed by the enzyme tDt.- by flow cytometry
/ fluorescence microscopy.
Advantage- detects both ds and ss DNA breaks.
TUNEL Value >36%- poor outcomes.
69

SPERM CHROMATIN STRUCTURE ASSAY/SCSA:
 Principle - after DNA denaturation with heat / acid, sperm
with ds DNA fluoresces green ( in acridine orange ). Sperm
with ss DNA fluoresces red.( fluoresent microscope)
 Simple, faster method but requires expensive flow
cytometer.
 - DNA fragmention index(DFI) - ratio of red to total (red+
green) fluorescence.DFI >25-27%- poor outcomes.
 In Patient with high DFI - reproductive outcomes improved
by isolating non damaged sperms by ICSI , IMSI , MFSS and
by electophoretic separation
70

SPERM CHROMATIN DISPERSION TEST/ HALO
SPERM ASSAY:
 Principle - sperm with intact DNA produces dispersion halo
due to release of chromatin from proteins when embedded
with agarose medium - by fluorescence/ bright field
microscope.
 Easy method/ commercial kits available.
 - sperm DNA fragmentation reported by SCD test negatively
correlated with fertilization rates and embryo quality in
ICSI/ IVF.
71

Limitation of semen analysis
Clinical research has shown,
Normal semen analysis may not reflect the true fertility
status of an individual.
Men with poor sperm parameters can cause spontaneous
pregnancies.
Men with good sperm parameters are still subfertile
Only 50% of subfertile men have recognizable causes
detectable by semen analysis.
72

Parameter Lower Reference Limit
Semen volume 1.5 ml
Sperm concentration 15 x 106/ml
Total sperm number 39 x106/ejaculate
Progressive motility 32 % A
Total motility 40 % A+B
Vitality (live sperms) 58 %
Sperm morphology 4 %
pH >/=7.2
Leucocyte <1 x106/ml
MAR/Immunobead test <50 %
WHO 2010
73

 THANK YOU
74

Infertility evaluation- semen analysis

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