Dr Sujoy Dasgupta was invited as a Faculty in the Masterclass on :"Male Infertility and IUI" at BOGSCON (the Annual Conference of Bengal Obstetric and Gynaecological Society) held at Kolkata in December, 2019

1. Case Scenarios on Different Semen
Analysis Results
Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata
Managing Committee Member, Bengal Obstetric & Gynaecological Society
(BOGS)- 2019-20
Secretary, Subfertility and Reproductive Endocrinology Committee, BOGS-
2019-20
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress,
London, 2019

3. WHO Standard 2010
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2
3
4
5
6

4. Esteves S C. Clinical relevance of routine semen analysis and controversies surrounding the 2010
World Health Organization criteria for semen examination. Int Braz J Urol. 2014; 40: 443-53

5. Esteves S C. Clinical relevance of routine semen analysis and controversies surrounding the 2010
World Health Organization criteria for semen examination. Int Braz J Urol. 2014; 40: 443-53

6. Cooper TG et al. World Health Organization reference values for human semen
characteristics. Hum Reprod Update. 2010; Vol.16: 3, 231–245

7. Limitations of WHO 2010 Semen Analysis
• Based on parameters in a large group of fertile men
along with defined confidence intervals from recent
fathers with known time-to-pregnancy (TTP).
• The WHO does not consider the values set as true
reference values but recommends or suggests
acceptable levels.
• Day to day variation

9. Laboratory Standard is important

10. Case Scenario 1

14. What to do
• Method of collection
• Hand washing before collection
• Special Tests- Round cells vs Pus cells
• History
• Culture
• Antibiotics?

15. EUA Guideline, 2018
• The clinical significance of an increased
concentration of leukocytes in the ejaculate is
controversial.
• Although leukocytospermia is a sign of
inflammation, it is not necessarily associated
with bacterial or viral infections.
• More leukocytes found in men with
prostatitis compared to those without
inflammation

16. MAGI

17. Case Scenario 2

18. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 2 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 12 million/ ml
Total Motility 42%
Progressive Motility 17%
Non progressive Motility 25%
Immotile 58%
Motile Sperm Count 5.04 million/ml
Normal Morphology 4%
Vitality 62%
Round cells Nil

19. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 2 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 12 million/ ml
Total Motility 42%
Progressive Motility 17%
Non progressive Motility 25%
Immotile 58%
Motile Sperm Count 5.04 million/ml
Normal Morphology 4%
Vitality 62%
Round cells Nil

20. Mild male Factor
• Antioxidants
• CC
• Other adjuvants

21. EUA, 2018; NICE, 2013

22. • Antioxidants do not appear to improve semen
parameters or DNA fragmentation among men with
male factor infertility.
• While previous data suggest that antioxidants improve
pregnancy rates in in vitro fertilization, these data
suggest they do not improve in vivo conception.

23. Lifestyle changes
1. Heat exposure to scrotum
2. Obesity
3. Food habit
4. Smoking
5. Alcohol
6. Anabolic steroids
7. Chronic scrotal fungal dermatitis

24. After 3 months of antioxidants here

25. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 2 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 8 million/ ml
Total Motility 30%
Progressive Motility 16%
Non progressive Motility 14%
Immotile 70%
Motile Sperm Count 2.4 million/ml
Normal Morphology 3%
Vitality 62%
Round cells Nil

26. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 2 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 8 million/ ml
Total Motility 30%
Progressive Motility 16%
Non progressive Motility 14%
Immotile 70%
Motile Sperm Count 2.4 million/ml
Normal Morphology 3%
Vitality 62%
Round cells Nil

27. IUI/ ICSI?
• Assess
1. Tubal factor
2. Ovarian reserve
3. Duration of Infertility
4. Age of the female partner

29. TMSC and motility– cut offs
TMSC PR/CYCLE
 10–20 million 18.29%
 5–10 million 5.63%
 <5million 2.7%
 TMSC should be 5-10 million
 If less than 5 million counsel and do IUI
(Guven et al, 2008;Abdelkader & Yeh)2009)

30. Post wash and decide
• “Trial IUI”

32. Double Ejaculate
• obtaining a second semen sample when the
motile sperm yield of the first semen sample is
1 million to 5 million significantly increases
the total motile sperm count in the final
inseminate.

33. Oligospermia and IUI
• TMSC 5-10 mil/ml- Do IUI 4-6 cycles
• TMSC <5 mil/ml- Counsel before IUI
1. Double Ejaculate
2. Post wash- IMSC
3. IMSC >1 mil/ml → Further IUI
4. IMSC <1 mil/ml → see Morphology

34. Case Scenario 3

35. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 1.5 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 1.2 million/ ml
Total Motility 30%
Progressive Motility 16%
Non progressive Motility 14%
Immotile 70%
Motile Sperm Count 0.36 million/ml
Normal Morphology 1%
Vitality 34%
Round cells Nil

36. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 1.5 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 1.2 million/ ml
Total Motility 30%
Progressive Motility 16%
Non progressive Motility 14%
Immotile 70%
Motile Sperm Count 0.36 million/ml
Normal Morphology 1%
Vitality 34%
Round cells Nil

37. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 1.5 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 1.2 million/ ml
Total Motility 30%
Progressive Motility 16%
Non progressive Motility 14%
Immotile 70%
Motile Sperm Count 0.36 million/ml
Normal Morphology 1%
Vitality 34%
Round cells Nil

38. Severe OAT
• IUI –Donor Sperm?
• HSG- Bilateral tube blocked
• AMH 0.9 ng/ml
• Husband 42, wife 38
• Trying for pregnancy for 5 years

39. • Overall, 16 (24.6%) of 65 patients with severe
oligozoospermia developed azoospermia.
• two (3.1%)patients with moderate oligozoospermia
developed azoospermia
• none of the patients with mild oligozoospermia
developed azoospermia.

40. Treatment should NOT be delayed
• Antioxidants
• Consider freezing
• ICSI
• In extreme cases- may need preparation for
TESA

41. • As in azoospermia, in extreme cases of
oligozoospermia (spermatozoa < 1
million/mL), there is an increased incidence
of obstruction of the male genital tract and
genetic abnormalities.

42. History Taking
• Lifestyle
• Medical history- Diabetes, Mumps, Cancer
• Surgical history- Hernia, Orchidopexy,
Pituitary Surgery
• Drugs history- Sulphasalazine, cytotoxic
drugs, steroids
• Sexual history

43. EAU Guideline, 2018

44. Physical Examination
• May diagnose serious disorders
• General body habitus, secondary sex
characters, gynaecomastia
• Testicular size and consistency
• Varicocele

45. Varicocele
• Subclinical: not palpable or visible, but can be
shown by special tests (Doppler ultrasound
studies).
• Grade 1: palpable during Valsava manoeuvre,
but not otherwise.
• Grade 2: palpable at rest, but not visible.
• Grade 3: visible at rest.

46. Surgery in varicocele

47. Investigations
• Endocrine
• Urological
• Genetic testing

48. Severe OAT
Volume/ pH of semen
Normal
Low testicular volume
FSH, LH,
Testosterone, blood
sugar
Karyotyping
Y chromosome
Microdeletion
Prolactin, TSH if
clinically suspected
Volume/ pH of semen
low
Abnormal physical
examination
Scrtotal USG
TRUS

49. Severe OAT
Volume/ pH of semen
Normal
Low testicular volume
FSH, LH,
Testosterone, blood
sugar
Karyotyping
Y chromosome
Microdeletion
Prolactin, TSH if
clinically suspected
Volume/ pH of semen
low
Abnormal physical
examination
Scrtotal USG
TRUS

50. In this case
• FSH 15.21 IU/L (normal 1-10)
• LH 12.8 IU/L (normal 1-10)
• Testosterone 159 ng/dl (normal 200-800 )

51. Testosterone Supplementation?

52. Estrogen in male?
• Estradiol , normal range- 10-40 pg/ml
• If T:E2 ratio <10 (T- ng/dl, E2- pg/ml),
consider Aromatase Inhibitors
(Anastrozole 1 mg/day or letrozole 2.5 mg/day)

53. Asian J Andr, 2019. A systematic review and meta-analysis of clinical trials
implementing aromatase inhibitors to treat male infertility

54. Case Scenario 4

55. Collection Method Masturbation
Abstinence 2 days
Collection Complete
Volume 0.5 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 6.8
Sperm Concentration 0.2 million/ ml
Most of the sperms are nonmotile.
However, detailed assessment of motility and morphology is not possible
Round cells Nil

56. Collection Method Masturbation
Abstinence 2 days
Collection Complete
Volume 0.5 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 6.8
Sperm Concentration 0.2 million/ ml
Most of the sperms are nonmotile.
However, detailed assessment of motility and morphology is not possible
Round cells Nil

57. Assess
• Abstinence period
• Completeness of collection
• Usual amount of ejaculate
• Exclude retrograde ejaculation
• Post-masturbation urine
• Suspect obstructive pathology- TRUS

58. Retrograde Ejaculation
• Exclude diabetes, neurological disorders,
prostate disorders
• Change medicines (alpha blocker)
• Medical therapy
• Vibroejaculator
• IUI / ICSI with alkalinized urine
• TESA- in extreme cases

60. Case Scenario 5

61. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 2 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 18 million/ ml
Total Motility 0%
Progressive Motility 0%
Non progressive Motility 0%
Immotile 100%
Motile Sperm Count Nil
Normal Morphology 2%
Vitality 32%
Round cells Nil

62. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 2 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 18 million/ ml
Total Motility 0%
Progressive Motility 0%
Non progressive Motility 0%
Immotile 100%
Motile Sperm Count Nil
Normal Morphology 2%
Vitality 32%
Round cells Nil

63. Collection Method Masturbation
Abstinence 4 days
Collection Complete
Volume 2 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 18 million/ ml
Total Motility 0%
Progressive Motility 0%
Non progressive Motility 0%
Immotile 100%
Motile Sperm Count Nil
Normal Morphology 2%
Vitality 32%
Round cells Nil

64. Steps
• Abstinence
• Place of collection
• Reliability of the laboratory reports
• Look for vitality- HOS, Supravital staining
• Can be associated with varicocele, Immotile Cilia
Syndrome
• Antioxidants- ?
• Repeat after proper abstinence
• ICSI with viable sperms in semen
• ICSI from testicular sperms

65. Take Home Messages
• Semen analysis must be done from reliable
laboratories, following WHO 2010 standards
• Single abnormal test must be repeated
• In severe abnormality, detailed investigations
should be done
• Evidence in favour of medical management is
limited