Case Scenarios in Different Semen Analysis Results
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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
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Case Scenarios in Different Semen Analysis Results
- 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
- 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
- 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.
- 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 )
- 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