Your Semen Analysis Results are Abnormal, Now What?

When the results of the semen analysis are abnormal on repeat tests, it is time to get serious about evaluating the underlying cause. A thorough past history is necessary along with an assessment in diet, lifestyle, exercise, and supplementation. It can never be harmful to improve health and I strongly prescribe to the notion that maximizing your health will maximize your fertility. But there are a number of reasons for poor semen analysis results and some reasons cannot be solved with these changes. Let’s take a look at a differential diagnosis based on results.

Qualitative measurements pH – acidic = blocked SV, alkaline = possible infection.

Azoospermia and severe oligozoospermia- (No or very little sperm) possible causes include:

• Retrograde ejaculation- Diagnosed by examining the post ejaculate urine. Presence of sperm and/or fructose will confirm. The cause is nerve damage, due to diabetes, multiple sclerosis, or surgery. Treatment includes Imipramine, Midodrine, Chlorpheniramine, Ephedrine, or Sildenaphil citrate. Ie. Pseudoephedrine 60 mg/6 hours or Imipramine 25 mg/8rs for 5-7 days.

Resistant patients can normalize pH and osmolarity of urine with consumption of sodium bicarbonate and sodium chloride and potentially conceive with homologous intrauterine insemination. Since this would occur post intercourse and does not separate the unitive and procreative purpose of the marital act, it would be morally licit.

• Ejaculatory duct obstruction- Diagnosed by transrectal ultrasound. Evidence of obstruction is usually manifested as enlarged seminal vesicles > 1.5 cm or an unusual appearance of the vas deferens and ejaculatory ducts. Treatment includes referral to a competent reproductive urologist although few will attempt to find and repair this because they believe it is easier to do IVF/ICSI. Potentially, the blockage could occur proximal to the seminal vesicles and this would require vasography to detect which has potential side effects. The correct human good (health) that should be pursued is diagnosis and treatment of the pathology. Over time, we may find more specialist who research and develop the surgical treatment of obstruction.
• Testicular failure- Diagnosed by small testicles, low testosterone and elevated FSH. Unless a cause for the failure can be identified and is reversable, such as steroid abuse, testicular failure is often not treatable. Adequate metabolic health, intratesticular testosterone and FSH levels are just a few of the necessary factors that need to be present for testicular function.
• Genetic/congenital causes- The congenital absence of the seminal vesicles and vas-deferens is usually associated with Cystic Fibrosis transmembrane conductance regulator (CFTR) gene mutations. About 10-15% of men with severe oligozoospermia or azoospermia have Y-chromosome microdeletions. These conditions are not treatable. Oligozoospermia, teratozoospermia, or athenozoospermia (low numbers, poor shape, or poor movement of sperm)
• Varicocele- Diagnosis can be done by physical exam, scrotal ultrasound, or MRI and most abnormalities can be surgically treated by a competent reproductive urologist.
• Infection- Acute infection increases the pH and has neutrophils present, chronic infection decreases the pH and has lymphocytes and monocytes present. Obvious signs of infection will show up as high levels (> 4 per HPF) of round cells in semen which can then be differentiated with peroxidase staining to identify leucocytes. Pyospermia is 1M/ml however since the testes is immune-privileged detection of fewer WBCs in the ejaculate would make antibiotic treatment reasonable. Men can experience chronic low grade or even asymptomatic infection however that can either be treated empirically or diagnosed with urine or urethral culture and/or PCR-DNA testing for the following. Try to get a positive on one of the partners before treatment but if other clinical symptoms are present empirical treatment is warranted. Both partners should be treated.

1. Chlamydia trachomatis
2. Mycoplasma vaginalis culture
3. Ureaplasma urealyticum culture
4. Gardnerella vaginalis culture
5. Neisseria gonorrhoeae culture
6. Fungus culture- Positive test would indicate some other issue such as immunosufficiency, stones, regular catheter use or HIV. Treat with Fluconazole.
7. HPV test.

• Metabolic or endocrine disease- A series of blood tests should be conducted to look for underlying health issues. Many times these things can be subclinical (you don’t notice the condition) or very early stages. Reproduction can be one of the first areas affected therefore, treating these aggressively is recommended.
• Anti-sperm antibodies- Male germ cells and sperm are normally isolated from a man’s immune system. They are completely supported by nurse cells called Sertoli cells unless there has been an injury, an extremely high fever or a vasectomy and reversal. Anti-sperm antibody testing is recommended when there is evidence of sperm agglutination, clumping, or reduced progressive motility.

For a positive anti-sperm Ab test, defer treatment for 4-6 effective cycles but then consider treatment with Prednisolone 20mg 2x/day for 10 nights followed by 5mg/day for 2 nights. This should be started 9 days before the woman’s estimated peak day. Men should have a chest x-ray before starting this treatment because of the potential side effects. Also blood pressure monitoring conducted and discontinue treatment if side effects are experienced. This strategy can be effective for about 21-33% of men with significant titers of ASAB (Hendry et al., 1986; 1990).