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• W1975587192 abstract "Semen analysis is the first step to identify male factor infertility. Standardized methods of semen analysis are available allowing accurate assessment of sperm quality and comparison among laboratories. Population-based reference ranges are available for standard semen and sperm parameters. Sperm numbers and morphology are associated with time to natural pregnancy, whereas sperm motility may be less predictive. Routine semen analysis does not measure the fertilizing potential of spermatozoa and the complex changes that occur in the female reproductive tract before fertilization. Whether assisted reproduction technology (ART) is required depends not only on male factors but female fecundity. Newer tests should predict the success of fertilization in vitro and the outcome of the progeny. Semen analysis is the first step to identify male factor infertility. Standardized methods of semen analysis are available allowing accurate assessment of sperm quality and comparison among laboratories. Population-based reference ranges are available for standard semen and sperm parameters. Sperm numbers and morphology are associated with time to natural pregnancy, whereas sperm motility may be less predictive. Routine semen analysis does not measure the fertilizing potential of spermatozoa and the complex changes that occur in the female reproductive tract before fertilization. Whether assisted reproduction technology (ART) is required depends not only on male factors but female fecundity. Newer tests should predict the success of fertilization in vitro and the outcome of the progeny. Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/wangc-semen-analysis-test-male-fertility/ Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/wangc-semen-analysis-test-male-fertility/ Semen analysis is the cornerstone for the assessment of the male partner in a subfertile couple. Compared with many other tests used in the assessment of the infertile couple, semen analysis has been standardized throughout the world. This was made possible through the efforts of the World Health Organization (WHO) since the 1970s by producing, editing, updating, and disseminating a semen analysis manual (1World Health OrganizationWorld Health Organization laboratory manual for the examination and processing of human semen.5th ed. World Health Organization, Geneva, Switzerland2010Google Scholar). The manual provides step by step methods on how to perform a routine semen analysis, guidance on establishing internal and external quality control for these measures, and recommendations on more commonly used tests to assess sperm function. The goal of the manual is to improve the standards of semen analysis and to ensure that the semen and sperm parameters assessed in one laboratory using this manual will be the same as the analysis done in another laboratory using the same manual. International and national societies of andrology, reproductive medicine, human reproduction, and pathology contributed by providing hands on training to ensure that the technologists are using these standardized methods to assess semen and sperm quality. This allows comparative studies and pooling of data from across the globe for epidemiology studies to assess semen quality (2Carlsen E. Giwercman A. Keiding N. Skakkebaek N.E. Evidence for decreasing quality of semen during past 50 years.BMJ. 1992; 305: 609-613Crossref PubMed Scopus (2212) Google Scholar, 3Swan S.H. Brazil C. Drobnis E.Z. Liu F. Kruse R.L. Hatch M. et al.Geographic differences in semen quality of fertile U.S. males.Environ Health Perspect. 2003; 111: 414-420Crossref PubMed Scopus (246) Google Scholar) and to develop reference ranges for semen and sperm parameters (4Cooper T.G. Noonan E. Von E.S. Auger J. Baker H.W. Behre H.M. et al.World Health Organization reference values for human semen characteristics.Hum Reprod Update. 2010; 16: 231-245Crossref PubMed Scopus (1707) Google Scholar). Semen analysis should be performed in laboratories with experienced technologists who have been trained in these standardized methods for routine clinical examination of semen. Despite our ability to assess sperm quality through a semen analysis methodology harmonized across laboratories, the use of these parameters cannot precisely and accurately predict the fertility of a man presenting to a clinician. This is because there are many factors in addition to sperm and semen quality that contribute to the ability of spermatozoa to fertilize an oocyte. To reach and fertilize the oocyte ejaculated spermatozoa have to traverse the female reproductive tract, hyperactivate and undergo acrosome reaction at the correct time and site, penetrate the cumulus and zona pellucida (ZP), and ultimately fuse with and fertilize the oocyte. The assessment of some of these changes in the spermatozoa will be discussed in other articles in this series. In addition to sperm function, female factors are extremely important to ensure optimization of the condition of the oocyte to allow for fertilization (5te Velde E.R. Eijkemans R. Habbema H.D. Variation in couple fecundity and time to pregnancy, an essential concept in human reproduction.Lancet. 2000; 355: 1928-1929Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar). Many studies have been criticized for the selection of subjects and methods used to develop reference ranges for semen and sperm quality, in particular the thresholds defining male factor subfertility using sperm concentration, motility, and morphology, the three classic sperm parameters measured by all laboratories. The WHO initially adopted a sperm concentration of <20 million/mL, >50% motile, and normal sperm morphology of >50% as thresholds below which subfertility may be present. This was based on studies done in the 1950s by Macleod and colleagues (6Macleod J. Semen quality in 1000 men of known fertility and in 800 cases of infertile marriage.Fertil Steril. 1951; 2: 115-139Abstract Full Text PDF PubMed Google Scholar, 7Macleod J. Gold R.Z. The male factor in fertility and infertility. III. An analysis of motile activity in the spermatozoa of 1000 fertile men and 1000 men in infertile marriage.Fertil Steril. 1951; 2: 187-204Abstract Full Text PDF PubMed Google Scholar, 8MacLeod J. Wang Y. Male fertility potential in terms of semen quality: a review of the past, a study of the present.Fertil Steril. 1979; 31: 103-116Abstract Full Text PDF PubMed Google Scholar, 9Macleod J. Gold R.Z. The male factor in fertility and infertility. II. Spermatozoon counts in 1000 men of known fertility and in 1000 cases of infertile marriage.J Urol. 1951; 66: 436-449Abstract Full Text PDF PubMed Scopus (241) Google Scholar) in 1,000 men of known fertility and 1,000 couples with subfertility. More recent studies, in 2001, evaluating male partners of fertile and infertile couples suggested that lower thresholds of sperm concentration <13.6 million/mL, motility <32%, and normal morphology <9% should be used to define possible male factor infertility (10Guzick D.S. Overstreet J.W. Factor-Litvak P. Brazil C.K. Nakajima S.T. Coutifaris C. et al.Sperm morphology, motility, and concentration in fertile and infertile men.N Engl J Med. 2001; 345: 1388-1393Crossref PubMed Scopus (900) Google Scholar). The WHO collected data from >4,500 men in 14 countries, including prospective and retrospective studies on fertile men and men of unknown fertility. It is important to note that all the centers used the WHO manual for semen and sperm analyses. Data from men with proven fertility whose partners had a time-to-pregnancy of <12 months were then chosen to provide reference ranges for semen parameters (4Cooper T.G. Noonan E. Von E.S. Auger J. Baker H.W. Behre H.M. et al.World Health Organization reference values for human semen characteristics.Hum Reprod Update. 2010; 16: 231-245Crossref PubMed Scopus (1707) Google Scholar). Using a one-sided lower reference limit of the 5th percentile (95% confidence intervals [CI]) the lower thresholds for semen parameters are as follows: semen volume 1.5 mL (range, 1.4–1.7 mL); sperm concentration 15 million/mL (range, 12–16 million/mL); total sperm number per ejaculate 39 million (range, 33–46 million); sperm motility 40% (range, 39%–42%); sperm morphology using strict criteria 4% normal forms (range, 3%–4%); and vitality 58% (range, 55%–63%). The semen quality from the general population was lower than that of fertile men. The WHO recommends using these reference limits in conjunction with clinical assessment, including the female partner's fecundity, to determine the fertility prospects for the couple. The seminal fluid is made up of a mixture of secretions from the testis, epididymis, prostate, and seminal vesicles, and the contribution from each of these glands varies by the interval of abstinence and the method used to obtain the semen samples. Although sexual abstinence of 2–7 days is generally advised before submission of a sample for analysis (1World Health OrganizationWorld Health Organization laboratory manual for the examination and processing of human semen.5th ed. World Health Organization, Geneva, Switzerland2010Google Scholar), a recent study suggests that in subfertile men, the samples should be collected after 1 day of sexual abstinence for optimal semen quality (11Levitas E. Lunenfeld E. Weiss N. Friger M. Har-Vardi I. Koifman A. et al.Relationship between the duration of sexual abstinence and semen quality: analysis of 9,489 semen samples.Fertil Steril. 2005; 83: 1680-1686Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar). In men, semen samples collected by masturbation in the clinic may be of a lower quality than those collected at home (12Elzanaty S. Malm J. Comparison of semen parameters in samples collected by masturbation at a clinic and at home.Fertil Steril. 2008; 89: 1718-1722Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar); however, erotic materials or isotonic lubricants do not appear to influence the quality of the sample (13Agarwal A. Malvezzi H. Sharma R. Effect of an isotonic lubricant on sperm collection and sperm quality.Fertil Steril. 2013; 99: 1581-1586Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 14Handelsman D.J. Sivananathan T. Andres L. Bathur F. Jayadev V. Conway A.J. Randomised controlled trial of whether erotic material is required for semen collection: impact of informed consent on outcome.Andrology. 2013; 1: 943-947Crossref PubMed Scopus (5) Google Scholar). When seminal fluid volume is markedly reduced, the clinician should suspect incomplete collection, severe androgen deficiency and obstruction in ejaculatory ducts, or bilateral absence of the vas deference. In the latter two conditions, the seminal fluid will have an acidic pH, very low fructose levels, and no spermatozoa, and the diagnosis can be confirmed by physical examination, confirming bilateral absence of vas deferens or by transrectal ultrasound showing dilated seminal vesicles in ejaculatory duct obstruction (15Wang C, Swerdloff R. Evaluation of male infertility. Available at: http://www.uptodate.com/contents/evaluation-of-male-infertility?source=machineLearning&search=male+infertility&selectedTitle=1%7E78&sectionRank=1&anchor=H8#H8. Accessed October 3, 2014.Google Scholar). There are a number of biochemical tests to measure functions of the accessory gland including zinc and acid phosphatase (prostate), fructose (seminal vesicle), and carnitine and alpha-glucosidase (epididymis) (1World Health OrganizationWorld Health Organization laboratory manual for the examination and processing of human semen.5th ed. World Health Organization, Geneva, Switzerland2010Google Scholar). These biochemical tests are not routinely performed and are of rare clinical usefulness as biomarkers of male factor infertility. The standardization of measurement of sperm concentration and semen volume allows for a more accurate calculation of sperm output. Despite many comments and discussions about using sperm concentration as a biomarker of male factor infertility, the accurate assessment of number of spermatozoa in an ejaculate remained the standard practice for the evaluation of the infertile couple. Fundamentally a single parameter cannot be used as a valid biomarker of fertility because a multitude of factors contribute to infertility including the inherent biological variability of sperm concentration, the methods of fertilization (in vitro vs. in vivo), the health of the man at time of collection, and female factors. Sperm concentration in a man showed considerable variation and at least two semen samples should be examined before providing a conclusion that the sperm concentration or total sperm count is below the reference range (16Berman N.G. Wang C. Paulsen C.A. Methodological issues in the analysis of human sperm concentration data.J Androl. 1996; 17: 68-73PubMed Google Scholar). Retrospective data analyses from cryobanks on 18–20 consecutive semen samples from 48 semen donors showed that an optimal duration of abstinence to distinguish high or low sperm production may be between 42 and 54 hours and collection of three samples may provide results closer to the true value (17Amann R.P. Chapman P.L. Total sperm per ejaculate of men: obtaining a meaningful value or a mean value with appropriate precision.J Androl. 2009; 30: 642-649Crossref PubMed Scopus (20) Google Scholar). Amann (18Amann R.P. Evaluating spermatogenesis using semen: the biology of emission tells why reporting total sperm per sample is important, and why reporting only number of sperm per milliliter is irrational.J Androl. 2009; 30: 623-625Crossref PubMed Scopus (11) Google Scholar, 19Amann R.P. Considerations in evaluating human spermatogenesis on the basis of total sperm per ejaculate.J Androl. 2009; 30: 626-641Crossref PubMed Scopus (33) Google Scholar) also suggested that the rate of daily sperm production may better reflect altered spermatogenesis and that the assessment of total number of spermatozoa per ejaculate is reflective of sperm production provided the abstinence interval is appropriate. The lower limits of sperm concentration and total number of sperm per ejaculate that reflects male subfertility is not known. The 5th percentile of WHO reference value for sperm concentration is 15 million/mL (95% CI 12–16) and for total sperm number per ejaculate is 39 million/mL (95% CI 33–46). This is based on data generated from 1,859 fertile men with a time-to-pregnancy of less than 12 month (4Cooper T.G. Noonan E. Von E.S. Auger J. Baker H.W. Behre H.M. et al.World Health Organization reference values for human semen characteristics.Hum Reprod Update. 2010; 16: 231-245Crossref PubMed Scopus (1707) Google Scholar) using a one-side distribution as there is no upper limit of sperm concentration that is associated with infertility. It is now recognized that there are geographic differences in sperm concentration across countries. Epidemiological studies (3Swan S.H. Brazil C. Drobnis E.Z. Liu F. Kruse R.L. Hatch M. et al.Geographic differences in semen quality of fertile U.S. males.Environ Health Perspect. 2003; 111: 414-420Crossref PubMed Scopus (246) Google Scholar, 20Swan S.H. Kruse R.L. Liu F. Barr D.B. Drobnis E.Z. Redmon J.B. et al.Semen quality in relation to biomarkers of pesticide exposure.Environ Health Perspect. 2003; 111: 1478-1484Crossref PubMed Scopus (282) Google Scholar, 21Jorgensen N. Andersen A.G. Eustache F. Irvine D.S. Suominen J. Petersen J.H. et al.Regional differences in semen quality in Europe.Hum Reprod. 2001; 16: 1012-1019Crossref PubMed Scopus (372) Google Scholar, 22Jorgensen N. Carlsen E. Nermoen I. Punab M. Suominen J. Andersen A.G. et al.East-West gradient in semen quality in the Nordic-Baltic area: a study of men from the general population in Denmark, Norway, Estonia and Finland.Hum Reprod. 2002; 17: 2199-2208Crossref PubMed Scopus (256) Google Scholar) suggest that this may be related to environmental toxicants, although the association is controversial. There are also differences in sperm concentration across racial/ethnic groups (23Redmon J.B. Thomas W. Ma W. Drobnis E.Z. Sparks A. Wang C. et al.Semen parameters in fertile US men: the Study for Future Families.Andrology. 2013; 1: 806-814Crossref PubMed Scopus (43) Google Scholar). More recent studies suggest that obesity is associated with suppression of the hypothalamic-pituitary-testis axis (24Macdonald A.A. Stewart A.W. Farquhar C.M. Body mass index in relation to semen quality and reproductive hormones in New Zealand men: a cross-sectional study in fertility clinics.Hum Reprod. 2013; 28: 3178-3187Crossref PubMed Scopus (79) Google Scholar) and morbid obesity may be associated with decreased sperm concentration and reduced fertility (25Chavarro J.E. Toth T.L. Wright D.L. Meeker J.D. Hauser R. Body mass index in relation to semen quality, sperm DNA integrity, and serum reproductive hormone levels among men attending an infertility clinic.Fertil Steril. 2010; 93: 2222-2231Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar, 26Hammoud A.O. Meikle A.W. Reis L.O. Gibson M. Peterson C.M. Carrell D.T. Obesity and male infertility: a practical approach.Semin Reprod Med. 2012; 30: 486-495Crossref PubMed Scopus (57) Google Scholar, 27Martini A.C. Tissera A. Estofan D. Molina R.I. Mangeaud A. de Cuneo M.F. et al.Overweight and seminal quality: a study of 794 patients.Fertil Steril. 2010; 94: 1739-1743Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 28Nguyen R.H. Wilcox A.J. Skjaerven R. Baird D.D. Men's body mass index and infertility.Hum Reprod. 2007; 22: 2488-2493Crossref PubMed Scopus (200) Google Scholar, 29Thomsen L. Humaidan P. Bungum L. Bungum M. The impact of male overweight on semen quality and outcome of assisted reproduction.Asian J Androl. 2014; 16: 749-754Crossref PubMed Scopus (45) Google Scholar). Lifestyle modifications and bariatric surgery reduce body mass index (BMI), which may be associated with improvement in semen quality and fertility potential (30Reis L.O. Dias F.G. Male fertility, obesity, and bariatric surgery.Reprod Sci. 2012; 19: 778-785Crossref PubMed Scopus (36) Google Scholar, 31Hakonsen L.B. Thulstrup A.M. Aggerholm A.S. Olsen J. Bonde J.P. Andersen C.Y. et al.Does weight loss improve semen quality and reproductive hormones? Results from a cohort of severely obese men.Reprod Health. 2011; 8: 24Crossref PubMed Scopus (204) Google Scholar). What is the predictive value of sperm concentration for fertility in men? Data from an observational study (32Slama R. Eustache F. Ducot B. Jensen T.K. Jorgensen N. Horte A. et al.Time to pregnancy and semen parameters: a cross-sectional study among fertile couples from four European cities.Hum Reprod. 2002; 17: 503-515Crossref PubMed Scopus (220) Google Scholar) of pregnant women from four countries in Europe showed increasing sperm concentration up to 55 million/mL affected time-to-pregnancy (a measure of fecundity). Similar to sperm concentration, the total sperm number per ejaculate was also associated with the probability of conception. There was also a direct correlation between normal sperm morphology (≤19% normal using strict criteria) and time-to-pregnancy (32Slama R. Eustache F. Ducot B. Jensen T.K. Jorgensen N. Horte A. et al.Time to pregnancy and semen parameters: a cross-sectional study among fertile couples from four European cities.Hum Reprod. 2002; 17: 503-515Crossref PubMed Scopus (220) Google Scholar). A prospective observation study (33Bonde J.P. Ernst E. Jensen T.K. Hjollund N.H. Kolstad H. Henriksen T.B. et al.Relation between semen quality and fertility: a population-based study of 430 first-pregnancy planners.Lancet. 1998; 352: 1172-1177Abstract Full Text Full Text PDF PubMed Scopus (571) Google Scholar) of 430 healthy couples who discontinued their contraceptive use for 6 months showed that the probability of conception increased linearly with sperm concentration up to 40 million/mL; a higher level did not increase the likelihood of conception. When 200 couples who had discontinued contraception were followed for 12 months, total sperm numbers and sperm concentration were significantly related to time-to-pregnancy (34Zinaman M.J. Brown C.C. Selevan S.G. Clegg E.D. Semen quality and human fertility: a prospective study with healthy couples.J Androl. 2000; 21: 145-153PubMed Google Scholar). In a more recent study of 501 couples who discontinued contraception in the Longitudinal Investigation of Fertility and the Environment (LIFE) study (35Buck Louis G.M. Sundaram R. Schisterman E.F. Sweeney A. Lynch C.D. Kim S. et al.Semen quality and time to pregnancy: the Longitudinal Investigation of Fertility and the Environment Study.Fertil Steril. 2014; 101: 453-462Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar), sperm concentration and total sperm number were related to time-to-conception, which became not significant in combined statistical models accounting for simultaneous effects of semen parameters. In summary the literature suggests that when sperm concentration or total sperm concentration is low, the fecundity of the men is probably decreased. Assessment of sperm motility is performed in most laboratories by visual assessment under the microscope and quantified as percent total motility, progressive motility, and spermatozoa with no motility. It is important to determine sperm viability. If a large proportion of spermatozoa in a semen sample is nonmotile because of dead cells the sperm will not fertilize the oocyte. Some laboratories use computer-assisted sperm analysis when different sperm motility parameters have been shown to be associated with fertility (36ESHRE Andrology Special Interest GroupConsensus workshop on advanced diagnostic andrology techniques. ESHRE (European Society of Human Reproduction and Embryology) Andrology Special Interest Group.Hum Reprod. 1996; 11: 1463-1479Crossref PubMed Scopus (128) Google Scholar, 37Krause W. The significance of computer-assisted semen analysis (CASA) for diagnosis in andrology and fertility prognosis.Int J Androl. 1995; 18: 32-35PubMed Google Scholar). Computer-assisted semen analysis is especially useful for research and epidemiological studies where objective assessment is necessary to detect small changes in sperm motility characteristics such as sperm curvilinear and straight line velocity and amount of head and tail movement. It can also be used to assess hyperactivated motility (required for penetration of the cumulus and ZP), which may be a biomarker for the success of human fertilization. Unfortunately, assessment of hyperactivated motility by computer-assisted sperm analysis is not standardized and inadequate data are available to support its routine use (36ESHRE Andrology Special Interest GroupConsensus workshop on advanced diagnostic andrology techniques. ESHRE (European Society of Human Reproduction and Embryology) Andrology Special Interest Group.Hum Reprod. 1996; 11: 1463-1479Crossref PubMed Scopus (128) Google Scholar). Sperm motility has no role when IVF and intracytoplasmic sperm injection (ICSI) are used unless no motility is present. Sperm motility was not found to be an important factor associated with the probability of conception in couples who discontinued contraception for 6 months (33Bonde J.P. Ernst E. Jensen T.K. Hjollund N.H. Kolstad H. Henriksen T.B. et al.Relation between semen quality and fertility: a population-based study of 430 first-pregnancy planners.Lancet. 1998; 352: 1172-1177Abstract Full Text Full Text PDF PubMed Scopus (571) Google Scholar) or 12 months (34Zinaman M.J. Brown C.C. Selevan S.G. Clegg E.D. Semen quality and human fertility: a prospective study with healthy couples.J Androl. 2000; 21: 145-153PubMed Google Scholar). In the LIFE study (35Buck Louis G.M. Sundaram R. Schisterman E.F. Sweeney A. Lynch C.D. Kim S. et al.Semen quality and time to pregnancy: the Longitudinal Investigation of Fertility and the Environment Study.Fertil Steril. 2014; 101: 453-462Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar) when 501 couples discontinued contraception and were followed for 12 months, time-to-pregnancy was significantly associated with percent sperm motility, straight line velocity, percent linearity, and straightness, but all of these motility parameters became not significant when multiple semen parameters and covariates were simultaneously assessed in the model. Manual assessment of sperm morphology is an integral procedure in routine semen analyses. In most laboratories specializing in assessment of infertile couples, sperm morphology is assessed by the “strict” criteria (38Kruger T.F. Ackerman S.B. Simmons K.F. Swanson R.J. Brugo S.S. Acosta A.A. A quick, reliable staining technique for human sperm morphology.Arch Androl. 1987; 18: 275-277Crossref PubMed Scopus (125) Google Scholar, 39Menkveld R. Stander F.S. Kotze T.J. Kruger T.F. van Zyl J.A. The evaluation of morphological characteristics of human spermatozoa according to stricter criteria.Hum Reprod. 1990; 5: 586-592PubMed Google Scholar). The strict criteria are based on characteristics derived from spermatozoa recovered from the cervical mucus after intercourse (39Menkveld R. Stander F.S. Kotze T.J. Kruger T.F. van Zyl J.A. The evaluation of morphological characteristics of human spermatozoa according to stricter criteria.Hum Reprod. 1990; 5: 586-592PubMed Google Scholar) and from the surface of the ZP. This criterion incorporates histomorphometric measurement of the sperm head and pattern recognition for the various defects of sperm head, neck, body, and tail. The technologist assessing seminal fluid smears needs training and retraining to be able to read the slides reproducibly and accurately. Any slight abnormality of the spermatozoa will classify it to have abnormal morphology using the strict criteria. The strict criteria gained popularity in the assisted reproduction practices because initial studies indicated that poor sperm morphology predicted the failure of IUI and IVF, but not all studies have confirmed this (40Coetzee K. Kruge T.F. Lombard C.J. Predictive value of normal sperm morphology: a structured literature review.Hum Reprod Update. 1998; 4: 73-82Crossref PubMed Scopus (196) Google Scholar, 41Menkveld R. Holleboom C.A. Rhemrev J.P. Measurement and significance of sperm morphology.Asian J Androl. 2011; 13: 59-68Crossref PubMed Scopus (110) Google Scholar, 42Van Waart J. Kruger T.F. Lombard C.J. Ombelet W. Predictive value of normal sperm morphology in intrauterine insemination (IUI): a structured literature review.Hum Reprod Update. 2001; 7: 495-500Crossref PubMed Scopus (168) Google Scholar, 43Check M.L. Bollendorf A. Check J.H. Katsoff D. Reevaluation of the clinical importance of evaluating sperm morphology using strict criteria.Arch Androl. 2002; 48: 1-3Crossref PubMed Scopus (31) Google Scholar, 44Kiefer D. Check J.H. Katsoff D. The value of motile density, strict morphology, and the hypoosmotic swelling test in in vitro fertilization-embryo transfer.Arch Androl. 1996; 37: 57-60Crossref PubMed Scopus (56) Google Scholar). This strict criterion is also used by the WHO for the assessment of normal sperm morphology in the latest version of the manual (1World Health OrganizationWorld Health Organization laboratory manual for the examination and processing of human semen.5th ed. World Health Organization, Geneva, Switzerland2010Google Scholar). If the percent of sperm with normal sperm morphology is more than 4% of sperm cells, this is generally regarded as within the 95% fertile reference range (4Cooper T.G. Noonan E. Von E.S. Auger J. Baker H.W. Behre H.M. et al.World Health Organization reference values for human semen characteristics.Hum Reprod Update. 2010; 16: 231-245Crossref PubMed Scopus (1707) Google Scholar). Is assessment of sperm morphology useful to predict in vivo fertility without assisted reproductive technique (ART)? In partners of pregnant women, the percent of morphologically normal spermatozoa assessed by strict or other criteria influenced time-to-pregnancy in these couples (32Slama R. Eustache F. Ducot B. Jensen T.K. Jorgensen N. Horte A. et al.Time to pregnancy and semen parameters: a cross-sectional study among fertile couples from four European cities.Hum Reprod. 2002; 17: 503-515Crossref PubMed Scopus (220) Google Scholar). In couples where contraception was withdrawn for 6–12 months to study the relationship between sperm parameters and time-to-pregnancy, the percent spermatozoa with normal morphology and the number of morphologically normal spermatozoa were important and significant predictors of probability of conception independent of sperm concentration (33Bonde J.P. Ernst E. Jensen T.K. Hjollund N.H. Kolstad H. Henriksen T.B. et al.Relation between semen quality and fertility: a population-based study of 430 first-pregnancy planners.Lancet. 1998; 352: 1172-1177Abstract Full Text Full Text PDF PubMed Scopus (571) Google Scholar, 34Zinaman M.J. Brown C.C. Selevan S.G. Clegg E.D. Semen quality and human fertility: a prospective study with healthy couples.J Androl. 2000; 21: 145-153PubMed Google Scholar). In the LIFE study (35Buck Louis G.M. Sundaram R. Schisterman E.F. Sweeney A. Lynch C.D. Kim S. et al.Semen quality and time to pregnancy: the Longitudinal Investigation of Fertility and the Environment Study.Fertil Steril. 2014; 101: 453-462Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar) of couples who discontinued contraceptive use in the United States, normal sperm morphology (using either strict or traditional methods), amorphous, round, and pyriform heads, neck, and midpiece abnormalities, and coiled tails were significant predictors of time-to-pregnancy. In this most recent study (35Buck Louis G.M. Sundaram R. Schisterman E.F. Sweeney A. Lynch C.D. Kim S. et al.Semen quality and time to pregnancy: the Longitudinal Investigation of Fertility and the Environment Study.Fertil Steril. 2014; 101: 453-462Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar), sperm head morphometry (width, elongation factor, and acrosome area of head) were also significantly related to fecundity rate. Again as with sperm concentration and motility, when simultaneous adjustment of multiple semen parameters was used in the statistics model, only percent of spermatozoa with coiled tail was significantly related to fecundity. Semen analysis remains the first laboratory test a clinician will order after completing a detailed medical history and physical examination for the male partner of an infertile couple. The standardization of the routine semen analyses (semen volume, sperm count, motility, and morphology) allows for comparison across laboratories. Reference range based on fertile men has been developed and generally adopted by most clinicians working with an infertile couple. The lower limit thresholds may not be applicable to every man, but can be used as guidance for determining the next step in the diagnosis and treatment. A semen analysis that is within the reference range (e.g., >5th percentile of the WHO recommended values) indicates that the male partner may not be the primary problem for the infertile couple. Focus should be first on the female partner. Whereas a semen sample that has triple defects—low sperm count, poor motility, and abundance of abnormal sperm morphology—indicates that male factor infertility is likely. Although specific approaches to the treatment of male factor infertility are very few, they need to be investigated during the workup of the female partner. Prospective studies (33Bonde J.P. Ernst E. Jensen T.K. Hjollund N.H. Kolstad H. Henriksen T.B. et al.Relation between semen quality and fertility: a population-based study of 430 first-pregnancy planners.Lancet. 1998; 352: 1172-1177Abstract Full Text Full Text PDF PubMed Scopus (571) Google Scholar, 34Zinaman M.J. Brown C.C. Selevan S.G. Clegg E.D. Semen quality and human fertility: a prospective study with healthy couples.J Androl. 2000; 21: 145-153PubMed Google Scholar, 35Buck Louis G.M. Sundaram R. Schisterman E.F. Sweeney A. Lynch C.D. Kim S. et al.Semen quality and time to pregnancy: the Longitudinal Investigation of Fertility and the Environment Study.Fertil Steril. 2014; 101: 453-462Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar) in couples who stopped contraceptive use showed that sperm count, total sperm number, and percent morphologically normal spermatozoa can predict time-to-pregnancy, which is a surrogate marker for fecundity. Spermatozoa have to undergo many changes before fertilization can occur. For IVF, spermatozoa must have adequate motility, propelled mainly by adenosine triphosphate (ATP), generated from glycolysis and not from the mitochondria. Sperm mitochondria are important for calcium homeostasis and for generation of controlled levels of reactive oxygen species necessary for normal sperm function (45Amaral A. Lourenco B. Marques M. Ramalho-Santos J. Mitochondria functionality and sperm quality.Reproduction (Cambridge, England). 2013; 146: R163-R174Crossref PubMed Scopus (300) Google Scholar, 46Piomboni P. Focarelli R. Stendardi A. Ferramosca A. Zara V. The role of mitochondria in energy production for human sperm motility.Int J Androl. 2012; 35: 109-124Crossref PubMed Scopus (246) Google Scholar). During the transit in the female reproductive tract spermatozoa undergo capacitation. The process of capacitation involves generation of adenyl cyclase, which activates protein kinase A, resulting in sperm protein tyrosine phosphorylation, enabling spermatozoa to acquire fertilizing capacity. Spermatozoa then undergo acrosome reaction and hyperactivation when in contact with the ZP (47Bailey J.L. Factors regulating sperm capacitation.Syst Biol Reprod Med. 2010; 56: 334-348Crossref PubMed Scopus (113) Google Scholar, 48Evans J.P. Sperm–egg interaction.Annu Rev Physiol. 2012; 74: 477-502Crossref PubMed Scopus (64) Google Scholar). Recent studies (49Cho C. Testicular and epididymal ADAMs: expression and function during fertilization.Nat Rev Urol. 2012; 9: 550-560Crossref PubMed Scopus (59) Google Scholar, 50Okabe M. The cell biology of mammalian fertilization.Development. 2013; 140: 4471-4479Crossref PubMed Scopus (123) Google Scholar) using advanced technology showed that spermatozoa can penetrate the cumulus without undergoing the acrosome reaction. Spermatozoa must be coated with the sperm surface protein ADAM3 to allow passage through the cumulus and binding to the ZP (49Cho C. Testicular and epididymal ADAMs: expression and function during fertilization.Nat Rev Urol. 2012; 9: 550-560Crossref PubMed Scopus (59) Google Scholar). These processes enable a sperm cell to penetrate the ZP and begin the process of fertilization of the oocyte. The fertilization of the ooctye requires at least the presence of IZUMO 1 on the spermatozoa and CD 9 on the ooctye (50Okabe M. The cell biology of mammalian fertilization.Development. 2013; 140: 4471-4479Crossref PubMed Scopus (123) Google Scholar, 51Inoue N. Ikawa M. Okabe M. The mechanism of sperm-egg interaction and the involvement of IZUMO1 in fusion.Asian J Androl. 2011; 13: 81-87Crossref PubMed Scopus (47) Google Scholar). Thus it is clear that examination of the semen and the spermatozoa in the ejaculate cannot assess: [1] the process of capacitation of the spermatozoa in the female reproductive tract, [2] the acquisition of sperm surface proteins that are required for ZP binding and penetration, and [3] the ability to fertilize the egg. Some of these sperm function tests are described in other articles on biomarkers of spermaotozoal fertilizing capacity. There are many sperm function tests including the sperm oocyte penetration test, hemizona assay, stimulation of acrosome reaction (AR), hyperactivated motility assessment using computer-assisted semen analysis, and in vitro capacitation tests that may assess each step that spermatozoa must undergo before fertilization occurs. These sperm function tests have been shown to be associated with fertilization in vitro but none of these in vitro tests have consistently predicted the time-to-pregnancy better than sperm concentration and morphology. Sperm DNA integrity was not associated with fecundity of the couple (35Buck Louis G.M. Sundaram R. Schisterman E.F. Sweeney A. Lynch C.D. Kim S. et al.Semen quality and time to pregnancy: the Longitudinal Investigation of Fertility and the Environment Study.Fertil Steril. 2014; 101: 453-462Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar). Because infertility is a complex process involving male and female factors, it will not be possible to predict fertility using parameters from either partner alone unless there is azoospermia in the man or premature ovarian failure (POF) in the woman. Female fecundity contributes significantly to the fertility potential of the couple (5te Velde E.R. Eijkemans R. Habbema H.D. Variation in couple fecundity and time to pregnancy, an essential concept in human reproduction.Lancet. 2000; 355: 1928-1929Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar). In a prospective study (52Van Geloven N. van der Veen F. Bossuyt P.M. Hompes P.G. Zwinderman A.H. Mol B.W. Can we distinguish between infertility and subfertility when predicting natural conception in couples with an unfulfilled child wish?.Hum Reprod. 2013; 28: 658-665Crossref PubMed Scopus (15) Google Scholar) based on 3,917 couples presenting with unexplained infertility, a mixed model was used to distinguish couples who may have chance of natural conception and those who would be infertile without using ART. The statistical mixed model estimated that 47% of the couple were infertile, only female age (odds ratio, 1.11; 95% CI 1.03–1.19) and previous pregnancy (odds ratio, 0.22; 95% CI 0.07–0.67) were significantly related to infertility and semen quality was not a statistically important factor for unexplained infertility. For a clinician who treats infertile couples, the questions are [1] Is there a problem with the male partner? [2] How significant is the abnormality? [3] Is there a cause of this abnormality? [4] Can the abnormality be treated? [5] Should the couple be referred for ICSI or IVF? [6] Can sperm biomarkers predict the success of ICSI and IVF? and [7] Will the defect in the male factor affect the progeny? Performing a routine semen analysis will provide leads to whether the problem may be present in the male partner and an estimate of the severity of the problem. To find out the cause of the abnormality will require further testing that may include assessing the general health of the male partner (smoking, obesity, hypogonadism, chronic diseases), genetic testing to exclude Y chromosome microdeletions and other common genetic defects, and excluding obstructive causes that can be amenable to treatment. Sperm function testing is not frequently done as the couple with moderate-to-severe nonobstructive oligozoospermia is usually referred for ICSI and IVF. At this stage, genetic testing should have been done and counseling, if necessary, should have been provided to the couple. Future sperm function tests need to accurately predict the success of fertilization in vitro and whether the progeny will be healthy. This may include using epigenetics and deep sequencing studies for clinical diagnosis of male factor infertility to discover spermatozoal epigenetic disorders (53Boissonnas C.C. Jouannet P. Jammes H. Epigenetic disorders and male subfertility.Fertil Steril. 2013; 99: 624-631Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 54Gannon J.R. Emery B.R. Jenkins T.G. Carrell D.T. The sperm epigenome: implications for the embryo.Adv Exp Med Biol. 2014; 791: 53-66Crossref PubMed Scopus (68) Google Scholar, 55Klaver R. Gromoll J. Bringing epigenetics into the diagnostics of the andrology laboratory: challenges and perspectives.Asian J Androl. 2014; 16: 669-674Crossref PubMed Scopus (35) Google Scholar), spermatozoal small noncoding RNA defects (56De Mateo S. Sassone-Corsi P. Regulation of spermatogenesis by small non-coding RNAs: role of the germ granule.Semin Cell Dev Biol. 2014; 29: 84-92Crossref PubMed Scopus (55) Google Scholar, 57Jodar M. Selvaraju S. Sendler E. Diamond M.P. Krawetz S.A. The presence, role and clinical use of spermatozoal RNAs.Hum Reprod Update. 2013; 19: 604-624Crossref PubMed Scopus (236) Google Scholar), and other subtle genetic abnormalities that may impact fertilizing potential and the outcome of the progeny (58Hotaling J. Carrell D.T. Clinical genetic testing for male factor infertility: current applications and future directions.Andrology. 2014; 2: 339-350Crossref PubMed Scopus (92) Google Scholar)." @default.
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