Assessing the quality of the semen is the most important aspect of a male workup. Whether the problem is hormonal or structural, all clues to a male factor problem are found within the semen. Before you can grasp exactly what's being analyzed when you deliver that sperm sample, here's a brief refresher on what happens to your sperm from the time they're produced until fertilization. Also, review Figure 5.1, for a visual refresher!

The male reproductive hormonal cycle controls semen production. The hormones involved are almost identical to those involved in the female cycle, except that testosterone is flooded into the bloodstream instead of estrogen and progesterone. The main difference between the male and female hormonal cycles is that, in the woman, the cycle runs in a continuous loop, whereas in the man, the cycle runs endlessly without any marked beginning, middle, or end. In women, the ovulation cycle peters out with age, resulting in menopause; in men, there is no time limit for semen production. This distinction in hormonal timing also causes vast differences in male and female sexual behavior, but that's another book!

Every day, a man's testes are busy producing millions of sperm. As in the female cycle, the hypothalamus starts the process by secreting gonadotropin-releasing hormone (GnRH) into the bloodstream. GnRH is released approximately every 90 minutes, triggering the pituitary gland to release both luteinizing hormone (LH) and follicle stimulating hormone (FSH) into the bloodstream, which carries the hormones to the testes. Within the testes, LH goes directly to the Leydig cells, which triggers the production of testosterone; FSH goes directly to the Sertoli cells, which triggers the production of sperm. When testosterone levels drop, this tells the hypothalamus to release more GnRH, which tells the pituitary gland to secrete more LH and FSH, which tells the body to make more testosterone and sperm. As we discuss later in this article, this hormonal interrelationship, clinically called the hormonal axis, must be in tip-top shape in order for men to produce enough high-quality sperm to fertilize an egg. Trouble with either the Leydig or Sertoli cells may cause unusually high levels of either LH or FSH or unusually low levels of testosterone. Trouble in the hypothalamus or pituitary glands will cause a breakdown of the entire hormonal axis. In all cases, sperm counts will be low or even nonexistent.

The testicles are situated inside the scrotal sac, which is positioned outside the body to keep the testicles at roughly 94 degrees F (35 degrees C), a few degrees cooler than body temperature. The testicles themselves are not visible to the eye and are made up of small, tightly coiled tubes known as seminiferous tubules. The sperm are produced inside these tubules, where they stay until they're mature. Sperm cells have their own guardians, the Sertoli cells, also known as nurse cells, which help protect and nourish the sperm until they're mature. These are the cells that respond to FSH. There is one nurse cell for roughly every 150 sperm.

It takes 2-3 months (about 74 days) for sperm to mature. Mature sperm gather in the center of the tubules, while the immature sperm remain on the outer edges of the tubules. The nurse cells continuously "sweep" sperm into the center as they mature. When the sperm mature, they leave the tubules and enter the epididymis, a coiled, tubular organ attached to the testes. Here, the mature sperm learn to "swim" and fine-tune their motility (movement). Mature sperm resemble microscopic tadpoles. They have an enzyme-coated head, a tail, and a thinner portion of the tail, called an end piece.

Once inside the epididymis, mature sperm wait to be ejaculated into the vagina -- not unlike the scene depicted in Woody Allen's satirical film, Everything You Always Wanted to Know About Sex, where the sperm are waiting to "parachute" out of an aircraft and complete their mission. What happens to the sperm if no ejaculation takes place? They die and are reabsorbed by the body. This is as close as a man comes to having a "period."

The penis is equipped with sensory receptors that tell the brain to make the penis erect. The erectile tissue that lines the penis fills with blood, causing the penis to grow and elongate. The sperm get ejected from the body through one of two parallel sets of tubes, known as the vas deferens, an artery that serves as a canal. The vas deferens carries the sperm above the pubic bone, past the bladder. (If you've had a vasectomy, the vas deferens does not carry the sperm anywhere, and the sperm are quickly reabsorbed by the body.) The vas deferens takes the sperm to the ejaculatory duct, which serves as a holding area. Until now, the sperm, along with small quantities of fluid (present to help propel the sperm along) are the sole ingredients to the ejaculate. In the holding area, seminal vesicles, small organs nearby, add large quantities of fructose, a sugar solution, to the ejaculate. The fructose nourishes the sperm and turns it into semen. The semen is then dumped into an enlarged section of the urethra called the bulbous urethra. The prostate gland is connected to the bulbous urethra through a separate duct system. At this point, the prostate gland adds an alkaline fluid to the semen, which will protect it from the acidic environment of the vagina. This, by the way, is the prostate gland's main function in life. A tiny amount of lubricating fluid is then added to the semen by the Cowper's gland. The ejaculate is now complete. The fluids are then forcefully ejected by contractions of the pelvic floor muscles and prostate gland. The bladder neck closes to stop sperm from going back into the bladder. An average ejaculate contains 40-150 million sperm, out of which only a few hundred will even come close to the egg. The semen measures between a half to a full teaspoon and is ejaculated through the urethra. (To the naked eye, semen without sperm is indistinguishable from semen with sperm, which is why males who produce little or no sperm do not realize it.)

Once inside the vagina, the semen immediately coagulates, for reasons not yet understood. Because the vagina is acidic, only about 10% of the sperm will survive the first 10 minutes inside the vagina. After about 20 minutes, the semen becomes fluid again, enabling the surviving sperm to swim up the reproductive tract. Here's where the cervical mucus enters the picture. When a portion of the surviving sperm reach the cervical mucus, they will find tiny strands of protein within it that will carry them toward the uterus. This protein is present only in midcycle mucus, which has an egg-white consistency. The mucus is a sign that ovulation has just taken place or will be taking place shortly. The woman's egg remains viable for about 12-24 hours; the sperm can live up to 48-72 hours. This creates a reproductive window of roughly four days.

New research indicates that when a woman reaches orgasm at the time of ejaculation (but not before), her orgasmic contractions also help to propel the sperm upward, toward the uterus. However, if a woman reaches orgasm prior to ejaculation (during foreplay, for example), the contractions may help to keep the sperm away.

Once the sperm reach the uterus and continue upward, they number in the hundreds. Some of these sperm will get lost or will become embedded in the lining of the fallopian tubes. The enzyme cap that coats the head of the sperm is covered with a net of membranes that protect it. This membrane is almost completely worn away by this point, so when the sperm reaches the egg, the enzymes are "naked" and can easily penetrate the egg. During many of the assisted conception procedures, this membrane is artificially worn away through a process known as sperm washing. The clinical term for this membrane wear and tear is known as the capacitation process.

When the sperm enters the egg's outer layer, a biochemical change in the egg takes place, making it impossible for any other sperm to penetrate it. The sperm and the egg at this point merge genetic material. The entire fertilization process takes about 24 hours, and the fertilized egg takes about four days to reach the uterus. The egg then secretes a hormone called human chorionic gonadotropin (hCG). In a home pregnancy test kit, this hormone causes the stick to change color.

Sometimes the egg will not travel to the uterus to develop, but will instead grow inside the fallopian tube. This is known as an ectopic, or tubal pregnancy, and is more common in women who have a history of sexually transmitted diseases (STDs) or intrauterine device (IUD) use.

Rarely, some freakish versions of fertilization can result in a molar pregnancy, where there is either no developing embryo or an embryo that will not be able to survive at birth. There are three ways this can occur: Two sperm can fertilize one egg, with the loss of the mother's chromosomes; one sperm can enter the egg and then divide, delivering a double dose of chromosomes to the egg instead of its usual single dose; or an abnormal sperm carrying two sets of chromosomes can fertilize the egg.

When you and your partner suspect infertility, the semen analysis begins the workup for both of you. A normal series of semen analyses will prompt a female workup; an abnormal series will prompt a male workup. This test can be handled by your primary care doctor, your partner's gynecologist, or your own urologist or andrologist. In short, whoever has been handling your preconception screenings and "weedings" until this point will manage the semen analyses.

This same doctor should also ask you questions about your medical/surgical history and perform a thorough physical exam, including an examination of your external genitals. This helps the doctor rule out infection, structural abnormalities, and so on. The doctor may order general lab tests to rule out other diseases, such as a urine test for diabetes or kidney infection; blood tests for complete blood counts, ruling out syphilis, anemia, or leukemia; and screenings to rule out viral or bacterial infections. Your doctor should also do a thyroid function test. In general, bloodwork is not routine, however.

You should also be asked about your sex life: How old you were when you reached puberty, first erections, viral infections after puberty (such as mumps or high fevers), previous paternity, how often you have intercourse, how often you masturbate, whether you use lubricants, whether you have any lifestyle habits that may interfere with your fertility. Sometimes this more probing look at your personal life isn't done unless your semen analysis is abnormal, or unless you're referred to a urologist or andrologist. Detailed physicial exams of the testes and rectal exams that evaluate the prostate gland and seminal vesicles aren't done unless you're referred to a urologist.

After you produce your semen sample, ask your doctor to perform a urinalysis (urine test) next. A common problem for men with these conditions is retrograde ejaculation, where the ejaculate is propelled backward into the bladder. Men with diabetes may gradually lose nerve function at the bladder's opening, causing sperm to shoot backward during ejaculation. Men who have had lymph nodes removed in the testicles may have nerve damage that may interfere with the closing of the bladder neck during ejaculation.

In these cases, semen would be present in your urine. In order to diagnose retrograde ejaculation, you must collect your urine immediately after an ejaculation. Doing the urinalysis first can save you a lot of time. Occasionally, antihistamines may improve sperm ejaculation because they help to close the sphincter muscle between the urethra and the bladder.

Otherwise, while there is no specific treatment for retrograde ejaculation, there is a procedure your doctor can do that will enable you to biologically father a child. It involves extracting live sperm from your urine and then depositing it into your partner. Success rates for this procedure are high.

You can do this test at home. Once your doctor gives you a requisition for a semen analysis, you can take the requisition to any lab. All labs are equipped with take-home semen analysis kits. As long as you live within a half-hour drive of the lab, you can produce the sample at home and drop it off at the lab. Sperm can survive for at least that long in the cup. It's important to keep the specimen warm. Placing it in a front pants pocket, tucking it into the waistline of your pants, or tucking it under your arm is the best way to transport it. If you spill any of the semen during or after collection, you'll need to repeat the test. Do not put the collection in the fridge or freezer overnight.

The kit includes some of the instructions I'll go into below, perhaps a small questionnaire with your name, address, insurance information, and some brief medical history questions and a sterile specimen cup. (A clean glass jar is also fine, but don't go the Dixie cup route.) If your doctor has a laboratory in his or her office building or clinic, you could produce your sperm sample in the office bathroom or another private room. This is certainly the simplest route.

There is currently a home semen test on the market called FertilitySCORE™ which can determine whether your sperm "has normal or less than normal activity." This means that it will identify if you have a lot of sperm or insufficient or no sperm, but it won't tell you anything about the characteristics of your sperm, such as how well they move, the shape, and so on. In short, this test looks at quantity, not quality.

The tests takes roughly 60 minutes to do (if you can figure out all the instructions), and if you test positive (meaning, "yep, looks normal") then there's an 87% chance that your sperm is normal. If you test negative (meaning "hmm... this looks strange"), there's an 87% chance that your sperm is not normal. In other words, this test has a roughly 10-15% false positive/false negative rate.

This home kit comes with two tests, since results can vary depending on activity, diet, environment, and so on. Urologists feel this test is really more of a marker for normal or abnormal results, but it cannot replace the high quality of a laboratory semen analysis.

You'll need to wait at least two full days after your last ejaculation to do the test.

If you've taken any medications (such as antibiotics, for example) prior to the test, you'll need to wait at least four months after you swallow your last pill before you can produce a sample. It can take 3-4 months for your sperm count to come back to normal levels. You can either masturbate into the specimen cup, or your partner can bring you to orgasm through petting. Some labs tell you it's fine for your partner to help you ejaculate via oral sex or coitus interruptus (pulling out), but saliva or vaginal mucus may interfere with the test results. If you're doing it through intercourse, don't use collected sperm from a regular condom. There are special condoms that may be used, known as "semen collection devices" (SCDs). Your doctor can tell you where to purchase them. If you are masturbating, avoid using creams or lubricants because they can poison the sperm.

There are several elements your doctor will look for in your lab results. Because semen is extremely volatile and changes daily, you'll need to deliver at least three semen specimens so your lab can establish a semen baseline. Since numbers and percentages vary from man to man, sample to sample, minimal limits of "normal" have been set. Your sample needs to meet these limits on at least two occasions to be truly considered a "normal" result. Warning: If your doctor sends you off for a female workup after only one normal semen analysis, you should seek a second opinion or request that your doctor order another semen analysis. If your doctor is satisfied that you're "normal" after only one sample, this indicates that your doctor doesn't know what he or she is doing. Two normal semen analyses are enough proof that you're indeed "normal."

On the flip side, if your sample comes back "abnormal" the first try, don't accept this finding until you do at least another test. Two abnormal semen analyses that are consistent are enough proof that there's a problem. If no sperm was found in your sample, immediately request that your doctor do a urinalysis to rule out retrograde ejaculation.

The semen analysis checks for a few things:

Sperm count. There is debate among the medical community about what a healthy number of sperm is. The World Health Organization (WHO) considers 20 million sperm per milliliter to be fertile; the International Society of Andrology (ISA) consider 40 million sperm per milliliter to be fertile. Generally, anything below 20 million is considered a low sperm count. Anything between 20 and 100 million sperm is considered normal. Keep in mind, however, that sperm numbers can change daily, weekly, and monthly. Colds, flus, STDs, infections, antibiotics, temperature, and ejaculation frequencies all will affect the number. Also keep in mind that men with sperm counts of well below 20 million have often been able to father children.

Motility. This refers to the sperm's ability to swim and move quickly. Again, infection, illnesses, or gonadotoxins such as marijauna or tobacco can affect movement. Just because the sperm are produced in high numbers and are shaped well doesn't mean they're all on the Olympic swim team. Motility is one of the most important determining factors in the sperm's ability to fertilize the egg. At least 60% of your sperm need to be motile in order to be considered "normal." At least 65% of the sperm must be alive. They also need to be moving forward. When you find out your motility percentage, this is the percentage of sperm that are moving. For example, 75% motility means that 75% of your sperm are moving.

Morphology. This refers to the shape and maturity of the sperm cells to determine the quality, viscosity of semen (consistency -- thickening is a bad sign), volume of semen (amount of semen produced -- about 1 teaspoonful is normal), and the pH balance (it should be slightly alkaline). Some examples of poor morphology would be large numbers of sperm with two heads, no tails; two tails; no heads; deformed tails and heads; and so on. Again, infection and gonodatoxins can affect morphology, and again, at least 60% of your sperm need to be formed normally in order to meet the "limits of adequacy." Your volume needs to reach between 1.5 and 5 cubic centimeters in order to meet these same limits.

Clumping. Sperm that clump together are unhealthy and could be a sign of immunological infertility, in which your body is making antisperm antibodies.

White blood cell count. High levels of white blood cells in the semen may indicate infection. Treatment for infections ranging from prostatitis (inflammation of the prostate gland) to orchitis (inflammation of the testes).

Red blood cell count. High levels of red blood cells in the semen aren't normal. You'll need to be evaluated for underlying conditions such as infections.

The following are the usual parameters for a normal semen sample:

*A high white blood cell count in a sperm sample usually indicates infection, and is often treatable.
Source: Adapted from the Consumer Journal of Infertility Awareness Association of Canada,

A significant percentage of all semen analyses will have flaws in them. Men tend to be more in the dark about their test results than women, who usually have some symptoms that hint at a problem. Men usually have no symptoms that would indicate male infertility, whereas women often experience pain or irregular cycles that indicate a female factor.

If you don't hear from your doctor's office within two weeks after your test, you can assume that the results are normal. The results are categorized into two basic groupings: Normal or abnormal. You should also request a copy of the lab report so you can study it yourself and ask questions about terminology you don't understand. Having a copy of the report will allow you to make copies for the next specialist(s) you encounter. (Don't count on your doctor to send the results.) A normal test series ends the male workup here. You and your partner will then go on as a couple to a gynecologist and/or reproductive endocrinlogist to begin the female workup.

An abnormal test could involve any one of the above categories. You could also have sperm that meet the limits in one category but not the other. For example, you could have excellent motility but a low sperm count. In this case, you would be classified as subfertile, which means you're not as fertile as you could be. Many men make the assumption that a diagnosis of being subfertile is the same as being infertile. This is not true. A subfertile faces lower odds of conceiving a child in any one cycle. This is quite different than being infertile, which is a complete inability to father a child. For example, if a normal couple has a 20% chance of conceiving each month, subfertile men have less than a 20% chance of conceiving each month. As one urologist told me, "It's like Las Vegas. If you roll the dice often enough, most of the subfertile couples will conceive. It may just take longer."

If your results came back showing you produced no sperm at all, a condition known as azoospermia, all categories in the sperm analysis would be affected, and you would be considered infertile. A diagnosis of azoospermia must always be followed up by a urinalysis to rule out retrograde ejaculation. Again, don't accept this diagnosis until two more semen analyses confirm it. In other cases, abnormalities may be found in several categories, such as motility, morphology, and volume, while the sperm count may be normal.

If after three collections your results are indeed abnormal, you'll be referred to a urologist and/or andrologist for further diagnostic tests. Before initiating more complicated lab work, though, your specialist will have you repeat the semen analysis at least twice over a three-month period. Again, fevers, infections, or viruses can affect the sperm count for months afterward. If two more collections come back abnormal, the male workup continues and will now focus on discovering why your results are abnormal.

Statistically, most male infertility revolves around structural problems. Roughly 40% of all male infertility is due to varicoceles, a varicose vein in the leg that moves up into the scrotum. Two to three percent of all male infertility is due to obstructions (blockage). Out of this group, 5% of the obstructions are in the ejaculatory ducts, 2-3% is due to post-testis obstruction ("bad plumbing"), and 95% of the time, the blockage occurs in the epididymis. In these cases, microsurgery can remedy the problem. About 10% of all male infertility is caused by infections. About 5% of all male infertility is caused by immunological problems, where your body produces antisperm antibodies that kill off the sperm. About 2% of male infertility is due to hormonal factors, while another 5% of all male infertility is caused by various anatomical defects, such as torsion or undescended testicles. The remaining percentage is caused by a hodgepodge of genetic problems, congenital abnormalities, and retrograde ejaculation.