Fertility Center and Applied Genetics of Florida and the offices of Julio E. Pabon, M.D., P.A. provide expert Reproductive Care for patients seeking evaluation and treatment of infertility or subfertility.  The expertise comes from our medical director, Dr. Pabon.  Dr. Pabon completed 10 years of medical training in 1995.  This included Medical School at a five star (ranking 5 out of 5 is the top) medical school.  During his medical school years he trained and performed research within Baylor College of Medicine’s Reproductive Endocrinology and Infertility Division.  He then completed a four year residency in the Univ. of Texas system in Houston Texas.  There he became Chief Resident and was awarded the outstanding surgeon award. 

After completing his residency, he obtained subspecialty training at one of the oldest and most respected programs in the world.  The University of Louisville Reproductive Endocrinology Fellowship was an intense surgical, microsurgical, endocrinology, molecular biology, and Reproductive Endocrinology experience.  Dr. Pabon has been evaluating and treating Male and Female patients since 1993.  Dr. Pabon works closely with local urologists in the evaluation and treatment of male factor infertility.  Dr. Pabon focuses on the hormonal and genetic aspects of male subfertility.

Additional expertise comes from our andrology and embryology technicians.  They have all been specially trained for just these special tasks.  Strict compliance with State of Florida guidelines, National guidelines, and International standards of care is observed.  We follow the latest World Health Organization guidelines.

The evaluation of infertility or subfertility begins with a definition of the potential problem.  Most Reproductive Endocrinologists and Infertility Specialists define infertility as the inability to conceive a normal pregnancy after one year of trying.  Recently, due to concerns of rapidly decreasing fertility potential in older women ( older than 35), the definition has been changed to include women older than 35 who have tried to conceive for six months without success.  The reason for this change has been brought about in order to avoid delay of a diagnostic evaluation and perhaps treatment in an older patient that has rapidly declining fertility.

The most important decision that a patient can make about the semen analysis is the kind of facility or laboratory that they choose for sperm testing or male fertility testing.

Dr. Pabon has been a Reproductive Endocrinologist and Infertility subspecialist since 1995.  He has always recommended that semen analysis or male fertility testing be done in facilities that specialize in human reproduction and in vitro fertilization (IVF).  The reason for this is that these facilities have the expert personnel that is essential for quality control, clinical review, clinical correlation, and follow up.  There is also a common sense reason; that is, if one does something often, one will usually be better at it.

IVF clinics usually accept patients for semen analysis and other andrology tests and procedures.  In an IVF clinic, there are critical decisions being made every day that are based on accurate semen analysis data.  This data can result in significant and life changing clinical decisions.  Therefore, the semen analysis and how it is performed and reported are taken very seriously.  Another great advantage is that your semen analysis will be always be reviewed by an expert that is happy to review it with you and your referring physician.

As a clinician, Dr. Pabon relates very common stories of patients that “wasted” many months or years being falsely reassured by erroneous semen analysis reports.  Sometimes patients have lost critical time in their late thirties or early forties.  If you have done a semen analysis in a lab or office other than an IVF clinic, you should ask the following questions:

1.  How often is a semen analysis done there?

2.  What are the qualifications of the person doing the analysis?

3.  What kind of quality control mechanisms are in place to verify the overall  accuracy of the testing facility?

4.  Is the facility inspected and licensed by their State or other entity?

5.  Is there an expert on site that can review the results and clinical implications with you?

It is difficult for a facility to be proficient in this test if they do less than 10 tests per month.  The more the better.  The person doing the analysis and the person overseeing them and doing random audits should have had specific training in Semen analysis (the best place for this is an IVF clinic or a Reproductive Endocrinology and Infertility Fellowship with Laboratory training as part of the 2-3 year fellowship).

The third question above refers to external quality control mechanisms that send the laboratory known samples that the personnel have to read correctly.  These results are graded so that the personnel have to pass interval tests.  An example of a company that does this is the American Board of Bioanalysts.

Regarding question five above, the person performing the tests should have the ability to “double check”  interval tests with either an experienced clinician or senior embryologists or andrologists in addition to the outside contracted companies.

It is a shame when a patient comes to the Fertility facility after prolonged infertility that is “unexplained” because a reference lab or a non Fertility lab performed a semen analysis that gave incorrect normal results.  One of the more common errors is overestimating the percent of normal cells in the sample.  This is called the morphology test.  It is performed by examining a fixed and stained slide of the sperm at high magnification and actually counting and rating 500 cells for either complete normalcy or abnormalities in the acrosome, the head, the midpiece, and the tail.

It is not rare to see a new patient that comes in with a semen analysis report with all normal parameters and 40 percent or higher normal cells.  Dr. Pabon often says…”not even Clark Kent (Superman) has 40% normal cells”.   This is a sign that the person doing the analysis was not critical enough regarding morphology.  This makes the other parameters suspect. 

Dr. Pabon and many reproductive medicine experts will only make clinical decisions based on semen analyses done in true fertility centers.  Therefore, he always recommends a repeat semen analysis if  the original one was not done either in his lab or that of another IVF center or highly qualified andrology testing center.

What is a normal semen analysis?  The parameters that define a semen analysis are based on large studies of normal and abnormal populations.  According to the most recent World Health Organization report, recommendations for the definition of the lowest normal results, a semen specimen is considered abnormal if any of the individual parameters are lower than the 5th percentile of a fertile population.  This means that if a parameter is “low”, that the result is lower than the lowest 5% of the thousands of patients tested for the study. 

On the other hand, if the results are all normal, they could still be quite low even if reported as normal.   An example of this is the “normal” result that is at the extreme lower range of normal.  Such a patient may have very few normal viable sperm in the ejaculate and may not even be a good candidate for artificial inseminations.  Oftentimes, depending on the clinical history, these patients require in vitro fertilization and even intracytoplasmic sperm injection in order to overcome their subfertility.

A very important number in our semen analysis reports is the total normal cell (sperm cells) count in the ejaculate.  This number is the result of multiplying the total volume, times the concentration, times the percent motile, times the percent normal cells (morphology):

[  Total normal cell count = volume x concentration x motility x morphology  ]

There can be concern even if all individual parameters are normal.  Scientific studies and years of clinical experience have shown that patients with a total normal cell count less than 10 to 12 million per ejaculate can have extremely low pregnancy rates with intrauterine inseminations (IUI) and should consider in vitro fertilization (IVF) procedures.  In these cases, a trial of intrauterine inseminations (IUI) can be tried if the female partner is young and if the couple understands that the chance of pregnancy may be less than 10% per try. 

This type of approach (IUI) can be considered if the total normal cell count is in “the grey zone” of between 5-12 million normal cells in the ejaculate.  Those with less than 5 million normal cells in the ejaculate are best served by IVF and even intracytoplasmic sperm injection (ICSI).  Patients with total normal sperm cell counts between 5-12 million per ejaculate should consider “in vitro” fertilization if they have been trying to conceive for more than 18 months given the very low pregnancy rates with simple intrauterine inseminations.

What is the difference between intrauterine inseminations and “in vitro” fertilization?

An Artificial insemination is a procedure whereby the male partner provides a semen specimen.  This specimen can be collected at home, in the office, or in a nearby hotel.  The specimen will be fine if the specimen is brought at room temperature in the provided specimen cup within 30 to 45 minutes of collection.  This semen sample is then processed in special media in order to concentrate and hyperactivate the sperm for insemination. 

The female partner then has an examination and the entire processed specimen is loaded into a small catheter that is passed through the cervix and into the uterus.  This allows the entire ejaculate to be usable for conception.  During normal coitus, only 10% of the ejaculate makes it past the cervix. 

Artificial intrauterine inseminations may benefit couples where the male or female partner have antisperm antibodies, when the sperm count is low or abnormal as described above, and also when there is unexplained infertility.  Some patients that have had cervical surgeries, freezing procedures, and laser treatments may also benefit from bypassing the cervix with intrauterine inseminations.

Intrauterine inseminations leave much to natural processes.  The sperm and egg need to meet at the ends of the fallopian tube.  There, in the ampullary segment of the fallopian tube, the sperm that succeeds in reaching the egg must bind with the egg and carry out the multiple steps involved in the actual fertilization of the egg. In contrast to intrauterine inseminations, with “in vitro” fertilization, the female patient receives about 10-12 days of fertility drugs and then has an office surgical procedure in order to harvest the eggs. 

The eggs are examined in the IVF laboratory.  Mature eggs can either be inseminated in a “petri” dish with 100-150 thousand sperm or with individual sperm with the ICSI (intracytoplasmic sperm injection) procedure.  The embryos are transferred into the uterus a few days later.

What needs to be done if the semen analysis is abnormal?

If the results are borderline, consider repeating the test.  Make sure that you have abstained from ejaculation for 2- 3 days and no more than 7 days.  Discontinue all kinds of smoking.  Make sure that you deliver the specimen to the lab within 45 minutes of collection.  Patients that use hormones, marijuana or have used anabolic steroids must indicate this in the lab paperwork or at least disclose this directly to Dr. Pabon.  Both of these habits can have very detrimental effects on the sperm number and quality.

If the results are markedly abnormal, this may warrant several steps.  The patient should have a thorough history and physical with a urologist.  In addition, the patient should have an endocrine (hormonal) evaluation in order to rule out pituitary, hypothalamic, and testicular problems.  The endocrine evaluation should include the following:

Serum FSH

Serum LH

Serum TSH

Serum Prolactin

Serum Total Testosterone

In addition to hormone tests, the patient with severe abnormalities ( sperm concentration less that 5 million per milliliter or cc) should have a chromosome analysis (or Karyotype ) since 5% of these patients have an easily detectible genetic abnormality. Unfortunately, a chromosome analysis is a very expensive test so many patients decline this if unsure of insurance coverage.  A cystic fibrosis carrier screen should also be done if there is a zero sperm count since cystic fibrosis mutations are more common in patients with no sperm in the ejaculate.

The pattern of these hormones can give insight into the possible cause of the the problem.  The clinical recommendations may be as simple as recommending less exercise, to as complex as prescribing gonadotropins (hCG or FSH).  These recommendations usually come from the reproductive endocrinologist (Dr. Pabon) or the endocrinologist and require full consultation and follow up.

Remember that smoking, steroids, marijuana, and testosterone supplements can lower the sperm count.

If a patient has an extremely low sperm count, he may be going into “testicular failure”.  This can be a slow process that can be difficult to diagnose until it is too late.  It is always prudent to “bank” sperm during evaluation and treatment just in case the sperm count is gradually decreasing.  Special consents and a panel of infectious disease tests are required before sperm can be banked (frozen).  Again, the best place for this service is your local IVF center.  The panel of infectious disease tests are :

Serum HIV antibody test

Hepatitis B Surface Antigen

Hepatitis C Antibody

RPR

CMV IgG and IgM titers

In summary, patients should have their sperm analysis or semen analysis and andrology procedures performed by experts as are found in IVF centers and also should follow the guidelines above and seek consultation from the  Reproductive Endocrinologist & Infertility Specialist early in the process. 

Treatment options for patients with intermediate low sperm counts that cannot be corrected by hormonal therapy may include intrauterine inseminations or in vitro fertilization with intracytoplasmic sperm injection of the eggs.  Patients with very low sperm counts will be counseled about either donor sperm inseminations or in vitro fertilization procedures.  These recommendations will require clinical correlation with clinical history and are also impacted by the age of the female partner.

Patients with a zero sperm count will be offered a Y chromosome microdeletion analysis in order to determine the probability that sperm may be obtained surgically for use in IVF.  A Y chromosome microdeletion study is expensive and could be done in any patient with a very low count.  This is not usually the standard of care since most patients would not choose to use a donor sperm sample even if there were aberrations in their Y chromosome.  This is discussed when counseling patients with severe male factor infertility prior to IVF and intracytoplasmic sperm injection. 

The male babies of men with severely depressed sperm counts have a higher risk of congenital anomalies of the “urogenital type” such as hypospadias, inguinal hernias, and undescended testicles.  These are conditions that are identified at birth and are corrected at that time.

A low sperm count may be a sign of a medical problem that is treatable.  A low sperm count does not mean that pregnancy is impossible, it just means that pregnancy is an improbable and rare event.  The clinical recommendations are made based on years of clinical experience and guidelines.  There are always outliers and small miracles that happen from time to time.