Just Keep Swimming - Understanding Your Semen Analysis Results

By Sonja Swanson

 

Sperm are the often-forgotten component of fertility; there is a focus on oocyte (egg) quality, maternal age, and follicle count, but eggs are only half of the puzzle. It is not only important to have sperm present, but they need to have the correct DNA structure and capacity to successfully transfer the genetic material into the egg. The sperm must also be able to attach and penetrate the outer shell of the egg (zona pelucida). That is a lot to do for such a little cell!

 

Biology of Sperm Production

Sperm production generally happens during the entire lifespan following puberty. Sperm begin as stem cells in the testes then go through many different stages of maturation: spermatogonial stem cell → primary spermatocyte → secondary spermatocyte → spermatid → spermatozoa (fully mature sperm cell). It takes between 75-90 days to go from a stem cell to a mature sperm cell. Once produced, they pass from the testes into the epididymis where they are stored until ejaculation. It is in the epididymis where they gain motility, sperm in the testes are generally immotile. Once ejaculation occurs, muscle contractions push the sperm through the rest of the reproductive tract where secretions from different glands (prostate, seminal vesicles, bulbourethral/Cowper’s gland) come together to form the semen.

Sperm production is regulated in a similar way to the menstrual cycle, using Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). However, the presence of Testosterone is a critical component for sperm maturation and circulates in the blood as well as locally in the testes.

 

Fertility Assessment

How to we assess the sperm and determine a treatment plan for someone seeking fertility care? At KARMA, we use a variety of tests to help us understand the qualities of the sperm; there is the “standard” semen analysis that looks at concentration (count), motility, and morphology (shape) as well as other physical properties of the semen but there are also new advanced tests that can give is even more insight!

All normal values are taken from the World Health Organization Semen Analysis Manual (2010).

 

Standard Semen Analysis

Volume – The expected volume of a semen sample is 1.5 mL or greater. If the sample is less, it may indicate that one of the accessory glands is not functioning properly. If a person is unable to produce any volume of semen, it is called aspermia.

pH – A measure of the acidity-alkalinity of the sample; semen is usually basic as the vaginal environment is more acidic. The expected value is around 8.0 and if it is much higher or lower, it may indicate that one of the accessory glands is not functioning properly.

Viscosity – Immediately after a sample is produced, the proteins in the semen will gel and become slightly solid. Over time (within 1 hour), the sample will liquefy and become more water-like. If the sample does not liquefy properly, the proteins keep it in a gel or viscous (thick) state. If a sample is very viscous, it may be more difficult for sperm to swim out.

Colour – A normal semen sample is white-grey and opaque. It may have a more yellow tint depending on diet or some medications. If a sample is brown, it indicates that there is blood and may indicate infection or damage to the reproductive tract.

Concentration – This measure is how many sperm are present in the sample (in millions per mL). The normal value is 15 million/mL or greater (normozoospermia). If a patient has less that that, it is called oligozoospermia. If it is very low (< 1M/mL) it is called cryptozoospermia. If there are no detectable sperm in the sample, it is called azoospermia. The concentration of sperm is a significant factor in determining a treatment plan. Patients with normozoospermia or mild oligospermia may try timed intercourse (TIC) or intrauterine insemination (IUI), patients with lower concentrations will be recommended to do IVF with intra-ctyoplasmic sperm injection (ICSI). A patient with no sperm may be referred to a urologist for further investigation and possible surgical sperm retrieval or advised to use donor sperm.

Motility – The number and type of motion of the sperm is very important. If the number of moving sperm is > 40%, this is considered normal. Sperm should also be progressive, meaning they swim quickly in approximately a straight line. Sperm that are sluggish or swimming in circles are not considered to be normal. Motility is also a significant factor for treatment as successful TIC or IUI requires a good overall motility and progression. Patients with samples below normal parameters may be referred to IVF with ICSI.

Viability – This test is performed when motility is very low (<15%). The sperm is mixed with a dye to determine if sperm are viable (alive). Sperm that does not allow the dye to penetrate are alive, sperm that are dead will have a leaky outer membrane and the dye will get in and they change colour.

Morphology – The shape of the sperm can help indicate the quality of the DNA and proteins inside. Sperm cells are judged using a “Strict” criterion and the normal value is >4% normal shaped cells. Defects in the cells are most commonly found in the head (e.g. large or small, misshapen) but abnormalities are also present in the midpiece/neck (e.g. bent, thin, thick) and the tail (e.g. short, coiled, multiple tails). Poor morphology has a decreased association with TIC and IUI, a patient may be referred directly to IVF with ICSI.

Culture & Sensitivity – If a sample has more than 1 million/mL of “round cells,” which usually consist of white blood cells from the immune system, then we send a portion to an external lab for bacterial culture. A sample may come back positive for a specific bacterial strain; these infections are quite common and are not considered sexually transmitted. A patient with a positive culture will be put on antibiotics then repeat the analysis to make sure the infection has cleared prior to beginning treatment.

Anti-Sperm Antibody Assay – Antibodies are produced by the immune system to help identify foreign objects, if there is injury or an error making sperm, they may be seen as foreign and are targeted for destruction. This would inhibit the cells from being able to move freely or can damage the proteins or DNA inside. A normal result is < 50% antibody attachment. A patient with a high result may be referred for IUI as the processing will help eliminate the antibodies or possibly IVF with ICSI depending on other sperm parameters.

 

Advanced Sperm Diagnostics

Survival Assay – This test selects the best sperm from a semen sample (the ones that would be used for IUI or IVF) and incubates them for 24h. This will show if the sperm are capable of surviving long enough to reach the egg if swimming in the fallopian tubes or if they will live long enough to fertilize an egg in culture.

DNA Fragmentation (SCSA) – The integrity of the DNA inside the sperm head is incredibly important, this is the genetic material that will combine with the egg DNA to create the embryo. The Sperm Chromatin Structure Assay (SCSA) is the gold standard for testing for breaks in the DNA chain. High DNA Fragmentation (>30%) is correlated with longer time to pregnancy and miscarriage rate in people doing Timed Intercourse or IUI and fertilization failure in IVF. A high DNA Frag can potentially do IUI or IVF, but a very high result (>50%) would likely be referred for IVF with ICSI.

 

Conclusion

One of the most common questions we receive is “what can I do to improve my sperm?” Sperm health is linked to overall health: eating well, moderate exercise, getting enough sleep, reducing or eliminating alcohol, cigarettes, and marijuana; avoiding injury to the testes (incl too much heat or pressure), and not using voluntary medications (like Testosterone for working out) that have a known impact on sperm are all ways to help make your little swimmers the best they can be. There are causes of sperm-factor infertility that cannot be helped with lifestyle changes like non-obstructive azoospermia, genetic conditions like Y-microdeletions, necessary medical treatments like chemotherapy, and many more.

Sperm quality is a critical component of fertility and a thorough assessment is needed to develop an effective treatment plan. If you have any concerns about your sperm quality, contact us to schedule a standard semen analysis or advanced semen diagnostics today!

Managing Egg-Spectations

by Samantha Wake

 

Introducing the Oocyte

In a fetus, there is a pool of around 7 million primordial follicles in the developing ovaries. At birth, this amount drops to 300 – 400,000 and at puberty the size of the pool plateaus around 200,000. At this stage in life, the primordial follicles will start to be recruited into a growing follicular pool that stay in a rested early Meiosis 1 stage of development.

Ovarian Reserve

The transition of primordial follicles into the growing follicular pool is regulated by AMH (anti-müllerian hormone). It is a growth factor secreted by granulosa cells in the developing follicles. AMH peaks at puberty and declines until menopause. It is a good indicator of ‘ovarian reserve’ since it reflects the size of the growing follicular pool. The AMH test is often ordered during infertility investigations and can be used to help diagnose someone’s infertility and/or predict how well individuals will respond to ovarian hyper-stimulation. The results are categorized into high, medium, low, and very low ovarian reserve.

The Menstrual Cycle

At the onset of puberty, cohorts of antral follicles are recruited from this growing follicular pool. During each menstrual cycle around 5-10 antral follicles are recruited in response to increasing FSH (follicle stimulating hormone) levels. Out of this cohort, one is selected to be the dominant follicle; the rest will undergo atresia (die). Around day 14 of the cycle, there is a surge of LH (luteinizing hormone). This causes the ovulatory (dominant) follicle to ovulate and expel one mature egg from the ovary. The remaining follicle structure (granulosa and theca cells) forms a corpus luteum that secretes progesterone to maintain a potential pregnancy by preparing the endometrium. Approximately 400 eggs will be ovulated during a reproductive lifetime.

Stimulated Cycles

Antral follicles are present in the ovary and will continue to grow when sufficiently stimulated with FSH. Therefore, by administering continual doses of gonadotropin medications (e.g GonalF/Puregon/Rekovelle) starting on day 3 of a cycle, the selection of one dominant follicle can be disrupted and multiple follicles can be stimulated to grow instead. This is known as controlled ovarian hyperstimulation.

Once follicles reach a size of 1.7mm or higher, a hCG (human chorionic gonadotropin) trigger can be administered. This medication is used since it shares the same receptors as LH and thus mimics the natural LH surge. The number of expected eggs to be retrieved can be estimated by counting how many follicles are measuring 1.5mm or higher on an ultrasound scan on the day of trigger. Estrogen levels measured on this day can also act as a predictor for egg number; the optimal estrogen:egg ratio is 734-1097 pmol/L per mature follicle.

Oocyte Maturation

Three stages of oocyte maturation are commonly seen in the IVF lab: MII (metaphase II), MI (metaphase I), and GV (germinal vesicle).

A GV is an oocyte where the nucleus is still visible. Through the process of germinal vesicle break down (GVBD), the oocyte becomes an MI stage with no visible nucleus. Maturation continues as the oocyte releases the 1st polar body (a small package of excess DNA) and becomes an MII stage oocyte, resting at the end of Meiosis I. This is the fully mature stage and the oocyte is now ready for fertilization with a sperm cell.

Transition occurs from GV (immature) to MI (partially mature) to MII (fully mature) in response to the mid-cycle surge of LH or the hCG trigger. Timing is important, if a retrieval happens too soon after the trigger shot, the eggs may not have enough time to make it to the MII stage!

Not all eggs retrieved will be mature; on average 85% will be at the appropriate MII stage, 4% will be MI, and 11% will be GVs. This does vary person-to-person depending on their own physiology and the response to the medications.

ICSI

Prior to the ICSI (intra-cytoplasmic sperm injection) procedure, oocytes are denuded or “stripped” which removes the support cells (cumulus) that surrounds them and allows the embryologists to assess the maturation of the eggs. Following that, mature oocytes are injected directly with a single sperm cell. Preferably MIIs are used as they are fully mature and have a higher fertilization rate, but MI may also be inseminated if the number of MIIs retrieved is low. GVs are not injected. Injection occurs approximately 3-4 hours after retrieval to allow the oocytes to “rest” following the stressful collection process and stripping procedure.

IVF

For standard IVF, the oocytes are not stripped prior to insemination. Instead, they are put in a culture dish with a specified amount of prepared sperm and allowed to inseminate overnight. This means that the maturation status of the eggs remain unknown. The cumulus cells are left intact as they assist in fertilization since they attract swimming sperm. The following morning, the possible fertilized eggs are stripped of the cumulus cells and the fertilization status is assessed under the microscope. Oocytes that did not successfully fertilize can be assessed for maturity.

Signs of Fertilization

Fertilization assessments take place 18 hours after the time of insemination (IVF or ICSI). Fertilization is successful when the presence of two pro-nuclei (2PN) are seen and two polar bodies are present. The 2nd polar body is released after the sperm penetrates the egg and the oocyte completes the Meiosis 2 stage, removing the final bit of unnecessary DNA before the two genomes fuse. PNs are formed when the egg and sperm DNA combine to create the correct chromosomal compliment (46 chromosomes). On occasion, the fertilized egg (zygote) may display one pronuclei or three pronuclei; any zygotes showing 1 or 3PNs are abnormal and will be discarded as they have a higher risk of genetic abnormalities.

Average Outcomes

Following IVF or ICSI, approximately 70% and 80% of MII oocytes will successfully fertilize, respectively. These success rates will decrease if there is any reduced quality of the sperm or eggs (e.g. increased age, poor response to medications, abnormal sperm motility/morphology etc.). Around 40% of these fertilized eggs (zygotes) will go on to develop to the blastocyst stage. Of these blastocysts 25–35% will be of good quality (A/B grade) and will be suitable for transfer or freezing for future use.

Conclusion

The purpose of this blog is to give patients insight into the science pertaining to the development of their oocytes and embryos. If you have any questions related to this blog topic, please get in touch with lab@karmaobgyn.com.

KARMA Blog – How does the Ontario Fertility Program Work?

By Sonja Swanson

 In December 2015, the Ontario Ministry of Health began the Ontario Fertility Program (OFP). This covers some of the costs associated with fertility treatments to help Ontarians grow their families. There are some eligibility criteria and some aspects of care that are not covered.

 

IUI Funding

The patient must have a valid OHIP card and there is no limit on the number of IUI cycles that can be done per patient in their lifetime. There is not an age limit for someone wanting to do IUI.

The Funding covers all monitoring (ultrasounds, blood work, doctor/nurse visits) during the IUI cycle and one IUI insemination procedure. However, there is an additional cost for processing the sperm sample and any medication costs are to be paid by the patient.

The IUI funding covers use of partner or donor sperm for IUI. If using frozen donor or partner sperm, the purchase cost or cryopreservation and annual storage fees are not included in the funding program.

 

IVF Funding

The Funding is billed to the person receiving the embryo transfer with the goal of establishing a pregnancy (the Primary Patient); this could be the intended parent (IP) or a surrogate. The Primary Patient must be less than 43 years old at the start of the cycle and have a valid OHIP card. There is one (1) funded cycle per lifetime as a Primary Patient. If the Primary Patient is a surrogate, at least one IP must also have a valid OHIP card and have not received a funded cycle previously.

The Funding covers all monitoring (ultrasounds, blood work, doctor/nurse visits) during the IVF cycle and standard embryology services to inseminate, culture, and cryopreserve the embryos. Fees that are not part of the funding include: annual storage, medication, PGT biopsy (KARMA) and PGT testing (CooperGenomics), and purchase of donor gametes (sperm or eggs).

Any funded cycles must follow the Embryo Transfer Policy, which means in most cases, patients are only allowed to have one embryo transferred at a time.

Milestone 1 involves the creation of embryos (and a possible fresh embryo transfer) in the following ways:

  • Primary Patient undergoes oocyte retrieval

  • Secondary patient (egg donor) undergoes oocyte retrieval

  • Primary Patient uses a previously frozen batch of their own oocytes

  • Primary Patient uses a single batch of frozen donor oocytes

Milestone 2 covers all the subsequent transfer of cryopreserved embryos:

  • Any/all frozen embryos from the Milestone 1 procedure

  • Embryos previously created during a self-pay IVF cycle

  • A single batch of donated frozen embryos

Once the funded IVF cycle is started, there are multiple end-points that indicates completion of the cycle:

  • Two attempts at cycle monitoring were conducted and no retrieval occurred

  • An oocyte retrieval was performed and no viable oocytes were found

  • A retrieval occurred, viable oocytes were found, but no viable embryos developed

  • All oocytes/embryos were thawed and no viable candidates for transfer developed (if using a previous batch of oocytes/embryos)

  • All viable fresh and frozen embryos generated by the funded cycle have been used for transfer (a pregnancy may or may not occur)

  • Primary Patient concludes care in writing (stating they no longer want to continue)

This means that if your IVF cycle “fails” and no oocytes are found, no embryos are viable, or no pregnancy occurs following transfers, that is still considered the funded cycle. At KARMA we do our very best to create embryos that are of good quality and are able to be transferred, but unfortunately, that cannot be guaranteed.

 

If you have any questions or concerns whether your cycle is eligible to be funded, please speak to the nursing team or the clinic manager (sonja.swanson@karmaobgyn.com).

The OFP has helped many families at KARMA and throughout Ontario to grow their families and is a great opportunity for those who may struggle to afford fertility care on their own!