Semen collection, Interpretaion and Treatemnt of nminorf defects in seemn.

What are the semen Collection problems specially in a  in IUI program when good amount of money has already been spent for Stimulation , Follicle monitoring & trigger.

-        10 % of men are   unable   to give a semen  sample

-        Some  have never  masturbated

-        Some   are inhibited  in the clinic 

-        Some   fail  on demand

Failure  to give a sample can be very embarrassing and disheartening  for a man   and can produce long  delays in treatment  . To  avoid this problem always    ask whether a man  can collect a sample when advising a semen test . If the reports  difficulty in collecting semen instruct him to try collecting at home  using coitus   interrupts . Special  non  spermicidal condoms are  also available. Those  who are still unable to collect a sample will usually be  able to ejaculate when  stimulated with a vibrator .

Interpretation

Many pathology  laboratories still  quote  the old  norms  misleading  the doctor and making   the couple    unnecessarily nervous.

It is  important  to remember  that semen   analysis is only a rough  predictor of fertility. Many  men with  poor semen   parameters will father   children while others  with seemingly normal   parameters will be infertile. The duration    of infertility   should be considered  in addition to the semen   analyses. If the duration is short   then even  with a low   count  the chances of pregnancy   are good  while if the   duration of infertility k  is long then even  with a normal analysis  the chances of pregnancy   are poor.  Time acts  as a filter  sorting  out the fertile from the sub fertile regardless of the semen parameters  Hence   young  couples  who have  been trying only for  a short time should not rush into advanced reproductive techniques.

Reassurance is very  important  when the semen  is sub normal   because  the male  ego is very threatened by a poor  semen report.

Further Evaluation

Investigations are needed only in some cases.

Hormone assay : Not required  in every  case

-        If count > 5 mill/ ml FSH will be    normal

-        If count < 5 mill/ ml  then FSH alone should be done

-        LH testosterone assay only if there is  hypo androgenisation  or ED

-        Prolactin assay only if there is ED.

Routine   USG : Is not  needed for every case since  a good  clinical examination can  detect the relevant   findings . Since   surgery  of sub clinical  varicocele  does not    improve  the semen quality    routine  ultrasound to screen for a sub clinical varicocele  is of no value. USG   is mainly  done to confirm the diagnosis  of a clinical  varicocele when surgery  is being planned. USG of the scrotal contents  is also  useful is very  obese  men in  whom clinical examination is difficult.

Sometimes   simple  advice can help a lot.

_ Advise correct timing of intercourse 

-        Prescribe  sildenafil   if man has situational Ed

-        Correct  personal habits

-        Avoid   sauna/steam

-        Regulars meals more salads fruits 

-        Loose   underwear

-        Therapy for stress relief

-        Reduce   smoking alcohol stop drugs

Don’ts   Unnecessary or  harmful treatment  should be avoided

-        Do not  give testosterone injections they  may cause  suppression of spermatogenesis   through   pituitary  feedback 

-        Do not   waste time and money  treating azoospermia or isolated sperm  defects  medically these need surgery     or ICSI.

-        Do not  give antibiotics   for pus cells  without confirming Pyospermia by stained smear examination.  There are 3 types  of round cells  in the semen leucocytes  macrophages and spermatocytes only leucocytes   indicate   infection  Most  labs do not distinguish between  these cell    types  and erroneously  label all round  cells as  pus cells  leading to a false  diagnosis   of infection and unnecessary  antibiotic therapy .

Hormone  injections  for hypogonadotropic  hypogonadism .

HMG and HCG injections mimic the action of natural  FSH  and LH. In men with    genuine hypogonadotropic  hypogonadism  where hormone levels  are well below  normal treatment  with HCG   followed  by HCG + HMG   can induce   spermatogenesis  in an azoospermic main . However  these injections are expensive  and men with k pituitary failure   need therapy  for 1-2 years . Hence   the cost of complete   therapy  is very high  Before   starting therapy   ensure that the patient  can spend   on the full  course  since stopping  midway will be   a waste  of all that he   has spent In our   country the  majority  of hypogonadotropic   patients  cannot  afford  gonadotropin therapy. The value  of empirical  gonadotropin therapy in men with normal     hormone levels  is unproven.

-        Varicocele   affects 15% of all men

-        Many  men with   varicocele  are fertile

-        A varicocele  in an infertile man  may be coincidental

-         After   varicocele  surgery  only some men will have  improved  semen

-        Some  infertile men with  varicocele may improve  on medical    therapy  alone

-        Hence not every  infertile man with  a varicocele  needs  surgery .

Microsurgical ligation

-        Preferred technique

-        Artery and lymphatics can be preserved

-        All veins can be  identified  lower recurrence rate

Laparoscopic ligation

-        No  longer  recommended

-        Higher  recurrence  rate

-        More invasive  than the open  microsurgical   approach