How do I provide a semen specimen for analysis? 

ReproSource (Cash pay or Insurance) 

• If you prefer to have your insurance company cover the cost of your semen analysis, we can go through a company called ReproSource who works with Quest Diagnostic Laboratory. 
• I will send a form, which needs to be filled out by the patient's husband and sent back to me. I will submit the form to ReProSource and the  spouse will receive a semen analysis (@home collection) kit via Fed Ex, and be able to collect a specimen at home to have this testing done. 
•  A ReproSource client services representative will call the couple within 48 hours after the order has been placed, to provide you with an overview of the process, answer questions about cost & insurance, and collect your shipping fee. 
• At the end of this call, the representative will send you an email with a link to online instructional videos that will review the details for using the @Home Collection supplies. 
• Next, you will receive your supplies on a date you have agreed upon. One of the items will need to be placed directly into the freezer. 
•  Within 24 hours of receiving your @Home Collection kit, you will receive your second call from a ReproSource representative. He/she will verify that you have stored the items appropriately, and he/she will answer any questions you may have about the instructional videos.
• On a day you have agreed upon, you will collect your semen speciman (the NaPro way, below), and then ship your specimen to ReproSource via FedEx using the shipping label previously provided to you. 
• You can find more details about this process by reading here.

PROVIDERS: 

• Connect with a ReProSource rep to find out how to register for an account here: clientservices@reprosource.com 

NaPro - Specimen Collection Instructions: 

• Click the image to purchase a the Male-FactorPack condom from Amazon. This is a polyurethane condom which is required in order to obtain an adequate semen specimen for analysis. 
• Your specimen will be obtained during the natural act of intercourse. 
• The condom will be punctured to allow for the natural transmission of life to permit you to adhere to Catholic/Christian moral teaching. 
• Using a clean pin, make a few small holes in the tip of the condom to permit the sexual act to remain open to life. 
• After intercourse, carefully remove the condom and transfer only the seminal fluid directly into the sterile container from the collection kit. 
• if you chose Fellow, you will have made arrangements for a same-day pick up by a courier who will deliver your specimen directly to the lab. 
• If you chose ReproSource, you will be responsible to mail the specimen on the same day via FedEx using the shipping label which will have previously been provided to you.

When we will we receive our results? 

• Results are sent to your medical provider in about 2-3 business days. 
• If the results of the first specimen is perfectly normal, a second specimen will not be required.  
• Whereas, if the results of the first specimen are abnormal, a second specimen will be required, which should be at least two weeks apart. 
• The reason for two specimens is because semen analyses can have a very wide degree of variability, and we would not want to make a diagnoses of "male infertility" unless we are absolutely sure. 

Most notable, men who have a "triple defect" of low sperm concentrations, low percentage of normal morphology, and low percentage of motile sperm have the highest probability of infertility. 

Volume of Ejaculate: 

• Average volume of ejaculate is approximately 2 to 5 mls. 
• Absence of ejaculate or very low volume may indicate a congenital defect where the ducts that transport sperm from testes to the penis are closed or mostly closed.  
• Low volume may also indicate ejaculatory dysfunction (inability to ejaculate), frequent ejaculations in which volume is depleted. 

Sperm Concentration: 

• At a minimum, concentration of sperm is considered to be 15 million sperm per 1 ml of ejaculate. 
• Oligospermia is the diagnosis given with sperm count < 15million/ml. 
• Azoospermia is the diagnosis given if sperm are completely absent. 
• Sperm count can have a wide variability  from week to week in a single male, so for this reason, if the sperm concentration is low, the man will be asked to repeat the analysis in 2-3 weeks. 
• A concentration of 5 million sperm per 1 ml of ejaculate is considered severely low, and a repeat analysis may not likely indicate a normal sperm count. 

Sperm Morphology (Shape or Form):

• At least 4% of the sperm should be of normal morphology. 
• As noted in the image above, there are many different types of abnormal morphology of sperm.  
• Each sperm cell should have a head which contains the genetic material and a single tail that permits motility (movement of sperm). 
• There are many types of abnormal morphology, including but not limited to: large or misshapen heads, sperm with multiple heads, tails bent at > 90º, sperm with multiple tails, coiled tails and/or shortened or elongated tails. 

Sperm Motility (Movement):

• Motility can be further divided into total motility = progressive (good forward movement) + non-progressive (poor forward movement). 
• Progressive motility: sperm swims in straight lines and large circles. 
• Non-Progressive motility:  sperm swims in straight lines and tight circles. 
• Healthy sperm should have a majority of sperm with progressive (fast) motility. 
• NaPro does not have specific parameters (that I could find) regarding progressive vs non-progressive motility percentages. 
• Normal total motility, per mainstream medicine guidelines, is 40% with 32% being progressive. 
• Napro protocols look for at least 40% total motility with 60% being optimal. 

OVER-THE-COUNTER SUPPLEMENTS (***to be taken under medical supervision, only)

First, the data seems to indicate that taking two or more supplements is better than taking one. The first three supplements listed below are very reasonably priced and can often be purchased for about $15 for a 3 mos supply. I have seen wonderful results in improving semen analysis parameters using the following: 

• L-Carnitine 2-3 grams per day. 
• CoQ10 200 mg per day. 
• Vitamin E 400 IU per day

Other supplements that are a bit more costly, and actually have fewer published studies supporting their efficacy are listed below. These three supplements are widely used by NaPro providers because many do see anecdotal evidence that they are helpful. 

• Proxeed
• FertilAid
• CountBoost 

PHARMACOLOGICAL AGENTS: 

Medical providers who specialize in Male Infertility may also prescribe various type of medications. 

Estrogen-receptor antagonists: 

An estrogen-receptor antagonist will interrupt the negative feedback provided by increased estrogen, which will result in an increased production of GnRH and  FSH. Increased FSH will in turn increase sperm production in the testes. A man is typically treated for about 6-9 mos. Examples of estrogen-receptor antagonists are: 

• Clomiphene (clomid) 25-50 mg daily
• Tamoxifen 20 mg daily

Aromatase inhibitors: 

Aromatase is an enzyme that catalyzes two reactions: a) the conversion of androstenedione to estrone (a type of estrogen), and b) the conversion of testosterone to estradiol (another estrogen). By inhibiting the formation of these two estrogens, the negative feedback loop is interrupted. Thus, GnRH and FSH are increased. Increased FSH will in turn increase sperm production. 

Aromatase inhibitors can also increase production of LH via the same loss of negative feedback. Increased LH production will promote increased testosterone within in the testes, also increasing production of sperm. Examples of aromatase inhibitors are: 

• Letrozole 

 Other (Lisinopril):

Some studies indicate that the use of Lisinopril, which is in the family of "Ace-Inhibitors" can help to increase the formation of sperm, enhance sperm motility and improve sperm morphology, overall resulting in an increase in pregnancy. 

• Lisinopril 2.5 mg daily

I would highly recommend a full physical exam with a primary care doctor along with routine laboratory testing and testicular US, which may uncover other conditions that could be contributing to male infertility. 

PHYSICAL EXAM:

• To ensure normal virilization and normal testicular size.
• To rule out a scrotal mass, such as varicocele, enlarged epididymis and/or any abnormal growth, which could indicate cancer. 
• Male Infertility doubles the risk for testicular cancer.
• Varicoceles (enlarged veins) are present in 4.4% to 22.6% of the general male population. They are present in 21% to 41% in men with primary infertility and present in in 75% to 81% in men with secondary infertility.
• Varicoceles on the LEFT side are more easily palpated on exam. Whereas, RIGHT-sided varicoceles are often missed.

*** See open access publications below.
 

IMAGING:

• A testicular ultrasound is a very reasonable and worthwhile test to rule out a varicocele for the male who has a partner who has been unable to get pregnant.
   

LABORATORY TESTING:

• Routine health labs: CBC, CMP, TSH, FT4, and Vit D levels. 
• AM testosterone and FSH levels can also be considered if the primary care doctor is amenable to this. 
• If FSH is elevated (> 12 IU/L),  primary testicular failure is present and testosterone is likely also going to be low.
• If FSH is elevated and/or testosterone is low, the provider may wish to repeat an AM testosterone and add LH, estradiol, prolactin and TSH to check pituitary function. 
• If FSH is low normal or low, testosterone will likely also be low and a "secondary testicular failure" would be suspected. Thus, the problem is likely at the level of the pituitary. The provider may wish to repeat the AM testosterone and add LH, estradiol, prolactin and TSH.

***Please have all records from your spouse's evaluation sent to me. 

• If your wife is a patient I am seeing through MyCatholicDoctor, the FAX# is 216-946-5932.