Monday, November 25, 2013

Understanding a Semen Analysis

In the infertility world, it seems that there is less attention paid to male infertility than female issues. Because our diagnosis was male infertility, we have seen this first-hand. It doesn't help that there are A LOT of differing opinions everywhere you go!

We have seen two different Reproductive Endocrinologists (REs), three different acupuncturists (two specializing in fertility issues) and three different urologists. Ugh! Not ONE of them has given us the same answer or treatment protocol for Mr. Piñata's issues. That's a whole lot of information and it can be very confusing to sort through. One urologist said we would need IVF with ICSI and another said that Mr. P's semen analyses looked like that of a "healthy, fertile male" to him (which we know is not true). That is on the opposite ends of the spectrum!

 All that to say, we've done a lot of research on our own. It turns out part of the issue is that there are different guidelines for "normal" sperm parameters. Add to that the fact that the term "normal" isn't very clear either makes it all very confusing to figure out on your own, or even with the help of a doctor. We thought "normal" parameters might mean "average," or at the very least that getting pregnant would be easy. But, as it turns out, neither of those things are true. I have looked up numbers and guidelines on all kinds of fertility clinic websites, blogs and even talked to one of the leading urologists in male infertility. What finally made all the numbers make sense was reading an article from the Oxford Journals. There was a lot of jargon and statistics that made it difficult to read easily, but after reading this article and the charts within it, I think I finally have a clearer picture of what a "normal" semen analysis means and what it should look like.

 Here are few take-aways from the article for me.

1. First of all, in 2009 the WHO (World Health Organization) did a clinical study that changed the sperm parameters to a new "normal." So, when you just google what sperm parameters should be, you can get all kinds of different answers from all different people from all different years. It makes the most sense to stick to what WHO considers the normal reference values from 2009 and not the older guidelines, or what you find on a Wikipedia article.

2. When they establish "normal" this does NOT mean average!

For me, this was the most important piece of information to understand. For the first year or so of our fertility journey, I thought that if Mr. Piñata's semen analysis could get to the normal range that this would mean it would be pretty easy to get pregnant, right? WRONG!

Actually, when they defined normal they took the semen analysis from 4,500 men from over 14 countries. The analysis numbers from those who were able to get their partners pregnant in one year or less were the ones that were used for the basis of "normal." So, not just men that got their wives pregnant within the first few months were included, but also those for whom it took a whole year! This was good information for me to learn.

Not only that, but they put these numbers into percentiles (just like those standardized tests we had to take growing up). When they gathered all the information on the sperm numbers, they consider everything normal that is above the 5th percentile. That's right! The 5th percentile (where you wouldn't want to be on a standardized test either)!

Let's say we're talking about total sperm count. It's in the "normal" range if a man has at least 39 total million sperm. However, 95% of fertile men have MORE sperm than that because that's the number from the 5th percentile! If you want to know what the average sperm count would be, you would want to look at the 50th percentile and see that  the average number of sperm in a sample is actually closer to 255 million! (255 million is actually the median number, which means that half of men have sperm counts higher than 255 million and half have sperm counts lower than 255 million.) Which is quite a lot more than the minimum required to be considered normal.

The same is true across the board for all parameters including motility, morphology, total volume, etc. This was both encouraging and discouraging at the same time. It was a reminder that just because someone has a "normal" semen analysis doesn't meant it will necessarily be easy to get pregnant. There may be nothing wrong in the sense that all the numbers are in the normal range, but it can also take longer than you'd like getting pregnant. So, if a couple is having a difficult time conceiving and all the sperm parameters are considered normal, but on the lower end, it definitely makes sense that it might take a littler longer. And maybe the not-too invasive procedure of IUI would be a good option for helping it happen quicker by bypassing the uterus. It was also encouraging for me  because the chart even shows the numbers in the 2.5th percentile as well. Those numbers may be even lower than normal, but those men did achieve pregnancy with their partners, so getting pregnant with a not-so-ideal semen analysis is definitely possible, just not easy.

3. There are two different measures of morphology. When they look at how sperm are shaped and if they're shaped correctly for good implantation into an egg, it's called morphology. But, there are two different scales for looking at it and it's good to know which method your laboratory uses. Most fertility clinics use the Kruger method, while there are some places that use the WHO method. The WHO method is a lot more general and it's more common to find "normal" numbers in the 30% range. However, using the Kruger method, they are much stricter on what qualifies as a "normally formed" sperm. The charts below in #4 are using the Kruger method even though these numbers come from WHO. You can tell that it's a lot stricter because it's considered normal if just 4% of the sperm are shaped correctly!

4. The actual numbers

Here is a chart taken from the article that shows the percentiles of each semen analysis parameter. This chart was SO helpful for me in understanding what normal vs. average actually looks like in numbers.

But, here is my simplified version for you if you're interested. It shows the difference between normal (5th percentile) and median (50th percentile).

 Whew! I know that's a lot of information. Thankfully, most of the population doesn't need these details and is able to achieve a pregnancy without ever needing to get a semen analysis done. However, there are those of us that have had far too many tests, lab work, ultrasounds, etc. and can get overwhelmed by the jargon that the doctors and nurses use, and just want to understand what is normal and where they fall in comparison to that.

Unfortunately for us, Dave falls below even the 2.5th percentile in the morphology department, so that's our constant fertility struggle. The good news is that even if your numbers fall outside normal, by seeing a Reproductive Endocrinologist there are procedures that can be done (like IUI and IVF) and even drugs and supplements that can help with sperm quality. We have yet to achieve a pregnancy, but also haven't gone too far down the fertility treatment route either. Finances play a big role in our hesitation to move forward with the likely needed IVF. Hopefully one day I will be able to get pregnant, but even if I don't, I hope all the research I have done can help someone else struggling with male fertility issues.

My biggest advice is to not delay seeing a specialist if you suspect you or your partner may have a problem. Knowledge is power and you and your doctor won't know which treatment route to take if you don't get tested and begin the process. Lots of luck to all of you on the roller coaster of infertility!

*The information on this site is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment, and is for education purposes only.  Always seek the advice of a qualified healthcare provider with any questions you may have regarding a medical condition.


  1. Girl, I totally understand the MFI!!!! Y'all are not alone!

  2. The normal vs average thing totally threw me for a loop too… I remember being so insanely frustrated! We'd hear that everything was "normal" but I was completely sure that is was NOT normal for 97% of the sperm to die when there were washed for an IUI. It is incredibly frustrating that male factor is ignored, but honestly, it didn't make any difference for us… we would have ended up at the exact same place when we thought it was just me (IVF + ICSI). : ( My biggest frustration has been the lack of ANY recommendations from RE's or Urologists for ANYTHING other than ICSI… no supplements, no diet changes, no acupuncture, it was either surgery or ICSI.

    I hate it for you and your husband because it is a very frustrating diagnosis, but you are definitely not alone!

    1. Yes, I totally agree about the frustration of REs and urologists pretty much not really understanding or having a consensus about MFI! I'm sorry your next step is IVF with icsi. You ARE courageous enough to do it though girl!!


Comments are the online version of a hug! Thanks for showing the love by commenting! :-)