A 33-year-old man is referred for evaluation of male infertility. He and his 29 years old wife have been trying to conceive for last 2 years. She is gravida (G0), para (P0) with complete medical evaluation revealing regular ovulatory cycles and normal reproductive anatomy with no history of reproductive tract disorders, pelvic infection or surgery. The couple has had unprotected vaginal intercourse at least 2–3 times a week, having undergone a normal puberty and well previously, he complains of poor libido and poor erection with decreased volume of ejaculate for past 1 year. He shaves once a week. There is no past history of any chronic ailments or any reproductive disorders, and has taken no medications or any illicit drugs. He has no family history of hypogonadism, cleft palate or infertility; he has 2 brothers who have fathered children. He works as a software professional with no habitual smoking or drinking. He has never fathered a child. He is well virilized with normal male voice and normal upper/lower segment ratio. His body mass index (BMI) is 33.5 kg/m2 with bilateral nontender gynecomastia; a normal genitourinary examination with normally descended testes that are 12 mL bilaterally and easily palpable vasa deferentia. His laboratory tests (performed at 8.00 am) reveal total testosterone 220 ng/dL (N: 300–1000 ng/dL), luteinizing hormone (LH)-2 mIU/mL, follicle stimulating hormone (FSH)-6 mIU/ mL. Hematogram, urine analysis, hepatic and renal profiles, serum prolactin, thyroid profile and iron studies are normal. Repeat hormonal analysis reveal similar results. The seminal fluid analysis yields no sperms with volume of 2.45 mL, normal pH (≥7.2) and fructose. Repeat semen analysis shows similar results. Sella imaging reveals no hypothalamic/pituitary abnormality.
What are the lower reference limits for various parameters?
Medicine
The WHO, in 2010 has published revised lower reference limits for semen analyses, which is depicted in Box 12.2. Semen volume: Aspermia or complete absence of ejaculation can be due to congenital absence of vas deferens or ejaculatory duct obstruction. Low semen volume with normal sperm concentration is most likely due to semen collection problems (loss of a portion of the ejaculate) and partial retrograde
ejaculation. Androgen deficiency is also associated with low semen volume and low sperm concentration. The patient should be asked to return for a carefully collected repeat semen sample after emptying the bladder; post ejaculation urine can be collected to assess whether there is retrograde ejaculation. Sperm concentration: Lack of sperm in the ejaculate does not indicate the absence of testicular sperm production; these patients should be evaluated for retrograde ejaculation, congenital absence of the vas deferens, and other causes of obstructive azoospermia. Sperm morphology: The criteria for normal morphology include shape, length, width, width ratio, area occupied by the acrosome, and neck and tail defects. These criteria are called “strict” criteria and have good predictive value in terms of fertilization in vitro and pregnancy rates after in vitro fertilization (IVF). Leukocytes: Polymorphonuclear leukocytes, are frequently present in the seminal fluid. Assessment of white blood cells is usually performed by using the peroxidase stain. The peroxidase positive cells are counted using the hemocytometer. Presence of increased white blood cells in the ejaculate may be a marker of genital infection/inflammation and may be associated with poor semen quality because of the release of reactive oxygen species from the leukocytes. The suggested cut-off for the diagnosis of a possible infection is one million leukocytes/mL of ejaculate.
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