It is the process of semen collection. The correct way to collect semen is masturbation. It is the safest way to collect all the semen and to ensure the sample's asepticity, especially when this sample will be tested for microorganisms. The sample must be collected in boxes which are not toxic and can close firmly, because spermatozoa are particularly sensitive to chemical effects. It is also important the patient to urinate and wash well his hands, penis and glans. In certain cases that the man is unable to collect the sperm sample by masturbation, special silastic non-toxic condoms that do not contain any spermicides (normal condoms that are not designed for this use usually contain spermicides).Finally, Medical Assisted Reproduction Units have a special leaflet with instructions for the procedure.

The man must have 2-5 days abstinence from ejaculation. This is because the final stages of sperm maturation last about 3 days. Spermatozoa are constantly produced and retain their motility for another 2-3 days on average. Consequently, as abstinence is prolonged, the sperm count increases, but the "oldest" sperm will begin to weaken, resulting in large numbers of immotile spermatozoa.

Conversely, the shorter the duration of abstinence, the fewer the spermatozoa, but  the motile ones are more. It is therefore wrong to compare samples made with different abstinence days. Semen analysis after a particularly long period of abstinence ( 10 or 20 days) are not indicative of sperm quality.

There are cases of men who deal with ejaculation problems.

In the case of retrograde ejaculation (backward release of semen into the bladder) the man needs to drink a sodium bicarbonate solution (to alkalinize the urine) before he collects a urine sample, and the spermatozoa are recovered following a special preparation process.

In patients with ejaculation deficiency, observed in cases of spine injury (paraplegic-tetraplegic), diabetes and neurological conditions, sperm can be collected by induced ejaculation using a special electro-induction device (electroejaculation).

When there is a chance that the man may not be able to provide a semen sample because of anxiety, the cryopreservation of a semen sample prior to the egg collection is recommended.

The total sperm volume is as follows: the seminal vesicles secrete 2-2.5ml (50-80%), the prostate 0.5ml (15-33%), the urethral and bulbourethral glands 0.1-0.2ml ( 3%) while epididymides 7% of the sperm volume. In the spermodiagram, beside  the demographic data of the man, the days of abstinence , the date and the data of the collection, the time of liquefaction, etc. are recorded. For objective assessment, it is considered necessary to check two or three samples within 2-3 consecutive months, especially if the first test shows some pathology. During semen analysis, the sperm is examined macroscopically, microscopically and biochemically.

Macroscopic and biochemical examination

Volume: Normally ranges from 1.5-6 ml. High volume is usually associated with a long period of sexual abstinence. Low semen  volume may be due to loss of part of the sample during collection, obstruction of the ejaculatory duct or congenital bilateral absence of vas deferens. It can also be result  of partial retrograde ejaculation or androgen deficiency.

Liquefaction: The sperm at the moment of ejaculation is a semi-solid coagulated mass. After a few minutes begins to liquefy, preferably at 30 minutes but no longer than 1 hour. The sperm parameters are evaluated after liquefaction. Excessive increase in  liquefaction time indicates prostate dysfunction.

pH: The pH of the semen is slightly alkaline (7.2-7.7). Clearly alkaline sperm pH (> 8) indicates inflammation of the adenomas, especially the prostate and the seminal vesicles, while acidic pH (<7) indicates congenital aggression or occlusion of vans deferens.

Appearance: Normal human semen has a grey-opalescent appearence. Pathological appearence (dark brown) is due to hematospermia, while colour changes in case of taking certain medications.

Biochemical control: Screening of spermatozoa metabolites is optional, but it can provide important information for the detection of the auxiliary genital tract pathology. It has been shown that in the seminal plasma, acid phosphatase, citric acid, zinc and magnesium originate by the prostate. Fructose and prostaglandins are secreted by the seminal vesicles. Carnitine, glycerylphosphorylcholine and α-glucosidase are good indicators of epididymide function, although their exclusive production by epididymis is questioned by some references in the literature.

Microscopic Investigation

Number of spermatozoa: It is usually expressed in millions per ml. Oligospermia is when the number of spermatozoa is less than 15 million per ml (WHO).

Sperm Motility: The  motile and immotile spermatozoa are usually assessed  in a percentage of 0-100%. The motility is graded in four categories: (a) rapid forward  (b)slow forward , (c) non-progressive and (d) immotility.

Sperm morphology: The morphology is assessed by histological observation of the head, neck (middle part) and tail of the spermatozoa after coating on a slide and pigmentation. Beside spermatozoa, other types of nucleated cells, such as inflammatory cells and immaturesperm cells, may be present. Regarding the characterization of physiological or pathological morphology, there are differences between the researchers (Kruger 1998, Kobayashi 1991) and the guidelines which has been established by the World Health Organization. Until now, no absolute correlation between sperm morphology and fertilization has been demonstrated, although researchers such as Kruger and Kobayashi have proposed criteria, by examining men's sperm with proven fertility capicity.

Other histological observations: The presence of a large number of white blood cells in general (> 3X10⁶), or pelvis (polymorphonuclear leukemia> 1X10⁶), may indicate acute inflammation of the prostate, seminal vesicles or epididymis. The observation is done in a coating stained with a specific peroxidase staining, which detects the pyospheres. Also, the semen analysis is supplemented by the vitality test(test Williams): the immotile spermatozoa are not always dead. Typically, an eosin solution is used: the stained spermatozoa  are the dead ones, as their membrane is not intact and allows  the stain to insert. The result is expressed as a percentage of live spermatozoa with lower reference limit 58%.

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Problems associated with infertility can greatly affect the psychological state of those concerned; on top of that, the process of Assisted Reproduction itself can be stressful, as for many couples, it constitutes their “last chance” to have their own biological child. Reproductive issues, such as biochemical pregnancies, early miscarriages, upcoming menopause, sperm-related issues and failed attempts at assisted reproduction, are all factors contributing to an emotional disturbance of the female and male partner, in their own and their families’ relationship.

The emotional state of the couple and its consequences, are often ignored and remain untreated, resulting in the couple feeling isolated, disappointed and distressed, which can have a negative impact on the treatment’s outcome.

The main aim of the counselor is not to simply listen to the problem being described, but to sympathize and participate in resolving the problem, by helping us understand our feelings and explore all possible means to a positive change. The counselor can also assist in other matters, such as the couple’s relationship, their relationship with their family and friends and if the couple are having difficulty dealing with deciding the appropriate treatment or the treatment itself, using a sperm or egg donor and dealing with stress itself.

Types of support that can be offered

Information counseling: to inform the couple of assisted reproduction techniques, so that they are fully aware of the procedure.

Effect counseling: to help the couple appreciate all consequences and the impact that the suggested treatment will have on themselves, their families and the child born as a result of the treatment.

Supportive counseling: to offer the necessary support during a stressful period, such as following an unsuccessful attempt.

Therapeutic counseling: to help the couple deal with the consequences of subfertility and IVF treatment and resolve any associated problems. It may also involve adjusting their expectations and accepting the current situation.

According to ethical regulations of psychology counseling, anything discussed during a session, will remain strictly confidential.

Medication is administered either in the female or the male partner in order to treat cases of infertility

For the woman: Medication that is administered to control ovulation, correct hyperprolactinaemia etc., is mentioned in further detail in the associated sections.

For the man: According to international bibliography, no statistically significant improvements have been noticed in the semen quality following medication. The only exception, are cases of hypogonadotrophic hypogonadism, where remarkable improvement is noted following drug administration, which involves a combination of pituitary gonadotrophins (Puregon-Gonal F-Alternon) and chorionic gonadotrophins (Pregnyl-Ovitrelle), or in addition, anti-oestrogens such as tamoxifen, clomiphene (Nolvadex, Clomiphene citrate), androgens aromatase inhibitors etc. The treatment has duration of 3 months and improvement is confirmed with a semen analysis and checking of hormonal parameters.

In conclusion, since the discovery of intracytoplasmic sperm injection (ICSI) in 1992, the suggested treatment for male subfertility practically involves evaluation of the semen sample and its classification as suitable for: sexual intercourse, intrauterine insemination, in vitro fertilization (IVF) or ICSI.

GIFT

GIFT (Gamete IntraFallopian Transfer) was an assisted reproductive procedure, which involved placing in the fallopian tube 3-4 oocytes mixed with sperm, using a special catheter. Sperm used in GIFT was activated using the Percoll method that includes separating an adequate number of motile, morphologically normal spermatozoa from the initial sample.

Before egg retrieval a woman’s ovaries were stimulated, according to medical protocols that promote multiple follicular growth. Egg retrieval is usually performed transvaginally and rarely laparoscopically. On the same day, laparoscopy was used to transfer the gametes (oocytes and sperm) in the fallopian tube. It is obvious that, GIFT required general anesthesia and hospital admission.

Tubal patency (at least one tube) and normal sperm were prerequisites for GIFT.

GIFT was commonly chosen in cases of unexplained infertility, mild endometriosis, mild oligo-asthenozoospermia and previous failed Intrauterine Inseminations (IUI), indications present in the majority of cases requiring infertility treatment.

GIFT disadvantages included, high incidence of ectopic pregnancy, laparoscopic surgery under general anesthesia, lower pregnancy rates compared to IVF and inability to check fertilization rates. In our days, GIFT is rarely the preferred choice of treatment.

ZIFT

ZIFT (Zygote IntraFallopian Transfer) was an assisted reproductive procedure involving placing laparoscopically in the fallopian tube, the fertilized eggs – at this stage called the zygotes-, using a special catheter. Zygotes were produced after mixing the oocytes with motile sperm in the laboratory.

Embryos were transferred in the fallopian tube, instead of the uterus, 24 – 48 hours after egg collection. In our days, ΖIFT is not a method of choice.

In-vitro fertilization is a safe and effective solution that offers the joy to thousands of infertile couples to have their own child.

In vitro fertilization is the procedure in which the oocytes are fertilised by the spermatozoa in the laboratory, either by the technique of conventional in vitro fertilization (IVF) or by intra-cytoplasmic sperm injection (ICSI). The fertilization is done in the embryological laboratory by the clinical embryologists and the embryos are transferred into the uterus by the specialized gynecologist. When the implantation is achieved, the pregnancy is the same as the one in a natural conception, and the children born, are equally healthy.

See in detail the process: IVF

Timed intercourse

The timed intercourse is the simplest form of assisted reproduction treatments.

It can be performed either during a natural cycle or using a simple ovarian stimulation protocol to induce multiple follicular development and ovulation.

It entails minimal risks and inconvenience to the patient while being relatively inexpensive.

Monitoring of the cycle and hormone tests are necessary, so that sexual intercourse can be "programmed" as close as possible to the ovulation day. Two or three ultrasounds and two or three measurements of E2 and LH levels are required.

Prerequisite for the success of this method is to have open fallopian tubes, normal ovulation and normal sperm parameters.

Ovulation is either achieved naturally or is scheduled 36 hours after administering chorionic gonadotropin (HCG).  It can be indentified by ultrasound and hormonal testing. Alternatively, ready kits are available to determine the fertile day. The old method of the thermometric chart is now used by very few women.

Natural Cycle or medicated

The main advantage of the natural cycle is that the procedure is simple: there are no drugs, the duration is shor, and the cost is limited.

The disadvantage is the possibility that no follicle will be developed. This occurs in cases of anovulated cycles, most commonly associated with polycystic ovarian syndrome. In this case it is preferable to cause ovarian stimulation. This is achieved by administering drugs which contain hormones. The most common drug is clomiphene citrate, used to stimulate the growth of follicles. This drug has an anti-estrogenic effect given on the first days of the menstrual cycle (typically a pill from day 2 to day 6).

Alternatively, gonadotropins (FSH, in small doses can be given subcutaneously or intramuscularly.

Disadvantages or side effects of timed intercourses

The main disadvantage is that this method does not allow any control of what actually happens within the body. Ovulation occurs naturally and fertilization takes place in the fallopian tubes, so it is impossible to check.

Furthermore, the success rates do not exceed the normal rates of conception (i.e. 20% per cycle) in young, fertile couples.

A major drawback is also that sexual intercourse must take place in a specific time. This can be inconvenient and stressful for several couples.

Clomiphene citrate treatment has minor side effects, while gonadotropin doses, if administered, are low and their side effects are also negligible. However, gonadotropin treatment actually induces ovarian stimulation. The risk of ovarian hyperstimulation is negligible. The method also involves a small risk of multiple pregnancy, if there are multiple  follicles.

• What is IUI
• Prerequisites
• How is IUI performed
• Modifications of the method
• IUI success rates

What is IUI

Intrauterine insemination is the oldest of all methods of assisted reproduction. It was first applied experimentally in animals in 1780 and in humans in 1791.It is a relatively simple method, that requires placing of sperm into a woman's vagina (vaginal), or placing of sperm near the cervix (pericervical), or into a woman's uterus (intrauterine). Intrauterine insemination is the first-line treatment in women of young age, with tubal patency and a male partner presenting with mild oligoasthenozoospermia. Moreover, IUI is recommended in cases of confirmed non obstructive azoospermia, where donor sperm is used. Sperm donation was very popular in the past, however the last few decades it has been περιορισθεί after the introduction of Intracytoplasmic Sperm Injection (ICSI). Tubal patency is a prerequisite, at least in one of the two fallopian tubes.

Prerequisites

In regards to sperm, the lowest number of washed spermatozoa that gave a pregnancy, according to international bibliography, is 100.000. However, in order to have realistic chances of success, a minimum of 2.000.000 washed, motile spermatozoa is required.

How is IUI performed

IUI can take place in a natural cycle or in a stimulated cycle. Monitoring involves ultrasound scans and hormone measurements. Ovulation may occur naturally, or it is induced 36 hours after hCG administration when the follicle(s) are mature. A few hours (usually 1-2 hours) before scheduled IUI, the husband must produce a sperm sample. After sperm processing, spermatozoa are concentrated and activated, in a low volume (usually 0,2 - 0,5ml) of specialized culture medium. The washed sample is loaded on a thin, plastic catheter attached to an insulin syringe. A speculum is inserted into the vagina so that the cervix is visualized. The catheter is gently introduced into the uterine cavity and the processed semen is injected. The whole procedure lasts only a few minutes and is painless.The catheter is removed and the woman should remain in a resting position for a few more minutes. After IUI, the woman may return to her daily routine, without any precautions. In some cases, progesterone administration is required in order to support endometrial receptivity, during the luteal phase of the cycle.

Modifications of the method

The main modification of IUI involves injecting a large volume of fluid (5-6 ml instead of 0,5 ml that is usually used). The fluid, containing washed spermatozoa, is slowly injected in the uterus, filling the uterine cavity, the fallopian tubes and finally is ekxeetai in the peritoneal cavity. Bibliography reports slightly higher success rates compared to conventional IUI. However, there are disadvantages such as longer duration of the procedure and the use of a specific type of speculum that cups the cervix, so that the fluid would not escape through the vagina.

IUI success rates

IUI success rates depend on various factors (ovulation, female age, sperm parameters e.t.c.) In general, the success rates range between 10 – 25% per treatment. This means that depending on the partner's sperm quality, it may take more than one treatments until a pregnancy is achieved.

Hysteroscopic surgery

It is a modern, safe and fast method of surgically treating benign pathological conditions of the uterus, related to infertility. Some cases in which hysteroscopy is applied are: the lysis of endometrial and cervical adhesions, the removal of polyps and submucosal fibroids and the resection of the uterine septum.

Pregnancy rates are significantly higher following hysteroscopic correction of pathological conditions of the uterine cavity.

See more: Hysteroscopic surgery

Laparoscopic surgery

Nowadays most of the gynecological conditions can be treated with laparoscopy. Indeed, in some cases (endometriosis, adhesions, hydrosalpinges) the use of laser offers better results than the traditional methods.

The technique can be applied in the entire range of gynecological surgical operations:

• Fallopian tube plastic surgery, fallopian tube opening. The use of CO2 laser achieves lysis of adhesions in salpinges-ovaries-uterus
• Removal of ovarian or paraovarian cysts
• Removal of uterine fibroids
• Treatment of peritoneal and ovarian endometriosis

See more: Laparoscopic Surgery

Cryptorchidism is the congenital abnormality in which the testicle has not descended into the scrotum.

Testicles are formed in the fetal abdomen and migrate through the groin into the scrotum in the 6th month of pregnancy. If this doen’t happen, cryptorchidism appears.

Cryptorchidism due to testicular overheating (temperature> 34 ° C) when the testis is outside the scrotum, causes atrophy of the cells that produce the spermatozoa. Testicular overheating also increases the incidence of malignant tumors. For these reasons, in case of persistent cryptorchidism, it is preferable to operate in a young age (about 1.5 years old). It has been shown that men who haven’t performed a surgery till the age of two, show problems with the quality of semen in their adult life.

Surgical sperm retrieval is recommended in cases of azoospermia or ejaculation failure.

See more: Testicular sperm extraction

Varicocele is the enlargement of the veins within the loose bag of skin that holds the testicles. It is observed in 8-22% of the general male population and is usually found on the left side. Bilateral varicocele is also frequent, while the right-sided is rare.

Diagnosis is usually confirmed with clinical examination and Doppler ultrasound while thermography, venography, scintigraphy, etc. have also been used.

Conditions such as varicocele and hydrocele (collecting fluid around the testicle) can cause infertility in men, which can be shown after a semen analysis. Surgery can improve the quality of sperm in some cases.

Various mechanisms have been implicated in the testicular dysfunction because of varicocele:

• Increase of temperature in the scrotum.
• Hormones and toxic substances retrograding.
• Increased intravascular pressure due to difficult venous drainage.
• Epididimal dysfunction due to residual conversion of testosterone to dihydrotestosterone and due to electrolyte disturbances.
• Hypoxia in the tubule epithelium, resulting in a significant influence on spermatogenesis.

Overall, it is estimated that the mechanism of spermatogenesis and endocrine disorders in varicocele is multifactorial. The increase in temperature in the scrotum, in the case of varicocele, occurs because the blood is stagnates in the venous network and therefore the testicle is overheated, which adversely affects spermatogenesis.

Varicocele treatment, despite having a very good theoretical basis, does not seem to offer the expected improvement in sperm parameters. Several researchers report about 7% improvement in sperm parameters following varicocele surgery.

The development of Medical Assisted Reproduction techniques now provides, in some cases, the possibility of avoiding surgery. The international literature (despite the objections of some) recommends to avoid surgery and apply non-invasive methods (eg insemination). Also, in cases in which IVF is required (eg due to a coexisting female factor), moderate sperm quality, by itself, is not an obstacle to in vitro fertilization.

Testicular torsion is extremely painful and is usually urgently treated (if blood circulation is interrupted, there is an immediate risk of ischemic necrosis of the gland).