E4

how the specimen was collected and how it was analyzed. Semen collections should occur after an abstinence period of 2-3 days, and they should be presented for analysis within I-W2 hours of ejaculation. The collection container should be wide-mouthed to ensure collection of the entire sample. The method of collection may be via masturbation, coitus interruptus, or condom collection (must be free of spermicidal agents). No one single semen analysis should be used to determine the patient's baseline. Usually 2-3 samples are collected and analyzed before a diagnosis and treatment plan are made. Semen parameters characteristically evaluated include: 1) volume, 2) density, 3) motility, and 4) forward progression. Normal values may vary slightly from lab to lab.

Several additional semen tests which are often utilized. An immumobead assay is done to detect the presence of antisperm antibodies, which can severely impair sperm motility.4 These may respond to treatment with corticosteroids. An assay for the presence of reactive oxygen species is important, for abnormally high concentrations may damage the sperm plasma membrane and impair its function. Reactive oxygen species are treated with antioxidant therapy, such as Vitamin E. As previously discussed, the presence of genitourinary infections can be detrimental to sperm function. A microscopic examination of the semen alone is not sufficient to detect the presence of white blood cells (WBCs), because of the similarity between their appearance and the appearance of immature sperm (round cells). Therefore, a combination of semen culture as well as a monoclonal antibody test to specifically detect the presence of seminal WBCs is performed. Urethral swab cultures should be performed if there is a question of urethritis (chlamydia, ureaplasm, etc.). Antimicrobial therapy is tailored appropriately, based on culture results.

Another test which is often performed is the Kruger Strict Morphology assay.6 It's purpose is to determine the percentage of normally shaped sperm within a sample, using a very rigid criteria. Normal values are >4% (in the Baylor Andrology Lab). Values less than 4% are associated with impaired sperm function and reduced potential for successful fertilization. A number of other tests are available to evaluate sperm function, however in this age of extensive use of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), whereby a sperm can be directly microinjected into an egg, many of the functional sperm problems associated with male factor can be circumvented.

In addition to the semen analysis, hormonal testing is usually undertaken in the evaluation of the infertile male. Serum FSH should be measured prior to any intervention. Elevation of FSH above 2-3 times the normal value should be construed as an unfavorable sign associated with a probable primary testicular pathology. This may be the result of longstanding metabolic disturbances or gonadotoxic drug effects in the transplant patient. Finally, a prolactin level should be ordered to rule out the presence of abnormalities involving the HPG axis, as previously detailed.

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