Why is it so hard to interpret a semen analysis test?

The sperm test is the simplest and commonest test done for evaluating an infertile couple. It allows us to evaluate a man's fertility, and because it's cheap, it's the one which is done first.

However, its apparent simplicity conceals how complex interpreting this test really is !

Because it's a routine test, one of the biggest problem is that lots of laboratories do it , and most of them have no idea how to do the test properly ! The technician does not have enough experience, and will often not have the right equipment ( such as a phase contrast microscope; or calibrate sperm counting chambers) .
This is why a lot of men end up with very unreliable reports, which their doctor cannot interpret intelligently, because they can't be trusted. This creates a lot of confusion ! This is why we see many men whose sperm counts fluctuate all the way from 5 million per ml to 60 million  per ml, depending on which particular laboratory they do the test from ! The irony is that all the reports are most probably wrong.  To add insult to injury , doctors will start "treatment" based on these reports - and it will be impossible to assess whether the treatment is helping - or harming !

Thus, it's very common to find round cells in the semen and these are usually sperm precursors, which are quite normal. However, these are often mis-reported as " pus cells ", and the poor man is treated for months on end with antibiotics to treat the " infection " !

Similarly, most labs are just not capable of staining the sperm to check their morphology - the proportion of normally shaped sperm in the sample, and these numbers are just cooked up by the technician.

The problem is not just poor quality labs however. Often men don't do the test properly because they have not been given the right instructions. There needs to be at least a 3-day abstinence period ;  the man needs to make sure that he collects the entire ejaculate in a clean container ; and the sample should be delivered to the lab within an hour or so . Unfortunately, lots of men don't follow these instructions , and sometimes they are too embarrassed to tell the lab that they have spilled the sample !

Another  huge problem is that gynecologists don't have the expertise to interpret the semen analysis report properly . Gynecologists are specialists in taking care of the health of women, and never see a man in their professional practice. Yes, they can figure out if the report is normal or not, but unfortunately they're not good at being able to understand the nuances of an abnormal sperm test report. This is why they often end up confusing the patient , and send him for all kinds of "advanced" sperm function tests ( which are promoted by the sperm testing laboratories  because they generate extra revenue for them!)  These tests serve absolutely no purpose at all, and make a bad situation even worse, because they don't provide any useful clinical information at all.

Often gynecologists will refer men with an abnormal report to a urologist or an andrologist, and this just compounds the problem,  because the left hand has no idea what the right hand is doing, and the treatment of the infertile couple gets fragmented and uncoordinated !

The truth is that there is very little effective treatment a male infertility specialist can offer, but because he needs to demonstrate his expertise, he will ask for a whole new batter of additional tests ! These include all kind of pointless , expensive and embarrassing tests, such as a colour Doppler to check for varicoceles ; and transrectal scans to check for ejaculatory duct obstruction. As part of the panel of tests which are ordered to be "thorough" with the evaluation, many doctors now also order hormonal blood tests ( FSH, LH, prolactin, testosterone); as well as chromosomes studies - all of which are a complete waste of time and money. The poor patient ends up going from one doctor to another , and since no one has a clue what is happening, he loses confidence in all the doctors.
It's not just a limitations with doctors - the truth is that medical science still doesn't know what a normal sperm test report is ! Many decades ago, a normal sperm count used to be considered to be 60 million per ml.  A few years ago, it was 20 million per ml. Currently, the "new normal" is 15 million per ml. It's hardly surprising that infertile men are going to say, "Hey, if science doesn't even know what a normal sperm count for a fertile man is, then how can they help me to interpret my particular report?"

The dirty little secret is we can't. We can tell a man with a zero sperm count that he can't father a pregnancy in the bedroom, but we can't really tell a man who has sperm in his semen whether he can get his wife pregnant or not !

This might seem surprising ! After all , isn't that the purpose of a semen analysis ? Yes, that's what an ideal sperm test would do, but a semen analysis is an extremely crude test , and doesn't provide us with that information. Yes, it does tell us what the sperm count is, and whether the sperms are moving or not, but that's not the question which the man is asking ! He wants to know, "Can I get my wife pregnant or not?" This is a completely different question , and because it's much more complex , it's not possible for us to answer this as yet.

After all, the fertility of a couple doesn't just depend on the man's sperm count or motility - it also depends on his wife's fertility ! This means that it's possible that if he had married a younger, more fertile woman, then he would have been able to get her pregnancy even with a very low sperm count !

This is why infertile men often end up getting such a raw deal - and this is why it's best for them to go to an infertility specialist , who deals with the infertile couple as a unit - and not just either a gynecologist ( who has no idea how to deal with infertile men) or an andrologist ( who has no idea how to treat infertile women!

You can see what a sperm test report should look like at
http://www.drmalpani.com/knowledge-center/resources/book/chapter4b

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !

Prenatal Testing: What is a Nonstress Test?

Expectant mothers always have this constant worry about their baby’s health, especially since congenital birth defects can possibly happen to some. Good thing there are prenatal screening tests that can be done, usually within the first and second trimesters, to rule out this possibility. Once a screening test shows a positive result, diagnostic tests will then provide a conclusive answer.

Some prenatal tests may be required for pregnant mothers as routine procedures, while others may be offered additional screening exams, especially those with higher risk of bearing a child with certain health conditions. One of these additional prenatal exams include a fetal nonstress test.

What to know about a nonstress test

Also known as a fetal heart rate monitoring, a nonstress test (NST) is a common prenatal exam to check on the baby’s health. The procedure involves a monitoring of the baby’s heart rate in response to his movements. The test is termed “non-stress” since it is noninvasive, meaning there is literally no stress placed on the fetus over the duration of the procedure.

During a nonstress test, the healthcare practitioner checks on the baby’s heartbeat on two occasions: while the baby is at rest and while he is moving. Normally, the baby’s heart rate increases when he is kicking or moving, just as our heart beats faster when we are active.

Nonstress test for high-risk pregnancies

Generally, the goal of a nonstress test is to evaluate the baby’s oxygen supply based on how his heart rate responds to his movements. But when is it really necessary?

Your doctor may recommend a nonstress test done if the mother is already past her due date, or if she is having a high-risk pregnancy a month or two leading up to her due date. Specifically, you may need to undergo a nonstress test if you have a pregnancy-induced high blood pressure, type 1 diabetes, or a heart disease.

You are also likely to need this screening test if you have had a history of complications during a previous pregnancy, Rh sensitization, oligohydramnios or a low amniotic fluid, or if your baby is shown to have decreased fetal movements or growth problems.

What to expect during an nonstress test

Before the procedure, the doctor may advise you to grab a meal to hopefully stimulate your baby to move during the test. It may also help to use the bathroom prior to the test, as you will remain strapped to a monitor for the next hour or so.

During the procedure, you will be asked to lie on your left side. Then, two fetal monitor pieces, an ultrasound transducer and a toco transducer, will be placed on your abdomen with elastic belts holding them in place. The ultrasound transducer measures your baby’s heart rate while the toco transducer keeps track of the uterine activity.

The results of an NST may either be reactive or nonreactive. It is reactive if the fetal heart rate increases when the baby moves, which should happen at least twice in 20 minutes. To stimulate the baby, the nurse may have you drink water or juice.

However, if the baby’s heart does not beat faster upon movement, or if he is not moving, the test will show a nonreactive result. But a nonreactive result should not be a cause of worry just yet as this could only mean the NST has not given enough information that you need. During such time, the doctor may recommend additional tests such as a contraction stress test or a biophysical profile to further check on the baby’s condition.

Prenatal testing is important to ensure that the baby is growing and developing normally. Although such screening tests and procedures may indicate undesirable results, the good thing is that certain measures can be done promptly to guarantee a safe and healthy delivery of your child. 

Why IVF patients need to be optimistic !

Most IVF patients are extremely optimistic that their IVF cycle is going to work for them. If every patient didn't think in their heart of hearts that the cycle was going to be successful, no one would ever have the courage to start one. After all, a failed cycle causes a lot of heartache and heartburn . Patients are putting a lot on the line when doing IVF - not just in terms of money, but also in the form of hope, time and energy .

 

 They know that a lot rides on the outcome of the cycle , and because IVF gives them the best chance of having a baby , they're gather up all their courage and start off on a cycle. Of course, they're also very worried that the cycle may fail, and the ones who are realistic and well-read and have done their homework understand that the odds are stacked against them. After all, human reproduction is not efficient, and embryo implantation is a biological process which no doctor in the world can control. 

 

Even after knowing that the chances of failure are more than the chances of success in a single cycle, the fact that they're still able to go ahead does mean that they need to be highly optimistic. And even if this optimism may seem to be irrational, it's often the only thing which allows them to start a cycle. 

 

IVF is not an easy ride , and tests the emotional resilience and maturity of a patient. Lots of them are never be able to start another cycle when the first cycle fails because they had so much hope invested in the first one. That's why it's important to find the right degree of balance between optimism and realism when starting the treatment.  Patients need to be prepared that it can take 3-4 cycles to have a baby, and these patients will have the courage to bounce back and give it another shot even if their cycle fails.

 

I agree this is not easy, and every patient needs to find what works best for them. Yes,  it's important to hope for the best, but it's equally important to prepare for the worst , so you don't go to pieces in case the cycle fails.  This is why it's important to step back and take a long-term perspective . Even though an individual cycle may fail, we still have the ability to learn a lot from that failed cycle, and can use this information to improve your odds of success for the next cycle. 

 

It's important to think of IVF as a process which may take three or four cycles before it gives you the deeply-loved baby you want , rather than think of it as a single shot affair. Of course, in a perfect world , every IVF cycle would work, but then patients wouldn't need any counseling at all ! IVF technology has not brought us to that point as yet, so you need to be able to shield yourself from the possibility of heartbreak.

Unnecessary testicular surgery for the infertile man

A common fashion these days in some IVF clinics is to do TESE-ICSI for men with severe oligoasthenospermia ( low sperm count).

This is justified by saying that these men with " abnormal sperm"  have  high sperm DNA fragmentation, and this will result in poor fertilisation and poor quality embryos.

The solution they propose is extracting sperm directly from the testes, by doing a TESE, the theory presumably being that testicular sperm will not have as much DNA fragmentation because they are "fresh".
Of course, it also goes without saying that doing an additional procedure allows the IVF clinic to charge more !

This is complete rubbish, and TESE should only be done for men with azoospermia ( zero sperm count).

If there are sperm in the semen, then these should be used for doing ICSI - there is no need to use testicular sperm at all

Please don't let the doctor assault your testes for no rhyme or reason !

IVF scams never seem to end !

I am always impressed by how creative IVF clinics are - at cheating their patients !

The latest scam is " Biologically Active Peptide Concentrate or BAPC , to improve a thin uterine lining ! This is completely untested and unproven, but is being "sold" to patients as the latest and most advanced treatment !

It's scary how easy it is to take advantage of a gullible infertile patient's emotional vulnerability. All you need to do is to coin a clever new acronym, and start selling your product ! Pay the doctor a hefty kickback, and he'll be happy to "treat" his patients using your clever new innovation - even if it's no better than sterile water!

What can patients do to protect themselves ?

Why an IVF doctor is an active angel investor

I am a full time practising IVF specialist, which is why people sometimes wonder why I am investing in startups so actively. Why do I want to wear a new hat at this stage of my life ?

There are many reasons why I am very glad I have gone down this path.

I believe you remain young as long as you keep on learning new stuff, and while I know a lot about IVF, there's lots of stuff I don't know about many other fields. I am curious and I like learning more, and a great way of learning is by investing in start-ups . These founders are domain experts, who have the courage to have a contrarian point of view. They  think they can do a better job than the existing incumbents, which is why they're willing to challenge them. This requires a lot of conviction, and I learn a lot about the domains I invest in, thanks to them.  This makes life much more interesting , because practically everything I read is grist to my mill, and can be of use to one of my founders.  I need to be interested in what is happening in many domains, rather than be myopic and think only about what I need to do for my IVF patients.

I believe in the T-shaped model of leading life, which means you acquire a lot of expertise and depth in one particular niche, and then apply it to other fields. Angel investing allows me to do this. If you want to be a good angel , you need to be a well read philosopher ! Because I invest across many different domains, I need to keep up to date on what's happening in all of them, so I can have intelligent discussions with entrepreneurs. This is why investing is the last liberal art !

Neither of my daughters  is a doctor, and  while one is doing her MBA at Stanford, the other is working in a clean-tech startup in San Francisco after completing her Masters in Environmental Management in Yale. I need to be able to understand what they are doing, and I don't want to lose their respect just because I cannot decipher cash flow statements. Angel investing allows me to keep up with them !

One problem with being a doctor is that you tend to hang out only with other doctors, and as doctors get older, they get a skeptical and cynical. They are always complaining about how people don't respect doctors anymore; and how patients are always on the internet,  trying to second guess their doctors. They keep on reminiscing about the good old days, but these aren't going to come back, so there's no point in wallowing in nostalgia ! The problem with hanging out with pessimists is that you become pessimistic yourself, and start thinking that the world is going to the dogs.

It's much more interesting to think about the future, and what we can do to make it better. Entrepreneurs have to be optimistic , because they're willing to invest time and energy on tackling complex challenges. My hope is that their optimism will rub off on to me as well !

Life has been kind, and because I have been lucky to have a friend like Rakesh Jhunjhunwalla ( India's Warren Buffett), I have more than enough money to be contented and happy.  Making more money is not going to change me or my lifestyle, so I would rather invest in startups, even though they are a riskier asset class. My investment in them has the potential to create much more good, especially because I have a soft corner for social impact investing. If I can help the next generation of entrepreneurs to make the world a better place by funding them, this is the best use I can find for my money ! This is why I find angel investing  very rewarding, and look forward to being an active angel investor in the future as well.

My next post will be on why being an IVF specialist helps me to become a better angel investor ! Stay tuned...

The poor infertile man

Male infertility is common, and is usually responsible for about 40% of all infertile cases. The commonest reason is the low sperm count, also known as oligospermia.

What breaks my heart is the poor quality of treatment which these men get. Typically, they go to a gynecologist who has no clue about how to deal with men , because all they do is deal with women. However, when confronted with something they don't understand, like most doctors, they mindlessly tick off lots of boxes on a laboratory order form, to "investigate" so they can make a "diagnosis". They usually order a panel of tests , including hormone levels ( such as FSH, LH, prolactin, tesosterone); karyotype                   ( chromosome test ) ;  and a doppler ultrasound ( to check for a varicocele). However, none of which these are any use whatsoever in a man with a low sperm count ! The very fact that the man has some sperm in his semen means all his tests are going to be normal ! Most minor abnormalities are of no clinical importance.
Even worse, these results don't provide any actionable information , because there's nothing we can do to increase the sperm count ! However, doctors are never happy just prescribing tests - they love to " treat" as well ! They advise a lot of lifestyle modification measures, such as eating a healthier diet; doing more exercise; taking cold water showers; wearing boxer shorts; reducing stress levels; taking holidays; as well all kinds of empirical therapy , such as antioxidants . All this expensive rubbish doesn't help with improving the man's fertility at all, but just ends up making him feel persecuted. Yes, a man's sperm count will occasionally increase , but this hardly helps - fluctuations in the sperm count are very common, even without treatment.
However, all this therapeutic meddling makes the poor man's life hell. As it is, he feels inferior and inadequate, because he can't get his wife pregnant - something which any normal man should be able to do with ease ! His low self-esteem just gets worse, and he blames himself for being the cause of his wife having to suffer taunts from the rest of the world.

Even after complying with all the onerous restrictions placed on him ( no social drinks, and not even an occasional smoke), most of the time there is no improvement in the sperm count at all. This is when he loses confidence completely in all doctors.

The man with a low sperm count should just accept the fact that there are lots of things doctors don't understand. One of these is why men have a low sperm count, which is why we can't do much to increase it.
If you are one of those unfortunate men who does happen to have a low sperm count, please stop beating up on yourself. Make sure you repeat the test again, preferably from another more reliable lab , to confirm the diagnosis. However, if the results  remain persistently poor, then your options are limited.

Some gynecologists and IVF centers will refer you to an andrologist , who's supposed to be a specialist in treating male infertility. However , the reality is there's very little this specialist can do for you.  Good andrologists will be honest and tell their patients, "Look, there's no point in wasting your money taking all the empirical therapy we're going to give you. It's far better to just go on and do ICSI".

However , this is not something which most patients want to hear, and they often pressurize the doctor into writing medicines for them. When the doctor can see the patient twist his arm for a prescription, he is happy to write this, so he can move on to the next patient , rather than wasting his time on these hopeless cases , for which he knows he really can't do anything. However, this means that another three months of the poor patient's life is wasted, and his poor wife keeps on getting older !

Sadly, the torture doesn't stop even after starting the right treatment, which is IVF/ICSI . If the embryo is of poor quality and the IVF/ICSI  cycle fails, many doctors blame the failure on the poor quality of the sperm, and suggest to the man that they use donor sperm the next time ! This is plainly ridiculous, since the only reason for doing the ICSI in the first place was the poor sperm . When doing ICSI, we need only 1 sperm to fertilise 1 egg , and it doesn't matter how poor quality the semen sample is at all !

The reason for poor quality fragmented embryos is much more likely to be a poor quality lab, but the doctor blames the man for this, and does even more pointless tests, such as sperm DNA fragmentation, to prove to him that the "fault" is his, and that it his poor sperm which are responsible for the IVF failure !