Ever hear of the Buddhist parable of blind men describing an elephant? The man facing the elephant describes it as thick like a snake. The man who grabs its large floppy ear suggests that the creature is fan-shaped. The man who holds its leg insists that elephants are tree trunks and the one on its side believes that it’s similar to a wall. All of them right, sort of. But the big picture’s the thing.
I took a similar tree-to-forest view of the semen analysis in my recent keynote speech at the Integrative Fertility Symposium (IFS) in Vancouver, British Columbia recently. Given that the semen analysis has been the cornerstone of the male fertility evaluation for at least 50 years, it’s remarkable for how long we’ve gotten by with so little information. In a nutshell, here’s my take on the vaunted semen analysis.
It’s part of our nature to count things. Maybe, in doing so and by ordering our universe, we get a sense of belonging or control over our environment. And so for the last 100 years, we count the sperm in our semen. But unlike a blood glucose level, which is incredibly tightly regulated and on point, sperm are part of a much more loosey-goosey biological secretion that varies by year, season and even by day. This makes “normal” values or “reference” ranges for semen quality both complicated and somewhat artificial. Bottom line: unless it reads zero, the semen analysis is a poor measure of a man’s true fertility potential.
Despite these caveats, the semen analysis has value. When viewed over time, they may reveal health-related patterns. Like the slowly declining sperm counts associated with the progressive effects of a varicocele, increased obesity or uncontrolled diabetes. More profound is the recently described relationship of semen quality as a “biomarker” of disease, mortality, and higher rates of later cancers in men. Yes, although this onion is not fully peeled, semen quality appears to be a window into men’s current and future health.
Although limited in isolation, when taken in full clinical context, which includes the clinical history and physical examination, the semen analysis can often tell a story. Think of sperm production as an engine that wants to run hard, at full tilt. When all is well and the body is at peak performance, the semen analysis tends to be normal. However, with ill-health, sperm production is hampered and sperm counts fall. When I do a deep dive into a man’s health and habits in the setting of impaired semen quality, it’s impressive how often I explain the male factor infertility problem.
A Great Book
But the bean-counted semen analysis is only part of the story. Men with normal semen analyses can be—frankly—infertile and men with abnormal semen quality can be fully fertile. In fact, there is virtually no linearity to the relationship between semen quality and fertility. What gives? Much of the secret to fertility, we’re learning, has nothing to do with sperm numbers or movement but is to be found in the sperm DNA payload. The way that sperm DNA is packaged (fragmentation) and marked (epigenetics) matters immensely not only to conception but also to embryo and fetal development. And as our understanding of what determines the build quality of the DNA payload improves, it is my belief that the single most important factor will end up being the health of the man who makes it.