An Ode to Semen Analysis

I was walking through the transcription area one afternoon about two weeks ago, and I noticed a sheet of paper in my box. I grabbed it, quickly scanned the contents, and twirled involuntarily with glee. The lone secretary in the room, covering all the others for lunch, looked up curiously. I thrust the memo from my lab director into her hands. It read something like this:

Attention all clinical pathologists:

From now on, it is no longer cost effective to perform semen analysis reviews in house. Therefore, we will be sending them out to (so and so) reference lab. If you have any questions or concerns, please contact me.

There are many tasks we are trained to perform that are never utilized. There are also those we encounter in our new jobs that are completely foreign. I remember the first time I got a semen analysis slide for review on my desk. I thought it was a peripheral blood smear - it came in a single cardboard slide tray with a sheet of paper. I threw it on the stage and peered through the microscope, expecting red blood cells. I thought, "What the hell is this?" and looked at the sheet of paper that came with it. Semen Analysis for Review. I jumped back from the scope, as if stung.

I walked across the hall into my partner's office to find out what to do. "Yes, we get these occasionally. Our job is to count the sperm, and to report if they are normal or abnormal." There is a saying in pathology: We Know Abnormal When We See It. At that time, I could not include sperm in that declaration. I asked her, "What does an abnormal sperm look like?" She gave me a book. An Atlas of Sperm Morphology by Adelman and Cahill. I decided to flip through the book that night, and get back to the slide the next day.

I remember e-mailing my friend that evening with incredulous horror. I had no idea there were so many ways that sperm could be abnormal. There are four parts to a sperm - head, neck, midpiece, and tail. Each part contains potential for grave error. Pointy heads. Flattened heads. Rounded heads. Enlarged and malformed heads. The neck can assume many undesirable conformations that render sperm nicknames; bullet, mushroom, acorn and dumbbell, to name a few. The midpiece might be kinked. The tail can be too short, too long, coiled or curled. Multiplicity is not normal in the head or tail; double and triple heads and tailpieces are the kiss of death. My all-time favorite description of an abnormal sperm is pear-shaped. Apparently pear-shaped sperm, like their gynecoid male counterparts, are highly undesirable.

The number of normal sperm required for fertility is 13%. A rather unlucky number in many circles, but not in the sperm world. A 9-12% sperm count denotes indeterminate fertility. [I love the word indeterminate. It is fabulously hedge-y. Indeterminate for dysplasia (pre-cancerous cells). Indeterminate for fertility. I try not to use it too much, but it certainly comes in handy sometimes.] If there are under 9% sperm, the specimen (who are we kidding? The MAN) is declared subfertile.

I have a good friend who has experience with subfertility. She and her husband decided about ten years ago to start a family. They tried for a few months unsuccessfully but their obstetrician was not alarmed because they were both young. Finally after almost a year with no results, the obstetrician began the infertility work-up by taking a detailed history and physical. Turns out her husband was having his breakfast and reading the paper each morning in their hot tub on the deck. The poor sperm didn't have a chance; they were being denatured each morning in boiling hot water. He quit the hot tub. They got pregnant immediately.

When I set myself to my new task the next day, armed with the information I needed, I actually contemplated putting on gloves. To put the slide on the scope. Hell, maybe I even did it the first time. Silly in retrospect. There are all kinds of body fluids smeared onto slides. Blood. Sputum. Cervical and vaginal smears. Why should semen be any different? Yet another mind over matter hurdle required in medicine. Akin to holding the heart for the cardiovascular surgeon during bypass surgery, so he or she can sew the new vessels together. Or walking into the decomposition room in the crime lab and blocking out the sights and smells of the long dead body in order to get to the task at hand.

When I actually looked at the slide, I got a little angry. Not only did I have to figure out which sperm were normal vs. abnormal, I had to do it on a crappy slide. They call these slides double frosted along the entire length. They were in vogue long ago, prior to the advent of positively charged slides. The point of both is to catch the cells and hold them to the slide for better yield. The positively charged slides use physics. The double frosted slides are sandblasted; they try to catch the cells with their rough texture. To the gross eye, the slides look like a morning windowpane in the dead of winter. Under the scope, it's like flying over the Ozark Mountains. The sperm are traversing mountains and craters. It is hard enough looking for abnormalities on a clear sunny day. Many of these sperm were hiding in shadows.

After a while semen analysis, like any other job one performs frequently, became banal. Semen analyses were the scourge of my clinical pathology rotation. Like placentas in surgical pathology, they tended to pile up on my desk over the course of the week, finally grasping my begrudging attention on Friday afternoon while cleaning up loose ends prior to the weekend. Before a new rotation began on Monday.

One Friday, I amassed quite a pile of semen analyses. It had been a couple of months since I had performed one so I grabbed the atlas, my sperm bible, again for review. I became curious. I performed counts and determined normalcy, but what about the all important motility test? How was that done? The book clued me in. There are all sorts of tests done for motility. But first, you must review the safety precautions for handling semen specimens. My favorite: Nothing should be pipetted by mouth.

Before the semen can be analyzed it must be liquefied in 5% alpha amylase. The first test is the simplest. One drop of liquefied semen is placed on a slide, and is covered by a coverslip rimmed in, of all things, petroleum jelly. The slide is incubated at room temperature and the percent of motile sperm is examined under the microscope at high power. From here, the tests get more complex. The swim-up test measures speed and endurance by averaging the time of the fastest sperm to travel up a conical tube. The estrous bovine cervical mucus test (that's cow in heat cervical mucus) measures how far they can travel through the cow goo.

I learned so much over the past year and a half about semen analysis. Now I will no longer need the information. But if I am ever required to recognize abnormal sperm again in my life, I have the tools. Medical technologists and clinical pathologists - we are all rejoicing that the semen is now sent out. I decided the semen analysis deserved a eulogy. Darn it. I'm gonna miss those little guys.