Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. In this episode, the docs welcome special guest Dr. Sam Ohlander, a reproductive urologist and the Head of Urology at the Fertility Centers of Illinois, University of Illinois at Chicago. Together, they take a deep dive into one of the most common and foundational tests in male fertility: the semen analysis.
Dr. Ohlander explains why timing is everything—specifically, the importance of an abstinence period of 2 to 5 days before testing. More is not better here; longer abstinence can negatively affect sperm motility. The team unpacks the meaning of sperm motility, including the distinction between progressive and non-progressive motility and how this can influence the total motile sperm count. They also discuss agglutination (clumping of sperm) and why it may not be as clinically relevant as once thought. Finally, they tackle the often-misunderstood topic of morphology. Even when sperm shape is abnormal, this doesn’t necessarily indicate issues with DNA integrity or a poor overall count. You won’t want to miss this episode sponsored by ReceptivaDx.
Episode Transcript:
Susan Hudson (00:01)
You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.
Carrie Bedient MD (00:22)
This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test that can help detect inflammatory conditions on the uterine lining that might be preventing you from becoming pregnant or staying pregnant. If you have experienced implantation failure or recurrent pregnancy loss, ask your doctor about ReceptivaDx testing. If found, uterine inflammation can be treated, providing a new pathway to achieving a successful pregnancy.
ReceptivaDx because the journey is worth it.
Susan Hudson MD (00:49)
Hello everyone, this is Dr. Susan Hudson from Texas Fertility Center with another episode of Fertility Docs Uncensored. I am here with my crazy, cunning, and confident co-host, Dr. Carrie Bedient from Fertility Center of Las Vegas and Dr. Abby Eblen from Nashville Fertility Center.
Abby Eblen MD (01:06)
Hey everybody, I hope I’m not the crazy one.
Susan Hudson MD (01:08)
I think we’re all a little bit crazy.
All right. We also are so excited to have Dr. Sam Ohlander join us today. He is a reproductive urologist, so we’ll be talking about everything about sperm, at Fertility Centers of Illinois, as well as University of Illinois in Chicago.
Sam Ohlander MD (01:26)
All right, well, thank you guys for having me. I’m hoping that I’m not the crazy one as the urologist here.
Abby Eblen MD (01:33)
You’re the unicorn, you’re the unicorn.
Sam Ohlander MD (01:36)
Thank you. I’ll take that.
Carrie Bedient MD (01:37)
I feel like all reproductive urologists have a streak of crazy in them because by default you’re always talking about penises and testicles and then you add a sperm component to them. I feel like there’s a special personality that goes to that that is always so much fun to talk to and hang around.
Abby Eblen MD (01:51)
I agree.
Sam Ohlander MD (01:55)
You have to be a little bit quirky, right, to do that for a living and have those conversations and such. So but it’s a hey, it’s a fun way to live.
Abby Eblen MD (02:02)
Yeah, I would say every reproductive urologist I’ve been has always been really nice and really funny. So. Okay.
Sam Ohlander MD (02:08)
Well, well we’ll see what we can do today. It’s a high bar I’ve got to get up to.
Susan Hudson MD (02:13)
You gotta represent your peeps.
Abby Eblen MD (02:15)
That’s right.
Sam Ohlander MD (02:15)
That’s right, that’s right.
Susan Hudson MD (02:17)
So Sam, we were talking before we started recording today and I understand you’ve got a battle with rabbits going on.
Sam Ohlander MD (02:26)
Yeah, it’s pretty serious at this point. I’ve lived for a really long time in Chicago proper, in the city there we have rats, but there are the city is taking care of those and we’re not messing with those too much. It’s concrete, right? You have concrete. You don’t have too much of a yard. I’ve recently moved out to the suburbs and we have some, some plants and things along those lines and they’re just getting mowed down by rabbits. We have a fence. I don’t know what to do.
Abby Eblen MD (02:37)
No bunnies there.
Sam Ohlander MD (02:49)
Been purchasing the various products from Home Depot or whatnot. And I just can’t keep these things away. And so I’ve been told that I need to purchase wolf urine. I’m not sure exactly where to get that. I’m intrigued. Again, urologist. you know, yeah, yeah. So so that’s, I think going to be the next step right now because we want to keep them alive and everything like that. And I even have a dog and my dog is a hunting breed, which in theory you would think that, okay, he can smell out these rabbits and scare them away. They will be sitting in the yard. We let him out and he just kind of stands there.
Abby Eblen MD (03:15)
Yeah, we don’t want to kill him.
Susan Hudson MD (03:33)
To a comment that in fact, you can buy wolf urine on Amazon.
Abby Eblen MD (03:38)
I told you, I knew it! How much is it? How much?
Sam Ohlander MD (03:38)
Well, there you go. How much though?
Susan Hudson MD (03:42)
It’s $43 for a 16 ounce spray bottle combo with scent tags. I’m not exactly sure what scent tags are, but I’m guessing this is something that complements the wolf urine.
Sam Ohlander MD (03:51)
Okay.
Yeah. I mean, steep price though. I know I’m a little bit concerned. There’s a spray that I use right now. That’s fairly strong, like cayenne pepper type smell to it. And, and that’s not very pleasant on the hands. So, that one kind of, caught a little burst of wind and it came back at me the other day. So, uh, that’s one that, all of these seem to be a little bit, a little bit nasty.
Susan Hudson MD (04:16)
There’s one that’s only $39 and it comes in a big jug. It doesn’t say how many ounces it is, but it’s Lenon Lures since 1924.
Sam Ohlander MD (04:26)
Okay.
They’ve been using it for that long.
Susan Hudson MD (04:30)
They’ve been using it for that long.
Sam Ohlander MD (04:32)
Interesting. Wow.
Carrie Bedient MD (04:33)
Where do you suppose they get all the wolves to get the urine? Because remember how menotropins were found with the in the convent? Like is there a convent full of wolves where you can collect wolf pee?
Sam Ohlander MD (04:40)
Yeah.
Yeah. And how exactly are they getting it? Just not just the animal, but then what’s the collection method?
Abby Eblen MD (04:51)
That is a question a urologist would certainly want to think.
Sam Ohlander MD (04:53)
I know in my head I’m thinking about like condom catheters and catheterizing thing, and yeah, exactly. Poor wolves.
Abby Eblen MD (04:59)
Wow, poor wolves.
Carrie Bedient MD (05:02)
Cool.
Susan Hudson MD (05:02)
I don’t think I would want to be the person responsible for collecting wolf urine. I’ll stick to eggs.
Abby Eblen MD (05:09)
We’ve never given a gift, I don’t think, to our guests, but maybe this could be your gift. Maybe in the next few days, a big gallon jug of wolf pee.
Sam Ohlander MD (05:20)
That would be wonderful at 30 to $40 for a jug. I mean, very much appreciated. Yeah.
Carrie Bedient MD (05:23)
It was a shock.
It’ll just show up at your front desk in your office and ⁓
Sam Ohlander MD (05:34)
Yeah, you know what? There probably wouldn’t even be that many questions. So it’d just be like, it’s It’s here. Yeah.
Susan Hudson MD (05:37)
Hahaha
Susan Hudson (05:45)
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Susan Hudson MD (06:13)
Let’s do a question today. All right. So our question today is I have found great comfort in your podcast while going through our infertility journey. Thank you so much for listening. We’re doing IVF due to low sperm count. My question is we had 18 eggs retrieved and of the 18, six fertilized. They had done ICSI. I’m wondering what would make the numbers low. I’m 31 and my husband is 37.
My estrogen was quite high. I don’t want my husband thinking it’s his fault and right now that’s how he’s feeling.
Sam Ohlander MD (06:43)
Well, from my perspective, I think that’s really a tricky scenario because one, I hate when people think it’s their fault because there’s so much of this that we can’t, we can’t say definitively it’s one side or the other side. And the reality is, is in most situations it’s for whatever reason, probably a combination of both. And so, you hate to hear somebody saying that they’re thinking it could be one or another.
There’s a lot of different factors when I’m thinking from the male perspective, I’m thinking about, is the sperm alive? What sort of motility are they looking at there? You think about certain aspects of sperm quality, thinking about the morphology to a certain degree, though I’ll kind of hit on that a little bit later on my thoughts there. So think that there’s a lot of different things. I think that just coming in with a short abstinence period, trying to get a real fresh sample, making sure that you’re leading up to it with frequent ejaculation. You’re trying to live a healthy lifestyle leading up to the specimen collection. I think that those are all different things that you can do to really try to optimize the sample and see if you can improve things.
Susan Hudson MD (07:45)
Sam, I’d like to ask you, you mentioned the short ejaculation period and that’s been a topic that’s coming up a lot lately. Okay, no pun intended. And so, I
Sam Ohlander MD (07:54)
I like it.
Carrie Bedient MD (07:57)
I would like to point out I was not the one who said…
Sam Ohlander MD (08:00)
Nor was I.
Susan Hudson MD (08:03)
What do you consider a short ejaculation period and who should be doing this? Is this something new that everybody should be doing or is it only people were worried about things like DNA fragmentation? What’s your thought on that?
Abby Eblen MD (08:06)
Yeah.
Sam Ohlander MD (08:16)
Well, it’s one of my general recommendations to patients. When I’m seeing patients, I tell them at baseline, whether they’re trying to conceive spontaneously or whether they’re going through assisted reproduction, it’s healthy to be ejaculating. If you’re sitting there trying to build up, I think the common misconception from guys is that they need to build up a really good sample. And so they’ll go for these extended periods of time where they’re just going to be getting that older sperm that’s going to be starting to degrade.
The products of degradation are going to reduce the sperm quality of the sample that’s there and everything. So you want to be moving that sperm through the reproductive tract. My general recommendation is around every two to five days for patients, just as their living life. However, when they’re coming up to a cycle, like an IVF cycle, then I’m telling them to ejaculate the night before and then producing the sample the morning.
Less than 24 hours ideally, the shorter the better to be very, very honest with you.
Abby Eblen MD (09:09)
Okay.
Carrie Bedient MD (09:11)
So if someone ejaculates, let’s say five days before their retrieval, or let’s not even say that, what if they’re one of those people who just went a long period of time and then they get to the night before their retrieval and they’re like, oh, oops, totally forgot to do this, they ejaculate and then they do another ejaculation the next morning. Will that ejaculation from the night before, will that totally…clear out everything that was sitting there or is there a percentage that’s going to remain that’s going to still show up in the next ejaculate?
Sam Ohlander MD (09:43)
No, they’ll probably still have something showing up. But I think that it helps improve things as is though, too. So every little bit helps in these things. So we can never really predict which sperm is going to be the one that produces success. So even if those instances I tell guys, don’t beat yourself up about these sorts of scenarios. It’s what happened. It’s the instance that occurred. We’re doing the best things that we can. We’ve got a lot of tremendous technology that helps us out with in vitro fertilization and ICSI and things. So we’re going to do everything that we can our end and if we don’t necessarily get the outcome that we want, well we’ll regroup, reevaluate and see what we can do next time.
Susan Hudson MD (10:19)
Carrie and Abby, do you have any other words of advice for our listener?
Abby Eblen MD (10:23)
Well, one thing I thought about, she mentioned that her estrogen level was really high and she got 18 eggs. Sometimes in situations like that, those are patients that have PCOS. And sometimes the estrogen level gets really high. Sometimes we tend to trigger people a little bit earlier than we normally would just because the estrogen level gets so high. And so what happens is a lot of those eggs that we get are undercooked, immature. And so therefore, if it’s an immature egg, it’s much less likely to fertilize.
So definitely would be worth talking to your doctor about that just to get some sense for how many eggs you really had that were mature that could be actually fertilized with a sperm.
Carrie Bedient MD (10:56)
The other thing that you can consider is there anything that happened in the previous month or so that might be related to lower egg quality? Fevers are the big culprit here. Did you happen to get sick and maybe that was related to it? The other thing is that as much as we all hate to admit this, ovaries are entitled to have a bad day and a bad day for an ovary is really a bad month. And there are patients where they will go through multiple cycles and their ovaries will perform in some way and then we’ll get some random cycle in the midst of it where it’s way better or way worse and we have no explanation for that whatsoever. And so that’s always a component of it as well and there’s a lot that we just don’t know that we can’t test for and so we just smile, take a deep breath and do it again.
Susan Hudson MD (11:41)
Totally agree. Totally agree. Well, let’s talk a little bit about the semen analysis, why it’s important. What are some things that are good about it? What are some things we really don’t care about in all honesty? And go from there. So, Sam, of describe why do we even do a semen analysis?
Sam Ohlander MD (12:00)
Yeah, it’s the best test that we have because it’s a semen analysis in of itself. It’s not a test of fertility. That alone cannot tell you whether somebody is fertile or infertile with rare exceptions. If somebody’s azoospermic, they have no sperm in the ejaculate, they’re going to be infertile. If somebody’s sperm is just completely not moving, well, they’re not be able to conceive spontaneously or with IUI. So there’s certain instances, but otherwise it just gives us an understanding a little bit of the patient’s reproductive potential.
And so, what a semen analysis is and how they establish these, these thresholds was they took this big, large cohort of a whole bunch of different people that frankly, there’s massive areas of geographic, spans that weren’t included in this, but they took all these guys and they took semen analyses from them. And then they took the bottom 5th % off.
And so it represents the bottom fifth percentile of very specifically a bunch of fertile men. So there’s 5 % of guys who are below those levels too that did spontaneously conceive as well. And so it’s giving us an understanding of somebody’s potential to conceive naturally. And then through the course of time, we’ve correlated these things back to intrauterine insemination, in vitro fertilization so that we can provide the best recommendations that we can to our patients.
Carrie Bedient MD (13:18)
I would just like to point out that even if you are in the bottom 5 % of your class, Bill Gates and Steve Jobs never finished college. And so just because you show up in that portion of the class doesn’t mean that bad things are going to happen. It just means that you are so amazing you could not possibly conform to everybody else’s standards. And so for patients who are listening to this, don’t despair. We got hope.
Sam Ohlander MD (13:44)
Yeah, there’s nothing that says that people with numbers below that necessarily can’t conceive or that they can’t have a child or anything. it’s just, yeah. Yeah. It just, it just gives us an understanding of what’s going on.
Susan Hudson MD (13:52)
It only takes one good one.
Susan Hudson MD (13:57)
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Carrie Bedient MD (14:27)
So can we talk about the parts of the semen analysis that don’t matter? Because we get a lot of this. I think a lot of people realize, these are the things that do matter, the count and the movement. Can we talk about the stuff that doesn’t matter first?
Sam Ohlander MD (14:33)
Yeah.
Abby Eblen MD (14:42)
Morphology, let’s talk about morphology.
Sam Ohlander MD (14:44)
Yeah, was gonna say morphology. Morphology is one of those things that is always emphasized. I think that is probably the topic that I discuss the most in my consultations with patients, but I care about it the least. Yeah. So it just gives everyone so much anxiety. And I get that, lots of times they’re getting these reports, they see 1 % normal. Are you kidding me? It’s hard not to spiral in those sorts of situations.
Susan Hudson MD (15:11)
So for our listeners when we’re talking about morphology, we’re talking about the shape of the sperm. So both the sperm head as well as the sperm tail. Sam what are some of the abnormalities that we can see in something like this?
Sam Ohlander MD (15:23)
Yeah, so basically when they’re looking they’re gonna see some sperm that maybe have large head, short tails, maybe they’re missing what’s called an acrosome, which is a little cap that’s at the head of the sperm. And sometimes they’re simply just saying head defect, midpiece defect, tail defect. And so the amount of information that you’re getting from a morphology assessment is gonna be really pretty variable based off of the lab that you’re going to as well.
Susan Hudson MD (15:46)
And I’d like to make the point that on the criteria that most of us use, we would say 4 % morphology is normal. And that means you can have 96 % of your sperm being abnormally shaped and that is still normal.
Sam Ohlander MD (16:04)
Yeah. And what I, when I’m explaining this to my patients too, is that we’re talking about these numbers. We’re talking about their concentrations, their total motile counts and everything like that. When they’re doing a morphology assessment, it’s typically an assessment of about 200 sperm. That’s, that’s about the amount. So it’s really a pretty small sample size of things.
Abby Eblen MD (16:23)
So Sam, is it fair to say that in years past we sort of said that morphology may have something to do with the sperm’s ability to bind to and penetrate the egg? And are there any other tests now that we could do that might look at that in a better way?
Sam Ohlander MD (16:36)
Yeah, in the past, that was the understanding of why we emphasize it so much is that we thought that it was about the ability to fertilize the egg. And it still may be so, but I think that the assessment that’s on a semen analysis can’t necessarily give us that information because it’s such a small sample size. Now, with morphology, if I’m looking at it and thinking about it from a embryologist who’s sitting there and looking at the full sperm sample, that’s a different morphology assessment to me than like a strict morphology on a semen analysis. And I put a little bit more emphasis into that in terms of sperm quality. But in terms of other tests that people can do for fertilization capacity or things along those lines, we’re trying to develop these sort of things that are clinically applicable. They’re looking at things like cap score, they’re looking at things like PS Detect, that’s one of the newer tests that looking at phosphotidylserine. And so there’s some of these things that are trying to understand the function of sperm rather than just is sperm there, is sperm moving, but not really knowing too much about it.
Carrie Bedient MD (17:39)
Is there a difference in what kind of results you get when you are getting an automated semen analysis, like one of the ones that comes through the big commercial labs versus one that’s done typically by hand or at least checked by hand by our andrologists in fertility centers? What do you see as a difference? Because I always I see a difference between what I get and then what I get when we actually prepare it at our place for the IUI. And sometimes there are massive differences.
Sam Ohlander MD (18:07)
Yeah, and some of that could be just the natural variation between the sampling of what they looked at. I’m always gonna trust a sample that’s looked at by somebody a lot more. And if I’m getting a sample that’s done by a big automated type thing, pretty much the first thing I’m gonna do is get a sample that’s done in our lab, because I know our technicians, I know what they’re doing, I know the quality of a semen analysis that I’m gonna get.
And sometimes I think it’s hard to explain to patients, why are we repeating a study that they have one of? But there is differences. That’s good that they got that initial one. It gave a screening mechanism. They found their way to me because they went through that process. But we need to dig a little bit deeper and get a little bit higher quality study.
Abby Eblen MD (18:49)
As a corollary, what do you think about those semen analysis? And I’ve had several patients lately that will do their own, they’ll do it via mail, they’ll contact somebody through the internet and do it through mail. What do you think about those in terms of screening?
Sam Ohlander MD (19:01)
Yeah. I think that I think it’s great for screening. So I think that’s the key. I think that there’s two different types the direct to consumers semen analysis, there’s the one that you can purchase, it’s an app on your phone, you’re getting the result there. Those ones have quite a bit of limitations with them. Whether it’s the concentrations, whether they can say below this threshold of sperm, it’s, less than 5000, well, that makes a little bit of a difference, whether it’s zero or 3000 or something along those lines, they might not be able to assess motility, different components of things, as well as you’re leaving a lot in the patient’s hands, as to how they’re doing and performing the actual tests too. So there’s some variabilities that can come into play there, the patient is not counseled on here’s the steps that you need to do to make sure that this is done in the highest possible quality fashion. So those quality control measures. Now, I think the ones that are the mail in type tests are a little bit better. For the most part, those are being run at high quality labs that do have measures of quality control and things yet there’s still a lot of variables that I think are hard to really understand. For me, it’s difficult to conceptualize how they can take the sample and they can mail it to somebody then yet still get a real good motility assessment of things. And, what is this being preserved in that they can run a DNA fragmentation test on and I can still feel pretty comfortable about those results. So yeah, they hold a great spot in getting patients evaluated, especially the ones that maybe don’t have access to care. There’s a big areas of land that don’t really have reproductive specialists.
Abby Eblen MD (20:16)
Yeah, I agree, yeah.
Carrie Bedient MD (20:18)
Yeah.
Sam Ohlander MD (20:39)
So there is a great role for those. But then I do think it’s important for them to get a semen analysis done at a reproductive center.
Susan Hudson MD (20:47)
What are some of the other components of a semen analysis that you don’t put as much weight on?
Sam Ohlander MD (20:52)
Well, I think that that’s tricky, because there can be scenarios where it’s relevant to me, but other scenarios where maybe I’m not as concerned about it. And one thing I’ll talk about is round cells in the sample. Round cells are a tricky thing, because it might be immature sperm, which really don’t have too many consequences to the reproductive potential of the sample, or could be inflammatory cells, it could be those leukocytes and such in really a basic semen analysis can’t differentiate those two things very well. Yeah.
Abby Eblen MD (21:21)
And what do you do with that? Because I think different urologists do different things. So what do you do if you see those round cells as opposed to what we might do?
Sam Ohlander MD (21:28)
So typically, what I’m going to do is try to get a formal pyospermia stain, where they can tell me is this truly leukocytes that we’re seeing within the sample is it a really evidence of inflammation. And then even if you get a result that says, yeah, it is inflammation, what do you even do with that? Because the data there is pretty inconclusive as to how does that actually impact outcomes? If it’s a couple that is, trying to conceive spontaneously, yeah, then I’m going to do everything that I can to try to, remove a variable for even if it’s something that we’re questionable about, its true clinical impact. I’m going to try to do what I can. So I’m going to typically start with telling them again, frequent ejaculation. Then I’m going to talk to them about, some antioxidants. There’s some debate there. And that’s where it’s going to become my starting point. And then I typically start with NSAIDs.
Abby Eblen MD (22:12)
I think for us it may be a little bit different, or at least in our lab. If we see that, we really jump on and actually do a sperm culture. Because if we’re doing IUIs, intrauterine inseminations, and we’re taking… So for our listeners that are listening, they may go, well, why did they do all this? But if we put sperm up inside the uterine cavity in an environment where there’s no germs, and it turns out that there is an infection in the sperm, then we worry that we could get like a PID, a pelvic infection. So we tend to be a little bit more aggressive. But didn’t realize until fairly recently that…I assume that the the urologists did the same thing, but you guys don’t, I just found out.
Sam Ohlander MD (22:42)
Yeah, I mean, for the most part, we’re gonna start with anti-inflammatories first, we’re gonna give a course of anti-inflammatories, because typically it’s an inflammatory nature, not infectious in nature. But again, this isn’t, there’s not a standard protocol for this. This isn’t something that has a guidelines based, standard of care, a treatment assessment pathway. And there’s so much of that within male reproductive medicine. There’s so much that I think is driven by, some degree of data but how high quality and a lot of comes from expert opinion.
Susan Hudson MD (23:12)
So when you’re addressing it from the urologist perspective and you’re using anti-inflammatories, are you using ibuprofen?
Sam Ohlander MD (23:18)
I usually will do something prescribed. So at times I’ll use ibuprofen, but otherwise I’ll use Celebrex a lot.
Susan Hudson MD (23:25)
Okay, all right, and you would do that for how long?
Sam Ohlander MD (23:28)
Two to four weeks. And then I’m gonna reassess the semen analysis, recheck to see if that’s cleared. Yep, yep.
Susan Hudson MD (23:29)
Okay. And ejaculating every two to five days. Okay.
Abby Eblen MD (23:36)
Why Celebrex Why do you choose Celebrex?
Sam Ohlander MD (23:39)
It’s the anti-inflammatory that I’ve always used. And I don’t know that I have a clear answer for that other than that.
Abby Eblen MD (23:46)
Okay, that’s fair. That’s fair.
Carrie Bedient MD (23:46)
I mean, it’s your favorite drug is a legit answer.
Sam Ohlander MD (23:49)
Yeah.
Carrie Bedient MD (23:50)
So tell us what you think when the semen analysis comes back and it says, moderate debris on it. First of all, what is the debris? You’ve got to figure nobody’s dragging their penis through a trash can. That’s not it.
Sam Ohlander MD (24:03)
Listen, I have seen a semen analysis that the read said there was carpet fibers in it before. So there can be all sorts of different things within a semen analysis. You never know. Yeah. I’m not exactly sure either, but it was very specific. It did say carpet fibers present so…
Abby Eblen MD (24:12)
Wow.
Carrie Bedient MD (24:19)
Maybe they were telling you to clean the office extra hard that day.
Sam Ohlander MD (24:22)
Yeah, I could be could be. Well, typically, though, it’s just gonna be various amounts of cellular debris, dead cells, sometimes there can be epithelial cells or things along those lines that just kind of accumulate and become a part of the cellular debris that’s in there.
Abby Eblen MD (24:26)
No collection in the back of the car or something.
Sam Ohlander MD (24:43)
It matters for me if the concentrations are low, sometimes if there’s an automated assessment of the concentrations, it might falsely say that the concentration of sperm is a little bit higher than it is. So I do put to pay attention to it in those scenarios.
Susan Hudson MD (24:57)
But in our offices where we’re doing more manual type of situation that usually when we get debris we shouldn’t have to worry about it.
Sam Ohlander MD (25:06)
Right, less significant in those instances where I’m typically not as concerned. Again, this just comes back to again, I’m telling these guys frequent ejaculation, make sure that you’re moving this fluid through the reproductive tract. And I’m talking about to them about collection technique.
Carrie Bedient MD (25:18)
So this is not something we’re recommending like penile exfoliation to get rid of dead cells is particularly necessary. We’re talking more about internal stuff that needs to get cleaned out and frequent ejaculation will fix that rather than having to go get a facial for not your face.
Sam Ohlander MD (25:31)
Yes.
Yeah, well, I will say I’m also doing an exam and all my visits are all my initial visits as well. So I’m going to be aware if they have some real significant, genital urinary eczema or something along those lines where I’m paying attention to those factors. Yeah.
Carrie Bedient MD (25:51)
Yeah, that’s right.
Susan Hudson MD (25:53)
So you’ve mentioned a couple of times collection technique. What are things that guys need to know when they’re collecting to help us get a good specimen? Because, I mean, if we don’t get a good specimen, we’re only as good as that is?
Sam Ohlander MD (26:06)
Exactly. And I tell them that it is awkward. There’s no way around that. It’s awkward. They’re typically not going to get the normal sexual stimulation that they might get from a spontaneous sexual encounter. So it’s going to be different. And so the first thing that I’m always telling them is just, have that expectation and understand that that’s okay, that we understand that that’s it’s not unique to them, that all of our patients, all guys that we’re having to go through this collection, that’s a part of it.
And then the other thing is the logistics of things. You tell a guy, okay, you have to masturbate into a cup. The guy’s thinking is mine, okay, I’ve got to go, I’ve got to masturbate into a cup. And then he’s got to do that. There’s the trying to hold the cup and everything and I mean, it’s not the easiest thing for a guy to do. So I also try to explain to them with that too, that, hey, listen, this might be a little bit tricky, try to do the best that you can to collect.
And then, not using lubricants or anything along those lines for the collection. Trying to get a time period of abstinence that’s accurate beforehand. I tell them again about two to five days. I tend to favor the two to three day abstinence period for collection. And then, when you’re transporting it, trying to keep it at body temperature.
Collecting at home and bringing it in, making sure that you’re doing that, that you’re not trying to get the sample as far away from you as possible during the time period, that you’re transporting it, that you’re not leaving it in the trunk of your car for an hour while you run an errand or those sorts of things.
Susan Hudson MD (27:31)
Coming from a different geography than you, but we’re always like, don’t stick in front of the air conditioner and don’t sit in on the Texas hot seat.
Sam Ohlander MD (27:36)
Exactly.
Abby Eblen MD (27:37)
People always think it needs to be on ice and we’re like, no, it doesn’t need to be on ice. ⁓
Sam Ohlander MD (27:41)
Yeah, yeah.
People always want I agree people always want to ice their specimen.
Carrie Bedient MD (27:43)
Don’t put it on your-but don’t put it on your heated seat in the car seat next to you either.
Abby Eblen MD (27:49)
Yeah, true. It likes body temperature.
Sam Ohlander MD (27:49)
Exactly, exactly.
Yep, yep. And so trying trying to do those sorts of things to one put them at ease to understand that, other guys struggle with this, and it can be challenging for other people to, I think, helps guys just relax a little bit. And so that for me is one thing that I’m talking about when I’m when I’m having my initial consultation, talking about how we’re going to get a repeat semen analysis.
Abby Eblen MD (28:04)
Yeah.
Sam Ohlander MD (28:13)
And different things that they might be able to do to help improve the sample. The big thing I see from the first semen analysis is almost always the volume is reduced. Again, not necessarily just because they lost some specimen, but because maybe they’re uncomfortable, they’re not getting that normal sexual stimulation, those sorts of things.
Abby Eblen MD (28:30)
But guys, if you lose volume, let us know. Don’t be embarrassed by it because that can affect, we’re like, why is his volume so low? And so make sure you let somebody know if you don’t collect your full sample in cup.
Susan Hudson MD (28:42)
Why it’s important is because when we come into our appointment with you and we’ve looked at your semen analysis and we’re like, we’re really concerned versus if it’s a semen analysis and it says, he missed part of the ejaculate, like we’re a lot less concerned and worried and we’re going to be like, okay, well, these are things that can be affected by having missed the cup. These are things that shouldn’t have been affected by missing the cup. So maybe we need to repeat or maybe we may not need to repeat but that that is so so important.
Sam Ohlander MD (29:17)
Yeah, there’s a lot of things with with volume that relate to my differential when I’m talking about a patient to like that’s a big component of my evaluation of patients. So when we’re talking about things that aren’t very important. Volume is something that for me is very
Abby Eblen MD (29:30)
So what are the other things that can affect volume?
Sam Ohlander MD (29:32)
Well, I mean, an obstruction. So if they have an obstruction somewhere, so some guys can have it where everything is completely obstructed at the level of maybe the testicle, those guys are still going to produce some fluid. It’s not like everything’s going to be absent. It’s the clue is going to be coming from the prostate and the seminal vesicles, they can have retrograde ejaculation. So it can be going in the backwards direction. They could have an absence of one testicle or one vas deferens. So maybe they’re only getting contributions from really one side. So different things there too.
Susan Hudson MD (30:07)
Medications that have an effect on volume
Sam Ohlander MD (30:09)
Yeah. I mean, the big one as a urologist is the prostate medications. So, things like Tamsulosin, which is an alpha blocker, the one major side effects of that is retrograde ejaculation. And so getting guys off of certain medications, because again, that’s a medication that that’s in my wheelhouse as urologist. So that’s one thing where I feel comfortable about making changes in medication to something that is, maybe a little bit more favorable has less of that side effect, maybe changing them from an alpha blocker to something like a daily Tadalafel, which can have some improvement of urinary symptoms and things like that as well, but doesn’t have the side effects. So we can change medications. Additionally, medications that can manipulate some aspects of the hormonal axis. So things like finasteride and such, which, we see so many guys using visits readily available, especially through various mail order avenues and things like that.
Susan Hudson MD (31:03)
Other components of the semen analysis that you do find is very important.
Carrie Bedient MD (31:07)
Wait, I have one quick question before we leave the volume issue. Does dehydration have any impact on that? Because in Vegas, this time of year, people ask me that all the time. Does dehydration have any impact on it?
Sam Ohlander MD (31:10)
Yes.
Abby Eblen MD (31:14)
as in Las Vegas. Yeah.
Sam Ohlander MD (31:21)
Yeah, I do see some some changes with it. So if a guy is pretty dried out, yeah, they’re gonna maybe see some reduced ejaculates and everything. If the dehydration is from a night out where they’ve they’ve had some fun and everything, there’s a lot of variables that are just the dehydration
Carrie Bedient MD (31:38)
Thank you.
Susan Hudson MD (31:38)
Okay, so back to other important parts of the semen analysis.
Sam Ohlander MD (31:42)
I’d say obviously concentration. I don’t know how much we needed to talk about that.
Susan Hudson MD (31:45)
Right, so concentration is important. Concentration is one of those big ones that if you miss the cup, that can have a huge effect, right? Because you have the highest concentration at the beginning of the ejaculate.
Sam Ohlander MD (31:53)
Yes.
Abby Eblen MD (31:57)
Okay.
Susan Hudson MD (31:58)
Very good. And then motility. Talk a little bit about progressive motility, non-progressive motility.
Abby Eblen MD (32:03)
Yeah, questions about motility for sure.
Sam Ohlander MD (32:06)
Yeah, usually for like a calculation of a total motile count, we’re primarily using total motility, but I’m always paying attention to progressive motility. If the couple is actively trying to conceive through methods other than in vitro fertilization, essentially, because if they are trying to conceive through IUI or spontaneously conceive, timed intercourse, those avenues, they need that sperm to be moving, they need it to find its way.
They needed to go and get that egg to fertilize. So progressive motility matters. You don’t want something that’s just seeing they’re twitching. But then you’re going to look at some of those variables like, Hey, how long ago did they collect this? How did they transport it? And confirming that they didn’t use any spermatotoxic lubricants or anything like that. So you’ll check in on those variables. If you’re seeing that if they’re trying to conceive through, something like IVF with ICSI, well, motility isn’t as important in those instances. Essentially, it’s a surrogate of viability. If a sperm is moving, you know it’s alive. And so then they’re able to use that for the insemination. So for me, the progressive motility maybe doesn’t matter so much in that instance, as it does for the other avenues of trying to conceiving.
Abby Eblen MD (33:16)
So then you must be glad that the WHO breaks it down now into like motility, progressive motility, and there’s like four different categories and used to it was just either motile or non-motile. I will say that made it much easier as a physician to explain to people, yeah, this sperm’s moving, this sperm’s not, but it’s little bit confusing now.
Sam Ohlander MD (33:31)
Yeah, I’m really only focusing in my discussion with patients about total motility and then progressive motility. I’ll have conversations about that, but the other factors and like they say some slightly twitching, I tell patients that, listen, we know that it’s alive. It’s helping us with understanding viability, but I don’t spend the time with big discussions there unless I get specific questions.
Abby Eblen MD (33:45)
Yeah.
Susan Hudson MD (33:54)
What are other parts of the semen analysis that you have strong feelings one way or the other about?
Sam Ohlander MD (33:59)
Well, now we’re gonna get back to morphology. So yeah, I mean, again, we hit on morphology a little bit earlier. And it’s just one of those factors that I feel like the more that we learn about it, the less important it’s become. Because it’s just not the data is just not showing that from a strict morphology assessment on a semen analysis, it’s just not correlating with the reproductive outcomes, things that matter.
The fertilization rates, the pregnancy rates, the live birth rates, things along those lines. It’s not dictating which avenue of reproductive care we might go down in most instances. Now, traditional IVF versus ICSI, sure, maybe you’re going to make some decisions based off of morphology. And everyone’s practices and how they approach morphology is a little bit different. But I’d say from a reproductive urology standpoint, I think there’s less and less relevance with it.
Carrie Bedient MD (34:49)
Awesome. One last thing for us to have to think about in a, my gosh, freak out kind of way.
Abby Eblen MD (34:52)
Yeah.
Sam Ohlander MD (34:54)
Right. And I always emphasize abnormal shaped sperm does not mean abnormal shaped child. Yeah. Yeah. Yes. Yeah. Because that is I mean, that is what everyone comes in scared about. Everyone is scared about that.
Abby Eblen MD (34:58)
Normal babies. yeah, that was genetics. Yeah, and then how do you do the genetics? Yeah. That’s huge.
Susan Hudson MD (35:08)
So I have a question regarding timing of a semen analysis and not necessarily since last time you’ve ejaculated, but when should a guy have a semen analysis completed? So we have lots of people who come into our clinic and they’re like, the ladies are like, we just need to check me out because he’s had kids before. I know it’s not him. Which of the guys need to give their little specimen in the cup?
Sam Ohlander MD (35:34)
All of them. That’s what my answer is. It doesn’t matter if somebody has had a child before things happen through life. Things change for various reasons. Somebody might have a varicocele or, they’re seeing a deterioration in semen parameters. There might be some epigenetic component of thing that’s triggered in that their gene expression has changed now. And now they’re seeing a reduction of spermatogenesis.
So there’s a lot of things that can change over the course of time. So if you’re getting an evaluation, mean, the evaluation should be in parallel. A semen analysis, yes, it’s awkward. Yes, it’s maybe for whatever reason, maybe a little bit embarrassing to have to be doing that, to hand over a cup, but it’s a pretty straightforward, easy test that gives us a lot of information. So it helps us understand the starting point of things. So for me, that is a very, very easy answer. I would love it if that was the first step along with whatever the first step might be on the female side of care as well.
Abby Eblen MD (36:32)
So Sam, I don’t want to end this without asking this most important question, because this is a question I get a lot. How strongly you feel about agglutination? Is that a big problem or not?
Sam Ohlander MD (36:42)
In most instances, I really don’t care about it too much. Okay. Yeah, yeah, especially
Abby Eblen MD (36:45)
Okay, I don’t either, but I just wanted to make sure you didn’t. ⁓
Carrie Bedient MD (36:49)
And liquefaction time as long as we’re talking about the random things.
Sam Ohlander MD (36:52)
Yeah.
Sam Ohlander MD (36:53)
Yeah, not not too concerned there. Agglutination, especially again, if they’re going through a process where they’re getting semen processing, it’s not gonna really hold much relevance at all. You know, if the lab is coming to me saying, Hey, listen, the sample, we’re having a lot of problems with it. That’s when it matters to me more. But you know, right? Right? Yeah, it’s usually and especially to have motility is maintained.
Abby Eblen MD (37:10)
If it’s like jello, you need to worry about it, but otherwise not so much.
Sam Ohlander MD (37:17)
They’ve got agglutination but they’re still producing good motility percentages and stuff, I certainly don’t matter about too much. Now if they have a bunch of agglutination and they have 2 % motility, Sure, we might look into little bit things a little bit more, we might look into anti-sperm antibodies, something along those lines. But for the most part, those instances are pretty rare.
Carrie Bedient MD (37:35)
So I have a series of questions that I’m gonna ask you of does it matter or not? We don’t need in depth because otherwise we’ll be here the rest of the day. Just yes or no. Okay, boxers versus briefs, do they matter?
Sam Ohlander MD (37:42)
Okay.
Carrie Bedient MD (37:52)
Biking a lot. Does it matter?
Sam Ohlander MD (37:54)
Can I answer you beyond yes or no? It depends on the time. It depends on the time of how they’re riding. I tell guys limit to an hour.
Carrie Bedient MD (38:02)
Okay, do the bike seats make a difference? Because they’ve got some that have more space.
Sam Ohlander MD (38:07)
Not too much. Lot of that’s about pressure on the perineum. They can get numbness, but not necessarily as much of a concern for me for sperm production, more about sexual function.
Carrie Bedient MD (38:18)
Hot tubs or really being immersed in really hot water whether it’s a bathtub or hot tub. Saunas.
Sam Ohlander MD (38:21)
Yes. Yes, that does matter.
Carrie Bedient MD (38:25)
Okay, working outside in perhaps Las Vegas heat in July, where you got an outdoor job. I get this one all the time.
Sam Ohlander MD (38:29)
Ha ha ha!
Sam Ohlander MD (38:31)
You know, don’t too much in Chicago, but I would say yes for that. I mean, I’ll compare it to firemen. They have a lot of heavy equipment, warm temperatures and stuff. And I think that, it can matter to a certain degree. The problem is it’s a variable that probably can’t do much change.
Abby Eblen MD (38:48)
Computers on your lap.
Sam Ohlander MD (38:49)
No, I’m not too concerned about that.
Susan Hudson MD (38:51)
Cell phones.
Abby Eblen MD (38:52)
Martians.
Sam Ohlander MD (38:53)
Yes, that’s going back to Las Vegas there in Nevada.
Carrie Bedient MD (38:54)
If I was gonna say if they had a heavy night drinking last night.
Sam Ohlander MD (39:00)
Yes. Just heavy night drinking in general. If you’re going through this process, I tell guys avoid binge drinking. I’m not saying you can’t drink. I’m not saying complete absence or anything like that.
Susan Hudson MD (39:10)
Marijuana.
Sam Ohlander MD (39:13)
Yes, if it’s daily, if it’s a couple, like a couple of times a week, I’m less concerned.
Susan Hudson MD (39:17)
Nicotine.
Sam Ohlander MD (39:18)
Yes, I’m typically more concerned about nicotine than I am about marijuana.
Carrie Bedient MD (39:21)
Vaping?
Okay, so it’s the nicotine, it’s not necessarily the cigarette.
Sam Ohlander MD (39:24)
Right, Pouches, zens, sort of things. Not good too.
Carrie Bedient MD (39:29)
Okay, thank you.
Susan Hudson MD (39:31)
I think that’s a great way to wrap up this episode and Sam, it has been so much fun having you. We definitely look happy back.
Abby Eblen MD (39:39)
I know, you need to come back again.
We can think of some other topics.
Sam Ohlander MD (39:42)
Hey, yeah, this is I mean, this is the best part. I love saying this is what I talk about in a consult. So I’d like having these conversations. And, I have a fellow and I always tell him my favorite thing to do every day is just sit and talk about reproductive medicine, because it’s so much fun. And there’s so much we we still have to learn and figure out too.
Susan Hudson MD (40:01)
I always think it’s fun when you have reproductive urologists and reproductive endocrinologists get together. I mean, honestly, it’s one of my favorite things at ASRM, our national meetings, because we get to talk about things that, you we kind of assume this, you kind of assume this, and we put them all together. And it’s like, hmm, maybe we should do something, it’s good.
Carrie Bedient MD (40:10)
Yes.
Abby Eblen MD (40:10)
Yeah.
Sam Ohlander MD (40:20)
Yeah, and I love it because where I practice at Fertility Centers of Illinois, integrating into a reproductive endocrinology clinic. And so, you my colleagues are right next door to me. So every single day that I’m in office, I’m having these conversations. If people are at different office, I get text messages and phone calls. And I love it. I mean, that collaborative care component is I mean, it’s truly, truly awesome.
Susan Hudson MD (40:43)
To say professionally outside of the people in my practice and these two lovely ladies, probably the most text messages go between me and my reproductive urologist colleagues.
Carrie Bedient MD (40:54)
Yeah. Yeah.
Sam Ohlander MD (40:55)
Well good, that’s a good thing
Susan Hudson MD (40:57)
It is a good thing. It is a good thing.
Well, thank you again for joining us and thank you to our audience for listening and subscribing to Apple Podcasts. We want you to get next Tuesday’s episode to pop up automatically and be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.
Sam Ohlander MD (41:15)
All right, thank you guys.
Carrie Bedient MD (41:15)
Visit fertilitydocsuncensored.com to submit questions and sign up for our email list. Keep an eye out for our book that’s being released September 23rd and get your pre-orders in now.
Abby Eblen MD (41:25)
And as always, this podcast is intended for entertainment. It’s not a substitute for medical advice from your own physician. See you guys later. Bye.
Carrie Bedient MD (41:32)
Bye.
Susan Hudson MD (41:33)
Bye!
Carrie Bedient MD (41:33)
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