Posts Tagged ‘infertility’

One Elite Sperm Wins the Marathon: Understanding Semen Analysis

January 19, 2019

Andrew Siegel MD  1/19/2019

The journey of sperm from ejaculation to egg fertilization is an arduous process that is nothing short of a marathon, or perhaps more like a “tough mudder” race. The pilgrimage covers challenging and demanding terrain with abundant obstacles and impediments — the hills and valleys of the vaginal canal, the unwelcoming and entrapping cervical slime, and in the final leg, the extreme narrows and expanse of the fallopian tubes. The few mighty sperm that are capable of overcoming these formidable obstacles and stumbling blocks are not always able to cross the finish line and penetrate the egg, so there is often no winner in this marathon. In that case, these elite sperm perish, having been so close, but so far away.

Health Sport Marathon Team Athletics Run Runners

 Image above, Xenzo at English Wikipedia [CC BY-SA 3.0 ( or GFDL (

A semen analysis is the best test to check a male’s fertility status and potential (or lack thereof when done following a vasectomy).  Although a specimen is easily obtained and analyzed, the results can be complex and nuanced.  Therein lies the utility of the marathon metaphor as an aide to help explain the complexities and meaning of the results.

Egg Sex Cell Sperm Winner Fertilization

Thank you, maxpixel for image above,

How does one provide a specimen for a semen analysis?

Most men are highly skilled and experienced at this activity.  It requires a minor modification from the usual routine.  Instead of cleaning up with tissues, carefully deposit the specimen into the specimen cup provided, seal the top and place the cup into a paper bag and hustle it off to the lab with the accompanying prescription ASAP.  The semen will be placed on a slide and examined microscopically.  Note that it is important to abstain from ejaculating for at least 48 hours prior to providing the specimen in order for the volume of the reproductive juices to be optimized.

What information will be obtained from the semen analysis?

  1. Volume of semen (1.5 – 5 cc)
  2. Number of sperm (> 20 million/cc)
  3. Forward movement of sperm (> 50%)
  4. Appearance of sperm, a.k.a. morphology (> 30% normal forms)
  5. Clumping of sperm, a.k.a. agglutination (should be minimal)
  6. White blood cell presence in semen (should be minimal)
  7. Thickness of semen

Marathon metaphor

A marathon is a long-haul endurance race (26.2 miles) with many participants (sperm) and usually only a single winner who crosses the finish line (fertilizes the egg). A sufficient number of participants (sperm count) ensure a competitive race to the finish line with the more participants, the greatly likelihood of a quality finish.

There are about 30,000 runners in the Boston Marathon, but in the fertility marathon there are millions and millions of participants. A fertile male can easily have over 300 million sperm in his semen (that’s 10,000 times the number of participants in the Boston Marathon).  If only a minimal number of participants show up on race day (oligospermia), there may be no one capable of crossing the finish line or doing so on a timely enough basis.

The runners need to stay on course, pace themselves and run in a forward direction. If the participants have poor mobility and move erratically without attention to direction (asthenospermia), they doom themselves to losing the race.

A quality runner most commonly has the characteristic size and shape (morphology) of an endurance athlete, which for a long-distance runner is typically long and lean.  If one has a build that deviates (head and tail defects) from that of the elite runner, it is likely that they will not finish the race, or not finish on a timely basis.

Runners need to focus and make every effort to meet the challenge.  However, if they are not serious about racing and instead of doing business decide to hang out and socialize (clumping together—a.k.a., agglutination) instead of pursuing the task at hand, the outcome will not be favorable.

If marathon security lapses and uninvited stragglers (white blood cells in semen, a.k.a. pyospermia) cross the mechanical barriers and infiltrate the course, the dynamics of the race are altered and the uninvited guests can cause direct harm to the participants, interfering with their ability to complete the marathon.

The runners (sperm) can be affected by the environment (semen) in which they participate.  Although these endurance athletes can deal with a variety of weather conditions, if conditions are extreme enough, the pathway to the finish line will be impaired.  Severe humidity (semen too thick, a.k.a. hyperviscosity), can be a substantial impediment to a competitive race time. In a severely dry and arid environment (minimal semen volume, a.k.a. hypospermia), the sub-optimal race conditions can also impair the race to the finish line.  Similarly, in severe rainy weather (too much seminal volume, a.k.a. hyperspermia), the route can literally be flooded with the marathoners’ capacity for finishing the race compromised.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Amazon author page with all books authored  including the following:

PROSTATE CANCER 20/20: A Practical Guide To Management Options For Patients And Their Families

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

MPF cover 9.54.08 AM

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor


Big Ball Series: What You Need to Know About Varicoceles

November 17, 2018

Andrew Siegel MD  11/17/2018

This is a continuation of the “Big Ball” series of entries, which provide information about common maladies that affect the contents of the scrotum.  The last few entries have covered hydrocele, spermatocele and epididymitis.  The final entry in the series will be next week, which will cover testes tumors–relatively rare occurrences, but one of the most common cancers involving young men. 

VaricoceleBy BruceBlaus [CC BY-SA 4.0  (, from Wikimedia Commons

A varicocele is a clump of varicose veins of the spermatic cord, the bundle of tissue containing the testicle’s blood supply. A varicocele causes an engorgement of blood that heats up the testicles, which is undesirable for optimal sperm production and fertility.  The reason testes are external to the core of the body is their necessity for temperatures lower than core temperatures; if testicular temperature is too high, sperm development can be negatively affected.

Varicoceles are not uncommon, found in about 20% of adult males.  Varicoceles are found commonly in infertile men, including 40% of men with primary infertility (unable to achieve pregnancy after at least 12 months of unprotected sexual intercourse) and 80% of men with secondary infertility (previously able to achieve pregnancy, but currently unable to do so).

Normally functioning veins have small valves that allow for only one direction of venous flow (backwards towards the heart).  A varicose vein has faulty valves that allow reverse direction of blood flow with gravitational maneuvers such as standing and straining. This causes a fullness in the cord of tissue in the scrotum immediately above the testes (spermatic cord).  Although many varicoceles do not cause symptoms, others give rise to fertility issues or a dull achy pain when the varicose veins are full.  90% of varicoceles are on the left side because of differences in venous drainage patterns of the left and right testicular veins.


Although men who have large varicoceles often complain of a mass or bulkiness felt immediately above the testes, many are diagnosed on physical examination in men who have no symptoms. They classically feel like a “bag of worms,” are most common on the left side and often cause the testes to be lower and lie horizontally as opposed to its normal vertical axis. They become more pronounced with straining and heavy lifting. They can vary from small, asymptomatic, unnoticeable varicosities that are only detected by your physician, to very large, symptomatic varicosities that can cause shrinkage of the involved testes, testicular pain and fertility issues.

Grading of varicoceles

Grade I: felt only upon asking patient to strain

Grade II: felt when patient stands

Grade III: visible

Ultrasound is a simple and non-invasive means of imaging the varicocele and the testes and is capable of diagnosing a small varicocele that is not evident on physical exam.

Varicoceles and fertility

It is important to know that most men with varicoceles are not infertile, but varicoceles are found commonly in infertile men. Varicoceles are associated with impaired sperm production and sub-fertility and are the most common correctable cause of male infertility. Varicoceles can negatively affect sperm count, motility and appearance.  In general, the higher the grade of varicocele, the greater the negative effect on fertility.  Proposed mechanisms for the impaired fertility are downward reflux of kidney and adrenal gland toxins, decreased testicular oxygen levels, increased testicular temperature that can affect sperm development, abnormal testicular blood flow, hormone imbalances, increased sperm DNA fragmentation, and oxidative stress.

Varicoceles merit treatment if there is discomfort or pain associated with gravitational and strain maneuvers or in the face of infertility. In the adolescent population, pediatric urologists generally repair varicoceles when there is discrepancy in the size of the testicles and when the smaller testicle is noted on the side of the varicocele.  In this setting, the goal of surgery is to improve testicular volume and sperm concentration.


An asymptomatic varicocele causing no pain or fertility issues needs no treatment. Treatment is recommended for men with infertility or chronic discomfort associated with the varicocele. The goal of treatment is to occlude all of the varicose veins draining the affected testes, to improve the fertility issue and/or the pain issue.  This can be achieved with surgery or embolization.  Surgery can be on an outpatient basis done laparoscopically or open, with the laparoscopic approach often chosen in children because of smaller caliber veins present in children.  Open surgery is done via a small groin incision with magnification. Each varicose vein is identified and tied off with suture to prevent the back flow of blood.  Potential side effects of surgery include testes arterial injury, hydrocele, testes atrophy and recurrent varicocele.

Percutaneous embolization is a non-surgical alternative done by interventional radiology. Using fluoroscopic guidance, the varicose veins are identified and occluded with permanent coils that are placed percutaneously.  Potential side effects include blood vessel perforation and coil migration.


Men can expect an average increase in sperm count of 10 million/cc, a 10% increase in motility and increased overall pregnancy rates.  Serum testosterone levels often increase as well.  About 70% of men will experience an improved semen analyses following varicocele repair with resulting conception in about 50%.

What you can do to keep your testes cool and functional

 Careful with the following habits:

  • Hot baths, saunas, steam rooms
  • Heated car seats
  • Keeping your laptop on your lap
  • Cycling in tight shorts
  • Wearing tight underwear


Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food


These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor


Clomid: Not Just For The Ladies

August 20, 2016

Andrew Siegel MD 8/20/2016


Frank Palopoli, Father Of Fertility

Frank Palopoli, the chemist who developed Clomid (clomiphene citrate), died last week at age 94. He conceived (pun intended) Clomid in the 1950s, a medication that stimulates ovulation and became the most widely prescribed fertility drug for women, resulting in pregnancy in millions of women who otherwise would not have been able to do so. Approximately 80% of women whose fertility is due to failure of ovulation respond to Clomid enabling conception. Clomid works by increasing production of hormones that spur egg ripening and release.

What’s Good For The Goose Is Good For The Gander

Clomid is not just for the ladies! In urology we have used it for many years to stimulate sperm production in infertile men with low sperm counts. But here is a little secret: it also raises testosterone levels nicely. It does so by stimulating the testes to secrete natural testosterone, as opposed to the other testosterone replacement products on the market that are external sources of testosterone that actually shut down testes production of sperm and testosterone. No shrunken testicles that have their function turned off, but respectable family jewels, happily churning out sperm and testosterone, as nature intended.

Clomid Biochemistry In A Nutshell (no pun intended!)

Clomid is a selective estrogen receptor modulator (SERM). It works by increasing levels of the pituitary hormones that trigger the ovaries to produce eggs and the testes to produce sperm and testosterone. It blocks estrogen at the pituitary, so the pituitary sees less estrogen and makes more LH (luteinizing hormone) that stimulates the testes to make testosterone, and more FSH (follicle stimulating hormone) that stimulates the testes to make sperm. This is as opposed to external testosterone, which does the opposite, increasing estrogen levels that prompt the pituitary to make less LH and FSH, which causes the testes to cease production of sperm and testosterone.

Clomid usually works like a charm in increasing testosterone levels and maintaining sperm production, testes anatomy (size) and function. Its safety and effectiveness profile has been well established and minor side effects occur in proportion to dose and may include (in a small percentage of people): flushes, abdominal discomfort, nausea and vomiting, headache, and rarely visual symptoms.

 One issue is that Clomid is not FDA approved for low testosterone, only for infertility. Many physicians are reluctant to use a medication that is not FDA approved for a specific purpose, requiring it to be used “off label.” However, Clomid is effective and less expensive than most of the other overpriced testosterone products on the market and has the major advantage of stimulating natural testosterone while not shutting down testicular function.

Bottom Line: By virtue of a very sophisticated biofeedback system involving the pituitary gland in the brain and the testes, the use of external testosterone to boost native testosterone results in whatever feeble function the testes might have had to virtually cease completely and the possibility of atrophied, non-functional testes that no longer produce any sperm or testosterone.

 Clomid is an oral, less expensive alternative to testosterone replacement that stimulates natural testosterone production as well as sperm production. Kudos to Dr. Palopoli, whose magic drug has not only helped millions of women get pregnant, but has also helped enable countless men to fertilize their partners as well as raise their testosterone levels. Clomid is safer and much more sensible than traditional testosterone replacement.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at

Author page on Amazon:

Apple iBook:

Trailer for The Kegel Fix: 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

Tobacco Keeps Me Way Too Busy As A Urologist

February 25, 2012




Blog # 47       Andrew Siegel, M.D.

To paraphrase Dr. David Katz—the master levers of our medical destiny are our fingers, forks and feet: fingers that may or may not bring cigarettes to our lips; forks that may or may not bring healthy food to our mouths; feet that may or may not participate in exercise and fitness pursuits.  The negligent use of our fingers, forks and feet is the leading causes of premature death and conversely, the appropriate use of them is capable of preventing 90% of diabetes, 80% of cardiovascular disease and 60% of cancers.

Bottom line:  Most everyone is knowledgeable about the role of tobacco in contributing to cardiovascular disease, stroke, lung cancer and emphysema.  However, the complications of tobacco abuse go way beyond the heart and the lungs; physicians in every medical and surgical specialty bear witness to the havoc that tobacco wreaks on every system in our body.  As a urologist, I am on the front lines of the deleterious and deadly effects of tobacco. Tobacco has clearly been linked to several urological cancers as well as numerous other non-malignant conditions. Tobacco is a major factor in the occurrence of bladder cancer, kidney cancer, sexual dysfunction, and infertility in both men and women.  Smoking cessation can help reverse these serious issues.

Bladder cancer is an incredibly prevalent cancer.  It is the 4th most common cancer in men and the 8th most common cancer in females.  It is highly correlated—hugely so—with the use of tobacco.  Cigarette smoking is the number one environmental cause and greatest risk factor for bladder cancer.  Cancer-causing chemicals known as carcinogens get inhaled into the smoker’s lungs, are absorbed into the bloodstream and are filtered by the kidneys, from where they pass into the urinary bladder.  In the bladder, these carcinogens have prolonged, direct contact time with the bladder lining, where they induce changes that ultimately can become malignant.  There is a many-year “latency period” from the time of exposure of the carcinogens to the actual occurrence of cancer—often several decades.  So the smoking that you did in your teens and twenties can come back to haunt you in your forties and fifties.

Continuing to smoke leads to worse bladder cancer outcomes compared to patients who discontinue tobacco use. Ongoing smoking after the diagnosis of bladder cancer greatly increases the risk of morbidity and mortality, treatment-related complications, recurrence of the cancer and the development of a second malignancy.  Smoking cessation will diminish all of the aforementioned consequences.  It is estimated that elimination of smoking could decrease the overall incidence of bladder cancer by 50%.

Prostate cancer is the most prevalent cancer in men and keeps our office bustling with patients.  Although smoking does not increase the risk of being diagnosed with prostate cancer, men who smoke at the time of prostate cancer diagnosis have an increased risk of recurrence and death from prostate cancer and also face an increased overall mortality from cardiovascular disease. Conversely, those who quit smoking at least a decade before the diagnosis of prostate cancer was made have mortality similar to those who never smoked.

Smoking is also strongly correlated with both male and female sexual dysfunction.  Anything that compromises blood flow to the genitals is going to interfere with sexual function, and the chemicals in tobacco do a marvelous job at constricting blood flow.  Approximately 40% of men with erectile dysfunction are smokers.  There is a direct relationship between the quantity of smoking and the extent of sexual dysfunction. Smoking cessation will help restore lost function, but tobacco takes its toll as former smokers have been shown to be at an increased risk of developing sexual dysfunction later in life.

Smoking adversely affects the reproductive system in both sexes.  As compared to non-smokers, the semen of smokers demonstrates poorer parameters, particularly sperm motility. Thus, sperm from smokers has reduced potential for fertilizing an egg.   Females who smoke have a higher prevalence of fertility issues including an increased risk of ectopic pregnancy and fare poorer than non-smokers when assisted reproductive techniques are needed.  Women who smoke during pregnancy increase their risk for bearing male children born with undescended testicles. Smoking has also been associated with increased risk of acquiring HIV infection, HPV infection, invasive cervical cancer, and pelvic inflammatory disease.

An estimated six trillion cigarettes are smoked worldwide every year.   It is not only the smokers who suffer the ill effects of tobacco use.  The health of individuals exposed to smokers is also at risk due to second-hand smoke. Second-hand smoke is a mixture of the smoke given off by a cigarette, pipe or cigar and the smoke exhaled into the air we breathe from the lungs of smokers.   Second-hand smoke is involuntarily inhaled by non-smokers and can linger in the air for hours after tobacco products have been extinguished.  There is no safe level of second-hand smoke, and even brief exposure can be harmful. Second-hand smoke clearly is associated with serious diseases and is responsible for shortening life spans. Second-hand smoke has been classified by the Environmental Protection Agency as a cause of cancer in human beings, causing approximately 3,000 lung cancer deaths and about 50,000 cardiac deaths in non-smokers in the United States annually.  Second-hand smoke is particularly harmful to young children, being responsible for hundreds of thousands of respiratory tract infections in those under 18 months of age.

There at least 43 carcinogens and more than 300 polycyclic aromatic hydrocarbons in second-hand smoke, as well as many other toxins including arsenic, carbon monoxide, lead, cyanide, DDT, formaldehyde and polonium 210. Polonium 210—a highly toxic radioactive poison that was brought to the attention of the public because of its use in the poisoning of a former KGB agent—is inhaled along with the tar, nicotine, cyanide, and other chemicals.

Smoking is a vile, incredibly harmful, self-destructive and miserable habit and addiction.  It is the single greatest cause of illness and premature death in modern society.  Every cigarette that is smoked can be thought of as another nail in one’s coffin.

Years ago, smoking was an excusable habit simply because we didn’t know any better.  It was thought of as a sophisticated, glamorous and sexually alluring and was so glorified on television, in magazines, and in Hollywood on the silver screen.   Magazine advertisements depicted physicians smoking and one slogan went so far as to state: “More doctors smoke Camels than any other cigarette.”   Even my father, a physician, smoked; however, as soon as he caught wind of the fact that smoking was dangerous to his health, he stopped immediately.

The greatest irony is that there are many smokers who have a pervasive fear of terrorism and potentially pandemic bacterial and viral illnesses such as avian bird flu, mad cow disease, SARS, anthrax, West Nile virus, etc.  What they fail to realize is that the cocktail of carcinogenic chemicals entering their lungs and bloodstream via smoking and being delivered to every single cell in their body can be thought of as little terroristssuicide bombers if you will, that can and certainly will ultimately wreak havoc on their health and their lives.  Smoking really is just a form of slow, voluntary suicide.  While we do not have a great deal of control over terrorist acts or deadly pandemics, we certainly have the ability to live a smart lifestyle that avoids self-destructive behavior such as smoking.

What truly is a source of amazement to me are the smoking lounges in the airports.  Glassed in like fish in an aquarium, these ridiculous-appearing humans are puffing away in unison, garnering not only the ill benefits of first-hand smoke, but also second-hand, third-hand, and every other permutation imaginable!  A motley group of men and women collectively inhaling and exhaling, hacking and choking within this absurd observatory, with plumes of smoke floating around like clouds—this glass menagerie is a showcase for the folly of humankind.

This folly is certainly aided and abetted by Big Tobacco. In 2006, a federal judge named Gladys Kessler ordered strict new limitations on tobacco marketing, sticking it to the cigarette manufacturing companies for their disingenuous behavior and forcing them to stop labeling cigarettes with deceptive descriptors including “low tar,” “light,” or “natural.”  The tobacco industry was shown to have “marketed their lethal product with zeal, with deception, with a single-minded focus on their financial success and without regard for the human tragedy or social costs that success exacted.”  She further stated that “cigarette makers profit from selling a highly addictive product that causes diseases leading to a staggering number of deaths per year, an immeasurable amount of human suffering and economic loss, and a profound burden on our national health care system.”

The WHO (World Health Organization) estimates that by the year 2020, cigarettes will be responsible for the deaths of 10 million people annually.   Cigarettes killed 100 million people in the period between 1900 and 2000, and we’re on track for nearly a billion tobacco-related deaths for the 21st century.  About half of all smokers will die of smoking-related diseases. Habitual smoking decreases general life expectancy by an average of 8-12 years. Many smoking-related deathsare not pleasant and quick deaths, but are often protracted and associated with significant suffering.

There is a magic pill—inexpensive, readily available, free of side effects and safe for all ages—that taken daily will reduce the risk of getting any major chronic disease by 80% or so. This pill is called healthy lifestyle, and if you don’t have it in your medicine cabinet yet, it would make all the sense in the world to acquire it.


Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

 Now available on Amazon Kindle


For my educational video on bladder cancer: