Spermogram (sperm analysis) and Kruger test are tests performed in patients with infertility problems. Infertility is a problem that concerns both men and women. The problem can sometimes be on the male side, sometimes on the female side, and in some cases both sexes. Evaluating the female factor in fertility cases is of interest to the obstetrics and gynecology department. Investigation of the male factor is the field of interest of the Department of Urology. The most common tests in the investigation of male infertility are spermiogram and Kruger tests. In this article, I will give general and up-to-date information about these two tests.

How is an infertile male patient evaluated?

It is not correct to request direct sperm analysis without urological examination in the evaluation of infertility. Before having this test in infertile patients, the man must be evaluated by a urologist. The urologist takes a general anamnesis from the patient about the lifestyle, the diseases he had, and the drugs he used. Then the patient is subjected to general urological and andrological examination. The urology doctor performs the andrological examination of the infertile man and reveals if there is a condition that may cause infertility. Sometimes, there may be no pathology that may negatively affect sperm values ​​in the examination.

What is a spermiogram, what is checked in a spermogram, what are the normal values?

Spermiogram is a test that evaluates the number, function and quality of sperm for the diagnosis of infertility in men.

Some parameters are checked while evaluating the spermiogram. For this purpose, the criteria of the World Health Organization (WHO, World Health Organization) are used most frequently.

• Volume of seminal fluid: 2-6.0 ml
• Sperm count: 20 million and above
• Total sperm count: 40 million and above
• Motile sperm: 50% and above
• Normal morphology: 30% and above
• Live sperm rate: 75% and above
• Leukocyte count: less than 1 million in 1 ml
• pH: Between 7.2-8
• Liquefaction: It means the solubility of seminal fluid, that is, its melting. Normally it is about 10-20 minutes.
• Morphology: 4% and above according to Kruger criteria

Why are spermiogram and Kruger test done?

Spermiogram (sperm test) is done to reveal the male factor in the investigation of infertility. Here, the number, movements, morphology, etc. of the sperms are examined.

The Kruger test is a microscopic test to show deformities in sperm. It is used to investigate the male factor in the evaluation of infertile couples.

How long does the sperm test take?

The sperm test is taken out in 3-4 hours on average after the sample is given. In this test, different parameters are checked and each has a different duration. In order to achieve a healthy result, it is important to follow the rules that have been told beforehand. A second test may be ordered 3-8 weeks later if needed. Sperm analysis is a very sensitive test. It should be done in centers that are interested and experienced in this subject. Manual methods may have different results depending on the individual. The safest method is the automatic method.

Some frequently used terms related to sperm testing

There are some frequently used terms related to sperm analysis. Some of these terms and their explanations are as follows;

• Normospermia: It means that sperm parameters are in normal values.
• Oligospermia: Sperm count is less than normal.
• Asthenospermia: It means the sperm’s movements are not enough.
• Teratospermia: It refers to deformities in sperm cells.
• Oligoasthenoteratospermia: Problems in the number, movement and shape of sperm.
• Azoospermia: It is the absence of any living or dead sperm cells in the seminal fluid (semen) in the sperm analysis.
• Necrospermia: It means that more than 25% of the sperm in the ejaculate are dead.
• Hypospermia: It means the ejaculate (seminal fluid) volume is less than 1.5 ml.

How is spermiogram test done?

Spermiogram test is done in two ways: Manual, that is, manual cypermigram test and automatic test (CASA: Computer Assisted Semen Analysis).

• Manual (manual) sperm analysis: In the manual sperm analysis, the evaluation is a subjective evaluation, not an objective one. In this method, all parameters in the spermiogram are done manually. Results vary from person to person. People’s experience is also important here. It is very difficult to accurately evaluate sperm movements, which are especially important in spermiogram, with this method. This method is now abandoned. Instead, automatic sperm analysis is used.
• Automatic test (CASA, Computer Assisted Semen Analysis): Spermiogram performed with this method is the healthiest and most frequently performed method today. In the CASA system, it is aimed to obtain high quality sperm analysis with computer technology by using advanced image methods. With this method, motile and immobile sperm rates are evaluated in detail by using the criteria of the World Health Organization (WHO, World Health Otrganisation).

The most important feature of the CASA system is the completely objective evaluation of spermiogram parameters. Here, personal differences disappear, a real result is achieved. Another advantage is that with this system, results are obtained in a shorter time.

What is the Kruger test and how is it done?

The Kruger test is a diagnostic method used in the investigation of male infertility. With this method, it is possible to understand whether the sperms are of suitable quality for pregnancy. Certain parameters are checked after a special staining in the sperm samples taken from the male for the test. It is called by this name because it was first described in 1986 by a scientist named Kruger.

Taking a sample for testing is the same as for a spermiogram. In the Kruger test, structural changes in sperm that may interfere with fertility are investigated. With this test, head anomalies in sperm are also investigated. With the Kruger criteria, the head, neck, tail, middle parts, acrosome and nucleus abnormalities of the sperm are investigated.

According to Kruger’s criteria, if the normal morphology in sperm samples is:

• If it is 14% or more, the fertilization success rate in these individuals is approximately 88.3%,
• If it is between 4-14%, the fertilization rate is 49.4%
• If it is 4% or less, the average fertilization rate is 7.6%.

What should be considered when performing spermiogram and Kruger test?

A healthy spermogram is very important in the evaluation of infertile couples. The important points that those who will give spermograms should pay attention to are:

• There should be sexual abstinence for at least 2-5 days, on average 3 days. In tests performed in a short time, sperm counts may be low. If the period is prolonged, then the sperm counts may be low.
• The sperm sample should be given at the place where the test will be performed.
• If it is to be given away, it should be delivered to the analysis site at body temperature and within 30-60 minutes.
• The sample should be placed in a clean container.
• Sperm should be given by masturbation, while soap, shampoo, lubricant etc. should not be used as they will kill the sperm.

What are the conditions that affect sperm count and movement?

Sperm count, morphology and movements are adversely affected by many conditions. Some disorders that may negatively affect spermiogram values ​​are as follows;

• Sexual abstinence period
• Drugs used
• Excessive alcohol and cigarette use
• Excessive stress
• Genital infections
• Radiation
• Past diseases
• Varicocele disease
• Diabetes
• Excess weight (obesity)
• Urinary tract surgeries
• Infections in the genitourinary system
• Varicocele
• Ejaculation problems (in men)
• Undescended testis
• Atrophic testis
• Hormonal disorders
• Obstructions in the sperm channels
• Chromosome errors
• Exposing the testicles to excessive heat
• Old age

What does the sperm wash test mean?

Sperm washing is a procedure applied to patients to be vaccinated. Sperm is given exactly as in the spermiogram. Washing test is done with a washing method called gradient or swim up. Here, sperms are cleaned from all secretions except sperm by undergoing special processes. These processes take 2-3 hours on average. The aim here is to select more mobile and structurally normal sperm, that is, sperm with a high ability to fertilize the egg.

What is sperm DNA damage (DNA fragmentation) test, how is it done?

The sperm DNA damage (DNA fragmentation) test is a test performed to show whether the sperm DNA maintains its integrity. Sperm DNA damage should be 15% or less. This test is a special test. It is not evaluated in routine sperm testing, but is requested in special cases.

Sperm DNA fragmentation test should be performed in the following situations:

• If there is an infertility problem whose cause is not fully understood
• If there is a pause in embryo development
• If there is abnormal embryo development in patients who have undergone assisted reproductive methods
• In case of failure in IVF attempts
• If there is frequent recurrent pregnancy loss

What is the sperm FISH test and how is it done?

Sperm Fish test is a special test that gives information about sperm genetics. In this test, chromosomes 13, 18 and 21, as well as X and Y chromosomes are examined numerically.

It is a diagnostically valuable test in couples with a history of recurrent miscarriage or in patients with severely impaired sperm morphology. In this test, the part of the sperm that is defective in terms of genetic material is determined by special staining methods. In order to get a healthy result from the FISH test, the sperm count must be 1 million or more in the spermiogram. Values ​​below this may not yield reliable results.

How much does the spermiogram test cost?

It is not always correct to give a clear price about the sperm test fee. Fees may vary depending on the center where the test is performed and the technique applied. In order to obtain a healthier result, the center where the test is performed and the method used are very important. We recommend our patients to centers that are more experienced and apply up-to-date methods.

Can azoospermic patients have children?

Azoospermia means that there is no sperm in the semen analysis. This is due to either the inability of the testicles to produce sperm or the inability of the produced sperm to be ejected due to obstruction in the sperm ducts. It is not possible for these men to have children with normal intercourse. These people can only have children with the in vitro fertilization method.

Is sperm production negatively affected in older men?

As in every function, sperm production and functions are negatively affected by aging. As age progresses, the number, movement and quality of sperm decrease. It has been reported in the literature that a 96-year-old man became a father (in India). In general, the best age for sperm quality is between 30-35 years in men. The best age for sperm motility (movement) is under 25 years old. After the age of 50, sperm motility decreases by 3-37%, morphology by 4-18%, and semen volume by 3-22% in men.

In summary; In the evaluation of infertile couples, spermiogram and akaruger test are important diagnostic methods. The male of the couples investigated for infertility should be evaluated by a urology specialist. The urologist may then ask the patient for spermiogram, Kruger’s test and further tests if necessary. Sperm testing should be done in experienced centers. In the centers where these tests will be taken, patients should be informed about the subject in advance. Manual tests do not give reliable results, automatic methods must be used to obtain a healthy result.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY