WHO Sperm Guidelines: Why “Normal” Isn’t Optimal for Fertility (Episode 609)

Full Transcript: Episode 609

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 609.

In today’s episode, we are diving into an important topic. We are diving into the sperm guidelines. And most people don’t know how they were derived. Most people haven’t looked at the study where the WHO sperm guidelines came from. But when you do, it really is eye opening and to some extent shocking how it was determined. Especially when you are trying to conceive or as a practitioner when you’re working with couples who are trying to conceive, these guidelines can create a false sense of security and they can certainly lead to skirting over potential issues with male fertility. So we’re going to get into that and more in today’s episode. So without further ado, let’s go ahead and dive right in.

Today I’m sharing a brand new episode in my FAMM research series and the topic of the day is sperm quality. This is one of the topics that I’ve been asked the most about when it comes to the new book Real Food for Fertility because we have an entire sperm chapter and let me tell you the sperm chapter is juicy. A little bit of background information for those of you who don’t know, there was a time when I was planning to write a book about sperm. I actually had a cover made and I had wrote at least a couple of chapters and so that forms in a way the basis of chapter 9 which is improving sperm quality in Real Food for Fertility and as I mentioned it is a juicy chapter. In this chapter alone I’m referencing 244 articles. And just to put it out there, when we put our reference numbers in these chapters, sometimes that one number is linked to multiple articles. So there’s at least 244 to anywhere from 250 to 300 articles cited in this particular chapter alone.

And we’ve had great feedback on the book so far, especially because the feedback that we’ve received is not a lot of fertility books focus so heavily on men. And what’s interesting about the book is that you can look throughout the book, we are talking about men. We’re bringing them in and talking about the importance of the various nutritional strategies that we share for both improving and supporting egg and sperm quality throughout the book. And of course, we have our throw-down chapter where we delve into it and we don’t let men off the hook. And the good news is that whatever you’re doing to support your fertility, it’s also going to help your partner’s fertility. And so there’s kind of like a mirror situation happening because what supports egg quality also supports sperm quality.

And in today’s episode, I wanted to talk about a really interesting study. It is the study that forms the basis of our World Health Organization guidelines. So if your partner has already had a sperm analysis or if you’re thinking about doing that or if you’re just interested in this topic in case it ever applies to you, this is the research study that these criteria came from. What the World Health Organization defines as normal. So we’re going to go into how this number came about, what the study shows, how these numbers compare to the optimal numbers, and what the implications are for you.

So the name of today’s study: World Health Organization Reference Values for Human Semen Characteristics. And as I mentioned, this study forms the basis of our current guidelines as it relates to sperm quality. And this is important because one of my biggest pet peeves, biggest frustrations when I’m working with fertility clients is that the vast majority of fertility clients who I’ve worked with who have had a semen analysis have been told that they’re fine. And I always use the word fine because that’s what they’re telling me. Oh, he’s fine. Everything’s fine. We were told that it’s all fine. He’s good. He’s good to go. But what’s typically missing about these conversations is that their health care practitioner, their medical doctor, fertility specialist, has not necessarily gone over the results with them to share what it means. They’re just being given this blanket statement that everything’s fine.

And what’s interesting is that when I’m working with clients, and also this applies to my FAMM practitioners when we’re working with clients and when we’re going into the conception unit, this is something interesting because when we take our clients through the same semen analysis that they were provided no information about and we just go through it step by step with them and compare the reference values that their partner had to what is considered optimal, it’s often extremely eye-opening and for all of my clients, all of them, 100%, that was the first time anyone had ever done that with them. So that’s why this is important and interesting and helpful.

So in this particular study what they did is they actually took 4,500 men. They took semen samples from over 4,500 men in 14 different countries on four continents and they analyzed the semen parameters of these men. And in particular, they took special interest in the men whose partners had successfully conceived within one year. So what they did, they had 4,500 men in 14 different countries. They took the semen analysis for all of these men, but in particular for the purpose of the study and for the purpose of determining the World Health Organization characteristics, they looked specifically at the men whose partners had conceived within one year. And they took all of those parameters and they actually put them in a graph and separated it by centile.

So if you take it back to math class, percentiles — fifth percentile, 10th, 50th, 100th, right? So if you’re in the 95th percentile, it means that your results are better than 95% of the other people, and there’s only 5% better than you. Or if you’re in the fifth percentile, then it means 95% of the men were higher than you and you are in that lower fifth percentile.

And if you grab a copy of Real Food for Fertility, we share a lot of these results. In chapter 9 in particular, we have some images of normal versus abnormal sperm. We actually share the guidelines from the WHO and how they’ve changed over the years. We have a table going through all this information. We also share a portion of these tables. We don’t go through and share all the percentiles, but we share some of the most pertinent ones so that you can get a sense of this. And if you’re a visual person, you’ll really appreciate that.

So back to the study. How they determined the characteristics — they actually did look at the lower fifth centile. So they identified the lower fifth centile of all the men in the study whose partners had successfully conceived in a year. So what that means is that 95% of these men did have higher parameters than the men who fell into that fifth percentile. And that actually represents the numbers that are used in the World Health Organization to identify what is considered to be normal.

So essentially what they did is they had this group of men. They looked at which group successfully were able to conceive within a year and they divided all of the parameters up from all these men. So in that particular group there were almost 2,000 men who fell into that category whose partners had conceived within two years. And what they did was they looked at that lower fifth centile.

When I present it this way, often the response I get from clients is, well what do you mean? Like, that seems kind of low. Like, why would they use those numbers? And so I think that it’s important to look at it from their perspective — the perspective of these public health organizations that are looking at creating reference ranges. So when they’re creating a reference range, they’re identifying a point below which it would be warranted for you to have medical intervention. So from that perspective, it doesn’t make sense for them to put the number so high that they’re sending everybody for medical intervention, especially when we’re thinking about a public health initiative.

So in the research paper they actually do talk about some of the challenges with coming up with a reference range. From the paper, what they say is there has been no consensus around the suitability of these values, as some centers consider the values to be high, whereas others consider them to be too low. So they’re even saying that within the parameters that are determined, there’s not necessarily consensus. Everybody doesn’t necessarily agree. And part of the reason that they disagree is because there’s inherent challenges with putting this reference range either too high or too low.

Because if they put the number too high, what they’re saying is fertile men could then be classified as subnormal. And so that could make it so that there are men who are actually fertile who are investigated for fertility issues who don’t necessarily have any. And then on the other hand, if they’re placing it too low, the probability of pregnancy is higher when you have sperm of a certain concentration or quality or motility. So they’re potentially not identifying couples whose fertility is limited, but not necessarily that they’re infertile.

And this actually brings me to the big point that we argue for in Real Food for Fertility and the big issue that we share with clients. It’s important to recognize about these sperm parameters and guidelines that they’ve identified this reference range based on this particular study. And so they’re identifying that men who fall into this particular range have the capacity to reproduce. They’re saying that within a year the partners of these men were successfully able to conceive, but there’s nothing in the way that they identified these parameters that would indicate that these numbers would lead to optimal chances of conception. And I think that’s the main point. When we’re looking at these guidelines, these reference ranges as set out by the WHO, they were not intended to provide you with what would be an optimal number, what would give you the best chances of conception. They’re trying to identify a point below which you might need to be further screened or investigated or might even require assisted reproductive technology.

So this is really key to understanding, and in the chapter of the book we look at a separate study where they’re trying to identify what would be optimal for conception. Essentially what the researchers did is they similarly looked at couples and how long it was taking to conceive and they looked at when these sperm parameters get below a certain point, at what point does that start to have a negative impact on your time to pregnancy.

The motility number relates to whether the sperm are moving. The morphology number relates to whether the sperm look normal. And of course the concentration relates to how many sperm there are in the sample. And at what point do these numbers start to have a negative impact on how long it’s going to take you to conceive?

So just to go through what the parameters are — what the World Health Organization considers to be normal. When we’re looking at sperm concentration, they’re saying that a concentration of 15 million per milliliter, a motility number of 40%, and a normal morphology number of 4%. To put that into perspective, the average man in the 1940s had a sperm concentration upwards of 113 million sperm per milliliter. The average man today has about, give or take, 50 million sperm per milliliter. So they’re looking at 15 million sperm per milliliter and saying this is what we consider to be normal. And again, that’s basically a tenth of what was normal for a man in the 1940s.

And then when we’re looking at 40% motility — 40% motility means 40% are moving. Does that mean the 60% aren’t moving? Something to think about. And then the morphology number, 4%. So that’s saying when you look at a sperm — if you think of a sperm, you think of a round head and a tail — 4% would look like that. And the 96% would have a variety of abnormalities.

And then if we look at that and compare it to what the other researchers in the other study identified to be optimal — their numbers are different. Instead of a sperm concentration of 15 million per milliliter, a sperm concentration of 48 million per milliliter was considered to be optimal. Instead of 40% motility, they identified a motility of 63% as being optimal. And instead of a morphology number of 4%, they identified a morphology number of 12% to be optimal.

And so what we argue in Real Food for Fertility is that when you are taking these two studies into consideration, what is not being stated when you have a client — or if you yourself have been struggling with fertility challenges and your partner has had a sperm analysis and you’ve been told that you are normal — what is missing from that conversation is this concept of a suboptimal range. That doesn’t make your partner infertile, because this range doesn’t mean that your partner and yourself couldn’t conceive. But there does come a point where if his sperm analysis falls into this suboptimal range — so it’s not low enough to be flagged by the World Health Organization, but it’s not high enough to meet those optimal parameters — what it means is that it could take you longer to conceive.

And so from that perspective, we should actually be paying attention to it. And it’s really interesting to read some of the articles that came out around the time that these numbers were set, when the 2010 World Health Organization document was released. There were a number of articles that were questioning if the numbers were too low, because they were saying that if we looked at the prior numbers that were used before 2010, those numbers were a bit higher. And in that case, there were men who were identified as needing to be screened and encouraged to get an evaluation if their numbers were in a range that all of a sudden was now classified as normal.

And again, it’s not that this number or this range provides a nuance — you’re either above it or you’re below it. And if you’re above it, you’re just told that you’re normal and you’re fine. And so I think this is not just an issue related to sperm in particular. I think that this issue comes up in a lot of different testing. For anyone who’s aware of the difference between the typical reference ranges provided for a variety of conditions versus what would be considered a more functional range — this is a topic that has come up related to thyroid health for example, where if your TSH is in the reference range you might be considered fine in the general sense, but if you’re working with a functional provider, even if your numbers meet what the reference range says is normal but it doesn’t meet what the functional range identifies as optimal, they may still encourage you to make some changes or refer you for further screening.

And this is essentially what we’re talking about here. There’s a little bit of similarity in terms of how this is looked at to the conversation around the impact of birth control on fertility. One of the topics that I touched on a few times in that series was just this idea that when the research is looking at data, they’re often looking at it within a 12-month period. So they’re looking at your time to pregnancy or your likelihood of pregnancy within 12 months. And so similarly in this study, part of the reason that they’re looking at this way of identifying what’s normal is because they are looking at a couple’s chance of achieving pregnancy within 12 months of unprotected sex.

From their perspective, whether it’s happening in month 1 or month 11 isn’t necessarily a point of contention for how they’re creating their reference ranges and for how they’re looking at this information. They’re simply looking at over the course of 12 months, who got pregnant and who didn’t.

And so interestingly, when you’re looking at it from the perspective of the couple who’s trying to conceive, if you’re trying for 10 months, 11 months and it’s not happening, you’re already feeling a certain type of anxiety or frustration about it. It’s typically by that stage, you’re not looking at it the same way as you did when you first started. So if we can identify men who are in that gray area, that subfertile range, then it potentially gives us an opportunity to improve some of those parameters that are out of that optimal range.

Many of these men who are in the suboptimal range, with a variety of evidence-based changes — whether it’s nutritional changes, the addition of specific evidence-based supplements, the removal of certain issues that are known to have a negative impact on sperm health — a significant portion of these men have potentially the opportunity to improve their parameters, get them into that optimal range. And what that could do is hasten the time to pregnancy. So instead of it taking a longer time because your partner’s in the suboptimal range and you don’t know that, you could identify if he does fit into that optimal range through a semen analysis and then work towards improving his parameters.

So I’ll end with a couple of stats because I think it’s really important and helpful. We also live in a culture where fertility issues are considered to be a woman’s issue for the most part. Even if we give lip service to male fertility, typically we are still thinking of it as a woman’s issue. And for the record, many practitioners think that way as well. Not all, but many. And I’ve had a number of clients who’ve been trying to conceive for a while and even still have a difficult time getting their practitioners to do a semen analysis.

A couple of stats to consider. Fertility rates are in that one in six couples range, which amounts to about 15% of couples overall, which is a fairly high number. And out of those cases of infertility, 20 to 30% are related to male factor infertility as the sole reason, the sole cause. And up to 50% of the time, male factor is related but not necessarily the sole factor. So if you have a couple who’s struggling with fertility issues, there’s a 50% chance that he is a contributing factor.

There are other studies that look at the sperm parameters of couples based on time frame. Similarly, you have couples who’ve been trying to conceive for one year or couples who have been trying to conceive for two years or more. And from a statistical standpoint, when you have men in those couples who have been trying to conceive for a year or more or two years or more, statistically speaking, their parameters are lower than the parameters of men who do conceive successfully within a year.

And that is one of the perspectives of the researchers who are in favor of the sperm parameters as laid out in the paper that we’re looking at today, because they’re saying that of these men whose partners conceive within a year, even though they’re looking at the lower fifth centile, these parameters are actually higher than men who don’t conceive in that period of time. So if you were to look at men whose partners did not conceive in a two-year time frame or longer, you would find that the semen parameters in this particular study are higher than those of the men who took longer.

So that’s something to consider as well. Because if you’ve been trying to conceive for a year or more, and you are listening to this podcast, so you have a good idea of timing and fertility awareness techniques to time sex accurately — you know how to identify your fertile window, your fertile days, you have been timing sex based on your cervical fluid and you know how to identify ovulation and all those things. So you are timing sex correctly, you’ve been trying for a while and it’s not happening. Statistically speaking, if it’s a year or more that you’ve been trying, then your partner’s sperm is probably not optimal in all of those areas. All that means is it warrants a test.

It’s not something that we’re blaming your partner. It’s not an issue actually of an individual nature either. Because as I mentioned, the sperm parameters have been steadily declining for many years. The average man in the 1940s compared to the average man today — those sperm parameters have declined upwards of 70% or more. And so this is not just an issue of your partner has poor sperm. This is something we all need to be aware of.

The biggest takeaway from today’s episode, of course, is that these guidelines were never intended to represent what is actually optimal and what would make natural conception easier. It was just never intended to do that. And so for that reason, it’s really important for couples and practitioners alike to educate themselves about what the parameters are, what they mean, and how we would take steps to ensure that when we are working with clients who are struggling with fertility challenges, we are really taking these extra steps to determine if the sperm quality is optimal. Because although we focus mostly on the woman because we are the ones who conceive and carry the child, male fertility plays a significant role. The stats alone tell us that it’s up to 50% of the time it’s involved — 30% solely and then 50% just involved in fertility challenges. When you add charting into the mix, it becomes really clear that we have to focus on male fertility just as much as female fertility.

So I hope that you enjoyed today’s episode. If you can think of somebody who would benefit from hearing it, the share link is fertilityfriday.com/609. And with that said, I hope you have a wonderful week, weekend, whenever you’re tuning into the show. And of course, as always, until next time, be well and happy charting.