WHO Sperm Parameters vs. Optimal Sperm Quality (Episode 513)

Full Transcript: Episode 513

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 513.

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. I don’t have this exact citation number — actually, I can look at the citation number as I’m talking to you and let you know. So 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 that not a lot of fertility books focus so heavily on men. And what’s interesting about the book is that 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 throwdown 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 let’s go ahead and dive into today’s episode.

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 healthcare 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 this also 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 — again, just to kind of put it out there — 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 — if you can think back, dial up the archives to whether it’s high school or junior high math — we were actually doing stuff like this. Centiles. So you have the fifth centile, 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, right? And there’s only 5% better than you. Or if you’re in the fifth centile, then it means 95% of the men were higher than you and you are in that kind of lower fifth centile.

So just to kind of put that out there — 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 results — so a portion of these tables. We don’t go through and share all the centiles, 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 lots of important details, graphs, information, images — all this information that really you’re not going to get anywhere else. I’ve never had a client of mine who had received this information from anywhere. So definitely unique in that respect.

So back to the study — how they determined then 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 centile. And that actually represents the numbers that are used in the World Health Organization to identify what is considered to be normal. So I’m going to say it again, just because I know sometimes eyes can glaze over when we start talking about numbers. But 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 one year. And what they did was they looked at that lower fifth centile. My apologies for repeating myself, but I just want to make sure that we are getting this information because it’s really interesting. And when I present it in this way and just kind of share it that 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 this just from their perspective — potentially 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 I think that that plays into it.

So in the research paper, they actually do talk a little bit 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 are 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 that 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. So that’s an issue that they’re concerned about with placing the numbers too high. And then on the other hand, if they’re placing it too low, what it says in the research paper is that the probability of pregnancy is higher — we know that it’s higher when you have sperm of a certain concentration or quality or motility, which we’ll get into a little bit more. So they’re potentially not identifying couples whose fertility is limited, but not necessarily that they’re infertile.

And you know, this actually brings me to the big kind of point that we argue for in Real Food for Fertility and the big issue that we share with clients. So what it’s important to recognize about these sperm parameters and guidelines is that they’ve identified this reference range based on, like I said, 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 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 artificial 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. And we can go through that study in a separate episode. But essentially what the researchers did is they similarly looked at couples and how long it was taking to conceive. And they looked at — at what point, when the sperm parameters get below a certain point, does that start to have a negative impact on your time to pregnancy? So exactly the challenge that was brought up by the researchers in this study that we’re looking at. At what stage, when the numbers dip to a certain point — whether it’s the total concentration or the motility number or the morphology number — does that start to have a negative impact on how long it’s going to take you to conceive? So the motility number relates to if the sperm are moving. The morphology number relates to if the sperm look normal. And of course, the concentration relates to how many sperm there are in the sample.

And so below what point do these numbers start to have a negative impact on how long it’s going to take you to conceive? And so what’s interesting is when the researchers asked that question, they had completely different results. So — just to go through what the parameters are — the parameters that they identified in the study, what the World Health Organization considers to be normal: when we’re looking at the 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%. So to put that into perspective, the average man in the 1940s had a sperm concentration upwards of 113 million sperm per milliliter. That number I got from an interesting study that was done in the 1940s where they had an average — and the men had a lot more sperm back then. And the average man today has about, let’s say, 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 the motility number of 40% — 40% motility means 40% are moving. So does that mean the 60% aren’t moving? Right? 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. So 4% would look like that, and the 96% would have a variety of abnormalities. So if you were to look at them, it could be like a funny-shaped head, a squashed head, some weird kind of growth on the side of the head, some issue with the tail, maybe it has no head, maybe it has no tail, maybe it has two heads. So there’s a lot of different morphological issues that could result in it not looking normal.

So this is what they’re saying is normal. And then if we look at that and compare it to what the other researchers in the other study that I mentioned identified to be optimal — well, their numbers are different. And what they identified in that study was that instead of a sperm concentration of 15 million per milliliter, a sperm concentration of 48 million per milliliter was considered to be optimal — 48 million per milliliter or higher. Instead of 40% motility, they identified 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 quote “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, by the study that we’re looking at today, but it’s not high enough to meet those optimal parameters — in that suboptimal range, 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 as I mentioned, in the study itself it says that not all clinicians agree with the parameters as they were set. 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 now was classified as normal. And again, it’s not that this number or this range provides 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. I think this issue does come up a lot. 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 as normal but they don’t meet what the functional range identifies as optimal, they may still refer you to make some changes or to further screening. And this is essentially what we’re talking about here.

So there’s a little bit of similarity, I think, in terms of how this is looked at, to the conversation that we had for the last few episodes when I released the three-part series on 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 it this way is because they are looking at a couple’s chance of achieving pregnancy within 12 months of unprotected sex. So from their perspective, if you have these participants who had these numbers and are conceiving within this timeframe — whether it’s happening in month one or month 11 — isn’t necessarily a point of contention or a point of consideration for how they’re creating their reference ranges. 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 — I mean, 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 not just something you’re looking at the same way as when you first started, especially given our culture and the way we look at fertility and pregnancy. And we have this expectation obviously that we’re going to conceive right away. So if we can identify men who are then in that gray area, that subfertile range, 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 it through a semen analysis and then work towards improving his parameters. That’s kind of like the whole point of why we’re really putting this out there.

And I want to end with a couple of stats, because I think it’s really important and helpful — because 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. I’ve had clients who’ve had to kind of fight to get their partner to have a semen analysis done even though they’ve been trying to conceive for some time, because basically the sentiment is, “Well, you know, he’s fine.” And so this is a really important consideration. And this is of course why we went so hard on the data and information and research in this particular chapter — so that you can see that it’s not just someone’s opinion. You can see that this is evidence-based information. And so if you do choose to go ahead to your practitioner and advocate for a semen analysis or further testing, you have the evidence and information behind you.

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 — so half — male factor is related, but not necessarily the sole factor. So half. So if you have a couple who’s struggling with fertility issues, there’s a 50% chance that he is a contributing factor.

We looked at a variety of research studies when we were looking at writing this chapter. And in particular, what I found interesting is that there are other studies that look at the sperm parameters of couples based on timeframe. So similarly, you have couples who’ve been trying to conceive for one year or couples who’ve 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 conceived 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 timeframe 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, let’s say for a year or more, and you are listening to this podcast — so you have a good idea of timing, fertility awareness techniques to time sex accurately, you know how to identify your fertile window and 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. And 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, like I said, 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 and we need to kind of put him aside and act as if there’s something wrong with him. This is something we all need to be aware of. And with men, I always say — they can provide a sperm sample fairly easily. As women, we can’t just provide an egg sample like they can. So arguably it’s not just men’s fertility that has been declining over time — it’s just that we have an easier way to measure their sperm numbers compared to how we could measure our egg quality.

So the quick summary of today’s research article would be that when we look at the World Health Organization document — the document that determines what is considered to be normal for sperm parameters — it’s really helpful to know that that information was not based on what would be optimal for conception. The researchers were not looking at what parameters would actually be optimal for a natural conception. They were instead looking to identify a reference range so that they could identify when there was more likely to be a problem. And as a result, there are men who have subfertile parameters that are not being further screened. So then that means it’s up to you to learn a little bit about this topic, identify what is optimal, and advocate if you have concerns or if you’ve been trying to conceive for a period of time. If your partner has not been screened for his sperm parameters, then we certainly recommend that you do that sooner than later.

If you did choose to work towards improving your partner’s sperm parameters naturally by changing diet, changing lifestyle factors, identifying some of the issues that lead to poor sperm parameters — you want to give yourself some time, because it takes a minimum of three to four months before you start to see some of those changes. And if this is a topic that interests you, if you’re wanting to delve further into the research, I highly, highly recommend that you grab a copy of Real Food for Fertility. As I said, Chapter 9 — we do a throwdown, because as I always say, there’s no man alive whose sperm is so healthy that he can’t even benefit from some nutritional dietary changes or some dedicated supplementation targeted to improving his sperm. There’s just — it’s just not a thing. And if you think about it also, if you are looking to optimize your cycles for conception and optimize your preconception nutrition, he should be doing the exact same thing. For those of you who are curious about egg quality, we do have an absolute throwdown chapter on supporting and improving egg quality. So the sperm quality chapter is Chapter 9, the egg quality chapter is Chapter 10. And you’ll find that many of the same things that are geared to supporting sperm quality also equally support egg quality.

You can head over to Amazon and type in Real Food for Fertility and you’ll find our book there if you wanted to grab a copy. You can also head over to realfoodforfertility.com for more information about the book and also more details about both Lily and myself and our other books and all the things. If you found today’s episode interesting and you can think of somebody who you know would love today’s episode as well, the share link is fertilityfriday.com/513. And 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.