ISSN: 2047-2919 ANDROLOGY

ORIGINAL ARTICLE

Correspondence:
Gunilla Malm, Reproductive Medicine, Association between semen
Department of Translational Medicine, Lund
University, SUS Malmo€ , 205 02 Malmo
€ , Sweden. parameters and chance of
E-mail: [email protected]
fatherhood - a long-term follow-up
Keywords: study
fertility, male infertility, reproduction, semen
analysis
1
G. Malm , 2L. Rylander, 1A. Giwercman and 3T. B. Haugen
Received: 12-Mar-2018 1
Molecular Reproductive Research, Department of Translational Medicine, Lund University, Skane
Revised: 20-Sep-2018 € , Sweden, 2Division of Occupational and Environmental Medicine, Lund
University Hospital, Malmo
Accepted: 24-Sep-2018 University, Lund, Sweden, 3Faculty of Health Sciences, OsloMet–Oslo Metropolitan University, Oslo,
Norway
doi: 10.1111/andr.12558

ABSTRACT
Background: Evaluation of male fertility includes standard semen analysis; however, there is uncertainty about the value of sperm
parameters in predicting fertility.
Objective: To evaluate the association between semen parameters and fatherhood during a long-time period.
Materials and methods: Semen parameters (total sperm count, concentration, motility, and morphology) and sperm DNA frag-
mentation Index (DFI) assessed on samples collected from 195 Norwegian men from the general population in 2001/2002 were
matched with information about fatherhood until 2015, obtained from the Medical Birth Register. The parameters were dichoto-
mized as normal vs. abnormal according to the WHO reference values from 1999 and 2010. Cut-offs at 20% and 30% were used for
DFI.
Results: Among men who had no children before 2003, those with normal progressive sperm motility had more often become
fathers (WHO 1999, cut-off ≥50%, adjusted OR 2.8, 95% CI 1.3–6.1 and WHO 2010, cut-off ≥32%; aOR 4.2, 95% CI 1.1–15). Based on
the WHO 1999 reference value, men with normal sperm concentration (≥20 9 106/mL) had more often become fathers (aOR 3.1, 95%
CI 1.1–8.6). Men with progressive sperm motility ≥50% and concentration ≥20 9 106/mL did more often achieve fatherhood (aOR 8.4,
95% CI 2.1–34). For DFI, there was a borderline significance at cut-off 20% in the group of men who had ever been fathers (OR 2.7,
95% CI 1.0–7.0 p < 0.05).
Discussion: The results indicate that sperm progressive motility, sperm concentration, and DFI are associated with fatherhood dur-
ing a longer time period, with sperm motility being most consistent. Although the sample size is relatively small and our results
should be replicated in larger studies, they may be of clinical relevance.
Conclusion: Semen parameters may have a diagnostic value not only in a short time frame but also for predicting future fertility
potential.

INTRODUCTION However, there is uncertainty about the value of standard

In most Western societies, there is a tendency to postpone sperm parameters to predict fertility. Earlier studies have indi-
parenthood, partly due to socioeconomic factors. Both increas- cated that the probability of conception increases with increas-
ing maternal and paternal age are associated with a higher risk ing sperm concentration up to 40–55 9 106/mL (Bonde et al.,
of involuntary childlessness (Sartorius & Nieschlag, 2010). There- 1998; Guzick et al., 2001; Slama et al., 2002). Sperm motility has
fore, there is a growing interest and need of offering both men been shown to be of limited predictive value in some studies
and women assessment and counseling regarding their present (Bonde et al., 1998; Slama et al., 2002), whereas other studies
and future fertility potential (Birch Petersen et al., 2015). In addi- have shown sperm motility to be the best predictive factor for
tion to the clinical examination, the evaluation of male fertility is fertility (Larsen et al., 2000; Nallella et al., 2006; Jedrzejczak
traditionally based on standard semen analysis, including total et al., 2008).
sperm count, concentration, motility, and morphology. To stan- Sperm morphology is the most controversial parameter of the
dardize and improve the quality of semen analysis, WHO has semen parameters due to the lack of standardization and the fact
published laboratory guidelines for the examination of human that scoring criteria and reference values vary across centers.
semen (World Health Organization, 1999, 2010). Thus, different methodologies may have prevented a consensus

© 2018 American Society of Andrology and European Academy of Andrology Andrology, 1–6 1
G. Malm et al. ANDROLOGY
on the clinical value of sperm morphology evaluation(Tomlin- spermatozoa should be categorized as rapid or slow, whereas in
son et al., 2013). the, WHO 2010 manual, the recommendation is that progressive
Impairment of sperm DNA integrity has been suggested as an motile spermatozoa should be in one category (World Health
independent predictor of male fertility (Bungum et al., 2007; Giw- Organization, 2010). The motility categories are denoted grade A
ercman et al., 2010), but due to the lack of standardization and (rapid progressive), grade B (slow progressive), and A+B (pro-
reference values, this parameter has still not been included in gressive) in the tables. For morphology, the lower reference limit
routine fertility assessment (Esteves et al., 2017; Rex et al., 2017). for normal forms (5th centile; 4%), according to the WHO guide-
In order to evaluate the association between semen parame- lines from 2010, was used (World Health Organization, 2010).
ters and chance of fatherhood during a longer time period, we All participants were recommended an abstinence period of
have performed a follow-up study by relating the semen param- 2–3 days before delivering the semen sample, and the length of
eters in a cohort of Norwegian men, collected in 2001–2002 abstinence was recorded.
(Malm et al., 2004), with data on children fathered until 2015 by As previously described, (Malm et al., 2004), the semen vol-
these men from the Norwegian Medical Birth Registry. Further- ume was determined by weighing and the spermatozoa concen-
more, the participants were asked to fill in a questionnaire about tration with a Neubauer hemocytometer after dilution of the
fertility wishes to investigate whether the pattern was similar to ejaculate using positive displacement pipette. For motility
the information from the registry. In contrast to previous studies, assessment, a drop of ejaculate was placed on a slide mounted
we have focused on the association between semen parameters on a heated stage (37°C). The motility of 200 spermatozoa was
and fatherhood during a long-term period (13 years and more) scored as rapid (A), slow or sluggish progressive (B), non-pro-
following the semen analysis. gressive (C), and immotile (D).
The interobserver coefficient of variation (CV) was calculated
based on analysis of the same sample performed by the two
MATERIALS AND METHODS
technicians and was 9% for the sperm concentration and 5% for
Subjects and study design the motility assessment (Rylander et al., 2009).
During the period May 2001 to March 2002, a cohort of Nor-
wegian men, between 19 and 40 years old, were recruited from Sperm chromatin structure assay
the general population (Malm et al., 2004). The original aim of All analyses were done using the same flow cytometer which
the initial study was to evaluate a possible seasonal variation in was calibrated using aliquots of the same batch of calibrator for
male reproductive function among the participating men. Of the every run. The principles and procedure to measure DNA dam-
221 men at study start, 204 men fulfilled the study criteria and age by the flow cytometry-based semen chromatin structure
delivered one semen sample in the summer and one in assay, SCSA, are described in detail elsewhere (Evenson & Jost,
the winter. 2000). In brief, the semen sample was subjected to a short acid
In the follow-up study in 2015, data if and when these men treatment that denatures DNA at sites of single–or double-strand
had become fathers were obtained from the Norwegian Medical breaks. The spermatozoa are stained with a fluorescent DNA dye
Birth Registry for 195 of the 204 men. The remaining nine men which differentially stains double (green)- and single (red)-
were lost to follow-up. These were either dead (1), or emigrated stranded DNA. The extent of DNA denaturation quantified by
(2), or lacking information of unknown reasons. flow cytometry is expressed as DFI, which is the ratio of red to
The cohort was divided into two groups, if they had become total fluorescence intensity, that is, the level of denatured DNA
fathers before and after January 1st 2003, that is, nine months over the total DNA. Five thousand cells were analyzed by FAC-
after the study was completed in March 2002 and if they ever Sort (Becton Dickinson, San Jose, CA, USA), and the data were
had become fathers. analyzed using the SCSASOFT software (SCSA Diagnostics, Brook-
In order to discriminate between voluntary and involuntary ings, SD, USA). A reference sample from a normal donor ejacu-
childlessness, men from the 2001 to 2002 study were contacted late retrieved from the laboratory repository was used (Evenson
in 2014 to 2015 and asked to complete a new questionnaire & Jost, 2000). The same reference sample was used for the whole
online about their present health and fertility status. The sub- study period and run for every fifth sample. The intra-laboratory
jects were asked if they ever had tried to get a biological child
and if they had biological children, yes or no? One hundred and Table 1 Cut-off reference values for semen characteristics in World Health
one men (52%) replied. Organization (WHO) manuals from 1999 to 2010
The study is approved by the Regional Committee for Medical
WHO WHO
and Health Research Ethics, South East, Norway, REC number (1999) (2010)a
2013/604.
Total sperm count (106) 40 39
Sperm concentration (106/mL) 20 15
Semen analysis Motility, grade A (%) 25
The semen samples were collected in 2001–2002 and analyzed Motility, grade A+B (%) 50 32
according to recommendations in the WHO guidelines from Total motility, grade A+B+C (%) 40
b
Morphology (% normal forms) 4 4c
1999 (World Health Organization, 1999). Subsequently, for Volume (mL) 2.0 1.5
sperm concentration, total number, percentage motile sperm,
a
and percentage morphologically normal sperm, they were cate- Lower reference limit obtained from lower fifth centile value. bValue not defined,
but strict criteria suggested. cStrict (Tygerberg) criteria, Grade A, rapid progres-
gorized as normal or abnormal according to both the 1999 and
sive motility (>25 lm/sec); grade B, slow/sluggish progressive motility (5–
2010 cut-off reference values (shown in Table 1). In the WHO 25 lm/sec); grade C, non-progressive motility.
1999 manual, it was recommended that progressively motile

2 Andrology, 1–6 © 2018 American Society of Andrology and European Academy of Andrology
SEMEN PARAMETERS AND CHANCE OF FATHERHOOD ANDROLOGY
coefficient of variation (CV) for the DFI analysis was 4.5%. All (adjusted OR [aOR] 2.8, 95% CI 1.3–6.1, p = 0.008) (Table 4). The
analyses were conducted at the same laboratory. same was seen for men with sperm concentration ≥20 9 106/mL
(aOR 3.1, 95% CI 1.1–8.6, p = 0.03). The combination of sperm
Statistical analysis motility and sperm concentration was also significantly associ-
The background characteristics are shown as mean (SD) and ated with higher chance of fatherhood when both parameters
median (range). For each individual, the mean value of the were above these cut-off values (aOR 8.4, 95% CI 2.1–34,
semen parameters was calculated based on the summer and p = 0.003).
winter values. For the whole group of men (had ever become fathers), the
By logistic regressions, generating odds ratios (ORs) and 95% result was similar for progressive sperm motility ≥50%; aOR 2.7,
confidence intervals (CIs), we investigated the associations 95% CI 1.4–5.5, p = 0.005). For sperm concentration, no signifi-
between each of the standard semen parameters (volume, total cant association was found (≥20 9 106/mL; aOR 2.4, 95% CI 0.9–
sperm count, concentration, motility [progressive and total], 5.9), whereas the combination of sperm motility and sperm con-
morphology, and DFI) and fatherhood. The outcome ‘father- centration showed a significant association (aOR 5.6, 95% CI
hood’ was defined in two ways: 1.8–18, p = 0.004) (Table 4).
• had become father for the first time after January 1st 2003
(yes vs. no; i.e. those who had become fathers before this Applying WHO cut-off values from 2010
recruitment were excluded in these analyses) and The chance of becoming father for the first time after January
• had ever become father (yes vs. no; including all men). 1st 2003 was higher for men with progressive sperm motility
The standard semen parameters were dichotomized according ≥32% than below (aOR 4.2, 95% CI 1.1–15, p = 0.03) (Table 4).
to the reference values given by the WHO guidelines in 1999 and No significant association was observed for sperm concentration
2010, respectively (Table 1). For DFI, we dichotomized at either (≥15 9 106/mL).
20% or 30% which were based on studies showing that the Also, in the whole group, there was a higher chance for becom-
chance of spontaneous pregnancy decreases when DFI exceeds ing a father for those men who had progressive sperm motility
20–30% and almost no chance if DFI is above 30%. ≥32% (aOR 3.4, 95% CI 1.1–10, p = 0.03), whereas for sperm con-
A combined variable based on the parameters sperm motility centration, no significant association was observed (Table 4).
and sperm concentration was created using the WHO reference Analysis of the association of the combined variable sperm
values (three categories: both parameters above the cut-off refer- motility and sperm concentration and outcome using the WHO
ence values, one parameter above and the other one below the 2010 reference values could not be done due to few men with
cut-off reference values, and both parameters below the cut-off abnormal values (data not shown).
reference values). In the whole group of men, there was a borderline significance
In addition to the crude analyses, we also performed analyses for the association between fatherhood and DFI at cut-off 20%
where we adjusted for age (as continuous variable) and absti- (OR 2.7, 95% CI 1.0–7.0, p < 0.05). Due to few men with DFI
nence time (as continuous variable). >30%, calculations based on this cut-off level could not be
Since register data do not discriminate between voluntary and performed.
involuntary childlessness, separate analyses among the 101 men Among the 101 responders of the questionnaire, 72 confirmed
who answered the questionnaire were performed. Those who child wishes. Neither in the group who had become father for
stated that they voluntarily had chosen not to have children were the first time after January 1st 2003 nor among those who ever
excluded in these analyses. had become father, significant associations with sperm parame-
A p-value <0.05 was considered statistically significant. All ters were found, but the trend was similar to the results based on
analyses were performed using SPSS (IBM SPSS Statistics 23, Chi- the registry data (data not shown).
cago, IL, USA).
DISCUSSION
We found that men with progressive sperm motility in the ref-
RESULTS
erence range more often had become fathers as compared to
Background characteristics those with values below the limit. Similar results were seen
The mean (SD) and median (range) for the semen parameters regarding fatherhood after January 1st 2003 and ever fatherhood.
for respective group are summarized in Table 2. Prior to the start Our findings are in agreement with previous results, showing
of the study (2001/2002), 30% of the men had fathered at least that sperm motility may be is a useful predictive parameter with
one child. In 2015, the last year from which the register data regard to fertility outcome (Nallella et al., 2006; Jedrzejczak
were available, 71% were fathers. In Table 3, differences for age, et al., 2008). Sperm motility is considered to be an important
sperm concentration, sperm motility, and registered fathers are indicator of semen quality and fertility potential, an indirect
shown between responders and nonresponder to the follow-up marker for normal development during spermatogenesis and
questionnaire in 2015. normal composition of seminal plasma and required for trans-
port through the female genital tract and penetration of the cor-
ona radiata (Nallella et al., 2006). The chance of pregnancy
Association between semen parameters and fatherhood
increases with increasing number of motile sperm in the ejacu-
Applying WHO cut-off values from 1999 late (Tomlinson et al., 2013). Guzick et al. showed a cut-off
Based on the data from the Medical Birth Register, the chance >63% for sperm motility in fertile men whereas values between
of becoming a father for the first time after January 1st 2003 was 32% and 63% were indicative of borderline fertility (Guzick et al.,
higher when progressive sperm motility was ≥50%, than below 2001). Furthermore, Nallella et al. reported that men with

© 2018 American Society of Andrology and European Academy of Andrology Andrology, 1–6 3
G. Malm et al. ANDROLOGY
Table 2 Background characteristics from 2001 to 2002, with mean (standard deviation, SD) and median (range) for men who had become fathers before
and after January 1st 2003, men who had ever become fathers, and those who not had become fathers

Semen parameters Had become fathers Had become fathers after Had ever become Had never become
mean(SD)/median (range) before January 1st 2003 January 1st 2003 n = 78 fathersa n = 140 fathers n = 54
n = 62

Abstinence time (h) 89 (37)/84 (21–216) 76 (24)/72 (18–168) 82 (31)/72 (18–216) 88 (39)/81 (42–288)
Total count (106 per ejaculate) 281 (198)/251 (15–835) 267 (190)/208 (6–836) 274 (193)/220 (6–836) 216 (1863/162 (8–849)
Concentration (106/mL) 80 (59)/66 (6–318) 62 (41)/59 (2–222) 72 (50)/62 (2–318) 58 (42)/54 (5–158)
Motility A+B (%) (WHO 1999) 48 (9)/50 (22–63) 48 (8)/50 (11–60) 48 (8)/50 (11–63) 44 (11)/46 (10–65)
Motility A+B+C (%) (WHO 2010) 33 (4)/34 (17–39) 32 (4)/33 (12–38) 32 (4)/34 (12–39) 31 (5)/32 (11–39)
Motility A (%) 25 (10)/25 (7–51) 28 (10)/27 (4–48) 27 (10)/26 (4–51) 24 (12)/25 (3–53)
Morphology (%) 8 (5)/7.0 (0–20)b 7 (4)/6 (0–19)c 7 (5)/7 (0–20)d 8 (5)/6 (2–24)e
Semen volume (mL) 3.7 (1.6)/3.2 (1.2–8.2) 4.0 (1.3)/3.9 (1.5–7.5) 3.9 (1.4)/3.7 (1.2–8.2) 3.8 (1.7)/3.8 (1.1–8.8)
DFI (%)c 11 (6)/10 (3–34)f 11 (7)/10 (2–52) 11 (6)/10 (2–52)g 13 (9)/10 (3–39)h

n, numbers; h, hours; A, rapid progressive motility; B, slow/sluggish progressive motility; C, non-progressive motility. aIncludes fatherhood both before and after the
sample collections in 2001–2002. bData from 4 subjects are missing. cData from 8 subjects are missing. dData from 12 subjects are missing. eData from 10 subjects are
missing. fData from 3 subjects are missing. gData from 3 subjects are missing. hData from 2 subjects are missing.

Table 3 Age and semen parameters from responders and non-responders conception in a single menstrual cycle; whereas we have studied
to the questionnaire (2015) long-term fertility. As we only had a single semen sample at each
time point (summer, winter), intra-individual variation is a factor
Semen parameters mean Responders Non-responders
(SD)/median (range) n = 101 n = 103
that could potentially have had an effect on the results.
There is a trend in postponing childbearing and therefore an
Age (years) 41 (5)a 40 (5)b increasing demand among men and women with no known
40 (32–52) 39 (31–51)
reproductive problems to obtain individual assessment and
Concentration (106/mL) 71 (50) 64 (46)c
60 (2–318) 58 (5–222) information about their fertility status (Hvidman et al., 2015).
Motility, A (%) 25 (10) 26 (11)d Earlier studies have focused on establishing threshold values for
26 (5–50) 26 (3–53) semen parameters to define subjects at high risk of subfertility
Motility, A+B (%) 46 (8) 47 (10)e
47 (11–61) 50 (10–65) (Tomlinson et al., 2013). In our approach, we rather focused on
Registered fathers n (%) 72 (71%) 73 (71%) how cut-off levels are associated with the subsequent probability
of fatherhood in a long-term perspective. The semen parameters
n, numbers; A, rapid progressive motility, B, slow/sluggish progressive motility.
a
Data from 1 subject are missing. bData from 8 subjects are missing. cData from 6
were categorized according to both WHO cut-off reference val-
subjects are missing. dData from 6 subjects are missing. eData from 6 subjects are ues from 1999 and 2010, the latter being based on a more well-
missing. defined reference population and more standardized methods
than the 1999 values (World Health Organization, 1999, 2010).
Based on the way of recruitment of participants, the men
proven fertility had a motility ranging between 72.5  16.6, and included were from the general population and relatively young
sperm motility was superior compared to other semen parame- (19–40 years old) at baseline in 2001–2002. Prior to the start of
ters with less overlap between men with proven and non-proven the recruitment, 30% of the men had fathered at least one child,
fertility (Nallella et al., 2006). In a study of Norwegian fertile and in 2015, the last year from which the register data were avail-
men comparing groups with time to pregnancy (TTP) during the able, 71% were fathers.
first cycle with those who conceived within 12 cycles, only the Only minor differences for age, sperm concentration, sperm
total number of sperm with progressive motility was significantly motility, and numbers of children were seen between responders
different when analyzed by multiple logistic regression (Haugen and non-responders to the follow-up questionnaire in 2015. Dur-
et al., 2006). ing the follow-up time between the sample collection (2001–2002)
In our study, also sperm concentration was associated with and 2015, some of the responders to the questionnaire reported
higher probability of becoming a father after sample collection for having been diagnosed with hypertension, hypercholesterolemia,
those with a value of ≥20 9 106/mL, but the whole group, this was type I and II diabetes, but none of them declared fertility problems.
a significant finding only before adjusting for age and abstinence All of these men who reported child wish had become fathers.
time. The threshold of sperm concentration related to fertility has Some studies demonstrate that a combination of semen
been a matter of discussion. Slama et al. found that a sperm con- parameters provides the best diagnostic profile that could dis-
centration less than 20 9 106/mL was associated with decreased criminate fertile from infertile men, since each semen character-
fecundity (Slama et al., 2002). In other studies, sperm concentra- istic contributes a different aspect to fertility (Nallella et al.,
tion or sperm morphology has been shown to be the best predict- 2006). This was also found in our study, with a higher chance of
ing semen parameters (Bonde et al., 1998; Zinaman et al., fatherhood associated with when both sperm motility and sperm
2000). Bonde et al. followed 430 young couples who did not use concentration were above the cut-off reference values than if
contraception and concluded that motility is of limited value and one of the parameter was below.
that the probability of conception increases with sperm concen- In contrast to sperm motility and concentration, sperm mor-
tration up to 40 9 106/mL. This study was designed to character- phology was not associated with fatherhood in our study. This is
ize the relation between semen quality and the probability of in agreement with some previous studies but not with others,

4 Andrology, 1–6 © 2018 American Society of Andrology and European Academy of Andrology
SEMEN PARAMETERS AND CHANCE OF FATHERHOOD ANDROLOGY
Table 4 Odds ratios for sperm parameters at cut-off reference values according to World Health Organization (WHO) 1999 and 2010 when comparing
those who had become fathers after January 1st 2003 vs. those who had not and those who ever had become fathers vs. those who had not

Had become fathers after January 1st 2003 Had ever become fathers

Univariate Adjusteda Univariate Adjusteda

Cut-Off value n yes/no OR (95%CI) OR (95%CI) n yes/no OR (95%CI) OR (95%CI)

DNA fragmentation <20 72/43 2.5 (0.8–7.6) 1.8 (0.6–5.9) 127/43 2.7 (1.0–7.0) 2.3 (0.8–6.3)
index (DFI) (%)
≥20 6/9 Ref Ref 10/9 Ref Ref
b
WHO (1999)
6
Total count (10 <40 6/8 Ref Ref 10/8 Ref Ref
per ejaculate)
≥40 72/46 2.1 (0.7–6.4) 2.4 (0.7–7.6) 130/46 2.2 (0.8–6.0) 2.0 (0.7–5.7)
Concentration <20 8/12 Ref Ref 13/12 Ref Ref
(106/mL)
≥20 70/42 2.5 (0.9–6.6) 3.1 (1.1–8.6) 127/42 2.8 (1.2–6.5) 2.4 (0.9–5.9)
Motility A (%) <25 30/25 Ref Ref 61/25 Ref Ref
≥25 48/29 1.4 (0.7–2.8) 1.6 (0.8–3.4) 79/61 1.1 (0.6–2.1) 1.2 (0.6–2.2)
Motility A+B (%) <50 39/39 Ref Ref 72/39 Ref Ref
≥50 39/15 2.6 (1.2–5.5) 2.8 (1.3–6.1) 68/15 2.5 (1.2–4.9) 2.7 (1.4–5.5)
Morphology <4 17/9 Ref Ref 32/9 Ref Ref
(normal forms %)
≥4 53/35 0.8 (0.3–2.0) 0.8 (0.3–2.0) 96/35 0.8 (0.3–1.8) 0.8 (0.3–1.9)
Semen volume (mL) <2 3/8 Ref Ref 11/8 Ref Ref
≥2 75/46 4.3 (1.1–17) 6.4 (1.5–26) 129/46 2.0 (0.8–5.4) 2.6 (0.9–7.2)
Concentration+ motility <20 + <50 4/9 Ref Ref 8/9 Ref Ref
(A+B) (106/mL + %)
<20 + ≥50 or ≥20 + <50 39/33 2.6 (0.8–9.4) 3.0 (0.8–11) 69/33 2.4 (0.8–6.6) 2.1 (0.7–6.2)
≥20 + ≥50 35/12 6.6 (1.7–25) 8.4 (2.1–34) 63/12 5.9 (1.9–18) 5.6 (1.8–18)

WHO (2010)c

Total count (106 <39 6/7 Ref Ref 9/7 Ref Ref
per ejaculate)
≥39 72/47 1.8 (0.6–5.6) 2.1 (0.6–6.8) 131/47 2.2 (0.8–6.1) 1.9 (0.7–5.6)
Concentration (106/mL) <15 6/7 Ref Ref 10/7 Ref Ref
≥15 72/47 1.8 (0.6–5.6) 2.0 (0.6–6.8) 130/47 1.9 (0.7–5.4) 1.5 (0.5–4.3)
Motility A+B (%) <32 4/8 Ref Ref 7/8 Ref Ref
≥32 74/46 3.2 (0.9–11) 4.2 (1.1–15) 133/46 3.3 (1.1–9.6) 3.4 (1.1–10)
Morphology <4 17/9 Ref Ref 32/9 Ref Ref
(normal forms %)
≥4 53/35 0.8 (0.3–2.0) 0.8 (0.3–2.0) 96/35 0.8 (0.3–1.8) 0.8 (0.3–1.9)

Bold numbers indicate significant values (p < 0.05).

n, numbers of men with and without offsprings; OR, odds ratio; ref, reference; CI, confidence intervals. A, rapid progressive motility; B, slow/sluggish progressive motil-
ity. aAdjusted for age and abstinence time. bWHO cut-off reference values from 1999. cWHO cut-off reference values from 2010.

most likely due procedural differences (Tomlinson et al., 2013). The strength of the study is the long-term follow-up after
Several classification systems for assessment of sperm morphol- semen analysis. A strength is also that the men were recruited
ogy have been introduced the last decades, thus, making it diffi- from the general population. However, the recruitment may
cult to compare various studies, and the association between result in a selection toward subfertile males, especially among
normal sperm morphology evaluated by strict criteria and fertil- the oldest men, who might have interest in joining a study con-
ity remains controversial. Slama et al. found an association cerning fertility. Furthermore, the study group is small, thus,
between the proportion of morphologically normal sperm and replication of the findings in a larger population is necessary to
TTP both with strict and less strict criteria (Slama et al., 2002), draw firm conclusions. Another weakness of our study is the lack
and Bonde et al. found a relation between the proportion of of data on female fertility as well as the broad age range at
sperm with normal morphology according to WHO 1992 (Special recruitment (19–40 years), representing a heterogeneity regard-
Programme of Research Development and Research Training in ing family planning. Therefore, we also included the group ‘ever
Human Reproduction World Health Organization, 1992) criteria become father’. Furthermore, according to the registry data, five
and likelihood of pregnancy (Bonde et al., 1998). of the 195 men had become fathers by in vitro fertilization.
Our results suggest a better chance for becoming a father Moreover, we performed many comparisons and can therefore
when DFI is <20%, although only significant in the group of men not exclude some by chance findings.
who ever had become fathers. This is in agreement with earlier In conclusion, despite the relatively small sample size in the
studies; the chance for conception decreases when DFI, as deter- present study, our results indicate that sperm motility and sperm
mined by the sperm chromatin structure assay (SCSA), exceeds concentration, both as a single parameter and in combination,
20% (Bungum et al., 2011). as well as DFI can be useful when predicting the chance of ever

© 2018 American Society of Andrology and European Academy of Andrology Andrology, 1–6 5
G. Malm et al. ANDROLOGY
becoming father during a longer time period. Our results also Vogel DL & National Cooperative Reproductive Medicine N. (2001)
indicate that semen parameters may have a diagnostic value not Sperm morphology, motility, and concentration in fertile and infertile
only in a short time frame and thus may be clinically useful men. N Engl J Med 345, 1388–1393.
when predicting future fertility potential. Before clinically imple- Haugen TB, Egeland T & Magnus O. (2006) Semen parameters in
Norwegian fertile men. J Androl 27, 66–71.
mentation, larger studies are needed to confirm our findings.
Hvidman HW, Petersen KB, Larsen EC, Macklon KT, Pinborg A & Nyboe
AA. (2015) Individual fertility assessment and pro-fertility counselling;
CONFLICT OF INTEREST should this be offered to women and men of reproductive age? Hum
The authors declare that there is no conflict of interest that Reprod 30, 9–15.
could be perceived as prejudicing the impartiality of the research Jedrzejczak P, Taszarek-Hauke G, Hauke J, Pawelczyk L & Duleba AJ.
reported. (2008) Prediction of spontaneous conception based on semen
parameters. Int J Androl 31, 499–507.
FUNDING Larsen L, Scheike T, Jensen TK, Bonde JP, Ernst E, Hjollund NH, Zhou Y,
This research has been given grants from the Swedish Skakkebaek NE, Giwercman A & Stu DFPP. (2000) Computer-assisted
Research Council (Grant 2014_3185), Skane University Hospital semen analysis parameters as predictors for fertility of men from the
general population. Hum Reprod 15, 1562–1567.
Foundation, and Swedish governmental funding for clinical
Malm G, Haugen TB, Henrichsen T, Bjorsvik C, Grotmol T, Saether T,
research.
Malm J, Figenschau Y, Hagmar L, Rylander L, Levine RJ & Giwercman
A. (2004) Reproductive function during summer and winter in
DISCLOSURES Norwegian men living north and south of the Arctic circle. J Clin
None of the authors has any financial or nonfinancial relation- Endocrinol Metab 89, 4397–4402.
ship to disclose. Nallella KP, Sharma RK, Aziz N & Agarwal A. (2006) Significance of sperm
characteristics in the evaluation of male infertility. Fertil Steril 85, 629–
AUTHORS’ CONTRIBUTIONS 634.
GM, AG, and TBH are responsible for study conception, Rex AS, Aagaard J & Fedder J. (2017) DNA fragmentation in spermatozoa:
a historical review. Andrology 5, 622–630.
design, and collection of data. All authors performed statistical
Rylander L, Wetterstrand B, Haugen TB, Malm G, Malm J, Bjorsvik C,
analyses, interpreted data, and approved of the final version to
Henrichsen T, Saether T & Giwercman A. (2009) Single semen analysis
be published. as a predictor of semen quality: clinical and epidemiological
implications. Asian J Androl 11, 723–730.
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