The Curious Case of the Missing Semen

Where did the semen go? In this week’s episode of Taco Bout Fertility Tuesday, Dr. Mark Amols unpacks one of the lesser-discussed causes of male infertility—low semen volume and retrograde ejaculation.

From the science of what makes up semen (spoiler: sperm is only about 3% of it!) to the coordinated dance between the sympathetic and parasympathetic nervous systems, you’ll learn how the body decides when to open and close the right channels during urination and ejaculation.

We break down:

• What qualifies as “low volume”
• How retrograde ejaculation happens—and how to spot it
• Conditions like diabetes, surgeries, and medications that can cause it
• Diagnostic tools including post-ejaculatory urinalysis
• Treatment options including Sudafed, sperm retrieval, and IVF/ICSI
• Other causes of low volume like ejaculatory duct obstruction and congenital absence of the vas deferens

Whether you're a patient, partner, or just curious about how sperm can get lost in transit, this episode is full of insight, clarity, and of course—compassion and tacos.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

Stay connected with us for updates and fertility tips – follow us on Facebook. For more resources and information, visit our website at www.NewDirectionFertility.com.

Have a question or a topic you'd like us to cover? We'd love to hear from you! Reach out to us at TBFT@NewDirectionFertility.com.

Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

0:01

Today we're talking about what happens when semen goes missing. Literally from low volume to sperm taking a detour, we'll dive into one of the lesser talked about causes of male infertility. I'm Dr. Mark Amols and this is Taco about Fertility Tuesday. I know last week we talked about malufactory infertility. And you know what? They should get another week as well. We rarely talk about men and their infertility, but they are about 50% of the problem. When people hear infertility, they often think about eggs, ovulation and hormone levels. But semen analysis is a huge part of the picture. And sometimes it'not the quality of the sperm that's the problem, but the quantity of the semen itself. Now, I'm not talking about the count of the sperm, I'm talking about the semen. So let's define what's normal. A normal semen volume is at least 1.5 millils. According to the World Health Organization, that's about a third of a teaspoon. When the volume is low, especially if it's less than 1 milliliter, that can be a sign that something is off. See, when we talk about semen, we're not talking about just the sperm. We're talking about the sperm as well as the fluid it comes with. Now, here's something that may surprise you. Sperm only makes up about 3 to 5% of the total semen volume. That means that 95 to 97% of what comes out isn't sperm at all. Its seminal vesicle fluid. So then where does the rest come from? Well, the seminal vesicles contribute about 60 to 70% of the volume. This includes fructose to nourish the sperm, prostaglandins and clotting factors. The prostate gland is next. It adds about 20 to 30%, including enzymes like PSA to liquefy the semen. The bumble urethral glands had a little bit more fluid and that's mostly the lubricate and ph balancing. Now, I'm not trying to ruin your dessert, but to give you an idea of what type of volume we're talking about is if a regular cookie that was about three inches in diameter was the whole semen, only one chocolate chip in the entire cookie would represent the sperm. I'm not a sweet lover, so that didn't bug me at all. Now, before we get into how there can be low volume, let's talk a little bit about the nervous system dance that occurs between peeing and pleasure. What you'll be amazed by is how coordinated the male reproductive and urinary system has to be. Urination and ejaculation both happen through the same tube, the urethra. But how does the body avoid sending urine out during an orgasm or sperm mount during a trip to the bathroom? Well, it all comes down to a perfectly timed hando between the two parts of your nervous system. Urination occurs through the parasympathic system, whereas ejaculation occurs through the sympathetic system. So think of urination being controlled by the parasympathetic system. That's your rest and digest system. So when you pee, the parasympathetic nerves, which are between S2 and S4, contract the bladder muscles, also known as the detrusion muscle. At the same time, the internal urethral sphincter, which is like the bladder neck, relaxes. This allows the urine to flow smoothly out of the bladder through the urethra. But injaculation, things change. It flips the switch. It'governed by the sympathetic nervous system, your fight or flight response system. So during ejaculation, the bladder neck clamps down shut. That's to prevent semen from going backwards into the bladder. The vas deferens contract, moving sperm up towards the urethra. The semical vesles and the prostate add their fluids and the bulble spongiosis muscle contracts rhythmically to propel the sperm outward. Think of it like air traffic control. One runways opens, the other shuts down. If both open at once, you get a crash. If the bladderneck fails to close during ejaculation, semen ends up in the bladder. That's retrograde ejaculation. So what is retrograde ejaculation? Well, it's when the semen, instead of exiting the body, flows backwards into the bladder because the bladderneck didn't close properly during ejaculation. Now, it's important to know retrograde ejaculation doesn't usually affect orgasm or erection. The sensation may still feel completely normal, but very little or no semen comes out. And there are many causes that can cause this. One of the more common causes is going to be diabetes. Up to 20 to 30% of men with poorly controlled diabetes can develop autonomic nerve damage affecting the bladderck. So as you can see, it's affecting that system. Another area are surgeries such as prostate surgery, specifically a terp. That procedure can affect the nerves, even blad or neck surgery, or even retroperitoneal lymph node dissection, which can occur with Testicular cancer can sometimes affect that autonomic nervous system, and that can affect things. So anything that's going to affect the nerves, even spinal cord injuries, can affect it, but also medications. So alpha blockers are going to cause an issue because you need the alpha stimulation to close the bladderneck. Even tricyclic antidepressants can cause issues. So there are drugs that can disrupt the sympathetic tone. So how do you know if you have this? I mean, if you have just drops of sperm, does that mean you have this? Well, not exactly. But if you have diabetes and that's happening, it's very likely. But the way you figure it out is you perform a SEME analysis and the volume is very low or absent. We know that's a possibility. Usually the patients can report things like, oh, their urine is very cloudy after an orgasm. And that's a key clue. Now, to confirm it, we do what's called a post ejaculatory urinalysis. This is where after you give a SEME analysis, you then urinate. And then we centrifuge the urine and look under a microscope. If we're finding more than 10 sperm per high power field or over a million sperm per milliliter, then that's diagnostic of retrograde ejaculation. It's one of the few times we'hoping to find sperm in the uterus. But why? Because if we can find sperm in the uterus, it means there is sperm there and it's something we can fix easier. Whereas in other times when we don't find sperm, the urine, then that means there's another issue going on causing low sperm volume. See, not every low volume case is retrograde ejaculation. There are other culprits that include obstructive causes. So you can have what's called ejaculatory duct obstruction. Now, this can be found through a transre rectal ultrasound. There can also be complete absence of the vas deferens. The acronym for this is cbavd, which stands for congenital bilateral absence of the VAS deferens. And this is sometimes linked to cystic fibrosis mutations. Other issues that could be going on are things like infections or inflammation, such as prostyitis and vesiculitis. Even surgical scarring from maybe one of those procedures we talked about, like a terp can cause some type of blockage. Now, there are other reasons too, that aren't so worrisome, such as incomplete collection where someone feels like they ejaculated, but really they didn't. And so there's very little volume, and usually that has very little sperm in it. So that can help us identify that. So the question is, what can be done? You're one of those people that have low volume. You're worried. Well, if the volume is low due to retrograde ejaculation, then what we need to do is first see if you're taking any. Any medications that can be causing problems. If you are not taking medications that are causing problems, one of the simplest treatments you can do is take pseudoephedrine about 60 to 120 milligrams before intercourse. And that will stimulate the bladder neck to close. Matter of fact, when many guys are taking Sudafed, they'll notice it's a little harder to pee. And that's because of that bladderneck being closed from the pseudohedrine. Now, if that fails, then what we need to do is collect the sperm from the urine, and then we can use it in IUI or ivf. Now, what we usually do is prepare the bladder first by putting sodium bicarbonate in the bladder to alkalize the urine. That way it won't hurt the sperm as much. Now, the way we do that is through oral, so then bicarbonate. Now, we still will have the person take pseudohedrine, so we can hopefully get lots of sperm with ejaculation. But if not, then we'll collect the urine, we'll isolate the sperm from it, and then we can use it for IUI or ivf. Now, if it's obstructed or absent, then we have to do other things to figure out what's going on. So using imaging, we can identify if there's a physical blockage, and sometimes surgery can repair that issue. Otherwise, what we usually do is some type of procedure to get the sperm, which is called a peisa, stands for percutaneous epididymal sperm aspiration, or a test C, which stands for testicular sperm extraction. And those will allow us to bypass the urethra to be able to get the sperm directly from the testicle. Now, if it's due to an infection or some other cause, such as severe hypogadism, then we can give medications to treat the infections or to increase testosterone levels that may be creating issues. But those are not the most common causes. So what does this mean? Well, it means having a low volume ejaculate doesn't mean you're infertile. It just means we need to dig a little deeper. Is sperm are present even in the urine, we have excellent chances with assisted reproductive technologies to be able to have success. Specifically IVF with ICSI using retrieved sperm either through the urine or directly through the testicle during one of those procedures has comparable success rates to ejaculate sperm. And for couples trying naturally, correcting the retrograde ejaculation with pseudohedrine may restore the forward progression of flow of the sperm completely, requiring you not even to see a fertility doctor. Therefore, if your semen analysis shows low volume, don't panic. It might not be a problem with sperm at all. It might just be a plumbing issue and with the right tools we can often fix the pipes. Maybe your partner also has low sperm volume or theyve mentioned to you or maybe you've even noticed it seems to be a little low. If thats true, have them listen to this episode. Or if you know someone who might be concerned about something like this, let them know as well. If you have friends with diabetes as having problems again, this may be a perfect episode for them. But as as always, I greatly appreciate everyone who listens to this podcast and I appreciate when people send me topics that they want me to go over. If you want to send a topic, send it to TBFT for talk about fertility Tuesday at newirectionffertility.com. and if you liked this podcast, tell your friends about it. Give us a five star review on your favorite medium. But most of all, keep coming back. I look forward to talking you again next week on Taco Bel Fertility Tuesday.