What does agglutination in a semen report indicate in a patient with idiopathic oligoasthenoteratospermia (low sperm count, poor sperm motility, and abnormal sperm morphology)?

Sperm Agglutination in Semen Analysis

Agglutination in a semen report indicates that sperm cells are clumping together, which is most commonly caused by anti-sperm antibodies and represents an immunological cause of male infertility that impairs sperm motility and fertilization capacity.

What Agglutination Means

• Agglutination refers to sperm cells sticking together in clumps rather than swimming freely as individual cells 1
• This differs from simple aggregation (sperm trapped in mucus or debris), as true agglutination involves motile sperm adhering head-to-head, tail-to-tail, or in mixed patterns 1
• The presence of agglutination strongly suggests an immunological factor contributing to infertility, typically from anti-sperm antibodies binding to sperm surface antigens 1

Clinical Significance in Oligoasthenoteratospermia

• In patients with idiopathic oligoasthenoteratospermia (low count, poor motility, abnormal morphology), agglutination adds an immunological component to the already compromised sperm parameters 2
• Anti-sperm antibodies can develop from various causes including infection (particularly Chlamydia trachomatis), trauma, varicocele, or obstruction that exposes sperm antigens to the immune system 2
• The combination of agglutination with oligoasthenoteratospermia significantly reduces natural fertility potential compared to oligoasthenoteratospermia alone 1

Diagnostic Workup Required

• Confirm true agglutination by examining fresh semen within 1 hour of collection under microscopy to distinguish from aggregation or debris 1
• Anti-sperm antibody testing should be performed using either direct immunobead testing (on sperm surface) or mixed antiglobulin reaction (MAR test) to quantify IgG and IgA antibodies 1
• Evaluate for underlying causes including history of genital tract infection, trauma, surgery (vasectomy reversal), or varicocele on physical examination 2
• Complete hormonal evaluation with FSH, LH, and testosterone to characterize the degree of testicular dysfunction, as elevated FSH >7.6 IU/L suggests primary testicular failure 3
• Genetic testing including karyotype and Y-chromosome microdeletion analysis if sperm concentration is <5 million/mL, as chromosomal abnormalities occur in 5-15% of severe oligospermia cases 4

Treatment Implications

• Assisted reproductive technology (IVF/ICSI) offers the highest pregnancy rates when agglutination is present with oligoasthenoteratospermia, as sperm washing and direct injection bypass both the antibody problem and the poor sperm parameters 5, 2
• Sperm washing techniques using density gradient centrifugation can separate motile sperm from antibody-bound sperm and seminal plasma, improving the functional sperm population for intrauterine insemination 5
• Avoid empiric medical therapy such as corticosteroids for anti-sperm antibodies, as evidence is weak and side effects significant; proceed directly to ART if natural conception fails after 6-12 months 1
• Never prescribe exogenous testosterone if fertility is desired, as it will completely suppress spermatogenesis through negative feedback, potentially causing azoospermia that takes months to years to recover 5

Important Caveats

• The presence of agglutination does not predict the severity of oligoasthenoteratospermia—some men with severe agglutination maintain adequate sperm counts while others with mild agglutination have severe oligospermia 1
• Anti-sperm antibodies affecting >50% of sperm significantly reduce natural fertility, but IVF/ICSI success rates remain good as the technique bypasses the antibody barrier 2
• Infection-related agglutination may improve with appropriate antibiotic treatment if active infection is documented, but chronic immunological agglutination typically persists despite treatment 2