| While the commonest
cause of male infertility is a low sperm count ( the
technical term for this is
oligospermia), some men are infertile because of
poor sperm motility. Normally, at least 50% of
sperm should be motile; and this should be good quality
progressive motility. This condition is called
asthenospermiaor asthenozoospermia ( astheno = weak). While many men with a
low sperm count will also have poor sperm motility ( the
two often co-exist, and this is called
oligoasthenospermia), some men will have a normal sperm
count, but very poor sperm motility. Sperm motility ( whether the sperm are moving well
or not ) can only be assessed when a
semen analysis is
performed in the laboratory . Sperm motility is the ability to move.
Sperm are of two types - those which swim, and those
which don't. Remember that only those sperm which move
forward fast are able to swim up to the egg and fertilise
it - the others are of little use. Motility is graded
from a to d, according to the World Health Organisation
( WHO) Manual criteria , as follows. Grade a ( fast
progressive) sperm are those which swim forward fast
in a straight line - like guided missiles. Grade b (slow
progressive) sperm swim forward, but either in a curved
or crooked line, or slowly (slow linear or non linear
motility) . Grade c ( nonprogressive) sperm move their
tails, but do not move forward ( local motility only).
Grade d ( immotile ) sperm do not move at all . Sperm of
grade c and d are considered poor. Other laboratories
grade sperm from a range of I to IV - and you need to
ask your doctor what the grade refers to.
Why do we worry about poor sperm motility ? A lot of
men who have a normal count of 50 million per ml with a
low motility of only 10% often ask me - I have 5 million
motile sperm - why can't I get my wife pregnant ?
After all, I need only 1 sperm to fertilise the egg ! However, if only 10% of the sperm are motile, this means
90% are immotile ! And if so many of the sperm being
produced in the testis are functioning so poorly that
they cannot even swim, the fertilising ( functioning)
ability of the remaining sperm is bound to be suspect !
These men often become obsessed about their low sperm
motility - and this seems
to become the central concern in their lives. Remember
that the real question the man with a fertility problem
is asking is not: What is my sperm count or what is my
motility ? But - are my sperm capable of working or not?
Can I have a baby with my sperm? Since the function of
the sperm is to fertilize the egg, the only direct way
of answering this question is by actually doing IVF for
test fertilization. This is, of course, too expensive
and impractical for most people which is why the other
sperm function tests have been devised.
The major problem with all these tests, however, is
that they are all indirect --- there is no very good
correlation between test results, pregnancy rates, and
fertilization in vitro for the individual patient. This
is why offering a prognosis for the individual patient
based on an abnormality in the sperm test result is
so difficult, and why we find that different doctors
give such widely varying interpretations based on the
same sperm report.
So what does the man with a low sperm motility do? Most
men go to their doctor and expect that their doctor
will prescribe a medicine which will help them to increase
their sperm count, and fix their problem. After all,
they expect that if medical technology has become so
advanced, then there must be some treatment available
to correct such a common problem !
The problem with the medical treatment of poor sperm
motility is that for most people it simply doesn't work.
After all, if the reason for poor sperm motility is a microdeletion on the Y-chromosome, then how can medication
help ? The very fact that there are so many ways of
"treating" poor sperm motility itself suggests
that there is no effective method available. This is
the sad state of affairs today and much needs to be
learnt about the causes of poor production of sperm
before we can find effective methods of treating it.
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However, patients want treatment, so there is pressure
on the doctor to prescribe, even if he knows the therapy
may not be helpful . When most patients go to a doctor,
they expect that the doctor will prescribe a medicine
and treat their problem. Since most people still believe
there is a "pill for every ill", they expect
that the doctor will give them a medicine ( or an injection)
which will increase their sperm count. No patient ever
wants to hear the truth that there is really no effective
treatment available today for increasing the sperm
motility .
Since most doctors know this, they are pressurised
into prescribing medicines for these patients, because
they do not want the patient to be unhappy with them.
They are worried that if they do not fulfill the patient’s
expectation of a prescription, the patient will desert
them, and go elsewhere, which is why they often do not
tell the patient the complete truth. The doctor also
remembers the occasional anecdotal successes (who come
back for followup , while the others desert the doctor
and are lost to followup) is why patients with poor
sperm motility are put on every treatment imaginable - with
little rational basis - clomiphene, HMG and HCG injections
( using the rationale that what's good for the goose
must be good for the gander !) proxeed, testosterone,Vitamin
E, Vitamin C, anti-oxidants, high-protein diets, hoemeopathic
pills , ayurvedic churans and even varicocele surgery.
However, the very fact that there are hundreds of medicines
itself proves that there is no medicine which works
! ( After all, if one medicine worked, then all doctors
would prescribe this, so there would be no need for
so many different medicines !)
Many doctors justify their prescriptions by saying
- " Anyway it can't hurt - and in any case, what
else can we do? " However, this attitude can be
positively harmful. It wastes time, during which the
wife gets older, and her fertility potential decreases.
Patients are unhappy when there is no improvement in
the sperm count and lose confidence in doctors. It also
stops the patient from exploring effective modes of
alternative therapy - such as IVF and
ICSI . Today empiric
therapy should be criticised unless it is used as a
short term therapeutic trial with a defined end-point.
A word of warning. Medical treatment for male infertility
does not have a high success rate and has unpleasant
side effects, so don't take it unless your doctor explains
his rationale. The treatment is best considered "experimental"
and can be tried as a therapeutic trial. Make sure,
however, that semen is examined for improvement after
three months and then decide whether you want to press
on regardless.
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What about surgery to treat a varicocele ? Remember
that many men with large varicoceles have excellent
sperm counts and motility , which is why correlating cause (varicocele)
and effect (poor sperm motility ) is so difficult. It is
possible that the varicocele may be an unrelated finding
in infertile men - a "red herring" so to speak.
This means that surgical correction of the varicocele
may be of no use in improving the sperm motility - after
all, if the varicocele is not the cause of the problem,
then how will treating it help? In fact, controlled
trials comparing varicocele surgery with no therapy
in men who have varicoceles and poor sperm motility have
shown that the pregnancy rate is the same – so
that it does not seem to make a difference whether or
not the varicocele is treated !
Because surgery for varicocele repair is simple and
straightforward , many doctors still repair any varicoceles
they find in infertile men, following the dictum that
it’s better to do something, rather than do nothing
! However, keep in mind that varicocele surgery will
result in an improvement in sperm count and motility
in only about 30% of patients - and it is still not
possible for the doctor to predict which patient will
be helped. Of course, just improving the sperm count
is not enough - and pregnancy rates after varicocele
repair alone are in the range of 15%. However, one danger
of doing a varicocele repair is that when it doesn’t
help, patients get frustrated, and refuse to pursue
more effective options, such as the assisted reproductive
techniques.
The sad fact of the matter is that there is no method
of increasing low sperm motility today! This is why modern
management of a low sperm count uses assisted reproductive
technology extensively. The modern protocol for managing
male infertility is based on the man's motile sperm
count; and on a simple test, called a sperm survival
test. The sperm are washed, and their recovery assessed;
the washed sperm are then kept in culture medium in
the incubator for 24 hours and then rechecked. If there
are more than 3 million motile sperm per ml, this is
reassuring. If, however, none of the sperm is alive
after 24 hours, this suggests that they may be functionally
incompetent. Treatment depends upon how low the count
is. If it is only moderately decreased (total motile
sperm count in the ejaculate being 20 million), it makes
sense to try to improve the fertility potential of the
wife, and the easiest treatment for men with moderately
low sperm counts is superovulation plus intrauterine
insemination. If after doing this and trying for 4 treatment
cycles (the reason 4 is the "magic" number
is that most patients who are going to become pregnant
with any method will usually do so within 4 cycles)
no pregnancy ensues, you need to go on and explore further
alternatives, such as IVF or
ICSI.
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Unfortunately, we find that many doctors still offer
IUI ( intrauterine insemination) treatment for men with
asthenospermia. The hope seems to be that washing the
sperm will help the doctor to recover the "best
sperm"; and since only one sperm is needed to fertilise
the egg, then IUI will improve the chances of achieving
a pregnancy. Unfortunately, IUI is a terrible treatment
for asthenospermia, with a very low pregnancy rate. The
problem is that asthenospermic men have sperm which are
functionally incompetent, which is why washing the sperm
and doing IUI does not help.
So what is the right treatment ? For men with a motile
sperm count of more than 5 million in the ejaculate,
logically IVF would be the first treatment offered.
This would allow us to document if the sperm can fertilize
the eggs or not. If fertilisation is documented, then
the patient has a good chance of getting pregnant. However,
if the motile sperm count is less than 5 million, or
if there is total failure of fertilisation in IVF, then
the only treatment available is
ICSI (intracytoplasmic
sperm injection, pronounced "eeksee") or microinjection. ICSI has revolutionised our approach to the infertile
man, and it promises the possibility for every man to
have a baby, no matter how low his sperm count.
We personally prefer offering ICSI treatment directly
to all men with asthenospermia, to bypass the risk of
total fertilisation failure with IVF. This allows us
to guarantee that we will be able to make embryos in
the lab, no matter how poor the sperm.
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What about the answer to the million dollar question:
--- Why do I have low sperm motility ? Unfortunately,
nine times out of ten, the doctor will not be able to
answer that question, and no amount of testing will
help us to find out - this is labelled as "idiopathic
asthenopermia" which is really a wastepaper basket
diagnosis for "god only knows!". Modern research
has shown that the reason some men have a low sperm
count maybe because of a microdeletion on the Y-chromosome.
This is an expensive test, which is available only in
research laboratories at present, and does explain why
we have little effective treatment for this common problem!
We do know that low sperm motility is not related to
physique, general state of health, diet, sexual appetite
or frequency. While not knowing the cause can be very
frustrating, medicine still has a lot to study and understand
about male infertility, which is a relatively neglected
field today.
The major cause of male infertility usually is a sperm
problem. However, do remember that this is no reflection
on your libido or sexual prowess. Sometimes men with
testicular failure find this difficult to understand
(but doctor, I have sex twice a day! How can my sperm
count be zero?). The reason for this is that the testis
has two compartments. One compartment, the seminiferous
tubules, produces sperms. The other compartment, the
"interstitium" or the tissue in between the
tubules (where the Leydig cells are) produces the male
sex hormone, testosterone, which causes the male sexual
drive. Now while the tubules can be easily damaged,
the Leydig cells are much more resistant to damage,
and will continue functioning normally in most patients
with testicular failure.
This is why the diagnosis of low sperm motility can
be such a blow to one's ego --- it is so totally unexpected,
because it is not associated with other symptoms or
signs. Men react differently - but common feelings include
anger with the wife and the doctor; resentfulness about
having to participate in infertility testing and treatment
since they feel having babies is the woman's "job";
loss of self-esteem; and temporary sexual dysfunction
such as loss of desire and poor erections. Many men
also feel very guilty that because of "their"
medical problem, they are depriving their wife the pleasures
of experiencing motherhood. Unfortunately, social support
for the infertile man is practically non-existent, and
he is forced to put up a brave front and show that he
doesn't care. Since he is a man, he is not allowed to
display his emotions. He is expected to provide a shoulder
for his wife to cry on - but he needs to learn to cry
alone. However, remember that the urge for fatherhood
can be biologically as strong as the urge for motherhood
- and we should stop treating infertile men as second
class citizens.
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