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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.

You can see what a normal sperm count looks like here!

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.

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

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 fertilization 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 fertilization 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 fertilization failure with In Vitro Fertilization. This allows us to guarantee that we will be able to make embryos in the lab, no matter how poor the sperm.

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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