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The Man with a Low Sperm Count Oligospermia : Cause & Treatment

Many infertile men are obsessed about their low sperm count - 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. You can see what a normal sperm count looks like here !

This is really not surprising when you consider how abysmal our ignorance in this area is - after all, we do not even know what a "normal" sperm count is! Since you only need one "good" sperm to fertilise an egg, we do not have a simple answer to even this very basic question! While the lower limit of normal is considered to be 10 million progressively motile sperm per ml, remember that this is a statistical average. For example, most doctors have had the experience of a man with a very low sperm count (as little as 2-5 million per ml) fathering a pregnancy on his own, with no treatment. In fact, when sperm counts are done for men who are undergoing a vasectomy for family planning, these men of proven fertility have sperm counts varying anywhere from 2 million to 300 million per ml. This obviously means that there is a significant variation in "fertile" sperm counts, and therefore coming to conclusions is very difficult for the doctor (leave alone the patient!)

In order to make sense of this, you need to understand two important concepts - "trying time" and "fertility potential of the couple". If your sperm count is low, but you have been trying to have a baby for less than 1 year, it still makes sense to keep on trying for about 1 year, since 10% of men with low sperm counts will father a pregnancy in this time. If however, you have already tried for more than 2 years with no success, you need to move on and do something more - the chances of a spontaneous pregnancy are now very low. Remember, that a doctor does not treat just a "low sperm count report" - he treats patients!

So what does the man with a low sperm count 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 a low sperm count is that for most people it simply doesn't work. After all, if the reason for a low sperm count is a microdeletion on the Y-chromosome, then how can medication help ? The very fact that there are so many ways of "treating" a low sperm count 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.

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 count.

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 low sperm counts 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 , which is why correlating cause (varicocele) and effect (low sperm count) 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 count - 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 a low sperm count 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 a low sperm count 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 oligospermia. 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 oligospermia, with a very low pregnancy rate. The problem is that oligospermic 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 oligospermia, 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.

What about the answer to the million dollar question: --- Why do I have a low sperm count? 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 oligospermia" 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 a low sperm count 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 a low sperm count 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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