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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 abnormal looking sperm . This is called teratozoospermia (terato=monster).

Many infertile men have sperm samples which have low sperm counts, with poor motility and many abnormally shaped sperms. This is called oligoasthenoteratozoopsermia.

When the laboratory checks the semen under the microscope, they analyse the sperm shape ( whether the sperm are normally shaped or not - this is called their form or morphology. ) Ideally, a good sperm should have a regular oval head, with a connecting mid-piece and a long straight tail. If too many sperms are abnormally shaped (round heads; pin heads; very large heads; double heads; absent tails) this may mean the sperm are abnormal and will not be able to fertilise the egg. Many labs use Kruger "strict " criteria ( developed in South Africa ) for judging sperm normality. Only sperm which are "perfect" are considered to be normal. A normal sample should have at least 15% normal forms (which means that even upto 85% abnormal forms is considered to be acceptable!)

Why do we worry about abnormally shaped sperm ? A lot of men who have a normal count of 50 million per ml with 98% abnormal sperm often ask me - I have 1 million normal sperm - why can't I get my wife pregnant ? After all, I need only 1 sperm to fertilise the egg ! This is because abnormally shaped sperm are not capable of fertilising the egg, because they do not function properly. And if 98% of the sperm being produced in the testis are functioning abnormally, the fertilising ( functioning) ability of the remaining 2% sperm is bound to be suspect !

So what does the man with abnormal sperm do? Most men go to their doctor and expect that their doctor will prescribe a medicine which will help them to improve their sperm morphology , 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 morphology is that for most people it simply doesn't work. The very fact that there are so many ways of "treating" poor sperm morphology 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 improve their sperm morphology. No patient ever wants to hear the truth that there is really no effective treatment available today for improving sperm morphology .

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 morphology 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 morphology 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 morphology , which is why correlating cause (varicocele) and effect (poor sperm morphology ) 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 morphology - 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 morphology 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 morphology 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 morphology 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 improving poor sperm morphology today! This is why modern management of a poor sperm morphology uses assisted reproductive technology extensively.

Unfortunately, we find that many doctors still offer IUI ( intrauterine insemination) treatment for men with teratozoospermia . 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 teratozoospermia, with a very low pregnancy rate. The problem is that men with teratozoospermia have sperm which are functionally incompetent, which is why washing the sperm and doing IUI does not help.

ICSIhas revolutionised our approach to the infertile man, and it promises the possibility for every man to have a baby, no matter how abnormal his sperm .

We personally prefer offering ICSI treatment directly to all men with teratozoospermia, 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 low sperm morphology ? 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 teratozoospermia" which is really a wastepaper basket diagnosis for "god only knows!". We do know that poor sperm morphology 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 poor sperm morphology 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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