A low sperm count
( the scientific term for which is oligospermia)
is the commonest cause of infertility in the man.
Many infertile men are obsessed about their 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 motility or whatever? 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.
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 is the man with a low sperm count to do? Unfortunately,
there is no method of increasing the sperm count today!
The modern protocol for managing male infertility is
based on the man's motile sperm count; and on a simple
test, celled 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 6 treatment cycles (the reason
6 is the "magic" number is that most patients
who are going to become pregnant with any method will
usually do so within 6 cycles) no pregnancy ensues,
you need to go on and explore further alternatives,
such as IVF or ICSI.
For men with a motile sperm count of more than 5 million
in the ejaculate, 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.
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 is 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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