Conventional treatment
of male infertility in the past used a wide array of
medicines to try to improve a low sperm count in the
infertile man. These included :
Gonadotropin injections ( HMG and HCG)
These hormonal injections of gonadotropins are only
useful in stimulating sperm production in azoospermic
men ( zero sperm count) who have hypogonadotropic hypogonadism
(men with low FSH and LH levels, because of hypothalamic
or pituitary malfunction), but this is a very rare condition.
In these men, treatment often takes many months to restore
the sperm quality to fertile levels. Combination treatment
is required, with HCG to stimulate testosterone production;
and HMG to stimulate sperm production. Initially, the
man takes HCG injections thrice a week for about 6 months.
This normally causes the size of the testes to increase
and the testosterone to reach normal levels. HMG injections
are then added. These can be mixed with the HCG and
are also given thrice a week. Once sperm production
has been achieved, the HMG can be stopped; and HCG treatment
continued alone. While sperm counts achieved are usually
low (less than 10 million per ml), a successful pregnancy
can be achieved in 50 % of correctly diagnosed patients.
Unfortunately, these expensive injections are often
misused as "empiric" therapy in men with low
sperm counts - with extremely disappointing results.
Since the vast majority of infertile males have normal
levels of these hormones, unfortunately, giving them
additional injections does not help to boost their sperm
production. The reason this is confusing for many men
is that the very same injections are given to their
wives to make them grow more eggs - so why can't the
injections be used to make them produce more sperm ?
While this is a logical argument, which is why doctors
will try out these injections, unfortunately they simply
do not work, so using them is just a waste of time,
money and energy.
Bromocryptine
As in the female, this is used to lower unusually elevated
levels of prolactin. However , this is a very rare problem
in infertile men; and most men with high levels of prolactin
are also impotent.
Testosterone
This is given to suppress sperm production in the hope
that when medication is stopped (usually after 5-6 months),
then the sperm production will "rebound "
to higher levels than originally (testosterone rebound).
This form of treatment is now seldom used as it may
further impair fertility and is hazardous. Testosterone
is also be used for the treatment of impotence or diminished
libido when blood testosterone levels are low. Testosterone
is available as an oily injection and is given intramuscularly,
usually once a week. Oral preparations are also available
now, but these are more expensive and may not be as
effective.
Clomiphene
This is the most commonly prescribed medicine for infertile
men - and the one which is most widely misused. Its
use is largely empirical and very controversial as the
results are not predictable. This is usually prescribed
as a 25 mg tablet, to be taken once a day, for 25 days
per month, for a course of 3 to 6 months. It acts by
increasing the levels of FSH and LH, which stimulate
the testes to produce testosterone and sperm. The group
of men who seem to benefit the most from clomiphene
have low sperm counts, with low or low-normal gonadotropin
levels. However, while clomiphene may increase sperm
counts in selected men, it hasn't been proven effective
in increasing pregnancy rates.
Antibiotics
Just as in the female, antibiotics can resolve a chronic
infection in the reproductive tract in the male. However,
there is no evidence that treating pus cells in the
semen helps to improve male fertility.
Vitamins and antioxidants
Again, there is no evidence that they work , but since
they "do no harm", many doctors will prescribe
them - and many patients will take them. Popular once
include Vitamin E and Vitamin C, along with arginine
and zinc.
Herbal treatment, ayurvedic treatment and other magic
potions
Everyone seems to have a "magic potion" to
cure low sperm counts - the trouble is that no one has
ever proven that anything works. Take all claims with
a liberal pinch of salt !
Many men will observe that their sperm count increases
after taking these medicines, and they get very excited
when this happens. However, do remember that sperm counts
fluctuate all the time - and often the increase is inspite
of the medicines, not because of it . In any case, a
sperm count is not like a bank account that you should
get excited when it increases ! The end-point is not
an increase in the sperm count or motility - it's a
baby ! While some of these medicines may improve sperm
counts in some men on some occasions, double blind clinical
trials have shown they do not help to improve pregnancy
rates. This criticism is also true for the currently
fashionable Proxeed, which is being marketed very aggressively
and cleverly in the USA.
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 - Vitamin E, Vitamin C, high-protein
diets, hoemeopathic pills and ayurvedic churans. However,
the very fact that there are hundreds of medicines itself
proves that there is no medicine which works !
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.
It is worth emphasising how small the list for male
infertility treatment is - especially as compared to
female treatment. This simply reflects our ignorance
about male infertility - we know very little about what
causes it, and our knowledge about how to treat it is
even more pitiable !
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