| 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.
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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.
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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.
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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.
ICSI has 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.
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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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