The definition of infertility is having unprotected intercourse and not conceiving for a period of one year. Approximately 40% of all infertility is due to a male factor. The semen analysis is the primary test to evaluate a male factor. The semen analysis includes assessment of volume, time to liquefy, presence of white blood cells (indicative of possible infections), the count or concentration of sperm, the motility, the percentage of normal shaped sperm. At the Florida Institute for Reproductive Medicine we also routinely include assessment of antisperm antibodies, a relatively common cause of male infertility.
What is a normal sperm count?
Over the last 40 years various definitions of what constitutes a low sperm count have been reported. The sperm count is the number of sperm counted in a certain volume of semen. The most recent World Health Organization criteria is 15 million sperm per milliliter, counts below this are considered low and are referred to as oligozoospermia. There are many potential causes of a low sperm count including anatomic problems, hormonal insufficiency, testicular pathology or a genetic disorder.
Treatment for low sperm count.
Treatment for a low sperm count depends on the cause. In general unless there is a correctable anatomic problem (uncommon) or a lack of hormone stimulating sperm production (uncommon) counts cannot be improved significantly. If an anatomic cause is identified referral to a urologist with experience in reconstructive surgery may be beneficial. If a hormonal problem is identified treatment with antiestrogens, i.e., clomiphene or tamoxifen or gonadotropin medications are often helpful. Counts may not be raised to normal, but often to the point where a simpler less costly treatment may be an option – such as superovulation with washed intrauterine insemination. In cases where there is not a correctible cause we are forced to work with what is in the ejaculate. If very low numbers of sperm are present intracytoplasmic sperm injection (ICSI)/in vitro fertilization (IVF) is usually the answer. With ICSI/IVF literally if a male has one sperm he can have his own genetic child.
Varicocele: Should I have surgery?
Varicocele is a collection of veins in the scrotum which may generate excessive heat to the testicles, (the source of sperm production). It is believed that excessive heat can effect sperm production. Many urologists will recommend varicocelectomy for men with low counts or poor motility. At the Florida Institute for Reproductive Medicine we have seen only rare instances where this surgery has significantly improved semen parameters. In general we have recommended varicocelectomy for those men who are experiencing significant testicular pain.
What are abnormal sperm?
Probably the most common abnormality found on the semen analysis is the shape or morphology of the sperm. Sperm can have a multitude of defects in the head, neck or tail. When an individual gets a semen analysis at most commercial labs, World Health Organization, non-strict criteria is used to determine normal morphology. It is not uncommon to see normal morphologies of 70-90% using these non-strict criteria. In the late 80s Dr. Kruger and colleagues came up with what is now referred to as “strict criteria” or Kruger criteria. Using strict criteria only those sperm having perfectly normal head, neck and tail characteristics are judged normal. These criteria were based on sperm that were identified to have reached the fallopian tube after timed intercourse as well as sperm fertilization in vitro. Using Kruger strict criteria greater than 14% normal sperm is considered normal. If an individual has between 5 and 14% normal forms this is considered abnormal, but to have a good prognosis – generally washed intrauterine insemination in conjunction with superovulation induction is the initial treatment option. If less than 5% of sperm are normal the prognosis for pregnancy with any therapy other than ICSI/IVF is poor. It is believed that abnormally shaped sperm generally cannot bind to the egg. An abnormally shaped sperm does not indicate that the sperm is genetically abnormal, indeed results from ICSI/IVF have shown that the great majority of even abnormally shaped sperm lead to healthy pregnancies. If a genetically abnormal sperm is injected into an egg the resulting embryo is likely to be genetically abnormal and result in either no pregnancy or a very early miscarriage.
Men with no sperm, i.e., azoospermia.
Just because an individual has no sperm in the ejaculate does not mean that there is not sperm production. In general there are two primary causes of azoospermia, i.e., an obstruction in the duct system leading from the testicles to the penis or a production problem which can be related either to a lack of healthy sperm producing cells or a hormonal deficiency. If a hormonal reason is identified these individuals can be treated successfully with antiestrogen or gonadotropin therapies. If an individual’s hormone levels are normal or elevated giving more hormones is not likely to be beneficial. In such cases sperm retrieval can be performed removing sperm from the epididymis (microscopic epididymal sperm extraction) or from the testicular tissue, testicular sperm extraction, itself. This sperm can then be injected into the egg, intracytoplasmic sperm injection (ICSI). In cases of obstructive azoospermia sufficient sperm for ICSI/IVF is obtained in 90-95% of patients. In cases of a production problem sperm recovery is in the 50-60% range.
What causes abnormally shaped sperm?
The cause of abnormal sperm shape is unknown. There are many theories relating to production of abnormally shaped sperm, the most common being adverse chemical or environmental exposures – food preservatives and pesticides with estrogen-like properties have been implicated. Whatever the cause there is no proven therapy to correct abnormal morphology.