The terms ‘low sperm count’ and ‘no sperm’ are very frightening to many men and couples, especially when there is a history of infertility. But what do these terms mean ?
Oligozoospermia or ‘low sperm count’ refers to semen with a low concentration of sperm cells and it is commonly associated with male infertility.
Based on the current World Health Organisation criteria, a concentration of less than 15 million sperm per millilitre of semen is termed oligozoospermia. There are also different classes of oligozoospermia (mild to severe). Mild refers to a concentration of 10 million to 15 million sperm, while moderate is between five million and 10 million sperm and severe is characterised by less than five million sperm per millilitre.
Azoospermia (no sperm) refers to the complete absence of sperm cells. It is a well-known form of male factor infertility and may occur in up to 20 per cent of male infertility situations.
Cryptozoospermia is a severe condition in which sperm cannot be seen in a fresh semen sample, but later found after extensive centrifugation and microscopic search. Since the sperm cells are very few and difficult to find, this diagnosis is easily missed.
In our society, the burden is placed more on the female partner when it comes to conception. When a couple can’t conceive after a year, the society automatically blames the woman. This assumption, most times, is false. As a matter of fact, male infertility accounts for approximately 40 to 50 per cent of infertility cases. About seven per cent of men are said to be infertile, but a lot of men with fertility problems are reluctant to visit a clinic for diagnosis and treatment.
The good news is that a diagnosis of oligozoospermia or azoospermia is not the ‘end of the road’. These conditions can be treated and a lot of men have benefitted from various treatment options. Furthermore, it has been observed that the success rate for the treatment of infertility is higher when both couples face the issue and attend clinic appointments together as seen in developed countries.
Before listing the treatment options it is necessary to discuss preventive measures which include, but are not limited to, life-style adjustments such as no smoking, avoidance of recreational drugs and environmental toxins, cutting down on alcohol and caffeine intake. It is important for men to avoid exposing their testicles to high temperatures, such as hot tubs, long distance driving and tight underpants. It is also important to seek prompt and regular medical care for a number of medical conditions associated with infertility, such as mumps, tuberculosis, and sexually transmitted diseases, i.e. gonorrhea and syphilis.
A detailed medical and sexual history, as well as complete physical examination, is done by a clinician to check for possible causes of varicocoele, testicular atrophy, undescended testis and other abnormalities. A seminal fluid analysis is done to properly assess the sperm parameters. Usually, patients are advised to abstain from intercourse for between 2 and 7 days before doing this test for optimal results. Further testing including hormone profile and scrotal ultrasound may be done especially to check for other underlying causes.
In our centre, we also recommend bio-energetic testing to determine food allergies, environmental toxins or the presence of pathogens.
Depending on the underlying cause, patients can benefit from various drugs. The following are commonly used:
Gonadotrophins: Gonadotrophins especially human chorionic gonadotrophin (HCG) have been used successfully in treating some patients with azoospermia especially those with underlying hormonal imbalance.
Anti-Estrogens: Drugs like clomiphene citrate and tamoxifen have also been used in patients with oligospermia/azoospermia. These drugs have been used in patients with idiopathic oligozoospermia as well as patients with low levels of the male hormone- testosterone.
Dietary supplements and antioxidants: The use of antioxidant therapy in the treatment of patients with male infertility has been associated with statistically significant improvements in sperm parameters. This is because many of these anti-oxidants are required at different stages of sperm production. Co-enzyme Q10, for example, has been shown to significantly improve sperm concentration, motility, and morphology in patients undergoing treatment.
Other drugs used include aromatase inhibitors like Anastrozole and cyclic steroids (for immunosuppression). It is important to note that these drugs can be combined to get better results. It is the duty of the clinician to identify the underlying causes and appropriate medication to use.
What we find most successful is to use these medications in a sequence but not together. For instance, many people use a testosterone medication like Proviron on a daily basis for several months. Unfortunately, in men, the physiological levels of testosterone are not constant; hence, the need to prescribe them in a pulsatile fashion for good results.
Lifestyle modification: Patients should be encouraged to stop smoking cigarettes and psychoactive substances. Stress relief, weight loss, dietary modification, avoidance of toxins have all been shown to be beneficial in treating male infertility.
Body detox: A lot of people are exposed to toxins from the environment, preservatives in food, drugs, cosmetics, stress. These toxins may accumulate in vital organs leading to organ damage and infertility. Total body medical detoxification in a medical spa helps to remove these toxins, thereby improving fertility.
There are some surgical procedures done to help improve male infertility
Vasovasostomy / Vasoepididymostomy: These are surgeries done to reverse vasectomies. A vasectomy is a form of permanent birth control whereby the vas-deferens are cut and sealed off to prevent the flow of sperm into the urethra. Pregnancy rates for these procedures vary between 20 and 70 per cent with vasovasostomy having a higher success rate.
Varicocelectomy: This is a common operation for the treatment of male infertility. Varicoceles are abnormally dilated testicular veins found in the scrotum. They can cause decreased sperm production and quality, which may lead to infertility. They are common and occur in 15 per cent of the general male population. This procedure involves clamping off the abnormal veins so blood flow is restricted to only normal veins.
Assisted Reproductive Technology
This refers to the use of advanced techniques to achieve conception. These techniques will not cure or treat the cause of infertility but they can help couples to achieve a pregnancy. The following are commonly used
Artificial Insemination (AI)/Fallopian Tube Sperm Perfusion: Patients with mild and even moderate oligozoospermia can benefit from this non-invasive treatment. It involves the direct intrauterine injection of ‘sperm suspension’ usually after adequate sperm processing (washing). The aim is to achieve higher concentrations of sperm in the ‘fallopian tubes’ to facilitate conception. Pregnancy rates are about 20 per cent per trial and multiple births are common when combined with superovulation.
Intra-cytoplasmic Sperm Injection: This is used for patients with severe oligozoospermia. It involves the direct injection of sperm into the oocyte (egg). For this to be done, the oocytes have to be retrieved from the female partner while semen is collected from the male partner and processed. This method has been extremely beneficial for patients with very low sperm concentrations. Globally, pregnancy rates are around 35 to 45 per cen and can go up to 60 per cent with multiple trials.
Advanced sperm retrieval techniques: A number of procedures can be used to collect sperm in patients with azoospermia using local anesthesia. Many patients with absence of sperm in their semen may have some sperm in their testis (organ where sperm is produced) and epididymis ( the organ that stores mature sperm). Certain procedures can be used to obtain sperm directly from these organs with the help of special needles.
In summary, there are various treatments available for oligozoospermia and azoospermia. The type and extent of treatment can only be determined after proper evaluation and testing by a skilled fertility physician using appropriate techniques and procedures.