Sperm disorders include defects in quality or quantity of sperm produced and defects in sperm emission. Diagnosis is by semen and genetic testing.
Spermatogenesis occurs continuously. Each germ cell requires about 72 to 74 days to mature fully. Spermatogenesis is most efficient at 34° C. Within the seminiferous tubules, Sertoli cells regulate maturation, and Leydig cells produce the necessary testosterone.
Fructose is normally produced in the seminal vesicles and secreted through the ejaculatory ducts. Sperm disorders may result in an inadequate quantity of sperm—too few (oligospermia) or none (azoospermia)—or defects in sperm quality, such as abnormal motility or structure.
Impaired spermatogenesis: Spermatogenesis can be impaired by heat, disorders (GU, endocrine, or genetic), drugs, or toxins ( see Table 1 ), resulting in an inadequate quantity or defective quality of sperm.
Sperm emission may be impaired because of retrograde ejaculation into the bladder, which is often due to the following:
Retroperitoneal dissection (eg, for Hodgkin lymphoma)
Obstruction of the vas deferens
Congenital absence of both vasa deferentia or epididymides, often in men with mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene
Absence of both seminal vesicles
Almost all men with symptomatic cystic fibrosis have congenital bilateral absence of the vas deferens.
Other causes: Men with microdeletions affecting the Y chromosome can develop oligospermia via various mechanisms, depending on the specific deletion. Another rare mechanism of infertility is destruction or inactivation of sperm by sperm antibodies, which are usually produced by the man.
How To Diagnosis?
- Semen analysis
- Sometimes genetic testing
When couples are infertile, the man should always be evaluated for sperm disorders. History and physical examination focus on potential causes (eg, GU disorders). Normal volume of each testis is 20 to 25 mL. Semen analysis should be done. If oligospermia or azoospermia is detected, genetic testing, including standard karyotyping, PCR of tagged chromosomal sites (to detect microdeletions affecting the Y chromosome), and evaluation for mutations of the CFTR gene, should be done. Before a man with a CFTR gene mutation and his partner attempt to conceive, the partner should also be tested to exclude cystic fibrosis carrier status.
Before semen analysis, the man is typically asked to refrain from ejaculation for 2 to 3 days. However, recent data indicate that daily ejaculation does not reduce the sperm count in men unless there is a problem. Because sperm count varies, testing requires ≥ 2 specimens obtained ≥ 1 wk apart; each specimen is obtained by masturbation into a glass jar, preferably at the laboratory site. If this method is difficult, the man can use a condom at home; the condom must be free of lubricants and chemicals. After being at room temperature for 20 to 30 min, the ejaculate is evaluated (see Table 2 ). Additional computer-assisted measures of sperm motility (eg, linear sperm velocity) are available; however, their correlation with fertility is unclear.
What is normal sperm count?
The sperm count checks to see if there are enough sperms. If the sample has less than 20 million sperm per ml, this is considered to be a low sperm count. Less than 10 million is very low. The technical term for a low sperm count is oligospermia (oligo means few).
Some men will have no sperms at all and are said to be azoospermic. This can come as a rude shock because the semen in these patients look absolutely normal – it is only on microscopic examination that the problem is detected.
What is normal sperm motility ?
Motility checks whether the sperms are moving well or not (sperm motility). The quality of the sperm (morphology) is often more significant than the count. Sperm motility is the ability to move. Sperm are of 2 types – those which swim, and those which don’t. Remember that only those sperm which move forward fast are able to swim up to the egg and fertilise it – the others are of little use.
Motility is graded from a to d, according to the World Health Organisation (WHO) Manual criteria as follows.
- Grade a (fast progressive) sperms are those which swim forward fast in a straight line – like guided missiles.
- Grade b (slow progressive) sperms swim forward, but either in a curved or crooked line, or slowly (slow linear or non linear motility).
- Grade c (nonprogressive) sperms move their tails, but do not move forward (local motility only).
- Grade d (immotile ) sperms do not move at all.
Sperms of grade c and d are considered poor. If motility is poor (asthenospermia), this suggests that the testis is producing poor quality sperm and is not functioning properly – and this may mean that even the apparently motile sperm may not be able to fertilise the egg.
This is why we worry when the motility is only 20% (when it should be at least 50% ? ) Many men with a low sperm count ask is – ” But doctor, I just need a single sperm to fertilise my wife’s egg. If my count is 10 million and motility is 20%, this means I have 2 million motile sperm in my ejaculate – why can’t I get her pregnant ? ” The problem is that the sperm in infertile men with a low sperm count are often not functionally competent – they cannot fertilise the egg. The fact that only 20% of the sperm are motile means that 80% are immotile – and if so many sperm ( Sperm Video ) cannot even swim, one worries about the functional ability of the remaining sperm. After all, if 80% of the television sets produced in a factory are defective, no one is going to buy one of the remaining 20% – even if they seem to look normal.
What is normal sperm morphology ?
Whether the sperms are normally shaped or not – what is called their form or morphology. Ideally, a good sperm ( Sperm Video ) should have a regular oval head, with a connecting mid-piece and a long straight tail. If too many sperms are abnormally shaped (this is called teratozoospermia, when the majority of sperm have abnormalities such as round heads; pin heads; very large heads; double heads; absent tails) this may mean the sperm are functionally 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 even upto 85% abnormal forms is considered to be acceptable!)
Sperm clumping or agglutination.
Under the microscope, this is seen as the sperms sticking together to one another in bunches. This impairs sperm motility and prevents the sperms from swimming upto through the cervix towards the egg.
Putting it all together, one looks for the total number of “good” sperms in the sample – the product of the total count, the progressively motile sperm and the normally shaped sperm. This gives the progressively motile normal sperm count which is a crude index of the fertility potential of the sperm. Thus, for example, if a man has a total count of 40 million sperm per ml; of which 40% are progressively motile; and 60% are normally shaped; then his progressively motile normal sperm count is : 40 X 0.40 X 0.60 = 9.6 million sperm per ml. If the volume of the ejaculate is 3 ml, then the total motile sperm count in the entire sample is 9.6 X 3 = 28.8 million sperm.
What does the presence of pus cells in the semen signify ?
Whether pus cells are present or not. While a few white blood cells in the semen is normal, many pus cells suggests the presence of seminal infection. Unfortunately, many labs cannot differentiate between sperm precursor cells ( which are normally found in the semen) and pus cells. This often means that men are overtreated with antibiotics for a “sperm infection” which does not really exist !
Some labs use a computer to do the semen analysis. This is called CASA, or computer assisted semen analysis. While it may appear to be more reliable (because the test has been done “objectively” by a computer), there are still many controversies about its real value, since many of the technical details have not been standardised, and vary from lab to lab.
What does a normal semen analysis report mean ?
A normal sperm report is reassuring, and usually does not need to be repeated. If the semen analysis is normal, most doctors will not even need to examine the man, since this is then superfluous. However, remember that just because the sperm count and motility are in the normal range, this does not necessarily mean that the man is “fertile”. Even if the sperm display normal motility, this does not always mean that they are capable of “working” and fertilising the egg. The only foolproof way of proving whether the sperm work is by doing IVF (in vitro fertilisation)!
What are the reasons for a poor semen analysis report ?
Poor sperm tests can result from:
- incorrect semen collection technique, if the sample is not collected properly, or if the container is dirty
- too long a time delay between providing the sample and its testing in the laboratory
- too short an interval since the previous ejaculation
- recent systemic illness in the last 3 months (even a flu or a fever can temporarily depress sperm counts)
If the sperm test is abnormal, this will need to be repeated several times over a period of 3-6 months to confirm whether the abnormality is persistent or not. Don’t jump to a conclusion based on just one report – remember that sperm counts do tend to vary on their own! It takes six weeks for the testes to produce new sperm – which is why you need to wait before repeating the test. It also makes sense to repeat it from another laboratory, to ensure that the report is valid.
If a man without hypogonadism or congenital bilateral absence of the vas deferens has an ejaculate volume < 1 mL, urine is analyzed for sperm after ejaculation. A disproportionately large number of sperm in urine vs semen suggests retrograde ejaculation.
Endocrine evaluation is warranted if the semen analysis is abnormal and especially if the sperm concentration is < 10 million/mL. Minimum initial testing should include serum follicle-stimulating hormone (FSH) and testosterone levels.
If testosterone is low, serum luteinizing hormone (LH) and prolactin should be measured as well. Men with abnormal spermatogenesis often have normal FSH levels, but any increase in FSH is a clear indication of abnormal spermatogenesis. Elevations in prolactin require evaluation for a tumor involving or impinging upon the anterior pituitary or may indicate ingestion of various prescription or recreational drugs.
Specialized sperm tests, available at some infertility centers, may be considered if routine tests of both partners do not explain infertility and in vitro fertilization or gamete intrafallopian tube transfer is being contemplated. The immunobead test detects sperm antibodies, and the hypo-osmotic swelling test measures the structural integrity of sperm plasma membranes. The hemizona assay and sperm penetration assay determine the ability of sperm to fertilize the egg in vitro. The usefulness of these specialized tests is controversial.
If necessary, testicular biopsy can distinguish between obstructive and nonobstructive azoospermia.
The first thing to do before doing any treatment is to cure the underlying disease first (if there is any, or if the disease is curable). Hopefully when the disease that cause sperm disorder is gone, the sperm condition is also improved.
After the underlying disease is treated, but the sperm condition doesn’t improve, you may want to consult your doctor to start:
1. Drug Therapy
While drug therapy is a fairly common form of fertility treatment for women, the use of fertility drugs in men is not. In fact, only about 5% of men with a hormone imbalance will be helped by medications. However, when fertility drugs are prescribed to men, it is generally for hormone imbalance issues. There are a variety of drugs that can be prescribed for male infertility. Just which you receive will depend on the problems you are experiencing.
When the hormonal imbalance is the result of disrupted signals between the hypothalamus, pituitary gland and the testes, thereby affecting sperm production, men often receive gonadotropins. This type of therapy is usually very helpful in men.
Gonadotropins are commonly used in men who have been diagnosed with unexplained infertility, abnormally low sperm count, or have less than 40% sperm motility. Common gonadotropins used in men include hCG and FSH, both of which are injectable fertility drugs.
Testosterone deficiency can often be attributed to a lack of gonadotropins. To help stimulate the release of gonadotropins, men can also receive antiestrogen fertility drugs. Usual antiestrogen medications prescribed to men include tamoxifen (Nolvadex) and clomiphene (Clomid).
However, the use of antiestrogens may boost testosterone production in men to above normal levels, which can negatively impact on sperm production. Therefore, men receiving this type of therapy should have their testosterone levels monitored. Moreover, the FDA has not approved the use of Clomid in men nor has it been found to be especially effective. Side effects of clomiphene in men include weight gain or loss, vision problems, skin changes, libido changes and neurological or gastrointestinal disturbances.
Men who have an excess of prolactin in their system often experience fertility problems. This is because too much prolactin can lead to a decrease in testosterone as well as abnormal sperm. To help decrease a man’s prolactin levels and get his sperm production back on track, bromocriptine is prescribed.
To be effective, though, the medication needs to be taken for at least four consecutive weeks. Side effects of bromocriptine use in men can include high blood pressure and worsening of certain mental disorders or liver disorders while older men are more likely to experience confusion, hallucinations and uncontrolled bodily movements.
When a lack of testosterone production, known as hypogonadism, is the cause of your male infertility problems, synthetic testosterone may be prescribed. This type of testosterone works to mimic the natural testosterone produced in men. It can be administered through oral pills, injections or as a transdermal gel or patch.
The use of oral testosterone pills is sometimes questioned as they have been associated with elevated liver function as well as abnormalities in liver scans and biopsy. Injections are generally thought to be safer than oral pills. However, testosterone injections do not always provide a consistent level of hormones causing a man’s libido, energy levels and mood to fluctuate. Additionally, many men find the injections to be inconvenient, as they require frequent trips to the fertility specialist.
Although they can be more expensive, transdermal testosterone applications are proving to be a popular choice for an increasing number of men. Not only are testosterone gels and patches safe and efficient to use, providing a consistent level of hormone in the body, they also have relatively few side effects associated with them. Some men may experience skin irritation at the sight of application, though.
2. ART/ MAC (Assisted Reproductive Technology/ Medically Assisted Conception.
ART main goal actually is not increasing the sperm condition, but created artificial environment that will make conception will have a higher chance to success.
The most commonly used ART including:
- Intra Uterine Insemination (IUI)
- In Vitro Fertilization (IVF)
- Intra Cytoplasmic Sperm Injection (ICSI)
You might want to visit the links for more information.