Low Sperm Count or Abnormal Sperm

Causes and Treatments


Diagnosing male infertility

couple with low sperm countApproximately 15% of couples at reproductive age are affected by infertility (i.e., do not conceive within the expected time period). Among those, approximately 40% demonstrate a male cause. Though rates fluctuate from year to year, at CHR approximately 20 percent of couples present with male infertility, though many amongst them also demonstrate significant problems in the female partner.

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What is low semen volume?

Low semen volume does not really matter in infertility context; what really matters is the number of healthy sperm that have the full potential of fertilizing an egg. To assess the ability of a man's sperm to fertilize an egg, fertility specialists and urologists use semen analysis.

What is abnormal semen analysis?

When pregnancy does not occur after more than a year of unprotected intercourse in women under age 38 and within six months at older ages, a couple should see a fertility specialist. As a part of an initial infertility workup, the fertility specialist, likely, will order a semen analysis, which tests quantity and quality of sperm. A complete semen analysis involves the assessment of many different parameters, but only three are really important:

  • Concentration (sperm count per milliliter of semen)
  • Morphology (shape of sperm)
  • Motility (mobility of sperm)

With any one or more "abnormal," male infertility may be diagnosed. Here is, however, the real truth: Nobody really cares very much about what sperm counts, morphology and motility results really are. The reason for that is rather simple: what we really are after is to find out how well or poorly sperm "functions." And sperm has only one biological function, which is to penetrate the wall of the egg (zona pellucida), and by doing so to fertilize the egg!

Unfortunately, we, however, have no reliable test to determine how well sperm does in this function (as it would not be very ethical to test sperm against someone's eggs). We, therefore, do the next best thing: we test sperm function indirectly via a semen analysis. If all three sperm parameters, count, motility and morphology, are normal, then, with over 99 percent likelihood the sperm's function will be normal as well.

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What is low sperm count?

Low sperm count, also called oligospermia, is the most common cause of male infertility. Complete lack of sperm, called azoospermia, is much less common, affecting less than 1% of the population. Low sperm count is diagnosed when the number of sperm falls below 20 million in a milliliter of semen. (Normal range is between 20 million and 120 million per milliliter of semen.) When sperm count is too low, sperm has a much lower chance of fertilizing the egg, leading to infertility.

Many possible causes of low sperm count exist. Some are structural: even when sperm is produced normally in the testes, an obstruction in the ejaculation tract may block the sperm. Other causes include hormonal insufficiency, testicular injuries and chromosomal/genetic abnormalities (such as Klinefelter syndrome). In addition, vasectomy can be considered a cause of male infertility, if the male partner changes his mind about having children after having had one.

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Treatment for low sperm count?

Treatments for low sperm count vary depending on the cause, and are, overall, unsatisfactory. Only rarely will a male treatment convert a male from being infertile to fertile. At best one can in most cases expect a marginal improvement. Treatment for low sperm count, in most cases, leaves the male and his female partner still in need of assisted reproduction.

An exception is the structural obstruction of the outflow tract. Surgery may in such cases on occasion overcome the obstruction and reestablish a normal count. Often, however, surgery only marginally improves counts, still mandating assisted reproduction.

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Varicocelectomy: Good treatment for low sperm count due to varicocele?

Probably the most overused surgical intervention in male infertility is surgery for varicoceles (abnormal enlargement of veins in the scrotum), called a varicocelectomy. While many of our urology colleagues may disagree with us on this matter, we have found most of these surgeries not to affect the male's fertility status. Yes, parameters on semen analysis may improve a bit, but we have almost never seen an infertile male turning into a spontaneously fertile one. They usually still are in need of assisted reproduction, and just wasted six months!

In rare cases of pituitary hypogonadism (abnormally low hormone production) administration of follicle-stimulating hormone (FSH) may boost sperm production. Success is, however, also anything but assured and the length of required treatment before results may be seen usually discourages patients from choosing this approach.

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Artificial insemination (IUI) to overcome low sperm count

In most cases of oligospermia there, simply, is no good medical or surgical treatment available to improve sperm. The determination that needs to be made, therefore, is whether the quality of available sperm is likely to be enough to allow spontaneous fertilization. If sperm is presumed capable of fertilization at a reasonable level, then intrauterine inseminations (IUIs) may be attempted. In such cases, by just bringing sperm closer to the egg, fertilization can be facilitated.

ICSI to overcome low sperm count

Whenever doubt exists about a sperm's ability to fertilize, it is time to make the fertilization process "visible." This means that we need to ensure that fertilization really occurs! To " ensure that fertilization occurs" means that we have to take the couple into in vitro fertilization (IVF), where the process can be observed. Moreover, if in doubt about the sperm's fertilization abilities, we can perform intracytoplasmic sperm injection (ICSI), a procedure that has revolutionized male infertility.

Since with ICSI we can now achieve fertilization for practically almost any male, as long as he has even only a handful of sperm, there is really no longer any reason to try mostly ineffective treatment options for male infertility. IVF+ICSI have for all practical purposes solved the problem of male infertility!

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Men with azoospermia can have children by ICIS

ICSI allows to work with such minute amounts of sperm that it has become possible to obtain very small amounts of sperm from the testicles of male with complete azoospermia (lack of sperm). In a procedure called testicular semen extraction (TESE) or sometimes through a so-called "open biopsy," our expert urology colleagues retrieve the necessary amount of sperm, which then allows us to fertilize the female's eggs in an IVF cycle. This method allows approximately 85 percent of azoospermic males to become the genetic fathers of their children.

Next steps

If you are interested in diagnosis and treatment of male factor infertility, please contact us.

Last Updated: May 17, 2011