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Many infertile men are obsessed about their low sperm
count - and this seems to become the central concern in their lives.
Remember that the real question the man with a fertility problem
is asking is not: What is my sperm count or what is my motility ?
But - are my sperm capable of working or not? Can I have a baby
with my sperm? Since the function of the sperm is to fertilize the
egg, the only direct way of answering this question is by actually
doing IVF for test fertilization. This is, of course, too expensive
and impractical for most people which is why the other sperm function
tests have been devised.
The major problem with all these tests, however,
is that they are all indirect --- there is no very good correlation
between test results, pregnancy rates, and fertilization in vitro
for the individual patient. This is why offering a prognosis for
the individual patient based on an abnormality in the sperm test
result is so difficult, and why we find that different doctors give
such widely varying interpretations based on the same sperm report.
This is really not surprising when you consider
how abysmal our ignorance in this area is - after all, we do not
even know what a "normal" sperm count is! Since you only
need one "good" sperm to fertilise an egg, we do not have
a simple answer to even this very basic question! While the lower
limit of normal is considered to be 10 million progressively motile
sperm per ml, remember that this is a statistical average. For example,
most doctors have had the experience of a man with a very low sperm
count (as little as 2-5 million per ml) fathering a pregnancy on
his own, with no treatment. In fact, when sperm counts are done
for men who are undergoing a vasectomy for family planning, these
men of proven fertility have sperm counts varying anywhere from
2 million to 300 million per ml. This obviously means that there
is a significant variation in "fertile" sperm counts,
and therefore coming to conclusions is very difficult for the doctor
(leave alone the patient!)
In order to make sense of this, you need to understand
two important concepts - "trying time" and "fertility
potential of the couple". If your sperm count is low, but you
have been trying to have a baby for less than 1 year, it still makes
sense to keep on trying for about 1 year, since 10% of men with
low sperm counts will father a pregnancy in this time. If however,
you have already tried for more than 2 years with no success, you
need to move on and do something more - the chances of a spontaneous
pregnancy are now very low. Remember, that a doctor does not treat
just a "low sperm count report" - he treats patients!
So what does the man with a low sperm count do?
Most men go to their doctor and expect that their doctor will
prescribe a medicine which will help them to increase their sperm
count, 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 sad fact of the matter is that there is no method of increasing
a low sperm count
today! This is why modern management of a low sperm count uses
assisted reproductive technology extensively. The modern protocol for managing male infertility is based
on the man's motile sperm count; and on a simple test, called a
sperm survival test. The sperm are washed, and their recovery assessed;
the washed sperm are then kept in culture medium in the incubator
for 24 hours and then rechecked. If there are more than 3 million
motile sperm per ml, this is reassuring. If, however, none of the
sperm is alive after 24 hours, this suggests that they may be functionally
incompetent. Treatment depends upon how low the count is. If it
is only moderately decreased (total motile sperm count in the ejaculate
being 20 million), it makes sense to try to improve the fertility
potential of the wife, and the easiest treatment for men with moderately
low sperm counts is superovulation plus intrauterine insemination.
If after doing this and trying for 4 treatment cycles (the reason
4 is the "magic" number is that most patients who are
going to become pregnant with any method will usually do so within
4 cycles) no pregnancy ensues, you need to go on and explore further
alternatives, such as IVF or ICSI.
Unfortunately, we find that many doctors still
offer IUI ( intrauterine insemination) treatment for men with
oligospermia. 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 oligospermia, with a very low pregnancy rate. The problem is
that oligospermic men have sperm which are functionally incompetent,
which is why washing the sperm and doing IUI does not
help.
So what is the right treatment ? For men with a motile sperm count of more than
5 million in the ejaculate, logically IVF would be the first treatment offered.
This would allow us to document if the sperm can fertilize the eggs
or not. If fertilisation is documented, then the patient has a good
chance of getting pregnant. However, if the motile sperm count is
less than 5 million, or if there is total failure of fertilisation
in IVF, then the only treatment available is ICSI (intracytoplasmic
sperm injection, pronounced "eeksee") or microinjection.
ICSI has revolutionised our approach to the infertile man, and it
promises the possibility for every man to have a baby, no matter
how low his sperm count.
We personally prefer offering ICSI treatment
directly to all men with oligospermia, 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.
What about the answer to the million dollar question:
--- Why do I have a low sperm count? 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 oligospermia" which is really a wastepaper
basket diagnosis for "god only knows!". Modern research
has shown that the reason some men have a low sperm count maybe because
of a microdeletion on the Y-chromosome. This is an expensive test,
which is available only in research laboratories at present, and
does explain why we have little effective treatment for this common
problem! We do know that a low sperm count 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 a low sperm
count 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.
Next
page: Microinjection: The Latest Advance in Treating the Infertile
Man
Previous page:
Diagnosis and Treatment for Male Infertility -- More Confusion!
(Page 3)
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