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Male Factor Infertility
factor infertility may result from low sperm count or low sperm motility, or
decreased ability of the sperm to fertilize the egg or abnormal shape of
sperms or lack of semen or inability of man to deposit the sperm into vagina
due to erectile dysfunction or hypospadios. The leading cause of male
infertility is low sperm count. Others may be low sperm motility, bad
quality sperms, lack of semen, presence of pus cells in semen & inability to
deposit semen into vagina either due to absent ejaculation or due to any
sexual dysfunctions as erectile dysfunctions. In general, most cases of
male infertility are due to low sperm count. There are many biologic and
environmental factors that can lead to low sperm count. Here is a list of
conditions that may cause low sperm count in men. Please click the links for
detail information about causes, investigations & treatment options.
What is Low sperm count
Causes of low count, motility
Investigations & Diagnosis
Response of treatment
What is Low sperm count:
sperm count is less i.e. decreased in number or amount than normal
is called oligospermia i.e. low sperm count. Whenever there is less
sperm count then chances of spontaneous pregnancy decreases (i.e.
difficulty in conceiving i.e. wife does not becomes pregnant). This
is one of the common causes of male factor infertility. This is also
one of the most common semen abnormalities in men.
How sperms develop: When boy becomes of 14 years of
age then L.H. & F.S.H. hormone secretion from pituitary increases.
The rise in these hormones leads to proliferation of sperm forming
cells (Germ Cells) in the testis. These germ cells start multiplying
under the effect of above-mentioned pituitary sex hormones along
with assistance of other hormones as testosterones, Growth hormones,
Androstenidione, insulin like growth factor-I, Thyroids hormone,
paracrine hormone & growth factors. Under the control of
above-mentioned hormones germs cells divide & transformed into
primary spermatocytes. Then further maturation of primary
spermatocytes to spermatids & then finally into mature spermatozoa
(i.e. normal sperms) occurs under the control of above-mentioned
hormones. After few weeks of progressive maturation inside the
testis these sperms become normally motile & develop the capacity to
fertilize the ovum. This total sperm cycle from first stage to final
stage of normal mature sperms is of three months. Any hindrance in
the development of these spermatozoa will lead to less count of
sperm & decreased motility, immotile or even dead sperms.
Causes of low sperm count: The
various causes of low sperm count are as follows:
1) Hypogonadotropic Hypogonadism:
Deficiency of central sperm producing
hormones as LH, FSH & other hormones may occur due to any of the below
mentioned cause as Hypothalamic – pituitary deficiency: Idiopathic GnRH
deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl
syndrome, Hypothalamic deficiency, pituitary hypoplasia, Trauma, post
surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other),
Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis,
histiocytosis, hemochromatosis) Autoimmune hypophysitis, Hypopituitarism,
Pituitary, Hypothalamic, Associated with multiple pituitary hormone
deficiencies: Idiopathic pan hypo pituitarism (hypothalamic defects),
Pituitary dysgenesis, Space-occupying lesions (craniopharyngioma, Rathke
pouch cysts, hypothalamic tumors, pituitary adenomas), , Laurence-Moon-Beidl
syndrome Prader-Willi syndrome , Frohlich syndrome,
Drugs (drug-induced hyperprolactinemia,
sex steroids use), Glucocorticoid excess
Isolated gonadotropin deficiency (non
2) Testicular disorders (primary Hypogonadism or Hypergonadotropic
Hypogonadism ), Chromosomal disoreder (Klinefelter syndrome and
variants, XX male gonadal dysgenesis), Defects in androgen biosynthesis,
Orchitis (mumps, HIV, other viral, ),Myotonia dystrophica, Noonan syndrome,
Cytotxic drugs, Testicular irradiation. Toxins (alcohol, opiates,
fungicides, insecticides, heavy metals, cotton seed oil), Drugs (cytotoxic
drugs, ketoconazole, cimetidine, spironolactone),
3) Partial obstruction in outflow tract from testis to
penile pening in epididymis or of vas deferens (cystic fibrosis,
diethlstibesterol exposure) also called obstructive oligospermia.
4) Varicocele: varicocele is dilatation of scrotal vein in
the scrotum that leads to rise in temperature of testis and raise testicular
temperature, resulting in less sperm production & death of whatever sperms
5) Partial Spermatogenic arrest due to interruption of the
complex process of germ cell diffrentation from spermatid level to the
formation of mature spermatozoa results in decreased sperm count i.e.
oligospermia. Its diagnosis is made by testicular biopsy. This is found in
upto 30% of all cases of low sperm count patients.18) Heat Exposure to
testis: as febrile illness or exposure to hot ambience induces a fall in
sperm count which is usually reversible.
6) Autoimmunity i.e. presence of Antisperm antibody. In some people
there occurs development of some abnormal blood proteins called anti-sperm
antibodies which binds with sperm and make them either immotile or dead or
decrease their count. These Antisperm antibodies bind with spems & either
make them less motile, totally imotile or even dead which is called
7) Undescended testicle (cryptorchidism). Undescended testis
is a condition when one or both testicles fail to descend from the abdomen
into the lower part of scrotum during fetal development. Undescended
testicles can lead to less sperm production. Because the testicles
temperature increase due to the higher internal body temperature compared to
the temperature in the scrotum, sperm production may be affected.
8) Infections. Infection of urogenital tract may affect sperm
production. Repeated bouts of infections are one of the common causes
associated with male infertility.
9) Viral orchits as mumps or other viral infections.
10) Infections as tuberculosis, sarcoidosis involving testis or
surrounding structures as epididymis.
11) Chronic systemic diseases as Liver diseases, Renal failure,
Sickle cell disease, Celiac disease
12) Neurological disease as myotonic dystrophy
13) Development and structural defects as mild degree of Germinal
14) Partial Androgen resistance
15) Mycoplasmal infection
16) Partial Immotile cilia syndrome
17) Drugs (e.g. spironolactone, ketoconazole, cyclophosphamide,
estrogen administration, sulfasalazine)
19) Infection – as bacterial epididimo-orchitis, even in prostatis
spermatogenic defect have been noted.
20) Hyper-thermia due to cryptorchidism, Environmental exposure as laptop
use or hot working conditions
21) Chromosomal abnormality: has been found in many cases of low sperm count
22) Alcohol use, Cocaine or heavy marijuana use or Tobacco smoking may lower
23) Anti-sperm antibodies.
24) Klinefelter's syndrome. In this disorder of the sex chromosomes,
a man has two X chromosomes and one Y chromosome instead of one X and one Y.
This causes abnormal development of the testicles, resulting in low or
absent sperm production. Testosterone production also may be lower.
25) . Mosaic Klinefelter's syndrome. In this disorder of the sex
chromosomes, of the man is abnormal. This causes abnormal development of the
testicles, resulting in low sperm production. Testosterone production may be
low or normal.
26) Trauma to testis
27) Environmental toxins: as Pesticides and other chemicals in food or as
28) Genetic Factors : as idiopathic partial hypo-gonadotropic hypogonadism
Diagnosis of Cause of Low Sperm Count
For correct diagnosis of cause of low sperm
count, we need detail history & physical examinations then certain relevant
investigations are required.
History & Physical
Examinations: First step in proper treatment is accurate diagnosis of
cause of low sperm count. So we first try to find out cause. We take
detailed history, thorough drug history and general physical examination,
examination of testis, epididymis, testicular veins & sperm carrying duct
examinations. These examinations give idea about whether testis is normally
developed or not & how is its function. After that depending on likelihood
of particular, cause relevant tests are
done. All testing facilities are available at
our centre. Thus you may consult us at our centre & at same time you may get
all tests done. The time taken in getting all the reports ready is 36 hours.
So if you are from out of Delhi, you may come here for two days.
Investigation & Diagnosis: For completes
diagnosis of causes of decreased sperm count & one or more of the following
tests may be required as
1) Complete male
hormone profile: This profile includes all the male hormone tests which
control testicular development, functions including normal sperm
Productions. The tests include L.H., F.S.H., Testosterones, prolactins,
thyroids test, & other relevant hormone tests depending on history &
2) Antisperm antibody
3) USG or Doppler study of scrotum & testis
4) Semen culture sensitivity
5) Semen fructose
6) Immunobead test
7) Sperm Function Tests
8) Human Sperm-Zona Pellucida Binding Ratio
9) Human Sperm-Zona Pellucida Pentration test
10) Genetic Studies
11) FNAC Testis
12) Egg penetration test
13) Molecular genetic studies done in some special cases
14) Chromosome analysis i.e. Karyotype
15) Assessment of androgen receptor
16) Combined Pituitary hormone tests is performed when needed
17) MRI head if pituitary hormone defect suspected
18) Hemogram test for systemic diseases.
19) Sperm Function
The hamster egg penetration assay (HEPA) and the hemizona assay (HZA) are
sperm function tests which can help assess the ability of sperm to fertilize
the egg. These tests will not definitively tell whether a pregnancy will
occur, but an abnormal test result helps predict reduced fertilizing
capability. These tests are performed only rarely today.
20) Semen Fructose
At our center facility for
all the above tests are available.
Treatment: Once the cause of low sperm
count are found then with in three months of treatment sperm count &
motility becomes normal in more than 90% cases.
The various treatments are
Correction of the Cause: First of all we
try to find out the primary cause of infertility by above mentioned
investigations. Then we correct the basic defect i.e. correction of hormone
disorder & other defects. We also give following treatment for permanent
cure of low sperm count & motility disorder.
Correction of Hormone deficiencies:
Once the hormone disorder is found
then it is corrected by any of the below medicines. Usually sperm count
normalizes in three month time with proper hormone treatment.
Therapy: Gonadotropins are most potent natural stimulators of sperm
production in the testis. Once we start gonadotropin therapy, these
gonadotropins stimulates the sperm producing cells in testis. Under the
stimulating influence of gonadotropins dormant sperm forming cells which
were not producing any sperms, they start dividing & produce multiple
immature sperm cells with in three to four weeks. These are further matured
in next two to three month into mature sperms under the influence of
gonadotropin treatment. Thus in more than 90% cases sperm production can be
normalized in three to four months time if it is started in properly
selected cases of low sperm count. Gonadotropin therapy is most successful
of all the available treatment for low sperm count till now. In many cases
of low sperm count, when all other treatment has failed even in those cases
gonadotropin therapy is effective. Thus treatment of low sperm count with
gonadotropin therapy results in pregnancy soon.
hormone (Gn-RH) analogs
Growth hormone therapy in many cases
where somatrop deficiency is found.
Growth Factor, Mineral & Micronutrient Therapy
9) Free Radial
Scavangers: These are drug to reduce the free damaging oxidative radical
in the testis. For your information every minute lot of oxidant radicals are
generated inside the testis which damages sperm forming cells. These special
antioxidant drugs scavange these damaging oxidative free radicals thus
leading to production of normal sperms by the testis. In many study these
free radical scavengers have been found to be very-very effective in
normalizing sperm count.
10) Coenzyme ubique:
These drugs improve the nutritional status of the testis. Thus testis as
well as sperm forming cells get enough nutrient which helps in fast
generation of sperms in good number with good motility & fertilizing
supplimentation increases the production of sperm, with normalization of
sperm count in three months.
12) Fertyl: This
drug is taken orally and it causes the pituitary gland to release more FSH
and LH, which then stimulates the testis to produce more sperms.
This medication is for men who has elevated levels of prolactin, then this
hormone rise decreases the sperm production
14) Correction of
15) Correction of
congenital adrenal hyperplasia
28) Certain Newer Drugs
has been found very effective
29) Treatment of
antisperm antibody is achieved by steroid therapy, intrauterine
insemination intra-cytoplasmic sperm injection (ICSI)
Depending on the cause, surgery may be a treatment option for low sperm
count due to partial blockade of the tract from testis to the tip of pennis.
Surgery is also the treatment of choice for significant varicocele.
Similarly surgery may be one of the treatment options for many endocrine
insemination: In certain patients motile sperms are selected by various
methods & then transferred directly in uterine cavity leading to improved
32) Test tube baby
is also delivered with our efforts by use of intra-cytoplasmic sperm
injection (ICSI), then transfer of embryo to uterus of mother.
33) Treatment of
general sexual problems. Addressing imppotence or premature ejaculation
can improve fertility. Treatment for these problems often is with medication
or behavioral approaches.
33) Semen Bank:
Facility for good quality sperm is semen bank in also available. At our
center we have facility for all the testing & treatment facility required
for low sperm count to achieve pregnancy.
reproductive technology (ART)
ART has revolutionized the treatment of infertility. Each year thousands of
babies are born in India as a result of ART. Medical advances have enabled
many couples to have their own biological child.
The most common forms of
a) In vitro fertilization (IVF). This
is the very effective ART technique. IVF involves retrieving mature eggs
from a woman, fertilizing them with a man's sperm in a dish in a laboratory
and implanting the embryos in the uterus three to five days after
fertilization. IVF often is recommended as a first-line therapy. It's also
widely used for unexplained infertility, male factor infertility.
b) Electroejaculation. Electric
stimulus brings about ejaculation to obtain semen.
c) Surgical sperm aspiration. This
technique involves removing sperm from part of the male reproductive tract
such as the epididymis, vas deferens or testicle. This allows retrieval of
sperm if blockage is present.
d) Intracytoplasmic sperm injection (ICSI).
This technique consists of a microscopic technique (micromanipulation) in
which a single sperm is injected directly into an egg to achieve
fertilization in conjunction with the standard IVF procedure. ICSI has been
especially helpful in couples who have previously failed to achieve
conception with standard techniques. For men with low sperm concentrations,
ICSI dramatically improves the likelihood of fertilization.
varicocele is an abnormal tortuosity and dilation of veins of within the
scrotum. It can be surgically treated - which might help fertility in some
Response of treatment: When we start
treatment, maturation of spermatocyte to mature spermatozoa start occurring
in three to 4 weeks time and achievement of normal sperm count in three
months. Thus cure rate is achieved in more than 95% of patients in three
Side effects: This treatment is harmless
because we prescribe well proven drugs which are prescribed in scientific
literature. These medicines have to be purchased from medical store by
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