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Overview - Evaluation - Treatment Options - Diagnosis

TREATMENT OPTIONS FOR SPERM PROBLEMS

There are ways to improve sperm counts, and we will detail those in the next few paragraphs. However, the treatment of male infertility and improvement of sperm counts has been a frustrating problem for both the patient and the physician for a long time. The process of spermatogenesis is an extremely complex one that occurs over the course of about seventy days. Our understanding of this remarkable process is rudimentary, at best, and our ability to define where a problem exists and to correct it is almost nonexistent. Until recently, we could do nothing for many cases. Now, however, with the advent of laboratory techniques such as IVF and ICSI, we have the ability to take the most compromised of sperm samples and achieve fertilization in the laboratory. Men with even just a few sperm can achieve pregnancy. The bottom line when it comes to treating male fertility is this: Much of the focus in the treatment of male infertility has shifted from trying to improve sperm production and quality to finding ways to work with whatever sperm are present.

Schedule Wisely
It is important to realize that it takes about seventy days for the testicles to produce a sperm that is fully mature and ready to achieve fertilization. Any significant insult during that seventy-day period can significantly affect the sperm count for two to three months. For example, if you have a very high fever today as the result of the flu or an infection, it may be three months before your sperm count will fully return to normal. Keep this in mind when scheduling your sperm countsCif you have any reason to think there may have been some event that could interfere with sperm production, it may be wise to wait a while between sperm counts and see if the count improves.

Remember to avoid toxinsCit's that simple. You don't necessarily have to abstain from drinking alcohol, but be reasonable. And, if there is any evidence of infection, treat it. It's straightforward, inexpensive, non-invasive, and it may help.

Urologist Evaluation
Evaluation by a urologist, particularly one who has a special interest in male fertility, is usually the first step in evaluating abnormal semen analyses. There are several problems that urologists treat effectively.

1. Varicocele: A varicocele is a dilated vein or veins around the testicles. It is thought that these dilated veins increase the heat of the testicle and thereby impair sperm production and the motility of the sperm that are produced. This effect of a varicocele can be progressive over time. Significant varicoceles can usually be appreciated on a simple physical exam. Correction of a varicocele requires a minor surgical procedure and can result in dramatic improvements in sperm numbers and function if the varicocele is large. Smaller varicoceles may or may not be important, and correction of small varicoceles is not likely to result in clinically significant improvements in the sperm count.

2. Obstruction: Most obstructions of the male reproductive tract are due to prior vasectomies, although they may occur as a result of infection, prior surgery (e.g., hernia repair), or may even be congenital. Microsurgery in the hands of one experienced in this technique can be very successful in reversing obstruction. The chances of successfully reversing an obstruction decrease the longer the obstruction has been present.

3. Failure of ejaculation: There are medications available that can remedy this problem for a large number of individuals. In others (for example, men who have suffered a spinal cord injury) electroejaculation has been very successful.

4. Retrograde ejaculation: In some individuals, the sperm are actually ejaculated backward into the bladder rather than out through the penis. This can be a congenital abnormality, or it may occur as the result of surgery, illness (e.g., diabetes) or medications. This can often be corrected through the use of medications, but if this does not work, the sperm can be isolated from the urine and used for insemination.

5. Testicular cooling: The testicles don=t work well if they are too hot. Taking steps to keep the testicles cool is a very reasonable thing to do. Wear boxer shorts instead of jockey shorts. Avoid long or frequent saunas or hot tubs. Sleep naked. Finally, there is some suggestion that actually placing a small ice pack in a sock and then sitting on it for a while in the evening may be worthwhile.

Medical Therapies
Clomiphene citrate (Clomid, Serophene): Clomiphene citrate is an orally administered medication often used in women because it leads to an increased production of FSH by the pituitary, stimulating the ovaries. The rationale behind the use of clomiphene in men is that it will result in increased levels of FSH stimulating the testicles to produce more sperm. There is no good evidence that the use of clomiphene in men results in improved sperm production or better pregnancy rates.

Human menopausal gonadotropins: These medications are actually preparations of the hormones FSH and LH (Pergonal, Humegon), or FSH alone (Metrodin, Fertinex, Gonal-F, Follistim). They must be administered by injections, usually on a daily basis, and they are very expensive. In the rare individual whose pituitary does not produce LH and FSH, these preparations can be quite effective. In individuals whose pituitary gland functions normally but the sperm count is decreased, the value of these medications is much more questionable. Human chorionic gonadotropin (hCG): Although this was a popular form of therapy in the past, it has not been found to be of value and is rarely used anymore.

Vitamins: There have been reports touting everything from vitamin E to vitamin C to zinc as the cure for decreased sperm production. I would suggest that everyone take some nice multivitamin, not megadoses, and leave it at that.

SEMEN ANALYSIS
Semen analyses were discussed in detail above. If the semen analysis is abnormal, it should be repeated. Before repeating it, eliminate any of the possible causes of abnormal evaluations as listed above. Also be sure to repeat it after an adequate period of time has elapsed to allow improvement to occur. Remember, it takes seventy days to produce a mature sperm.

Postcoital Test
If the semen analysis is normal, the next step should be a post-coital test. The postcoital test (also known as the Huhner Test) is an excellent means of assessing the interaction of the sperm and the cervical mucus. In order to reach the fallopian tube and fertilize an egg therein, the sperm must first migrate through the cervical mucus. There are many factors that can impair the ability of the sperm to survive and traverse the cervical mucus, including faulty intercourse (e.g,. premature ejaculation), infection, prior surgery on the cervix and production of antibodies (substances that can kill or immobilize the sperm).

During a normal menstrual cycle, there are only a couple of days during which the sperm can survive in the cervical mucus. At other times of the cycle, the mucus is a very effective barrier. Around the time of ovulation, the cervical mucus becomes very thin and watery, and probably even somehow assists the sperm as they migrate through to the uterus and on to the fallopian tubes. The timing of this test is, therefore, crucial. If a woman=s cycles are regular, an ovulation predictor test can be used. If she is on medication or has very irregular cycles, the timing of this test should be discussed with your physician, but must always be just prior to ovulation.

Have intercourse the morning of the post-coital test. Do not use lubricants or douche or take a bath after intercourse (showers are fine). Note the approximate time of intercourse since that is important in evaluating the results. Although some authors state that this test must be done within two hours of intercourse, this is not important. Simply note how long it has been and notify your physicianCthey can adjust their interpretation based on the length of time.

In the office, a speculum exam is performed. A small amount of cervical mucus is withdrawn from the cervix (this is painless). This is then examined under the microscope. The quality of the cervical mucus as well as the number of sperm present and their motility will be assessed. You should be able to know the results right away. If the post-coital test is abnormal, it should be repeated. This test is very dependent on proper timing in the cycle. If the test remains abnormal, there are a couple of possibilities:

1. Poor cervical mucus: Is there infection or prior surgery on the cervix, or is the woman on medications ( e.g., clomiphene) that might account for poor cervical mucus. Inseminations (see below) may be suggested as a means of dealing with this problem.

2. Poor sperm motility: This can suggest the presence of sperm antibodies. Sperm antibody testing should be considered. The presence of sperm antibodies would suggest that either inseminations or an ART procedure such as IVF or ZIFT be considered.
If the post-coital test is normal, evaluation of other possible factors should proceed. Sperm function testing should be considered before initiating treatments such as superovulation (Chapter 12), or an ART procedure.

Alternatives
If the semen analyses are repeatedly abnormal, sperm function testing and urologic referral should be obtained. If no significant improvement in the semen analysis is obtainable, then the TMNS should be calculated, the results of the sperm function testing taken into account, and the appropriate interventions or treatments considered. The number of TMNS that is adequate for each intervention will vary from lab to lab and physician to physician, but the alternatives include the following:

1. Inseminations (also known as AIH): A semen sample is collected (preferably by masturbation although intercourse with a special condom is an option) and provided to the laboratory in a sterile specimen container. The semen sample obviously contains much more than just the sperm, including proteins, sugars and prostaglandins. The laboratory will treat the semen sample in such a fashion that a pure sperm sample suspended in a specially designed buffer is obtained. This sample is then placed in a small syringe to which is attached a small plastic tube, or catheter. A speculum is placed in the vagina, the catheter is directed through the cervix and into the uterus, and the sperm preparation is slowly injected. While this procedure may cause slight cramping, it is generally painless. This procedure allows a far greater number of sperm to reach the uterine cavity and fallopian tubes than would normally occur with intercourse.

2. ART (assisted reproductive technologies): These procedures will be discussed in detail in Chapter 13, but far fewer sperm are needed for these procedures to be successful than is the case even with inseminations, let alone intercourse.

3. ICSI (intracytoplasmic sperm injection): This too will be discussed in more detail in Chapter 13, but in short this procedure involves injecting a single sperm into an egg using a microscope and micromanipulation instruments. Fertilization and pregnancies can be achieved even if only a few sperm are present.

4. Donor sperm (Chapter 14): If there is complete absence of sperm (azoospermia), this may be the only option for achieving conception. Some couples will also opt to use donor sperm rather than resorting to some of the more high-tech procedures, often because of cost considerations.