Abnormal Sperm: How can it be treated?
In general, it should be remembered that the predictive value (in terms of fertility) of the semen analysis is low. A man with an abnormal semen analysis with a history of proven fertility (prior pregnancy) without an intervening event associated with infertility has a better prognosis than a similar man without proven fertility.
When the cause for the semen abnormality can be identified, treatment directed specifically at this cause is the most direct and effective plan. In many cases, the cause for the semen abnormality will not be discovered. In this situation, treatment is directed at improving the sperm’s ability to fertilize an egg. Even in extreme cases of male factor infertility, if any live sperm can be retrieved either by ejaculation, from the post ejaculatory voided urine, or through surgical retrieval from the scrotal sac there are fertility options that have reasonable success. This section reviews these options.
Treatment for specific identified causes include:
(1) Excessive exposure to heat
Limit such exposure and recheck the semen analysis 3-5 months later to allow for a nonoverlapping cycle of spermatogenesis
(2) Substance abuse, toxin exposure, and medications
Discontinue these substances (only change medications in conjunction with the prescribing physician) and recheck the semen analysis 3-5 months later to allow for a nonoverlapping cycle of spermatogenesis.
The effects can be transient, but are often permanent when greater than 60 rads has been administered to the pelvic region.
Postoperative changes are rarely treatable with further surgery. One possible exception is an obstruction in the outflow tract from the testicle involving the epididymis, vas deferens or ejaculatory duct.
(5) Testicular failure
These causes for azoospermia and severe oligospermia are rarely correctable. If any live sperm can be retrieved assisted fertilization (such as ICSI) at the time of IVF has a good pregnancy success rate. Use of very poor quality semen for COH/IUI or standard microdroplet IVF rarely results in pregnancy.
(6) Antisperm antibodies
Usually treated with intrauterine inseminations (to avoid the cervical mucus) or In Vitro Fertilization, regardless of antibody type. Since this treatment does not change according to the site on the sperm that is attached to the antibodies simply determining whether the patient has an abnormal postcoital test appears to be the most direct, simple and cost effective test for these antibodies.
Antisperm antibody titers may be suppressed with steroids. These medications have potentially serious complications, appear to have an effect on antisperm antibody titers only after several months of administration, and the dosages of the medications for this indication have not been clearly established. Therefore, I have not tried to suppress the production of antibodies with steroids.
Repair is not always recommended. Specific findings on semen analysis and/or exam suggest the utility of repair. The semen analysis of subfertile men with a varicocele may show increased numbers of abnormally shaped sperm, a decrease in sperm motility and/or a decrease in sperm concentration.
Repair of a clinically detectable varicocele appears to be indicated if a persistent abnormal semen analysis is detected, especially if characterized by the so called “stress pattern” that is associated with a varicocele (a decreased sperm count or an increased number of tapered forms with an increased number of amorphous or immature sperm)
Repair of subclinical varicoceles (varicoceles that can only be detected by special tests like ultrasonography, doppler studies or invasive venograms) have not been shown to result in improved fertility. Therefore, the repair of these subclinical varicoceles is highly controversial.
Repair of a varicocele detected in the presence of a normal semen analysis, normal testicular exam and “unexplained infertility” is also controversial, with no clear basis for the surgery. That is, the mere presence of a varicocele in the context of a couple suffering from infertility is not independently an indication for surgery.
Following varicocele repair there usually is little improvement in the shape of the sperm (morphology) yet there is improvement in the sperm counts and motility in up to 70% of patients. The improvement in fertility, the desired goal, is unpredictable and different reports suggest a wide range of outcomes.
Some urologists have suggested hormonal treatment of varicoceles with either Clomiphene citrate or hCG (which acts like LH on the Leydig cells of the testes, improving parameters like testosterone production) alone or following surgery. In general, the research in this area is lacking. Limiting hormonal management to patients with a solid basis for treatment (such as a documented serum FSH, LH or testosterone concentration deficiency) seems prudent at this time.
(8) Disorders of emission or ejaculation
Treatment options also include