We can usually determine whether you have low sperm count by doing a semen analysis. It is calculated by multiplying the volume (cc) of the semen by the concentration (million sperm/cc) by the motility (% moving). Normal sperm count is more than 40 million motile sperm in the ejaculate. Fewer than 40 million may cause conception difficulties.
There are a number of things that can cause low sperm count and a number of things that can help increase sperm count.
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Just like varicose veins in the legs, the scrotum is also subject to dilated veins. What happens is that the veins become dilated when blood doesn't drain properly from them. This extra blood pools in the scrotum, and it negatively impacts sperm production. The positive news is that this is the most common reversible cause of male infertility and may be corrected by minor outpatient surgery.
Most doctors perform this surgery microscopically to preserve the arterial supply and lymphatic. An incision is made about one inch above the penis (it's called a subinguinal incision) avoiding the abdominal muscles which means less post-operative pain.
Abnormalities in the seminal fluid
This occurs when the semen is very thick, making it difficult for the sperm to move into the woman's reproductive tract. Here, an attempt is made to separate the moving sperm from the dead sperm and surrounding debris, process it, and place it directly into the uterus with a small tube. This is called intrauterine insemination (IUI).
Problems with the ductal system
Some of these are: sperm carrying ducts that may be missing or blocked; an absence of both sides of the vas deferens since birth; obstructions at the point where the delicate tubular structure drains the testes or higher up in the more muscular vas deferens; or blockage that occurred during hernia or hydrocele repairs or from scar tissue from due to an infection.
The mechanics of the situation are that sperm must travel through the ejaculatory ducts as they go from seminal vesicles to the urethra. If these ducts are blocked, the sperm can't get through.
Options here include repairing or unblocking the ducts, or if that's not possible, the sperm can be harvested so they can go through the man's reproductive tract. In cases like this, sperm is obtained in low numbers, so this procedure must be used in conjunction with advanced reproductive techniques to attempt a pregnancy.
What happens here is that a man has developed antibodies to his own sperm. This could occur because of testicular trauma, testicular infection, large varicoceles, or testicular surgery. Or sometimes, there are unexplained reasons for this occurrence.
The antibodies have a negative effect on fertility, but the exact reason isn't clear. Most likely, the antibodies act negatively at several points along the pathway to fertilization as the sperm have trouble penetrating the partner's cervical mucous and making their way to the uterus. It becomes more difficult for the sperm to bind with external membrane or shell of the egg or to fuse with the eggs themselves.
Can the antibodies be treated? Yes, but that treatment is controversial. Men are sometimes treated with corticosteroids but this can result in disease such as noninfectious destruction of the joint (aseptic necrosis), which requires hip replacement. To avoid that, often the first level of treatment is intrauterine insemination. If the couple is planning in-vitro fertilization (IVF) and antibodies are present, the sperm are injected directly into the egg (ICSI) instead of the conventional IVF.Testicular Failure
What this means, in general, is that the sperm-producing part of the testicles can't make an adequate number of mature sperm. It can happen at any stage in sperm production and for any number of reasons such as: the testicle may lack the cells needed to divide and become sperm; or the sperm can't complete their development; there are too few sperm to be able to travel through the ducts into the ejaculated fluid. Genetic abnormalities, hormonal factors, or varicoceles, the veins in the scrotum, may cause this situation.
On the plus side, even if your testes are producing a low sperm count, the sperm can be harvested and, using advanced reproductive techniques, pregnancy can be attempted.
Even fairly common drugs could have a negative effect on sperm production and/or function. Some of those include:
- Ketoconazole (an anti-fungal)
- Sulfasalazine (for inflammatory bowel disease)
- Spironolactone (an anti-hypertensive)
- Calcium Channel Blockers (anti- hypertensives)
- Allopurinol, Colchicine (for gout)
- Antibiotics: Nitrofuran, Erythromycin, Gentamicin
- Methotrexate (cancer, psoriasis, arthritis)
- Cimetidine (for ulcers or reflux)
- Antipsychotics: Chlorpromazine, Haloperidol, Thioridazine
- Antidepressants: Amitripltyline, Imipramine, Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft)
- Anti-hypertensives: Guanethidine, Prazosin, Phenoxibenzamine, Phentolamine, Reserpine, Thazides
The testicles need pituitary hormones to be stimulated to make sperm. If these are absent or severely decreased, the testes cannot produce sperm to maximum capacity. Importantly, men who take androgens (steroids) for body building, either by mouth or injection, shut down the production of hormones for sperm production.
If you're a male with infertility problems we do a hormonal profile. It's an important check for us to rule out serious medical conditions, get more information on the sperm-producing ability of the testes, and tell us whether we should go ahead with hormonal treatment.
Men may have infections of their reproductive tract. These may include infections of the prostate (prostatitis), of the epididymis (epididymitis), or of the testes (orchitis).
After passing through puberty, if you’ve had a viral infection of the testes, it may have caused absolute and irreversible infertility. Other issues are bacterial infections or sexually transmitted diseases that can cause blockages of the sperm ducts. Here, the sperm production may be normal but the ducts carrying them are blocked.
If bacterial or viral infections are active, that may also have a negative effect on sperm production or function. Additionally, white blood cells, the body’s response to infection, may also have a negative effect on sperm membranes, making them less hearty.
We recommend having a culture done if excessive white blood cells (more than one million/cc) are seen in a semen specimen. This usually includes cultures for commonly asymptomatic, sexually-transmitted diseases including mycoplasma, ureaplasma, and Chlamydia. Also, a general genital culture is usually taken. If the infection and the white blood cells are persistent, antibiotics may be considered.You should understand that in most men, the ejaculate isn’t sterile, often testing positive for two organisms. That’s why it’s important to be judicious in treating non-sexually-transmitted organisms found on cultures.
When these conditions are treated, a man will often see a significant improvement in his semen analysis.
It's a fact that cigarette smoking significantly affects semen quality.
A regular smoker has a 23% decrease in sperm density (concentration) and a 13% decrease in its ability to move (when averages are taken from nine separate studies). To a lesser extent, smoking causes toxicity to the fluid ejaculated with the sperm (seminal plasma). And when sperm from non-smokers were placed in the seminal plasma (hormonal) of smokers, the sperm were adversely affected (had significantly decreased viability).
Smoking affects the hypothalamic-pituitary-gonatropin axis, most commonly affecting levels of estrogens, which are hormones found in higher concentrations in women (estradiol and estrone). Other problems are secretory dysfunction in the Leydig Cells, which are in the testes and produce testosterone. Most worrisome is that there is evidence that suggests that paternal smoking may also be associated with congenital abnormalities and childhood cancer, though the relative risk in most studies is less than two.
This can affect sperm positively or, in some cases, negatively. While moderate exercise is definitely helpful, long-distance runners (men who run more than 100 miles per week) and distance cyclers (men who ride more than 50 miles per week) have decreased spermatogenesis. These activities should be moderated when a man undergoing fertility problems is attempting conception.
Marijuana often causes a decreased average sperm count, movement of the sperm (motility), and when the sperm is viewed under a microscope the size and shape may be compromised (normal morphology). It affects the hormonal axis (HPG), causing decreased plasma testosterone. It may also have a direct negative effect on the Leydig Cells.
Even infrequent cocaine use causes decreased sperm count, motility, and normal morphology. These effects can be found in men who have used cocaine in the two years preceding their initial semen analysis. Cocaine also decreases the ability of sperm to penetrate the cervical mucous, making it difficult for them to enter the uterus.
Anabolic Steroids (male hormones)
- The use of anabolic androgenic steroids has reached almost epidemic proportions. Nearly seven percent of 12th-grade males use or have used them to build muscle mass and improve athletic performance.
- These male hormones suppress the testes' ability to make testosterone. This decreases the intratesticular testosterone level. This may cause severely diminished spermatogenesis or complete absence of sperm (azoospermia).
- When taken, these steroids cause a persistent depression of the hypothalamus and pituitary, which may be irreversible even when the steroids are stopped.
Moderate alcohol use does not affect male fertility. However, excessive alcohol use affects the hormonal axis and has negatively affects the gonads. It may cause associated liver dysfunction and nutritional deficiencies, which are also detrimental for sperm production.
Most vaginal lubricants, including K-Y Jelly, Surgilube, and Lubifax, are toxic to sperm. Couples should avoid their use during the fertile time of a woman's cycle.
The purpose of all of this testing is to move ahead with a treatment that can improve your fertility or to discuss other ways to achieve results. More than 50% of men will have a treatable cause of male factor infertility. These factors include varicoceles (dilated veins in the scrotum), infections, hormonal abnormalities, abnormalities in the seminal fluid, ductal blockages, and difficulties with erections and ejaculation. When these conditions are treated, either through medication (hormones or antibiotics) or surgery (varicocelectomy, vasal reconstruction, repair of a blocked ejaculatory duct), a man will often see a significant improvement in his semen analysis.
Those men with poor semen analyses whose conditions are not treatable may still have the option of using advanced reproductive techniques to achieve a pregnancy. Even those men with no sperm in the ejaculate may be able to have some living sperm procured from them through other methods and achieve a pregnancy using advanced reproductive techniques. Those few men who produce absolutely no sperm at all will have this information to help them explore other options.