What are the next steps and treatment options for a patient with asthenozoospermia (weak sperm motility) on semen analysis for infertility, and should they be referred to a urologist?

Management of Asthenozoospermia (Weak Sperm Motility)

A patient with asthenozoospermia (weak sperm motility) on semen analysis should be referred to a urologist for specialized evaluation and treatment, as this condition requires expert management to optimize fertility outcomes. 1

Diagnostic Evaluation

Initial Assessment

• Review the semen analysis results:
  • Progressive motility <30% or total motility <42% confirms asthenozoospermia 1
  • Check other parameters (concentration, morphology, volume) to identify additional abnormalities

Urological Evaluation

• Physical examination focusing on:
  • Testicular size and consistency
  • Presence of varicocele (dilated veins in scrotum)
  • Vas deferens and epididymis examination
  • Digital rectal examination to assess prostate 1, 2

Laboratory Testing

• Hormonal evaluation:
  • Serum testosterone
  • Follicle-stimulating hormone (FSH)
  • Additional hormones if indicated (LH, prolactin) 1, 2
• Consider genetic testing if severe asthenozoospermia:
  • Karyotype testing
  • Y-chromosome microdeletion testing (especially if sperm concentration <5 million/mL) 1

Additional Testing (Based on Clinical Findings)

• Transrectal ultrasonography (TRUS) if ejaculatory duct obstruction is suspected 1, 2
• Scrotal ultrasound if physical examination is difficult or testicular abnormality is suspected 1

Treatment Options

Medical Therapy

1. Hormonal Treatments:

   • Selective estrogen receptor modulators (SERMs) like clomiphene citrate
   • Human chorionic gonadotropin (hCG) may improve motility in selected cases 1, 3
   • Aromatase inhibitors if testosterone levels are low 1

2. Antioxidant Therapy:

   • Coenzyme Q10 (200 mg/day) has shown improvement in sperm motility in placebo-controlled trials 4
   • Other antioxidant supplements have questionable clinical utility 1

3. FSH Analogues:

   • May be considered for idiopathic infertility to improve sperm parameters 1

Surgical Interventions

• Varicocelectomy if varicocele is present and contributing to asthenozoospermia
• Transurethral resection of ejaculatory ducts (TURED) if ejaculatory duct obstruction is identified 1

Assisted Reproductive Technology (ART)

• Intrauterine insemination (IUI) may be considered but has reduced success rates with low total motile sperm count 1
• In vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) is often recommended for severe asthenozoospermia 1

Clinical Algorithm for Management

1. Confirm diagnosis with repeat semen analysis (at least one month apart)
2. Refer to urologist for specialized evaluation
3. Identify and treat reversible causes:
   • Varicocele → varicocelectomy
   • Hormonal abnormalities → appropriate hormonal therapy
   • Ejaculatory duct obstruction → TURED
4. Trial of medical therapy for idiopathic cases:
   • Antioxidants (CoQ10)
   • Hormonal therapy if indicated
5. Proceed to ART if no improvement after 3-6 months:
   • IUI for mild-moderate cases
   • IVF/ICSI for severe cases

Important Considerations

• Avoid testosterone monotherapy in men interested in fertility as it suppresses spermatogenesis 1
• Time is critical - treatment decisions should consider female partner's age and fertility status
• Semen analysis alone cannot predict fertility except in extreme cases 5
• Multiple abnormalities in semen parameters may require more aggressive treatment approaches

By following this structured approach, the management of asthenozoospermia can be optimized to improve fertility outcomes and quality of life for affected couples.