How is oligospermia (low sperm count) managed?

Management of Oligospermia

The management of oligospermia should begin with a comprehensive evaluation to determine the underlying cause, followed by targeted interventions based on etiology, with exogenous testosterone therapy being strictly avoided in men desiring fertility. 1

Diagnostic Evaluation

Initial Assessment

• Complete reproductive history
• Physical examination focusing on:
  • Testicular size and consistency
  • Presence of varicocele
  • Secondary sex characteristics
• Semen analysis (at least one high-quality sample)
  • Repeat if abnormal parameters are found

Hormonal Evaluation

• Serum testosterone and follicle-stimulating hormone (FSH) levels
  • Especially important if sperm concentration is <10 million/mL 1
• Consider additional hormonal testing:
  • Luteinizing hormone (LH)
  • Prolactin (if clinically indicated)
  • Estradiol (if gynecomastia is present) 1

Additional Testing Based on Clinical Findings

• Genetic testing for men with severe oligospermia (<5 million/mL):
  • Karyotype testing
  • Y-chromosome microdeletion analysis 1, 2
• Scrotal ultrasonography if:
  • Physical examination is difficult
  • Testicular mass is suspected 1
• Transrectal ultrasonography if:
  • Low ejaculate volume with palpable vas deferens
  • Suspected ejaculatory duct obstruction 1

Treatment Approaches

Lifestyle Modifications

• Weight loss for obese patients
• Smoking cessation
• Moderate alcohol consumption
• Avoiding excessive heat exposure to testes 1

Medical Therapy

For men with hypogonadotropic hypogonadism:

• Human chorionic gonadotropin (hCG) injections (500-2500 IU, 2-3 times weekly)
• Add FSH injections if needed after testosterone normalization 1

For men with idiopathic oligospermia:

• Selective estrogen receptor modulators (SERMs) such as clomiphene citrate
  • Can increase endogenous gonadotropin release and intratesticular testosterone 1, 3
  • Studies show significant improvement in sperm counts in 64-71% of patients 3, 4
• Aromatase inhibitors may be considered for men with low testosterone 1, 2
• FSH analogues may improve sperm concentration and pregnancy rates 1

Important Caution

• Exogenous testosterone therapy must be avoided in men interested in current or future fertility as it suppresses spermatogenesis and can cause oligospermia or azoospermia 1, 2
• Recovery after cessation of testosterone therapy may take months or even years 1

Surgical Interventions

• Varicocelectomy for men with clinically palpable varicocele and abnormal semen parameters 1
• Transurethral resection of ejaculatory ducts (TURED) for men with ejaculatory duct obstruction 1

Assisted Reproductive Technologies (ART)

• Intrauterine insemination (IUI) if total motile sperm count is adequate
• In vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) for:
  • Severe oligospermia
  • Failed medical or surgical therapy
  • Presence of female factor infertility 1
• IVF with ICSI typically allows for a 37% live delivery rate per initiated cycle 1

Special Considerations

Gonadotoxic Therapies

• Sperm banking prior to gonadotoxic treatments (chemotherapy, radiation) 1
• Multiple specimens when possible

Nutritional Supplements

• Limited evidence for antioxidants and herbal therapies 1
• Phytoestrogens have shown some promise in isolated case reports but require further validation 5

Follow-up

• Repeat semen analysis after 3 months of medical therapy to assess response
• Consider referral for ART if no improvement after 3-6 months of appropriate therapy

The management of oligospermia requires a systematic approach to diagnosis and treatment, with careful consideration of the underlying etiology and the patient's reproductive goals.