How to evaluate and manage teratozoospermia (abnormal sperm morphology)?

Evaluation, Management, and Response Evaluation of Teratozoospermia

Teratozoospermia (abnormal sperm morphology) requires comprehensive evaluation with at least two semen analyses obtained one month apart, followed by targeted interventions based on severity, associated parameters, and underlying causes. 1

Initial Evaluation

Semen Analysis

• At least two semen analyses should be performed one month apart to account for biological variability 1
• WHO reference values define teratozoospermia as <4% normal morphology (using strict Kruger criteria) 1
• Comprehensive semen analysis should include:
  • Volume (normal: 1.5-5.0 ml)
  • pH (normal: >7.2)
  • Sperm concentration (normal: >20 million/ml)
  • Total motility (normal: >40%)
  • Morphology (normal: >4% normal forms)

Additional Testing

• Hormonal evaluation:

  • FSH, LH, and testosterone (mandatory) 1
  • Consider prolactin if LH levels are low/normal 2
  • Free testosterone is a better indicator of gonadal status than total testosterone 2

• Genetic testing:

  • Karyotype testing for patients with severe teratozoospermia (<1% normal forms) 1
  • Consider Y-chromosome microdeletion analysis if teratozoospermia is accompanied by oligozoospermia (<5 million/ml) 1

• Specialized tests when indicated:

  • Sperm DNA fragmentation testing for couples with recurrent pregnancy loss or failed ART cycles 1
  • Consider evaluation for oxidative stress markers 3

Management Approach

Isolated Teratozoospermia

For teratozoospermia with normal sperm count and motility:

1. Lifestyle modifications 2:

   • Weight management
   • Smoking cessation
   • Moderate alcohol consumption
   • Avoiding excessive testicular heat exposure
   • Reducing environmental toxin exposure

2. Medical therapy:

   • Antioxidant supplementation may be beneficial (though evidence is limited) 3
   • Consider empiric treatment with selective estrogen receptor modulators (SERMs) or aromatase inhibitors if hormonal imbalances are detected 2

3. Assisted reproductive technologies:

   • Intrauterine insemination (IUI) can be effective even with isolated teratozoospermia 3
   • Consider IVF with ICSI for severe teratozoospermia or failed IUI attempts 2

Severe or Monomorphic Teratozoospermia

1. Macrozoospermia (enlarged head syndrome):

   • Genetic counseling is essential as >90% of spermatozoa may be aneuploid 4, 5
   • ICSI is generally contraindicated due to extremely high aneuploidy rates 5
   • Consider donor sperm as the preferred option 5

2. Globozoospermia (round-headed sperm syndrome):

   • ICSI may be attempted but has lower success rates 4
   • Consider assisted oocyte activation techniques to improve fertilization 4
   • Genetic counseling regarding potential mutations in SPATA16, PICK1, or DPY19L2 genes 4

3. Teratozoospermia with oligoasthenozoospermia:

   • More aggressive approach with direct progression to IVF with ICSI 3
   • Consider testicular sperm extraction if DNA fragmentation is high 2

Response Evaluation

Monitoring Treatment Response

• Repeat semen analysis every 3 months during treatment to assess morphology improvement 2
• For couples attempting natural conception with isolated teratozoospermia:
  • Allow 6-12 months of attempts before proceeding to ART 6

ART Outcome Assessment

• For IUI: Evaluate pregnancy rates after 3-4 cycles
• For IVF/ICSI: Assess fertilization rates, embryo quality, and pregnancy outcomes

Important Considerations

• Genetic implications: Severe forms of teratozoospermia may have genetic causes that can be transmitted to offspring 4
• Prognostic value: Isolated teratozoospermia alone should not preclude attempts at natural conception before proceeding to ART 6
• Correlation with DNA damage: Teratozoospermia often correlates with sperm DNA damage and oxidative stress, which may impact fertility outcomes 3
• Specific morphological abnormalities: The type of abnormality (head, midpiece, or tail defects) may have different clinical implications 7

Common Pitfalls to Avoid

• Overreliance on a single semen analysis: Sperm parameters fluctuate significantly; at least two analyses are required 1
• Ignoring associated parameters: Evaluating teratozoospermia in isolation without considering count and motility may lead to inappropriate management 3
• Premature progression to ICSI: For isolated teratozoospermia, less invasive approaches like timed intercourse or IUI may be effective 6, 3
• Failure to identify specific syndromes: Not recognizing monomorphic teratozoospermia patterns (like macrozoospermia or globozoospermia) can lead to inappropriate treatment choices 4, 5