How can I improve my low sperm count?

Improving Low Sperm Count

Address lifestyle modifications immediately, pursue genetic testing if severely low, and proceed directly to assisted reproductive technology (ART) with intracytoplasmic sperm injection (ICSI) for the most reliable path to pregnancy, as medical treatments have limited efficacy for improving sperm quality. 1

Immediate Lifestyle Interventions

These modifications should begin now, as they enhance sperm parameters and work synergistically with any other interventions:

• Weight loss if obese, regular physical exercise, and smoking cessation are recommended as they improve sperm parameters and overall reproductive health 2, 1, 3
• Reduce or eliminate alcohol consumption, as drinkers have slightly lower semen volume and poorer sperm morphology 2
• Avoid anabolic steroid use, which is strongly associated with reduced fertility 2
• Minimize exposure to environmental toxins, particularly DEHP (di-2-ethylhexyl phthalate), certain pesticides (pyrethroids, organophosphates), and occupational exposures to oil/gas extraction 2

Essential Diagnostic Workup

Before pursuing treatment, determine the severity and cause:

• Obtain at least two semen analyses one month apart, as semen parameters are highly variable and a single test may be misleading 2, 3
• Check morning total testosterone and FSH levels to identify hormonal abnormalities that may be treatable 3, 4
• Perform karyotype testing if sperm concentration is <5 million/mL, as chromosomal abnormalities occur in 5% of severely oligospermic men and have implications for offspring 2, 1, 3
• Test for Y-chromosome microdeletions if azoospermic or sperm concentration <1 million/mL, as these genetic abnormalities may be transmitted to children 2, 4
• Physical examination should assess for varicocele (palpable, not ultrasound-detected), testicular size/consistency, and presence of vas deferens 2, 4

Treatment Algorithm Based on Findings

If Clinical Varicocele Present with Abnormal Parameters

• Varicocelectomy should be performed, as it improves sperm parameters and DNA integrity in men with palpable varicoceles and abnormal semen analysis 1, 4
• Only palpable varicoceles warrant treatment; do not pursue ultrasound-detected subclinical varicoceles 4

If Hormonal Abnormalities Identified

• For low testosterone with low/normal FSH (hypogonadotropic hypogonadism): Consider FSH analogues, selective estrogen receptor modulators (SERMs), or aromatase inhibitors 1, 3
• Never prescribe testosterone replacement to men desiring fertility, as it suppresses spermatogenesis and worsens infertility 4
• FSH analogues may improve sperm concentration and pregnancy rates in idiopathic infertility, though evidence is limited 1, 3

For Idiopathic Oligozoospermia (No Identifiable Cause)

• Medical treatments have limited efficacy and may delay more effective options 1
• Clomiphene citrate 25 mg on alternate days showed some improvement in older studies, with 26.7% pregnancy rates after 6 months 5
• Any improvement from medical therapy requires at least 74 days (2.5 months) to manifest, as this is the duration of spermatogenesis 1

Primary Recommendation: Assisted Reproductive Technology

For severe oligozoospermia or when natural conception has not occurred after appropriate interventions, IVF with ICSI is the most effective treatment and should be considered the primary option 1

• ICSI bypasses poor sperm quality and provides the best chance for healthy pregnancy as long as viable sperm are present 1, 6
• When total progressive motile sperm count (TPMC) is <5 million, IUI success rates are reduced and IVF/ICSI should be considered 4
• Partners of men with TPMC ≥50 million have 45% greater chance of conception within 5 years compared to those with lower counts 7

Critical Warnings

• Sperm cryopreservation should be performed now if you have severe oligozoospermia, as 12.8% of men with severe oligozoospermia progress to azoospermia over time, and sperm retrieval success drops significantly once azoospermia develops 8
• Sperm should be collected before initiating any cancer treatment, as sperm DNA integrity may be compromised after even a single chemotherapy treatment 2
• Do not delay ART while pursuing medical treatments of questionable benefit, as this wastes time and the female partner's fertility window 1
• Female partner evaluation is essential, as 33-78% of wives in couples with male oligozoospermia also have ovulatory dysfunction 9