What are the treatment options for male patients with asthenozoospermia (low sperm motility)?

Treatment for Male Patients with Low Sperm Motility (Asthenozoospermia)

For men with isolated asthenozoospermia, the most effective treatment is assisted reproductive technology (IVF/ICSI), which offers superior pregnancy rates compared to empiric medical therapies. 1

Initial Diagnostic Evaluation

Before initiating treatment, a comprehensive workup is essential:

• Perform at least two semen analyses separated by 2-3 months to confirm persistent asthenozoospermia, as single analyses can be misleading due to natural variability 2
• Measure hormonal parameters including FSH, LH, and total testosterone to identify potentially correctable endocrine causes 1
• Evaluate for varicocele on physical examination, as correction of palpable varicoceles can improve both semen quality and fertility 2
• Consider sperm DNA fragmentation (SDF) testing, as asthenozoospermia frequently coexists with elevated sperm DNA damage and oxidative stress, which can decrease fertilizing capability 3

Treatment Algorithm Based on Severity

For Mild to Moderate Asthenozoospermia with Total Motile Sperm Count >10 Million

• Intrauterine insemination (IUI) with ovarian stimulation may be attempted for up to three consecutive cycles 4
• Time insemination 24-40 hours after hCG trigger or 1 day after LH surge 4
• If no pregnancy occurs after three IUI cycles, progress to IVF/ICSI 4

For Severe Asthenozoospermia or Failed IUI Attempts

• IVF with ICSI should be the first-line treatment, as this directly overcomes the motility defect 1, 5
• ICSI is particularly indicated when asthenozoospermia coexists with other sperm abnormalities (oligozoospermia or teratozoospermia) 5

Medical Interventions: Limited Role

The evidence for medical therapies in asthenozoospermia is weak, and these should be considered adjunctive at best:

Hormonal Therapies (Conditional Use Only)

• For men with hypogonadotropic hypogonadism, treatment with hCG followed by FSH analogues can successfully initiate spermatogenesis, with 75% achieving sperm in ejaculate 2
• For idiopathic asthenozoospermia with mildly elevated FSH, aromatase inhibitors, hCG, or selective estrogen receptor modulators (SERMs) may be used off-label, though benefits are limited and outweighed by ART advantages 1, 2
• Human chorionic gonadotropin (HCG) 5000 IU weekly for 12 weeks showed modest improvement in sperm motility (34% to 40%) in one older study, with 6 pregnancies occurring 6

Antioxidant Therapy

• Antioxidant therapy may be considered given the strong association between asthenozoospermia and oxidative stress in semen 3
• However, available data are insufficient to recommend specific antioxidant agents or dosing regimens 5

Testicular Sperm Extraction for High SDF

• If sperm DNA fragmentation is markedly elevated, testicular sperm extraction for ICSI should be considered, as testicular sperm have lower SDF values than ejaculated sperm and may provide better ART outcomes 5
• Meta-analyses show improved clinical pregnancy rates, live births, and reduced pregnancy loss rates with this approach 5

Critical Pitfalls to Avoid

• Never prescribe exogenous testosterone to men desiring fertility, as it completely suppresses spermatogenesis through negative feedback on the hypothalamus and pituitary, potentially causing azoospermia that can take months to years to recover 1, 2, 5
• Do not delay referral to ART when medical therapies fail, as female partner age is a critical factor in fertility outcomes 2
• Treat underlying infections if bacteriospermia is identified, though this alone may not normalize the underlying infertility factor despite improving motility parameters 7

Concurrent Female Partner Evaluation

• Both male and female partners should undergo concurrent assessment, as couple infertility may involve multiple factors 1
• Without adequate male evaluation, the female partner may pursue unnecessary, costly, time-consuming, and invasive treatment options 5