How can I improve my sperm count and fertility?

Improving Sperm Count and Fertility

Start with lifestyle modifications and address reversible causes first, as oxidative stress from poor lifestyle (smoking, obesity) impairs sperm quality, and these interventions may improve sperm parameters without high-quality RCT evidence but with minimal risk. 1

Initial Diagnostic Evaluation

Obtain at least two semen analyses separated by 2-3 months to establish baseline fertility status, as sperm parameters are highly variable biological measures that fluctuate substantially between tests. 1, 2 Single analyses are insufficient for diagnosis given the 51% reproducibility rate between first and second analyses. 2

Key Semen Parameters to Assess:

• Sperm concentration: Lower reference limit 16 million/mL 1
• Progressive motility: Lower reference limit 30% 3
• Total motile sperm count (TMSC): >10 million associated with good natural conception rates 4
• Morphology: Lower reference limit 4% normal forms 1

Perform hormonal evaluation including FSH, LH, and total testosterone in all men with abnormal semen parameters, as male infertility is frequently linked to hypogonadism with long-term cardiometabolic implications. 1

Lifestyle Modifications (First-Line Interventions)

Implement these evidence-based lifestyle changes immediately, as oxidative stress from poor lifestyle is associated with sperm DNA damage, reduced DNA integrity, and poor embryo development. 1

Specific Actions:

• Smoking cessation: Smoking directly increases oxidative stress and impairs sperm quality 1, 4
• Weight optimization: Obesity with or without metabolic syndrome causes mildly reduced fertility 1
• Dietary improvement: Poor diet results in reduced fertility 1
• Minimize heat exposure: Avoid hot tubs, saunas, and tight underwear that elevate testicular temperature 4
• Avoid anabolic steroids and exogenous testosterone completely: These suppress FSH and LH through negative feedback, causing azoospermia that can take months to years to recover 1, 4

Medical Interventions Based on Specific Findings

For Elevated FSH with Oligospermia:

Consider antioxidant regimens and lifestyle interventions as first-line therapy, though high-quality RCT evidence is lacking. 1 Antioxidant treatment may mitigate oxidative stress-related DNA fragmentation and improve sperm quality. 1

Aromatase inhibitors or selective estrogen receptor modulators (SERMs) may be offered for men with low testosterone and elevated FSH, though benefits are limited and outweighed by assisted reproductive technology advantages. 1, 4

For Varicocele:

Surgical correction of palpable varicoceles results in improvement in both semen quality and fertility, unlike non-palpable varicoceles which should not be treated. 1

For Hypogonadotropic Hypogonadism:

Treatment with hCG followed by FSH analogues can successfully initiate spermatogenesis, with 75% of men achieving sperm in ejaculate. 4

When to Pursue Assisted Reproductive Technology

Discuss IVF/ICSI early in the evaluation, as it offers superior pregnancy rates compared to empiric hormonal therapy, particularly when:

• Female partner age is a limiting factor 4
• TMSC remains <10 million despite interventions 4
• Time to pregnancy exceeds 12 months of regular unprotected intercourse 1

For Severe Oligospermia or Azoospermia:

Obtain genetic testing including karyotype analysis and Y-chromosome microdeletion testing when sperm concentration is <5 million/mL. 1, 4 Complete AZFa and AZFb deletions have almost zero likelihood of sperm retrieval. 1

Microsurgical testicular sperm extraction (micro-TESE) offers 40-60% sperm retrieval rates in non-obstructive azoospermia and is 1.5 times more successful than conventional TESE. 1, 4

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. 1, 4

Do not rely on routine reactive oxygen species (ROS) testing, as no standardized testing methods are available and routine measurement requires validation in well-designed RCTs. 1

Avoid treating non-palpable varicoceles, as treatment is not associated with improvement in either semen parameters or fertility rates. 1

Remember that semen analysis alone cannot distinguish fertile from infertile men - it provides important information about sperm quality but requires clinical correlation with other findings. 1

Couple-Oriented Approach

Investigate both partners simultaneously to categorize the cause of infertility, as 50% of involuntarily childless couples have a male-associated factor. 1 Without adequate male partner workup, the female partner may pursue unnecessary costly, time-consuming, and invasive treatment options. 1