What are the treatment options for a male patient of reproductive age with oligospermia?

Treatment for Oligospermia

For men with oligospermia, treatment should begin by identifying and treating reversible causes (hypogonadotropic hypogonadism, bacterial prostatitis, varicocele), followed by ICSI as the primary therapeutic option when natural conception fails or when severe oligospermia (<5 million/mL) is present. 1

Initial Diagnostic Confirmation

• Confirm oligospermia with at least two semen analyses spaced one month apart with 2-3 days of sexual abstinence before collection 1, 2
• Centrifuge the ejaculate and examine the pellet microscopically, as this can identify rare spermatozoa in 18-23% of men initially thought to have azoospermia 1
• Measure serum testosterone and FSH in all patients, particularly if sperm concentration is <10 million/mL 1, 2

Identify and Treat Reversible Causes

Hypogonadotropic Hypogonadism

Human chorionic gonadotropin (hCG) is the first-line treatment for hypogonadotropic hypogonadism: 1, 2

• Administer hCG 500-2500 IU, 2-3 times weekly to restore testosterone production and spermatogenesis 1, 2
• Add FSH injections after testosterone levels normalize on hCG if needed 1, 2
• The degree of response correlates with testicular size prior to treatment 2

Critical pitfall: Never prescribe exogenous testosterone therapy to men desiring fertility, as it suppresses spermatogenesis and can cause oligospermia or azoospermia that may take months or years to reverse 2, 1

Bacterial Prostatitis

• Perform the Meares and Stamey test (4-glass test) to diagnose chronic bacterial prostatitis 1
• Treat confirmed bacterial prostatitis (NIH type II) with appropriate antibiotics 1
• Refer sexual partners for evaluation if infection is from a sexually transmitted disease 1

Varicocele

• Treat clinically palpable varicocele when oligospermia is present and minimal/no female factor is identified 1, 2
• However, IVF with or without ICSI may be the primary option when female factors require treatment, regardless of varicocele presence 2, 1

Other Reversible Causes

• Check for history of chemotherapy, bilateral orchitis with testicular atrophy, or current anabolic steroid use 1
• Perform post-ejaculatory urine analysis if ejaculate volume is <1 mL to diagnose retrograde ejaculation 1

Genetic Testing for Severe Oligospermia

Perform karyotype testing and Y-chromosome microdeletion (YCMD) analysis for all men with severe oligospermia (<5 million/mL) prior to any therapeutic procedure 2, 1

• FSH >7.6 IU/L suggests spermatogenic failure (non-obstructive azoospermia) 1
• Conduct CFTR mutation analysis for men with congenital bilateral absence of vas deferens 2

Assisted Reproductive Technology

ICSI is the primary therapeutic option for severe oligospermia when natural conception fails despite treatment of underlying causes: 1, 3

• ICSI bypasses the sperm defect and has dramatically improved fertility prospects 4
• Surgical sperm extraction (micro-TESE) followed by ICSI offers the best chance of biological paternity in very severe oligospermia 1
• Micro-TESE shows higher sperm recovery rates (40-60%) than conventional TESE 2, 1

Medical Optimization Before Surgical Retrieval

For non-obstructive azoospermia or very severe oligospermia, limited data support using selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), or gonadotropins to optimize spermatogenesis before surgical sperm retrieval 2

Lifestyle Modifications

• Recommend weight loss for obese patients (especially with BMI indicating morbid obesity) and smoking cessation, as these factors negatively impact sperm parameters 2, 1
• Evidence for heat exposure (occupational, clothing, body position) affecting semen quality is insufficient to make firm recommendations 2

Antioxidants and Herbal Therapies

There are insufficient data to recommend supplemental antioxidant or herbal therapies for men with abnormal semen parameters 2, 3

Critical Follow-Up Consideration

Recommend sperm cryopreservation if follow-up semen analyses show a declining trend: 1, 5

• 12.8% of patients with severe oligospermia become azoospermic during follow-up 1, 5
• 17.9% experience significant decline in sperm count detectable only after centrifugation 1, 5
• Early intervention improves chances of successful sperm retrieval if azoospermia develops 5

Counseling Points

• Inform patients that genetic abnormalities are more common in severe oligospermia with potential implications for offspring 3, 2
• Discuss realistic outcomes of ART, alternatives such as adoption or donor gametes, and psychosocial concerns 4
• Recovery of spermatogenesis after testosterone-induced suppression may take months or rarely years 2