A low sperm count indicates that the seminal sample contains a lower number of spermatozoa than normal. This condition is known as oligospermia, while the complete absence of spermatozoa is called azoospermia. We consider it a low sperm count when the sperm concentration is below 15 million per milliliter.

We are seeing a growing level of awareness that problems with infertility are often attributable to male factors. In fact, current estimates are that between one third of infertility cases in a couple arise from this cause. And within that group, the vast majority, 90% of cases, are because of a low sperm count. In recent times this subject has gone from being somehow unmentionable to something that can be discussed more openly.

In this article we examine the causes of the condition and the question of whether there is a cure for low sperm count. We also consider recent developments in how to test for low sperm count. Finally, our optimistic message is that there are a range of low sperm count treatment options available.

Symptoms of low sperm count

The main sign of a low sperm count is difficulty in achieving a pregnancy. However it is important to note that it is still possible to conceive. The other symptoms of a low sperm count may include:

• Sexual function problems, such as a decrease in desire or difficulty in maintaining an erection.
• Pain or swelling in the testicular area.
• Decreased facial or body hair or other signs of chromosomal or hormonal abnormalities.

Causes of low sperm count

Sperm production is a complex process that requires normal testicular function, as well as the involvement of the hypothalamus, pituitary gland, and other brain structures related to sperm generation. Once spermatozoa are produced in the testicles, they are transported until they mix with semen and are ejaculated out of the penis. Problems in any of these steps can affect sperm production. Additionally, it is important to consider abnormalities in sperm morphology, motility, and/or function. While the cause of a low sperm count is often unidentified, let’s explore some potential reasons:

Medical causes

• Varicocele. This is the inflammation of the veins that drain the testicle. It’s the most common reversible cause of male infertility. Although the exact reason why varicoceles cause infertility is unknown, it could be related to abnormal temperature regulation in the testicles. 

• Infection. Certain infections can interfere with sperm production and/or cause scarring that prevents the passage of sperm. These include inflammation of the epididymis (epididymitis), testicles (orchitis), and some sexually transmitted diseases such as HIV or gonorrhea. While some infections can cause permanent testicular damage, sperm recovery is often possible.

• Ejaculation problems. Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of exiting through the penis.

• Medications, such as alpha-blockers used to control blood pressure.

• Antibodies that attack sperm. Anti-sperm antibodies are immune cells that mistakenly identify sperm as foreign cells and attempt to destroy them.

• The presence of cancer or benign tumors can directly affect the function of the male reproductive organs. Surgery, radiation, or chemotherapy used to treat oncological conditions can also affect male fertility.

• Undescended testicles. During fetal development, one or both testicles fail to descend from the abdomen into the scrotum. Decreased fertility is more common in males with this condition.

• Hormonal imbalances.

• Defects in the tubules that transport sperm. These ducts can be blocked for various reasons, such as inadvertent injury during surgery, previous infections, trauma, or abnormal development. Blockage can occur at any level, including within the testicle, epididymis, vas deferens, or urethra.

• Chromosomal abnormalities. Inherited disorders such as Klinefelter syndrome lead to abnormal development of male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kallmann syndrome, and Kartagener syndrome.

• Celiac disease. This digestive disorder caused by gluten insensitivity can be associated with male infertility. Fertility may improve after adopting a gluten-free diet.

• Certain medications. Prolonged use of anabolic steroids, chemotherapy drugs, antifungals, antibiotics, some medications for ulcer treatment, etc, can affect sperm production and reduce male fertility.

• Previous surgeries. Vasectomy, inguinal hernia repair, scrotal or testicular surgeries, prostate surgeries, and major abdominal surgeries for testicular and rectal cancer, among others. In most cases, it is possible to perform a surgical procedure to reverse these blockages and restore sperm function directly from the epididymis or testicle.

Environmental causes

• Prolonged exposure to chemicals or industrial products such as benzene, toluene, herbicides, pesticides, organic solvents, etc.
• Exposure to heavy metals.
• Exposure to radiation or X-rays can reduce sperm production, which may take several years to recover to normal levels. With high doses of radiation, sperm production can be permanently reduced.
• Frequent use of saunas or hot tubs can temporarily affect sperm count due to increased testicular temperature. This can harm sperm production and function. However, studies are limited and do not provide conclusive evidence

Lifestyle causes

• Drug use. Cocaine and marijuana affect semen quantity and quality. Anabolic steroids taken to stimulate strength and muscle growth can cause testicles to shrink and decrease sperm production. 
• Alcohol consumption. Drinking alcohol can reduce testosterone levels and cause a decrease in sperm production.
• Smoking
• Severe or prolonged emotional stress, including stress related to infertility itself, interferes with the hormones necessary for sperm production.
• Obesity can affect fertility in various ways, including direct impact on semen and inducing hormonal changes that affect male fertility.

Other causes

Prolonged sitting, wearing tight clothing, or working for long periods with a laptop on the lap can increase scrotal temperature and slightly reduce sperm production.

There are also cases of abnormalities in semen analysis due to the seminal analysis being taken too soon after the last ejaculation. In other cases, there may not have been sufficient semen collected due to problems during collection. For this reason, results are based on the collection of multiple serial samples over time.

Risk factors

In addition to these signs or symptoms, the presence of some factors would be indicative of oligozoospermia.

These include an inherited chromosomal abnormality, dilated testicular veins, or a condition that blocks the passage of spermatozoa. Age is also a risk factor: as men age, it is common to experience a decline in sperm quantity and quality.

An unhealthy lifestyle will also be detrimental, as we already mention concerning drugs, alcohol or smoking. A poor diet, lack of exercise, obesity, and excessive stress can contribute to a low sperm count.

Hormonal imbalances are also a risk factor. Conditions such as hypogonadism, thyroid disorders, and pituitary gland disorders can affect sperm production. Testicular overheating, some medications and certain medical conditions may have aswell adverse effects on sperm production.

How to prevent low sperm count

The treatment of a low sperm count includes:

• Surgery. For example, a varicocele can often be surgically corrected, or an obstructed vas deferens can be restored. In cases where no sperm is present in the ejaculate, they can be directly retrieved from the testicles or epididymis using sperm retrieval techniques.
• Treatment of infections. Antibiotics can cure a reproductive tract infection, but this does not guarantee a restoration of fertility.
• Treatment of sexual dysfunction. Medications or counseling can help improve conditions such as erectile dysfunction or premature ejaculation.
• Hormonal treatments and medications. Hormone therapy or medications may be used in cases where infertility is due to hormonal imbalances.

Diagnosis

The diagnosis of a low sperm count includes a physical examination and medical history. This condition is diagnosed as part of a semen analysis.

Semen analysis

A normal sperm concentration ranges between 15-200 million/ml; below 15 million/ml or 39 million total sperm in the ejaculate is considered a low sperm count.

Other tests

Depending on the initial findings of the semen analysis, your doctor may recommend additional tests to search for the cause of this decreased sperm concentration and other possible causes of male infertility. These tests may include:

• Scrotal ultrasound, useful for observing the testicles and supporting structures.
• Hormonal determinations: they play a key role in sexual development and sperm production.
• Post-ejaculation urine analysis, as the presence of sperm in the urine is indicative of retrograde ejaculation.
• Genetic testing.
• Testicular biopsy.
• Anti-sperm antibody testing, used to detect the presence of antibodies that attack sperm, although they are uncommon.
• Specialized sperm function tests. Rarely performed, they usually do not change treatment recommendations.
• Transrectal ultrasound.

Low sperm count: the fertility treatment options

There is no specific medical low sperm count treatment designed to bring a low sperm count up to normal, except in the case of some hormonal abnormalities which can respond to medication. In most cases however, although natural conception can eventually take place, some form of assisted reproduction is required.

How low sperm count is treated in your individual circumstances is a matter to decide in consultation with your medical practitioner. Here are some of the pssibilities: 

• IUI (Intrauterine insemination). This is a specialised type of artificial insemination whereby the highest quality sperm are selected, prepared and injected into the uterus where they are left to fertilise the eggs naturally. Compared to IVF, whereby eggs are removed from the body and fertilised in the lab, it is a less invasive procedure which involves fewer drugs. It can certainly help increase the chances of conception in a simpler way than IVF. It is also suitable for people who need donated sperm but have no female fertility problems, including lesbian couples and single women. It can also be recommended for couples with unexplained infertility and those who are unable to have vaginal intercourse or who have a condition that requires sperm washing to remove the risk of disease, especially in the case of men who are HIV positive.
• In Vitro Fertilisation involves uniting the ovum with the spermatozoon in the laboratory, in vitro, in order to obtain fertilised embryos for transfer to the patient’s uterus. The fertilisation of the ova can be carried out either by means of the conventional IVF technique or by Intracytoplasmic Sperm Injection (ICSI).
• ICSI using the male partner’s semen is recommended for cases of severe male factor infertility as well as for women with fallopian tube lesions, advanced endometriosis or limited oocyte numbers. It is also often recommended for patients for whom previous simpler treatments, such as artificial insemination, have failed. The man needs to provide a semen sample or undergo a testicular biopsy if necessary in order to extract and select the best spermatozoa which will be used to fertilise the oocytes.

Even though there may be no specific cure for low sperm count, IVI’s success rate per patient is among the highest. Nine out of ten couples that consult IVI due to problems with infertility and put their trust in us achieve their goal of becoming parents. Furthermore, from the outset IVI has pioneered many different techniques. Proof of this can be seen in the more than 250,000 babies born to date with the help of IVI. If you would like to find out more, simply pick up the phone, or fill in our contact form, and our Patient Care team will schedule in your appointment with you. We’re always here to help.