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Low Sperm Motility (Ashtenospermia)   

What is Low sperm motility
Causes of low sperm motility  
Investigations & Diagnosis 
Treatment 
Response of treatment

What is Low sperm motility: When sperm motility is less than normal i.e. less then 50% of sperms are actively motile is called Oligo-asthenia i.e. low sperm motility (when all the sperms are immotile are called astheno-spermia. This leads to difficulty in conceiving i.e. wife does not becomes pregnant. This is one of the common causes of male infertility. This is also one of the most common semen abnormalities. 

What is Low sperm motility: When less than 50% sperms are motile then this condition is called oligoasthenia. When motility is less then chances of spontaneous pregnancy decreases (i.e. difficulty in conceiving i.e. wife does not becomes pregnant). This is one of the common causes of male factor infertility. This is also one of the most common semen abnormalities in men. 
 
How sperms develop:
When boy becomes of 14 years of age then L.H. & F.S.H. hormone secretion from pituitary increases. The rise in these hormones leads to proliferation of sperm forming cells (Germ Cells) in the testis. These germ cells start multiplying under the effect of above-mentioned pituitary genital hormones along with assistance of other hormones as testosterones, Growth hormones, Androstenidione, insulin like growth factor-I, Thyroids hormone, paracrine hormone & growth factors. Under the control of above-mentioned hormones germs cells divide & transformed into primary spermatocytes. Then further maturation of primary spermatocytes to spermatids & then finally into mature spermatozoa (i.e. normal sperms) occurs under the control of above-mentioned hormones. After few weeks of progressive maturation inside the testis these sperms become normally motile & develop the capacity to fertilize the ovum. This total sperm cycle from first stage to final stage of normal mature sperms is of three months. Any hindrance in the development of these spermatozoa will lead to less count of sperm & decreased motility, immotile or even dead sperms.

Causes of low sperm motility: The various causes of decreased motility are as follows:

  
1) Deficiency of central sperm producing hormones: 
 
Hypothalamic pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome, Hypothalamic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, hemochromatosis) Autoimmune hypophysitis, Drugs (drug-induced hyperprolactinemia, genital steroids use)  
Untreated endocrinopathies, Glucocorticoid excess, Hypopituitarism, Isolated gonadotropin deficiency (non acquired): Pituitary, Hypothalamic, Associated with multiple pituitary hormone deficiencies: Idiopathic pan hypo pituitarism (hypothalamic defects), Pituitary dysgenesis, Space-occupying lesions (craniopharyngioma, Rathke pouch cysts, hypothalamic tumors, pituitary adenomas), , Laurence-Moon-Beidl syndrome Prader-Willi syndrome , Frohlich syndrome, Hypergonadotropic hypogonadism : Klinefelter syndrome,  Noonan syndrome,  Viral orchitis, Cytotxic drugs, Testicular irradiation. 
2) Testicular disorders (primary leydig cell dysfunction i.e. Hypoganadism)
, Chromosomal (Klinefelter syndrome and variants, XX male gonadal dysgenesis), Defects in androgen biosynthesis, Orchitis (mumps, HIV, other viral, ),Myotonia dystrophica, Toxins (alcohol, opiates, fungicides, insecticides, heavy metals, cotton seed oil), Drugs (cytotoxic drugs, ketoconazole, cimetidine, spironolactone),  
3) Partial obstruction in outflow tract from testis to penile opening in epididymis or of vas deferens (cystic fibrosis, diethlstibesterol exposure) also called obstructive oligospermia.  
4) Varicocele:  varicocele is dilatation of scrotal vein in the scrotum that leads to rise in temperature of testis and raise testicular temperature, resulting in  decreased sperm motility, less sperm production & death of whatever sperms are produced. 
5)
Drugs (e.g. spironolactone, ketoconazole, cyclophosphamide, estrogen administration, sulfasalazine)
6) Autoimmunity i.e. presence of Antisperm antibody. These Antisperm antibodies bind with sperms & either make them less motile, totally immotile or even dead which is called necrospermia.  
7) Undescended testicle (cryptorchidism). Undescended testis is a condition when one or both testicles fail to descend from the abdomen into the lower part of scrotum during fetal development. Undescended testicles can lead to decreased sperm motility. Because the testicles temperature increase due to the higher internal body temperature compared to the temperature in the scrotum, sperm production may be affected.
8) Mosaic Klinefelter's syndrome. In this disorder of the genital chromosomes, of the man is abnormal. This causes abnormal development of the testicles, resulting in low sperm production or decreased sperm motility. Testosterone production may be low or normal.
9) Viral orchits as mumps or other viral infections.  
10) Infections as tuberculosis, sarcoidosis involving testis or surrounding structures as epididymis. 
11) Chronic systemic diseases as Liver diseases, Renal failure, Sickle cell disease, Celiac disease  
12) Neurological disease as myotonic dystrophy  
13) Development and structural defects as mild degree of Germinal cell hypo-plasia
14) Partial Androgen resistance  
15) Mycoplasmal infection  
16) Partial Immotile cilia syndrome 
17) Partial Spermatogenic arrest due to interruption of the complex process of germ cell  diffrentation from spermatid level to the formation of mature spermatozoa results in decreased sperm count i.e. oligospermia. Its diagnosis is made by testicular biopsy. This is found in upto 30% of all cases of low sperm count patients.18) Heat Exposure to testis: as febrile illness or exposure to hot ambience induces a fall in sperm count  or motility which is usually reversible.
19) Infection as bacterial epididimo-orchitis, even in prostatis spermatogenic defect have been noted.
20) Hyper-thermia due to cryptorchidism
21) Chromosomal abnormality: has been found in many cases of low sperm count
22) Alcohol use, Cocaine or heavy marijuana use or Tobacco smoking may lower sperm count
23) Anti-sperm antibodies.  In some people there occurs development of some abnormal blood proteins called anti-sperm antibodies which binds with sperm and make them either immotile or dead or decrease their count.
24) Infections. Infection of urogenital tract may affect sperm production. Repeated bouts of infections are one of the common causes associated with male infertility.
25) Klinefelter's syndrome. In this disorder of the genital chromosomes, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production & what ever are produced are less motile. Testosterone production also may be lower.
26) Trauma to testis
27) Environmental toxins: as Pesticides and other chemicals in food  or as ayurvedic medicines.
28) Genetic Factors: as idiopathic partial hypo-gonadotropic hypogonadism

Diagnosis of Cause of Low Sperm motility

For correct diagnosis of cause of low sperm count, we need detail history & physical examinations then certain relevant investigations are required.

History & Physical Examinations: First step in proper treatment is accurate diagnosis of cause of low sperm motility. So we first try to find out cause. We take detailed history, thorough drug counseling, and general physical examination, examination of testis, epididymis & testicular veins sperm carrying duct examinations. These examinations give idea about whether testis is normally developed or not & how is its function. After that depending on likelihood of particular, cause relevant tests are done. All testing facilities are available at our centre. Thus you may consult us at our centre & at same time you may get all tests done. The time taken in getting all the reports ready is 36 hours. So if you are from out of Delhi, you may come here for two days.

Investigation & Diagnosis: For completes diagnosis of causes of decreased sperm motility & one or more of the following tests may be required as

1) Complete male hormone profile: This profile includes all the male hormone tests which control testicular development, functions including normal sperm Productions. The tests include L.H., F.S.H., Testosterones, prolactins, thyroids test, & other relevant hormone tests depending on history & examinations. 
2)
Antisperm antibody   
3) USG or Doppler study of scrotum & testis 
4) Semen culture sensitivity 
5) Semen fructose 
6) Immunobead test 
7) Sperm Function Tests 
8) Human Sperm-Zona Pellucida Binding Ratio 
9) Human Sperm-Zona Pellucida Pentration test 
10) Genetic Studies 
11) FNAC Testis 
12) Egg penetration test 
13) Molecular genetic studies done in some special cases 
14) Chromosome analysis i.e. Karyotype 
15) Assessment of androgen receptor 
16) Combined Pituitary hormone tests is performed when needed  
17) MRI head if pituitary hormone defect suspected
18) Hemogram test for systemic diseases.
19) Sperm Function Tests
The hamster egg penetration assay (HEPA) and the hemizona assay (HZA) are sperm function tests which can help assess the ability of sperm to fertilize the egg. These tests will not definitively tell whether a pregnancy will occur, but an abnormal test result helps predict reduced fertilizing capability. These tests are performed only rarely today.
20) Semen Fructose

At our center facility for all the above tests are available.

Treatment: Once the cause of low sperm motility are found then with in three months of treatment sperm motility & motility becomes normal in more than 90% cases.

The various treatments are as follows:

Correction of the Cause: First of all we try to find out the primary cause of infertility by above mentioned investigations. Then we correct the basic defect i.e. correction of hormone disorder & other defects as varicocele surgery, stopping of alcohol & smoking, stopping of offending drug. We also give following treatment for permanent cure of low sperm motility & motility disorder.

1) Correction of Hormone deficiencies: Once the hormone disorder is found then it is corrected by any of the below medicines. Usually sperm motility normalizes in three month time with proper hormone treatment. 

2) Gonadotropin Therapy: Gonadotropins are most potent natural stimulators of sperm production in the testis. Once we start gonadotropin therapy, these gonadotropins stimulates the sperm producing cells in testis. Under the stimulating influence of gonadotropins sperm forming cells start dividing & produce multiple normally motile sperms.Thus in more than 90% cases sperm production can be normalized in three to four months time. Gonadotropin therapy is most successful of all the treatment available till now for sperm motility & motility enhancement. Gonadotropin therapy is indicated & effective all cases of hypogonadotropic Hypogonadism& almost all case of low sperm motility & motility. In many cases of low sperm motility when all other treatment has failed even in those cases gonadotropin therapy is effective.

3) Repronex.

4) Bravelle

5) Ovidrel

6) Gonadotropin-releasing hormone (Gn-RH) analogs

7) Growth hormone therapy in many cases where somatrop deficiency is found.

8) Growth Factor, Mineral & Micronutrient Therapy 

9) Free Radial Scavangers: These are drug to reduce the free damaging oxidative radical in the testis. For your information every minute lot of oxidant radicals are generated inside the testis which damages sperm forming cells. These special antioxidant drugs scavange these damaging oxidative free radicals thus leading to production of normal sperms by the testis. In many study these free radical scavengers have been found to be very-very effective in normalizing sperm motility.

10) Coenzyme ubique: These drugs improve the nutritional status of the testis. Thus testis as well as sperm forming cells get enough nutrient which helps in fast generation of sperms in good number with good motility & fertilizing capacity.

11)  Carnititine supplimentation increases the production of sperm, with normalization of sperm motility in three months.

12) Fertyl: This drug is taken orally and it causes the pituitary gland to release more FSH and LH, which then stimulates the testis to produce more sperms.

 13) Bromocriptine. This medication is for men who have elevated levels of prolactin.

14) Correction of thyroid hormone

15) Correction of congenital adrenal hyperplasia

16) Vitamins

17) Zinc

18) MethyPredinisolone

19) Antibiotics

20) Antiestrogens

21) Tamoxifen

22) Clomiphene

23) Hgh

24) Antimicrobials

25) Anti-inflammatory

26) AIH

27) ART'

28) Certain Newer Drugs has been found very effective

29) Treatment of antisperm antibody is achieved by steroid therapy, intrauterine insemination intra-cytoplasmic sperm injection (ICSI)

30) Surgery: Depending on the cause, surgery may be a treatment option for low sperm motility due to partial blockade of the tract from testis to the tip of pennis. Surgery is also the treatment of choice for significant varicocele. Similarly surgery may be one of the treatment options for many endocrine tumours.

31)  Intra-uterine insemination: In certain patients motile sperms are selected by various methods & then transferred directly in uterine cavity leading to improved pregnancy rate.

32)  Test tube baby is also delivered with our efforts by use of intra-cytoplasmic sperm injection (ICSI), then transfer of embryo to uterus of mother.

33) Treatment of general genital problems. Addressing imppotence or premature ejaculation can improve fertility. Treatment for these problems often is with medication or behavioral approaches.

34) Semen Bank: Facility for good quality sperm is semen bank in also available. At our center we have facility for all the testing & treatment facility required for low sperm motility to achieve pregnancy. 

35) Assisted reproductive technology (ART)
ART has revolutionized the treatment of infertility. Each year thousands of babies are born in India as a result of ART. Medical advances have enabled many couples to have their own biological child.

The most common forms of ART include:

a)       In vitro fertilization (IVF). This is the very effective ART technique. IVF involves retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF often is recommended as a first-line therapy. It's also widely used for unexplained infertility, male factor infertility.

b)       Electroejaculation. Electric stimulus brings about ejaculation to obtain semen.

c)       Surgical sperm aspiration. This technique involves removing sperm from part of the male reproductive tract such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if blockage is present.

d)       Intracytoplasmic sperm injection (ICSI). This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.

35) Varicocele ligation

A varicocele is an abnormal tortuosity and dilation of veins of within the scrotum. It can be surgically treated - which might help fertility in some cases.

Response of treatment: When we start treatment, maturation of spermatocyte to mature spermatozoa start occurring in three to 4 weeks time and achievement of normal sperm motility in three months. Thus cure rate is achieved in more than 95% of patients in three months time.

Side effects: This treatment is harmless because we prescribe well proven drugs which are prescribed in scientific literature. These medicines have to be purchased from medical store by patient himself.

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