WORDS LIM TECK CHOON

KL Fertility CentreGoing through Father’s Day can be hard for men who experience difficulties conceiving a child with their loved one. If you are one of those men, don’t lose hope. Advances in fertility research and treatment have kept the door open even for men with low sperm count to become a father. This month, Dr Agilan Arjunan shares some insights on the options available to transform a man’s dream of fatherhood into reality.

Looking at the two men below, which one do you think has a sperm count issue? There is no way of telling, actually. A man can have every stereotypical element associated with masculinity — big strapping muscles, lots of body and facial hair, height, etc — but he can still have low sperm concentration.

Let’s have Dr Agilan explain the sperm production process to get a better idea of the big picture.

SPERM PRODUCTION

1. The pituitary gland produces follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The hormones then travel to the testicles.
2. FSH stimulates the Sertoli cells in the testicles to produce sperm cells. LH stimulates the Leydig cells in the testicles to produce the male sex hormone testosterone.
3. As more sperm and testosterone are produced in the testicles, the Sertoli cells begin to produce another hormone called inhibin. 
4. High levels of inhibin and testosterone cause the pituitary gland to reduce its production of FSH and LH. Subsequently, sperm cell production decreases.

Once sperm cells are produced, they will take around 72 days to reach maturation. Therefore, any changes made to improve sperm count and quality usually need about 3 months before any noticeable improvements are seen.

DOWN FOR THE COUNT

“The World Health Organization defines low sperm count as sperm concentration of below 15 million per millilitre of semen,” says Dr Agilan. Given the drop of fertility rate among men worldwide, he adds that this figure is expected to be redefined into a higher figure in the future.

How can a man have low sperm count? Basically, there are two possible reasons.

One, something affected the sperm production process. Dr Agilan reveals that about 15%of men with zero sperm count (azoospermia) are born with defects in their Y-chromosome. Hormonal imbalances can also affect sperm production — one common example is the use of anabolic steroids by men who want to improve their physique.

The other possible cause is that something is blocking sperm cells from being present in the man’s semen. Typically, this is due to past infections, previous surgery that led to obstructive scar tissues or trauma to the genitals.

However, there is hope! We only need one sperm cell to successfully fertilize a woman’s egg cell and create a child, and that’s the key. Now, we have the technology and expertise to retrieve sperm cells from the man’s genitalia, even if his sperm count is low.

THE TROUBLE WITH ANABOLIC STEROIDS

There are many different types of steroids. When people talk about the steroids used to build up muscles, they are referring to anabolic steroids. These steroids bind to muscle cells to promote growth.

Now, anabolic steroids are synthetic compounds that are based on testosterone. Therefore, when one uses anabolic steroids, Dr Agilan says that the body senses that there are already high levels of testosterone present, and as you can see in the previous page, high levels of testosterone will lead to reduced sperm cell production. Prolonged use of anabolic steroids can even lead to a complete shutdown of sperm production!

Thus, there is no other way about it. Don’t take steroids if you are concerned about your fertility!

But what if I’m already on anabolic steroids? Dr Agilan recommends visiting a fertility specialist for a proper assessment. Men whose sperm count is affected will have to halt taking the anabolic steroids for the time being; they will be given hormone therapy (usually human chorionic gonadotropin, along with FSH if necessary) in the meantime to stimulate sperm production.

Depending on how long they had been on anabolic steroids and the dosage they were taking, recovery may take place over a period of a few months or even a year or two.

OPENING THE DOOR TO FATHERHOOD

Dr Agilan shares that the fertility specialist will first run some tests to first determine the nature of the problem.

• Sperm sample. Sperm samples will be needed to determine key details such as how much sperm is made, the shape of the sperm cells and how these cells move. The semen will also be analyzed to measure its volume, acidity and uniformity.
• Blood tests. This will help determine whether there is any hormonal issue that affects sperm production. It also gives information about how ‘hard’ the brain is working to stimulate testicles to produce sperm.
• Physical examination. This gives information about the size and consistency of testicles as well as the presence of vas deferens (the tube connecting the testicles to the penis).
• Ultrasound examination may be useful to determine whether there is any issue with the man’s genitalia that can affect his fertility.
• Biopsy. If necessary, a small piece of tissue may be obtained from the testicles to be further examined in a laboratory.

NEXT STAGE: HORMONE TREATMENT AND SPERM ANALYSIS

Based on the test results, the fertility specialist will prescribe the appropriate hormone treatment to improve the man’s sperm count. The man will provide his sperm sample at predetermined intervals (usually once every 4 to 8 weeks) for assessment.

IF GOOD IMPROVEMENTS ARE SEEN

The fertility specialist may recommend simple fertility treatments such as intrauterine insemination (IUI) to help the couple have a child.

IUI involves extracting the man’s sperms and placing them directly into the woman’s uterus. This is done in order to place the sperms nearer to the fallopian tube and hence increase the chance of fertilization of the egg cell by a sperm cell.

In most cases, though, the sperms would be frozen and used later for in-vitro fertilization (IVF). Dr Agilan strongly recommends that the man should take measures to improve his sperm quality prior to this, via healthy diet, regular physical activity, good stress management and healthy weight management. Cigarettes and alcohol should be avoided.

WHAT HAPPENS WHEN THE SPERM COUNT STILL REMAINS LOW?

Dr Agilan says that there are still options that can be explored.

ICSI-IVF. In normal IVF, a viable healthy egg obtained from the woman will be placed in a dish in the IVF laboratory and mixed with many sperms obtained from the man.

In ICSI-IVF (ICSI is short for intracytoplasmic sperm injection), the embryologist will directly inject a single sperm  cell into an egg cell using a thin hollow needle-like structure called a pipette. This procedure will be repeated for every egg harvested from the woman. This process improves the chances of a successful fertilization compared to IVF without ICSI, although

Dr Agilan notes that it does not guarantee a 100% chance of success. If the man is still unable to produce adequate sperm cells after hormone treatment, or if nearly all the sperm cells seen in provided samples are dead, then there is the option of PESA or TeSA.

Percutaneous epididymal sperm aspiration (PESA) is carried out if there is a blockage in the vas deferens preventing sperm cells from being present in the semen, or if the vas deferens is absent from birth.

Sperm produced in the testicles is stored in a tube-like structure called the epididymis. In PESA, a very fine needle will be

inserted into that structure to collect some epididymal fluid. The fluid will then be examined carefully under the microscope to locate healthy- looking sperm that can be used for ICSI-IVF or frozen for later use.

This process is performed under local anaesthesia, so there should be no pain, and there is no incision and hence no scar formation. The entire procedure doesn’t take too long, and the man can go back to his usual routine on the same day or the day after.

Testicular sperm aspiration (TeSA) is an option when there is no sperm cells observed in the man’s sperm sample. The procedure is nearly similar to PESA, only this time the fine needle is inserted directly into the testicular tissue instead of epididymis.

THE DOOR IS NEVER COMPLETELY CLOSED

Dr Agilan assures that there are many options these days that can help men with low sperm count. Many things that seemed impossible once upon a time are indeed possible today. Therefore, if you have always dreamed of being a father, but have troubles conceiving a child with your loved one, don’t feel embarrassed or emasculated. Talk to a fertility specialist (discretion is guaranteed) — it may just be the best gift you can give yourself, possibly opening the doors for future Father’s Day celebrations to cherish with a family you have always yearned for. HT

If you like this article, do subscribe here.