Low sperm count: Impact on insemination

QMy husband has an extremely low sperm count (1 million/ml, with 40 percent motility). I've read that couples with sperm counts this low do not have much success with intrauterine insemination. I have heard it suggested that my husband could provide several frozen samples which could be prepared together. Is this a real possibility?


AIntrauterine insemination is utilized for the abnormal sperm parameters of number, shape and motility. Additionally, intrauterine insemination is used for immunologic conditions (male and or female antisperm antibodies), cervical factors (antisperm antibodies, decreased cervical mucous), male ejaculatory difficulties, and physical inability to have adequate coitus. Samples with a minimum progressive motile sperm count of one million may benefit by four to six cycles of LH kit timed intrauterine inseminations prior to more aggressive and costly interventions (IVF with ICSI). One should expect a per cycle pregnancy rate of about five percent. Some programs offer to combine multiple semen samples for insemination in order to increase the number of motile sperm. On a personal note, the author is aware of two pregnancies resulting from the insemination of less than 150,000 progressively motile sperm.

In half of men with either low sperm counts (oligospermia -- production of less than 20 million sperm per milliliter), abnormal sperm morphology (teratospermia -- more than 50 percent of sperm with an abnormal shape), or low motility (asthenospermia -- less than 50 percent of sperm are motile) no cause is detected. In the other half, the history and physical examination will reveal the cause. Alcohol intake should be quantified as this can have potentially significant effects if over 40 g of alcohol are ingested per day. Serum FSH levels may help determine if hypothalamic hypogonadism (low FSH) or testicular factors (high FSH) are the cause of absent sperm (azospermia -- no sperm seen on semen analysis).

Karyotypic analysis is helpful in males with a high FSH, azospermia and small testes. The most common chromosomal abnormality resulting in azospermia is Klinefelters syndrome which occurs in 1 in 500 live births and results in the destruction of all germ cells and seminiferous tubules. Gynecomastia and varying degrees of androgen deficiency are noted.

Obstruction of the ejaculatory ducts can be diagnosed by ultrasound. Congenital absence of the vas deferens can be detected by the absence of fructose in the semen sample.

The most common vascular abnormality associated with male infertility is the varicocele.

Minor sperm concentration (oligospermia of 10 to 20 million/ml), shape (teratospermia), or motility abnormalities (asthenospermia) are usually initially treated with a series intrauterine inseminations using various sperm preparation methodologies to enhance the number of progressively motile sperm.

Obstructive causes are treated with surgical correction (vasoepididymostomy or vasovasostomy) or percutaneous, microsurgical or biopsy-derived sperm to be used for in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). Significant sperm abnormalities or severe oligospermia (counts less than one million progressively motile sperm per ejaculate) are usually successfully treated via IVF using ICSI.

I recommend that you review the individual case of oligospermia with your andrologist, urologist and reproductive endocrinologist to provide a rational treatment program, which will culminate in IVF with ICSI, if other measures are unsuccessful.