Low sperm count

A low sperm count is a common reason for difficulty conceiving. It does not mean infertility: many men with reduced counts become fathers, including without assisted reproduction. What matters is something else — the male factor is involved in roughly half of all cases where a couple cannot conceive, and it is checked with one simple, inexpensive test. That is why investigation should start with both partners at the same time.

Symptoms

Usually there are none: the only sign is that pregnancy does not happen. Sometimes there are:

• reduced sex drive, erectile problems;
• pain, swelling or a lump in the testicular area;
• reduction in testicular size;
• reduced facial and body hair — a sign of low testosterone;
• breast tissue enlargement;
• impaired sense of smell, which can point to a rare congenital condition;
• recurrent chest infections, which in some inherited disorders accompany fertility problems.

Causes

Medical

• varicocele — dilated veins around the testis; the most common correctable cause;
• infections — mumps after puberty, sexually transmitted infections, prostatitis;
• hormonal disorders — low testosterone, pituitary disease, high prolactin, thyroid dysfunction;
• obstruction of the sperm ducts — after surgery, infection or from congenital causes;
• retrograde ejaculation — semen passes into the bladder;
• undescended testes in childhood;
• previous trauma or testicular torsion;
• genetic causes — Klinefelter syndrome, Y-chromosome microdeletions, mutations related to cystic fibrosis;
• cancer treatment — chemotherapy and radiotherapy;
• antisperm antibodies;
• severe chronic illness and poorly controlled diabetes.

Medicines and substances

• anabolic steroids and testosterone from outside — a common and important cause. Taking testosterone suppresses the body's own sperm production, sometimes for a long time. Many men do not know this;
• some blood pressure drugs, antidepressants, antifungals, sulfasalazine and acne medicines;
• heavy alcohol use, smoking, cannabis, cocaine;
• anabolic and "sports" supplements of unclear composition.

Lifestyle and environment

• heat — frequent saunas, hot baths, a laptop on the lap, tight underwear;
• excess weight;
• contact with pesticides, solvents, heavy metals and industrial chemicals;
• prolonged severe stress and chronic sleep loss;
• sedentary work with long hours driving.

When to see a doctor

• pregnancy has not happened after a year of regular unprotected sex;
• after six months if your partner is over 35 or there are known fertility problems;
• you have taken or are taking testosterone or anabolic steroids;
• there is pain, swelling or a lump in a testicle;
• you have had groin or scrotal surgery, undescended testis or torsion;
• you have had cancer treatment;
• your sex drive has fallen or you have erectile problems;
• your sense of smell has been impaired since childhood.

How it is investigated

The basis is semen analysis. It is done after 2–5 days of abstinence and is always repeated after 6–12 weeks: the values fluctuate considerably and no conclusions are drawn from a single sample. Equally important, after an illness with fever the values can be reduced for two to three months — which is not a cause for alarm.

Where needed: hormones (testosterone, LH, FSH, prolactin, thyroid function), scrotal ultrasound, post-ejaculation urine analysis if retrograde ejaculation is suspected, infection screening, genetic testing where counts are very low, and sperm DNA fragmentation testing in specific situations.

What you can do

The sperm maturation cycle takes about three months, so any change is assessed no earlier than that. That is the main thing to understand about timescales.

• stop smoking, cannabis and other substances;
• limit alcohol;
• stop anabolic steroids and testosterone completely — and discuss this with a doctor, because recovery takes time and sometimes needs pharmacological support;
• bring your weight into a healthy range;
• avoid heat: fewer saunas and hot baths, loose underwear, no laptop on the lap;
• regular moderate exercise, without exhausting training;
• a complete diet with vegetables, nuts and fish; zinc and folate deficiencies matter;
• sleep 7–9 hours;
• use protection when working with chemicals;
• have sex every 2–3 days — this is the optimal frequency; prolonged abstinence "to build up" worsens quality.

Treatment

• treating infection;
• varicocele surgery where indicated — it improves the parameters;
• correcting hormonal disorders;
• withdrawing or substituting the drug affecting sperm production;
• surgical repair of an obstruction;
• retrieving sperm directly from the testis where none are present in the ejaculate;
• assisted reproduction — intrauterine insemination, IVF and ICSI; with low counts, ICSI offers good chances.

Common questions

Is a low count a verdict? No. Pregnancy is possible with reduced values, and modern techniques are effective even with very low figures.

Do supplements help? Antioxidants and zinc may improve the parameters slightly, but they do not work miracles. Lifestyle and finding the cause come first.

Will testosterone help? The opposite: it suppresses sperm production. This is the most widespread misunderstanding in the field.

When is the result rechecked? No earlier than three months.

Does age matter? It does, though far less than in women: semen quality declines gradually after 40–45.

Online consultation

In an online consultation the doctor interprets your semen analysis — including why a single sample decides nothing — reviews the medicines and supplements you take, assesses lifestyle factors, plans the investigations and advises when it makes sense to go straight to a fertility clinic.

This material is for information only and does not replace a medical consultation.