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One of the most frustrating problems for infertile men is the fact that their sperm counts seem to vary all the time. On some days it is 5 million per ml; on others it drops to 2 million per ml; while on good days it goes upto 10 million per ml ! It's like the Sensex; as volatile; as hard to predict ; impossible to control; and variations in the sperm count cause as much stress as dips in the Sensex !

Remember that the testes are sperm production factories which produce billions of sperm daily. The efficiency of this factory is affected by many variables, many of which we still cannot identify ! Even in a normal healthy fertile man, sperm counts fluctuate all the time - and can vary all the way from 10 million per ml to 80 million per ml !

What makes a bad situation worse is the fact that many medical laboratories are not very good at testing the sperm. A semen analysis is a high-complexity test, but because it costs very little, many laboratories do it very casually, and provide erroneous results, which just cannot be trusted !

The problem of varying sperm counts is exacerbated in infertile men ! While the truth is that we do not know what causes the sperm count to drop ( or to rise for that matter), when the count drops, men often tend to blame themselves. Wives will often add to their guilt by blaming the drop on the usual culprits : a poor diet; unhealthy lifestyle; late nights; stress; or on smoking or drinking.

Many wives will nag their husbands to completely stop smoking, drinking or partying. It's very unlikely that social drinking or an occasional smoke affects the sperm counts and all these prohibitions just create unhappiness and bickering. Some men will deliberately throw away all their bad semen analysis results and just show the good results to their wife and the doctor
( and some continue to refuse to believe that a macho man like them can have poor quality sperm !)

We need to understand that we really know very little about sperm production - and there's very little the poor man can do to improve his sperm count ! In all honesty, there's very little the poor doctor can do either ! All we can provide are the standard platitudes - Eat a well-balanced nutritious healthy diet ; exercise regularly ; avoid stress; stop smoking; stop drinking; take vitamins; take supplements ; take these medicines ; and so on, but all these measures have very little effect on the infertile man's low sperm count !

Most men are very reluctant to get their sperm tested. For one, most men hate going to a doctor - and they need to be dragged to the clinic for any medical testing - whether it's a X-ray or a sperm test. Secondly, most men still believe that having a baby is their wife's job, so it's the wife who should get tested. For another, they expect that their sperm count must be fine , so why bother to get it tested ? " Hey - I can have sex as often as I want, and if my virility is fine, I am sure my fertility will be superb too ! Why waste time and money getting it tested ? " Finally, it can be quite humiliating to have to go to a lab to produce a semen sample - and this is an experience most men are quite happy to bypass.

The problem is much worse for men who know that they have a low sperm count. They are secretly petrified that their sperm count may drop even further , which is why they are so reluctant to get their semen re-tested ! ( They also know that if their sperm count is low, their spouse will nag them incessantly to stop smoking and stop drinking - and is having a baby really worth giving up all the pleasures of life for ? )

This reluctance on the part of the man is not something many wives understand - " I am the one who has to go through all the painful tests and shots , so why is he making such a big deal about getting his semen tested ? " Ironically, the wife is being amazingly unempathetic in this case. While it's true that it's usually men who are clueless, any wife who does not understand the heartburn an infertile man goes through when his sperm count come back as below normal is being remarkably obtuse and clueless. The secret fear many men with a low count have is that the sperm may keep on dropping until it goes to zero - and then what ? Men are masters as denial - and since most of them hate going to a doctor for any medical problem, it's quite understandable that they are not happy about allowing their vulnerability to be exposed to the whole wide world ! And while producing a semen sample is not as painful as doing a HSG, being forced to produce semen on demand in a dark, smelly bathroom when there are five other men waiting in line can be very unpleasant ! Even worse , if the man fails to get an erection and produce a sample when asked to, this can often be the last nail in the coffin of his self-confidence. He'd rather go and shoot himself than put himself through the humiliating ordeal once again.

Sadly, many doctors do not realise the enormous stress some infertile men go through when producing a semen sample - and this just contributes to the difficulty. Since most nurses in an IVF clinic are female, it's very hard for a man to talk about his personal problem to anyone ( the doctor's never available in any case !) And if he fails once, this often becomes a self-fulfilling prophesy, setting up a negative vicious cycle which is very hard to crack. Seeing his wife angry and upset just adds to the man's woes - and he'd rather just forget about having a baby rather than subjecting himself to the stressful exercise all over again !

Infertile patients expect that their doctors will provide them with treatment to improve their chances of having a baby. Tragically, some medical procedures can actually end up reducing your fertility !

Here's a list of the top ten procedures which can actually harm you, rather than help you ! If your doctor advises any of these, please get a second opinion before agreeing !

1. D&C ( dilatation and curettage) . This is a "minor" surgical procedure in which the doctor dilates the mouth of the uterus ( the cervix) and scrapes the uterine lining using a curette
( curettage). This endometrial tissue is then sent for pathological examination. In the past, when doctors had very little to offer to their patients, this used to be the mainstay of the treatment of an infertile couple. In fact, even today, some women will ask the doctor to do a D&C for them because their mother conceived after doing this procedure ! They feel that it helps to "clean the uterus", thus improving their fertility ! While it is true that some women will get pregnant after a D&C ( sometimes this is just a placebo effect; while sometimes the endometrial inflammation induced by the procedure can improve uterine blood flow and fertility), this is an obsolete procedure which should be used in this day and age only for confirming the diagnosis of endometrial tuberculosis.

2. Metroplasty. This has become quite a fashionable procedure in some parts of India, where the doctor "improves" the shape of the uterine cavity to improve fertility. It can actually create uterine scarring and induce fertility. It's only in India that doctors use this technique for "treating" infertility. In all other countries, it is reserved for correcting uterine anomalies or removing intrauterine adhesions.

3. Hydrotubation. This is a procedure in which the doctor flushed the uterus and the tubes with fluid ( which often contains a concoction of chemicals such as steroids and antibiotics) to treat infertility. While it can help some women with cornual blocks, for the vast majority this painful treatment ( which is often repeated many times in one month) is a waste of time and money.

4. Empiric treatment for abnormal sperm . This continues to remain a major time-waster for infertile couples. Tragically, most doctors are still unaware of the recently revised criteria of what a normal sperm count is - and will often reflexively treat men with what they think is an "abnormal sperm report". There are various levels of sophistication to this futile effort. To cloak this with an aura of scientific respectability, high tech labs will now test sperm for DNA fragmentation levels - and doctors are quite happy to "fix" the problems these tests will often pick up. What many patients do not realise that there is very little correlation between these test results and their fertility potential - and that even fertile men have high DNA fragmentation levels ( but are fortunately unaware of this, as they have enough sense not to get their sperm tested in a lab !)

5. Treatment for genital tuberculosis. We are now seeing an "epidemic" of uterine TB in India - especially in north India, where it appears that practically even woman who goes to a gynecologist has TB ! Doctor use dodgy tests called PCR to test the endometrium for the presence of DNA fragments which are supposed to be be specific markers for the tubercle bacilli - without even bothering to determine what the prevalence of this TB PCR positivity is in the fertile population ! Not only do these poor patients end up taking 6 months of toxic and expensive drugs; their husbands will often stop having sex with them ( because they are worried that they will transmit the TB to them); while others are scared that they will give the TB in their uterus to their baby !

6. Treatment for TORCH infections. Women who have been unfortunate enough to have a miscarriage will get routinely ( and mindlessly) tested for the presence of antibodies against the TORCH group of infections. If any of these tests is positive, the doctor then promptly treats this infection with antibiotics ( which are completely useless and uncalled for !). The truth is that pregnancy. You can read about this at www.drmalpani.com/torch.htm

7. IUI ( Intrauterine insemination ) for treating couples men with a low sperm count. Since everyone knows that " you need just one sperm to fertilise an egg", it seems to make a lot of sense to treat infertile couples who have a low sperm count with IUI . After all, IUI is a simple and inexpensive treatment, which every gynecologist can offer - and patients understand the logic as to why it should help. The truth is that the problem with men with low sperm counts is not just that their sperm count is low - its often that the sperm are functionally incompetent - and no amount of concentrating the good sperm or washing them is going to help !

8. Diagnostic laparoscopy. Once upon a time, a laparoscopy was a major advance in evaluating the infertile woman, because it actually allowed the doctor to visualise the ovaries and fallopian tubes without having to cut open the patient ! Minimally invasive surgery was a major advance then , but now it's being overused. Many doctors still routinely perform a laparoscopy for all infertile women, which is completely unnecessary surgery, as is does not change the therapeutic options for these patients. The status of the fallopian tubes can as easily be checked with a simple HSG, which is much less expensive ! It's true that a laparoscopy allows the doctor to also "find" adhesions and endometriosis, but making the diagnosis of this ( or "treating" them ) does not really improve the patient's fertility at all !

9. Medications for treating endometriosis. Endometriosis is an enigmatic and frustrating disease; and mot doctors will still reflexively "treat " this with medications, such as GnRH analogs. While these medications are great at suppressing the endometriosis (and will provide dramatic pain relief), this suppression is only temporary - and does not improve the patient's fertility at all (since they also suppress ovulation at the same time !) Once the meds are stopped, the endo recurs ! Even worse, "treating" the endo with meds just wastes the patient's time - something which most infertile patients cannot really afford to fritter away !

10. Operative laparoscopy for myomectomy and cystectomy. One problem with today's high tech diagnostic tools ( such as vaginal ultrasound scans) is that it allows the doctor to "diagnose" small 1 cm size ovarian cysts and fibroids. Now while cysts and fibroids are very common in fertile women as well; and small cysts and fibroids do not affect fertility, once the sonographer has "reported" his "diagnosis", the patient often panics ! The doctor is happy to point out these abnormalities - and convinces the patients that it is these abnormalities which are the cause of her infertility - and that once these are "treated", she'll get a baby quickly ! What's worse is that it's easy to do the surgery with a laparoscopy ( which is just "minor surgery"), that patients are quite happy to sign on the dotted line without realising that these are incidental findings of no clinical importance; and that the surgery will not help them. What's worse, is that this unnecessary surgery can reduce your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

I sometimes think we are seeing an epidemic of overtesting and overtreatment. Doctors seem to like doing tests - and patients like being tested ! Unfortunately, patients are still not sophisticated enough to differentiate between useful tests and useless tests - and the truth is that some tests can actually be harmful !

The hidden danger with a lot of these unnecessary testing is that patients get fed up; lose confidence in doctors; and refuse to pursue more effective treatment options, because they do not trust doctors any more !

The message is simple - if you have a medical problem, remember that Information Therapy is invaluable ! Please get a second opinion if you are unsure and confused. Send me your medical details by filling in the free second opinion form at www.drmalpani.com/malpaniform.htm and I'll be happy to help !

This is a guest post by Dr. Sai, Senior Embryologist at Malpani Infertility Clinic

The collection of testicular sperm directly from the testes allows us to help men with azoospermia to have a baby with their own sperm ! This is called testicular sperm extraction with ICSI ( TESE-ICSI ). It’s easy to find sperm in men with obstructive azospermia, because their testes produce sperm normally. However, it can be very challenging to find sperm in men with non-obstructive azoospermia who have partial testicular failure, because sperm production in these men is very patchy.

When doing a testicular biopsy, there is sometimes some bleeding, and often the testicular tissue which the surgeon hands over to the lab is blood stained. When these samples are processed in the lab to recover the testicular sperm, it’s extremely difficult to identify viable sperms , because the RBCs obscure the field completely.

This is the protocol I use for processing testicular tissue for TESA at our centre .

• Dissect the tubules with sterile tuberculin syringes. This allows me to separate the testicular tissue tubule wall from its content. I discard the content, and collect the content in a sterile 15cc centrifuge tube.
• Centrifuge the content at 1200 rpm at 5 min.
• Draw off the supernatant (discard)
• Resuspend the pellet in 1 ml of room temperature RBC Lysis Buffer solution. This contains 8.3 g/L Ammonium Chloride in 0.01M Tris-HCL Buffer (pH of 7.5 + 0.2)
• After 5 minutes, add 2 ml of room temperature sperm preparation medium.
• Mix it gently and centrifuge at 1200 rpm for 5 min.
• Draw off the supernatant.
• Resuspend the pellet in 0.2 ml room temperature sperm preparation medium.

After processing , I place microdrops of the washed testicular tissue content on the ICSI dish , which is layered with culture oil. I then scan the sperm selection drop, and use the injection pipette to pick up the testicular sperm from the prep and move it to a PVP drop until injection.

There can be a lot of debris in the testicular homogenate ( precursor or immature sperm cells ) . Therefore it requires a lots of patience to process this tissue. I repeat this process until I have enough sperm to inject the eggs with, plus a few extra for spares.

Here’s a case study of a very challenging patient we treated recently. He had non-obstructive azoospermia, with small testes ( volume of 6 ml); and a FSH level of 18.2 mIU/ml.

During the treatment cycle, our andrologist, Dr Vijay Kulkarni, took 6 microbiopsies from each testes on the day of egg collection. Because the tissue was blood stained, it was very difficult to identify the sperm. This is why the tissue suspension was treated with RBC Lysis Buffer as per the protocol mentioned above, to remove the RBCs.

This improved visibility dramatically, and it now became possible to identify a few testicular sperm. In the picture below, you can see the injection pipette picking up a single sperm. Note that the background is full of other testicular cells, which emphasizes the fact that finding testicular sperm requires a lot of expertise and patience ! Also note that there are very few RBCs ( the circular cells with a central halo) in this field.



It took me almost 2 hours to collect enough sperm. Since the RBCs had been cleared, identifying sperm was possible, making my task much easier ! However, the majority of sperms appeared abnormal. They had a cytoplasmic droplet, amorphous head or stumped tail, and none of them were motile.

3 hours later, 24 eggs were collected from the wife, of which 20 eggs were mature ( metaphase II) . All 20 eggs were injected, each with a single spermatozoon immobilized by stroking the tail.

After overnight culture, 11 oocytes showed two pronuclei and five 8-Cell and 6-Cell embryos (Grade B and Grade C) were transferred into the uterus on day 3.

The patient conceived in this cycle, and this pregnancy is presently progressing well.

I see many men with completely normal sperm reports who have been prescribed all sorts of medicines, presumably to "boost their fertility" . These include a wide variety of pills ( depending upon which part of the world they come from) , ranging from Proxeed to Speman to Manix to CoQ and antioxidants.

Why are doctors so keen to treat normal men who do not need any treatment
whatsoever ?

I feel there are multiple reasons.

First is ignorance. Many sperm testing labs and doctors still do not even know what a normal sperm count is. I still see labs which print the normal sperm count range as being from 60 - 150 million per ml ! This means that even men with normal counts of 40 million are " diagnosed " as having a low sperm
count !

Second is pressure from patients. Many men are petrified that they cannot get their wife pregnant because their sperm count is not good enough. They want medicines to "boost " their sperm count and enhance their fertility ( along the same lines of their eternal desire to increase the size of their penis and increase the volume of their ejaculate ! I wonder why men have this obsession with size and numbers ? Is this a result of the exposure to the trick photography they use in pornography films, which distorts their sense of what is normal and average ? )

This means that there is a lot of pressure on the doctor to treat ! Let's do something - anything ! They do not want to lose the patient and are quite happy to pander to their desire to consume medicines ! And it's easier to write a medicine ( even if it is useless) rather than sit and spend 10 minutes with the patient and explain that there is no need to prescribe anything !)

It's very easy to justify this prescription. Many doctors say - Yes, these medicines may not help, but at least they do no harm ! And doctors often fall prey to the " post hoc ergo propter hoc fallacy" . They remember their anecdotal successes - the men with completely normal sperm counts who got their wife pregnant after taking the tablet prescribed by the doctor ( it's quite likely that they would have achieved a pregnancy even without taking the tablet, but the doctor is always happy to take the credit !)