Often we see men are coming to us with abnormal semen analysis report showing very low ("Oligospermia") or absent ("Azoospermia") sperm count or very poor "motility" (ability to move) of the sperms. They ask, if they require sperm donor. The answer is "NO".

Two things must be remembered-
1) Semen Report must be REPEATED from an AUTHENTIC LABORATORY after ABSTINENCE of 3-5 days. This is important, as the sperm count varies day to day. It takes almost 3 months to produce the sperms. therefore, if today you wear very tight underwear or you have high fever, your sperm count (checked after 3 months from today) will be low. As a result, a SINGLE ABNORMAL SEMEN ANALYSIS report does NOT HAVE ANY SIGNIFICANCE. You need to repeat it.

2) Both Male and Woman should be seen together. What treatment is required, actually depends on the reports of both the partners, their age and duration of infertility. Moreover, the pregnancy will ultimately happen on the woman. That's why, we need to see both together.

Unfortunately, in many of such cases, medicines cannot work. Still, you can become biological father using your own sperms. Initially you can take medicines. but even after taking medicines, sperm counts remain abnormal, you should consider IUI or IVF.

That means, we may not be able to improve your sperm count in most of the cases, but we can definitely help you to become the biological father of your baby.
What is IUI (Intrauterine Insemination) ?
Medicines (tablets, injection) are given to your wife to help her eggs grow. By ultrasound, we see whether eggs are growing. If the eggs about to rupture, husband’s sperm is collected, processed (“preparation�) and then inserted inside the uterus. The success rate is 10-15% per cycle. That means out of 100 couples trying IUI, 10-15 can conceive after the first cycle. You can try maximum 3-4 cycles of IUI.

When IUI can be done?
If the sperm count is mildly/ moderately low, IUI can be tried. However, for doing IUI, at least one fallopian tube of your wife MUST be open. Moreover, the success rate of IUI is higher if your wife's age is less than 35 years, she is having good number of eggs in the ovaries and you are not trying for pregnancy for long time.

What is IVF (in vitro fertilization)?
Your wife will be given some injection (gonadotrophin) to promote growth of the follicles (fluid filled sacs in the ovaries containing eggs). Injections are NOT painful and are needed to be taken under the skin. She has to come to TVS (ultrasound by putting probe in the vagina) follicular study regularly to see if the follicles are growing. Usually, injections are needed for 10-12 days. After that, under anaesthesia, eggs are collected from her body by inserting small needle. The eggs are then fertilized with the sperm to produce the embryos. The embryos are then transferred after 2-3 days (Fresh Transfer) or after 2-3 months (Frozen Transfer). The success rate of IVF is 40-50%. That means out of 100 couples undergoing IVF, 40-50 can conceive after the first cycle.

When IVF should be done?
If you have tried IUI for 3-4 cycles and failed, you should consider IVF. If your wife's fallopian tubes are blocked, her age is on the higher side, she is having less number of eggs in the ovaries and you have been trying for pregnancy for longer time, you should NOT delay IVF.

What to do if the sperm count is severely low?
In that case, you require a special type of IVF, called ICSI (Intracytoplasmic Sperm Injection). Here, the sperms collected from you, will directly be injected inside the eggs collected from your wife to form the embryo. It increases the success rate.

What to do if there is no sperm (Azoospermia)?
There is also no need to use donor sperms. You can father your own baby using your own sperms, collected from your testicles, by small needle (TESA- Testicular Sperm Aspiration). Those sperms can be used for ICSI.

Donor sperms are used for IUI ONLY when your sperm count is very low, you require IVF-ICSI but unfortunately you cannot afford. Donor sperms can ONLY be used after taking consent from BOTH the husband and the wife.
Conclusion-
In most of the case, you can become biological father of your own baby using your own sperms by IUI or IVF. If the problem is mild, IUI can be tried. In case of severe problem, you should not delay IVF. Donor sperm is not usually needed.

Often we see men are coming to us with abnormal semen analysis report showing very low ("Oligospermia") or absent ("Azoospermia") sperm count or very poor "motility" (ability to move) of the sperms. Naturally, they are very much worried and want to know whether medicines can be helpful.

Two things must be remembered
1) Semen Report must be REPEATED from an AUTHENTIC LABORATORY after ABSTINENCE of 3-5 days. This is important, as the sperm count varies day to day. It takes almost 3 months to produce the sperms. therefore, if today you wear very tight underwear or you have high fever, your sperm count (checked after 3 months from today) will be low. As a result, a SINGLE ABNORMAL SEMEN ANALYSIS report does NOT HAVE ANY SIGNIFICANCE. You need to repeat it.

2) Both Male and Woman should be seen together. What treatment is required, actually depends on the reports of both the partners, their age and duration of infertility. Moreover, the pregnancy will ultimately happen on the woman. That's why, we need to see both together.

What medicines should I take if the second semen analysis report is also abnormal?
It all depends on how abnormal the report is. In case of mild abnormalities, we give medicines called "Antioxidants" (special types of minerals and vitamins that act on the sperms) for 2-3 months and ask to repeat the test again to see if there is any improvement. At the same time, some life-style changes are advised. These include avoidance of smoking and alcohol, reducing weight, avoidance of using tight underwear, prolonged sitting and driving.

However, if the problem is severe, you can take antioxidants. But it is more IMPORTANT to do some tests to FIND OUT THE CAUSE. Sometimes, we can find the cause like diabetes, which if controlled, can improve your sperm count without any other treatment.

What tests are required?
You may need physical examination of your genital organs by the doctor. You may be advised some blood tests for hormones (Testosterone, FSH, LH, Sugar etc). Some ultrasound examination of your testicles or prostate gland may be advised. In severe cases, some genetic testing (blood test to see if there is any chromosomal problem) may be needed.

Can any medicines help if there is severe problem?
In most of the cases, medicines cannot help. You can take antioxidants but SHOULD NOT RELY solely on it. In most cases, you will require IUI or IVF. However, there is ONLY ONE CASE where medicines can ACT DRAMATICALLY. That is if there is problem in the pituitary gland (situated in the brain). In that case, taking gonadotrophin injections for 3-6 months will significantly improve your sperm count.

What's the problem if medicines are taken for long time?
As such, medicines will not harm. But if you take medicines despite the fact that your sperm count is not improving, you can land up in azoospermia. This is because, in male having severe oligospermia, there is a tendency that sperm count may further decrease over time. Therefore, relying on medicine will INDIRECTLY HARM you. Rather, you should think of IUI or IVF.

Can Testosterone be taken?
Even if your testosterone is low, if you start taking tablet/ injection of testosterone from outside, your SPERM COUNT WILL DECLINE FURTHER. Therefore, under any circumstances, if you want to become father, you SHOULD NOT TAKE TESTOSTERONE. Sometimes, after hormonal tests, we can advise tablets like Letrozole, which can help to improve the testosterone level, indirectly.

IUI or IVF- What to do?
If the sperm count is mildly/ moderately low, IUI (Intrauterine Insemination) can be tried. however, if its severely low, you should go for special type of IVF (in vitro fertilization), called ICSI (Intracytoplasmic Sperm Injection). All of these will be done using your sperms only.

What to do if there is no sperm (Azoospermia)?
You need some investigations to find out the cause. If there is pituitary gland problems, injections can be helpful. In most of the other cases, no medicines can help. But you can become the biological father of your baby using your own sperms, collected from your testicles, by small needle (TESA- Testicular Spwerm Aspiration). those sperms can be used for ICSI.

Conclusion-
In most of the case, we may not be able to improve your sperm count by medicines. Taking medicines years after years, can rather be harmful. In most cases, you can become biological father of your own baby using your own sperms.

Women with PCOS have good number of eggs inside the follicles but they cannot be released (Ovulation). As a result, sperms cannot meet the eggs, leading to infertility. Unfortunately, there is no cure for PCOS. However, it can be kept under control. You should aim to keep your weight to a level that is normal.

Is IVF ONLY treatment for PCOS?
Treatment of PCOS-Infertility depends on your age, duration of infertility and other fertility factors. Usually the first line of treatment is OI (Ovulation Induction). If patient fails to conceive with OI, then IUI is offered. If IUI also fails, then ONLY IVF is usually advised. Therefore, majority of the women with PCOS conceive without IVF; especially if they are young (age less than 35 years), infertility duration is short, husband;s sperm condition is OK and Fallopian tubes are alright.

When IVF is suggested for PCOS?
If your age is on the higher side (age more than 35), infertility duration is of longer time, husband's sperm reports are not good or your fallopian tubes are blocked then you should consider IVF. Moreover, if you tried OI several cycles (4-6 cycles) with oral tablets and injections and also tried IUI 3-4 cycles, the chance of pregnancy is low, without IVF. Therefore in that case, you should seriously consider IVF.

What should you do before IVF?
First of all please remember, the success rate of IVF is only 40-50%. That means out of 100 couples undergoing IVF, 40-50 can conceive after the first cycle. Some may need additional cycles. Keep your weight normal. reducing weight helps to improve success rate of IVF.

How IVF is done?
You will be given some injection (gonadotrophin) to promote growth of the follicles (fluid filled sacs in the ovaries containing eggs). Injections are NOT painful and are needed to be taken under the skin. You have to come to TVS (ultrasound by putting probe in the vagina) follicular study regularly to see if the follicles are growing. Usually, injections are needed for 10-12 days. After that, under anaesthesia, eggs are collected from your body by inserting small needle. The eggs are then fertilized with the sperm to produce the embryos. The embryos are then frozen and are transferred after 2-3 months.

Why embryos are not transferred in the same cycle and are frozen?
In PCOS, there is a risk called, OHSS (Ovarian Hyperstimulation Syndrome), where excessive number of focllicles can develop, leading to fluid accumulation in tummy and chest. It may turn serious, sometimes. Therefore, if we freeze the embryo, the OHSS severity decreases. At the same time, during IVF, we give some medicines to reduce the risk of OHSS, ask to come for regular monitoring and request the women to take protein rich diet and plenty of water.

Overall, the success rate is higher in PCOS, after IVF, compared to other causes of infertility.

The basic problem in PCOS (Polycystic Ovary Syndrome) is that there are numerous eggs in the ovaries but they do not grow and Ovulate (release of eggs).

The first line of treatment in PCOS, therefore, is Ovulation Induction (giving medicine to grow and release the eggs). This has to be done VERY CAREFULLY. If medicines are ineffective, eggs won't grow. On the other hand, slight increase in dose can cause many follicles to grow, leading to serious complications like OHSS (Ovarian Hyperstimulation Syndrome- ovaries enlarge, water can accumulate in various body parts) and Multiple Pregnancy (Twin, Triplet etc). That's why we must do TVS Follicular Scan to see if eggs are growing and whether there is chance of OHSS or not.

The first line of agents in Ovulation Induction (OI) are usually oral tablets like CC (Clomiphene Citrate) and Letrozole. Sometimes we add Metformin tablet to improve the response to the oral medicines.

What to do if the oral medicines are not working (you are not ovulating with oral medicines)?
If these do not work we have 2 options-

1) Injection Gonadotropin (that carries small risk of OHSS and Multiple pregnancy, therefore, needs intense Monitoring by TVS)

2) surgery called LOD (Laparoscopic Ovarian Drilling- the electric current is used to burn few follicles in PCO). However, LOD carries surgical, anesthetic risks and also the risk of ovarian damage, if not done in proper way.

What to do if you had ovulation with oral medicines but failed to conceive?
If OI is done with oral medicine, the success rate is 15% per cycle. That means, out of 100 women taking the tablet, having regular intercourse and undergoing TVS Follicular Study, 15 will conceive at the end of one month.

It is useless to take the medicines for OI years after years. Pregnancy should happen within 6-9 cycles of OI.

If oral tablets has been tried for 4-6 months, it's better to add injections for next 3-4 months.

How to take the injections?
Injections are usually started from day 2/ 3/ 4 of the period. The number of injection depends on your response. The injections are NOT painful and need to be taken under the skin. TVS Follicular Study is done from day 8/9, once in every 2-3 days (until day 14-16) to confirm that the injection is working. You should have regular physical relationship as well.

How long injections can be taken?
How long you can take injections, depends on your age and the duration of infertility.

It is useless to take the injections for OI years after years. Pregnancy should happen within 3-4 cycles of OI.

If still pregnancy cannot happen, it's better to consider IUI or IVF.

How PCOS is related to the infertility?
Women with PCOS have good number of eggs inside the follicles but they cannot be released (Ovulation). As a result, sperms cannot meet the eggs, leading to infertility. Additionally, obesity, diabetes, high testosterone and insulin level all can be risk factors for infertility.

How PCOS is treated?
Unfortunately, there is no cure for PCOS. However, it can be kept under control. Majority of the women can keep the disease under control with lifestyle changes (diet and exercise), rather than medicines. These can also help to prevent the long-term consequences.

You should aim to keep your weight to a level that is normal. Losing only a small portion of weight will improve regularity of your periods, ovulation and also the chance of pregnancy.

Some women are prescribed “Insulin sensitizers� like inositol and metformin to reduce the level of insulin.

Treatment of fertility depends on your age, duration of infertility and other fertility factors. Usually the first line of treatment is OI (Ovulation Induction). The next lines are IUI (Intrauterine Insemination) and IVF (In Vitro fertilization) respectively.

What is Ovulation Induction?
Medicines (tablets, injection) are given to help your eggs grow and rupture. In the first cycle, it is important to see (by ultrasound) whether eggs are growing or not. If the eggs rupture, the chance of pregnancy per cycle is 15% and after 4-6 cycles of OI, it is nearly 50-60%. That means, out of 100 women who had ovulation, 15 can conceive after one month.

How IUI is done?
IUI is one step ahead of OI. Here along with medicines given for OI, husband’s sperm is collected, processed (“preparation�) and then inserted inside the uterus. The success rate is 15-20% per cycle.

When IVF is advised?
If a woman fails to conceive after 4-6 cycles of IUI, if the age is on higher side, there is long duration of infertility or additional problems like sperm defects or tubal blocks, IVF is advised. The success rate is 40-50% per cycle. But caution should be taken as these women are at risk of developing OHSS (Ovarian hyperstimulation syndrome- excessive response by ovaries) and twin pregnancy. Frozen embryo transfer reduces the risk.

Is there any role of laparoscopy?
Only very few women who fail to ovulate with any medicines, sometimes laparoscopy is done where some cysts are punctured using electric current (laparoscopic ovarian drilling- LOD). Additionally, LOD can be done for women requiring laparoscopy for other purposes (like pain, testing the tubes). However, LOD carries risk of ovarian damage and therefore, should be done in selective patients.

Conclusion-
PCOS is common but majority of the women can do well with life style changes. The chance of pregnancy after treatment is higher for women with PCOS than for other women.