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BackTable / Urology / Article
Low Sperm Motility: What it Means & How to Increase It
Sophie Frankenthal • Updated Dec 10, 2024 • 49 hits
Semen analysis is a primary component of male fertility evaluation, offering valuable insights into a man’s reproductive potential. By examining sperm parameters such as motility, morphology, and total motile sperm count (TMSC), this simple test provides a detailed understanding of fertility status and guides treatment decisions. Given that male factors contribute to roughly half of all infertility cases, understanding what sperm reveals about fertility is essential for effective reproductive care.
Reproductive Urologist Dr. James Smith explains the clinical significance of semen analysis, highlighting key factors that influence sperm quality and outlining strategies to improve reproductive outcomes. This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Semen analysis is a key diagnostic tool for assessing male infertility, with parameters like motility and total sperm count (TMSC) determining the likelihood of natural conception, suitability for intrauterine insemination (IUI), or the need for in vitro fertilization (IVF).
• Male fertility, as indicated by sperm quality, is influenced by various medical conditions such as varicocele and hypogonadism, as well as lifestyle factors like diet, weight, smoking, and exposure to environmental toxins. Clinicians should take a holistic approach in addressing all these factors in order to optimize reproductive potential.
• The presence of white blood cells in semen, clinically referred to as leukocytospermia, is often the result of sample contamination and generally has limited clinical relevance unless accompanied by symptoms such as prostate tenderness, which may indicate infection or prostatitis.
• Evidence suggests population-scale declines in male fertility over time, though the lack of robust national surveillance data makes it difficult to draw definitive conclusions. Temporary declines in fertility caused by febrile illnesses, such as COVID-19 or the flu, could play a role in these trends.
Table of Contents
(1) The Role of Sperm Motility in Guiding Assisted Reproductive Techniques
(2) Factors That Affect Sperm Motility
(3) How to Increase Sperm Motility
(4) The Clinical Significance of Leukocytospermia
(5) Population-Level Trends in Sperm Quality
The Role of Sperm Motility in Guiding Assisted Reproductive Techniques
Semen analysis plays a central role in assessing male infertility and guiding treatment decisions, with sperm motility serving as a key parameter. Higher motility is strongly associated with greater fertility success, and patients are classified based on their total motile sperm count (TMSC). Men with a TMSC above 30-40 million are typically able to achieve natural conception with timed intercourse, while those with 5-30 million are candidates for intrauterine insemination (IUI) after a year of unsuccessful attempts. Patients with a TMSC below 5 million are more likely to require in vitro fertilization (IVF).
[Dr. Jose Silva]
What about progression? The classic semen analysis parameters, there's a progression one, two, three, four. How does that impact you in the decision-making?
[Dr. James Smith]
Yes. When you look at this from zero, no motility at all, one twitching cells, two and three starting to move, and four just having linear progression across your microscope slide, generally, the higher the progressive motility, the more success you'd have with IUI. In general, the semen analysis, I think, gives you a pretty good idea of what's going on. Is the man likely to conceive with timing sex? Is he going to need something like intrauterine insemination or is in vitro fertilization more likely way to go?
I think of the semen analysis in that big bucket. Generally, I'm thinking if a man's total motile count is less than about 5 million sperm or so, this is my IVF bucket. Is he between 5 million and 20, 30 million, 40 million total moving sperm? That's my IUI range, at least assuming that they haven't conceived for a year. For that man who has more than 30 or 40 million moving sperm, then they're likely to conceive on their own if given enough time and they're timing sex with ovulation.
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Factors That Affect Sperm Motility
Multiple factors influence male fertility, including medical conditions such as varicocele, pituitary dysfunction, and hypogonadism. Lifestyle habits, such as smoking, marijuana use, poor diet, and unhealthy weight, as well as environmental exposure to heat and toxins, also negatively impact sperm quality. Clinicians should focus on optimizing fertility potential by addressing these modifiable factors.
[Dr. James Smith]
As a reproductive urologist, I'm always thinking, "What can I do to shift men among those three categories?" If he has 3 million moving sperm, is there something about his lifestyle or his diet, or his exposures in his environment? Does he have a varicocele? Does he have a pituitary dysfunction? Is he hypogonadal? Does he smoke? Does he use marijuana? As part of the history, the exam, his lab testing, I'm trying to figure this out. Is there anything that I can modify to try to shift him from being in that IVF range to being in the IUI range? If he's in the IUI range, is there something I can do to shift them into the just having sex at home range.
How to Increase Sperm Motility
Although antioxidants like CoQ10 and L-carnitine have shown mixed efficacy in clinical trials, including the NIH-supported MOXIe Trial, a comprehensive approach emphasizing dietary improvements, regular exercise, and avoidance of harmful exposures remains effective. Semen analysis follow-up is generally recommended at least three months after initial interventions, considering the sperm production cycle, but should be tailored to the patient’s specific circumstances and fertility goals.
[Dr. Jose Silva]
Vitamins like CoQ10, is that something that you tell the patient that they might help?
[Dr. James Smith]
I think this is a really interesting area. There has been growing interest in antioxidants of one sort or the other. These are certainly very important in semen as far as capacitation and other parameters for sperm. The data is more than a little bit mixed in this area. Some studies have shown significant benefit from CoQ10 and L-Carnitine and many others.
The largest randomized control trial was one that I was pleased to be part of, and it was with about eight or nine different academic centers. This was called the MOXIe Trial. This NIH-supported study randomized men with low numbers of total motile count to see whether or not antioxidants would improve. Overall, it did not lead to improvement. I generally try to focus on a holistic approach for patients. I talk about diet, and exercise, and weight, and removing toxic exposures. I'll tell them if you take supplements, it certainly may benefit you, but sometimes they can be quite expensive. I've gotten away from routinely advising them for patients, but I don't think they cause any harm other than sometimes to your pocket.
[Dr. James Smith]
How long do you wait? Like six month trying to do this diet, exercise, all the holistic method, six months? How long do you wait to tell them to come back with a new semen analysis?
[Dr. Jose Silva]
Each patient is very different. It depends on the circumstances. Some people have been trying for two years already, and I probably wouldn't wait very long at all. If a patient saw me in the very beginning of their journey, which I think is the place where urologists can really do the most good if a patient had not even started trying yet or was two months into their journey, then I certainly would wait three months. Three months is that minimum time for sperm production to happen. That takes roughly two months, and then for another couple of weeks for that sperm to make its way from the testicle through the ductwork and then out the penis with ejaculation.
I'd wait a minimum of three months before rechecking a semen analysis. One of the things I think that's tricky is to be scientific about this. Is it the diet or is it antioxidants or is it the varicocele or is it the obesity or is it the tobacco or a whole host of things. Typically, I try to fix them all at once and talk about the whole range of potential ways that man could improve his semen quality, and then I'll recheck him again three months later.
The Clinical Significance of Leukocytospermia
The presence of leukocytes in semen is a common cause of confusion for both patients and clinicians, yet their significance for male fertility is limited. Dr. James Smith suggests that leukocytospermia – elevated white blood cell levels in semen – is most often the result of contamination from bacteria on the patient’s hands or genitalia during sample collection. Routine staining for leukocytes is only reflexively performed when round cell counts exceed one million per milliliter, and even in such cases, the presence of leukocytes often lacks clinical relevance.
In cases of asymptomatic men with high TMSC, leukocytes are unlikely to impair fertility, and patient reassurance is key. However, leukocytospermia that is accompanied by clinical symptoms such as prostate tenderness or significant lower urinary tract symptoms may indicate prostatitis, warranting further evaluation and treatment.
[Dr. Jose Silva]
Jim, you mentioned leukocytes, the preferred lab to use from my institution. I will say 100% of the patients have leukocytes and it says that it has bacteria and even patients that are asymptomatic. You talk about quality, how confident are those labs that every time they have leukocytes, they have bacteria, most likely it's contamination, right?
[Dr. James Smith]
Yes, that's right. I don't generally make too much out of leukocytes. The first finding that shows up in the semen analysis are round cells. What we'll do at UCSF is if there's more than a million round cells per milliliter, well, we'll reflexively stain those for leukocytes. If there's still a high fraction of leukocytes in the sample, then I'll think that it's possible there's an infection.
In a man who's asymptomatic though, this could very well just be contamination. He's producing samples through masturbation and he has bacteria perhaps on his hands or on his genitalia. Most times, I don't find that the leukocytospermia, the white cells in the semen are terribly informative. It is an area of concern for REI and there's the concern that these elevated white blood cells are going to impair the in vitro fertilization cycle.
The data on this is very mixed, as is treatment with antibiotics for this situation. Often if you culture semen in this situation, you'll often see a mix of flora. Treat with antibiotics, you'll see a new mix of flora and often grow yeast or something else and not necessarily change your IVF outcomes. This is a tricky area, but I've grown to think that it's not a terribly helpful metric on the semen analysis.
[Dr. Jose Silva]
The patients that come with that type of situation, that they probably have done already a sperm test, a semen analysis with the primary, they come to the office thinking that they're infertile because there's a bacteria there. How do you approach that patient to change the way they're thinking or just to try to, "Hey, that's nothing. Don't worry, let's do some tests."?
[Dr. James Smith]
I think that's a great question, Jose. I think for me, the number one metric is the total motile count. When I look at the semen analysis, the first thing that I'm doing is if it's not already calculated for me, I'm looking at the semen volume, the sperm concentration, and the percent motility, and I'm multiplying those to look at the total number of moving sperm in the sample.
If a man had 100 million moving sperm and he had some white blood cells, I'd do everything that I could to reassure him. If I did a rectal exam and he's got a very tender prostate or he has significant LUTs, then I'd be treating him for prostatitis. From a fertility standpoint, I'm looking at the total number of moving sperm in the sample and if there's lots of sperm, and he has some white blood cells, I'm usually telling him that this is something you don't need to worry too much about, other than if he had symptoms and maybe think he had prostatitis.
Population-Level Trends in Sperm Quality
The potential decline in semen quality at the population level is a topic of growing interest, but the lack of robust surveillance data makes it difficult to draw definitive conclusions. Dr. James Smith suggests that fertility impairments caused by febrile illnesses, such as COVID-19 or the flu, can temporarily affect sperm quality—impacting concentration, motility, and morphology. These declines are typically short-lived, with sperm parameters often returning to baseline levels within three to six months.
While such temporary declines are a natural part of recovery, they may contribute to broader trends observed in population-level fertility, especially in the absence of comprehensive national surveillance systems. Initiatives like Fellow are working to address this gap by collecting data on fertility trends. Incorporating semen analysis into national surveys, such as the National Survey for Family Growth (NSFG), could offer valuable insights into how both short-term health events and long-term trends are influencing male fertility on a larger scale.
[Dr. Jose Silva]
Jim, so in terms of quality, there's mention that quality has been decreasing in the last couple of years or a long time ago. Is that something that you've been seeing or have you been able to study that in your research?
[Dr. James Smith]
I think it's really an interesting question, Jose, and I hope to be able to answer that question. Research is a big part of what we do at Fellow, and we've built research and these kinds of understanding into everything we do. Men are asked to participate in research. Over time, as the sample grows, I'd like to be able to answer your question well. I haven't looked at that yet in the Fellow data.
In general, COVID and other febrile illnesses are bad for fertility. I definitely advise my patients to try to avoid COVID when they can, particularly in that fertility window, but I would like to study that. There's no current national surveillance system for semen analysis, and that's something that I think Fellow might do a really good job at. Easy to get a semen analysis. Imagine could it be built into something like our NSFG, the National Survey for Family Growth. There's no current system like this to assess whether or not there's an epidemic of fertility problems.
[Dr. Jose Silva]
Fever or illness like COVID, is the damage permanent or is there data about it or there's nothing right now?
[Dr. James Smith]
There is data on this and it does not appear to be permanent. Most men tend to recover in three to six months after their illness has resolved. This is a time where I'd repeat the semen analysis. Sometimes I'll see men with a normal semen analysis, then their quality will fall off the map. I'll talk to them and they'll tell me they had the flu. They had COVID and they recover, we repeat a semen analysis three months later and we see that their numbers are coming up. That happens nearly every time.
[Dr. Jose Silva]
Is it decreasing amount in total sperm? Is it motility? Is it the morphology? What exactly do you see?
[Dr. James Smith]
Yes, it can because abnormalities in all three. It can cause the concentration to go down, it can cause more cells to die and so show poor motility so that it can affect morphology as well.
Podcast Contributors
Dr. James Smith
Dr. Jim Smith is a reproductive urologist and clinical professor at UCSF in San Fransisco and the chief medical officer at Fellow Health.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2024, May 14). Ep. 167 – Solving Semen Analysis Barriers: Innovation & Accessibility [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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