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TC(799).(20).Sexology Case No 5. Teratozoospermia

Definition — Teratozoospermia কাকে বলে?

Teratozoospermia হলো semen analysis-এ sperm morphology বা শুক্রাণুর গঠনগত স্বাভাবিকতা কম পাওয়া। সাধারণভাবে WHO strict morphology অনুযায়ী normal sperm forms <4% হলে teratozoospermia বলা হয়। অর্থাৎ ১০০টি sperm-এর মধ্যে ৪টির কম sperm স্বাভাবিক head, midpiece ও tail structure থাকলে morphology abnormal ধরা হয়। WHO semen manual semen analysis-কে male fertility evaluation-এর standard basic test হিসেবে ব্যবহার করে।

এটি একা থাকলে isolated teratozoospermia, আর sperm count ও motility-ও কম থাকলে oligo-astheno-teratozoospermia বা OAT syndrome বলা হয়। EAU guideline অনুযায়ী semen parameter একা infertility নিশ্চিত করে না; abnormal result কমপক্ষে দুইবার হলে further andrological evaluation দরকার।

2. Causes — কারণ

  • Varicocele: testicular venous reflux → scrotal heat ও oxidative stress বাড়ায় → sperm morphology খারাপ হতে পারে। Palpable varicocele + infertility + abnormal semen parameter থাকলে varicocelectomy guideline-supported।
  • Oxidative stress: smoking, pollution, obesity, infection, varicocele, heat exposure—এসব reactive oxygen species বাড়িয়ে sperm membrane/DNA damage করতে পারে। EAU guideline oxidative stress-কে sperm quality-এর ক্ষতিকর factor বলেছে, তবে routine ROS testing recommend করে না।
  • Smoking, alcohol, cannabis, anabolic steroid/testosterone misuse: AUA/ASRM অনুযায়ী smoking sperm concentration, motility ও morphology-তে small adverse effect করতে পারে; anabolic steroid spermatogenesis suppress করে fertility নষ্ট করতে পারে।
  • Genital tract infection / STI / prostatitis / epididymitis: inflammation, leukocytospermia ও oxidative stress sperm morphology খারাপ করতে পারে।
  • Fever বা recent febrile illness: spermatogenesis প্রায় ৭৪ দিন লাগে, তাই high fever-এর ২–৩ মাস পরে semen morphology খারাপ দেখা যেতে পারে।
  • Heat exposure: tight underwear, sauna, hot bath, laptop on lap, prolonged sitting, high-temperature workplace।
  • Endocrine cause: hypogonadism, thyroid disorder, hyperprolactinaemia, diabetes, obesity।
  • Genetic / congenital cause: complete globozoospermia, macrozoospermia, Y-chromosome abnormality, cryptorchidism history।
  • Drugs / toxins: chemotherapy, radiotherapy, sulfasalazine, testosterone therapy, pesticides, heavy metals।
  • Idiopathic: অনেক ক্ষেত্রে clear cause পাওয়া যায় না।

3. Symptoms — লক্ষণ

  • বেশিরভাগ ক্ষেত্রে কোনো direct symptom থাকে না।
  • প্রধান presentation: ১ বছর নিয়মিত unprotected intercourse-এর পরও pregnancy না হওয়া।
  • Associated symptom থাকতে পারে:
    • scrotal heaviness বা dragging pain — varicocele
    • burning micturition, urethral discharge — STI/urethritis
    • low libido, erectile dysfunction — hypogonadism
    • small testes, কম body hair — endocrine/testicular failure
    • recurrent miscarriage বা repeated IVF failure — sperm DNA damage সন্দেহ

4. Clinical diagnosis — কীভাবে clinically diagnosis করবেন?

  • Diagnosis শুরু হবে couple-based infertility assessment দিয়ে; শুধু male partner নয়, female partner evaluation-ও parallel করতে হবে। AUA/ASRM initial evaluation-এ reproductive history এবং এক বা একাধিক semen analysis recommend করে।
  • History নিতে হবে:
    • infertility duration, previous pregnancy history
    • coital frequency, timing, erectile/ejaculatory function
    • fever in last 3 months
    • smoking, alcohol, drug, anabolic steroid/testosterone use
    • occupational heat/toxin exposure
    • mumps orchitis, undescended testes, testicular trauma/surgery
    • STI/prostatitis/epididymitis history
    • medication history
    • female partner age, ovulation, tubal factor
  • Physical examination:
    • BMI, waist circumference
    • secondary sexual characters
    • testicular size/volume
    • epididymis, vas deferens palpation
    • varicocele examination standing position with Valsalva
    • gynecomastia
    • signs of endocrine disorder

5. Investigations — পরীক্ষা

  • Semen analysis
    • ২–৭ দিন abstinence-এর পর sample।
    • WHO-standard lab-এ semen volume, concentration, total sperm number, motility, morphology, vitality, pH দেখা।
    • morphology abnormal হলে কমপক্ষে ১ মাস ব্যবধানে repeat semen analysis করা উচিত, কারণ semen parameter ejaculate-to-ejaculate vary করে। AUA/ASRM abnormal semen parameter থাকলে at least two semen analyses গুরুত্বপূর্ণ বলে উল্লেখ করেছে।
  • Strict sperm morphology
    • Normal forms ≥4% হলে generally reference limit-এর মধ্যে।
    • Normal forms <4% হলে teratozoospermia।
    • Severe teratozoospermia বা special morphology pattern যেমন globozoospermia থাকলে ART/ICSI planning দরকার হতে পারে।
  • Hormonal profile
    • Morning total testosterone
    • FSH, LH
    • Prolactin
    • TSH
    • Estradiol if obesity/gynecomastia/low testosterone
    • AUA/ASRM impaired libido, ED, oligozoospermia/azoospermia, atrophic testes বা hormonal abnormality থাকলে FSH ও testosterone testing recommend করে।
  • Infection work-up
    • Semen WBC / leukocytospermia
    • Urine routine/culture
    • Urethral discharge থাকলে NAAT for Chlamydia trachomatis ও Neisseria gonorrhoeae
    • CDC urethritis guideline অনুযায়ী suspected NGU-তে doxycycline regimen ব্যবহার হয়।
  • Scrotal Doppler ultrasound
    • varicocele confirmation, testicular volume, epididymal lesion, obstruction সন্দেহে।
    • তবে শুধু ultrasound-detected non-palpable varicocele হলে varicocelectomy recommend করা হয় না।
  • Sperm DNA fragmentation
    • routine initial test নয়।
    • recurrent pregnancy loss, repeated ART failure, unexplained infertility, severe varicocele/oxidative stress সন্দেহে করা যায়। AUA/ASRM initial evaluation-এ routine sperm DNA fragmentation recommend করে না।
  • Genetic tests
    • Severe oligozoospermia বা azoospermia থাকলে karyotype ও Y-chromosome microdeletion।
    • AUA/ASRM severe oligospermia <5 million/mL বা azoospermia with testicular failure pattern-এ genetic testing recommend করে।

6. Treatment / Management

A. General management

  • Teratozoospermia-এর একটি universal medicine নেই। Treatment cause-specific।
  • Smoking, alcohol, cannabis, anabolic steroid/testosterone বন্ধ করতে হবে।
  • BMI optimize করতে হবে।
  • ৭–৮ ঘণ্টা ঘুম, regular exercise, Mediterranean-type diet।
  • Heat exposure কমাতে হবে: sauna/hot bath/tight underwear/laptop on lap avoid।
  • Frequency: fertile window-এ প্রতি ১–২ দিন intercourse।
  • Semen parameter improve দেখতে সাধারণত ৩ মাস লাগে, কারণ spermatogenesis cycle প্রায় ৭৪ দিন।

B. Pharmacological treatment — generic drug name, dose, duration, side effect

Table ছাড়া point আকারে দেওয়া হলো। এগুলো prescription-only; cause না জেনে self-medication করা উচিত নয়।

  1. Coenzyme Q10 — antioxidant support, idiopathic teratozoospermia/oxidative stress suspected

Capsule 1.ResQ 200mg AS A Coenzyme Q10(Ubidecarenone) AS A Herbal and Nutraceuticals, Supplements & adjuvant therapy.

  • Generic name: Coenzyme Q10
  • Dose: 100–200 mg orally once or twice daily; commonly total 200–300 mg/day
  • Duration: 3–6 months, তারপর semen analysis repeat
  • Use: idiopathic abnormal morphology, oxidative stress suspected, varicocele post-op support
  • Evidence note: AUA/ASRM বলেছে antioxidant/vitamin supplement-এর clinical benefit questionable; নির্দিষ্ট agent recommend করার মতো evidence adequate নয়।
  • Side effects: nausea, dyspepsia, headache, insomnia, mild rash; warfarin effect alter করতে পারে।

2. L-carnitine — sperm motility/morphology support

  • Generic name: L-carnitine
  • Capsule 1.ProFertil AS A L- carnitine,L-arginine+ Coenzyme Q10 +Vitamin E+Zinc+Folic Acid +Glutathione +Selenium AS A Drugs for Infertility.
  •  
  • Dose: 1–2 g orally daily; কখনও 2–3 g/day divided dose
  • Duration: 3–6 months
  • Use: idiopathic male infertility, astheno-teratozoospermia, oxidative stress suspected
  • Side effects: nausea, abdominal cramp, diarrhea, fishy body odour; seizure disorder থাকলে caution।

3. Vitamin C — antioxidant

  • Generic name: Ascorbic acid
  • Tablet 1.Ceevit 500mg AS A Ascorbic acid AS A Vitamin-C Preparations.
  •  
  • Dose: 500 mg orally once or twice daily
  • Duration: 3 months
  • Side effects: gastric irritation, diarrhea; high dose-এ renal stone risk predisposed patient-এ বাড়তে পারে।

4. Vitamin E — antioxidant

  • Generic name: Alpha-tocopherol
  • Capsule 1.E-CAP 400 mg AS A Alpha-tocopherol  Acetate AS A Herbal and Nutraceuticals, Vitamin-E Preparations.
  •  
  • Dose: 200–400 IU orally daily
  • Duration: 3 months
  • Side effects: nausea, loose stool, headache; high dose-এ bleeding risk, anticoagulant ব্যবহার করলে caution।

5. Zinc — deficiency থাকলে বেশি logical

  • Generic name: Zinc sulfate / zinc gluconate
  • Tablet 1.Xinc 20 mg AS A Zinc sulfate Monohydrate AS A Specific mineral preparations, Vaccines, Anti-sera & Immunoglobulin.
  • Dose: elemental zinc 20–40 mg orally daily
  • Duration: 3 months
  • Side effects: nausea, metallic taste, abdominal pain; long-term high dose copper deficiency করতে পারে।

6. Folic acid — often combined with zinc, but evidence mixed

  • Generic name: Folic acid
  • Tablet 1.Folison 5mg AS A Folic acid AS A Drugs for Megaloblastic Anemia, Vitamin-B preparations.
  •  
  • Dose: 400 microgram to 1 mg orally daily
  • Duration: 3 months
  • Side effects: usually safe; high dose vitamin B12 deficiency mask করতে পারে।

C. If infection / STI suspected

7. Doxycycline — nongonococcal urethritis / chlamydia suspected

  • Generic name: Doxycycline
  • Capsule 1.Doxibac 100 mg Doxycycline Hydrochloride Tetracycline group of drugs.
  • Dose: 100 mg orally twice daily
  • Duration: 7 days for nongonococcal urethritis; epididymitis suspected হলে 10 days
  • Guideline note: CDC NGU regimen doxycycline 100 mg orally twice daily for 7 days; acute epididymitis likely chlamydia/gonorrhoea হলে ceftriaxone plus doxycycline 10 days recommend করে।
  • Side effects: gastritis, nausea, photosensitivity, esophagitis; milk/antacid/iron-এর সাথে absorption কমে; pregnancy/children caution।

8. Ceftriaxone — gonorrhoea / STI epididymitis suspected

  • Generic name: Ceftriaxone
  • Injection 1.Axon IM 500MG/VIAL AS A Ceftriaxone Sodium AS A Third generation Cephalosporins.
  • Dose: 500 mg IM single dose; body weight ≥150 kg হলে 1 g IM single dose
  • Duration: single dose; chlamydia not excluded হলে doxycycline add
  • Guideline note: CDC acute epididymitis likely chlamydia/gonorrhoea-তে ceftriaxone 500 mg IM single dose plus doxycycline 100 mg twice daily 10 days recommend করে।
  • Side effects: injection site pain, diarrhea, rash, allergy/anaphylaxis rare, biliary sludging rare।

9. Levofloxacin — enteric organism epididymitis suspected

  • Generic name: Levofloxacin
  • Tablet 1.Levomax 500 mg AS A Levofloxacin Hemihydrate AS A 4-Quinolone preparations.
  •  
  • Dose: 500 mg orally once daily
  • Duration: 10 days
  • Use: enteric organism suspected epididymitis; gonorrhoea excluded হলে বেশি appropriate
  • Guideline note: CDC enteric organism epididymitis-এ levofloxacin 500 mg daily 10 days regimen দেয়।
  • Side effects: tendinitis/tendon rupture, QT prolongation, dysglycaemia, insomnia, dizziness, peripheral neuropathy; unnecessary use avoid।

D. If hypogonadotropic hypogonadism / low testosterone with fertility desire

10. hCG — endogenous testosterone ও spermatogenesis support

  • Generic name: Human chorionic gonadotropin, hCG
  • Injection IM/SC 1.HCG  5000IU/Vial AS A Human chorionic gonadotropin AS A Female Sex hormones.
  • Dose: 1,500–2,000 IU subcutaneous/IM, 2–3 times per week; অনেক specialist protocol-এ 1,000–2,500 IU 2–3 times/week ব্যবহার হয়
  • Duration: minimum 3–6 months; sperm response পেতে 6–12 months লাগতে পারে
  • Use: hypogonadotropic hypogonadism, low/normal LH with low testosterone, fertility desired
  • Guideline note: AUA/ASRM low testosterone infertile men-এ hCG, SERM, aromatase inhibitor ব্যবহার করা যেতে পারে; fertility চাইলে testosterone monotherapy দেওয়া যাবে না।
  • Side effects: acne, gynecomastia, mood change, edema, headache, increased estradiol, injection site pain।

11. FSH analogue — hCG-এর পর sperm production inadequate হলে

  • Generic name: Follitropin alfa / follitropin beta / urofollitropin
  • Injection 1.Gonal-F SC Injection75IU/Pre-filled syringe AS A  Follitropin alfa Drugs for Infertility.
  • Dose: 75–150 IU subcutaneous/IM, 2–3 times per week
  • Duration: 3–6 months or longer, specialist follow-up সহ
  • Use: hypogonadotropic hypogonadism; hCG দিয়ে testosterone normalize হওয়ার পর sperm production optimize করতে
  • Guideline note: AUA/ASRM বলেছে HH-তে hCG শুরু করে testosterone monitor করা হয়; testosterone normalize হলে FSH/FSH analogue add করা যায়।
  • Side effects: injection site reaction, acne, gynecomastia, mood change, testicular discomfort; cost high।

12. Clomiphene citrate — selected low testosterone infertile male, off-label

  • Generic name: Clomiphene citrate
  • Tablet 1.Ovuclon 50 mg AS A Clomiphene citrate AS A Drugs for Infertility.
  • Dose: 25 mg orally every other day বা 25 mg daily; response অনুযায়ী 50 mg every other day/daily specialist supervision-এ
  • Duration: 3–6 months, testosterone/LH/FSH/semen analysis follow-up
  • Use: secondary hypogonadism pattern, low testosterone with fertility desire, idiopathic infertility selected case
  • Guideline note: AUA/ASRM অনুযায়ী SERMs যেমন clomiphene infertile men-এ off-label ব্যবহার হয়, তবে idiopathic infertility-তে benefit limited এবং ART-এর তুলনায় কম।
  • Side effects: mood swing, headache, visual disturbance, acne, gynecomastia, raised estradiol, rarely thromboembolism।

13. Anastrozole — high estradiol / low testosterone-to-estradiol ratio selected case

  • Generic name: Anastrozole
  • Tablet 1.Entroza 1mg  AS A Anastrozole AS A Hormonal Chemotherapy.
  • Dose: 0.5–1 mg orally 2–3 times/week; কখনও 1 mg daily, but close monitoring দরকার
  • Duration: 3–6 months
  • Use: obese male, high estradiol, low testosterone-to-estradiol ratio, fertility desired selected case
  • Guideline note: AUA/ASRM aromatase inhibitor infertile men with low serum testosterone-এ considered option হিসেবে উল্লেখ করেছে।
  • Side effects: low libido if estrogen over-suppressed, joint pain, hot flush, reduced bone density with long-term use, liver enzyme alteration।

E. Important warning: Testosterone injection/gel/capsule

  • Generic: Testosterone enanthate / cypionate / undecanoate / gel
  • Teratozoospermia বা infertility treatment হিসেবে testosterone দেওয়া উচিত নয়, যদি patient current/future fertility চান।
  • কারণ exogenous testosterone LH/FSH suppress করে sperm production কমিয়ে severe oligospermia বা azoospermia করতে পারে। AUA/ASRM স্পষ্টভাবে fertility চাইলে testosterone monotherapy prescribe না করতে বলেছে।

F. Surgical / ART management

  • Palpable varicocele + infertility + abnormal semen parameter: microsurgical varicocelectomy consider; improvement দেখতে 3–6 months লাগে।
  • Severe isolated teratozoospermia, globozoospermia, failed IUI, long infertility duration, female age advanced: IVF/ICSI consider। AUA/ASRM guideline অনুযায়ী ART male infertility management-এর accepted option; ICSI morphology-related sperm quality issue অনেক ক্ষেত্রে bypass করতে পারে যদি viable sperm থাকে।
  • Low total motile sperm count: IUI success কমতে পারে; repeated abnormal semen results হলে IVF/ICSI earlier consider।

Overview / Summary

Teratozoospermia হলো sperm morphology abnormality, সাধারণত normal forms <4%। এটি বেশিরভাগ সময় symptomless; প্রধান সমস্যা infertility। Diagnosis semen analysis দিয়ে হয়, তবে একবার abnormal report দেখে final diagnosis করা উচিত নয়—repeat semen analysis দরকার। Treatment cause-specific: lifestyle correction, infection treatment, hormonal correction, varicocele repair, selected antioxidant support, এবং severe case-এ IVF/ICSI।

Actionable Plan / Steps

  1. WHO-standard lab-এ semen analysis repeat করুন — ২–৭ দিন abstinence, ১ মাস gap।
  2. Report-এ শুধু morphology নয়—count, motility, total motile sperm count, volume, pH, WBC সব দেখুন।
  3. Clinical exam করুন: testis volume, varicocele, vas deferens, epididymis।
  4. Test করুন: FSH, LH, morning testosterone, prolactin, TSH, HbA1c; infection symptom থাকলে urine culture/NAAT।
  5. Smoking, alcohol, heat exposure, anabolic steroid/testosterone বন্ধ করুন।
  6. Idiopathic হলে ৩ মাস lifestyle + selected antioxidant trial করা যায়, কিন্তু evidence limited।
  7. Palpable varicocele থাকলে urologist/andrologist referral for varicocelectomy।
  8. Severe morphology defect, female age >35, long infertility, repeated ART failure হলে reproductive medicine referral for IVF/ICSI।

Reference List

Textbook

  • Harrison’s Principles of Internal Medicine, 21st ed. Male Infertility, Hypogonadism, Reproductive Endocrinology sections.
  • Davidson’s Principles and Practice of Medicine, 24th ed. Endocrinology and Reproductive Medicine sections.
  • Robbins & Cotran Pathologic Basis of Disease, 10th ed. Male Genital System chapter.
  • Guyton and Hall Textbook of Medical Physiology, 14th ed. Male reproductive physiology chapter.

Guidelines

  • WHO Laboratory Manual for the Examination and Processing of Human Semen, 6th ed., 2021.
  • AUA/ASRM. Diagnosis and Treatment of Infertility in Men: Guideline Part I and II, 2020–2024 update.
  • EAU Guidelines on Sexual and Reproductive Health: Male Infertility, 2025.
  • CDC Sexually Transmitted Infections Treatment Guidelines, 2021.

Peer-reviewed DOI

  • Schlegel PN, et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. J Urol. DOI: 10.1097/JU.0000000000001521.
  • Schlegel PN, et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. Fertil Steril. DOI: 10.1016/j.fertnstert.2020.11.015.
  • Björndahl L, Kirkman-Brown J, et al. The sixth edition of the WHO manual on semen examination. Fertil Steril. DOI: 10.1016/j.fertnstert.2021.12.012.

Md.Rafiqul Islam Lipu Date:-12-05-2026 Monday Time:-07-08-14 Pm

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