Spontaneous Pregnancy after Conventional non-Assisted Reproductive Therapy of Male Infertility due to Sever Oligoasthenoteratozoospermia-Case Report

Infertility is a worldwide health problem and it is considered as one of the most common health disorders among young adult couples [1]. According to our previous study, male infertility was found to be responsible for ~1/3 (29.9 %) of infertility cases (1281/2622) and the percentage of OATS was around 7% (183/2622) [2]. Jo and Ja Kang in 2016 reported that in 30-45% of male infertility cases, the cause of the abnormal semen parameters was hesitant. But Jo & Ja [3] were reported also treatment of OATS is standardized approach for the dealing with idiopathic male infertility but it remains elusive. On the other hand, traditional treatment of OATS by non-assisted reproductive techniques (non-ART) is still not standardized. Regarding the conventional oral therapy (oral therapy by antibiotics and antioxidant) of male infertility due to OATS, a gap in published reviews was noted in the last decade. Furthermore, the conventional ART therapy is still expensive and usually used as the last option of infertility treatment. In this case report, we successfully treated a patient with male infertility due to severe OATS which we called it oral therapy or conventional nonassisted reproductive therapy (non-ART therapy) for infertility treatment. It is the policy of our In vitro Fertilization (IVF) Center to give a chance for antiinflammatory, anti-bacterial and supportive therapies before embarking on ART therapy.


Introduction
Infertility is a worldwide health problem and it is considered as one of the most common health disorders among young adult couples [1]. According to our previous study, male infertility was found to be responsible for ~1/3 (29.9 %) of infertility cases (1281/2622) and the percentage of OATS was around 7% (183/2622) [2]. Jo and Ja Kang in 2016 reported that in 30-45% of male infertility cases, the cause of the abnormal semen parameters was hesitant. But Jo & Ja [3] were reported also treatment of OATS is standardized approach for the dealing with idiopathic male infertility but it remains elusive. On the other hand, traditional treatment of OATS by non-assisted reproductive techniques (non-ART) is still not standardized. Regarding the conventional oral therapy (oral therapy by antibiotics and antioxidant) of male infertility due to OATS, a gap in published reviews was noted in the last decade. Furthermore, the conventional ART therapy is still expensive and usually used as the last option of infertility treatment. In this case report, we successfully treated a patient with male infertility due to severe OATS which we called it oral therapy or conventional nonassisted reproductive therapy (non-ART therapy) for infertility treatment. It is the policy of our In vitro Fertilization (IVF) Center to give a chance for anti-inflammatory, anti-bacterial and supportive therapies before embarking on ART therapy.

Case Report
A 34-year-old man was presented to IVF Center on 25/1/2017 with primary infertility of 12 years duration. No history of testicular injury, varicocele, torsion/hydrocele, cancer and chemotherapy was found after thorough questioning. Physical examination revealed normal vital signs with a BMI of 23.5kg/ m2, bilaterally palpable vas deferens, and normal masculine habitus with no signs of gross abnormalities. He was married to 32-years-old-lady who was apparently reproductively fertile i.e., all infertility investigations were done and shown to be normal. Verbal consent was taken from the couple prior to sending this case report for publication.

Semen analysis
The semen analysis was investigated on the first visit (patients already familiar with procedures of infertility centers and from the first visit they are usually ready to collect semen analysis for investigation) to the clinic with sexual abstinence period of 3-5 days. Semen was collected in the outpatient semen-Global Journal of Reproductive Medicine laboratory in a sterile plastic. In the analysis, the volume was measured using a graded tube and the sperm count was done by the manual slide method. Motility was scored as percentages of: A.
Fast forward progressive, B. Slow forward progressive, C. Non-progressive and D. Immotile spermatozoa in total number of 200 counted spermatozoa in at least five power fields per replicate, according to the WHO manual [4].

Results
After conventional non-ART treatment of this case, an improvement in the semen volume, sperm count and motility were noted and reported, Table 3. Active grade 1 motile sperms were recorded. On 25th May, 2017, the couple reported a oneweek missed-period. During transabdominal ultrasound, a normal gestational sac of 6-7 weeks with viable fetal pool was noted. Pregnancy was confirmed by positive laboratory result for the presence of 2,798.01IU/mL serum beta human chorionic gonadotropin.

Discussion
Absent or markedly decreased sperm count/motility or both can cause male infertility and is an indicator for an assisted reproductive technique [5,6]. However, as in this case, the policy of our IVF center for management of male infertility is to give a chance for classical or conventional non-ART treatment before the couple is enrolled for any assisted reproductive technology (conventional-ART). However, it should be noted that severe oligoasthenoteratospermia is the most difficult to treat among all causes of male infertility and is the cause of approximately 7% of infertility cases.
The purpose of antibiotic use in this case was to treat any possible infection by fastidious bacteria (which usually reported "no growth" during semen culture test) that may have caused the increased number of white blood cells in the semen analysis in spite of the negative bacterial growth in the semen culture. Allow, et al. [1] had reported that male infertility accounts for a high percentage (40-50%) of total infertility and that male Global Journal of Reproductive Medicine seminal fluid infections and sperm agglutination due to antisperm antibodies account for 17.73% and 29.90% respectively of male infertility factor [1].
The role of antioxidants in the management was important to improve the sperm parameters both qualitatively and quantitatively. In a study published by Ashok in 2017, it was reported that antioxidants such as glutathione, vitamins E and C, carnitines, coenzyme-Q10, N-acetylcysteine, selenium, zinc, folic acid, and lycopene have shown to reduce OS-induced sperm damage [7]. In our case, we believe that all the sperm parameters were improved, at least partially, by the antioxidant treatment.
The role of gonadotropins in this case was also in improving the sperm count, motility and viability. In an observational study of 166 infertile male partners of couples undergoing in-vitro fertilization, it was shown that FSH treatment improves sperm DNA fragmentation, which in turn leads to increased pregnancy rates in infertile males undergoing in-vitro fertilization [8].

Conclusion
The husband (case) became a father after a mild improvement in his sperm quality tests. We recommend at the end of this case report to extend the study to cover more cases, and if proved beneficial to recommend it as worthwhile effort to try for male infertile-patients with asthenospermia before turning to ARTtherapy.