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Abstract: The patient was a 42-year-old male who had been infertile for 10 years without contraception. After completing semen analysis, ultrasound and other related examinations, he was diagnosed as: infertility, oligozoospermia, and lethal spermatorrhea. He was then given medication. After medication, the patient’s sperm density and sperm activity rate improved. Then he started to try to conceive, and his spouse became pregnant in 4 months of trying to conceive and gave birth to a daughter.
Basic information】Male, 42 years old
Type of disease】Infertility, oligozoospermia, and dead sperm
Hospital】Henan Provincial Hospital of Traditional Chinese Medicine
Time of consultation】August 2018
Treatment plan】Medication (hippocampus kidney pill, vitamin C tablet, vitamin E soft capsule, coenzyme Q10 capsule, disodium adenosine triphosphate tablet, zinc gluconate tablet)
Treatment Period】3 months of outpatient medication
Treatment effect】The sperm density and sperm motility rate have improved
I. Initial consultation
The patient came to our clinic because he had been infertile for 10 years without contraception, and he came to our clinic after multiple treatments failed. Patient’s self-report: 1 year ago, he underwent semen examination in a foreign hospital, semen analysis: incomplete liquefaction; sperm density: 17.63 million/ml; class a: 6.67%; class b: 7.43%; sperm motility rate: 23.51%.
After coming to our hospital, he completed semen analysis: sperm density <4.01 million/ml; grade a: 2.27%; grade b: 6.82%; sperm motility rate: 9.09%; dead sperm rate: 86%; chromosome: 46XY. Ultrasound examination: varicocele of the left spermatic cord, internal diameter 2.5 mm.
II. Treatment process
Because of the patient’s heavy spermatozoa, weak sperm, and dead sperm, and the spouse’s small ovaries, poor ovarian function, pelvic inflammatory disease, and tubal problems (the left side is not passable, the right side is passable but not smooth), we discussed with the patient and family whether to consider IVF, and the patient decided not to do IVF, and both spouses were treated to observe the effect of treatment. So after discussion, it was decided to give the patient medication, including: hippocampus kidney pills, vitamin C tablets, vitamin E soft capsules, coenzyme Q10 capsules, adenosine triphosphate disodium tablets, zinc gluconate tablets, etc., and first treated for 1 cycle.
III. Treatment effect
The patient’s semen analysis was repeated after 1 cycle of drug treatment: sperm completely liquefied; sperm density: 30.21 million/ml; class a: 16.18%; sperm motility rate: 25.98%; dead sperm rate: 68%; total effective sperm: 1.5996×10^6 /ml. In summary, the patient’s sperm density, class a, motility rate and total effective sperm improved after 1 cycle of treatment. The patient was instructed to start trying to conceive while on medication, and the patient’s spouse also met all the criteria for trying to conceive, and her spouse became pregnant and delivered a baby girl in 4 months of trying to conceive. Thus, the patient has been treated with medication for 3 months in total, with good results and successfully achieved the goal of conception.
IV. Precautions
We are happy that the patient got a daughter as she wished, but we also told the patient to relax, not to think too much, to sleep, to combine work and rest, to live a regular life, to exercise moderately, to strengthen immunity, to adhere to the medication, not to miss or take less medication, and to strictly prohibit smoking and alcohol because they are very damaging to sperm. Because the sperm production cycle is 3 months, this treatment cycle will be longer, and there will be discomfort in taking the medication, but you must adhere to the medication and follow up regularly according to the doctor’s instructions.
V. Personal insight
At present, we encounter more and more patients with infertility in the clinic, such as the patients in this case, most of them are accompanied by anxiety and psychological stress, when the treatment is not only medication, but also to comfort the patients to relax and share some successful treatment cases with them to enhance their confidence and increase their compliance, which seems to be very necessary and effective.