SART Fertility Experts - Male Fertility

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assisted Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. Hello, my name is Dr. Kelly Lynch and I work at Baystate Reproductive Medicine in Springfield, Massachusetts. My guest today for the SART Ask the Expert podcast is Dr. Stanton Honig, Clinical Professor of Urology, Director of Men's Health, Department of Urology, Yale School of Medicine in New Haven, Connecticut.

Dr. Honig, thank you so much for joining me today. My pleasure, Kelly. Dr. Honig, I'd like to ask you some questions about male infertility.

The first question I have for you is how common is male infertility? Well, the general sense is that fertility is a female issue because generally speaking women bond with their OBGYNs and men kind of don't really bond with doctors generally speaking. And women are focused on getting pregnant, things like that. But it turns out that about half the time it's a male factor problem.

So about 40% of the time it can be male, it can be male problem, 40% it can be female problem, and there's an overlap for about 10-20%. So there's a significant amount of the time there's a male factor issue. We see a lot of our male patients are somewhat resistant to undergo testing.

Is there anything that you can say to encourage them or to make it easier on their part? Well, number one, men don't like to go to the doctor. And their partners, if they're female, can be gatekeepers for that. And one of the things that we like to stress is that, number one, taking a history and a physical exam is a painless experience.

So there's no physical exam things that are uncomfortable, things like that. Number two, there are many treatable, reversible causes of male factor infertility. So men are kind of reticent to come in, see a doctor, get examined, things like that.

But generally speaking, it's a safe place. And if there is an underlying issue, the sooner we know that there's a problem, the better. What kinds of things can we do to treat a male factor infertility problem? So generally speaking, where I usually like to start is that we want to rule out a significant medical problem, some underlying problem.

Once or twice a year, a patient will walk into the office with a testicular cancer because they came in with a diagnosis of male factor infertility. So number one, it's not uncommon for us to identify an underlying medical issue. And it could be a cancer of the testicle.

It could be a benign growth of the brain. It could be an underlying genetic issue. But I think it's important if there is an underlying male significant pathology.

The second thing, there are simple things that we can do. So for instance, it's not uncommon for men to come in and have some what I would call situational anxiety relating to sexual activity. Maybe 20% or 30% of couples, when they're told, tonight's the night, honey.

We've got to skip dinner. And we've got to take care of this. Men get anxious.

We kind of stress to them that try to take the edge off of these types of things. Have intimacy not only during the fertile period, but throughout your relationship. And try to take the edge off things.

Most of the time, these issues are either reversible with stress reduction, simple things. And sometimes we need to treat patients with underlying erectile dysfunction. But this is an example of a first step, the conduit problem, getting the sperm to the egg.

So just simple things like that to start out with. That sounds like good advice for a healthy relationship anyway. Yeah, no question.

And we also just stress the concept of being healthy. So we look at lifestyle issues. We look at smoking.

We look at alcohol. We look at marijuana. We look at things like testosterone.

So my feeling is anything in moderation is probably okay. But if you're smoking two packs a day, if you're drinking a significant amount of alcohol, if you're smoking weed every day, these are things that can really make a difference if you have a borderline male factor problem. Now, if your numbers are great and everything is good, these things aren't going to probably make a big difference.

But if you come in and there's an underlying male factor, and there may be a subtle female factor, little changes in lifestyle can make major differences. Little changes in lifestyle can make major differences in whether or not you get pregnant or not, either naturally or otherwise. So what you're saying is these lifestyle factors may not be the only cause, but they might worsen a preexisting cause.

Exactly. So stress in and of itself is not necessarily going to be a problem. All these other lifestyle issues in and of itself may not be a problem.

But if you do have an underlying problem, we'll get to that in a minute, the things that can cause these things, minor differences can make a major difference with a couple in terms of getting pregnant and not. One of the things that we see a lot of now is men who have been put on testosterone. Okay.

And testosterone is essentially a contraceptive for men. So men need to make their own testosterone to make sperm. We see a lot of this as well.

Right. And when a man is on testosterone, whether he's taking it at the gym from his gym rat buddies, or he's been put on it by his internist or his endocrinologist, and unfortunately some urologists will as well and not ask about if they're trying to get pregnant, it'll actually shut off sperm production. Because if you're taking testosterone, the body says, hey, I don't need to make my own testosterone.

I'm getting it on the outside. So it doesn't make its own testosterone. You can go down to sperm counts of zero or close to zero.

And many times if you stop the testosterone, these numbers will bounce back in three or four months and couples will be able to get pregnant naturally. Now sometimes if this has been going on for years, sometimes they have to have medical therapy. So there are other either oral or injectable medical therapy that sometimes can be used to augment patients that have been put on testosterone long term.

Well, that's really good to know. I think that's an important issue of testosterone and fertility. And I think there are some misconceptions out there.

So thank you for clearing that up. I have another question for you. So you typically, you talked about a detailed history and a physical exam, but what other testing is available for the male? So just to go back to the history and the physical.

So we'll want just to talk about the history per se. We want to make sure the couple are just asking things about couple issues. Are they timing intercourse appropriately? Get a little cursory evaluation of the female.

Is there anything in the medical history of significance? Are they on any medications that may affect fertility? Some antihypertensive medicines, some medicines for GI upset with Crohn's disease, things like that. Have they ever been exposed to chemotherapy? It's not uncommon for us to see patients who have had treatment for immunological diseases where they've been on drugs like Cytox. Taking them off these medications and switching them onto similar medications that are not toxic to the sperm can alleviate these problems.

Then we go to things like physical exam and we'll examine the testicles. We'll check for something called a varicocele. Varicoceles are enlarged veins that sit around testicles that in some men can heat up the testicles and affect the sperm.

Now not everyone who has these enlarged veins will necessarily have a fertility problem. But a significant number of men who have fertility problems will have varicose veins around their testicles. And then some men may benefit by fixing these veins and it may improve semen quality and allow them to get pregnant naturally.

Just going back to that blood pressure medication that you mentioned, is there a specific type of blood pressure medication that you recommend against or ones that you would counsel may have more of an impact on fertility? Well the calcium channel blockers have been shown kind of indirectly to affect certain receptors on sperm. So we try to keep people away from calcium channel blockers, things like Norvasc or other drugs. The ACE inhibitors, those aren't too bad.

The diuretics aren't particularly bad. They may affect sexual function to some degree. But generally speaking they're not bad for fertility.

We ask about diabetes. So diabetics actually have pretty good quality sperm, but they tend to have drops in their ejaculate volume. So a man may go from having a high or normal ejaculate volume and over time it may get smaller and smaller and smaller.

And it may actually just be really a coital factor, meaning that the sperm is just not getting where it needs to get to the cervix. So something simple like putting a patient on an over-the-counter medicine like Sudafed. It sounds crazy, but Sudafed's a cold medicine.

But it stimulates the ejaculate volume to increase. And sometimes just simply putting a patient on that may either increase the ejaculate volume. It may change a patient who may be sending sperm back towards the bladder.

It may reverse it back to going forward. If that doesn't work, sometimes you need to resort to things like natural cycle insemination. So we'd send a patient to a reproductive endocrinologist.

They'd collect the semen sample. The volume may be very low, but the numbers and the movement is great. So we just need to get the sperm where it needs to go.

So again, treatable, reversible causes of male factor fertility issues. So definitely reason to visit a urologist sooner rather than later, because I think that's what men need to know is that there are treatable, reversible, causable, reversible causes and things that can be helped relatively simply. Right.

So as part of the evaluation, we talked about the history. We talked about the physical exam. If there is an underlying male factor, and we'll get into what those numbers really mean, we'll usually do a hormonal panel.

So that will include a testosterone, brain hormones called a luteinizing hormone, and follicle stimulating hormone. We'll typically check a level called prolactin, which is a hormone that's released in a portion of the brain called the pituitary. And we typically will check an estradiol level, which is the estrogen level in men.

We know we have a major obesity epidemic in this country. Fat cells will convert testosterone to estrogen, and that can have a negative effect on sperm. And that may not be the only problem, but all these little things may make minor difference, may put them on a medication that will block the conversion of testosterone to estrogen.

Sometimes if their brain hormones, FSH or LH, are on the low normal sign, we can put them on a medicine called clomiphene citrate. Clomiphene citrate is FDA approved for women to make more eggs. It's not FDA approved for men, but we use it off label to increase the brain hormones, which will indirectly increase testosterone, which in a certain number of patients may increase the total number of sperm in the ejaculate.

So you're saying that men... We hope you're finding this episode of SART Fertility Experts helpful. Remember, for more information on this and related topics, visit www.sart.org and click on the tab labeled patients. And now back to SART Fertility Experts.

So you're saying that men might require some blood testing as well to figure out what might be the cause of their infertility? Right. So we usually start with the semen analysis. And generally speaking, there are guidelines for what these numbers are.

And they're actually a series of now at-home sperm tests that if men are interested in taking, they can buy it off Amazon, they can buy it in their drugstore. And you got to be careful with what you're buying there because you have to kind of understand what they're testing. Are they looking for just the count? Are they looking at the volume? Are you looking at the count and the movement on the sperm? So it's somewhat... This is the type of thing that's exciting in our field because it's kind of changing.

But generally speaking, if you look at the male factor, if you look at the average number of sperm in men whose wives are getting pregnant after one year, that number is around basically 95% of people who get their wives pregnant after trying for a year will have counts greater than 15 million. So if your number is 15 million or less, you have a much lower chance, generally speaking, of getting your partner pregnant in the first year. It doesn't really tell us of what goes on in the second year.

Similarly, there are numbers that you can look at for motility, the movement of sperm. So the average in men whose wives are getting pregnant is about 50%, so half the sperm are moving. That number, which is called two standard deviations, 95% of patients who get their wives pregnant within the first year will have sperm movements of 40% or more.

And the total modal number of sperm moving is typically 6 million moving sperm. So those are the kind of cutoffs that we use. And it doesn't mean that if you have numbers less than that, that you can't get your wife pregnant.

And it doesn't mean necessarily that if your numbers are higher than that, that you will necessarily get your wife pregnant. But those are the general cutoffs that we use. And the semen analysis also looks at other things.

It looks at the shape of the sperm. There are different parts of the sperm. There's the head part.

And when you look at the shape, you look at different parts of the head that are important. You look at the mid-portion. That's where all the energy is.

And then the tail. So all these things are important in evaluating the male, the history, the physical, the laboratory, blood testing, and then semen analysis testing. And then we try to put everything together.

We work with the female team, make sure there's not an underlying issue. And we look for things that are either treatable or reversible. And if not, we look at ways to move the sperm closer to the eggs.

So what if the sperm count is low? Or what if the shape of the sperm is abnormal? Are there anything that we can do? Is there anything that you can do about that? Well, it depends. So for instance, fixing a varicocele, if one is identified, is one of the things that will work. 70% of men who have their varicoceles fixed with a minimally invasive procedure will have an improvement in their semen quality.

Sometimes, as we talked about, there can be medication that can be used to increase sperm counts. Sometimes if the volumes are low, we have to figure out why. Is it a problem, an underlying medical problem where the sperm is going the wrong way or the ejaculate is low? Sometimes there can be an underlying issue.

They've had exposures to chemotherapy, radiation, testosterone. And you want to remove the offending agent. And a lot of times you'll see a bounce back in the quality of the sperm.

Or treat an underlying physical bounce back in the quality of the sperm. Or treat an underlying physical problem that can cause these problems as well. So, and do you think it's reasonable for men to use the at-home sperm testing as a first step? Well, I think right now there are three home tests that are FDA approved.

There are other home tests that are out there. Two of them look at count alone. One of them also looks at volume.

The third one looks at moving sperm concentration. So, I think we try to look at it as a screening test. So, if you have, if you are a male and you kind of don't want to go to the doctor and you just want to be tested at home, I think the test that's best out there is the one that tests for both the count and the movement in the sperm.

The modal sperm concentration. So, and if you do that and it's low, that's the point where I think you need to go see a reproductive urologist or seek further treatment. But by the same token, if you are above that normal level, it doesn't absolutely mean that you're quote unquote normal.

So, I think it's a good screening test, but it's not a perfect test. There are false positives, meaning that there are some tests that can show that you're actually worse than you are and you do a sperm test, a formal sperm test, you're actually okay. And you can also have what's called false negatives, which are where you do a test and it comes out normal, but when you do a formal sperm test, it may actually come out being low.

So, you have to be careful about these at-home screening tests. It doesn't look at the shape of the sperm. It doesn't look at other tests.

And you know, one of the other things that we might want to talk about is sophisticated sperm testing above and beyond the standard sperm tests. I would like to hear about that. When is that? Well, I think everyone uses it in a different way.

I try to use it in patients where we don't have a clear answer. So, the female looks fine. The male looks fine.

And on paper, the standard semen analysis looks okay. The numbers are okay. The movement is okay.

The shape is okay. But they're still not getting pregnant. So, in that type of situation, I may offer the patient to have what's called a DNA fragmentation test, where you more critically look at the genetic material, the DNA of the sperm, and how fragile it is, if it's held together appropriately.

In certain situations, there appears to be a, there may be a contribution from the male factor when it comes to, let's say, in vitro fertilization. So, for instance, if you have a couple that is clearly not fertilizing the way most other couples, starting off developing okay, and then they're arresting. There is evolving evidence to suggest that that may be an underlying male factor.

That may be a situation where we would do a DNA test on the ejaculated sperm. And there's kind of evolving evidence that in certain cases, maybe if you get sperm from the testicle, or if you fix their varicocele, or that you're, you may reverse some of their underlying lifestyle issues, that if that changes, that they may either be able to get pregnant naturally, or improve their chances of getting pregnant with in vitro fertilization. So, that's kind of the cutting edge of what we're doing in terms of looking at male factor above and beyond the standard semen analysis testing.

What about older males? We're seeing a lot more older men who want to become fathers coming to us with their wives. And we're just wondering, what else can we do to help them? Well, I think that it used to be thought to be thought that it didn't matter how old you were. If you were 50, 60, 70, 80, or 20, it didn't really matter.

A sperm was a sperm. And what we know now is that unlike egg quality, which drops dramatically, we know that sperm quality does drop, but it drops kind of slowly over age. So, as you hit 35, 40, 45, 50, semen quality does drop over time, specifically the genetic material, the DNA of the sperm, things like that.

So, we try to stress to, we're not recommending men freeze their sperm at age 20. We're not recommending kind of drastic movements, but we're stressing the fact that there may be an underlying issue in a male that's 45 as opposed to 35, or 55 as opposed to 40, things like that. We know that those changes do occur.

What about supplementation? Are there any supplements out there that can? We know that those changes do occur. What about supplementation? Are there any supplements out there that can help men? So, I think that gets into a somewhat controversial issue, because it's so hard to separate out what we call confounding variables. So, if a patient comes in and he's smoking, and he's not eating well, and he's doing this, what's the cause of the problem? Is it the smoking? Is he not eating well? Is he not getting enough sleep? And is he missing any particular supplement? So, there's certain supplements that have been shown in scientific literature to make a difference.

So, for instance, carnitine is good for sperm. Vitamin E is good for sperm. Vitamin C is good for sperm.

A lot of these other supplements that come with tons and tons of other stuff that, if you're eating a relatively healthy diet, you're going to get in your diet, it may be a little bit overkill. I'm not saying that your style improvement is probably just as important as supplements, but I think any supplement that has a reasonable amount of vitamin C, vitamin E, carnitine, L-acetylcarnitine, you really have to look at the package inserts in more detail, because those are the ones, at least as I read the literature, are the most important. Female Speaker 1 What about how can a male reproductive urologist help with the decision-making for IVF or IUIs? So, in vitro fertilization or inseminations? Dr. Michael Soto Well, I think that above and beyond the guidelines that are set for IUI and IVF, we offer two approaches.

One is to either treat the male or go directly to IVF. So, I think, number one, it's important that every man be screened. Make sure he doesn't have a testicular tumor.

Make sure he doesn't have an under-liable, treatable, reversible cause. Once you get to that point and there's no other treatable, reversible causes, I kind of move forward with assisted reproductive technologies. But if there appears to be something that doesn't make sense, as we talked about a little bit earlier, they're not fertilizing well, especially in a female partner where egg quality appears to be good.

They're getting good fertilization, but the embryos are arresting as you move forward. Those are the cases where you have to maybe take a step back and say, hey, maybe there is an underlying male factor that could be a problem. Female Speaker 1 Thank you so much, Dr. Honig.

I really appreciate the opportunity to sit and talk with you today. My pleasure, Kelly.