SART Fertility Experts - Urology and Male Reproductive Health

Male infertility is less often discussed than female infertility. Dr. Ajay Nangia, a urologist specializing in male infertility, discusses when a man should seek help with conceiving, what constitutes a "normal" semen analysis, and what treatments are available to help men dealing with infertility create the family they desire.

Hi, this is Dr. Bill Petok, here for SART Fertility Experts. My guest is Dr. Ajay Nangia, Professor and Vice Chair of Urology at the University of Kansas Medical School. Dr. Nangia, thank you very much for joining us for a discussion about men's fertility.

Thank you for having me. It's our pleasure. Dr. Nangia, when should a man see a urologist about fertility issues? So the definition of infertility in the United States is one year of trying naturally with their partner.

And beyond that point, then they should be probably evaluated. Sometimes that can be adjusted if there are issues of male and female age that they want to expedite their workup. In Europe, though, the definition of infertility is actually two years.

And part of that is related to the statistics that approximately 85% of couples achieve a pregnancy by one year and half of the remaining 15% achieve it in their second year, so another 7.5%. So in a mandated world, sometimes they want to maximize natural before paying for assisted reproduction. The U.S. doesn't have a mandate per se, other than somewhat in about 15 states. But nevertheless, the ASRM, American Society for Reproductive Medicine definition is one year.

And so by that point, or if they have other issues, as I said, not just male age or female age, but obviously a vasectomy that would require not waiting a year. And if they had other known diseases, they've had chemotherapy, or they've had history of testicular trauma or cancer, sometimes that would warrant progressing much, much earlier when they already know there was a compromise to their potential fertility. When a man does go to see a urologist about fertility issues, would it be usual for the doctor to recommend a semen analysis? Yes.

I think what's important, though, to always remember, and this comes out straight out of medical school, is 80% of a diagnosis is actually made from a history, 20% from a physical. And of course, maybe that's the initial part in terms of creating differentials. But yes, of course, laboratory testing is important.

But I like to tell everybody that a man is not a semen analysis, infertility is not a semen analysis. And as such, although yes, we do need a baseline semen analysis, but the important part is the history and the physical, and therefore defining everything from timing to pre-existing conditions or medications and issues of, God forbid, missing testicles on the exam. That may not require a semen analysis.

Sometimes testicular cancer men show up or equally a vasectomy. The semen analysis may not be appropriate. But generally in people who have not had all of those kind of pre-existing concerns, and yes, a semen analysis is the next step.

Now, you mentioned timing, and I wonder if you could tell us a little bit more about what you mean by that. So this is becoming actually an interesting research question of mine. And many of my research questions come from clinical practice.

And over the years, which now is nearly 25 years of practice, I have discovered one important thing that people do not know about the birds and the bees. And in that light, I mean, yes, we all kind of giggle when we first learn that to have babies, you have to have sex and intercourse, penis and vagina kind of thing. But nobody then teaches very well on how to have a child.

And some of that is off the playground like we used to do in the old days and now through the internet. But timing of intercourse to have a child can occur when people have a lot of random sex over a period of month. Fine.

Yes, those are the ones that are, you know, don't aren't planned necessarily and happen. Like oops, babies is what I call it. But when someone is actively trying and having and planning their life, and trying to time their intercourse to have a potential child nine months later, then they need to understand that first of all, what's going on on the female cycle events, meaning what's the definition of a cycle from the beginning of the period to the one that starts? They don't always know that.

When is the middle of the month in a 28 day cycle? Is that ovulation? Well, if they learn any basic biology, maybe they would know that but not necessarily these days. I don't know what they teach in high school and junior college or college, but needless to say, they don't always know that. So it would be very helpful to have a conversation with your urologist as well as your partners OBGYN about when is the appropriate time to have intercourse.

Absolutely. I think that, believe it or not, as much as one can learn it from the internet, one of the things in our research study we're finding is products on the market, apps that define ovulation, what there is on the internet in terms of telling you that. At the end of the day, I actually go by Optimizing Natural Fertility by the American Society of Reproductive Medicine.

And there's a fact sheet for couples to go to that website, maybe before they even have trouble and go follow those guidelines, everything from timing, as I indicated, starting before ovulation every other day, to lubricants or not lubricants, to things to not use like hot tubs and bathtubs, to toxins. So they're all actually well described in a fact sheet by the American Society for Reproductive Medicine. That would be available to ASRM.org? Correct.

Absolutely. Thank you. So let me come back to semen analysis.

And obviously, as you said, a good history and a physical examination would be important before doing a semen analysis. And could you briefly review for us what are normal semen parameters? And then what might cause those things to be abnormal? So I have this conversation every day, virtually. And my biggest fundamental discussion is about what this word normal means.

I don't like that word, actually. Okay, it's a reference value. All right.

And here's the reason why the word normal doesn't work. Okay, because no normal number exists for any, you know, for the male species, so to speak, there is a range. And I kind of go into a little bit of detail of this to explain to patients that the WHO created this criteria based on, you know, nearly 8-900 men who achieved a pregnancy within one year, i.e. within the definition of fertility, and then just graphed it out and proved that there is a spread, quite a large spread where the fifth percentile, 50th percentile, meaning when 95% of people are higher than that to 50% of people are higher, and you kind of graph it out.

And unfortunately, what happens in the world of reference values is you cannot use the whole range for what's considered normal. You have to create a statistical starting point, a kind of a line in the sand, if you will. And we talk about the fifth percentile, which means this statistically everything's in the 5% kind of world.

So anything above numbers that are 5% below and 95% above is where the cutoff, the peak cutoff of a reference value in this case begins. And that is 1.5 milliliters, 15 million per cc, 40% motility, 4% normal forms. And that's all created statistically from this group of, if you will, fertile men.

Now, the important thing, though, I have to just highlight is the definition of those values was for fertile men. In a man who has normal values based on those reference values, who has gone beyond a year, technically those values are not totally as relevant. There could be a functional problem of the sperm, right? The definition of normal, which I hate, as I said, or reference value is when normal fertility occurs.

So even a man with a normal sperm count based on those reference values, who has taken more than a year to achieve a pregnancy, cannot 100% say that those numbers are normal. So I guess it's fair to say that since it only takes one sperm, those normal values are less important than getting the sperm to the egg. That's right.

It's the way the sperm gets to the egg. And again, it's amazing it ever happens. It really truly amazes me that anyone ever gets pregnant, to be honest.

But 1 in 70 to a 700,000 sperm make it beyond the vagina slash cervix to the fallopian tube. 1 in 700,000, 70 to 700,000, depending on what literature you read. And some of this is old literature, right? And then at some point in the fallopian tube, fertilization has to occur, where, as I described to couples, a sperm is like the blade of grass on a football field, okay? And the length of the fallopian tube is the length of the football field, all right? And the egg is the size of a football, all right? Somehow in all of that, the blade of grass finds the football.

And it's got lots of, it's not a straight shot either. It's a miracle that the, you know, the beacon, as I call it, the acrosome of the sperm or finding the sperm, sorry, finding the egg, and a kind of a chemotaxic, meaning it uses a chemical pathway, they think, as a beacon to find the egg. It's really amazing.

So the functionality of that sperm and things then like DNA fragmentation or reactive oxygen species do play a role. Immunological abnormalities of the uterus can play a role and attack the sperm. The sperm can only live for 24, 48 hours in the best environment where it's not hostile in the middle of the month, so to speak.

And so it's not just the number, it's getting enough, you know, to the egg, you know, sperm don't ask for directions, as they say. And, you know, they need a lot of them to get there. You mentioned something before, and that was vasectomy.

Obviously, many men have a vasectomy to prevent conception. And at some point, they may decide that they now want to have children again. What can be done for a vasectomy that has taken place? Can it be reversed? And how difficult is it to do that? Yes.

And just to put that into perspective, just in the US, nearly five, 600,000 vasectomies are done. And that only accounts for about 11% of the contraception done in this country. But nevertheless, about 6% of men consider having it reversed.

And this is, again, old data, but nevertheless. And in that equation, then the question is, that needs to be considered is how many years from vasectomy? How old is the female partner? Are there any female factors? Are there any male factors associated with vasectomy? And what we're starting to see is men who've had a vasectomy, then happen to be on testosterone, which inhibits or prevents sperm production. So that has to be stopped and then rebooted in terms of the testicular function.

But needless to say, when man has had a vasectomy, the obvious consideration is you can reverse it. It's using microsurgery, it can take three and a half, four hours. It's using very, very thin stitches, nylon, that are smaller than a human hair, and using a very big microscope, many times much bigger than what you see in Grey's Anatomy on TV, with those lenses on the glasses.

This is up to 20 to 25 times the magnification. And the reconnection is complicated, it's detailed, it takes skill, and it's very doable. And the statistics on does it work, is absolutely it does work, but it has to be, again, based on some variables, i.e. the length of time from vasectomy, blockage further back into the back of the testicle called the epididymis, and the female age, as I said.

And there are good statistics, actually based on an old study, but again, of a large number of patients that were studied, and the groups of men were subdivided by length, how long they were from their vasectomy, and anything from 75% to 15 or 20%. And unfortunately, yes, could go down to zero if they're scarring. Well, let me interrupt you for a second and say a man chooses that that's a bad option for him, the cost, the length of time he might have to wait into finding out if it works.

Is there another option for a man who's had a vasectomy, who wants to conceive a child with his own sperm? Yes. So, you know, again, I've been taught by very ethical mentors and Dr. Anthony Thomas from Cleveland Clinic used to say, when I was with him, there are five or five ways a person post vasectomy can have a child. There are two that are biological.

One is a vasectomy reversal, meaning his sperm and getting his partner pregnant naturally. And then there is the ability to do in vitro fertilization, a specific type called intracytoplasmic sperm injection (ICSI), where we can get sperm from the testicle or the epididymis without undoing the vasectomy and sticking one sperm into each egg outside the body, of course, from the female partner, and then divides outside the body, and then they put it back about five days nowadays into the partner. So that's the in vitro method that bypasses, but yet is, of course, biological.

Now, just to be complete, though, I always talk to couples about donor sperm as an alternative, adoption as an alternative, foster care as an alternative, or of course, do nothing. Sometimes they're here just to talk about it and don't want to pursue anything. But if a man wants to use his own sperm, a couple wants to use their own sperm, it sounds like there are two options.

That would be a vasectomy reversal or one of these surgical procedures to remove sperm and then do ICSI, as you said. That's right, exactly. You mentioned something earlier about lubricants, and we know that many couples use lubrication to make sex more comfortable for them.

Are there issues with lubricants in male fertility? Yes, in general, I guess. Absolutely. You know, again, going back to some fundamentals about the birds and the bees, you know, the vaginal pH changes from being acidic and hostile, which is a defense mechanism and anti-infection mechanism, to being alkaline in the middle of the month.

And the mucus changes in the cervix and in the vagina as well. It's called mittelschmerz. So the environment is better on a pH level in the middle of the month with natural lubrication.

Now, if they need some support, because often, unfortunately, getting pregnant is a bit of a chore, it's not like an act of making love, but even though they have to time this, they're tired at the end of the day, they have to, you know, they're having sex to have sperm delivered and have sex to have a baby, not just to have lovemaking. And in so doing, lubrication can be a little bit less efficient naturally. And that's when one could say, well, what about average lubricants out on the shelf in a pharmacy? Well, often they have products in them that are designed to prevent them breaking down, obviously, and be disinfected in their own rights and not cause them, like, you know, KY jelly is not because I have any concerns or problems with it, but it's in a carrier which has hydrochloric acid that's not the good thing, kills the sperm.

So they have to be sperm-friendly lubricants of which there are only one or two, and not just the act of lubrication to make it concerning or friction for the couple. So the pH of that lubricant matters. And then some of them have to be validated to prove they don't kill sperm.

And that's actually been done with a couple of them on the market and ones I recommend when they come in, knowing that they're having trouble. A man and woman could then talk with you or someone like you to get advice about which kind of lubricant would be best for them if they're trying to achieve a pregnancy. Exactly.

Very good. You know, you've mentioned an awful lot of things that can inhibit pregnancy that involve men. And I would imagine that giving that news to a man that he has problems that are physical, either with his sperm or with the way the sperm is going to get to the egg can be quite troubling.

Can you tell us a little bit about how you counsel men under those circumstances? Yes. And that's actually a very good question. I think what we forget as clinicians is sometimes we can talk in med speak all we want.

But at the end of the day, someone who doesn't know medicine, like I don't know the mechanics of my car is listening. And in so doing, they're like, you know, what, what, what, what, what? They're not actually hearing much. And they're like, oh, my God, there's a problem.

And I've affected my manhood. I'm not a I'm not going to be a good father. I'm not going to be able to be a father.

My machismo, everything that makes me virile is being challenged right now. And all of a sudden, they're like in kind of mental defensive mode, or in shock, or it's too embarrassing for them, because no one ever talks to men like often ladies talk to each other, because we're not exposed to this. Everything we do as a child, as a male child, is kind of, you know, kind of slap on the back, you know, making fun of each other, you know, machismo, you know, never show any signs of weakness.

So then to talk about your penis and your testicles to a doctor is so like, alien, and let alone being examined, whereas young ladies and women expect it from the day they have their breast exams and their pap smears. We don't have any of that until some, you know, doctor ends up seeing you for this kind of problem. And so they're kind of in deer in headlights a lot of times.

And so they're in kind of denial mode and shock mode and embarrassed mode. And so getting through to them many times, you can't use words like low, or zero, I mean, you can use zero, sometimes you have to use words, but low, it kind of it just has a derogatory, you know, but it kind of makes people feel inadequate. So I say words like decreased, or they're not swimming as well, or whatever.

And I always have to make sure that they realize that it's not the be all and end all of the problem. I mean, they get terribly focused on I, I thought about something bad once, and I did something bad once. And is this the guilt that I'm going to pay the price for now? And I'm like, no, it's not your fault.

You know, kind of Good Will Hunting kind of style. I'm like, I really tried to explain to them that this is a couple's problem. And not a single person is blamed, as I like to call it, and they'd like to, unfortunately, sometimes think like that, that they feel that burden is now on them.

And I have to say, Look, no, nothing ever happens without both of you. And you have to be each other's support structure, you for your wife or partner, whatever. And similarly, the other way around, and we'll get through this.

And when they start relaxing, and realizing you're not the enemy, so to speak, or you're not there to belittle them, then often, they relax, open up, maybe explain a little bit more. I calm them down, I reassure them, I kind of do absolution on them and say, Look, no, it's not that one joint you smoked in college. That's not the problem.

Sometimes No, no, it's not the one time you had STD. When you were in college, you know, it can be but not like that often, it's, you know, caused a bad infection and stuff. And, you know, and often, interestingly enough, in the guys who've had a vasectomy, do they, of course, really want a child, right? Or are they doing it for their partner, and I have to make sure that they really do and they want to be a potential father, and I kind of call it the social work of medicine, and that this is a union of their love, and they really understand the concept of what they're trying to do.

And, you know, kind of really get under the under the skin in the sense of being intimate. So it sounds like what you're saying is that when a man sees a urologist, he should be able to anticipate two or three different things. One is a good consultation, a good evaluation, a good history, a good physical exam, a good explanation of what possible things may be getting in the way of achieving a pregnancy, and an understanding here that this is a team project, that your job is to help him, and that you understand that there may be psychological insults, if you will, when you discover that you've got a fertility problem, and that you're there to work with him to get him through all the way through to the other side.

Exactly, that all that summary is exact. Very good. Are there other nuggets that you would want a man to know, listening to this podcast, who's trying to understand male infertility? So, you know, not that misery loves company, but, you know, everyone's got problems.

Everyone thinks that they're, you know, it's better on the other side. And, you know, I mean, I know how brains work somewhat. But just remember, you're not alone.

15 million couples, that doesn't make any better. But just to know that a lot of people struggle with this more than you think. On top of which, it's not a blame game, right? It's not a blame game.

It is a discovery of the situation to be positive and trying to move their lives forward to have children. I think some myth busting has to happen. Boxes or briefs doesn't make a really big difference.

Hot tubs and bathtubs, yeah, that does make a difference. If you stop drugs, smoking, yes, there's some degree of that. Usually, what I say is if it hurts, you know, your brain, and you get a hangover, it's probably hurting your testicles too, because that's the other brain.

So in many ways, you know, these simple things, and timing and education, and really, really, really doing what I said is kind of an absolution. In many times where all right, even if they've something stupid along the way, or had some disease, you know, the fact that you can take away a sense of guilt or blame is a huge weight off their shoulders, right? That you're on their side, and that they're not alone. And you know, I hate to say it, fertility for a young couple is like an older person getting cancer.

You know, it's really a horrible, horrible diagnosis that gnaws into your soul. And here we have Mother's Day coming up. And I will tell you that I never thought of Mother's Day as a negative day.

Until one day, someone said, What about all the people who have not been able to have children? Sure. What do you think Mother's Day and Father's Day feels to them? You're right. And I just totally blew my mind.

I'm like, Oh, my goodness. You know, it's a joy, joyous day, hopefully to celebrate mothers and fathers. Everyone does have one last time I checked, you know, for good or for bad, and to really be their champion, and to help them navigate what I call a roller coaster every month that goes by.

So you're really looking for, when you're looking for a urologist to help you with a male factor problem, you're looking for somebody who's going to be part of a team to help you find a solution, I guess is what you're saying. Absolutely. I think the one thing we always forget, it's not them and us.

It's not the male side or the female side. It's not the female gynecologist who don't care about the male partner, or you're a sperm number, right, which that should not be the case. The reason why urologists who specialize in reproduction do well, is they work as a team with the gynecologist.

So because the end product is the outcome for the couple, not because of our own turf war. I guess really the most important players on the team are the man and his partner. That's right.

And that and that, and that everybody else is there to help them achieve their goals, right? It's very much a factor that you don't want to play leapfrog, you don't want to ignore one partner, you don't ignore one partner, you know, and you really realize that you've got to do a workup on both partners, since you know, 50 plus percent is both partners, many times. And I think the fact that reproduction is unique that way, right? Even though there may be technically or may not be what I hate the word there are the patient, but both of them are your patients. So I guess, you know, for the man who is listening to this podcast, who is your average patient who's seeking to create a family, and has walked into your office or a colleagues like your office, the takeaway message is, there are people who are well trained who are ready to help you.

And there are multiple things that need to be evaluated in order to give you the best outcome. Would that be fair? Very fair. Very good.

Dr. Nangia, I want to thank you for joining us on SART Fertility Experts. We really appreciate your knowledge and your insight into this problem, which affects so many people. My pleasure.

Thanks for having me. The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates. These are provided as a source of general information and are not a substitute for consultation with a physician.