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Male Fertility Mysteries Solved

Medical Contribution By Dr. Melissa Esposito and Michael Tucker,

Thirty percent of couples experience infertility related to a male factor, either alone or in combination with a coexisting female factor. For the affected couple, discovering that they need to seek assistance to get pregnant is often emotionally challenging. Men often react differently than women to the news because of society’s cultural measurements of virility and manhood. The good news is that treatment for male factor infertility is usually successful, often with minor intervention.

Fatherhood, From the Start

A crucial element of successful fertility treatment is that both partners are equally involved in the diagnostic and treatment processes. Proceeding toward treatment without first taking a diagnostic look at both partners’ fertility status will likely result in wasted time, energy, and money.

Though men don’t often want to hear it, the fact is that the semen analysis is one of the first tasks to accomplish in diagnosing the cause of infertility (along with the preliminary testing of the female). It may not be a pleasant test to consider, and it truly is not what any individual has in mind when thinking about making babies, but the semen analysis is the best test in its ability to rapidly and inexpensively detect problems with male infertility.

The often heard phrase “sperm count” is actually only one important component of male fertility. It refers to the concentration of sperm per milliliter (ml). This aspect of a man’s results can impact the type of treatment recommended but, as Shady Grove Fertility’s Dr. Melissa Esposito explains, “There’s no definite count where we’ll say you must use IVF or IUI. It’s really a combination of the multiple semen analysis parameters that we measure.”

The other important parameters besides the number of sperm cells are their shape (morphology) and movement (motility). In fact, even men with zero sperm count (called azoospermia) can often have conception success through various sperm extraction techniques and in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI- a procedure where a sperm can be injected into an egg to try and achieve fertilization), if indeed healthy sperm cells can be found.

As with other health conditions, the definition of “average” plays a part in diagnosis and treatment. The World Health Organization long ago established reference standards for “normal” semen analysis parameters that are widely respected. Dr. Esposito and her colleagues occasionally review the lab results brought in by patients who had their semen analysis done elsewhere. The numbers can be misleading, especially for people without medical training. “Not all labs use WHO criteria and parameters. Some may not even test for morphology, for example. So we encourage patients to use Shady Grove’s andrology lab if at all possible.”

Dr. Esposito discusses the importance of taking all criteria into account. “We look at all of the parameters in relationship with each other — count, motility, morphology, and also, volume. For example, some men can produce four to five milliliters of ejaculate, which is considered more than average (2 mls is the norm). Let’s say they have a count of 10 million sperm per ml. If they have good overall parameters, and would be left with more than 5 million total motile sperm after the sperm wash (the procedure done for IUI), then they may benefit from IUI despite the initial low count. But if they have a good count, but less than 1 ml ejaculate and low motility and morphology, then they may have a low total motile sperm count after the sperm wash and need something more in the way of treatment.”

Some important points to understand about semen analysis:

  • Because the normally functioning male body is constantly producing new sperm cells, a single “negative” test may not be the most reliable indicator of a man’s true fertility status. As with all other health systems, the reproductive system is impacted by lifestyle issues such as stress, nutrition, sleep, and illness.
  • A test that is poorly run — subject to human and lab errors — can render inaccurate findings. Examples of test problems include: too much time passing between the patient procuring the sample and the lab running the test; and labs using more general, non-fertility focused parameters for results.
  • For the above reasons, many patients are asked to undergo subsequent semen analyses for accuracy.

In many cases, the semen sample for analysis or, later, for prescribed fertility treatment can be obtained in privacy at the patient’s home, so long as it can then be transported in relatively warm conditions and within about an hour’s time to the lab. Regarding the use of semen for treatment, cases warranting special attention — such as for men whose jobs require travel that conflicts with scheduled treatment dates — can even make use of previously frozen samples.

Urological Approach to Better Family Health

For some men, finding the answers to their infertility leads serendipitously to better overall health. When the situation warrants it, Shady Grove Fertility’s reproductive specialists refer patients to a team of urologists who specialize in male infertility. An example would be a couple with severe male factor for unknown reasons. Some couples, Dr. Esposito says, simply don’t want to pursue aggressive therapy like IVF and may have a male factor issue that can be corrected by a urologist.

Dr. Esposito details how seeing a urologist can result in more than just assistance with fertility issues. “Virtually any patient with azoospermia or severe male factor infertility will be referred to the urology team. The urology exam can determine, for example in an azoospermic patient, if there’s an absence of the vas deferens (part of the male reproductive tube system), so then we know that we need to test for the cystic fibrosis gene to see if there are any mutations.” Men with congenital absence of vas deferens (CBAVD) often also carry the risk of transmitting cystic fibrosis genetically to their offspring if their wives also carry the gene mutation.

Even prior to urology referral, though, Shady Grove’s doctors will test all men with azoospermia and some cases of oligospermia (very low sperm count) for genetic conditions that can not only stand in the way of fertility but can also impact the health of their children.

High-Tech Conception Help

Depending on the diagnosis, there are a variety of techniques to treat male factor infertility. Problem areas can be roughly grouped thus:

  • barriers to sperm cell transport and delivery
  • barriers to sperm production

Treatment can either focus on the individual problematic condition, such as repairing a varicocele to promote higher quality of future sperm cells produced, or treatment can be used to bypass the condition, which is essentially the effect of ICSI with IVF. Patients will likely hear their condition referred to as either obstructive or non-obstructive or, in fewer cases, neurogenic. Neurogenic reasons for infertility would be related to nerve damage, such as for men with spinal cord injury or complications of diabetes.

In addition to ICSI with IVF, other treatment options that may be considered are:

  • Vasectomy reversal
  • Varicocele ligation
  • Microsurgical repair of obstructions
  • Electroejaculation
  • Several methods of sperm retrieval, both surgical and needle-aspiration
  • Intrauterine insemination (IUI)

Male reproductive surgery can be used to clear the path, which is made up of several different sections of tiny tubing, for sperm cells. In cases of severe oligospermia (low sperm count) or azoospermia (no sperm in ejaculate), cells can be retrieved through a variety of sperm aspiration techniques.

Medical treatment is sometimes recommended for less severe cases of sperm quantity and quality issues. Therapeutic level hormones and antioxidants may be prescribed, or antibiotics if infection is found to be a factor.

Cellular Level Experts

The laboratory is an important component in the treatment of male factor infertility, particularly since treatment has successfully been narrowed down to the cellular level.

Michael Tucker, PhD, Director of Shady Grove Fertility’s IVF and Embryology Laboratory, pioneered ICSI over fifteen years ago. The cell-by-cell conception technique remains the predominant successful treatment for male factor infertility resulting from myriad causes.

“ICSI is the standard for enabling us to take a small number of sperm and be able to fertilize however many eggs the patient has available,” says Tucker, “but there’s been a change in thinking about it as we’ve learned more about male infertility. Early on, we thought all we needed was one sperm, just any one cell, to make ICSI work. You can, in fact, have pregnancy success with technically dead sperm cells in mice, but no one’s ventured to attempt it in humans routinely. So now, we know more about how much sperm quality really counts.”

The result is that Shady Grove’s lab staff and clinicians work together more to try and find those healthy sperm cells. Sometimes that means going to the point of cell production — the testicle. Sperm removed directly from the testes are often healthier than those that have traveled all the way through the male reproductive tubing and urethra.

Highly sophisticated equipment now allows increased magnification and a better perspective of individual cells by lab scientists. “More than just whether or not a sperm is moving,” Tucker details, “we can really focus now on apparent qualities of them. Defects in the head morphology, in particular, can indicate potential problems. For example, very generally, smaller sperm heads are often lacking DNA, whereas unusually large ones are often diploid and have too many chromosomes. We also assume that misshapen heads may be a manifestation of underlying poor quality.”

A key area that is now being analyzed beyond what lab staff can see with their state-of-the-art optical equipment is actually measuring the DNA integrity. “That’s a sort of catch-all term for the amount of fragmentation of the DNA in cells,” Tucker explains. “For example, if a man is taking chemo-toxic or recreational drugs, or is a frequent user of hot tubs, we’re finding a deleterious effect on the production of sperm itself. That often registers in terms of the health of the sperm’s DNA.”

Semen samples can be tested for DNA integrity at specific laboratories, and Tucker believes there may even be home-testing for the fertility indicator in the future.

Today’s high tech fertility labs might resemble a computer gamer’s dream. The Lab Director describes the equipment of his profession. “We use joysticks, micro-manipulators, tiny glass micro-tools, hollow needles.”

“We’re talking about holding an egg that’s only about 120 microns across. The tool that holds it measures about 100 microns across, about a tenth of a millimeter. The sperm head is about 3 to 3.5 microns across, the length of the head is about five microns, while the tail is a good 20 to 30 microns long. The tool used to pick up the sperm and push it into the egg cell is about seven to eight microns across.”

Tucker says that his technical field that demands the highest level of skill has done nothing but improve over the years. “Not only our fertilization rate, which has crept up, but the overall level of damage [to cells manipulated in the lab] seen annually has dropped off.” He believes that one factor in the improved quality of embryo quality resulting from ICSI-fertilized eggs is testament to the increase in skill. “We’ve honed the process over the past decade, not unlike any surgeon whose skills get better with time and experience.”

The diagnosis and treatment of male fertility problems has improved significantly over the past couple of decades, to the point that pregnancy success is the most usual result. The scientific and technological advances have interacted in tandem to develop a wide array of answers to the perplexing questions of what stands in the way of reproduction for many men.


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    March 9, 2018 - 12:33 pm

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  4. cyril osereme

    July 11, 2017 - 11:14 am

    I have just been diagnosed with a low sperm count before a planned IUI therapy for my wife. Are there any drugs i can take to boost it before undertaking this therapy.

    • Shady Grove Fertility

      July 11, 2017 - 11:40 am

      Hi Cyril – It may be dependent on the cause of your low sperm count, but your physician may recommend vitamins as well as ensuring you are maintaining a healthy lifestyle. Some drugs that seem like they would have a positive result on sperm count (such as low-testosterone medication) often have the opposite effect and your physician would likely recommend avoiding that type of medication while you are trying to conceive. Please consult with your physician to see what recommendations they have for your individual case.

      If you are interested in learning more about treatment at SGF, please call 1-877-971-7755 or submit a contact form at https://www.shadygrovefertility.com/appointment.

  5. arun

    June 12, 2017 - 1:22 pm

    Exactly you have solved the infertility mysteries very well…thanks

  6. gladwellmakumi

    May 8, 2017 - 11:36 am

    My hubby has a low sperm count(oligospermia) is there hope for us to have a kid naturally. So much worried

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  8. faithharry

    December 26, 2016 - 8:19 am

    Low sperm count was one of the problem my husband suffered for three years, the doctor gave him Gonal-F subcutaneous and clomiphene citrate which was not working.until I told a friend about it, We search the internet and got the contact of Dr John ewoig. I made purchase of the product which I use for two weeks, and the problem of low sperm count was over. Thanks to dr john. His herbal is the only permanent cure to low sperm count and weak erection, You can always contact the Doctor through his email for more information.

  9. paul

    September 8, 2016 - 2:35 pm

    Maybe you’d like a male perspective? Sorry but I’ve been reading stuff here and found it useful as i am now a proud father of two kids..
    To cut a long story short, I am 40 years old and when I was 35ish I tried for a year with my ex with no joy. I had all the tests, e.g. from 2011:
    Total count 14m
    Motility 45%
    Normal forms 1%
    I was told it would be very difficult to have a successful natural conception. The pressure and constant disappointment got to my wife and we ended up separating a year later.few months later i had a new partner and a doctor told us about Dr John and his medications,we contacted him through his email account (johnsammuel95@gmail.com) and bought some of his drugs.Few months later my wife took in and now i am a proud father of two kids thanks to Dr john sammuel.Please do not die in silence contact Dr john

  10. williams Brown

    August 30, 2016 - 1:21 pm

    I was married in March and wanted children fairly quickly, so in June,My wife stopped taking birth control. Two years later without a pregnancy, my General Practitioner suggested a fertility consultation. We were referred to Dr.Larry Mcgregor, and our first visit was in November. We were told that because of a low sperm count, IVF would be our best option. We had prepared ourselves to hear that, but it was still scary – and we were very concerned about the cost because, like most insurance plans, ours covered diagnostic testing, but didn’t cover the actual IVF procedures or any of the drugs. But we were pleasantly surprised to find out that John’s costs was much more affordable than we had read online. Why are people paying so much in other places and big cities?

    We were ready but needed to delay so I could get settled into a new job. However, when we returned in January, we learned that a test suggested low ovarian reserve– meaning my wife’s egg count was very low for someone her age, and there was a possibility she could go into menopause sooner. That wasn’t a certainty, but it was devastating to think that I might never be able to have children of our own, so we decided to start the IVF process right away. The idea of giving herself a shot every night was scary, but the staff members at Dr.Larry’s are incredibly supportive and empathetic. They made themselves available to us at all hours in case we had questions or concerns. In mid-February, we made the short trip to Pensacola for the egg retrieval and lucky to have found 12 eggs. Eleven were mature, and 9 fertilized. We were thrilled, and it seemed that the staff was just as excited for us as we were! Five days later we went back to have two embryos transferred. All of the procedures were quick and painless, and we even got to watch our “babies” go into her uterus on ultrasound. It was amazing!

    Only 10 days later we got the news we’d been dreaming of for almost three years – we were pregnant! Just two weeks later we saw the heartbeat by ultrasound. Our son was born on October 20th, perfectly healthy and weighing 6 lbs 4 oz.

    The uncertainty of infertility was stressful and scary, but Dr.Larry’s Medications were helpful and makes the process easy.I’m not sure that we would have had the same experience and outcome had we gone somewhere else, and we recommend Dr.Larry’s Medication to anyone who is having issues conceiving.Please do not die in silence,contact Dr. Larry at Larrymcgregor414@yahoo.com

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