Video

FAQ: Male factor infertility causes and treatments

11/12/2019

While infertility is often regarded as a female problem, the partner’s role is equally as important, as 40 to 50 percent of all infertility cases are due to male factor infertility. Dr. Paul Shin, Reproductive Urologist at Shady Grove Fertility, answered common questions about male factor infertility. Watch the full interview:

Male factor infertility accounts for upwards of half of couples trying to conceive who can’t. About 40 percent of the time you’ve got a female-related factor, about 40 percent of the time you’re dealing with a male factor, and another 20 percent or so is a combination of the two.

The causes of male factor infertility can really run the gamut from things that people are born with, so congenital abnormalities to different chromosomal issues, to things that can be acquired and can worsen over the course of a man’s lifetime, like testicular tumors, varicose veins, hormone deficiencies, lifestyle-related problems. These are all things that can factor into what a man’s effective sperm count is.

The lifestyle changes are always a little bit of a tricky thing to advise people on and the tack that I usually take with many of my men is to ask them to observe more or less common-sense health measures. In general, when you’re talking about issues of general health and fertility, the two concepts are going to really dovetail pretty nicely together. The things that you know you should do for a healthy lifestyle are all things that are going to promote better fertility. No smoking, get some exercise, try to manage the stress in your life, but things like alcohol use, even tobacco and marijuana consumption, are all dose dependent. If you’re a heavy user almost to the point of abuse or addiction, that’s going to be such an assault on your overall health, that your fertility is going to suffer. However, if you have a glass of wine with your dinner at night, it’s not going to make that big of a difference. I think it’s more of a common-sense lifestyle that I try to propose to people.

In general, I tend to be a bit of a purist in that you really ought to shore up your diet first before you lean a lot on supplements. Eating not as much processed food, more whole food, cooking more at home as opposed to eating out at restaurants. All of these things I think add up to a healthier lifestyle, which in turn is just going to benefit your fertility.

For a lot of reasons. The first reason is that it’s super easy to test men. All you need is a masturbated semen sample, which most men aren’t going to have too much difficulty providing you. We also have the luxury of having so many different labs that men can produce in the privacy of their own home, which is a big deal for them. To walk into a strange place in a laboratory, get shut in a room that there are all these people around and they know what’s going on, so there’s a lot of apprehension amongst men because they have this preconceived notion of what it’s like to go in and give a semen analysis. When you can demystify that and make it available for them to do at home, it’s easy to do.

The biggest reason to get men evaluated early is that when you identify male factor problems, there’s oftentimes things that we can do or intervene to impact a change, but they take months to affect the change. The time that you want to identify a male factor problem is earlier on, so you have more options later on down the line as opposed to getting painted in the corner of having to do something more aggressive.

At baseline and at its most fundamental, the thing that we’re trying to identify with the semen analysis is simply what is a man’s capacity to achieve a natural pregnancy with his female partner. At baseline, that’s the way we’d prefer everybody to do it, right? It’s certainly more fun, it’s more cost effective, it’s more convenient than doing it with the help of medications and injections and shots. Some couples don’t have a choice but what you’re really trying to draw a beat on with that first or second diagnostic semen analysis is – can the guy simply deliver enough or a reasonable amount of motile sperm into the female reproductive tract?

The analogy that I oftentimes would give to people is the female reproductive tract is like this big obstacle course or obstacle race. Just like any other obstacle course, the number of sperm that you start with isn’t always the number that you finish with and so it’s to your benefit to optimize that. The things that we focus on are the ejaculated volume of semen, the overall number of sperm, the percent of sperm that are moving and swimming, how those sperm are shaped or how they look, and then probably the most powerful number in the whole analysis is simply what is the raw number of moving sperm that you have to start with because that’s really going to be your best estimate as to what your potential to move forward is. There’s a lot of variability amongst semen analyses too so oftentimes we’ll want to check one or two just to get an idea of what neighborhood the patient lives in so that we can make our best guess as to how much help the couple is going to need.

Yes and no. It is definitely true that the reproductive decline that men go through as they get older happens over decades as opposed to a handful of years. In general, if you look at a man’s sperm-making capacity as he ages, the count and the number may be affected by things like an enlarged prostate or a diminished semen volume, but a man’s capacity to make sperm should continue throughout most of his adult life. The decline in that function, just like it is for women, can vary. The steepness of that decline can vary, but for the most part, we expect that it’s more of a gradual issue.

As to the question, can a man father pregnancies as he gets older, the answer is absolutely yes. You see examples of that in popular culture everywhere you look, but the subtext is that we are aware of more and more research where the sperm of older men don’t perform as well. The sperm of older men can take longer to get their female partners pregnant and you can have higher rates of miscarriage. When that sperm is put through an ultimate functional test, like in vitro fertilization (IVF), you can sometimes see that that sperm doesn’t function as well, you don’t get as many blastocysts or embryos. There are different clues that as a man reproduces or as a man gets older, his capacity to reproduce does take a little bit of a hit but it’s more of a qualitative look.

The strongest link with the effects of older men really have more to do with things along the neurocognitive end of the spectrum for the offspring. We’re talking about things like Asperger syndrome and autism and even to the point of things like schizophrenia, all have higher incidences in the offspring of older men. Again, we’re talking about more common occurrences of things that are still relatively rare, so I’ve never had it be a major obstacle for men, but it is something that we always talk to men about in terms of counseling because for a lot of those things, early intervention and recognition is really the key. If you can clue them into that ahead of time, it can really help with the development of the child.

Age and male infertility is also a relatively new phenomenon because we’re actually having a generation of fathers at ages that people in the past really didn’t concern themselves with fathering kids. We’re in a stage of really figuring out what those age effects are as well.

The treatment options for male factor infertility span really the range of doing things to improve native sperm counts to help men’s ejaculated counts get better, which will improve natural pregnancy rates or even through IUIs.

There’s also sperm retrieval procedures for men who either don’t produce sperm or who are blocked or obstructed. On the production aspect of things, we treat things like testicular tumors and cancer, varicose veins. These are all surgical things that we do to help to augment men’s sperm counts.

There’s different hormonal treatments that you can offer. One of the big things that we’re seeing more of is men who come in on some form of testosterone replacement therapy that without even knowing it has really impacted their sperm counts. We can work from an endocrine perspective and help those men maintain hormone levels that are reasonable, so they have energy and libido and sex drive while preserving their sperm counts.

Then on the obstructive side of the spectrum, we do reconstructive surgery and microsurgery so that you can reestablish the flow of sperm into the semen. Example being vasectomy reversals but also just sperm retrievals from either the testicle or the epididymis, and freezing that sperm in an IVF cycle. The treatment options that we offer really run the full range from medical intervention all the way to different aspects of surgery.

The interesting thing in reproductive urology is that if you look at the world of medicine, urology is this little black box that most people just don’t want to deal with and they’re happy to send patients into. Then in the world of urology, reproductive urology is this small box within the realm of urologists, so there’s maybe a hundred people in the U.S. that do what I do. We actually have two of them here at Shady Grove Fertility.

One of the main differences is going to be that male factor reproductive problems are exceedingly complex. They run the gamut from things people are born with to correctable lesions to sometimes things that you can’t do anything about. You have to have a wide and varied skill set with regard to how to take care of these couples, but more than anything else, one of the big differences with going to see a reproductive urologist is that we’ll devote the time it takes to really figure these problems out. This is not just a simple five to ten-minute office visit where you adopt one treatment plan and that’s your only option. Oftentimes, couples come in having multiple different pathways that they can follow and there’s so many different factors that need to go into that decision-making, not the least of which is the medical and surgical impact on a guy, what the medical burden is for his female partner, and you also have to factor in cost. Many of the fertility treatments that we can offer sometimes can be very expensive but there’s also a time factor to consider.

As reproductive urologists, we’re trained to think at the end of the line of – how do we help this couple achieve a pregnancy in a manner that makes sense for them, that’s ethically sound for them, and that makes cost-effective sense. I think that’s the difference that sets us apart. Not that we know any more or less urology. It’s like anything else. There’s a certain familiarity that comes with the subject matter with being specialized in it but it’s really having the breadth of knowledge and the time to really put into helping couples solve these problems, which can sometimes be pretty significant.

There are a couple of things that male patients will specifically bring up. The first is that there’s a hefty amount of sexual dysfunction that goes along with infertility and it’s something that no one really likes to talk about. Think about what’s happening. You’re taking something that is fun and elective, and you do it to your choosing and turning it into work. You’re making it a chore; you’re making it number eight on your to-do list of things that you can’t get through number six on. As a result, I make it a real point to talk to a lot of couples, and the guys especially, about things like difficulty maintaining erection and problems with ejaculating or premature ejaculation or just not being in the mood. These are all things that I feel are important to remind patients that it’s part and parcel for going through the infertility process. That intercourse becomes less frequent, it becomes more workman like and that it’s important to address those issues up front because once you have a kid those problems can continue to fester.

I always remind couples that we also have really robust counseling services here at SGF to talk about just the psychological and emotional burden of infertility. We live in an age where we’re instantly connected to a billion people on Instagram who are having babies, we’re subject to our parent’s questions to say where are my grandchildren, what’s wrong with you guys, what’s going on, what’s the holdup? We have a lot of couples come in where that’s a big deal for them psychologically and emotionally and they don’t have any outlet to talk about that. I do try to talk to people about the emotional and psychological toll that infertility has not only on your personal self-esteem, but also for your relationship at large.

One of the other things that really gets to couples about infertility is the lack of control that they have over it. Sometimes, you don’t have a choice in the matter. This isn’t anything that you opted into or out of and when couples find themselves in there, it can really feel like drowning in this sea of information. All these websites and chat rooms that you can go into and get advice and you get this unfiltered advice from everywhere, so it really pays off to talk to reproductive specialists for that reason. To help give you some clarity on what the treatment options are, what is likely to work, what is likely to not, and put it all into some perspective.

SGF’s Center for Male Fertility offers a range of male services including basic evaluation and testing to state-of-the-art microsurgical techniques including varicocele repair, vasectomy reversal, and vasectomy, as well as sperm injection and extraction techniques that have nearly eliminated infertility among couples with a severe male factor.

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