Valley Health Magazine

By Michael Synn, M.D.

Millions of men in the United States struggle with reproductive issues. They, along with their partners, probably never expected to have fertility issues in their lives. Child bearing was most likely the last thing on their minds when they were younger. But, as grown-ups, having children is thought to be a natural thing and a personal right for many couples. When difficulties do develop, that’s when most people start to wonder, “What’s going on? Could there be something wrong with me?”

In the January 2008 issue of Valley Health Magazine, “Bringing Home Baby – Treating Infertility,” by Dr. Gail Newel reviewed the various aspects of infertility/subfertility and the different treatments available for couples who are struggling with this condition. Newel crafted a straightforward and empathetic look at the background, classifications, origins, evaluations, and treatment options for infertility/subfertility as they pertain to women. This article will focus on the opposing aspect of infertility – the male factor.

This is a very common problem.  About 1 out of every 5 reproductive age couples in the United States have problems with becoming pregnant. For these 10 million couples in our country experiencing difficulties conceiving, about half of them have some form of male factor issues involved. Thus, the popular notion that “It can’t be me, it must be her” is often wrong. Men must overcome any reluctance to consider themselves as part of the problem and be brought into this equation; and they must be active participants in its solution.

Easier said than done. When this occurs, most men have a tough time dealing with their condition. It is not easy accepting a problem with fertility. It can affect self-esteem, sense of masculinity, emotions, and relationships. The treatments are often time-consuming and frustrating. In fact, dealing with fertility issues is so difficult, only 1 out of every 4 couples will actually seek treatment. The good news is, about 70% of couples receiving treatment will ultimately become pregnant. Therefore, we need to do a better job of supporting men and women dealing with infertility, and encourage them to seek medical care so their dream of having children has the best chance of becoming a reality.

It’s probably surprising to most people that a very fertile man and a very fertile woman have only about a 20% chance of conceiving in any particular menstrual cycle. Human beings are very complex creatures and as such, their reproductive processes are quite complex as well. This results in a relatively low fertility (or fecundibility) rate. On average, most fertile couples will take about 3-5 months to naturally conceive when they want to get pregnant.

The definition of infertility/subfertility is the inability to become pregnant after one year of unprotected sex. Couples with infertility/subfertillity have about a 1 to 4 % chance of becoming pregnant each cycle they are attempting conception on their own. The various treatments available have success rates ranging from about 8 to 40% per cycle, depending on the nature of the treatments. So it is easy to see that it may take several attempts before a successful treatment cycle occurs.

The basic fertility evaluation for a man includes a good review of his medical history and a physical examination. A history of chronic medical conditions like hypertension or diabetes, sexually transmitted diseases, cancer treatments, abdominal or urologic surgeries, use of steroids or medications, mumps after puberty, certain genetic conditions like cystic fibrosis, may cause male infertility. Examination may detect a varicocele (a varicose vein around the testicle), undescended testis (testis not in normal position in the scrotum), atrophic testis (a possible genetic problem), or other possible causes of male infertility.

The first diagnostic test to determine whether a male factor exists is a semen analysis. A determination of sperm concentration (count), motility (how much movement) and morphology (shape) is done. It is very important that this sample is taken to a center with personnel that are experienced in performing and interpreting this test. A wide range of results could end up in unnecessary or sometimes inappropriate treatments. If an abnormal test result is found, then male factor infertility/subfertility is diagnosed and treatments by a reproductive urologist or andrologist (male fertility specialist) may be indicated.

Conservative measures include avoidance of prolonged exposure to high heat, alcohol, tobacco, drugs, pesticides, and other toxins. So, no “tighty whities”, prolonged time in hot tubs or hot showers,  or partaking other “fun” habits such as bike riding are required. Studies have shown a diet rich in anti-oxidants promotes sperm quality as do folate, selenium, and zinc supplements.

Medical treatments for the man may include fertility pills or injections that can correct hormonal imbalances and increase sperm production. Antibiotics may treat certain infections and prevent harm to the sperm. Minor surgical procedures that fix varicoceles may improve sperm quality.

For most male factor patients, intra-uterine insemination or “artifcial insemination” will be the preferred treatment. This is where a semen sample is washed and prepared in a very precise manner to produce a specimen that keeps the good quality sperm and separates out the poor quality sperm. This high quality specimen is then injected into the partner’s uterus like a Pap smear during ovulation. This higher quality specimen has an increased chance of penetrating and fertilizing the ovulated egg. This is usually done in conjunction with the woman taking hormones to increase the number of eggs ovulated during a treatment cycle in order to generate even higher chances of success. Such treatments are known to have increased rates of multiple gestations (twins, triplets, and more) and therefore close monitoring is required to minimize this possibility as much as possible.

For severe male factor, there may not be enough high quality sperm from intra-uterine insemination, and advanced reproductive technologies like intra-cytoplasmic sperm injection (ICSI) is necessary to achieve fertilization. This is done with in-vitro fertilization (IVF) where a woman takes hormones to increase the number of eggs produced and then the eggs are retrieved via a minor procedure. ICSI is then performed where one high quality sperm from a man’s washed and prepared sample is microscopically injected into each retrieved egg. If fertilization occurs then the resultant embryos are transferred into the woman’s uterus. There are 380 registered IVF programs in the United States. It is very important to chose an IVF center wisely as each program has different capabilities. ICSI is available at level III (the highest classification) programs. The sole level III IVF laboratory in the Central San Joaquin Valley is the Community Fertility Center located at Clovis Community Medical Center.

When men with no sperm in their ejaculates are discovered, some can undergo a simple procedure called microscopic epididymal sperm extraction (MESE) or testicular sperm aspiration (TESA) where sperm is recovered from the testicular area by a reproductive urologist and used for ICSI during IVF. Others may elect to utilize a sperm donor for traditional insemination.

As you can see, the treatment of male infertility often requires the woman undergo treatment as well. That it why this is truly a couple’s problem and not just a man or a woman’s issue alone. Just like women, men also lose fertility as they age, although not as drastically as women do.

Additionally, newer advanced andrology standards of care include the freezing and banking (cryopreservation) of sperm for future use. Cancer patients prior to undergoing chemotherapy can store sperm in case the cancer treatment halts future sperm production. Men prior to undergoing vasectomy can also store sperm in case unforeseen circumstances arise in future.
Men undergoing vasectomy reversals can also have sperm retrieved at the time as the procedure and stored in case scarring causes the reversal not to work. The use of columns to separate genetically abnormal sperm from normal sperm is coming to
select andrology centers as well. The sole andrology program in the entire Central California is called the Valley Andrology Fertility Center located in Fresno.

It is vital to seek assistance from the medical community to help deal with challenges caused by infertility. Going through reproductive issues can be very burdensome and even effect performance capabilities. Fortunately, these are usually temporary problems and treatment can help. Gaining knowledge goes far in dealing with anxieties and fears and in overcoming reluctance to seek assistance or to stay in treatment. It is these couples that will hopefully, and most likely, overcome their challenges and achieve their dreams of having children.

About the Author: Michael Synn, M.D.is one of California’s leading obstetric, gynecological and fertility specialists as well as an assistant clinical professor at UCSF Fresno. He serves as director of the Clovis Community Fertility Center, which offers the only Level III (highest level) fertility program in central California. Dr. Synn is an advanced fertility specialist from the Women’s Specialty & Fertility Center in Clovis, California.