It's In the Male
Posted on October 8, 2010
Getting A Grip On Male Factor Infertility
You've done everything you can think of and you've done it all by the book. But after months of temperature taking and carefully timed intercourse, there's still no pregnancy. The "i" word has elbowed its way into conversation and you've agreed it's time to see a doctor. You're both going to be evaluated for infertility because, statistically speaking, it's as likely to be a reproductive glitch in the male as it is in the female.
In fact, infertility is an equal opportunity disease that afflicts roughly 6 million people in the US, that's 1-in-10 US couples. In 20% of these couples it's attributable entirely to a male factor. In another 30%-40% it is a combination of both male and female. Therefore, in a majority of infertile couples a male factor is identified.
Under the circumstances, it's imperative that you and your doctor include the man's systems in the reproductive calculus and wait no longer than one year if unprotected sex has not produced conception (no more than 6 months if you're 35 or over). It's surprising how often, enlightened as we are, that men are bypassed. In large measure it's because infertility was perceived as a women-only phenomenon until 50 years ago.
While the advances in diagnosing and treating male factor have been, and continue to be, breathtaking, attitudes evolve at a relatively glacial pace. It's still the norm for the woman to initiate action when a couple suspects infertility. And it's a good bet that her first call will be to her gynecologist. Certainly more gynecologists than ever are savvy and sensitive enough to bring the man into the process at the outset. But for many others, male issues are still an afterthought and aren't addressed as promptly as they should be.
One other thing. As touchy as the subject of infertility is, it seems especially sensitive when male factor is involved. It taps into social and cultural stereotypes about manliness, potency and prowess. It often sparks guilt and reflexive blame-laying. All of it is counter-productive and absolutely beside the point. Male infertility is a disease. It's attributable to a range of causes. Often, it is treatable.
As people who have been through this will testify, you've got to make sure you and your team identify as many variables as possible so your doctor can target the most cost-effective, time-efficient - and least emotionally distressing - protocols and treatments. Be demanding. By the end of your first visit, the doctor should have detailed health histories of you and your spouse, including the most critical variable of all, the age of the hopeful mother. (Even if you're both in perfect shape, fertility inexorably declines with maternal age.) Ask about, and get the basic medical tests and physical exams that rule in or exclude genetic, hormonal, medical or physiological issues that may stymie conception.
Remember, you're in this together. Whether you track the problem back to you or your partner, infertility is ultimately a couple's situation. Remind yourselves of that when you're going for workups. Because most infertile couples discover the path to pregnancy means a comprehensive, coordinated medical approach that involves the two of you.
CHECKUPS AND THE MAN
Step One, Part One: The Profile View
That first encounter with an MD is a journey into self-revelation. Be prepared to talk about yourself with thoroughness and unflinching candor. Expect your doctor to scrutinize every fillip, quirk and tick in your health history and lifestyle. You never know when a long-forgotten infection, your evening hot tub ritual, your five-espresso-a-day habit or smoking may be compromising fertility. The answers you provide become part of a comprehensive profile that helps bring your particular case into focus.
- Your family and personal histories. Is there a pattern of infertility in your family?
- Whether you've ever achieved a pregnancy. It makes a difference if you're experiencing primary or secondary infertility.
- Have you had pelvic or scrotal surgery? Have you had any abdominal surgeries, like a hernia operation, that could scar or injure delicate internal structures?
- Were or are you exposed to gonadotoxins (substances that literally poison the sperm-producing organs). This category includes a wide range of substances - from chemotherapy drugs to pesticides to workplace chemicals.
- How much alcohol do you consume? Do you use recreational drugs, like marijuana? These are gonadotoxins as well.
- Are you exposed to heat for long periods of time? (Think sauna or steam.)
- Do you have a condition or disease that requires medications? Which meds are you taking? Some prescription drugs interfere with sperm production. Some diseases-diabetes, for instance, may hinder normal ejaculation.
- Have you had a sexually transmitted disease? Those could also lead to reproductive tract scarring.
Step One, Part Two: Magazines or Video? Semen Analyses
This is the nitty-gritty. Yes, it's somewhat surreal to abstain for at least two days so you can masturbate into a sterile cup and rush your output to a lab within two hours. And, you'll have to repeat the process at least two times to accommodate normal fluctuations in the amount and quality of semen you produce to establish your average, your baseline. But these analyses are indispensable to the infertility investigator figuring out the specifics of your case.
A semen analysis reveals the volume of ejaculate, the concentration or density of sperm, their motility and the morphology (shape). There are minimal standards of adequacy for each parameter and anything below those standards is called "abnormal." Let's be clear here. An abnormal finding is an indicator that infertility may be a problem, not a declaration of sterility. So relax.
Those standards include:
- Ejaculate volume of between 2.0 and 5.0 cubic centimeters
- Sperm concentration of at least 20 million per milliliter or a total count of greater than 40 million.
- Motility. Sperm have got to swim. Quantitatively, doctors look for at least 50% to demonstrate any movement.
- Morphology, the shape of each sperm. Doctors look for normal appearing sperm-checking for the proportions of head to body to tail.
The most important value is the calculated total motile sperm count. It simply means the total number of sperm multiplied by the percent of motile sperm. It's that final number that's going to lead to various therapeutic options - trying naturally, inseminations or high-tech Intracyctoplasmic Sperm Injection (injecting a single sperm into a single ovum).
In addition, the sample should be cultured specifically looking to detect sexually transmitted diseases.
It's essential to get copies of your lab reports and confer with your doctor.
Beyond the semen analysis, there are advanced tests to assess sperm function that your physician may recommend, but they are not necessary for routine evaluations.
While an "abnormal" finding can result from any number of things, including a recent high fever or infection, semen analyses that don't meet the minimal standards should trigger a more comprehensive evaluation. Get yourself to a qualified urologist for the next round.
Step Two, Part One: Up Close and Personal. The Physical
A good urologist who specializes in male infertility will give you a thorough going-over. It's important because the exam can detect conditions such as a varicocele, dilated veins around the testicles, a surgically correctable condition affecting 40% of all men with fertility problems. Varicocele repair may be a primary treatment option when there is no female factor. It can also pick up life-threatening conditions such as testicular cancer, the most common cancer in men of reproductive age. Aside from your general health, the doctor will be checking:
- Contents of the penis and scrotum
- The presence of the vas deferens, the sperm duct
- Tenderness or swelling of the epididymis, the duct in which sperm mature and gain motility
- The presence or absence of a varicocele
- The health of the prostate gland
The urologist will be on the lookout for any blockages or obstructions that can impede the flow of sperm.
Step Two, Part Two: In the Same Vein. The Blood Tests
This battery of assays is simple enough but each lab has it's own standards. Make sure you get copies of the reports and go over them with your doctor. You'll find out if your hormone levels are where they should be for testosterone and sperm production or whether there's a genetic anomaly. The tests determine such things as:
- Follicle Stimulating Hormone (FSH) level, the brain message to produce sperm
- Luteinizing Hormone (LH) level, responsible for motivating the testicles to produce testosterone. A low testosterone level not only has an impact on sperm production, but also has significant implications for a man's health in general including sexual dysfunction, depression, fatigue, bone density and muscle integrity.
- Genetic evaluation. Between 30% and 40% of the patients with low or no sperm in the ejaculate have a genetic problem. For example, an extra X chromosome indicates Kleinfelter's Syndrome which is linked to azoospermia (no sperm). Pieces of the Y chromosome may be missing, and will be transferred to the sons; it may also indicate a cystic fibrosis mutation that requires the spouse to be screened to accurately assess the risk to the offspring.
Revelations: What To Do With What You Know
The phone rings, the doctor wants to see you both for a consult. The results are in. Anxiety producing? Indeed. Don't forget, though, that there's a distinct possibility that you're just fine, as in "there's nothing wrong." You could help improve semen by taking antioxidants and nutritional supplements containing amino acids. You could stop smoking and cut down on alcohol.
The second possibility is that the tests indicate a male factor. That is not the same as being unable to produce a biologic child. There are treatments and therapies that can help correct, overcome or circumvent even the most severe problems.
If your hormones are too low, there are ways to boost the levels. If there's an obstruction in one of the delicate male ducts, there are sophisticated, overwhelmingly successful microsurgical repairs. Vasectomy reversals, too, have been vastly improved.
Even for men with no sperm in their semen, or those born without a vas deferens, male reproductive specialists can, in many cases, now extract sperm from within the testicles.
Using the most significant treatment advance for male factor infertility, Intracytoplasmic Sperm Injection (ICSI), men who a decade ago couldn't dream of producing progeny, can. As long as there are even a few viable sperm doctors can get to, it is possible to create an embryo by injecting just one sperm into an egg, fertilizing it in vitro, and implanting it in the woman's body. It means that in cases that were once deemed beyond help, there is an effective treatment modality.
What we're talking about here is possibility and hope. We're talking about compassion between the partners and an understanding physician. Because good medicine demands it and treatment success depends on it, evaluation of both the man and the woman is absolutely fundamental. Correctable causes of infertility can be identified and life-threatening conditions uncovered. Your best chance to conceive the child you want is a comprehensive and carefully coordinated approach.
For more information and support please call Path2Parenthood at (888) 917-3777. We know how you feel and we're here to help.