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Deborah Howell (Host): You know what they say, getting older can be challenging. So, how does the aging process impact male fertility? Today, we'll explore that question and find out about the latest medical research around aging and male fertility. I'm Deborah Howell and our guest today is Dr. Juan Alvarez, a Reproductive Endocrinologist and Infertility Specialist at Fertility Centers of Illinois. This is The Time to Talk Fertility Podcast. I'm your host, Deborah Howell. Dr. Alvarez, is there an age when men start to become less fertile?

Juan Alvarez, MD (Guest): Yes, there is an age and we know that starting around age 40, we can see that men will start to produce less sperm.

Host: And do men ever stop producing sperm?

Dr. Alvarez: That's a good question. As far as we know, men do not stop producing sperm, but like I said, starting around age 40, we start to see about a 10% decline in sperm concentration and the older men get, the lower the sperm concentration. Although sperm production does not stop completely.

Host: Now when people hear the term male fertility, they usually think of sperm count. Can you tell us about the other factors men should be thinking about?

Dr. Alvarez: Yes. So, there is other factors. So, sperm concentration, we know that it impacts fertility because there has to be a certain density of sperm in order for one sperm to be able to find the egg. Now, there are other factors such as sperm motility. How many sperm are moving? And how many of the sperm look normal, which is called morphology?

Host: All right let's start with sperm count, what's considered normal?

Dr. Alvarez: So normal sperm count is considered to be a concentration of 15 million sperm per milliliter or greater than 10 million total motile sperm.

Host: And how has the sperm count changed in recent years?

Dr. Alvarez: Well, the research has shown that in the past two decades, we have been seeing a greater than 50% decline in sperm counts.

Host: Wow. I had not realized that. But in addition to count, the shape also known as morphology is also important. Can you tell us more about that?

Dr. Alvarez: Yeah. So, the shape of the sperm has to be normal and during the semen analysis, we look at three different components; the shape of the head, the neck and the tail, and only a normal shaped sperm can fertilize an egg. There's a lot of different abnormalities, which is why it's called morphology, shape of the sperm. There could be a large head, small heads, two tails, no tails, short neck. So, there's a lot of different morphologic abnormalities that we see. And this is what we do during the semen analysis.

Host: Now another aspect of sperm health is how they move also known as motility. What should we know about that?

Dr. Alvarez: We should know that in the ejaculate, there should be, like I said, more than 10 million motile sperm. And the reason for that is because sperm is a cell that moves. And so they have to be able to travel from the cervix all the way up the uterus and fallopian tubes in order to fertilize an egg. So, the motility is very important.

Host: And the three factors we've talked about, which is the most common.

Dr. Alvarez: The most common abnormality that I see in semen analyses is morphology. We are seeing a lot of amorpheus or abnormal shapes.

Host: And if there's an issue with one factor, is that common for others to be present too?

Dr. Alvarez: Most of the time there is. Some men can have isolated abnormalities, either on count, on motility or just on morphology. So, they don't really correlate with each other. Usually, if there is a motility problem, there can be a concentration problem, but usually they are, these factors are separate.

Host: Okay. Now you touched on count earlier doctor, but have morphology and motility experienced any trends with age as well.

Dr. Alvarez: Yes. So, these studies showed that not only has concentration been going down in the past two decades, but we do see that there are more abnormal shaped sperm. And we think that could be either genetics or environmental.

And switching Host: it up just a little bit. What are endocrine disruptors and what do they do?

Dr. Alvarez: Yeah, that is very important. Endocrine disruptors are chemical compounds that mimic hormones, and one of the most famous one is BPA, which acts like estrogen. And so when these chemicals, which are in plastics and the environment they get into our body or they either they get absorbed into the skin, or we ingest them. They can actually act as an hormone and possibly cause problems with sperm production.

Host: Okay. We've been talking a lot about problems, now for solutions. What kinds of treatment options are required for sperm issues?

Dr. Alvarez: Well, that will all depend on what issue it is. If the concentration is low, there is a full workup to see why a man has a low sperm count, but there are different options such as hormone replacement therapy, as well as stimulation to the testicles in order to improve sperm count. For morphology, we know that most likely it's environmental. And so we prescribe antioxidants to help with DNA packaging and sperm production.

Host: Now, recently I heard the term male menopause, which was fairly new to me. What is male menopause?

Dr. Alvarez: So, male menopause is a set of symptoms that is due to a decline in testosterone, which can include decrease in sex drive, loss of body hair, increase in erectile dysfunction, loss of lean muscle, increase in fatigue, as well as increase in weight. And it can also cause depression.

Host: Wow, that doesn't sound like any fun at all. When do men usually experience menopause?

Dr. Alvarez: So, men start to experience male menopause around age 40. We start to see that there's a decline in testosterone about 1% per year, starting around age 40. Now the majority of men will still have testosterone levels within the normal range, but about 10 to 20% of these men will have low testosterone, which can impact all of the factors that I mentioned, which could cause problems with sperm production.

Host: Okay. And how do we treat male menopause?

Dr. Alvarez: Well, there's two ways of treating male menopause. One would be if a patient no longer wants to preserve his fertility, then we do testosterone replacement therapy. And the reason for that is because when a man takes testosterone, their sperm production will decline and sometimes it can even stop altogether. If a man has low testosterone, but is also looking to have a child, or is in the process of fertility treatments, we use another medication called Clomid, which stimulates the brain so that it can stimulate the testes to produce more sperm. And the by-product of more sperm production is testosterone production.

Host: And what should men know about testosterone supplements and their fertility?

Dr. Alvarez: This is very important. Any man who gets on testosterone supplementation, so like intramuscular testosterone, or transdermal testosterone, any testosterone replacement will cause a problem with sperm production. And the reason for that is because the body is sensing a rise in the level of testosterone, and so it stops the signal to the testes to produce more testosterone and therefore to stop producing sperm. So, any man who's on hormone replacement therapy with testosterone can have low or zero sperm counts.

Host: Yeah, sad, but it does make perfect sense. How common is low sex drive or erectile dysfunction with fertility issues?

Dr. Alvarez: It actually is not very common. Many of my patients will come in, don't have problems with erections or low sex drive. Now we do know that fertility itself can cause some problems with desire, with low sex drive. And that is because after a while, if you are timing intercourse and a man has to perform at a certain time and a specific day, that can cause problems psychologically, of course, with erections. And so, we don't see a lot of problems with erectile dysfunction with fertility. Now, men who are over 40, we do start to see higher incidents of erectile dysfunction. There's 40% of men by age 40 and 70% by age 70 who have erectile dysfunction, which can lead to problems with timed intercourse.

Host: Sure. Now we'll all experience health issues as we age. Can any of these issues impact fertility as well?

Dr. Alvarez: Oh yes. Many chronic medical issues can cause problems with fertility, such as diabetes, hypertension, obesity. There's other conditions also that impacts like if a man was born with undescended testicles, if he's had an infection as a child, like mumps or chlamydia or gonorrhea, this can cause injuries to the testicles. As well as testicular cancer can cause problems with testicular production and also treatment of cancer.

Host: Okay. And is there a prescription medication that can actually hurt male fertility?

Dr. Alvarez: Yes, there are several medications and that can impact fertility. Medications for high blood pressure and depression can cause low sex drive or erectile dysfunction. We do know that the medication for hair loss, like Finasteride can cause problems with sperm production. So, I recommend for any man who's on any chronic medications to and they're trying to get pregnant to discuss these medications with their physician.

Host: Okay. And here's a big factor. How does extra weight affect male fertility?

Dr. Alvarez: Well, this is another issue. And we do know that the prevalence of obesity is also increasing in the population and extra weight and extra fat does cause problems with them sperm production. And the reason for that is because the circulating testosterone gets well, the scientific word is aromatized. So, testosterone gets converted into estrogen and this happens in the fat tissue because fat cells have a special enzyme that can do this conversion of testosterone to estrogen. And so men who have extra weight have higher levels of estrogen, which causes problems with sperm production.

Host: Oh, this is fascinating. So, what's the latest medical research around aging and male fertility that our listeners should know about?

Dr. Alvarez: So, there's two fairly good studies. One is called the Massachusetts Male Aging Study, where they looked at over 2000 men, ages 40 to 70 to look at their fertility potential. And they saw that after controlling for female age, because we know that female age also impacts fertility. So, after you control for female age, men who are older than 40, we do start to see a decline in pregnancy rates about 30% pregnant, lower pregnancy rates for a man who was 40 compared to a man who was 30.

There was another study that also evaluated some IUI cycles. So, couples who have already gone through fertility treatments and this study showed that also we saw lower pregnancy rates in men after controlling for female age, in older men, older than 35.

Definitely a reason to start earlier. Host: Now there's a lot of sperm tests in drugstores now. What can they tell you?

Dr. Alvarez: Yes. So, these tests I would say they are kind of crude tests. They just tell you about sperm concentration. So, it tells you if there's enough sperm density in the ejaculate. Now it doesn't tell you anything about motility, nothing about morphology. And so it's not a very complete test, but it could be a great initial test to see if there is sperm or not.

Host: Okay. And when you compare an at-home test versus a semen analysis from a fertility clinic, what's the difference?

Dr. Alvarez: So, the difference is more detail in a semen analysis in a fertility clinic. Now, at home test, like I said, it's a great initial test but it doesn't give you all the information and sometimes men have a problem either getting to a fertility clinic, or if there's not a fertility clinic nearby, if somebody lives in a rural area, it would be a great place to start with just the at home test. But really the fertility clinic will give you more information like I said on motility, morphology, the total motile sperm count, which is very important. And morphology is also very important because we do know that men who have low morphology have low fertilizations when we do IVFs.

Host: Sure now what's the rough cost of an at-home test compared to a lab evaluation.

Dr. Alvarez: So, an at-home test can be anywhere between 50 to a hundred dollars. And then a test in the lab could be anywhere between a hundred to $200.

Host: Is that usually covered by insurance or not?

Dr. Alvarez: Usually it's not covered by insurance.

Host: Okay. Can you share some anecdotal examples of patients who have experienced some of these setbacks and went on to have treatment success?

Dr. Alvarez: Yes. So, about 30% of all fertility is male factor. So, something that the listeners should definitely know is that it's not rare. About a third of all infertility has to do with either low sperm counts, low mortality, low morphology. And so I have many patients who've had many successes with intrauterine inseminations with IVF. I've also had patients who've had zero sperm in the ejaculate and after further evaluation, we were able to do either testicular sperm extraction, which we can do IVF. And there's a special procedure for men who have low sperm counts. It's called ICSI, intracytoplasmic sperm injection. And so if there's one sperm we're able to fertilize an egg and be able to get an embryo so that couples can get pregnant. So, it is common and that's something that I would like the listeners to is to know that male fertility is common. And we have a lot of treatment options, inseminations, ICSI, and patients are very successful with these treatments.

Host: Well that's good. And that was my last question for you. Can you share some words of hope with listeners?

Dr. Alvarez: Yeah. This field of infertility is growing day by day and every day we learn a little bit more about male and female fertility. And I think that in the future, we're going to be able to do a lot more. And so right now, the basic tests and the basic procedures that we have are only going to get better. And pregnancy rates have been increasing steadily using our technology since the late eighties. And so our listeners should be very hopeful in the field and that we're going to be doing even more in the future.

Host: Well, this is some very enlightening information, Dr. Alvarez. Thank you so much for being with us today.

Dr. Alvarez: Oh, thank you for having me.

Host: That was Dr. Juan Alvarez, a Reproductive Endocrinologist and Infertility Specialist at Fertility Centers of Illinois. Find out more about the services FCI provides for patients by calling (877) 324-4483. Or visit us at FCIonline.com to schedule an appointment with Dr. Alvarez. And if you enjoyed this podcast, you can find more like it in our podcast library, and be sure to give us a like, and a follow, if you do. This has been The Time to Talk Fertility Podcast. I'm your host, Deborah Howell. Have yourself a terrific day.