Transcription:

Deborah Howell: Infertility affects approximately one in eight couples. While it's often thought about as a female reproductive issue, couples can also struggle to conceive due to male factor infertility. In honor of November or Men's Health Awareness Month, Dr. Samuel Ohlander, a board-certified urologist at Fertility Centers of Illinois and a specialist in reproductive urology is here to discuss symptoms, causes, and what you can do about male factor infertility.

This is the Time to Talk Fertility Podcast. I'm your host, Deborah Howell. Dr. Ohlander, so nice to have you with us today.

Samuel Ohlander, MD: Yeah, Deborah. Thank you so much for having me. I've been really looking forward to this.

Deborah Howell: Happy Movember.

Samuel Ohlander, MD: Thank you. Thank you.

Deborah Howell: All right. If it's all right with you, let's dive right in. I'm going to ask you, what are the causes of male infertility?

Samuel Ohlander, MD: Oh, there's so many of them. I could go on and on for a long time talking about this. But I'll kind of break it down into certain categories. There can be genetic components, so deletions within certain chromosomes or extra chromosomes. There can be mutations in certain genes. There can be hormonal abnormalities like low testosterone or elevated prolactin levels which are hormones secreted by little glands at various points in your body. There can be anatomical abnormalities like dilated veins within the scrotum called a varicocele or an absent vas deferens, that tube that carries the sperm away from the testicle. Things from childhood, like an undescended testicle.

And then, there can be functional issues too. I mean, in order to conceive, you need to be able to function, so things like erectile dysfunction or ejaculatory dysfunction. There can be what we call in medicine iatrogenic causes, which means things we do that cause infertility. So, things like chemotherapy, radiation, testosterone therapy, a vasectomy, things like that. And unfortunately, oftentimes too, it's just unexplained. We don't always have the answers as much as we wish that we did.

Deborah Howell: Okay, that's fair. Are there genetic or aging issues that hurt male fertility?

Samuel Ohlander, MD: Yeah. These are two issues that are getting a lot of attention these days because we're continuing to learn more and more about them, genetic components that I kind of hit on a little bit when we were mentioning those causes. Some of the more common ones are deletions within the Y chromosome, which is the male chromosome or abnormalities in just the number of chromosomes. A disorder called Klinefelter is one common example. That's where men carry an extra X chromosome. So, instead of 46 chromosomes and X and Y, there are 47 chromosomes and XXY. And then, being a carrier for cystic fibrosis can be a genetic abnormality as well, where if you're a carrier, a male carrier of cystic fibrosis, sometimes you don't develop your vas deferens, that tube that carries the sperm away from the testicles.

And then, if we're talking about age, we're getting to learn more about that too. We've always known kind of about the female age side of things, but we're learning more about the male side of things too. And a lot of the studies don't show a magic number, a magic age because guys just continue to crank out sperm as they continue to age. But there is decline in certain semen parameters starting in the 30s, but more commonly cited around the age of 40. And then, there can be increased risk of rare disorders, so things like autism, schizophrenia, and things like that. I always explain to my patients that these are rare disorders, so they aren't real significant rises or real common disorders, but there are increased risks.

Deborah Howell: Right. And how common is male infertility?

Samuel Ohlander, MD: So, it's about 50% of infertile couples have a male factor component, 50 to 60%. So, it's a pretty common component to fertility in general. Now, strictly or sole male factor is probably going to be closer to 20% to 30% of cases. But it is a component of infertility in many couples.

Deborah Howell: Okay. And what are the symptoms, if any, of male infertility?

Samuel Ohlander, MD: Yeah. I'm glad you said if any, because oftentimes there aren't. A lot of times guys will be finding out about their fertility status when they're struggling to conceive and they're undergoing some testing. They don't have really any symptoms whatsoever. If guys do have some symptoms, it could be things that go back to kind of those functional components that I talked about, things like a erectile dysfunction or ejaculatory dysfunction. What I mean by ejaculatory dysfunction is when a guy has an orgasm. It might be an instance where the amount of fluid that comes out is very small or maybe there's nothing that comes out with an orgasm or they have difficulty achieving an orgasm.

Other symptoms might be symptoms associated with hormonal abnormalities, so fatigue, low sex drive, decreased energy levels. And then, you know, things the guys might pick up on their own self examinations is, you know, if they have real small testicles, that might be a clue that something is underlying.

Deborah Howell: Okay. Now, with so many variables that you've outlined for us, how is male fertility diagnosed?

Samuel Ohlander, MD: So, usually, when a guy's coming in, one of the main steps is going to be getting a semen analysis. That gives us kind of a snapshot of that moment of what the ejaculate looks like, how much fluid is coming out; within that fluid, how much sperm is there. And of that sperm that's there, is it motile? Is it moving around and swimming the way that we would expect it to be? So, that's one of the most utilized tests in terms of understanding a guy's reproductive potential.

Otherwise, we'll oftentimes order some blood work hormonal evaluation. Rare instances testing like genetic testing or certain aspects of imaging ultrasounds may be used as well. But otherwise, real big component and step one in addition to that semen analysis, actually preceding that semen analysis is just a good old history and physical examination, getting us the information to help us determine what might be going on.

Deborah Howell: Got it. Now, when it comes to sperm count, what's a normal range?

Samuel Ohlander, MD: So, normal is a funny term with semen analyses. And this is where I can sometimes get into a long explanation with my patients because I do try to educate on what a semen analysis is showing. With semen analyses, what your numbers are compared against is a reference range. So, it's not really a clear normal range. And to try to keep this short, but what the World Health Organization did is they took about 2000 guys who achieved a pregnancy naturally within a year. They took their semen analyses and then they took the bottom fifth percentile on each category, and that's what our "normal threshold" represents. So, it's not really above it, your fertile; below it, your infertile. And to be honest, it's not really above it, your normal; below it, your abnormal. It just gives us an idea of your reproductive potential. So, if we're talking about where that count is and the concentration of sperm and where that threshold lies, it's around 15 million per milliliter, so 15 million sperm per milliliter of ejaculate.

Deborah Howell: Okay. And can you tell us more about sperm morphology or shape of sperm?

Samuel Ohlander, MD: Yeah. So, the shape of the sperm is another interesting thing. And it's probably, well, I tell my patients it's oftentimes the least concerning of my factors on a semen analysis. And that's because it's not great at predicting reproductive outcomes, meaning how a patient might have success with regards to natural conception, intrauterine insemination or in vitro fertilization. It's an assessment of about 200 sperms, is how they do it. They do a smear on a slide and assess 200 sperm for perfect criteria. The vast majority of sperm get classified as abnormal. There's very, very few ideal sperm. And so, you know, it's one of those tests I think has certain aspects of relevance, but it's one of those that I rarely make my treatment decision solely on sperm morphology.

Deborah Howell: Okay. And now, the nitty gritty, what's a common fertility treatment protocol for a man with infertility?

Samuel Ohlander, MD: Yeah, and that's another good question because it all comes down to the diagnosis. So, you know, if it's sexual dysfunction, there's medications we can use to help along with that. If it's an issue of hormonal imbalances, we have certain medications that can stimulate the production of hormones. For an example, something if you have low testosterone, there's certain medications that we can use to induce your own natural production of testosterone, which I think we'll touch on here shortly a little bit deeper. If there's something like an abnormal dilation of veins within the scrotum called a varicocele. We can do a surgical repair of things there. So, there's a lot of different treatments and, ultimately, it just comes down to what the underlying etiology might be.

And just to make a note, you know, one of these things with these treatments is a lot of them are what we call off-label, meaning that the medications that we use, this isn't necessarily their FDA approved use. But these medications that we're using off-label, for the most part, have been used for decades, very safely, very effectively to accomplish improvements in fertility.

Deborah Howell: Okay, good to know. What should men know about testosterone supplementation and their fertility?

Samuel Ohlander, MD: So, the most important thing to know is that if you're taking testosterone, and I mean by actual testosterone, so injections, gels, patches, and they even have some oral forms that are coming out. It's one of the most studied drugs for male birth control. So testosterone, when you're taking it from outside of your body, it shuts down your own production of testosterone. And so with doing that, it shuts down sperm production too. So, I think guys think that testosterone, It's a masculinizing medication; it's going to boost my ,you know, fertility potential. But in fact, it has that opposite effect. And the rule is that it drops your sperm counts to zero or close to it. There are certain exceptions, but it can greatly, greatly impair a man's fertility potential and can medically make him unsterile in many instances.

Deborah Howell: That is very eye-opening. I did not know that. So, how common is low sex drive or erectile dysfunction with fertility issues?

Samuel Ohlander, MD: So, I think that one thing guys don't understand is how common erectile dysfunction is just in general. So, you know, one in five guys over the age of 20 has some degree of erectile dysfunction. So, it's not even necessarily fertility-related. It's in that reproductive age. There are components of erectile dysfunction.

That being said, we see that quite a bit within reproductive care. The dynamics of sex change. You know, it's not this spontaneous event that's just occurring at a whim. You know, it's a lot more planned. You have a window where your fertility potential is kind of optimal. And so you're planning these events, you know, it's very much a scheduled activity, more than a spontaneous activity. So with that, guys oftentimes can struggle to achieve or maintain their erections. So, we see quite a bit of it and we treat quite a bit of it.

And one thing to know too is that once guys have an issue one time, they're going to have to think about it the next time. They get in their heads. That's pretty darn uncommon for guys, is to overthink things, especially when it comes down to erections. And low sex drive kind of goes in with that as well. If you're struggling with your ability to achieve or maintain an erection, your desire drops a little bit because you're just not as competent. And then, some of the hormonal abnormalities that I discussed, the low testosterone and things like that can be associated with decreased libido or sex drive.

Deborah Howell: Completely understandable. Are there prescription medications or supplements that can hurt male fertility?

Samuel Ohlander, MD: Yeah. So, we discussed testosterone and how that can negatively impact fertility. So, you know, the, the gels, the injections, the topicals, some of the oral agents, those can have a negative impact. Other things that can have a negative impact that's a common medication used in this age group of guys is finasteride. It has the potential to decrease fertility potential. Finasteride is a medication that has two primary uses, one for enlarged prostate, but the reproductive age use that we see more common is for hair loss. Guys will use a low dose of finasteride for that. And while the low dose has less of an impact on semen parameters and hormones and ejaculate volume, it still does have that potential. So, it's a medication that I do discourage guys from using.

Otherwise, you know, medications like tamsulosin, which is a medication used for urination that can cause what's called retrograde ejaculation, where instead of the ejaculate going out the end of the penis, it goes backwards into the bladder. If it's going into the bladder, you can't get somebody pregnant. So, that can impact things as well.

And then, with regards to supplements, I think the biggest thing I tell my patients is just be careful. Certain things like T boosters is something that I caution them from using. Reason being on that is a lot of these just aren't regulated for the purity. And the recent study has shown that about 10% of these supplements that are T boosters or advertised as T boosters actually contain ingredients that have been found to decrease a man's testosterone. So, you just need to be careful on what you're using.

Deborah Howell: Okay. Now, women get this all the time, but how does extra weight affect male fertility?

Samuel Ohlander, MD: Yeah,. So, the scrotum is outside the body because it likes to be there. And there's a reason for it. The testicles like to be a little bit cooler than the rest of the body, and that's how they function optimally, is at a temperature that's a little bit lower than the normal body temperature. So when guys carry a little extra weight, a lot of guys carry it in their inner thighs, their lower abdomen and things get hot down there, and that can impact spermatogenesis or the production of sperm. And then, even for some guys, the scrotum gets tighter up to the body and the testicles are almost a little bit more inside the body. So that's one way, is just the heat factor of things can decrease sperm production.

Another thing is testosterone, which is still integral to sperm production. I don't want the misconception being that testosterone's not an important hormone because it is. It just needs to be your own testosterone, not from outside the body. So, your own testosterone gets converted to estrogen and fat. And so, if you're carrying a lot more fat, you're converting potentially more testosterone over to estrogen, which then has an impact on your hormonal loop in terms of kind of shutting down the hormonal cycle and the stimulation of the testicles for sperm and testosterone production.

Deborah Howell: Now, is there anything a man can do to boost his fertility?

Samuel Ohlander, MD: Yeah. The biggest thing that I tell my patients is just, you know, live a healthy lifestyle. So, you know, don't all of a sudden try to pick up binge drinking or heavy partying or anything along those lines. You know, if you're a smoker, try to quit smoking. Smoking can have a negative impact on semen parameters and hormonal aspects of things. Regular exercise is a good thing as well. And then, the guys oftentimes ask about diet. And there's not necessarily a specific fertility diet that I recommend. But what I would say to my patients is a heart-healthy diet is oftentimes a fertility-healthy diet. So, things like plant-based diets can be pretty darn good, as well as Mediterranean diets, heavier on the fish and the chicken, the vegetables than it is on red meat, which sometimes can be a little bit more pro-inflammatory and things along those lines. So, you know, what I say is just live a healthy lifestyle.

And then, just one of the last things is guys will always ask about stress, and this stress is inherent to this whole process. There's not really a way that we can just say, "Hey, hey, try to relax." That's not a realistic recommendation to make to patients. And so, it's all about incorporating whatever your stress relievers are, as long as they're healthy outlets. And that's encouraging guys to make the time to schedule these things whether it's something they're doing with their partner or something that they're doing on their own. Make time for it and support their partner in making time for it as well. I think that open communication and making sure that you're going about this together is just so important because, like I said, the stress is inherent to this process.

Deborah Howell: Excellent information and advice as a matter of fact. Now, can you provide some words of hope for any man who might be struggling with infertility?

Samuel Ohlander, MD: Yeah. One thing I would just say is that even though male factor infertility isn't commonly discussed, that doesn't mean it's a rare condition or that nothing can be done. There's a lot of treatable forms of male factor infertility and many modalities of assisted reproduction that can help a guy achieve his desired family. So, I understand that the evaluation can be anxiety-provoking. But hopefully, this gives a little bit of knowledge and understanding to help guys realize that coming in, being seen, you know, hopefully, it's not an embarrassing or traumatic experience. It's about just getting the information, addressing the issue, and trying to optimize their fertility potential. And you know, we're here. We're here as reproductive specialists with a goal to help you achieve this family that you desire.

Deborah Howell: Yeah. They're not alone, and you have some working information that can really be helpful to them. Well, this is such great information, Dr. Ohlander. Thank you so much for being with us today to share your expertise.

Samuel Ohlander, MD: Thank you for having me.

Deborah Howell: That was Dr. Samuel Ohlander, a board-certified urologist here at Fertility Centers of Illinois. You can schedule an appointment to talk to a fertility specialist at 877-324-4483 or visit fcionline.com for more information. 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.