Melanie Cole, MS (Host): What are some of the potential reasons for declining fertility rates in the United States? And what are some of the potential treatments for someone who may be struggling with fertility issues? Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole and joining me today is Dr. Kian Asanad. He's a Urologist on the medical staff at Henry Mayo Newhall Hospital and Keck Medicine of USC. Dr. Asanad, it is a pleasure to have you join us today. It's been widely reported that fertility rates in the U.S. have been declining for years. What's going on? Is this true? How common is infertility?

Kian Asanad, MD: Thank you, Melanie. It's a pleasure to join you guys today. it's really important and there's a lot of new data suggesting declining fertility. And I kind of want to take a step back and take a broader view and kind of get into some of the more details. The CDC released some new data in April of 2024 and the general fertility rate in the U.S. has decreased by 3%, from 2022, it's been the lowest it's ever been. And it's especially amongst women between the ages of 20 and 39 years. It's been the lowest it's ever been over 40 years to 3.5 million births. And there's, I think, many factors really playing a role in terms of fertility in general for women and couples. These days we're dealing with economic changes, financial struggles. I think COVID really changed the landscape. There's a lot of uncertainty after the pandemic. There's many kind of broad issues at play. Student debt, access to health care, changes in politics and I think, from a male factor standpoint, there's also male factor contributions to declining fertility. We could talk about some of that as well in terms of sperm counts.

Host: Well, thank you for that. And so when we think of all the stress that you're mentioning and how that affects us overall. It affects our health in so many ways that we really can't even pinpoint how many ways. When we think of these fertility issues, Dr. Asanad, is it mostly the women or is it sometimes issues with the men? Is it kind of equal? Tell us a little bit about that.

Kian Asanad, MD: It's very common to think that it's mostly a female factor. I see a lot of couples in the office and it's kind of sad. A lot of the couples when they come, they say like, oh, I thought it was my fault or it's her fault. I didn't realize it was. There's a lot of fault at play, which is really not the case. I think there's contributions from a male standpoint, contributions from a female standpoint. There's definitely contributions from both. So female factors definitely play a role. Women over the age of 35 we know have decreased egg quality and quantity, and that plays a significant role, right?

 Women are born with a certain number of eggs and that changes as they get older. It's not the same for men. But male factors do play a huge role in couples having an inability to achieve a pregnancy. So, 15 to 20% of the time it's solely due to a male factor, there's no female factor involved. There is a male factor involved, and male factors contribute to about 30%. So overall men are contributing to couples' infertility about half the time. That's a lot. It's not insignificant whatsoever.

Ah Yeah,

Host: No, I'm really surprised to hear that statistic, Doctor. It's surprising because you do always think of it as being mostly a woman's problem. And as you say, we are born with just a certain amount of eggs. So we always just assume, and I know that you specialize in male infertility, and we're going to get into that in just a minute.

But I'd like you to speak to couples. How would they know if their fertility is in question? Are there signs and symptoms of low fertility? How many months do you have to go? How long do you have to have tried? Because I know when I was trying to get pregnant the first time and my doctor said, just relax, go ahead, have a lot of sex. Don't stress about it all the time. And then I got pregnant, but I was stressing out about it all the time.

Kian Asanad, MD: Easier said than done. I think achieving a pregnancy for couples is incredibly stressful. The American Society of Reproductive Medicine guidelines, they define infertility after 12 months for a couple of being inability to achieve a pregnancy. It can take 75 percent of couples, at least six months to achieve a pregnancy, 85 percent will achieve a pregnancy after 12 months of trying, and there's 15 percent of couples, who are, we quote, infertile or are unable to achieve a pregnancy after a year.

We don't really recommend testing until it's been about a year. But I think in 2024, discussing fertility is so much less taboo than it used to be. I see a ton of guys in the office who may or not even be in a relationship. Maybe they're in a relationship. They just want to get baseline testing.

It's easy to do. It's some blood tests and a semen test. I think getting a baseline reproductive health evaluation is a great idea. I think our guidelines also support testing after six months of being unable to achieve a pregnancy, if there's risk factors involved. So, for example, if the female partner's over the age of 35. We already know that they're at a significantly higher risk of being unable to achieve a pregnancy. You can do testing as soon as six months, or if the male has some sort of congenital problem. Maybe they have a history of undescended testicle. They've had testicular infections in the past are at higher risk for having infertility. Those are really the kind of the recommendations. Outside of that, there's not really any signs or symptoms per se, you could consider symptoms of low testosterone as maybe a potential sign. But even then, I mean, plenty of guys have low testosterone and have normal fertility and still achieve a pregnancy without an issue.

Host: So if somebody is concerned and they've waited the approximate time, what should they do? So does the woman first go to her obstetrician? Do they see a fertility specialist first and try simple medications, Clomid, that sort of thing? Tell us a little bit about the first steps. Who do they go see?

Kian Asanad, MD: From a female side, I think most commonly they're seeing an OBGYN, and getting baseline testings, baseline blood work, can also include a hystrosalpingogram, also known as a dye test where they shoot an x-ray and put some contrast in the uterus and the fallopian tubes to make sure there's no blockages.

Nowadays, they can also do an ultrasound with saline and air bubbles to see if those go all the way across, making sure there's no roadblocks, if you will, in the female reproductive tract. From a male side of things, a lot of men actually get semen testing done as really the only baseline screening, which I think is fine as a screening test.

A lot of these tests come from referrals from actually the female partner's physician, such as an OBGYN will order a semen analysis for the male. And if the semen analysis is normal, it's pretty unlikely to be a male factor. Let's see what we can optimize on the female side of things.

Sometimes we see, if the women are older and maybe this is a second marriage and, they're higher risk. Sometimes they'll go straight to an IVF clinic or a reproductive endocrinologist, an infertility specialist who can do some of the more kind of granular testing for women. Also, similarly, get a baseline semen analysis.

We'll typically refer men to either a urologist or a male fertility specialist like myself if there's evidence of abnormalities on a semen test, such as low sperm counts or the shape of the sperm is abnormal or they're not moving or something like that.

Host: So, what can specifically a man, as we're talking about male infertility at this point, do to improve that concentration, whether it's the shape, as you mentioned, morphology, motility, movement. What are some things you advise couples in general, but the men, to do to help the situation to increase their fertility?

Kian Asanad, MD: The first step is, just as in women, hormones are important for men. And 15 to 20 percent of men who present for a fertility evaluation will have a hormonal imbalance. Meaning maybe their testosterone levels are low, maybe the ratio of testosterone to their estrogen is abnormal, something of that sort.

And there's sometimes we can actually treat and optimize the male hormones, and we want to make sure the hormones are optimized from a sperm and semen quality standpoint. So sometimes if the sperm counts are low, for example, we find hormonal imbalances, for example, the testosterone is low. We can actually treat that with medicines like Clomid, which is used off label also in men to improve endogenous or testosterone production from within the testicle, and that can help improve some of the numbers.

Other things we do is, we do a physical exam, which is super important. And so for men, we're checking a few things. We're checking to make sure that the vas deferens, the tubes that carry the sperm are present and palpable. We're checking the size and consistency of the testicle. We're also checking for something called a varicocele or dilated veins of the testicle and scrotum.

Varicoceles are very common. They're found in 20 percent of men. It's the most common cause of infertility in men and can cause low sperm counts. It can cause severely low numbers actually. Sometimes it can cause issues with motility. Sometimes fixing the varicocele can really help improve their sperm quality as well.

And there's a lot of lifestyle factors, Melanie, that can play a role. We talk about smoking, marijuana, alcohol, those habits can impact fertility. Other lifestyle factors like heat exposure, being in a hot tub, sauna, steam room, even a single episode can disrupt sperm production. And there's a few supplements that I recommend guys that they can try, you know, supplements are not magical, but I do think they can help. So it's really a combination of these many different avenues that we can work on in improving a man's fertility potential.

Host: This is so interesting, Dr. Asanad. And before we get ready to wrap up, as we're speaking about the declining fertility rates and we mentioned the anxiety, the stress for both female and male or just the couple, whether it's same sex or not. It's an anxiety inducing time, it's stressful. What expectations would you like to speak to couples about when they're thinking about going through fertility treatments, even if they're going to go to a reproductive endocrinologist, as you mentioned. But can you just give us your best advice as a urologist that specializes in this? What expectations do you want them to have when they're going through this? And your best advice for really going through this.

Kian Asanad, MD: It's really a stressful time. It is a stressful time and it's, really hard to predict how quickly a couple can achieve a pregnancy. And so, when I see couples, it's easy to say don't stress, but I think there's a few things we can do to really alleviate that stress, right? So I see a lot of men and these are like 25, 30 year old young, healthy men, who are who have issues with erections. They have erectile dysfunction, which is very common in couples. And this is really due to stress and performance anxiety. So there's a lot of things we can treat and help optimize to help give the couple confidence.

I recommend really only having sex every other day during that fertile window. You don't need to have sex daily. It's been shown to be associated with increased stress. So, you know a few things we can do to help give the couple some alleviation that what they're doing is right and giving them time. Like I think going over the statistics with couples. It can take six months for 75 percent of couples to achieve a pregnancy is really eye opening, it could take 12 months for 85 percent of couples is really eye opening. And I think what contributes to that is you have friends and family and they achieved a pregnancy within a week. And you don't really know the couples who took nine months or longer. And so I think as we can continue to have discussions about this and kind of normalize discussions about fertility and infertility, I think that'll really help get us where we want to be.

Host: Thank you so much, Dr. Asanad, for joining us and sharing your incredible expertise. What an interesting topic. And if you're concerned about your fertility and want to schedule a consultation with Dr. Asanad, you can call 661-839-1804. You can also always visit the free health information library at library.henrymayo.com. So much great information. And did I mention it's free? Yeah. So there's lots of information there. That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. Please always remember to subscribe, rate, and review It's Your Health Radio on Apple podcasts, Spotify, iHeart, and Pandora.

Until next time, I'm Melanie Cole. Thanks so much for joining us.