Scott Webb (Host): Having low sperm count could impact a couple's ability to conceive a child. Many men aren't aware of their low sperm amounts unless they have difficulty conceiving and seek help from a physician. Many lifestyle factors and medical conditions can affect sperm count. However, there are some ways to produce healthy sperm and improve fertility. And joining me today is Dr. Keri Greenseid. She's a reproductive endocrinologist and OB-GYN.

Host: Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. I'm Scott Webb.

Doctor, it's so nice to have your time today. We're going to talk about low sperm count, maybe some of the things we think can cause that versus the reality, what's on the horizon, how you help folks, and all of that. So just as a little bit of a foundation here, what does that mean? If I say low sperm count, what does that mean?

Dr. Keri Greenseid: So, low sperm count means that the actual concentration of sperm in the ejaculate is technically less than 20 million sperm per milliliter. However, there are many other factors in addition to sperm count that can affect male fertility.

Host: Yeah. As I was telling you, you know, I was lucky enough to have both of my kids without any trouble, no fertility issues. But I certainly have had friends and family who have had these issues. And maybe it's obvious, but how does someone know if they have low sperm count? Do they not know until they come and see you? Or have they've been having these fertility issues and think, "Oh, maybe it's me. I should maybe talk to Dr. Greenseid"?

Dr. Keri Greenseid: So, many men will have no idea that they have a low sperm count unless they have seen a physician or had a semen analysis performed, looking for low sperm count.

Host: Yeah, I see what you mean. So, like I said, I figured it would be obvious like, "We've been trying to have a baby and it's not happening. So, it's either her or it's me or somewhere in the middle there." So obviously, you reach out to your provider. There's obviously some tests and things you can do. Does the amount of semen predict the amount of sperm? Are those things connected?

Dr. Keri Greenseid: It is not. It is not a good prediction whether the amount of semen can be normal and the sperm counts can be low. The amount of semen can actually be low, and the sperm counts can be normal. So unfortunately, that is not a good way to predict what the actual sperm count is.

Host: It's so good to have the advice of experts because, you know, we think we know things until we talk to doctors and we go, "Oh, I was wrong about all of that." Okay. So, let's talk about things that maybe folks are either right or wrong about. Let's talk about what causes low sperm count, and I know there's a sort of a laundry list of things that we think maybe are contributing factors. Is it tight underwear, CBD, marijuana, smoking? Is it basically lifestyle and behavior, family history? Generally speaking, doctor, what do we know about this? What causes low sperm count?

Dr. Keri Greenseid: There are so many factors that can contribute to low sperm count, including even unexplained factors where men can come in and have low sperm counts, and we are unable to find a cause for it. When we think about some of the medical causes that can be associated with low sperm count, there are a variety of different reasons. We often break it down on where the problem is starting from. So, sperm production is actually stimulated from hormones from a man's brain. So actually, there can be hormonal production or issues in a man's brain that could be contributing to their low sperm count. And then, we know that sperm is made in the testicles. And so, the hormonal production can be perfectly normal, but the testicles could be the issue leading to low sperm production. And there are some men who actually have normal hormonal production, normal testicular production of sperm, but there's actually an outlet obstruction where the sperm is unable to be ejaculated or it is blocked from being ejaculated. And so, these are the different reasons that could be associated with it.

In addition to this, there's also lifestyle issues that can be contributing. And, you know, some people ask when they come in, "Does tight underwear make a difference?" And the answer to that is probably not. Sitting in the hot tub or a sauna is unlikely to affect sperm production and male fertility. But let's talk about where did this myth come from. The rationale behind this is that sperm production is decreased by high heat around the testicles. So if we keep the testicles cool, we can improve fertility. However, even though there's no evidence that wearing loose fitting underwear is helpful or sitting in a hot tub or a sauna is not likely to affect sperm production and male fertility, it's always possible that if somebody is sitting in a hot tub or sauna for 20 minutes or longer, they could temporarily lower their sperm concentrations. And so, we often tell patients to minimize that when they are trying to conceive. There's also a lot of talk about bicycling and if that can impact sperm production. And the answer is possibly. But again, unlikely to be a drastic cause of low sperm count unless a man is cycling, you know, for an extreme amount of time, that could be contributing.

Other lifestyle changes that we often recommend when couples are trying to conceive is to avoid smoking, limiting alcohol intake, and avoiding marijuana or other recreational drugs. Eating a healthy diet and maintaining a healthy weight, because we know these things can somewhat impact the sperm parameters.

Host: Right. Yeah. So, it sounds like it's possibly mental, possibly physical, and we really, really need experts like yourself to help us sort through this. So, it could be behavior, it could be lifestyle, it could be diet. There's all things that we could do to improve our chances. There could be some, you know, mental health involved, some stress involved from work or whatever it might be. So, again, great that we have your expertise to help us sort it all out and figure out, you know, what the root causes are of low sperm count and maybe this one falls under the myths as well. Does the frequency of sex or ejaculation have any impact on sperm count?

Dr. Keri Greenseid: This is a great question. And yes, this can impact sperm count. Most of the data shows that the sperm quality is optimal. And we didn't get into this too much, but we can, talking about the different elements of a semen analysis. But usually, semen quality is optimal when there's two to three days of ejaculatory abstinence. So, that means when I have men come in and give me a sperm sample that I want to analyze, I usually tell them to avoid ejaculation for two to three days prior to coming in for their semen analysis. With that being said, you don't want to wait too much longer than that either. So, we usually tell men to come in usually between two to five days after their last ejaculation.

Now, with that being said, when couples ask me how often should they have intercourse when they're trying to get pregnant, I usually tell them to have intercourse every one to two days when they're in the timeframe to yield the highest success rate, and that is usually for the six days leading up to ovulation, including that day of ovulation. So, it's actually for the five days leading up to ovulation and including the day of ovulation, that yields the highest success in achieving a pregnancy, especially when intercourse is had two days prior to ovulation and the day of ovulation.

Things that do not affect the chance of conception are the position when a couple is having intercourse, the presence or absence of female orgasm or the female position after a male ejaculates. So, you know, a lot of my patients ask this, and a lot of patients probably don't ask because they're embarrassed to ask. And I think that's important to know.

Host: Right.

Dr. Keri Greenseid: What I do think affects success the most, and I think it's important for couples to know is the age of the female actually has one of the highest impacts on success rate when couples are trying to get pregnant.

Host: Yeah. My wife, when we had our second child, our daughter, my wife was 36. And she was stunned to find out that she was of advanced maternal age.

Dr. Keri Greenseid: I know.

dp-valleyhealth_vhs016_scott-j8jcz44t8_2023-apr-24-1613pm-utc-riverside: We we went to see her, you know, went to see the doctor. And we're sitting there and the doctor said, "Well, of course, you are of advanced maternal age." And we both looked at each other and we're like, "Wow, 36 is that old? Holy cow." Like, I had no idea. So, yeah, maybe you could talk a little bit more about that, about the female age. You know, I often hear of, you know, especially like actresses, you know, having babies in their mid-40s, and I'm like, "Well, if 36 was old, you know, 45, oh my gosh, how did she even pull that off?"

Dr. Keri Greenseid: You know, it's really true. And the media sometimes doesn't help us because sometimes they present a portion of the case but not the full case, and it gives patients sometimes this idea that it won't be an issue or it'll be easy to get pregnant at those older maternal ages. I know that term advanced maternal age is rough. But unfortunately, it is commonly used in the medical community to describe anybody who's 35 and above. And the reason that age came into play is that that is the age when the risk for having a child with Down syndrome or other genetic abnormalities begins to increase. And so when we see that, that's where that term advanced maternal age comes from.

It also helps us to tell patients when to potentially seek a workup for infertility. And we tell people that when the woman is under age 35, they can try for a year and then seek an infertility workup. And if the woman is over 35, we often recommend seeking an infertility workup if they've tried for six months without getting pregnant. With that being said, I usually tell patients that if you have some other concerns, let's say a woman is not ovulating, or her menstrual cycles are extremely irregular, or she has other diagnoses such as endometriosis or history of pelvic inflammatory disease or prior surgeries, or maybe a male somehow knows he has a male factor or he has some other suspicion or any type of sexual dysfunction, we're happy to see patients prior to that timeframe.

Host: Sure. Yeah. And if someone has been diagnosed, a man obviously has been diagnosed with low sperm count, what are their options, doctor? I know before we got rolling here, you were saying basically like there's so much we can do, so let's share that with the audience.

Dr. Keri Greenseid: There is so much we can do to help couples with a low sperm count. I always like to first start with a workup, of course, and see if we're able to identify what the actual cause is for the low sperm count. But regardless of the cause, if it's unable to be fixed by fixing that cause, we can work with low sperm to achieve a pregnancy.

So, one of the most common ways that we achieve a pregnancy in patients who have male factor infertility or low sperm counts is with in vitro fertilization or IVF, many couples have heard of that. And this involves collecting eggs from the ovaries of a woman and then fertilizing them with a sperm in the laboratory. And this allows us to actually see the eggs and the sperm under the microscope. And we have the opportunity to inseminate the eggs, which is mixing the eggs with the sperm or injecting a single sperm into the egg if the sperm parameters are very low. And this has been amazing at achieving fertility in couples that may not be able to achieve a pregnancy trying naturally.

Host: This is all really fascinating. I love listening to compassionate experts like yourself share this knowledge and just trying to piece it all together. And of course, you know, if folks are really interested in learning more, having trouble, whatever it might be, speak with their own providers. This is just some, you know, free medical advice. But obviously if they're trying to conceive and they're having issues, speak with your own doctors, so that they can, you know, get the help that they need. I'm wondering, doctor, how long, you know if a couple's trying to get pregnant, how long should they try before seeing a fertility specialist? Is it a month, three months, six months? I know it took us a long time apparently. Maybe because my wife was of advanced maternal age, it took us a long time to get pregnant, to have our daughter. And we had just about sort of given up or just about gotten to a point where we were going to see a fertility specialist but didn't need to. What's your best advice on how long folks should try before seeing a specialist?

Dr. Keri Greenseid: I would recommend that if the woman is under age 35, couples can try to conceive for a year prior to pursuing a workup. But if the woman is 35 or above, I would recommend that they try for six months and, if they're unsuccessful, to come see a physician for an evaluation and an infertility workup.

Two other things that I thought might be good to discuss with one other treatment option that comes up for fertility treatment. So, one of the other common fertility treatments is something called IUI, which stands for intrauterine insemination. And this is a process that consists of washing a sperm specimen to remove any prostaglandins or sperm proteins that can promote an allergic reaction if they were ejected into the uterus. And so basically, an IUI takes a sperm specimen, washes it, and concentrates it into a smaller volume, which we can then directly inject into the uterine cavity. It sounds very technical, but it's not painful. And this can increase pregnancy rates. It's often combined with other medical treatments for the female, and it can increase pregnancy rates. It is not often our first choice when there is a more severe male factor in play. But when there is any type of erectile or ejaculatory dysfunction or couples that are unable to attempt conception for a variety of different reasons, maybe it's timing, maybe it's travel, maybe they're missing things, from a timing perspective, we can pursue IUI as another course of action prior to or as opposed to moving to IVF.

And one of the other things that I thought we could talk about was the semen analysis. The semen analysis looks not only at sperm count, which is something we were discussing today, but it also looks at volume, which is just the amount of semen that is ejaculated; the sperm count, which of course is critical, that's the amount of sperm that's in that volume. But we also want to see the motility, which is the percentage of the sperm that are actually moving and alive. And one other thing that we look at is the sperm morphology, which describes the shape of the sperm, and it is an assessment of the quality of the sperm. So all of these factors come into play when we are looking at a semen analysis and analyzing potential reasons why a couple may not be having success in achieving a pregnancy.

Host: Got it. And as we wrap up here, doctor, I was reading, you know, doing some research for this podcast about sort of a global crisis, if you will, of low male sperm count, and just wanted to give you a chance, final thoughts and takeaways, and maybe you can take that one on. Is that true? Is there sort of a global crisis?

Dr. Keri Greenseid: So, this is somewhat of a tricky question to answer, but the answer is possibly. There was a study that was published in the Journal of Human Reproduction. And what it reported was there was a significant decline in sperm counts between 1973 and 2018. Now, when this gets publicized, that sounds really scary, a significant decline in sperm counts.

However, let's talk about this a little bit more. This study was something called a meta-analysis. And what a meta-analysis is, it's a type of statistical analysis that combines many scientific studies together. So, this is helpful because it can increase the number of patients that are being analyzed. However, there are some methodological problems with meta-analysis. And it is sometimes prone to drawing conclusions that may not actually be entirely correct.

The other thing is, is that although a decline in sperm count was seen, this doesn't mean that human fertility is going to decline because if the parameters of the sperm are still in the normal range, they're just lower within the normal range, this may not impact fertility at all. And so, it is possible that there could be a global crisis of lower male sperm count. But if it's not impacting fertility, it is much less concerning.

Host: I see what you mean. Yeah. Well, this has been so educational today, doctor. I really appreciate your time and your expertise, your compassion. I've learned a lot, I'm sure listeners have as well. So, thank you so much. You stay well.

Dr. Keri Greenseid: Thank you.

Host: And for more information about fertility services at Valley, please visit valleyhealth.com/fertility or call 1-800-VALLEY-1, that's 1-800-825-5391 to schedule an appointment. And thanks for listening to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-291-6090 or email valleypodcast@valleyhealth.com. I'm Scott Webb. Stay well.