What a urologist wants you to know about male infertility

By Dr. Jamin Brahmbhatt, CNN

(CNN) — When opposite sex couples are trying and failing to get pregnant, the attention often focuses on the woman. That’s not always the case.

Several times a month, men come into my office to ask, “Could I really be the problem?”

Why are some men in denial? I think the possibility that the man could have fertility issues can be more than just a clinical concern. For men who associate their virility with their identity and self-worth, it could lead to a deep personal crisis.

While it’s easy for me to offer tests and treatments for infertility, it’s difficult to handle the emotional and physical challenges that may arise for my patient or the couple on their journey to parenthood. I’ve seen couples split up over the struggle to get pregnant.

The recent Alabama state court ruling on what defines an embryo and access to assisted reproductive care has thrust fertility issues into the spotlight, often spotlighting them primarily as women’s concerns. That isn’t the case, which is why it’s crucial to broaden our focus and address male infertility. It also contributes to the challenges couples face and affects the people involved.

When to get treatment for male infertility

In the United States, about 1 in 8 couples have difficulties in getting pregnant or sustaining a pregnancy. Within this context, male infertility plays a significant role, contributing to around 40% of cases of infertility.

Couples are generally advised to seek fertility testing after one year of trying to conceive without success, based on the time it may take for healthy couples when the woman is under age 35. When the woman is over age 35, couples should seek help after just six months of trying. The latter is due to the decrease in fertility that can occur with age, making early intervention important. Even though the ages listed are dependent on the female partner, it’s essential both partners get tested during the fertility evaluation.

Moreover, if there are specific health concerns that might affect fertility, such as known genetic conditions, previous surgeries affecting the reproductive organs, previous cancers that required chemotherapy or chronic diseases such as diabetes, men should consult with a health care provider before beginning to try for a pregnancy. This proactive approach helps address any potential complications early in the process and sets the stage for a more informed and focused attempt at conception.

Clearing the air with facts

The first few minutes of my encounter with my male patients is clearing the air on what is fact and myth about their fertility. It’s about getting on the same page on what is online hype and what is real medicine. Here are the top points I clear up with my patient.

Men’s fertility naturally declines with age, affecting sperm quality and genetic integrity. This process is influenced by lifestyle choices such as smoking cigarettes or vaping, excessive alcohol use and obesity, which significantly reduce sperm quality and production. Health issues such as varicocele, infections and hormone imbalances also impair fertility, just as environmental factors such as heavy metals and excessive heat can damage sperm function. Stress, too, disrupts hormones necessary for sperm production.

It’s important to dispel myths: Tight underwear and recreational cycling have minimal impact on fertility, contrary to popular belief. Supplements, while beneficial for specific deficiencies, do not universally enhance fertility and should be used with caution. Lastly, frequent ejaculations do not harm overall fertility. They may temporarily lower sperm count but can help improve the chances of successful fertilization by flushing out older sperm.

How to diagnose male infertility

Men of any age can begin evaluating their fertility at any time, and modern technology makes it easier than ever. Various “fertility” apps and semen analysis kits available for home use allow men to assess the quality of their sperm without a doctor’s prescription. These tools provide an important starting point, but for those seeking a comprehensive understanding of their reproductive health, consulting with a specialist is key.

Urologists with expertise in male reproductive health are equipped to conduct thorough evaluations that go far beyond what home tests can offer, addressing the intricate issues of male infertility that can be influenced by genetic conditions, hormonal imbalances, lifestyle factors and environmental exposures.

Semen analysis is a critical diagnostic tool in this process. It evaluates sperm count, motility and morphology — key indicators of sperm health. A sperm count below 15 million per milliliter, known as oligospermia, can reduce the likelihood of successful fertilization. Motility issues, where less than 40% of sperm are moving effectively, can hinder their journey to an egg. Abnormal morphology, with fewer than 4% of sperm having a normal shape, can impede the sperm’s ability to fertilize an egg effectively.

A complete fertility evaluation also includes physical exams to check for varicoceles or other anomalies, hormone tests to uncover potential imbalances that could affect sperm production, and imaging studies to identify structural obstacles. By integrating these data points, health care providers can determine the most appropriate treatment options tailored to each individual’s unique circumstances, ranging from lifestyle adjustments and medical interventions to surgical solutions.

Treating male infertility

Treating your male fertility issues can start right now. If you’re sitting, stand up, and if you’re standing, start moving. Any improvements in physical health and activity can improve fertility potential. What else you can do depends on what’s found on your detailed evaluation.

Your doctor may recommend the following changes:

Start nutritional supplements. Take caution though. Not all supplements that promote fertility improvement are the same. A 2019 study found that many claims made on over-the-counter fertility supplements are not backed by sufficient evidence and should be used with caution. Backed by research, in our office we will start men on a cocktail of Coenzyme Q10, fish oil and a combination supplement that is full of beneficial antioxidants (vitamin D, vitamin E, zinc and selenium).

Get your large veins repaired. Recent guidelines backed by research have promoted the surgical correction of high-grade varicoceles for the improvement of sperm quality and even testosterone values. This procedure addresses the abnormal dilation of veins in the scrotum, which can alter the temperature around the testicles and impair sperm production. The improvements post-surgery can lead to better chances of natural conception.

Start medications. Depending on the underlying cause of infertility, medications can play a crucial role. Hormonal imbalances, for instance, might be corrected with medications that enhance the body’s natural production of testosterone and other hormones involved in sperm production. These non-testosterone-based medications include clomiphene citrate or anastrozole.

Direct testosterone replacement is not often recommended as it can shut up complete sperm production. However, recent studies have found the use of intranasal testosterone as a viable option for men who want to continue with replacement therapy but not affect their sperm counts.

Assisted production may be needed. Intracytoplasmic sperm injection is a powerful technique often used in conjunction with in vitro fertilization. It involves directly injecting a single sperm into an egg to facilitate fertilization. It is particularly useful for men with low sperm counts or issues with sperm motility or morphology.

Don’t stay silent

Tackling male infertility requires care that extends beyond the confines of medical treatment. In a culture where men don’t talk about fertility and infertility wrongly defines someone as less of a man, we need to create a culture where we can talk about male reproductive health.

As a urologist specializing in this field, I see the critical need for greater awareness and understanding. By providing both emotional support and comprehensive education on the topic, we can transform the conversation around male infertility, making it a subject that’s openly discussed rather than whispered about in the bedroom or the clinic.

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