Age Does Matter For A Male's Fertility

Everyone knows about advanced maternal age.  Everyone knows that as women age it becomes progressively difficult to conceive a pregnancy.   Everyone know that beyond a certain age, women can no longer become pregnant.  Everyone knows that certain birth defects are associated with advanced maternal age.  

But how about men?

Emerging scientific data demonstrate that advanced paternal age exists and is associated with fertility problems.   Advanced paternal age is associated with an increase in sperm DNA damage.   Advanced paternal age is associated with increase incidence of certain both defects (though this is still rare).   Advanced paternal age is associated with an impaired ability of a sperm to fertilize an egg, lower success rates with in vitro fertilization, and lower success rates with ICSI.   

What can one do about it?

Counseling

Sperm cryopreservation prior to age 50

Pre-implantation genetic diagnosis

Sperm DNA testing

Thanks,

Dr Schoor

The Semen Analysis: What it can and cannot tell us about male infertility.

For most men, the fertility evaluation starts with a semen analysis and most of these men will have normal semen analyses.  Does this mean that they are fine?  Does it mean that they don't have a male factor--a condition that is preventing their sperm from fertilizing an egg?

The answer is no it does not.

The semen analysis is a very crude indicator of a man's true fertility potential.  In other words it is very possibl to have a serious male infertility factor yet have a normal semen analysis.  How is this possible?

The semen analysis looks at a number of measures.   These features are:

• Seminal fluid volume
• Seminal fluid pH ( a measure of acidity)
• Seminal fluid viscosity (a measure of liguidity)
• Sperm concerntration
• Sperm motility
• Sperm morphology ( a measure of the sperm's shape)

While an abnormality in one or more of these measures indicates that a male factor may exist, an analysis in which all these features are normal does not mean that such a condition is absent.

So why do it at all?

Because it is the best we have and it is a good place to start.  It is a good, though imperfect, screening tool.   Used this way, if several semen analyses are normal, then it is less likely that the man will have a male factor condition.

Of course, as in everything in medical practice, there are exceptions.  Men who smoke or who are exposed to other environmental toxicants can have normal semen analyses yet have sperm that do not function properly.  I have this also in men with testis tumors and occult diabetes (undiagnosed diabetes).  I have also seen this in men with varicoceles.

So how, in my opinion, should we counsel a couple with infertility.  I think it is reasonable to start with several semen analyses rathe than just one.  If 2 or 3 are normal and the man has no urologic complaints, than the couple may proceed with assisted reproduction aimed at the women.  However, if after several attempts at the lower cost assisted reproductive procedures, like artificial insemination, the woman is still not pregnant and the  next option is for the couple to proceed to in-vitro or ICSI, then I think referral to a urologist is reasonable and beneficial.  Often it is the urologist who uncovers a treatable and reversible male factor that was probably contributing to the couple's infertility problem.  At best, after correction of the male factor the couple can enjoy a natural, unassisted pregnancy.  At worst, the couple proceeds with in-vitro after a brief and inexpensive delay. 

Thanks,

Dr Schoor

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REVERSABLE CAUSES OF MALE INFERTILITY

Here are some treatable and reversable conditions that cause fertility problems in men. In my office in Smithtown NY, I see patients with these conditions routinely.

1. Smoking: Even intermittent smoking smoking affects sperm production and function. Smokers can have normal semen analyses yet have severe defects in important sperm functions that are critical to fertilization.
2. Varicoceles: These dilated, varicoce veins are common in all men, but much more common in men with fertility problems. They can fixed.
3. Infections: prostate infections, diverticulitis, epididymitis, or bladder infections can transiently impair sperm production and function.
4. Malignancy: Cancer itself can cause infertility. Cancer treatments can also cause male infertility
5. Enironmental toxicants: Second hand smoke, soil fertilizers, dry cleaning waste, plastic bottle chemical products, publishing dyes can all lower sperm counts or impair sperm function.

These factors can all be found on a thorough clinical history and physical examination.

SPERM MORPHOLOGY: DO WANT STRICT OR STANDARD, AND WHAT’S THE DIFFERENCE?

Strict morphology is
not designed to be a screening test for male infertility. It is far too sensitive for that
indication. In fact, using strict
morphology, only 5% of men will have normal sperm and thus be considered
fertile. Rather than use strict
morphology, W.H.O 3^rd edition morphologies are designed for
screening populations of men for infertility.
Under this classification system, up to 50% of m en will have normal
sperm.

In the 1950’s, McLeod, an andrologist, began to examine the
shape of sperm in men of proven fertility and sterility. His research led to a classification
system. Under McLeod’s classification
system, only the shape of the sperm head mattered and 50% of men had normal
sperm morphology.

Things sure have changed.

Now most labs use Strict Morphology—also known as Kruger
Morphology—or the World Health Organization standard, the W.H.O 4^th
edition. These methods take sperm head,
midpiece, and tail features into consideration.
In the early 1990s, when these categorization schemas were developed, 20
to 50% of men had abnormal sperm morphologic features. Now, only about 5% of men will have “normal”
sperm when these strict criteria are applied.
Why is that?

Well, no one knows for sure, but one can infer that part of
the problem lies in the way that sperm morphology information is used. Strict morphology is used to decide on when
to send a couple for ICSI rather than standard IVF. Couples with less than 5% normal forms have
better fertilization rates with ICSI compared to IVF. Used In this way, morphology assessments can
only determine which treatment option to pursue.

Strict morphology is not designed to be a screening test for
male infertility. Iit is far too
sensitive for that indication. In fact,
using strict morphology, only 5% of men will have normal sperm. Rather than use strict morphology, W.H.O 3^rd
edition morphologies are designed for screening populations of men for
infertility. Under this classification
system, up to 50% of men will have normal sperm.

Ask if your lab can do both Strict and
W.H.O 3^rd and report them simultaneously. That way doctors can get the information they
need and patients can avoid unnecessary worry.

Thanks,

Richard A Schoor MD FACS

Clomid and Male Fertility

I like clomid--AKA clomiphene citrate. It is a good drug and very effective for the right patient at the right time. Unfortunately, clomid is not indicated or approved for use in men and it is expensive. Clomid is indicated for use in infertile woman and is used to induce ovulation. Men don't ovulate. Prescribing clomid for men is difficult due to insurance coverage issues. Every time I write for clomid, I get a flurry of phone calls, first from the pharmacist who informs that the clomid is only for women, then from the patient who informs me that the pharmacist informed them that clomid is only for women, and then I get the phone calls back and forth to the insurance carrier as I try to get the medication covered for the patient. As you can imagine, prescribing clomid to men is a royal pain and I, therefore, really and truly only do it when it is indicated.

Here is when I think it works.

• Men with low AM testosterone and low sperm counts AND low or low normal FSH and LH levels.

Other male infertility specialists that I know and respect use clomid in other situations as well, such as for men with low testosterone and sperm counts but high/high normal FSH/LH levels. Personally, I don't do this, but they do and claim to have results.

When I have men on clomid, I like to check hormone levels, specifically testosterone and estradiol, every 2 or so weeks, at least until hormone levels stabilize. Why do I check estradiol levels? Testosterone can be converted to estradiol, which can then cause breast enlargement.

There you have it.

Thanks,

Dr S.

The Testis Biopsy

The testicular biopsy is done during the evaluation of infertilility in men that do not have sperm in the ejaculate--azoospermia. The testis biopsy is essentially done to differentiate between the 2 causes of azoospermia--obstruction vs testis failure. Testis biopsies will typically reveal 1 of several possible pathology types:

• Normal


• Hypospermatogenesis


• Germ Cell Aplasia


• Inflammation

Testis biopsies are not performed, in general, in the evaluation of a testicular mass or tumor, such as testicular cancer.

The testis biopsy is a diagnostic procedure only and does not, in and of itself, help couples become pregnant. Occasionally, a testis biopsy is done in conjunction with a testicular sperm aspiration.

The above testis biopsy result was from a patient with azoospermia and shows hypospermatogenesis.

Thanks.

The IU.