Search for tag: "male infertility"

Interviewer: When it comes to issues of infertility, it's important that both members of the couple are involved in the diagnosis and treatment of the issue.

To find out why that is, we're joined by Dr. Kelli Gross, a men's health specialist and assistant professor in urology at University of Utah Health.

Now, Dr. Gross, why is it so important that both partners are involved when we're trying to, say, diagnose why a couple can't get pregnant?

Dr. Gross: It's incredibly common that men come to see me and they've never been considered at all in their fertility workup. We find that up to about 40% of the time, there is what we call male-factor infertility or an abnormality in fertility in the male partner. So it can be greatly underdiagnosed.

With all of the technology that we have in fertility, things like in vitro fertilization can make it so that optimizing the male partner is not as essential as it once was. But it can be a lot more expensive and have its own set of downsides.

Interviewer: So when you say that it's 40% of the time, does that mean that it is often misdiagnosed, or do we often deal with the female issues more often?

Dr. Gross: It wouldn't necessarily be that it's misdiagnosed, more that it's ignored. With couples, they may be experiencing infertility without having any major health issues or causes. It can be both sides things are a little bit abnormal. So having things that are less than optimal in one partner can still lead to issues, but sometimes we just get around these by other sorts of things.

Interviewer: And what kind of things are those?

Dr. Gross: So it would be things like intrauterine insemination or in vitro fertilization. So what that is, for intrauterine insemination, is we put the sperm directly into the uterus. So it bypasses some abnormalities if there are low counts in the sperm or if there are issues on the female side.

We can also do things like in vitro fertilization, which is where the egg and the sperm are joined outside of the body. And that can, likewise, overcome a lot of issues on both sides, such as having very low sperm counts or issues from a female partner side.

Interviewer: So if a couple is trying to identify what is causing their infertility, why is it more economical to have both partners involved from the start?

Dr. Gross: So there are things that we can improve from a male side that can make it easier to get pregnant either naturally or with help. So, for example, there are certain procedures that we do that can improve sperm counts in certain men.

So if we have somebody who has very low sperm counts, then doing something like that where they previously would not be a candidate for something like intrauterine insemination, which takes a certain amount of sperm, by raising those counts, we then make them a candidate for that, or they are able to get pregnant naturally because the sperm counts are higher. So they can save a lot of money from the cost of, for example, in vitro fertilization.

Interviewer: We spoke about why it's so important to have both partners involved in diagnosing and treating infertility. How long should a couple be trying before they technically are dealing with infertility issues, or when should they start to see a specialist?

Dr. Gross: So we usually define infertility as trying for one year. And that's kind of just because 90% of couples will get pregnant within one year.

It's kind of arbitrary. So, for example, if you've been in a long-distance relationship and you haven't been having intercourse, of course, a year may not mean that there's anything wrong biologically. And at the same time, if there's any sort of history or medical concerns that make you seek treatment earlier, there's nothing wrong with that at all. We don't say, "Keep trying," necessarily. We would typically evaluate to see if there was anything that we can improve, no matter what time it is.

Interviewer: For a couple that is having difficulty getting pregnant, as often as 40% of the time, it's actually an issue with the male partner. Why is that, and what are some of the more common things that can be causing infertility in men?

We're joined by Dr. Kelli Gross, a men's health specialist and Assistant Professor in urology at University of Utah Health.

Now, Dr. Gross, if we were to pick out the top three reasons why men might be infertile, what are they and how can they be treated?

Dr. Gross: So, number one, one of the top modifiable reasons that I see is exposure of the testicles to heat. What that commonly is, is a hot tub, bathtub, sauna. And the reason why is because sperm really likes the cooler temperature of the testicles. The testicles are outside of the body. They're about four degrees cooler than the rest of the body. And things like hot tubs, that increases the heat and the sperm just doesn't work as well, isn't produced as well.

People are surprised that those effects last about three months. Seventy-four days is the lifecycle of the sperm, so going in the hot tub once is going to potentially affect your fertility for the next three months.

Interviewer: Wow.

Dr. Gross: Yeah. People are always shocked by that number. Now, we found that things like showers don't necessarily make a big difference, the kind of underwear that you wear, those sorts of things. But a lot of direct heat from the testicle you do want to avoid.

Interviewer: I guess how big of a temperature change are we talking before we see that 74-day impact on the sperm count or functional sperm count?

Dr. Gross: I don't know if we necessarily know an exact number, but I usually advise patients the testicles are four degrees cooler than the rest of the body, so kind of keep it under that point.

Another common thing that we see is fevers. So after fevers, it's incredibly common to see abnormalities on a semen analysis.

Interviewer: Wow. Okay. So that's number one. That's pretty common. It's not something that's at the forefront of your mind. What about number two?

Dr. Gross: So number two would be something called a varicocele. Those are dilated veins to the testicle. So if you think about varicose veins in your legs, it's the same kind of thing. And they happen in about 15% to 20% of men overall, but we find it in up to about 50% of men who see a urologist for fertility issues. They are repairable surgically.

We think the reason why they have such an effect is potentially because it does trap heat. So the blood pools in those dilated veins, so it traps more heat in the testicles, which sperm doesn't like.

Interviewer: And what causes these veins? Is it just genetics? Is it just maybe lifestyle stuff?

Dr. Gross: It's mostly just genetics, kind of the way that you were born. They're incredibly common. So it's in part just the way that we're constructed, the way the veins have to travel such a long distance.

Interviewer: And so is this an outpatient procedure type of surgery? What kind of . . . what is involved in treating the varicocele?

Dr. Gross: Yes, it's an outpatient surgery. It takes about an hour more or less, depending on if we have to do both sides or what. We make an incision that's about an inch, inch and a half long, and then just divide all the veins. It's fairly straightforward as far as surgeries go. Not everyone needs it, but a fertility specialist can help determine if it's something that needs to be repaired.

Interviewer: Okay. So we have heat. We have an outpatient procedure if there are some extra veins or some varicoceles that have been formed. What about number three? What is the third most common thing?

Dr. Gross: So number three that I see very frequently is people who are on supplements that can potentially harm fertility or other medications. Testosterone, for example, is one of the biggest culprits that I see. Most other medications that are prescribed aren't going to have a big effect.

But there are certain other ones like Propecia or Finasteride, which is used for hair loss, that can potentially affect fertility. Cancer medications, unsurprisingly, can affect fertility. But the one that people don't really expect is supplements. They've done studies on supplements, and I've been absolutely shocked with what's actually in a lot of the supplements that we take. For example, there are steroid hormones. There are things like testosterone, including testosterone, that are in some of these supplements, even ones that aren't labeled, or that you would necessarily worry about. There's even oral testosterone, which is actually pretty bad for your liver. It's just not well regulated.

I see patients all the time who I look at their hormone panels and I'm like, "You may not be on testosterone, but there's something that you're taking that has testosterone in it." And we usually can pick something out and stop it and then those effects go away.

Interviewer: Wow. And so are these just over-the-counter type? Are we looking at like a daily multivitamin supplement? Are we looking at, say, muscle building, those things that you get in the big jugs at the supplement store?

Dr. Gross: Not usually the multivitamin, the Centrum or anything like that. Those are usually pretty safe. But it's like pre-workouts, even ones that aren't "boost your testosterone pre-workout," just regular pre-workouts, anything that's kind of marketed towards the erectile dysfunction, men's health kind of thing. I've seen potentially having issues with that.

Interviewer: And how long does it usually take for someone to see the effects go away after they stop taking it?

Dr. Gross: It can really vary. For example, with people who've been on testosterone for years, it can take up to about 18 months for that to come back. So in 90% of men it'll come back in about 18 months, but 3 months is usually a minimum. And some people won't come back in at all.

Interviewer: Okay. So those are three common things that can be causing male infertility. Now, Dr. Gross, how long should a couple be trying before they come and see a specialist like yourself?

Dr. Gross: So it's different for every couple. We generally say if after a year, definitely come in. But we won't question if it's sooner. It's easy to check to see if things are normal or not.

Interviewer: At-home male fertility tests that you get over the counter. You go to the drugstore, you get the fertility test, you take it. Does that give you helpful information? Are they accurate? Are they worthwhile? That's what we're going to find out today from urologist Dr. John Smith. What is your take on those over-the-counter, at-home male fertility tests?

Dr. Smith: We see a lot of people for fertility at the University of Utah, and those at-home tests really are very rudimentary. They don't tell you a lot of information. They pretty much tell you if you have an adequate amount of sperm in the ejaculate or not. And that's really all they can tell you.

So if you had a positive test where it said, "Hey, you've got enough," that doesn't tell you if those sperm are alive, if there's any motion in those sperm, the morphology or the shape of those sperm. It doesn't give you really any other information. The only thing it tells you is if there's enough sperm there to hopefully not have fertility issues.

And the way these tests work is similar to a pregnancy test where it looks for a protein that's only on the sperm. And so that's how they quantify. So you've got to have enough of that protein in order to have the test come back positive that you've got a high enough quantity of sperm to have a normal sperm count.

Interviewer: But if partners have been trying to have kids and they have not been successful, and the man goes and gets this and finds out, "Oh, hey, I've got enough sperm according to this test because they detected enough protein," but you're still not having kids. You really haven't solved anything by taking the test, have you?

Dr. Smith: No. You really haven't. And that's the other part of things that go on. There's also two parties when you're trying to have kids. You've got the male side of fertility and the female side of fertility, and we're going to talk about the male side today.

But if you have been trying unsuccessfully, having unprotected intercourse for over . . . usually the definition is one year. Some people will say six months to a year. But all in all, if you've been trying and you haven't been successful and you get that at-home test and it tells you that there's enough sperm there, that still doesn't tell you that there's not necessarily a problem. Because if there's low motility, meaning you don't have any that can move and get where they need to be, the viability of things, so to speak, and then the morphology, the shape, if they're not the normal shape where they're not going to travel in a uniform way . . . there are a lot of things that go into a sperm test.

And so when we do a semen analysis at the University of Utah in our lab, we get the volume of the semen. It tells us the total sperm count, the sperm concentration, or how much there is per milliliter that's in the sample that we received. It tells us the viability, how many of those are alive and moving. It tells us the motility, how many of them are moving in an adequate amount to be beneficial for you. And then the shape and morphology. So it really gives us a lot more information.

However, the biggest thing I find for most patients is fertility may not be covered under their insurance. So they're looking for a quick test that can give them some information. And that test may or may not be helpful for them because if there is another aspect to the semen parameters that's not good, that's not just the number, then they're never going to see that on the test.

And so I think a lot of people are looking for a cost-effective way to just get some answers, but sometimes the most cost-effective way is just to come in and get a full semen analysis done with a fertility specialist.

Interviewer: Yeah. That way you can discover exactly what the issue is, and then go about perhaps solving that issue if there is indeed an issue.

Dr. Smith: Exactly.

Interviewer: So, from a male perspective, when you get this information back, generally then when you start solving the problem, is it going to be an expensive process or sometimes are there some simple changes that can be made that can make all the difference?

Dr. Smith: It's different for every patient. Some guys come in and they have a hormone-related issue that we can solve with some medication. That can really be an inexpensive fix. Oftentimes a lot of medications are still covered by insurance, which can be helpful.

And then in some men, if there is an issue where there is a low sperm count or no sperm count, some of the procedures to check and see if the testicles have viable sperm in them can be a little bit more expensive.

However, the real expense comes if you had to have IUI or IVF, which are insemination techniques. Most of the male stuff tends to be less expensive than that.

Now, again, when you're looking at things, fertility is not cheap by any stretch of the imagination. A lot of the procedures that are done to check for viable sperm within the testis can run anywhere from $2,000 to $5,000, but then a round of IVF can cost greater than $10,000 upwards, even much more than that.

So, when I talk about cost, it's very interesting because the male side of things generally is a skosh less expensive than the total amount that it takes to get the fertility solved in some cases.

Interviewer: So it is possible that you go and you get the test, you get some solid results, and it might be an inexpensive fix. That is not unheard of.

Dr. Smith: No, not at all, and we do a lot of that. And sometimes if the sperm count looks maybe borderline, we can also try some medication to try to bolster that sperm count for a few months and then do a retest type of thing.

And so a lot of times, we usually don't run right to the higher dollar surgical procedures, things like that, unless they're absolutely needed because we do understand that a lot of times this stuff isn't covered by insurance and we want to try to make it as best we can and most cost-effective for these folks.

It's a tough road. Fertility is tough. I see quite a few folks who we have success with, and it's great to see that, but any of those couples that are having trouble, I would say just get in and see if there's something that can be done to really help you because sometimes it is a simple solution.

Fertility can be one of the toughest portions of a relationship, but also one of the most rewarding. So I would say don't delay. Just get in and see if there is something that can be done to make things easier for you.

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Interviewer: If you watch any TV at all you can't escape the ads, ads for you need testosterone therapy. It looks like it's pretty easy to get, but should you get it? That's the question. Right now I've got with Dr. Tom Miller, University of Utah health care.

Dr. Tom, for a guy that's over 30 years old, it's been scientifically proven that testosterone levels start dropping at that point. Should I be ordering some of this testosterone online? I mean after all, I want to look like that guy.

Dr. Tom: I think the question, Scot, is why do you think you need it? What's different?

Scot: So, the ads tell me my energy levels have dropped, which they have, that I start putting on more body weight, that my mood is affected, and my sex drive is decreased. Testosterone is going to cure it. It's kind of cure-all is what they're telling me.

Dr. Tom: That's a great concern. That's a concern of many men, and women, throughout the country, but the real question is are there different causes for those things you mentioned? There are many causes for people being a little overweight, feeling a little fatigued. It isn't just testosterone; it's a whole basket full of causes.

Scot: So, if I came into your office, and I gave you those symptoms, and I said that I want testosterone what would you say to me? Where would you start looking?

Dr. Tom: I would ask a few questions. One I'd ask, "What's your sex drive like? Has it dropped off? Are you interested in sex? Do you have the same drive that you had five years ago?" And if the answer to that is no and that you were concerned about it, I'd then go ahead and measure your testosterone level.

Scot: Okay.

Dr. Tom: But I'd also ask you a number of other questions. If the testosterone levels came back low, then we might do a trial of testosterone replacement, and we would then monitor how you felt. Did it make you feel better over the course of time that we try the medicine? If not, it might be wise to stop it.

Scot: So, let's back up for a second, these ads that I'm seeing on TV, I can just order without a doctor's prescription?

Dr. Tom: No, you have to have a doctor's prescription. There's a doctor on the other end that's asking a set of questions.

Scot: So, when I make that call, there is a doctor?

Dr. Tom: There's somebody that has to write the prescription.

Scot: Got you. How do they know how much I need, because it sounds like you would do tests to find out what the actual level is? It sounds like they're just asking me some questions and if I pass they're going to write me the prescription.

Dr. Tom: That's probably true. I can't attest what other things that they do, I'm not sure that's the best way to get health care. Basically you're telling them that you need testosterone, and they're saying, "Fine. Answer these questions. Here's your prescription." I'm not sure that's the best way to try to define what your problem is. As I mentioned before, the causes of fatigue and weight gain there are multiple issues related to that not just testosterone.

Scot: So, let's pretend that I come into you because I want to be a little smarter about it. You ask me some questions; you decide to run some tests. You find I'm in the normal range, on the low end of the normal range. Would you do anything at that point?

Dr. Tom: I probably would counsel you about your lack of sexual drive. Well, I'd seek more information about that, and it might me that there are other reasons for that aside from the fact that the testosterone is in the borderline range. I suppose if you really wanted to try it we could do a trial.

Scot: Sure.

Dr. Tom: I'm not opposed to that if the patient thinks that's right, but I try to give them a realistic expectation. Also tell them that, "Look, it's not a wise thing to take medicine if we do this for several months and you find there's no difference, and you're honest with yourself about it." Just as with any medicine, in my mind, it doesn't make sense to take it if you really aren't getting a benefit from it.

Scot: So, let's take a look at these ads; they promise me so many things. Let's talk about the benefits of testosterone therapy, just from a strict benefit. Why would I, as a man, even come to you and talk to you about it?

Dr. Tom: Certainly, if you had low levels, it might be affecting your sexual drive, you might have some fatigue, you might have less muscle mass then you were used to. In that instance, if you were replacing testosterone, it might help you quite a bit; you might have a great improvement. The problem though, long term, is we don't really know if the side effect . . . we don't know what the side effects are of testosterone replacement over the long haul greater than five years. We just don't know that yet.

Scot: So, this is kind of the risks part right now, is we don't know what the risk are.

Dr. Tom: We don't really know what long-term risks of testosterone use might be, replacement. There are a number of men that I know who have low testosterone and they don't notice any difference. So, do you replace testosterone by testing for it in men who are low? The answer is I don't think we really know. We don't have enough information. We do know that testosterone helps maintain bone integrity and strength but we're not at the point where we say screening for testosterone is a thing to do.

Scot: So, it falls off as I turn 30, and as I get older. When you're testing, are you testing for the normal range for, say, a 55-year-old man, if I'm 55, or were you...?

Dr. Tom: I want to back you up a little bit; testosterone may decrease variably in men so it's not the same as menopause in women.

Scot: Okay.

Dr. Tom: So, when women enter menopause their levels of estrogen drop precipitously. The same is not uniformly true in men. Some men have lower levels of testosterone over time, but not all. So, it's unclear which men would have low testosterone and others have normal testosterone; we just don't know yet. There's not a recommendation to screen all men for testosterone levels.

Scot: So, you really can't say how much should a 50 year old man have?

Dr. Tom: Well that's correct, I mean because we don't screen.

Scot: Got you.

Dr. Tom: We don't test for testosterone as part of an annual exam in the same way that we test blood pressure or test cholesterol or test blood sugar.

Scot: So, your advice is don't order the stuff on TV because you're playing with something that...?

Dr. Tom: My advice is that if you have questions about the way you feel, whether you have fatigue or decrease in energy level or a decrease in your sexual drive, then you should probably talk to your physician about that and decide if testing your testosterone level is right for you. Nothing wrong with that.

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