Male Infertility: Changing Conceptions
Sometimes, the Problem Is Primarily His, Not Hers. And Its Cause Is Often Almost Invisible.

By Ranit Mishori
Special to The Washington Post
Tuesday, February 19, 2008

When doctors at Shady Grove Fertility Centers told a 34-year-old construction supervisor that he had a low sperm count and that was likely why he and his wife had been unable to conceive, the news came as something of a shock.

Like many men in his situation, the Washington area resident had never really considered that the glitch might be at his end of the transaction. His sexual performance had always been normal, said the man, who asked that his name not be used. "I didn't think I had a problem," he added.

Infertility is a growing problem in affluent societies, according to an editorial last week in the journal BMJ, already affecting about 15 percent of couples trying to conceive. And "the biggest myth," says Robert Stillman, a reproductive endocrinologist and medical director of Shady Grove Fertility Centers, which has locations in Maryland, Virginia and the District, "is that it is a female problem."

And unlike impotence, male infertility is relatively invisible. "If a man can perform sexually," explains Richard Sherins, who practices at Columbia Fertility Associates in Bethesda, "he thinks he is normal, which we know is not always the case."

In fact, Stillman says difficulties can be traced to the man alone a third of the time. With more than 6 million U.S. couples reporting difficulty conceiving, that's a lot of men. Either their bodies are not producing sperm of sufficient quality or quantity, or anatomical defects are preventing the sperm from getting where they're supposed to go.

The male reproductive system consists of hormones, tubes and organs that act like a factory for sperm and the semen that carries it. Any of these can malfunction, preventing healthy sperm from penetrating the egg.

The first questions fertility doctors ask new patients are likely to be about timing and frequency of intercourse. Many men eager to have a child, Sherins says, don't know they need to be sexually active the week before and several days after the woman's ovulation -- a total of about 10 days.

Assuming timing is not the issue, doctors will next evaluate each partner. A comprehensive evaluation in a man will include a full history and physical exam because medical problems such as cancer or diabetes, kidney or liver disease can affect a man's fertility.

Next, the doctor will conduct sperm studies and is likely to look for physical conditions such as varicoceles -- in which veins in the scrotum are enlarged, much like varicose veins. Some experts blame varicoceles for as much as 40 percent of male infertility, theorizing that they raise the temperature in the testicles or lower levels of testosterone, the key male reproductive hormone.

A relatively simple surgery can correct the abnormality. But the procedure is controversial since, as both Stillman and Sherins note, nearly two-thirds of men with varicoceles are able to impregnate a woman. Should every man with a varicocele have it fixed if he wants to father a child? "The jury is still out," Sherins says.

Often, as was the case with the construction supervisor, the problem may lie with the sperm itself. Anything affecting its quantity (a normal sperm count is more than 20 million sperm per milliliter of semen), quality (curled, crooked or two-tailed sperm are less effective) or motility (about 60 percent of a normal man's sperm show good forward movement) can affect a couple's chances of conception.

Sometimes the solution is as straightforward as avoiding a source of heat. Because the testicles are suspended outside the body cavity, they operate at a lower temperature, ideal for sperm production. Raise that temperature temporarily -- by using hot tubs, for example -- and there can be problems. When celebrity chef Gordon Ramsay, of TV's "Hell's Kitchen," disclosed last year that he suffers from low sperm counts, he blamed it on "being in front of all those hot ovens."

Age also plays a role. Sperm quality appears to degrade in men older than 50, with more "DNA fragmentation" occurring, Sherins says; how exactly that affects fertility isn't known. Some studies have also shown higher rates of autism and schizophrenia in children conceived to older fathers, he says.

There's increasing evidence that environmental factors, such as lead and pesticides, may also affect sperm quality. And a report presented in 2006 to the American Society for Reproductive Medicine even pointed a finger at cellphone use. Among men who used their mobile phones for more than four hours a day, average sperm counts were lower -- perhaps, researchers theorized, because of electromagnetic radiation or heat emitted by the devices.

But until there are more studies, Stillman cautions, "it is premature to tell a man to keep the cellphone away."

Many causes of poor sperm quality or count remain a mystery. "Our ability to treat individuals . . . by improving their sperm counts has been and remains very limited," Stillman says.

But in the end you need to find only one fine sperm to fertilize an egg. A technological breakthrough called intracytoplasmic sperm injection, or ICSI, helps do just that.

In a 10-minute procedure performed under general anesthesia, sperm is removed from the testicles with a needle. Then, in the lab, a good-quality sperm is isolated and injected into an egg, which can then be inserted into the uterus.

The procedure has been "phenomenally successful," Sherins says, resulting in "thousands of pregnancies."

The construction supervisor and his wife are trying the treatment at Shady Grove Fertility Centers -- and hoping for the best. ¿

Ranit Mishori is a family physician and faculty member in the Department of Family Medicine at the Georgetown University School of Medicine.

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