A guy thing too

When A couple is infertile, often the first question asked is, “What’s wrong with her?” “There’s a common misperception -- even among healthcare providers -- that infertility is a female problem,” says Dr. Thomas Walsh, director of the men’s reproductive health program at UC San Francisco School of Medicine.

In fact, male infertility is quite common. At least 20% of infertility cases are due solely to male factors such as low sperm count, and in 40% to 50% of cases, male factors contribute. Many male fertility problems go undiagnosed and untreated, however -- either because attention focuses on their partner or because men are reluctant to get help or unable to find it when they seek it.

Numerous factors influence men’s fertility. Some infertile men don’t produce adequate amounts of sperm to cause pregnancy. Normally, the precursors to sperm -- germ cells -- mature in the testes under the influence of hormones produced by the pituitary gland. Abnormal or absent germ cells, or disorders that affect the production of pituitary hormones, can impair a man’s sperm count.

In some cases, genetic disorders cause low sperm production. Klinefelter’s syndrome, which affects between 1 in 500 to 1 in 1,000 men, is among the most common. Men with Klinefelter’s carry an extra X chromosome (genetically, they are XXY instead of XY). The condition leads to small testicles with very few germ cells, and most of these men suffer from infertility. Tiny missing pieces of genetic material in the Y sex chromosome can result in poor sperm counts too.

Certain lifestyle behaviors, such as smoking and excessive alcohol and drug use, depress men’s sperm counts. For some men, high levels of stress can as well.

Sometimes men are able to make sperm in sufficient quantities but poor sperm quality causes conception difficulties. For fertilization to take place, sperm must be able to reach the egg and then penetrate its outer layer. Sperm that don’t move well or are abnormally shaped may be unable to do so. As with low sperm count, causes can be genetic or tied to lifestyle.

Even men who produce healthy sperm in adequate amounts sometimes suffer from infertility. Infections such as chlamydia and gonorrhea can damage the vas deferens (the tube leading from the testes to the urethra, through which the sperm travel), blocking it and preventing sperm from leaving the body.

Some men even produce antibodies against their own sperm; functional when first produced, the sperm are quickly damaged by the immune system.

Ironically, vasectomy is one of the most common causes of male infertility. Nearly half a million vasectomies are performed in the U.S. each year, and up to 6% of men who have the procedure want a reversal at some point -- either because of divorce or the loss of a child, or simply because they decide they want another child after all.

Regardless of the underlying cause, infertility is a couple’s problem. But according to a recent online survey of infertile couples conducted by IntegraMed, a national network of fertility centers, women generally are evaluated first. Sixty-seven percent of those responding to the survey said that the female partner sought initial treatment for infertility.

“Both the male and female partner should be worked up simultaneously,” Walsh says. “Men are just as deserving of a comprehensive evaluation.”

A male fertility assessment typically starts with a thorough medical history and examination, and generally also includes a semen analysis that examines the volume of a man’s ejaculate, the concentration of sperm in the ejaculate and what percentage of those sperm can swim.

Further testing is based on the results of the analysis. Men with low sperm counts, for example, might require hormonal or genetic testing. If no sperm are found in the ejaculate, a testicular biopsy -- removal and examination of a small piece of tissue from the testicle -- may be necessary.

Unfortunately, men often resist being tested. Nearly half of all women responding to the IntegraMed survey said that it was only after pressure that their male partners were willing to seek medical consultation.

The reasons for this reluctance have not been well studied. Some fertility experts suggest it’s purely a macho thing -- that a man’s sense of masculinity tends to be strongly tied to his ability to reproduce, making him afraid to acknowledge that he might have a fertility problem.

Of course, it’s almost certainly more complicated than that and likely involves a broad range of issues and concerns. It may simply reflect men’s general tendency to utilize healthcare less than women. But regardless of the reason, “When men feel responsible for infertility, it has a profound impact on them,” Walsh says.

Unfortunately for men interested in a fertility evaluation, getting help isn’t always easy. Whereas most women of childbearing age have a primary healthcare provider such as a gynecologist or family practitioner who deals with their reproductive issues, men generally do not. “Young men are a medically underserved population,” Walsh says. “They simply don’t have places to go to seek out healthcare for reproductive issues.”

Couples struggling with infertility should make every effort to find help for both partners. While ob-gyns typically deal with women’s reproductive problems, urologists are the best people for men to turn to for help. Some urologists -- like Walsh -- actually specialize in men’s reproductive health. In recent years, there have been tremendous advances in the field of male reproductive medicine. In fact, with current technology, even men who produce just a single sperm can cause a pregnancy.

“We can dramatically increase the likelihood of couples conceiving at home or with the least amount of technology possible,” Walsh says.

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Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. She can be reached at themd@att.net. The MD appears the first Monday of the month.

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Improving your chances

Lifestyle changes can help boost a man’s sperm count and go a long way toward promoting fertility. There’s scientific evidence to suggest that men who are trying to have a child should consider the following recommendations:

* If you smoke, make every attempt to quit.

* Consume alcohol in moderation.

* Do not abuse drugs such as marijuana and cocaine.

* Eat a well-balanced diet.

* Drop a few pounds if you are overweight.

* Engage in regular physical activity.

* Some evidence suggests that raised scrotal temperature may lower sperm counts, so avoid prolonged use of hot tubs. Wearing loose-fitting boxer shorts instead of tight fitting briefs may not be a bad idea, though the benefits are far from certain.

* If you have underlying health problems such as diabetes or high cholesterol, get them under control.

“Reproductive function is one of the first things to go in states of poor health,” says male fertility expert Dr. Thomas Walsh of UC San Francisco. “If your goal is to family plan, your job is to be the healthiest person you can possibly be.”

-- Valerie Ulene