In honor of June being National Men’s Health Month, we partnered with urologist and men’s fertility expert Dr. Justin Dubin to highlight male-factor infertility. The world of infertility, especially on social media, is so heavily focused on females, but male-factor infertility plays just as much of a role and gets considerably less attention. Dr. Dubin helped to break down the basics of male-factor infertility to shed some light on the other 50% of the fertility equation.
Dr. Justin Dubin, MD
Berry: To start off, what would you say is the definition of male-factor infertility and how is it diagnosed?
Dr. Dubin: Male infertility is the inability for a man to achieve a pregnancy through normal sexual activity without contraception. This does NOT mean that they cannot have a child, it just means that they are having issues doing so. Typically, infertility is diagnosed when a couple is unable to achieve a pregnancy after 1 year of unprotected sex.
About 15% or 1 in 7 couples struggle with fertility. Now this may sound surprising because there is a huge stigma right now that focuses on the female aspects of fertility, but in couples struggling with fertility, male fertility contributes about 50% of the time to the couple’s fertility problems, and 30% of the time it is strictly a male factor fertility problem. I really want to stress that because we know that guys don’t want to talk about fertility.
In fact, about 18% of male partners are not evaluated for fertility and even if they are concerned about it, men don’t want to talk about it - a study out of Northwestern showed that only 30% of men who were concerned about their fertility were likely to discuss their concerns with their doctor! By knowing the numbers and understanding it takes two to tango, I am hoping we can motivate men to do their part and talk to their local urologist about getting evaluated for fertility.
I also think it is important for men to know that a fertility evaluation is pretty easy. If you are interested in getting your fertility checked, your doctor will need to do 4 things with you:
Get a good history - assess any lifestyle or medical history concerns that put you at risk or suggest you are at risk for fertility issues. Includes partner history
Do a physical exam - make sure anatomy is all normal - testicle size, vas deferens present, assess for varicoceles
Get blood work - hormone panel - testosterone, FSH, LH, estradiol, Prolactin are commonly ordered
Semen Analysis - the gold standard for fertility evaluation
As you can see, a fertility evaluation for men is fairly quick and easy.
Berry: What are some causes of male-factor infertility?
Dr. Dubin: We can break this down into several categories:
Genetics (i.e. cystic fibrosis, kleinfelters, Y microdeletions):
This also includes some people that just have very low sperm counts or no sperm at all. Sometimes we don’t have an exact reason why, but we understand it was likely something that the person was born that way
Anatomy:
Varicoceles - 15% of men have varicoceles and about 40% of men with fertility issues have them
Blockage/Obstruction - sperm can't get out from things like retrograde ejaculation or vasectomy
Medications:
In this situation I really want to highlight testosterone usage. Testosterone usage has really been on the rise in younger men and one thing most people don’t know is that taking testosterone causes infertility. In fact, 65% of men with normal sperm become sterile within just 4 months, the longer you are on it, more likely you are to have zero sperm
This also includes things like radiation and chemotherapy for cancer
Health Conditions:
Obesity, having a history of cancer, being treated for cancer, having diabetes - all can impact and worsen your sperm count
Having low testosterone can impact your sperm
Finally - Lifestyle:
Smoking, vaping, using marijuana can impact your sperm
potentially heavy alcohol usage can impact sperm
Wet heat exposure - hot tubs, saunas, jacuzzis steam rooms - they can all kill your sperm
Lubricant during sex - most kill sperm, the lubricant (Preseed actually does not!)
Ejaculation frequency - Infrequent ejaculation leads to poorer quality sperm
EDC exposure - endocrine disrupting chemicals, which can disrupt your testicular function and hormones like testosterone or estrogen in your body - potentially compromising your sperm and fertility. Some of the names of these chemicals include bisphenol A and phthalates - they are found in everything from plastics, flame retardants, electronics, food packaging and pesticides to personal care products and cosmetics.
Berry: We are well versed in how age affects female fertility, but would love to know if/how age plays a role in male fertility.
Dr. Dubin: For a long time we really didn’t think that men had biological clocks - unlike women who are born with their set amount of eggs, men make sperm for their entire lives and therefore are technically fertile until they die.
You’ve seen recent examples of this - Al Pacino, Robert Deniro recently having kids even though they are in their 80s.
We are starting to understand however that as men get older - starting in their mid 40s and 50s, their fertility does decline and the risk of issues with their offspring increase. This decline in fertility makes sense - as you get older your testicles just don't function as they used to. Aging can affect the quality of sperm, including the motility, morphology (shape) and concentration, which then makes it more difficult for sperm to fertilize an egg. Men also produce lower sperm counts as they get older. It can potentially make conceiving naturally a bit harder.
There is data showing that increased age in men puts the child at increased risk for premature birth, low birth weight, birth defects, and autism - while it is an increased risk, it is not a very significant increased risk and in general these risks are hard to really quantify. Older age should NOT deter people from having kids, but it is important to understand that it may be more difficult to achieve a pregnancy than if you were younger.
Berry: What are some common ways to treat male-factor infertility?
Dr. Dubin: As you can see there are a lot of factors involved with fertility, but at the end of the day, the most important factor is the semen analysis and determining if there is sperm present or not. If there is sperm, we can look at the other factors - testosterone, medical history, physical exam, lifestyle factors and see if we can modify them and optimize your fertility. This can be done through medications, lifestyle changes, surgeries, etc.
If there is zero sperm in your ejaculate, that is called azoospermia - about 10% of infertile men and 1% of all men have it. To treat azoospermia we have to find out if it is a blockage issue - in which the sperm is being made but it can’t make it out or if it’s a production issue - where sperm is not being made well by the testicle. Based on the cause there are surgical options like sperm extractions or testicular explorations that can help retrieve sperm.
Berry: Are there any lifestyle changes that can be made to increase sperm count and/or quality and if so, how quickly would you expect to see the results from these types of changes?
Dr. Dubin: We have established that lifestyle can play an important role - exercise, eating healthy, quitting smoking cigarettes or vaping, avoiding exposure to EDCs - these are all good ways to help your fertility. Avoiding medications like testosterone replacement therapy that can kill your sperm is also important.
Another important consideration is avoiding wet heat - hot tubs, saunas, steam rooms and jacuzzis. Listen, your balls are outside your body for a reason. It’s because the ideal temperature for sperm to develop is a few degrees cooler than your body temperature. This is why your balls shrink up in the cold and drop down in the heat - the goal is to maintain that ideal temperature for sperm to develop. Anything that elevates your testicles above that temperature for prolonged periods of time can literally cook your sperm - and hot tubs, saunas, steam rooms can do just that. Theoretically, just one session can compromise your sperm. So if you are trying for a family, just avoid them.
The sperm cycle is about 3 months, so anything that you do to impact your fertility, either positively or negatively, will take about 3 months to take effect in your sperm. Many times it can take longer.
The best thing you can do though, is if you are concerned about your fertility, go talk to your local urologist. They can help you on this path.
If you are looking for more great male sexual health and fertility content, check out Dr. Dubin on his podcast “Man Up Pod” where he is joined by his fellow urologist and co-host Dr. Kevin Chu and other special guests. You can also find him on Instagram at @justindubinmd.