Male Infertility Issues-- Sheldon Marks, MD-- 02/26/04

Last Editorial Review: 10/19/2004

By Sheldon Marks
WebMD Live Events Transcript

Trying to get pregnant? Congrats! You're ready and willing, but are you able? Whether you're concerned about erectile dysfunction, low sperm count, or vasectomy reversal, check out what for WebMD's own men's health expert, Sheldon Marks, MD, had to say about the male side of fertility.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only .

Member question: How can varicocele be fixed does it need surgery and if it's an infection what are my options?

Marks: A varicocele is a collection of dilated blood vessels that sits above the left testicle. This is bad for sperm, because it brings a large amount of blood into the vicinity where the sperm are being produced, and are supposed to be a few degrees cooler than the body temperature.

When a man has a significant varicocele and his sperm count is affected then we usually recommend surgery to tie off these veins and block the flow of this extra blood around the testicles. There are different approaches to tying off these veins. The newest and most effective is a microsurgical repair, which is performed through a small groin incision, under a surgical microscope. This usually works to improve the sperm count, the motility, and morphology for most men. It's a very safe operation and is usually effective.

Member question: What if it's an inflammation; does that affect the shape of the sperm? And what are the treatment options?

Marks: If there is infection, the best way to detect this is with a culture of the semen. He can have the doctor perform prostate massage and get a few drops of fluid for culture, but the best way is to simply have him provide the semen specimen as he would for a semen analysis and have that semen cultured to see if there are any signs of infection or bacteria.

If there is a growth of bacteria, then the lab will also check to see what antibiotics the bacteria are sensitive to. He would need to be treated with an appropriate course of those antibiotics at least for several weeks.

One way to improve the quality of sperm is also to use antioxidants, such as vitamin E, vitamin C, and selenium. There are many studies showing how sperm improve with antioxidants.

Member question: Could normal conception without taking any artificial measures be possible with this low morphology?

Marks: Yes. The whole concept behind men's sperm count is not quality, but quantity. Men put out tens if not hundreds of millions of sperm, of which really only a small percentage is healthy enough to get up to the egg for fertilization. Ideally, the better the sperm, the more motile the sperm, and the healthier the sperm, the higher the chances are.

Also, it's important to remember that it takes 74 days to make a sperm, so any insult, such as a fever or the flu during that 74 days will impact on the sperm count for the next few months. So we usually like to check several different semen analyses scattered over time to be sure that we're not misinterpreting one single specimen that may not be representative of the true count.

Member question: My husband got the results of his second SA yesterday and has been referred to an urologist. The results said, "Specimen consists of blood containing few inflammatory cells and few spermatozoa. A reliable count cannot be made. Unfit for morphologic analysis." What could this mean and what can he expect at the urologist? His thyroid meds were upped 1/2/04 and he has a terrible cold.

Marks: This does not look like a good specimen, and before I would become upset or worried I would obtain another specimen once he has recovered from his cold. It's essential that every drop go in the cup and that it be delivered within one hour and maintained at body temperature.

If it appears that he continues to have blood and inflammation, I would suspect an infection and would agree that seeing the urologist is the correct next step.

Problems with thyroid levels can impact on sperm production, but this sounds more like an infectious process than anything else. Before he provides the specimen he should be well hydrated and have abstained from any sexual activity for three days.

Member: His first SA was the same without the blood given in December.

Marks: That still makes me concerned about infection, because of the inflammatory cells, but even in the face of a bad prostate or testicular infection he should still have millions of sperm to be counted. So I would be worried about possible other causes, including blockage, scarring, hormone imbalance, or other testicular abnormalities that could explain the very low count and inflammation.

It is essential that he see an urologist for a good testicular exam, because there are rare cases where testicular tumors or scars or other irregularities could be found by an experienced urologist.

Member question: If my husband and I have an 8-year-old, does that improve our odds that his sperm are viable?

Marks: Yes. If a couple has proven they can conceive together their chances are significantly better than a couple that has never conceived together.

Member question: My husband is on Coreg, Lipitor, and HCTZ and just switched off of Norvasc. He has a sperm count of 25 million and 50% motility, but has poor morphology (1% or 7,000) and low testosterone 290 and a vericocele in one teste. What are our chances of conceiving naturally? Could any of his medication be causing the poor morphology? What causes low testosterone? We are both 34 and have been TTC for one year.

Marks: First of all, the count and the motility are fine. The morphology is low, and we usually like to see 5% or greater normal sperm. So they definitely can conceive, but the odds are less because he has fewer healthy sperm to do the conceiving.

The low testosterone may or may not be real, as this level fluctuates dramatically throughout the day and from day to day. It is essential that he not take any testosterone supplements, as this will zero out his sperm count. The body senses the extra testosterone from the supplements and basically triggers the body to stop making its own testosterone and to stop sperm production.

The varicocele is probably the cause of the abnormal morphology because of the extra heat, which injures sperm production and maturation. It's possible that if his testosterone is really low the varicocele could be causing damage enough to testosterone production. So my first thought would be to have an experienced urologist address the varicocele with a repair.

In the meantime, he should avoid heat, such as hot tubs, hot showers, Jacuzzis, and saunas, and he should also be taking antioxidants. This combination may boost his sperm production and quality. As far as the medications it is possible that they are playing a role individually or in combination, but my first thought would be the varicocele is the culprit.

Member question: What course of antibiotics is usually recommended for an infection of the sperm that could be affecting its morphology?

Marks: Because of a number of factors within the testicle and the prostate, and the accessory glands, certain antibiotics work better than others. Depending on the result of the culture we most often use quinolones such as Cipro. 

The biggest mistake that most doctors make when treating an infection in men is not to use a complete course of antibiotics. So often we hear about a 10-day course of medication, and the origin for that is the number of days needed to treat strep throat. More often for men, we need anywhere from three to four and sometimes six weeks of antibiotics to achieve appropriate levels within the tissue to kill the bacteria.

Quite often men will have improved results when they also take anti-inflammatory medications, which make it easier for the antibiotics to work, and to reduce any swelling and inflammation. The biggest problem with a long course of medication for anyone is that it's hard to take the medication as directed for that long. Men are especially bad at this, and have in general, much lower compliance than women.

Member question: I am 40 years old and my wife is 35 years old. We have a child, 7 years old, through a normal conception. Over the past two years, I developed a large spermatocele on my right testicle due to trauma and also found that my sperm count ( <2 million) has fallen drastically with about 53% motility. I went to a male infertility specialist and was told that both the testes were in very good condition but possibly the spermatocele was blocking the sperms from moving out. For immediate conception, which is what we wanted, he suggested IVF. How successful are IVFs and what usually is the success rate if my wife is in very good condition and my sperms are isolated with motility at 53%? What normally is the time frame and what are the costs?

Marks: Yes, a spermatocele can cause a reduced sperm count. A spermatocele is, basically, a weakness in the tiny, very delicate tubules of the epididymis, where the sperms mature. As the fluid builds up under pressure, a weak spot in the tubule can essentially blow out, releasing sperm into the surrounding tissues, which can develop into a small cyst of sperm. Another name for a spermatocele is an epididymal cyst.

Surgery to remove this can still result in further damage, so we usually leave this alone. Even with a spermatocele on one side I would expect your sperm count to be much higher from the sperm of the opposite side. Even with that, my first thought would be to see if they can collect enough motile sperm for intrauterine insemination, or IUI. That is a fraction of the cost or IVF, usually just a few hundred dollars, and has a very high chance for conception, assuming that the quantity and quality of sperm placed up in the uterus is about 5 million sperm.

So the critical factors in this particular situation would be the semen volume and also the technical skill of whomever is doing the wash. When a man provides a specimen to be inseminated into his partner most of the nonsperm fluid has to be washed away. If the person performing the wash is skilled, then there usually is only a 40% to 50% reduction in total count. So often we see great counts before the wash and absolutely horrible counts after the wash, which pretty much guarantees that the IUI will not be successful. This is a direct reflection, again, of the skill and experience of the person doing the wash, which is usually a technician, and sadly is often someone who really doesn't know what he or she is doing.

The IVF involves taking the sperm and either mixing them with the egg or injecting the sperm directly into the egg, which is called intracytoplasmic sperm injection, or ICSI. This is not an area where I am an expert, but I can tell you that it is very effective but it is very, very expensive and can cost $10,000 to $15,000 to $20,000 or more, as opposed to a few hundred per cycle for IUI.

Member question: I am 30 and about two months ago I noticed I would have some pain in the area that the testicle is connected into the abdominal area after sex/ejaculation (and sometimes during). Then I noticed that it seems my body has had trouble keeping the blood flow into the penis going during arousal, meaning a weak erection. I can still have intercourse and ejaculate, but a weak erection is a bit of a problem. I have no symptoms of any STD or such illness. Is this something that could be temporary, based on stress, etc. or are there known ailments this could be a result of?

Marks: Pain is the antidote for a good erection. If a man has pain in the lower abdomen or genital region or associated with erections or sex, then it is very common to not have good erections. I like to think of it as if the brain and the penis function on a toggle switch. If one works, then the other doesn't. There's no in between. So if a man is concerned or worried about pain, and the brain is working, then it is common to have erection problems down below.

The big thing is to address the pain. More likely this is a situation called epididymitis, where there is inflammation of the delicate tubules within the epididymus. This can result from:

  • InfectionInjury, such as being kicked or even mountain biking Obstruction, such as is seen after a vasectomy
  • Sterile reflux, where urine, which is very caustic to delicate tissues, backwashes from the urethra through the vas into the epididymus, essentially causing a chemical burn.

Whatever the cause, epididymitis can be quite severe and cause pain in the groin, lower abdomen, testicle, and surrounding areas. It is best treated conservatively with an athletic supporter, 24/7 for two weeks, avoiding heavy lifting and straining, no sexual activity for 10 to 14 days, as well as anti-inflammatory medications.

Recovery from epididymitis is a slow, smoldering process, where men can have good and bad days, and this can go on for weeks and even months. It is very, very important that one does not assume you have epididymitis, as it is rare, but it is possible that more serious problems, such as testicular cancer, can present with very similar symptoms. A good urologic exam is necessary up front.

Member: Follow-up: I had a physical right about the time the erection problems started and all my blood and urine tests and the physical itself came back good. Is a urological exam the next best idea to find out possible problems?

Marks: Yes, a good urologic exam, in a matter of moments, will determine if there's anything serious and/or correctable, such as epididymitis, so that this can be addressed before it progresses. Once pain with sex goes away chances are erections will be just fine. Please do not send Polaroids.

Member: Deal!

Member question: I am a 67-year-old man with a 42-year-old wife. What are the chances of my wife getting pregnant through sperm cropping and then having artificial insemination? I had a vasectomy when I was 25 years old. 

Marks: There are several points to make on this question. First of all, there is no question at all that we could get healthy viable sperm from you. My biggest concern is that at age 42 many women are no longer ovulating, or may ovulate but have a much lower chance for conception. Again, this is not an area where I am an expert, but the fertility specialists that I talk with suggest that she have blood tests drawn, including an FSH, on the third day of her period. If it looks like she is indeed ovulating and her doctors feel it would be safe for her to conceive, then there are a few options to consider.

The first one is vasectomy reversal. With this technique, over about three hours under a high-power surgical microscope, we cut out the damage of the vasectomy and sew the two ends together with tiny sutures that are about 1/4 the thickness of an eyelash. Recently I had one patient who just fathered a child who had his vasectomy 42 years ago, which, as I understand it, is a world record. So this is one approach to obtaining sperm and restoring that back to the semen.

The other approach would be to have an urologist remove sperm from your testicle with a tiny biopsy or sperm from the epididymus. The problem with this approach is we do not obtain enough sperm to do simple and inexpensive insemination (IUI). We can only get enough sperm to do the far more expensive sperm injection with in vitro.

So the first step is to find out if pregnancy is even a viable option for her and if it is, then to talk with an experienced microsurgical specialist in male factor fertility for a consideration of a reversal versus sperm aspiration. You should be careful, as there are many doctors who will gladly take your money and perform a reversal, even though they don't have the volume of cases, skill, or expertise to give you the best chances for success.

Member question: What are the odds of normal conception with a very low morphological sperm value of 0.2% of normally shaped sperm?

Marks: It's impossible to give out exact or even close numbers without actually having you as a patient, performing a comprehensive fertility exam, and actually looking at the slides myself or having someone who I know and trust to look at the slides. Sadly, there is tremendous variability from lab to lab and office to office when people look at semen analysis specimens. Because we have patients from all over the U.S. sending us their semen analysis reports, it's almost a daily battle to try to understand what the reports mean, because there is not consistency. With that in mind, I would suggest perhaps taking a specimen to a different lab, or even better, a lab that specializes in fertility.

Getting back to the question, we like to see a morphology of 5% or greater normal sperm. So 0.2% is quite low. I would guess that the odds for natural conception with such a low morphology would be very low, as well. That being said, we have many patients that have had absolutely horrible sperm counts with very, very poor morphology that conceive naturally, and other couples with great counts that can't conceive under any circumstances.

I would simply refer you to a male fertility expert and a reproductive endocrinologist to look at the counts, perform an exam, see if there's any cause that can be addressed, and then review the options with you, so that you can make an informed consent and decision. I know that this is not a black and white answer, but there is so much that we don't know that there is no obvious or correct answer.

Moderator: Do you have any final words for us, Dr. Marks?

Marks: I think that being an informed healthcare consumer/patient is the only way in today's medical climate to be sure that you're getting the absolute best care available. No one should ever compromise, and every single patient I see I encourage them to seek out the best of the best for their own healthcare.

Moderator: Thanks to Sheldon Marks, MD, for sharing his expertise with us.

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