Male Infertility: What to Know and How to Cope

Male Infertility: What to Know and How to Cope

MALE INFERTILITY: WHAT TO KNOW AND HOW TO COPE

Infertility is largely thought of as a woman’s issue, but male infertility can affect at least one-third of couples who are struggling to conceive.

By Hallie Levine

THE GIST

  • As with female infertility, male infertility isn’t anyone’s “fault.” 
  • In the past three decades, according to a large study published in 2017, sperm counts have decreased significantly in industrialized nations such as the United States, Australia, New Zealand and those in Europe. 
  • The most common cause of male infertility is low sperm count, but in more than 20 percent of cases, there’s no known cause.
  • As with women, men have a biological clock; and research suggests that starting in their 40s, men may take longer to conceive with their partners than men who are younger do.
  • If you’re a man who is infertile and are experiencing shame, depression or loneliness, seeing therapists or joining support groups or support apps can help. If you’re not able to conceive naturally or through assisted reproductive technologies, such as I.V.F., consider other options such as sperm donation or adoption.

When Paul Flynn, 47, began having trouble conceiving with his wife about 15 years ago, he assumed that the issues lay with his wife, not him. But after what Flynn thought would be a routine sperm check, his results shocked him. 

“The fertility specialist informed us I had virtually no sperm,” Flynn recalled. “I sat there thinking, ‘I’m a man, I’m supposed to procreate.’ It was a real blow to my self-esteem and who I thought I was.’”

About one in eight married couples have trouble conceiving, according to the Centers for Disease Control and Prevention. And while infertility is still largely thought of as a woman’s issue, the male partner plays a role in at least one-third of cases. 

When it comes to discussing fertility issues with others, men often feel uncomfortable and may find it hard to cope. “They still believe that fertility equals virility, and the fact that they’re having trouble points to a lack of manliness,” said Barbara Collura, president and chief executive officer of RESOLVE, a nonprofit national infertility organization.

But contrary to popular belief — even among some doctors — male infertility is not linked with impotence. In fact, said Dr. Marc Goldstein, M.D., director of the Center for Male Reproductive Medicine and Microsurgery at the New York-Presbyterian Hospital/Weill Cornell Medical Center, most men who struggle with infertility have completely normal sexual functioning.

To help you understand the factors that can contribute to male infertility — and what to do if you’re diagnosed — I reviewed the latest scientific research on the topic and spoke to two male-fertility specialists, one ob-gyn, one infertility advocate and two men who have gone through male infertility themselves.

WHAT TO DO

Understand the most common causes of male infertility.

You may have read news reports that sperm counts are dropping. It’s true that a 2017 analysis of 185 studies — which looked at semen samples from nearly 43,000 men from 50 countries — concluded that sperm concentrations per million milliliters of semen had declined by about 52 percent in men from North America, Europe, Australia and New Zealand between 1973 and 2011.

That may sound scary, but fertility experts, such as Dr. Peter Schlegel, M.D., urologist-in-chief at New York-Presbyterian/Weill Cornell Medical Center and president of the American Society for Reproductive Medicine, are skeptical that we’re approaching a sort of sperm Armageddon. “For most patients in the study, their sperm count was still in the normal range,” he said. “If this was such a dramatic drop, we’d be expecting our offices to be flooded with patients. They’re not.”

Still, as many as 80 percent of men who are infertile have low sperm counts. One frequent reason for this is a varicocele, or an enlarged vein in the testicle, which can affect the amount or shape of sperm. Most of the time, varicoceles (which are common) don’t lead to fertility issues, but they’re estimated to occur in 35 percent of men tested for infertility. If the varicoceles are particularly large — as they are in 3 percent of men — they might cause a steady decline in fertility over time. “These enlarged veins raise temperature in the testicles, which can lower sperm count,” Dr. Goldstein said. 

Most men with a varicocele don’t show symptoms and are unaware that they have one, though most doctors find them during a physical exam of the testicles (it feels like a bag of worms). An ultrasound can confirm the diagnosis. If your doctor believes a varicocele is the reason for your infertility, a procedure that cuts and ties the enlarged vein can boost your chance of pregnancy success. “They’re the easiest source of male infertility to treat,” Dr. Schlegel said. 

Other issues — such as a condition called retrograde ejaculation, where semen enters the bladder during orgasm instead of coming out of the tip of the penis — can contribute to low sperm count. With epididymitis, there’s an actual blockage in the ducts that transport sperm from the testicles, so they can’t leave the urethra during ejaculation. These conditions can sometimes be treated with surgery.

Consider how your age can affect your risk.

According to recent data, about 9 percent of births in the United States were fathered by men of “advanced paternal age,” meaning — depending on which definition you use — that they’re above 35 or 45. According to one 2003 study cited in a 2019 review, fathers older than 45 were nearly five times more likely to take more than a year to get their partners pregnant than men who were 45 or younger, even when their partners were under 25. 

“The older the man is, the more likely his sperm is to have DNA damage that doesn’t make them as potent,” said Dr. Gloria Bachmann, M.D., a co-author on the review and director of the Women’s Health Institute at Rutgers Robert Wood Johnson Medical School in New Jersey. 

One March 2019 study mentioned in the review also found that babies born to fathers who were 45 or older had a higher risk of complications such as low birth weight, low Apgar scores (a quick test to gauge a baby’s well-being one to five minutes after birth) and premature birth; and could be more likely to develop autism, schizophrenia and obsessive-compulsive disorder compared with the children of men who were younger. 

“Women at every age are made painfully aware of their biological clocks, but every man in his 30s should be thinking about theirs, as well,” Dr. Bachmann said. “That doesn’t mean that a 70-something man can’t have a very healthy child. But the example I like to give is comparing driving on the highway at 65 miles per hour versus 95 m.p.h. If it’s the latter, it doesn’t mean you’ll always have an accident, but the risk is much greater.”  The studies cited in Dr. Bachmann’s paper were all observational, meaning that the study authors couldn’t prove that advanced paternal age was directly responsible for those outcomes. But if you’re a man who is planning to delay fatherhood until later in life, Dr. Bachmann recommended that you consider banking your sperm before your 35th or 40th birthday.

Realize that diet and lifestyle may play a role.

Women are often advised to get themselves “pregnancy ready” far before they even begin trying to conceive, such as by maintaining a healthy weight, taking a folic acid supplement each day and avoiding cigarettes and alcohol. Similar strategies may hold true for men. 

One reason sperm counts may be dropping globally, according to Dr. Schlegel, is because of the rising rates of obesity. According to a 2019 study out of China that analyzed the sperm of more than 3,100 men in infertile couples, those who were classified as obese were about 1.5 times more likely to have a low semen volume — the amount of semen ejaculated — than men who were normal weight; and those who were overweight were 1.2 times more likely to have a low semen volume.

Smoking and heavy drinking may also be factors. A 2019 review of studies found that smokers were significantly more likely to have low sperm counts and sperm defects when compared with nonsmokers. And another 2014 study published in the medical journal BMJ Open found that consuming more than 25 alcoholic drinks per week was linked with much poorer sperm quality than those who had five drinks or fewer. In particular, men who consumed more than 40 drinks a week had a 33 percent reduction in sperm concentration compared with men who drank five or fewer drinks per week.

Diet may be important, too. A Mediterranean-style diet rich in fatty fish, whole grains, nuts, fruits, vegetables and healthy fats like olive oil has been associated with better sperm quality, according to a 2018 review published in the journal Fertility and Sterility. 

There’s also evidence to suggest that heat — particularly from tight undergarments — may play a role. One 2018 study of 656 men published in the journal Human Reproduction found that men who wore boxer shorts had a 25 percent higher sperm concentration than those who didn’t.  Of course, all of these studies have important limitations, so more research is needed to confirm these associations.

If you’re struggling to conceive, get evaluated.

The American Society for Reproductive Medicine has advised that all couples who can’t get pregnant after a year of unprotected intercourse — or after six months of trying if one or both members of the couple are over 35 — seek medical help. [See our guide to fertility.]

But it’s important for both partners to be checked by a fertility specialist at the same time, Dr. Goldstein said. “When a woman sees her gynecologist and tells them she’s having trouble conceiving, it’s common for them to focus on her, because she’s their patient,” he explained. “It’s almost an afterthought to have the male checked, after the woman has already undergone a battery of tests.” 

The first step is a careful and thorough medical history and physical exam by a urologist or fertility specialist. “You can get most of the information you need by asking the patient a lot of questions, and really listening to him: ‘Have you ever gotten anyone pregnant before? Has your wife ever been pregnant with prior partners? Is there any history of infertility in your family? Have you ever had a sexually transmitted disease?’” Dr. Goldstein said. The next step is to do a semen analysis, or sperm count, which provides information about the number, shape and speed of your sperm. If the results of your semen analysis suggest that your sperm counts are low, don’t panic: Sperm counts can fluctuate week to week, and even sometimes from day to day. Your doctor will most likely order a repeat of the semen analysis about a month later.

If your doctor is stumped as to a cause, go straight to I.V.F.

In more than 20 percent of cases, there’s no known cause for male infertility — even after a thorough workup. Sometimes, infertility specialists simply can’t find a condition; or if there is one, it’s not correctable, like a genetic mutation, Dr. Goldstein explained. In these cases, your doctor may advise you to move straight to in vitro fertilization (I.V.F.), a type of assisted reproductive technology where an egg is fertilized with sperm outside of the body and then transferred into the uterus. 

In cases of male infertility, doctors often recommend either traditional I.V.F. or I.V.F. with intracytoplasmic sperm injection (ICSI), a procedure where a single sperm from the man is injected directly into an egg, which is then transferred to the womb.

Seek support.

“My knee jerk reaction was I didn’t want to tell anyone,” said Denny Ceizyk, 53, author of “Almost a Father: A Memoir of Male Infertility.” “It was the first time in my relationship with my wife, Lisa, where I felt like I couldn’t provide what she wanted,” Ceizyk said. 

Although Lisa successfully conceived via I.V.F. and gave birth to their daughter in 2002, at one point during the six-year infertility process, Ceizyk said he had to seek therapy after becoming suicidal because of the shame he felt for not being able to conceive. “I felt like there was a whole support system built in for my wife, while I was just given a cup and told to go to the bathroom,” he said. 

Indeed, said Collura of RESOLVE, there are many infertility support groups, but few are just for men. To compound their feelings surrounding their own diagnoses, some may feel guilty when watching their partner go through intrusive fertility treatments. “Their attitude is, ‘I have to see her take all these shots and have invasive medical procedures all because of my condition,’” Collura said.

Ceizyk said that reaching out, whether to a therapist, a support group or another patient your fertility specialist connects you with, can be helpful for men who have been diagnosed with infertility. Though make sure your therapist specializes in infertility, said Ceizyk: “There’s nothing worse than having to sit in a session trying to explain the different procedures.”  You might also seek support online. In March 2018, Alice Domar, Ph.D., an associate professor of obstetrics, gynecology and reproductive biology at Harvard Medical School and director of Integrative Care at Boston I.V.F., launched FertiSTRONG, the first fertility app devoted to addressing the emotional health of men who are infertile. It helps them deal with a variety of situations, such as feeling sensitive on Father’s Day or receiving unsolicited advice. “We wanted to make sure men who didn’t have access to a support group, or didn’t feel comfortable going to one, had another, more private option,” Dr. Domar said.

If treatment doesn’t work, consider other options.

Sometimes, a man’s infertility problems simply can’t be treated, even with assisted reproductive technology. In these cases, you might consider sperm donation or adoption. “At first, I was very resistant to either idea,” said Flynn, who was finally convinced by his wife to explore sperm donation. “I was worried that if the donor wasn’t my clone, everyone would realize that biologically the baby wasn’t my child.” 

What helped him, he said, was feeling like he had control over the process. “The sperm bank we used offered photo matching, so they were able to provide a list of donors whose faces were most similar to mine,” he recalled. “Once they did that, I was able to really review the donors — their family health history, their personality, their interests — to pick the one I wanted.” 

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