Male Fertility: Q&A with Edmund Sabanegh, MD

Q: *My husband had a testicle biopsy, and the results came back negative for sperm. The doctor said that he is missing a certain enzyme that helps create sperm. Is there any way he can father his own children? Can the enzyme be supplemented? Thank you.*

A: There are a number of genetic causes which can impact the production of enzymes which are important for sperm production. Depending on the exact cause, sometimes we can do a microsurgical testicular biopsy and find sperm that was not located on a prior biopsy.

Q: *Can male infertility to be treated?*

A: Male infertility can often be treated successfully. Sometimes there are obvious causes such as blockages that we can repair. Often we will use medications to treat infections or improve hormone levels, which can also improve fertility. Finally, in some cases, we will use assisted reproduction such as insemination to cause a pregnancy.

Q: *Do hot tubs kill sperm?*

A: High temperatures such as those that result from hot tubs or laptop computer use can greatly lower fertility. It is important to avoid hot tub use when you are trying to cause a pregnancy.

Q: *Are there are any obvious symptoms of male infertility?*

A: Often there are no symptoms of male infertility except the inability to cause a pregnancy. Sometimes, male infertility can be from a hormone imbalance and patients may have decreased sexual desire or erectile dysfunction. In addition, a small number of men may have infertility due to testicular abnormalities such as tumors, so men should have a complete examination if they have difficulty causing a pregnancy.

Q: *What are the chances of pregnancy when you have XXY syndrome?*

A: Men with 47XXY syndrome, also called Klinefelter's syndrome, often have no sperm in their ejaculation. However, in 60% of those patients, we can find a small number of sperm in the testes using a careful microsurgical biopsy. These sperm can be used for intracytoplasmic sperm injection (ICSI), a type of in vitro fertilization, to cause a pregnancy.

Q: *How do you get tested for male infertility?*

A: Usually, we see the man in a clinic appointment and take a complete medical history and perform a physical examination. We then recommend that the patient produce a semen specimen for laboratory analysis. Further testing including blood tests of hormone levels may be indicated based on the results of the semen tests.

Q: *What is currently considered a good morphology/Kruger score?*

A: Kruger morphology, also known as "strict morphology," is considered abnormal when it is lower than 4 by World Health Organization standards.

Q: *Does carrying a cell phone in the pocket decrease a man’s fertility and why?*

A: Some research in the laboratory has suggested that exposure to radiation that is produced by a cell phone may lower a man's sperm count and motility. This is an area of ongoing research, and we do not have a definite answer to this question yet. Until we know for sure, we recommend that men who are actively trying to cause a pregnancy keep their cell phone as far as possible from their pelvic area.

Q: *Are there any medications that have infertility as a side effect?*

A: Yes—many medications can hurt fertility. Testosterone therapy can greatly impair sperm counts and should be avoided until men have caused a pregnancy. The list can be quite long, but other medications that impair fertility include chemotherapy medications to treat cancer, hormone treatments, and drugs to treat prostate enlargement.

Q: *I know that prior drug use can cause infertility. What are the worst drugs in causing male infertility? Also, is the damage permanent?*

A: Recreational drugs, such as marijuana, can alter hormone levels and cause infertility. Anabolic steroids used for muscle building can greatly affect fertility by lowering sperm counts. In those patients, it may take 3 to 6 months to recover; it has been observed to take up to 4 years to recover in some patients.

Q: *What is the shelf life of frozen sperm?*

A: Frozen sperm can last indefinitely. We have seen patients successfully use frozen sperm to cause a pregnancy after 22 years of freezing. Based on our analysis, there is no upper limit for when it has to be used.

Q: *What are some of the causes of infertility?*

A: Infertility is caused by the male side in 30% of cases, the female side in 40% of cases and a combination of male and female factors in 20% of cases. As regards male side causes, impairment of fertility can be caused by blockages in the sperm tract, hormone imbalances, varicoceles (dilated scrotal veins), infections, and genetic abnormalities, to name a few.

Q: *If DNA fragmentation is damaged due to smoking, does it recover if a person quits smoking? If yes, how long does it take?*

A: Many sperm characteristics, including DNA fragmentation, motility, and concentration, can be negatively affected by smoking. Studies have shown that these factors will improve by quitting smoking. The sperm cycle is usually about 74 days, so we usually tell patients that they may observe an improvement as soon as 3 months after quitting tobacco use.

Q: *Is there anything a male patient can do to increase morphology score?*

A: Morphology can improve with a variety of treatments, including treating an infection or removing certain medications. However, the most common factor we see in clinical practice is improvement of morphology after treating a clinical varicocele, which is a dilated vein in the scrotum.

Q: *What lifestyle changes can a man make to improve his sperm quality?*

A: Sperm quality is a snapshot of our overall health. Things that we do to improve our overall health such as getting regular exercise, maintaining a healthy body weight, and eating a diet rich in fruits and vegetables for their antioxidants will often improve our fertility. Avoidance of things which can hurt our fertility—including tobacco, illicit drugs such as marijuana, and anabolic steroids—will also help.

Q: *How long should I abstain from intercourse prior to my upcoming semen analysis?*

A: Ideally, you should abstain for 3 to 5 days before performing a semen test. This allows a replenishment of sperm count so we can get a true picture of your sperm production.

Q: *What is the recommended treatment for varicoceles and how does that affect infertility?*

A: Varicoceles are enlargement of scrotal veins which can cause the scrotum to stay too warm and hurt sperm production. Patients with varicoceles can have reduced sperm counts, motion and shape abnormalities. Varicoceles are usually treated with a minor surgery where the abnormal veins are treated through a small incision in the groin using an operating microscope. Typically this surgery takes about an hour, and patients can resume all normal activities within a couple of days.

Q: *My husband had epididymitis in college, and we just found out that the genetic form of amyloidosis is in his family (his grandfather and father both passed away from the disease). According to his doctor, his count is "normal" right now. Could either epididymitis or amyloidosis have an effect on the viability of his sperm?*

A: Epididymitis is more likely to cause fertility issues in some patients. The epididymis is a small tube that conducts sperm from the testis so if it gets infected, it can block sperm flow in some men. Your husband is fortunate because his sperm count is normal, so it does not appear that the epididymitis affected his fertility.

Q: *I am a 53-year-old male with motility = 0 who took Clomid for 3 months without improvement. My doctor asked me to take an ultrasound exam. Would it be helpful? What is the purpose of it? What is the IVF rate for my case? Is there a solution to treat motility?*

A: Low sperm motility can be caused by a variety of things including varicoceles (dilated veins in the scrotum), antibodies to sperm, infections, and some medications. Your doctor wants to perform a scrotal ultrasound to make sure the testicles are healthy and to look for varicoceles. The IVF success rates are really dependent on the viability of the sperm (how many are alive), which can be determined by special sperm tests. Regarding ways to treat low motility, it really depends on the cause. In addition, sometimes low motility is a temporary condition due to a recent illness or fever and may recover in 3 to 6 months.

Q: *How soon after having a blockage repaired can one start having sexual intercourse?*

A: It depends on whether the repair is of the male side or the female side. After repair of an obstruction in the male, patients should not start having intercourse until at least 3 weeks. Following repair of a blockage on the female side, couples should wait at least one full menstrual cycle before resuming sexual activity.

Q: *I have recently been diagnosed with testicular cancer, but the doctors say it is treatable. What options do you have available for men to bank their samples for later use? I want to be sure my fertility is not taken away.*

A: You raise a very important point. I recommend that all men bank a semen specimen prior to receiving chemotherapy or radiation therapy for treatment of testicular cancer. Ideally, men should bank sperm prior to surgical treatment of the testicular cancer if possible. We offer sperm banking for patients at the Cleveland Clinic. We also offer the NextGen program where a patient who is not in the vicinity of the Cleveland Clinic can have a sperm preservation kit sent to their home, and they can ship it to our site for sperm freezing (Cleveland Clinic sperm bank phone: 866-9BANKIN or 866-922-6546). It is indeed very wise to preserve your fertility prior to receiving testicular cancer treatment.

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