by Steven J. Hirshberg, MD and Lawrence Grunfeld, MD
Most of us assume that our ability to have children is secure. After all, procreation is a basic human right, is it not? Well for some, this basic right is not so simple.
Infertility can be a painful and confusing experience for couples mentally prepared to have children. Approximately fifteen percent of American couples struggle with infertility, and although neither partner is ever "to blame," the situation can become enormously stressful for individuals and couples alike.
Approximately one-third of infertility cases can be attributed to problems with the sperm. Below, Dr. Steven Hirschberg and Dr. Lawrence Grunfeld discuss diagnosis methods for male factor infertility.
Q: When should a couple begin to think about seeking professional help for infertility?
In general, after one year of unprotected intercourse, we recommend seeing a doctor who deals with infertility regularly. We make it earlier in women who are over the age of thirty-five, especially because once women get to age of forty, the percentage of infertility within the couple itself increases.
Q: Who comes to the first consultation?
We encourage a couple to come together for the first consultation. It doesn't always happen. Sometimes the guys are a little shy, and the woman is representative of the couple. As a gynecologist, I also see single women who are interested in becoming pregnant. But the couples are always encouraged to come together. It's always a team effort.
Q: What type of screening tests do you do to see if there is a male infertility problem?
Quite often, a couple comes to me and the man in the couple says,"I have male infertility. I had a test and my sperm are a little slow or a bit misshapen." The first thing we need to do is look at both individuals in the couple before we entertain that as the primary diagnosis. We completely evaluate the woman to make sure that we're not missing a more profound or serious problem.
When we determine there is a true male infertility diagnosis, as presented by an abnormal semen analysis, the man always deserves a thorough evaluation by urologists competent in the evaluation and treatment of male infertility.
Q: What are you looking for in a semen analysis?
The first thing is the volume or amount of fluid. If there is merely a drop versus the normal amount-which is approximately a half teaspoon-it's going to be much harder for the sperm to find their way up to the egg. Sometimes this can indicate a hormonal problem. Sometimes it indicates a blockage in the system.
Sperm count is also important, but I don't believe it's the most important factor. I think that the percent of the sperm that are moving, and how the sperm are moving, are more important factors.
Q: What is a normal sperm count?
For fertility purposes, we usually like to start with about 20 million. If the sperm are moving relatively well, we can work with that number. I can then do things to try to help bring the count up if that's indicated. If not, there are ways we can manipulate the sperm that are there, since 20 million is a relatively reasonable number.
Q: Can you describe what you're looking for in terms of sperm motility?
We like to see about 50 percent of the sperm moving, and about half of the sperm moving with a straight-forward progression, swimming in a nice straight line, and not just sitting there with their tails wagging, spinning their wheels. How the sperm moves is sometimes as important as how many are moving and how many there are in the first place.
Q: What are you looking for on the female side of things?
We have to know that the plumbing is working, that the uterus and the fallopian tubes are normal. We have to know that there is some ovulation. Often, history is the best test to determine there is ovulation. Quite often, a simple test, although somewhat controversial as to how significant it is, is to see the couple at midcycle; to see them when she is ovulating after intercourse. That test is called a postcoital test.
The couple has intercourse the night before, goes to the gynecologist's office, and we take a little drop of mucous and see if the sperm are moving in there. This is also a wonderful opportunity to determine what's going on in the woman's reproductive system at the time of ovulation. Does she have normal cervical mucous? Does she have a normal ovulation? The gynecologist who does the fertility evaluation uses the sonogram machine extensively to evaluate the woman's reproductive tract.
During this time, we do a transvaginal sonogram to determine that there is an ovulation follicle, that there is an egg. We make sure that the anatomy is normal. We make sure the eggs and the ovaries are in a normal location. With this information we can tell quite a bit about the couple. Most often, as we're working with the female partner to try to optimize her reproductive system, we send the male off to the urologist for tests.
Q: So while the urologist is trying to figure out if there is a problem with the sperm, the gynecologist is working with the woman, trying to figure out how to best use the sperm that is being produced. Is that right?
That's right. The way I like to explain it to the patient is that the urologist is responsible for the sperm until it gets into a container, and the gynecologist is responsible from the time the sperm is in the container until it gets up to a woman's egg.
Q: What are some other useful tests for men?
One thing I use very commonly is hormonal tests. We want to make sure that there is the right environment for sperm production before we decide what to do and how best to take advantage of the sperm that are there. There is a certain percentage of patients that have hormonal problems that can be treated.
Some men may have had serious infections, may have had some injuries or damage or trauma to their system, or may not have gone through puberty normally, which may indicate some other problems. A small percentage of men have antibodies in the their systems, which is something we need to rule out before making therapy decisions. Antibodies result in something like an allergic reaction to one's own sperm. Sometimes we can treat it with medications, but more commonly we use treatments to wash the antibodies off the sperm and better utilize those that are there.
Q: Does a man's age play a role?
Age probably plays a less significant role in men than it does in women. Unfortunately, we don't have great data available to use that tells us which man might have a problem based upon age.
Certainly on physical examination, there are some critical considerations. You want to make sure that the man looks like a man, that's he's got normal sexual characteristics of a man. Then, of course, my examination focuses mainly on the male genitalia. It's more than just the testicles themselves. It's the size of the testicles, as well as the consistency of the testicles. I also examine the accessory structures, such as the vas deferens, or the tube that brings the sperm up to the outside world. Some men are actually born without that. If I examine a man and he doesn't have a vas on either side, and we get a semen analysis and there is no sperm, that's the diagnosis. It happens at the first office visit.
There are some other, more sophisticated tests that would be warranted at that point, but based on the physical examination alone, that can sometimes give us the answer. One of the biggest diagnoses in men with infertility is a varicocele, which is a dilated vein in the scrotum. We think it causes overheating in the testicle, and that's also a diagnosis that's made in the office.
Couples concerned about infertility can ask their general practitioners for a referral to clinics that specialize in the problem. Together with a urologist and gynecologist, couples can work to reach a diagnosis. Once the problem is identified, couples and their doctors can customize a treatment approach that makes sense.
Dr. Steven J. Hirshberg is the director of male infertility at the Toll Center for Reproductive Sciences at Abington Memorial Hospital in Abington, PA. Dr. Hirshberg is also affiliated with Pennsylvania Reproductive associates. Dr. Hirshberg is also on the clinical faculty at Temple University Hospital in Philadelphia, PA. Dr. Hirshberg received his medical degree from Boston University School of Medicine. He did his surgical internship and a second year of surgery at Temple University Hospital in Philadelphia. His urology residency was also performed at Temple University Hospital. Dr. Hirshberg then completed a fellowship in Male Reproductive Medicine and Surgery at Baylor College of Medicine in Houston, TX.
Dr. Hirshberg is one of only a few urologists in the Philadelphia area with specialized training in male infertility and microsurgical techniques. He is affiliated with 2 of the busiest IVF programs in the Philadelphia area and works with 11 reproductive endocrinologists. He is a Clinical Associate Professor of Obstetrics and Gynecology at the Mt. Sinai School of Medicine and is associated with the Institute for Reproductive Medicine and Sciences at St. Barnabas in Livingston, NJ.
Dr. Grunfeld received his medical degree from the Mt. Sinai School of Medicine in New York after which he completed his residency in obstetrics and gynecology again at Mt. Sinai. He then went on to do a fellowship in reproductive endocrinology at the Albert Einstein Medical College. Dr. Grunfeld is board certified in both obstetrics and gynecology, and reproductive endocrinology.
The Institute for Reproductive Medicine and Sciences, under the directorship of Jacques Cohen, PhD, runs one of the most highly regarded IVF centers. They perform IVF, ICSI, sperm extraction, preimplantation genetic diagnosis (PGD) and various experimental culture conditions to improve embryo quality.
Copyright © Steven J. Hirshberg and Lawrence Grunfeld. Permission to republish granted to Pregnancy.org, LLC.