Male Health

A reader recently asked whether acupuncture helps sperm.

I have to admit I’m a Western thinker, but that doesn’t mean that I automatically dismiss anything Eastern. It does mean that, as is true of any treatment, I will want to see evidence of effectiveness before I believe that it works. The most compelling proof will include:

• A comparison of those patients who are treated and those who are not,
• Patients (and preferably doctors) who don’t know which patients are being treated and which are not,
• Statistics that demonstrate the chances that the conclusion is wrong,
• More than one study that says it is right.

A number of published studies report how sperm fares with acupuncture.  One, published in Fertility and Sterility in 2009, described the use of a special device that either performed acupuncture or just looked like it did, so that patients did not know whether or not they were being treated. Comparing men who were actually treated to those who weren’t, the authors could say with around 95% confidence that motility after acupuncture increased about 10%. The authors didn’t observe an increase in sperm count, and semen volume decreased a little.

If effective, acupuncture would be a great treatment for men who need to improve motility. But first,  I’d like to see a study similar to the one done in 2009, but from different investigators and showing similar results. Until then,  I’d say acupuncture looks promising but needs a bit more study.

After last week’s post about pus in semen, I thought that it might be helpful to describe another important sperm test, one that shows whether or not they’re alive.

Good sperm are alive.  Not only do they swim, they live and breathe just as all living cells do.  Some are dead, meaning that the ship is no longer sailing, and its motor and crew are gone.

One way of figuring out whether or not sperm are alive is to dip them in colored dye.  A dead sperm can’t push the dye out of its body, but a live sperm can.  In the picture, the sperm are stained with a pink dye called Eosin.  The dead sperm are the ones that become pink, and the live sperm are the ones that push the dye outside and stay clear (a light bluish green in the photograph.)

The result of the test is typically described in the percentage of sperm that are alive, and of course, the more living sperm the better.  But even when all of the sperm are dead, a condition called “necrospermia”, couples can still conceive using in-vitro fertilization with intra-cytoplasmic sperm injection.

That doctors can successfully use dead sperm with in-vitro fertilization illustrates a conundrum in reproductive medicine today.  The ultimate barrier to fertilization is no longer the entire sperm’s health, but the quality of its DNA cargo.  Unfortunately, we don’t yet have a way of knowing the condition of a single sperm’s DNA before inserting that sperm into an egg.

So if a man’s sperm don’t wiggle, the first thing to know is whether they’re alive and sluggish or whether they’re dead.  A vital stain makes that distinction.  But if they’re dead, a man shouldn’t despair.  Dead sperm can still be used in intra-cytoplasmic sperm injection as long as their DNA is good.  Unfortunately, the only way to know that right now is to inject the sperm and to see what happens.

The horrific earthquake and tsunami in northern Japan remind us that no matter how powerful we become or careful we are, nature asserts itself in ways that we can’t imagine.  The nuclear engineers and technicians working to contain the radiation leaking from the damaged power plant in Fukushima are nothing short of heroic.  Radiation can cause all sorts of ills, from acute sickness to cancer and infertility.

In the testis, developing sperm cells are exquisitely sensitive to radiation.  Kyodo News reported that after an explosion at the Fukushima No. 2 reactor on March 15, radiation levels measured as high as 8,217 micro sievert or 0.8217 rem per hour.  (Micro sievert and rem are units of radiation dosage.)

Does that amount of radiation harm developing sperm cells?  I asked Marvin Meistrich, Ph.D., Professor of Experimental Radiation Oncology and the Florence M. Thomas Professor of Cancer Research at the University of Texas M. D. Anderson Cancer Center, a world’s expert in radiation and sperm.  Dr. Meistrich explained that sustained exposure to 20 rem of radiation over 4 weeks caused sperm counts to drop to 1/10th of their original amount.  At doses of 40-80 rem, sperm counts fell to about 1/100th of the starting number, and in some cases were wiped out entirely.  At 200 rem, that drop to zero sperm became permanent. For one-time doses, Dr. Meistrich explained that 15-20 rem caused a short-term fall in sperm count, and 400 rem or more resulted in permanent loss of sperm.

We know that radiation changes DNA, the sperm’s precious genetic cargo.  What we don’t know is what dose causes a harmful DNA change that damages a developing embryo or causes disease later in life.

The radiation leakage in Fukushima seems to be in the range at which damage to sperm occurs.  I can only hope that the workers at Fukushima and the people near the plants are aware of the dangers and take action to protect themselves.

Bis-phenol A, or “BPA”, is everywhere.  It’s a chemical commonly found in plastic bottles, like those holding sodas and water.  It leeches out from the plastic container, and seeps into the drink.  To the body, it looks like the female hormone estrogen, and may throw male hormones out of whack.

Mounting evidence suggests that BPA is bad for sperm, slowing the soldiers and lowering their numbers. Look for “BPA Free” on bottles if you want your sperm to be the best that they can be.

Has it really been over three months since my last post?  Between becoming one of the next Co-Editors in Chief of Fertility and Sterility, preparing for a review of our urology training program and finishing my latest book (Thank You, Chapter Authors!) I guess that I’ve let my blogging slip a bit.  Fortunately, thanks to my Italian co-faculty’s discovery of the Saeco Vienna Plus espresso maker at Costco, I’m back at the keyboard.

I turned off the two-week limit for comments, and so far, that’s been a good idea.  People are commenting on older posts (like How Clomid Works in Men) with good questions and thoughtful points.  For new commenters, please read the FAQ.  I can’t answer questions about specific patients.  Those are best left to a live visit with a doctor with an interest in male reproductive medicine.  One great resource is the American Society for Reproductive Medicine’s Society for Male Reproduction and Urology page and the ASRM’s find a doctor search page, (just click on the “Society for Male Reproduction and Urology (SMRU)” button in the “Find Member by Affiliated Society:” section.)  Another excellent way to find a specialist who treats men with reproductive issues is to use the American Urological Association’s Society for the Study of Male Reproduction’s search engine.

This blog post was inspired by several patients who asked after I explained surgical sperm retrieval, if there was somewhere they could go for more information.  I realized that I hadn’t written about such a common issue.

Just as a carpenter has many ways to make a cabinet, a surgeon can tackle a problem in a number of ways.  And just as two cabinets may differ, different surgical problems demand different approaches.  Such is the case in retrieving sperm from the testis.

Most of the time, taking sperm directly from the testis is necessary when a man has azoospermia, where no sperm is found in the ejaculate.  Azoospermia takes two basic forms, obstructive and non-obstructive.  As the name implies, obstructive azoospermia is due to a blockage in the tubes and structures that convey sperm from the testis to the outside world.  In the best case, a surgeon can fix the errant anatomy, allowing a couple to conceive children without further ado.  But because the tubes are so tiny, sometimes the tubes can’t be reconnected with surgery, and the alternative is to take sperm from the testis for it to be used in in-vitro fertilization.

The other form of azoospermia, non-obstructive, arises when the factory making sperm in the testis isn’t working quite right.  Sometimes, the cells starting sperm are missing entirely, a condition known as “Sertoli cell only syndrome”.  Occasionally, sperm may be rolling along their assembly line, a process that takes two to three months to complete, and stop mid-production.  When that happens, it’s called “maturation arrest“.  But frequently, sperm can be found in small amounts in the testis and can be retrieved using surgery.

Because it isn’t mature, sperm from the testis can only be used with in-vitro fertilization and intra-cytoplasmic sperm injection.

How can a surgeon remove sperm?  He or she can take it from the testis itself, or the epididymis, the tiny coiled tube lying on the back of the testis where sperm mature.  The surgeon can insert a needle into the testis or epididymis, he or she may make one or several small incisions into the testis or use microsurgery to retrieve sperm from either the testis or epididymis.  In the case of obstructive azoospermia, it doesn’t seem to matter which technique is used.  There’s plenty of sperm wherever it’s sought, and any method will do to retrieve it.  When a man has obstructive azoospermia, I usually recommend taking a small piece from the testis, as the sperm may be frozen and is good for a number of in-vitro fertilization cycles so that the man doesn’t need to go through a procedure for every cycle, and can be there for his wife during her procedures.

We’ve found that frozen sperm is just as good as fresh.  in fact, the chances for fertilization are the same for fresh and frozen sperm, and the chance for pregnancy may even be a little better for frozen sperm than for fresh.

Frozen sperm should literally last forever.  It’s in liquid nitrogen, which is so cold that the building blocks making sperm don’t decay.  Freezing sperm gives a couple time to plan when in-vitro fertilization is done.

When he has non-obstructive azoospermia, a man’s options are more limited.  A surgeon can use the operating microscope to comb through the testis looking for areas that may contain sperm, a procedure known as “microsurgical testis sperm extraction“.  Other techniques include making several small incisions in the testis or piercing the testis with a needle in a dozen or so different spots.  When a man has non-obstructive azoospermia, I usually recommend microsurgical testis sperm extraction.  More areas of the testis can be examined, and I can see the places that most likely contain sperm.

We’ve observed that prescribing a man with non-obstructive azoospermia clomiphene citrate for a few months before surgical retrieval seems to increase the chance to retrieve sperm.  In many men, sperm appears in the ejaculate and surgery isn’t needed.  If a couple has a few months, taking clomiphene before surgical sperm retrieval might be a good idea.