Male Health

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.

You may have heard the news that British biologist Robert Edwards won the Nobel prize in Medicine for his work developing in-vitro fertilization. Gynecologist Patrick Steptoe pioneered advances in retrieving and replacing a woman’s eggs without open surgery, and Edwards made breakthrough discoveries in keeping sperm and eggs alive outside of the body. Together, their work resulted in the first “test tube” baby born in 1978. She’s now a healthy adult with children of her own.

I clearly remember the breaking news of that first IVF baby. I was headed to college, and it read like science fiction. All sorts of horrors were imagined and published, alongside articles expressing the thrill of bringing children to childless couples. More than four million IVF babies have been born since that remarkable first, four million people who otherwise wouldn’t be here with us today.

Patrick Steptoe couldn’t share the Nobel prize with Robert Edwards, although he most certainly would have if he could. He died in 1988, ten years after his great success, and the prize isn’t awarded posthumously. Congratulations, Drs. Edwards and Steptoe. You not only brought us great science, you brought children into our homes.

The testes must be kept cool for the proper production of sperm.  One way the human body achieves this is to house them outside the body.  Another is to have a network of veins surrounding the artery pumping blood into the testis: the veins take the heat away in a “counter-current” heat exchange similar to a radiator.  (The human body is an amazing piece of engineering.)

Arteries don’t need to worry about moving blood; there’s a huge amount of pressure coming from the heart to help with that.  But once the blood goes through the capillaries and into the veins, getting back to the heart isn’t easy.  Veins have little valves to help hold the blood while it pulses its way back.  If those little valves start to separate, the vein expands, causing the condition known as a “varicose vein.”  Varicose veins can happen in many places in the body, often visibly in the skin of the legs, but, believe it or not, also in the scrotum.  And if varicose veins develop in the scrotum, they can disturb the counter-current heat exchange.  The testes then get hot, posing a problem for developing sperm cells.

Varicose veins in the scrotum are called a “varicocele,” and there are three kinds.  A grade I varicocele can’t be felt or seen without equipment like ultrasound.  Almost all experts now consider grade I varicoceles to be unimportant.  Varicoceles that can be felt (grade II) or visible by the naked eye (grade III) are the ones that may cause problems with sperm production. Some men have such high sperm production that their varicoceles don’t significantly alter their chance of making women pregnant.  But many men’s testes are affected by grade II or III varicoceles.

Inside of a man, the left vein draining the testis back towards the heart is longer than the right. As a result, varicoceles are most often found in the left scrotum. Sometimes, they’re on both sides, and infrequently, they’re on the right side alone. A right sided varicocele that suddenly appears in adult life is worrisome, as it may be a sign of kidney cancer.

What can be done about a varicocele that may be throwing a wrench into the sperm factory?  A urologist can tie or clip the veins in a procedure called “varicocelectomy,” or an interventional radiologist can inject material into the veins to block the flow of blood.

A first test of male fertility is the semen analysis.  You do your thing, and a technician counts the sperm, sees how they’re moving, what they look like and whether they’re alive.  For decades, the World Health Organization has published criteria for these numbers to alert a man that he might have a problem when it comes to impregnating a woman.  Until recently, the numbers were a consensus of expert opinion, but in the latest edition, the WHO criteria changed substantially.

What the WHO is currently doing is to dispense with expert opinion, and just lay the numbers out for all to see.  Table II from the paper shows the numbers for men from couples who conceived within a year.  Take sperm concentration, for example.  For centile 5, the sperm concentration is 15 million per ml.  That means that only 5% of couples where the man had 15 million/ml sperm or less conceived within a year.  For centile 50, the concentration was 73 million/ml, meaning that 50% of couples conceived within a year when the sperm concentration was up to that number.  You get the idea.

The problem is that people like cutoffs, and in the latest edition, the WHO chose centile 5 as the line in the sand.  It’s a good number for thinking that below it, couple infertility likely involves the male.  But keep in mind that at centile 10, only 10% of couples conceived within a year.  In other words, having sperm numbers above the centile 5 cutoff doesn’t guarantee that the sperm are trouble free.

Frankly, I think the WHO numbers are most useful to get a ballpark idea of how fertility may be related to what’s inside the semen.  I prefer the approach David Guzick and colleagues took, where they applied a statistical method called Classification and Regression Tree (CART) analysis to sperm, which gives two cutoffs in a “green light, yellow light, red light” fashion.  For example, CART analysis came up with 13.5 million/ml and 48 million/ml for sperm concentration.  At 13.5 million/ml sperm or less, the “red light,” couple infertility likely involves the male.  At 48 million/ml or more, your sperm probably are “green light” good to go.  Between 13.5 million/ml and 48 million/ml, the “yellow light,” sperm may or may not be the problem.  You can find the Guzick CART cutoffs here.

A lot of people, including doctors and fertility specialists, are confused about the new WHO cutoffs.  Expect a little consternation about them for a bit.

WHO Table II Distribution of values, lower reference limits and their 95% CI for semen parameters from fertile men whose partners had a time-to-pregnancy of 12 months or less

*PR, progressive motility (WHO, 1999 grades a + b); NP, non-progressive motility (WHO, 1999 grade c).