The Best Way to Improve Male Fertility
You want to increase your chances of becoming a dad? Find out more about common causes of male subfertility, including treatment options and non-prescription tips on how to improve male fertility.
So today we are going to talk about male subfertility and I called it subfertility mainly because in this day and age, there are very few men that we're not able to help somehow and not look at this as a condition of infertility but really how can we optimize men's health, men's sperm production and men fertility options to really provide a wealth of services to couples that are struggling with fertility issues.
We are going break this down into a two different categories:
- Background and common causes of male subfertility
- Ways to improve male fertility
So I'll be telling you how to improve their fertility with non-prescription methods so in other words how can you stay out of my office or what can you do before you get to my office so that we can help your fertility goals be achieved.
Background on male fertility
A background on male fertility is kind of interesting. Obviously since the time of creation there have been a lot of philosophers that have thought about what is the origins of male fertility. Some early thoughts were that the we knew that semen was responsible for procreation. Early thoughts were going back to the fact that maybe maybe they're these little men that would run out through the male ejaculatory system and become fully developed babies in utero.
So that the female part of this was really just a holding ground for that male which was fully developed within the male reproductive tract to mature. So again, a very male centric thought about fertility and therefore lack of fertility.
It was Aristotle actually that came up with the thoughts behind gender selection in fertility. So his thought was that if a man was thinking about himself during the point of climax, then the child would be a boy. If the man was thinking about his partner at the time of climax, the subsequent child would be a girl. As the father of two sons everybody competing my wife at this point.
But either way that was yet another early thought about the origins of fertility and gender selection.
In the 1700s, the father of microscopy, a Dutch tradesman Antony van Leeuwenhoek, was the first person to actually see sperm under a microscope presumably discovered on a long weekend when mrs. van Leeuwenhoek was at her mother-in-law's house.
The sperm that he found under that microscope really forwarded the science at that point.
Classifying male subfertility
So in order to classify male subfertility, I look at it in two categories:
- Oligospermia: too few sperm
- Azoospermia: no sperm at all
Oligospermia is further categorized into a few different subcategories:
- Oligospermia: too few sperm
- Teratospermia : Poorly shaped sperm (morphology)
- Asthenospermia: Poorly moving sperm (motility)
- Oligoteratosthenospermia: all of the above
A few words on semen analysis
For a little background on the semen analysis, we look at four main components:
- Volume in mL.
The first metric we look at is the volume - how much semen comes out when a man ejaculates. That's critical to looking at the various causes of fertility, either a blockage or a production problem.
- Concentration in millions/mL.
We then look at the concentration, which is essentially a function of how many sperm per milliliter of ejaculate volume a man makes.
Motility is essentially how fast they move and that's subcategorized into a few different degrees of motility: 0=not moving; 1=twitching; 2=slowly moving; 3=fast progression.
Morphology is characterized as a percentage of normal sperm. It's a ratio essentially of how many normal sperm per ejaculate a man produces. Believe it or not, it's a very low number to be normal. So a number of patients come to me very concerned when they're told that their morphology is only 2% and they're afraid that that means that 98% of their sperm is not shaped correctly and they have severe fertility impairment. But when I tell them that 96% misshapen sperm is considered normal, it alleviates some pressure and allows us to move forward to see how much more we can optimize to get that extra 2%.
Categorizing male subfertility
There are two main categories of male fertility:
- Non-obstructive: meaning that there's no production going on in his testicles.
- Obstructive: meaning that the factory is there but the highway is closed.
In both of these you have a problem with amount of sperm in the ejaculate. The ejaculatory system really starts in the testicle and so that's dealing with the obstructive side. A sperm is made in the testicle. It then finds its way in through a series of a few ducts into the epididymis (which is the sperm holding gland) which eventually uncoils into the vas deferens and then out into the urethra in the ejaculatory duct. So anywhere along that system there could be a blockage.
What can go wrong?
What are the different common things we see in male infertility?
- Huge and Hurt (anabolic steroids and narcotics)
We previously discussed a little bit, essentially it's where for some reason there's a blockage along the highway there.
Heat and Varicocele affects male fertility
So what about heat? The reason that we as men have scrotums is essentially to keep the testicles outside of the abdomen to keep it the sperm about two degrees colder than the rest of the body. If you have any sort of heat source, on those testicles, it can be a very common source of male subfertility.
One of the most common sources of heat is something called a varicocele. Which is something I see very frequently in my practice as a male fertility specialist. Approximately 40% of the men that come to my office with fertility problems have varicocele.
Varicocele is varicose veins that are enlarged because the system of transport of that blood from the testicle back up into the heart is too stretched out. It's dilated. The valves that normally work to push that blood away from the testicle are too far stretched apart and the blood tends to pool against gravity.
I always say if a man was able to walk on his hands, for the entire day, he wouldn't have a varicocele and those sperm would be colder. Now obviously that's impractical but that's essentially a good way to look at this. Gravity plus the varicocele is what causes the the extra heat on that testicle.
Obesity and sedentary lifestyle can cause hot scrotal temperature
There are other things that can cause heat: obesity. Just imagine the scrotum sitting between two very large thighs. Then the body temperature of that of those thighs are actually going to cause difficulties with heat.
Sedentary lifestyle: same thing. If you're sitting down all the time and you're not moving around. Testicle is going to be a little bit hotter than they should be.
Boxers vs briefs
I get that all the time. If we remember back to the presidential elections of over 20 years ago, we learned about Bill Clinton's boxers versus briefs habits. Since then it has always been a topic of conversation. There's been a lot of literature and it seems as if there's a very weak correlation between a man's underwear choice. Having said that, a lot of men that's the first thing they do before they come see me is proudly telling me that they've gone commando in hopes of improving their sperm counts. So it's a it's certainly a fun topic of discussion but maybe not clinically useful.
Whatever's good for the man is good for the sperm. So conversely whatever is bad for the man is also bad for the sperm.
Cigarette smoking: bad for sperm
Alcohol consumption: in moderation probably not bad for sperm. In excess, greater than five to six drinks at one setting, especially highly correlated with poor sperm quality.
Obesity: I talked about it in the heat section. Obesity also has problems with hormones. Men that have very large body mass indices will also have abnormalities in their testosterone production, as well as their their conversion of testosterone into estradiol. That can have some mega defects on sperm production. Obesity really a multi-hit problem with sperm production
Hypertension is also associated with male infertility. Some of that hypertension medications can have a negative effect. This is something to discuss with your physician if you are trying to conceive. You might want to look for an alternative medication or figure out other ways to control blood pressure: diet, exercise, all the other good stuff we hear about.
The hormone side of non-obstructive infertility
Men are not as simple as testosterone alone. Although that's what we are sort of known for and given credit for. They're actually a lot of hormones that can be responsible for problems with fertility. They most start in the pituitary gland.
1. High FSH is a good indicator of production problem
There is a sperm producing hormone called FSH is actually named for the female hormone which is follicle stimulating hormone. It turns out it has a similar function in pituitary gland of men and essentially works as a regulatory hormone for production of sperm.
If a guy is making normal sperm numbers his FSH should actually be pretty low. If a guy is making no sperm then his FSH is going to be elevated because his pituitary gland is telling his testicle "look, you need to crank up the factory production here". But you're not meeting the goals and the only way that our body has to tell the testicle to do that is through that FSH hormone. So it's a very important indicator for me to determine where the problem is. There's really no great number I threw out 12 milli international units per milliliter (12mIU/mL) as the upper limit of what I would consider normal.
However, a lot of different considerations go into that number. So I can get concerned about FSH is as low as 6. But certainly over 12 I start to be a lot more concerned that we have a primary testicular problem.
2. Low testosterone could indicate either pituitary or testicular dysfunction
It turns out that testosterone is critical for sperm development in the testicle. This is where a common mistake is made both on a patient as well as multiple physician side in understanding how to treat male infertility. Because if you believe what I just said, that testosterone is important for normal sperm production, and a man comes your office with low testosterone, then you would think the most natural thing to do would be to put them on testosterone replacement therapy.
Unfortunately it has exactly the wrong effect.
3. Prolactin elevations could indicate adenoma
Prolactin is another interesting hormone from the pituitary gland. If it is elevated, it can actually shut down the whole system. So prolactin elevation usually affects the other hormones in the pituitary gland, again that FSH hormone, to essentially stop production. So the problem is not down in the testicle, the sperm machinery is there, but there's a problem up here in terms of sending the proper signals down to the testicle.
Prolactin elevations often can be treated with medication. Sometimes, if there is a prolactin secreting tumor involved in the elevated prolactin, a patient may even need surgery to remove that tumor.
4. Estradiol may be role for medication
Finally, estradiol. We touched on that a little bit earlier when we're talking about obesity. Higher estradiol levels feedback on the pituitary gland to shut down those pituitary hormones. Much like testosterone does. But to the point where then sperm production may be affected by that pituitary shut down.
One of the treatments that I offer to patients if their estradiol levels are too high, I put them on a medication to lower those levels and drive the equation back to higher testosterone levels. Then we may be able to improve their sperm counts.
Heredity role in infertility
There are a number of genetic abnormalities associated with male infertility. Some are 100%, if a man has that abnormality, we won't be able to find sperm on him. Even with a micro surgical procedure, where we actually go into the reproductive tract looking for sperm.
It's important for me to get these studies on men that have extremely low sperm counts. Some people would put at less than five million and I think that's a relatively good number. It's pretty rare to find a man with a genetic abnormality if his sperm counts are above 5 million.
But if they are low, then here are the genes that we can see a responsible for potential male infertility:
1. Klinefelter syndrome 47XXY
There's a chromosomal abnormality called Klinefelter's syndrome where a man actually has an extra X chromosome. So he looks just like a guy, walks just like a guy, talks just like a guy, but he has some hormonal abnormalities as well as having poor development of his testicular tissue and therefore poor sperm development as well. We can still find sperm in those men especially if we find them early and especially if we find them before they start testosterone replacement therapy. Which almost all of them need because their testosterone levels are going to be low.
2. Y chromosome micro-deletion
The Y chromosome itself has a region called the AZF region which stands for azoospermia factor. The AZF region is subcategorized into an A, B and C region.
When we do molecular analysis of men's chromosomes (this is a blood test); we look for that what we call Y microdeletion. Because if there is missing one category, one part of one of those chromosomal regions, that may be the reason for infertility.
The worst Y microdeletion to have is an AZF B. So in other words, if that component, and again these aren't individual genes, these are just regions along the chromosome, but if that B region is missing, we will never been able to find sperm. So unfortunately, that's one of the few deal-breakers.
3. Kallmann Syndrome
There is another not so common but one certainly that we all learn about in medical school called Kallmann syndrome. It is what we call a central defect syndrome. So in other words, men with Kallmann syndrome have a defect of the midline of their body and in the pituitary gland. They're not secreting those hormones especially FSH. They are just not there and and they don't have the actual material to secrete it. So the testicle never gets the stimulus to make testosterone or to make sperm.
In fact, those men are usually diagnosed late in adolescence when they fail to go through puberty. The nice thing about men with Kallmann syndrome is that we can replace those hormones and potentially offer not only testosterone boosting therapies but also sperm production. So that's not a deal breaker.
Huge and Hurt
1. Testosterone replacement
Testosterone replacement is becoming a multibillion-dollar industry and the number of men that I see on testosterone replacement that then come to me for fertility issues keeps escalating. It's not going to go away.
What happens is when a man takes testosterone, his pituitary gland goes to sleep. Because it's getting the signal that his testosterone levels are so high, he actually doesn't need to make testosterone anymore. So his own production goes down.
It suppresses hypothalamic secretion of GnRH and pituitary secretion of LH and FSH. The sperm counts go down often to zero. So that's a big thing to remember and a big thing to discuss with your doctor, because a lot of these testosterone preparations is supplements and they may not even mention as medication. So when you're filling out your intake sheets and you go to your physician and it says medications and you don't put testosterone therapy, you think of that as a supplement, you have to let your doctor know that you're on some sort of testosterone therapy. It's going to change the diagnosis, it's going to change the workup and ultimately it's going to change your success for the better.
Infertility is actually very reversible, so for me I look at all those labs to get an idea of how much that testosterone replacement may be affecting his sperm counts.
2. Narcotic use
The incidence of narcotic use is also skyrocketing and not all of this is through prescription drugs. Not all the times men are going to tell me that they are taking those medications. I can find out by doing the appropriate blood tests to see if they actually are on those medications. I'll check the FSH levels, I'll check their other pituitary hormones and be able to determine if their narcotic use is actually causing their fertility issues.
There's nothing wrong with the testicles in this situation. The sperm factory is there. It's just out to lunch or sitting on the couch disabled from the narcotic use. Their testosterone levels will be so low, so they will not only have a sperm production problem but also testosterone production problem.
So we have done non-obstructive, our five H's (Heat, Health, Hormones, Heredity, Huge and Hurt). Now we are going to move over to the obstructive side.
The obstructive side is a little bit more plumbing, which is truly what most of urologists do is unblock pipes. In the reproductive tract, there are multiple sources of obstruction and it's important for me to determine where the obstruction is.
The most common point of obstruction is a vasectomy. When a man decides that he wants to have a vasectomy for birth control, all we are doing is basically blocking the highway. So a big part of my practice is to put those back together when a man or a couple changed their mind. Knowing exactly where the vasectomy was done, I can go in using a microscope and put those two channels back together so that he can have continuity again. We relieve the obstruction and sperm come back.
Congenital bilateral absence of vas deferens (CBAVD)
It's not always that straightforward. There are things that men can be born with either genetic defects or even blockages from cysts, stones, all kinds of things that can cause obstruction elsewhere in the reproductive tract. One of the most common genetic abnormalities in at least a European population is a cystic fibrosis gene. Up to one in 25 men or people are carriers for the Cystic Fibrosis gene. So the incidence of the disease is a lot less than that. But if a man has at least one copy of that gene, usually it takes two, he may have an absence of the vas deferens where basically again the sperm production is there but he's not actually able to get sperm into the ejaculate.
Inguinal hernia repair with mesh
I've also seen obstruction from inguinal hernia repairs. If you're a male thinking about fertility and you have a hernia, talk to your surgeon. If he's going to use mesh, take extra caution around the vas deferens so that that area isn't blocked.
Lastly infections can also cause a problem with fertility. Epididymitis which is that little tube that can get so gummed up with infection, inflammatory tissue, that all the sperm are blocked at that level. Most of the time we are able to catch epididymitis and treat it with antibiotics.
Obstructive infertility diagnosis
So how do I make the diagnosis of obstructive infertility. With the non-obstructive we do blood test and semen analysis.
When it comes to obstructive infertility, a man's physical exam should essentially be normal. Occasionally a man will have some obstruction higher up in the reproductive tract near the prostate or near the seminal vesicles, where the semen is made. I may be able to feel that on a rectal exam. But for the most part, he should have normal testicles. Maybe I won't be able to feel that vas deferens and that will lead me down the pathway of thinking about that cystic fibrosis gene, we talked about.
Maybe I won't be able to tell anything is wrong at all and we will have to use some other diagnostic modalities. I use a lot of ultrasound in my practice to look for those areas of obstruction for example.
The obstruction can be way down low. If it's higher, up near the seminal vesicles in the ejaculatory ducts itself, or it from the prostate area, that's where the seminal fluid comes from so I might find that he has lower seminal fluid. That is going to be a key indicator on that semen analysis.
What about the hormones? Those should all be normal because the FSH up here is only responding to feedback from the sperm. It gets that feedback through the bloodstream not through the tract. So the sperm that are trapped are still sending that signal to the FSH that "hey factory is good, production numbers where we need to be" they don't know that the road is closed and so those numbers are going to be absolutely normal and where they should be.
So getting back to the cystic fibrosis I think it helps to discuss that just a little bit more. It is interesting in that the the obstruction is certainly anatomic but the defect is genetic. What I mean by that is a cystic fibrosis male will actually have a fully intact reproductive system as he's developing. So that the problem is not in the development. But what happens is somewhere while he's still in the uterus he the fluid that normally gets turned over in the vas deferens in the epididymis becomes thick and the secretions become so thick, it causes that as deferens to gum up and that is a signal for that tissue to basically collapse. Eventually what we say involute or go away.
So the key to that is that wherever cystic fibrosis affects us - that is a mostly we think of as a lung disease or gastrointestinal disease - wherever it is it's a malformation or malfunction of transport of chloride across cell membranes that leads to that junkie fluid. So whether it's a junky fluid in the lungs that causes pneumonia and all of the lung complications of cystic fibrosis, or whether it's in the pancreas and the small intestinal ducts causing the digestive problems or in the vas deferens gene is the same all over the body. It's just the organ system that's targeted is going to be different in terms of the effects we see.
So the other key thing about cystic fibrosis is the number of times I make that diagnosis as a urologist and a male reproductive specialist is far more common than you might think. In other words a lot of these men don't have any of those serious life-threatening abnormalities and cystic fibrosis that gets that condition picked up much earlier. So they may be in their 30s and have a little extra cold symptoms in the winter or they've had pneumonia once or twice. But nobody's ever thought to test them for that because they never been that sick. When I do their exam and find that I can't feel that vas deferens, I order the genetic testing and sort of recreate our steps to make that diagnosis of congenital absence of the vas deferens and cystic fibrosis.
The oldest male I've ever picked up in with cystic fibrosis and my practice was over 60 years old. So two things to know about cystic fibrosis:
- it can be a relatively benign condition
- the treatments for men that have severe cystic fibrosis are allowing them to live well into their adult years and really be interested in reproduction whereas before this was such a devastating condition that most people didn't live through adolescence
The important thing also about cystic fibrosis is because there's a genetic test for this, whenever I make the diagnosis and a male it's important for the female partner to also have the genetic testing. Because they have a much higher chance of having a child with a full-blown cystic fibrosis, if both of them test positive for that carrier status.
Easy ways to improve male fertility
So here's the big reveal! Remember at the beginning of this discussion today, I was going to tell you what can you do not to get into my office to improve your fertility. That's perhaps the only reason that you made it through that entire article.
The big reveal is actually what you haveve probably been told forever: change your lifestyle!
Whatever is good for the man is also good for his sperm.
- Don't smoke
- Don't binge drink. There are lots of studies out there that the more man drinks at one setting the worst is fertility parameters are. By ceasing that alcohol sperm counts get improved. So it is reversible up to a certain extent.
- Lose weight and keep moving. One of the best things a guy can do is exercise. Remember that whole thing about obesity? So if you can get out and move let those testicles cool off a little bit, let those thighs get a little smaller, a little more toned, then you're going to improve sperm parameters. Plenty of good studies out there to show that weight loss and exercise can improve sperm counts.
- Keep cool. It goes back to what we were talking about earlier. Heat: bad for sperm. There have even been studies of scrotal cooling where guys will put ice packs around the testicles. You have it a couple of days before a woman's ovulatory cycle to see if they can improve the motility of sperm. It is actually very successful.
The big reveal is that there are no secrets. This is common sense. It's much easier for me to tell you than for you to do, but it's crucial to do everything you can to improve your lifestyle to optimize your chances of fertility.
When that doesn't work, we strongly encourage you to try our natural fertility supplements to improve your overall health and your sperm quality.