Men can be infertile too

Los Angeles Times

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Genetic disorders and lifestyle behaviors can affect the
quality and quantity of sperm. But male infertility often goes undiagnosed and
untreated.

By Valerie Ulene, Special to The Times
July 7, 2008

WHEN A couple is infertile,
often the first question asked is, "What's wrong with her?"
"There's a common misperception -- even among healthcare providers -- that
infertility is a female problem," says Dr. Thomas Walsh, director of the
men's reproductive health program at UC San Francisco School of Medicine.

In fact, male infertility is quite common. At least 20% of infertility cases are
due solely to male factors such as low sperm count, and in 40% to 50% of cases,
male factors contribute. Many male fertility problems go undiagnosed and
untreated, however -- either because attention focuses on their partner or
because men are reluctant to get help or unable to find it when they seek it.

Numerous factors influence men's fertility. Some infertile
men don't produce adequate amounts of sperm to cause pregnancy. Normally, the
precursors to sperm -- germ cells -- mature in the testes under the influence
of hormones produced by the pituitary gland. Abnormal or absent germ cells, or
disorders that affect the production of pituitary hormones, can impair a man's
sperm count.

In some cases, genetic disorders cause low sperm production. Klinefelter's
syndrome, which affects between 1 in 500 to 1 in 1,000 men, is among the most
common. Men with Klinefelter's carry an extra X chromosome (genetically, they
are XXY instead of XY). The condition leads to small testicles with very few
germ cells, and most of these men suffer from infertility. Tiny missing pieces
of genetic material in the Y sex chromosome can result in poor sperm counts
too.

Certain lifestyle behaviors, such as smoking and excessive alcohol and drug
use, depress men's sperm counts. For some men, high levels of stress can as
well.

Sometimes men are able to make sperm in sufficient quantities but poor sperm
quality causes conception difficulties. For fertilization to take place, sperm
must be able to reach the egg and then penetrate its outer layer. Sperm that
don't move well or are abnormally shaped may be unable to do so. As with low
sperm count, causes can be genetic or tied to lifestyle.

Even men who produce healthy sperm in adequate amounts sometimes suffer from
infertility. Infections such as chlamydia and gonorrhea can damage the vas
deferens (the tube leading from the testes to the urethra, through which the
sperm travel), blocking it and preventing sperm from leaving the body.

Some men even produce antibodies against their own sperm; functional when first
produced, the sperm are quickly damaged by the immune system.

Ironically, vasectomy is one of the most common causes of male infertility.
Nearly half a million vasectomies are performed in the U.S. each year,
and up to 6% of men who have the procedure want a reversal at some point --
either because of divorce or the loss of a child, or simply because they decide
they want another child after all.

Regardless of the underlying cause, infertility is a couple's problem. But
according to a recent online survey of infertile couples conducted by
IntegraMed, a national network of fertility centers, women generally are
evaluated first. Sixty-seven percent of those responding to the survey said
that the female partner sought initial treatment for infertility.

"Both the male and female partner should be worked up
simultaneously," Walsh says. "Men are just as deserving of a
comprehensive evaluation."

A male fertility assessment typically starts with a thorough medical history
and examination, and generally also includes a semen analysis that examines the
volume of a man's ejaculate, the concentration of sperm in the ejaculate and
what percentage of those sperm can swim.

Further testing is based on the results of the analysis. Men with low sperm
counts, for example, might require hormonal or genetic testing. If no sperm are
found in the ejaculate, a testicular biopsy -- removal and examination of a
small piece of tissue from the testicle -- may be necessary.

Unfortunately, men often resist being tested. Nearly half of all women
responding to the IntegraMed survey said that it was only after pressure that
their male partners were willing to seek medical consultation.

The reasons for this reluctance have not been well studied. Some fertility
experts suggest it's purely a macho thing -- that a man's sense of masculinity
tends to be strongly tied to his ability to reproduce, making him afraid to
acknowledge that he might have a fertility problem.

Of course, it's almost certainly more complicated than that and likely involves
a broad range of issues and concerns. It may simply reflect men's general
tendency to utilize healthcare less than women. But regardless of the reason,
"When men feel responsible for infertility, it has a profound impact on
them," Walsh says.

Unfortunately for men interested in a fertility evaluation, getting help isn't
always easy. Whereas most women of childbearing age have a primary healthcare
provider such as a gynecologist or family practitioner who deals with their
reproductive issues, men generally do not. "Young men are a medically
underserved population," Walsh says. "They simply don't have places
to go to seek out healthcare for reproductive issues."

Couples struggling with infertility should make every effort to find help for
both partners. While ob-gyns typically deal with women's reproductive problems,
urologists are the best people for men to turn to for help. Some urologists --
like Walsh -- actually specialize in men's reproductive health. In recent
years, there have been tremendous advances in the field of male reproductive
medicine. In fact, with current technology, even men who produce just a single
sperm can cause a pregnancy.

"We can dramatically increase the likelihood of couples conceiving at home
or with the least amount of technology possible," Walsh says.

Dr. Valerie Ulene is a board-certified specialist in preventive medicine
practicing in Los Angeles.
She can be reached at themd [at] att [dot] net. The MD
appears the first Monday of the month.

http://www.latimes.com/features/health/la-he-themd7-2008jul07,0,1828171....