Expert's Perspective

The Male Fertility Evaluation: Enhances Options and Signals of Future Health

Fertility is a team sport and when problems arise, it’s important for both members of a couple to be evaluated. Approximately 15% of all US couples suffer from infertility (1 - 3) and of those a male factor is identified half the time. However, data from the Centers for Disease Control demonstrates that a male evaluation is bypassed 20 - 25% of the time (4).

While the reasons for this have been debated, there are probably several contributors:

  1. The myth persists that infertility is always a female problem. However, data reliably demonstrates that is simply not the case.

  2. The reluctance of reproductive age men to go to the doctor. In general, men of all ages seek care less often than women. As a result, the first point of contact with medical help for pregnancy is often the woman visiting her gynecologist for an evaluation with men reluctant to get checked.

  3. The reticence of some urologists to get involved in fertility care. The field of reproductive urology has exploded in the past few years but before this occurred many urologists were not trained or interested in such diseases and as such infertile men were underserved.

  4. The power of IVF/ICSI has caused many to bypass a male evaluation altogether. The thinking is IVF/ICSI is so powerful it can overcome most male factor issues and so addressing any underlying issues is not necessary.

However, the male fertility evaluation offers major benefits for both the infertile couple and the infertile man and really needs to be done, and done thoroughly. Here’s two concrete reasons why.

Improved treatment options


There’s more than one path to a child and often a male evaluation will provide several options for treatment. Opportunities to improve sperm production or methods to obtain sperm can quicken the time to pregnancy or reduce the intensity or cost of required treatment.

Below you’ll see the list of issues identified during a male evaluation: 60% of these can be corrected, sometimes without IVF, to improve a couple’s ability to conceive.

Also, it’s important to remember that it only takes 2 - 3 months to make a sperm and so most treatments (e.g. medication or surgery) take a short time before fertility will improve.

Given the timing of sperm production, it also makes sense to undergo a male evaluation early in the journey. There is ample data from systematic reviews that shows male treatments (e.g. varicocele repair, surgical sperm extraction, medical treatments) improve male sperm production, pregnancy, and IVF outcomes (6-10). Having the tests done early, to see if these options can be used before, or in conjunction with, IVF is crucial. It’s extremely painful for a couple to get far down the path with IVF, watch it fail, only to realize they had poor information, and fewer options, from the start.

Window into health


Emerging data also suggests that male fertility may provide a window into a man’s current and future health. Studies demonstrate that up to 5% of men with fertility issues also have genetic abnormalities, cancer, diabetes, or thyroid disorders (11,12). If a man has these issues, he certainly needs to know about them and the male fertility work-up can help reveal the answer.

This is an area of real interest for me at Stanford and through collaborations with investigators all over the world, we’ve demonstrated associations between hypertension, diabetes and a man’s reproductive health (13-15). Some of the medications used to treat the hypertension may in fact abet his fertility challenges.

Emerging data also suggests that a man’s fertility may be a window into his future health. The evidence is compelling enough that the NIH and CDC recently convened thought leaders from around to discuss just that.

Current evidence suggests that lower sperm counts or infertility are associated with higher risks of some cancers, cardiovascular disease, and even mortality (16-18). While the etiology remains uncertain, an early window into later health may provide the opportunity to positively affect men’s health as we work to evaluate and improve their fertility. So exercise more, eat healthier, lose weight, quit smoking, and visit your doctor for regular age appropriate checkups (e.g. blood pressure, cholesterol, etc.) which can help a man’s overall and reproductive health.

References:

  1. ASRM. Optimal evaluation of the infertile female. Fertility and sterility. 2006;86(5 Suppl 1):S264-267.
  2. ASRM. Report on optimal evaluation of the infertile male. Fertility and sterility. 2006;86(5 Suppl 1):S202-209.
  3. Thoma ME, McLain AC, Louis JF, et al. Prevalence of infertility in the United States as estimated by the current duration approach and a traditional constructed approach. Fertility and sterility. 2013;99(5):1324-1331 e1321.
  4. Eisenberg ML, Lathi RB, Baker VL, Westphal LM, Milki AA, Nangia AK. Frequency of the male infertility evaluation: data from the national survey of family growth. The Journal of urology. 2013;189(3):1030-1034.
  5. Trussell JC, Christman GM, Ohl DA, et al. Recruitment challenges of a multicenter randomized controlled varicocelectomy trial. Fertility and sterility. 2011;96(6):1299-1305.
  6. Kroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012;10:CD000479.
  7. Attia AM, Abou-Setta AM, Al-Inany HG. Gonadotrophins for idiopathic male factor subfertility. Cochrane Database Syst Rev. 2013;8:CD005071.
  8. Showell MG, Brown J, Yazdani A, Stankiewicz MT, Hart RJ. Antioxidants for male subfertility. Cochrane Database Syst Rev. 2011(1):CD007411.
  9. Ohlander S, Hotaling J, Kirshenbaum E, Niederberger C, Eisenberg ML. Impact of fresh versus cryopreserved testicular sperm upon intracytoplasmic sperm injection pregnancy outcomes in men with azoospermia due to spermatogenic dysfunction: a meta-analysis. Fertility and sterility. 2014;101(2):344-349.
  10. Kirby EW, Wiener LE, Rajanahally S, Crowell K, Coward RM. Undergoing varicocele repair before assisted reproduction improves pregnancy rate and live birth rate in azoospermic and oligospermic men with a varicocele: a systematic review and meta-analysis. Fertility and sterility. 2016.
  11. Kolettis PN, Sabanegh ES. Significant medical pathology discovered during a male infertility evaluation. The Journal of urology. 2001;166(1):178-180.
  12. Honig SC, Lipshultz LI, Jarow J. Significant medical pathology uncovered by a comprehensive male infertility evaluation. Fertility and sterility. 1994;62(5):1028-1034.
  13. Eisenberg ML, Sundaram R, Maisog J, Buck Louis GM. Diabetes, medical comorbidities and couple fecundity. Human reproduction (Oxford, England). 2016;31(10):2369-2376.
  14. Eisenberg ML, Li S, Behr B, Pera RR, Cullen MR. Relationship between semen production and medical comorbidity. Fertility and sterility. 2015;103(1):66-71.
  15. Eisenberg M, Li S, Behr B, Nakajima S, Baker VL. The relationship between a man’s somatic health and ART outcomes. Fertility and sterility. 2015;104(3):e294.
  16. Jacobsen R, Bostofte E, Engholm G, et al. Risk of testicular cancer in men with abnormal semen characteristics: cohort study. BMJ (Clinical research ed. 2000;321(7264):789-792.
  17. Eisenberg ML, Li S, Cullen MR, Baker LC. Increased risk of incident chronic medical conditions in infertile men: analysis of United States claims data. Fertility and sterility. 2015;105(3):629-636.
  18. Jensen TK, Jacobsen R, Christensen K, Nielsen NC, Bostofte E. Good semen quality and life expectancy: a cohort study of 43,277 men. American journal of epidemiology. 2009;170(5):559-565.