Rescripted S02E06_Male Fertility_ Testing And Treatment Options: Audio automatically transcribed by Sonix

Rescripted S02E06_Male Fertility_ Testing And Treatment Options: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi! I'm Kristyn Hodgdon, an IVF mom, current IVF patient, and co-founder of Rescripted.

Lucky Sekhon:
And I'm Dr. Lucky Sekhon, a board-certified reproductive endocrinologist at RMA of New York.

Kristyn Hodgdon:
Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for the millions of people globally who have trouble conceiving.

Lucky Sekhon:
We're here to answer real questions from real fertility patients about what to expect during each stage of the fertility journey and to provide you with the patient-centric advice and guidance you need to be your own advocate when trying becomes trying.

Kristyn Hodgdon:
Now, let's dive in and help you feel more empowered during this overwhelming process.

Kristyn Hodgdon:
Hi everyone, and welcome back to Dear Infertility. I'm your host, Kristyn, and I'm here with Dr. Lucky Sekhon. Hi, Lucky!

Lucky Sekhon:
Hi. How's it going?

Kristyn Hodgdon:
I'm well. How are you?

Lucky Sekhon:
Good. I'm excited to be here to talk to you about male fertility.

Kristyn Hodgdon:
Yeah. I mean, you know, men are 50% of the fertility equation, and yet I think because women bear sort of the physical brunt of treatment, it can, it can seem like a female issue, or at least it's perceived that way sometimes. But it's so important to talk about male fertility, male factor infertility, and what are some of, what are some of the reasons why this is such a common issue, and how to treat it?

Lucky Sekhon:
Definitely. I think people are shocked when I tell them that 40% of couples with infertility have a male factor issue. Maybe it's not the entire picture, but it's at least part of the picture. And it's a really easy thing to test for, right? And it's a cheap test, it's readily available, and it's something that I think is worth looking into even before you see a fertility doctor, because it could be a very helpful piece of information for them to have in front of them while they're talking to you.

Kristyn Hodgdon:
Right. So it's just a simple semen analysis, correct?

Lucky Sekhon:
Correct. So a semen analysis is giving a sample which usually is produced by masturbation and collection, and this is important in a sterile specimen cup. You know, if you have it stored in plastics or things that aren't sterile or that have chemicals that could leach into the sample, that could obviously affect the analysis, so that's something that a lot of people aren't aware of. And we recommend collecting the sample within a 2 to 7-day window of abstinence, meaning it's good to not have a buildup of old dead sperm. So if someone hasn't ejaculated for a week or longer, it might not be reflective of the true quality of their sperm, if that's the type of sample we're getting. But also, you want to have an adequate amount of time to build up sperm production. And so, I would say a minimum time of abstinence of at least two days before doing a semen analysis is recommended. And men are always making new sperm, right? So they're always generating new sperm cells, roughly every 72 days. And so I think something to go into a semen analysis thinking about is the fact that if the results are less than ideal or there's any issues, it's not a reason to panic because for men there's always room for improvement because taking antioxidants or certain types of supplements can actually help improve sperm production moving forward.

Kristyn Hodgdon:
Yeah, lifestyle changes.

Lucky Sekhon:
Exactly. Eliminating things like smoking, exercising, improving your BMI, all of these things can make a huge difference for male fertility. But I think we should talk about the semen analysis. What do you think? Because I think people don't really know what we're looking for, right?

Kristyn Hodgdon:
Yes. I was just thinking like there's sperm count, there's motility, morphology, and I'm missing one.

Lucky Sekhon:
Volume.

Kristyn Hodgdon:
Volume.

Lucky Sekhon:
Everyone forgets about the volume. So we care about the volume of the sample. We want it to be at least 1.5 milliliters. And the reason is, is because if there's low volumes, that can be a sign that the ducts that are supposed to be in place in the male reproductive tract, that there could be blockages or strictures caused by things like infection or injuries. And if there's blockages, then it might not be as good of a sample as it could be if sperm production is physically being obstructed or blocked or the delivery of the sperm into the ejaculate is being blocked, so that's why we care about volume. The most important thing I think is the sperm concentration, so it's like the sperm count. Being able to have at least 20 million sperm per milliliter is considered a normal count. And that signifies that production is normal, and things that can affect sperm production and cause a lower count can be hormonal, you know, if there isn't adequate stimulation of the testes to produce testosterone because of problems with the pituitary gland, or if the cells of the actual testes aren't able to produce testosterone properly, those are different types of production problems. You could have genetic reasons why there would be a low sperm count. Some men have microdeletions of their DNA on their Y chromosome that can lead to something called Azoospermia, which means no sperm or very, very low amounts of sperm. So if I have a semen analysis with an extremely low concentration, I'll always retest because it could just be a mistake or the way that the sample was collected, so we always kind of recheck. And if it's persistent, I definitely will, give a very early referral to a urologist. Where I work at RAM of New York, we have a urologist on-staff that we work closely with, and he's amazing, and I think that's a really nice setup. Not all clinics are set up that way, and they don't have to be, but I like being able to kind of collaborate on these types of cases, and he'll do a really extensive workup. So the REI themselves usually will refer because their whole area of expertise is to get a very focused evaluation done. So they'll bring you in, they'll do hormonal testing, all of the genetic testing, including the Y-chromosome microdeletion, they'll check a karyotype. Sometimes a piece of your chromosome could be flipped or rearranged in a way that can also influence your ability to produce normal amounts of sperm. They'll also test you for things like cystic fibrosis mutations, because these are mutations where you can carry one copy and not have actual cystic fibrosis, but it can cause things like an absence of the vast difference, so there just isn't a way for the sperm to get inside the ejaculate. So those are different reasons or things that we would look into if you had a very low concentration. The other major factor is motility, which is the percent of the sample that can swim in a forward direction, and it can be interpreted in a sense as viability of the sample as well, because the living sperm or the ones that are motile and moving. And if sperm have low motility, it might be harder for the sperm to get to where it needs to go. It needs to get through the reproductive tract into the fallopian tube. So it could be, you know, it could be a case for intrauterine insemination, optimizing the delivery of the sperm to where it needs to go. But it just depends on how severely low the motility is and why it's low. So there are different tests that would be done downstream of that. And then morphology is referring to the percent of the sperm cells that are viewed under the microscope that look like they're shaped normally. And if you Google image abnormal morphology, you can actually see examples of the different types of forms of sperm that you can observe. You can have like a two-headed sperm, which is interesting, or two tails.

Kristyn Hodgdon:
Yeah.

Lucky Sekhon:
They look at like the ratio of the size of the head of the sperm to the tail, so it's really interesting. But in general, the bar is very low. We don't expect there to be 100% normal forms. Like if 4% of the sample is shaped normally and has normal morphology, then that's the threshold above which we would say it's normal, believe it or not. And I think morphology causes a lot of undue anxiety because there are good studies that suggest if everything else is normal and the morphology is the only thing that's low, think about it, you still have maybe hundreds of millions of sperm count-wise, and they're all swimming, or a large majority are swimming, if you have 2% morphology versus 4%, it's not really going to make a difference, not going to move the needle. And so I would tell someone who has everything normal but just 2% morphology, it's probably not the reason why they're not getting pregnant. But we know that lifestyle changes and being the healthiest version that you can be of yourself might help to improve the overall morphology and the overall sperm quality.

Kristyn Hodgdon:
So will you, after you do a semen analysis, and if something comes back abnormal, will you sort of make the couple or advise that the couple wait the three months until the, the guy sort of gets his lifestyle changes in check or will you like, will you move forward?

Lucky Sekhon:
I would move forward. I mean, I think it depends on what it is and what our plan is. I think if the plan is IVF, I'd move forward regardless because you should work towards making these changes in the hopes of improving the overall situation. But there's no data that suggests that you need to take three months to then optimize the sample to have a better outcome. I think it depends on the situation though. I think especially if you're doing like IUIs because the sample isn't so bad, but there are suboptimal things that need to be improved, work on improving them, but let's also not lose time and let's be efficient. And I think we could move forward with medicated IUIs. And, you know, a lot of times when we do the insemination, we're doing like a mini analysis, we're looking at the sperm under the microscope. So it's kind of interesting if you can see if there's improvements over time. But in general, you know, I think I'm all about being efficient. And I think that it doesn't make sense to take long breaks in your fertility journey because those types of long breaks can add up and just be additive in a way that can also influence other factors like egg quality and quantity, which are time-sensitive issues as well.

Kristyn Hodgdon:
Right. No, that makes total sense. So what about DNA fragmentation? Where does that come in?

Lucky Sekhon:
Yeah, so DNA fragmentation is a test that I will do. It's a bit controversial because people have questioned the validity of the test itself. What it's testing is looking at the degree of sperm DNA. So the DNA that's tightly wound and packaged into the sperm head of the sperm cell, there's this idea that there can be fragment, fragmentation that disrupts the integrity of the DNA and that this could be related to the underlying cause of fertility or pregnancy loss issues. And there are tests that can be done for this, there are some studies that have shown these tests are not as reliable as we like tests to be, meaning you might get a different result each time, and there might not be a high degree of correlation or agreement between multiple tests within the same individual. And then there's some studies, you know, just like everything else, like you have to have a balanced view. There are some studies that show a more compelling support for this type of testing and some that, that don't. But I sometimes send it off because now there are things that you can do differently in the lab. There's actually a newer technology called ZyMot which can allow you to sort the sperm. And the thought is, is that you're using sperm with better DNA integrity to fertilize the eggs. And some people believe that that might improve the degree to which fertilized eggs can grow into embryos. I'm all about adding in interventions or thinking outside the box and using different steps that aren't going to have a harmful downside but could potentially help. But I think it's about being honest with patients about what we know and what the quality or the lack thereof is of the data to support any intervention or test that's being done. Sometimes patients will ask for that type of measure to be added in even without the DNA fragmentation testing. So it's a specialized test, I don't think it's prohibitively expensive, and it's something that might be worth looking for if you're trying to understand reasons behind certain aspects of your outcomes and your treatment. And even the ASRM, the American Society of Reproductive Medicine, recently updated their, they have a bunch of committee opinions and they recently updated their document on the recurrent pregnancy loss workup because before it never really mentioned DNA fragmentation, but now it says, yeah, there's some weak evidence to suggest that some cases of recurrent pregnancy loss, it might be worthwhile looking into DNA fragmentation testing. So I think that it's controversial, not widely accepted, but it could be something that's worth looking into, particularly if you're looking for answers.

Kristyn Hodgdon:
Okay. And where does ICSI come in? Which of these markers would, would mean that you would do ICSI with IVF?

Lucky Sekhon:
So, I like to look at, we should be looking at the sample as a whole. We look at the volume multiplied by the concentration, multiplied by the percent motility to get something called the total modal count. And if someone has a total modal count of ten or more, 10 million or more, then I think it's very reasonable to be doing IUIs and even trying on, on your own. Once you get below 5 million, then that's a really strong argument that you're going to benefit from ICSI because overall the amount of sperm and the ability of the sperm to get to where it needs to go is very limited at a total modal count of less than 5 million. And it's going to ultimately help if you're able to just bypass all of that by taking single, healthy sperm cells identified under the microscope and injecting them into each egg directly. And ICSI, or intra cytoplasmic sperm injection is used a lot in even, other cases that have nothing to do with male factor fertility. I think that's important to talk about as well because people might be confused about why their clinic or doctor is recommending ICSI if their partners semen analysis is completely normal.

Kristyn Hodgdon:
Okay! And so what what other situations would it be recommended? Or some people, some clinics, it's just kind of across the board.

Lucky Sekhon:
Well, some clinics will use it across the board because there's this theoretical idea that if you're doing genetic testing of embryos, you want to make sure that there isn't any contamination of the sample being taken by a bunch of dead sperm that are stuck to the outer part of the, the shell of the egg and the resulting embryo. If you're doing conventional insemination, remember, you're dumping like 50,000 sperm onto each egg cell. And so there are plenty of sperm that didn't make the cut that didn't actually contribute to this embryo that are going to be stuck to that outer wall. And if you're, then biopsy the embryo, there's a theoretical concern that that could limit the accuracy. There are some studies that have been done that have shown that that's not really a concern. And there are some clinics that will still utilize conventional insemination, even in cases where you're doing PGT and doing the biopsy for the genetic testing. But that just seems to be like a stylistic thing. And some clinics, just like using ICSI because they feel like it's going to maximize the chance of getting as many fertilized eggs as possible, because sometimes ICSI is used not just for male factor infertility seen on a semen analysis that's abnormal, but it's definitely an indication if you had a cycle where you use conventional insemination and you had really low fertilization rates or none of the eggs fertilized, then you have to, you should be using ICSI in the subsequent cycle. So some clinics are like, well, IVF is high stakes. Like, I want to just do that preemptively. I don't want to wait till you have that outcome.

Kristyn Hodgdon:
Got it, that makes sense. So I want to also talk about the, because we did get a few questions about this, when IVF, when does IVF not become an option anymore? Would it be a Azoospermia, or in cases like that?

Lucky Sekhon:
Yeah. So even in cases of Azoospermia where there's no sperm on the semen analysis, if the urologist does the genetic testing, the hormonal testing, and there's nothing that clearly screams this patient is not going to have any sperm in their testes, right? It could be worth it to do something like a testicular sperm extraction, TESE, meaning you'd probably want the female partner to go through the stimulation, have their eggs retrieved, and on the day of the egg retrieval plan for the urologist to do a separate procedure on the male partner where they're under sedation or anesthesia and they make an incision in the testicular tissue and actually extract a piece of tissue and hand it off to the embryologist. And they look at it under the microscope and actually try to find sperm. And it is a very labor intensive process and it can take like 10 hours.

Kristyn Hodgdon:
Wow!

Lucky Sekhon:
We will have a team of people looking. We work really hard to find sperm and if they can isolate like even just a few sperm and inject whatever eggs that we have, then that can work. And I've had, and it's always a very challenging type of case because even for me, as their REI, look, I don't really know what to expect going in, I'll speak to the urologist and he'll say, based on my experience, based on his hormonal profile and lack of genetic abnormalities, like I think there's a 40% chance that we'll find sperm, so we'll always go in with a backup plan. What is your backup plan? Do you want us to just freeze the eggs if we can't find sperm? Maybe we've already done that. And you have some eggs frozen, and this time around you're like, okay, if we don't find it a second time, let's have a backup plan of having donor sperm waiting, already purchased, and let's just utilize that. I think it's obviously such a big decision. I highly recommend having couples counseling. At RMA, we have a clinical psychologist that will often meet with couples who are grappling with these types of decisions. And some couples really don't want to go down the donor sperm route and they would rather just not move forward at all. So they're just going to keep freezing eggs as a backup plan and kind of deferring that decision to later and sometimes later is maybe a certain amount of time passes. And then they come around to the decision and decide, let's throw out the eggs and use donor sperm. So I've been shocked, like there's been times where I've gone into a cycle thinking I don't know if I feel confident, like I don't think we're going to find sperm and we find sperm and they make beautiful embryos and it's a happy ending to the story. So it's always a little bit tenuous, it's hard to predict.

Kristyn Hodgdon:
No, that, that's really helpful, though. I wasn't sure if there were any, was anything that could be done if there were zero sperm, but that that makes total sense, that there's a procedure because why wouldn't there be?

Lucky Sekhon:
And usually in the lead up to the procedure, we might put the male patient on like Clomid to try to strengthen.

Kristyn Hodgdon:
I have heard of that.

Lucky Sekhon:
Yeah, try to strengthen the pituitary stimulation of the testes to get more sperm to be produced like we do anything and everything that we can before you have to come to that decision of whether there's an alternate that you're willing to accept.

Kristyn Hodgdon:
So, but overall male factor infertility is a diagnosis that's very treatable, right?

Lucky Sekhon:
Yeah, yeah. I think there's the exception of cases that are very clear cut where, you know, donor sperm is the only option. But outside of that, for the male side of things, there are a lot of encouraging pieces of information that I think are takeaways of today's discussion. One is that there's always room for improvement because there's always ongoing sperm production. There are things that you can do and lifestyle changes can really go a long way. And two is that there are really effective workarounds like ICSI, which have revolutionized our field in how it treats male factor fertility issues. And even in the most dire of circumstances, there are procedures and things that we can do to try to optimize the chance of finding. Erm and I think working with a good specialist and having a multidisciplinary team that talks to each other is really key.

Kristyn Hodgdon:
That's a great point. It always helps to have a specialist in your diagnosis, sort of on your side throughout this process.

Lucky Sekhon:
Yes. And I believe in early referral. I don't want to cause undue delays. And I think they're the best people that are well versed to be looking into all of the potential underlying causes.

Kristyn Hodgdon:
Absolutely. Well, this is so helpful. Dr. Sekhon, thank you so much. And men, go get tested. Yes, that's easy. Absolutely. Well, thank you so much again for your time and we'll chat next time.

Lucky Sekhon:
All right. Thank you for having me.

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear and Fertility. We hope it helps you feel more empowered to be your own advocate on your fertility journey. Whatever you're currently struggling with, Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe to find this episode show notes resources and more. Head to Rescripted dot com and be sure to join our free fertility support community while you're there.

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