Male Health

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.

Can diet help sperm production?  We are what we eat, and the sperm factory is such an active one that it would be strange if diet didn’t affect sperm one way or another.

Antioxidants protect the body from free radicals, which are released from unstable compounds as they break down and damage molecules in cells.  (I’ve always loved the phrase “free radical,” which conjures images of 1960s miscreants running amok inside the body.)  Antioxidants soak up these bad actors and prevent their misdeeds.  But knowing which antioxidants work and in what dose is still being learned.  I discussed Coenzyme Q10, which may function as an antioxidant, in a previous post.

Jaime Mendiola and colleagues reported in the March issue of Fertility and Sterility that men with a lower intake of carbohydrates, fiber, folate, vitamin C and lycopene and a higher intake of protein and total fat had worse sperm than men with the opposite diet. I’d of course like to see studies which involve giving specific antioxidants first and then measuring sperm improvement relative to a placebo, but this is a promising start.

Bottom line: if you’re worried about your sperm, a diet higher in fiber, folate, vitamin C and lycopene, and lower in fat can’t hurt.

Adam recently asked about a product which claimed to improve semen.  There are many of those out there, and many are vitamins and combinations of vitamins.  These “nutraceuticals” can be found in drug stores, in groceries, on the internet and elsewhere.

A big problem with claims about how a nutraceutical may improve sperm and semen is that most aren’t based on studies that have a placebo, a pill that looks just like the vitamin but doesn’t have the ingredients being studied.  Why is that a problem?  Because nature virtually guarantees that if you start out with a bunch of men that happen to have lower than average sperm or whatever, and you measure their sperm (or whatever) before and after treatment, they will always improve.  It’s an effect called “regression to the mean.”  It’s like if you took twenty people with colds and gave them all a pill and waited two weeks, most would get better.  Was it due to the pill or to just nature doing its thing?  You don’t know.  The way to figure it out would be to give half of them the pill, and half of them a pill that looked like that one but had no active ingredients, and compare how the two groups did over that two weeks.  That’s called a “controlled study,” and it’s critical in figuring out if a drug or vitamin works.

Last year, two controlled studies were published looking at a vitamin involved in the energy machine inside cells called “Coenzyme Q10” and sperm.  In one, men with poorly wiggling sperm who took 200 mg daily improved while taking the vitamin compared to men taking placebo.  In another, men taking 300 mg daily improved in both sperm number and motility compared to men taking placebo.

They’re small studies, and bigger studies are always better.  But Coenzyme Q10 might help sperm numbers and especially motility. (I have absolutely no relationship, financial or otherwise, to companies that make it.)

Just about everything outside the female reproductive tract kills sperm, including lubricants.  But sometimes lubricant is desirable during sex.  In 2008, an independent lab at the Cleveland Clinic headed by Ashok Agarwal published in the journal of Fertility and Sterility a comparison of different lubricants and how they degrade sperm movement and the DNA that the sperm contains.  Of Pre-Seed, FemGlide, Astroglide, and Replens, Pre-Seed was the one that didn’t seem to have much negative effect on sperm motion and DNA.  So, if you’re going to use lubricant during sex and you want to conceive, Pre-Seed seems to be a good choice.  (I have absolutely no relationship, financial or otherwise, to the company that makes it.)

It’s useful to know how long it takes to make sperm in the testis.  Based on the brilliant work of Charles Leblond and Yves Clermont in the 1950s and 1960s studying how testes looked under the microscope, scientists guessed that it took about two and a half months to make a human sperm.  But Leblond and Clermont were looking at specimens that weren’t actively making sperm.

In 2006, Paul Turek did a clever experiment.  He gave men radioactive water (not enough to be dangerous, of course,) and waited until their sperm became radioactive. In most men, it took about 60 days.  From the moment a sperm sets out on the testis assembly line, it looks like it takes about two months before it reaches the end.

So if you’re taking a medication like clomiphene that works on the sperm factory, expect it to take about two months to begin to work.