How To Use This Website
This website is intended to be useful for couples in all stages of the fertility process, whether they are just getting started or have been trying to conceive for many years.
How to Use This Website
The Male Infertility Guide website is not designed to be read straight through from start to finish. A wide range of potential problems can affect male fertility, and it can be frustrating and unhelpful for couples to have to wade through information on topics unrelated to their particular situation. This website has therefore been organized in a way that helps identify the topics that may be pertinent to you, and to guide you to those sections that are most relevant to your situation.
The goal of this website is to provide a set of basic guidelines and principles that are easy to understand and useful on a day-to-day basis for couples who do not have formal medical training. As you go through the book, keep in mind that the recommendations provided here are general guidelines for a typical man. Health-related interventions and medication dosages listed are those generally used in most men, but these may need to be modified depending on each man’s individual medical history, health status, and physical characteristics.
Finally, this is not intended to be a do-it-yourself guide. Working with a licensed and qualified medical care provider is mandatory for safe and effective management of male-factor fertility problems. The human body is a very complex system, and any interventions related to male fertility should be supervised by a trained medical professional. From a practical standpoint, most medical testing and prescription medications also need a signed order from a physician, physician assistant, or nurse practitioner.
If you have access to a fellowship-trained expert on male fertility in your area, it would definitely be in your best interest to work with that person. This specialist may not agree with every recommendation made in this book, and that is to be expected—if you spend any time with a group of specialists in any medical field, you’ll quickly find that they disagree on many things. I have tried to point out common controversies among male infertility specialists and provide both sides of the basic arguments, to help facilitate further discussions on these topics with your physician. This website includes a section on finding a fellowship-trained male infertility specialist in your area. If you do not have access to a fellowship-trained specialist, this website can help you to determine if the general urologist you are working with is using the latest management guidelines.
Since 50 percent of infertility is in some way related to male-factor issues, all male partners in couples with infertility problems should have a semen analysis performed. This website explains how to arrange for accurate semen testing, interpret the results of the tests, and review the options if any abnormalities are discovered. It also provides you with sample forms for testing, the diagnostic codes that can be used, and general costs for the different tests if they are not covered by insurance. Diagnostic codes are number codes assigned to tests ordered by medical professionals; the codes are used by insurance companies for billing and to determine if coverage is available.
Male Fertility and General Health Problems
Beyond the fact that the majority of male fertility problems are reversible, there are other reasons to evaluate men with problems such as a low sperm count or poor sperm quality. Some potentially significant health problems can be associated with decreases in male fertility potential. Rates of testicular cancer are three to thirty times higher in infertile males than in fertile males, and genetic abnormalities are thirty to a hundred times more common in this population. Overall, between 1 and 6 percent of men who undergo male fertility evaluations uncover some form of potentially serious underlying medical problem, such as prostate cancer, diabetes mellitus, hypothyroidism, or a brain tumor. If couples are sent straight to treatment from the female side (such as insemination procedures or in vitro fertilization) without evaluating the man, potentially serious medical problems could be missed.
A Note to My Medical Colleagues and Industry Representatives
As everyone is well aware, medicine is a combination of both art and science, and it is in a constant state of development and change. The content of this book is the product of ten years of clinical experience and a thorough review of the existing medical literature. Despite this, there will always be differences of opinion about how to handle certain clinical situations. I wholeheartedly welcome input from my colleagues for future updates of this website. I also encourage the pharmaceutical and medical device industry to provide feedback on new products and updated product information in order to keep the website as accurate as possible. Please feel free to contact me at maleinfertilityguide@gmail.com, or through the Suggestions/Comments/Feedback link below and near the bottom of the website Home Page.
Timeline for improvements in male fertility potential
The Sperm Boot Camp section of this website presents a program designed to optimize the environment for sperm production by identifying and correcting any reversible male-factor issues that are present. In general, it takes at least one spermatogenic cycle (about 10 weeks) for any interventions to improve a man's fertility potential to take full effect.
As the Introduction to this website describes, the formation of mature sperm is a very complex physiologic process that takes place in a man’s body over a ten-week period of time (called a spermatogenic cycle). A large number of factors play a role in determining the number and quality of sperm that are being produced. Some of these, such as genetic influences, are not under the man’s control. However, a large number of factors that influence sperm production can potentially be modified and optimized. These potentially modifiable factors include:
Hormone levels
Lifestyle choices
Medications
Infections/inflammation
Job-related factors
Varicoceles
Erectile/ejaculatory problems
The Sperm Boot Camp includes a comprehensive evaluation of all of these modifiable factors, with the goal of trying to maximize each man’s own fertility potential effectively and efficiently.
Most of the women in couples who are reading this book want to be pregnant as soon as possible. For many, the process of trying to become a parent has been going on for many months already, and ten more weeks can seem like an eternity. However, the plan’s timeline is a direct product of every man’s basic physiology. It takes ten weeks for a sperm precursor cell from the testicles to transform into a mature sperm within the vas deferens that is ready to swim to and fertilize a woman’s egg. Any positive or negative factors or events that occur during this ten-week period can impact the number and quality of sperm that are being produced during that spermatogenic cycle.
For example, if a man spends time in a hot tub, this can have a negative impact on all of the sperm that are currently in his body. It will then take about ten weeks for these potentially damaged sperm to clear the body and be replaced by an entirely new batch of sperm produced after the exposure to the hot tub.
Along the same lines, any positive changes that are made (such as quitting smoking, improved hormone levels, etc.) generally take around ten weeks to be fully reflected in the number and quality of sperm. The reason for this is that it takes this long for 100 percent of the sperm in the body to have been produced in the improved environment.
The length of the spermatogenic cycle therefore dictates the timeline of the Sperm Boot Camp. As you’ll see, the basic structure of the plan is to improve the environment for sperm production as much as possible and then repeat fertility testing in ten weeks to reevaluate sperm quality. Of course, every couple’s clinical situation is different, and specific circumstances may lead to modification of their individual plan’s timeline.
For example, if a woman is forty-two years old, then waiting a full ten weeks to do a repeat semen analysis may not be in the couple’s best interests—it might be a good idea to repeat the analysis sooner. On the other hand, some men require two spermatogenic cycles (twenty weeks) to see the full improvement in semen parameters following positive interventions. The human body is a complex system, and no two men (as well as no two couples) are exactly the same, so the ability to be flexible and modify the plan as the situation requires is important. For most men, however, a plan timeline that is ten weeks in length is ideal.
After all reversible male factor issues have been addressed and modified for ten weeks, most men can assume that their semen parameters have been optimized as much as possible (although some may continue to improve further with time). A key point in male fertility management is that all positive changes (lifestyle, hormonal, and so on) should be continued until the woman is pregnant and through her first trimester. If a man stops his interventions after the ten weeks are over, then the fertility improvements can be lost. Since the chance of a woman losing a pregnancy substantially decreases after she has entered her second trimester, it is generally recommended that men stay on the plan at least until the first trimester of pregnancy has passed (assuming everything is going fine with the pregnancy).
Where to Start
Whether you’re just getting started in your efforts to conceive or you’ve been working on fertility issues for a while, The Male Infertility Guide can help.
The first step is deciding which of seven basic scenarios you fall into. These scenarios include:
1. Just getting started (no male fertility testing yet)
2. Abnormal semen analysis findings
3. Normal semen analysis but still unable to conceive
4. Unable to successfully provide a specimen for semen analysis
5. Recurrent pregnancy loss
6. Recurrent IVF failure
7. Previous vasectomy
Each of these scenarios corresponds to a section below. These sections will guide you to the appropriate diagnostic and therapeutic pathways of the plan.
Just Getting Started
When should a couple who would like to have children undergo fertility testing? There are no strict guidelines here, as a couple’s preferences play an important role in deciding when and if testing should be performed. However, general guidelines have been developed to give couples an idea of when fertility testing is typically initiated.
These guidelines recommend that testing should be considered after:
• One year of unprotected intercourse without pregnancy if the woman is under thirty-five years of age and the man is under forty, or
• Six months of unprotected intercourse without pregnancy if the woman is thirty-five or older or the man is forty or older
Immediate testing can be considered in men with a known history of significant fertility risk factors, such as previous chemotherapy or radiation therapy, undescended testicles at birth, a personal history of testicular cancer, hormonal or genetic problems, or a history of anabolic steroid use.
As mentioned earlier, these are general guidelines that do not have to be followed exactly. Some young couples choose to wait a few years before testing, while other decide to undergo basic fertility testing prior to even starting trying to conceive, just to make sure that there is likely not going to be a problem. If this helps decrease stress and assist in their future planning, that’s fine.
Since male-factor issues impact approximately 50 percent of couples who are having trouble conceiving, it is strongly recommended that both the male and female partners in a couple have basic fertility testing as part of an initial evaluation. From the male side, two semen analyses performed at least ten weeks apart is recommended for initial testing.
If you and your partner are just getting started with trying to conceive, begin with "Male Infertility Testing" section of this website, which will review recommendations for getting a semen analysis performed the correct way and discuss interpretation of the results.
Abnormal Semen Analysis Findings
Many couples have already had semen testing performed, ordered either by their primary care physician, local urologist, or the woman’s gynecologist. However, an accurate fertility picture cannot be obtained with just one semen analysis; I recommend men get at least two analyses spaced at least ten weeks apart. If a couple has had only one semen analysis (or two that were performed less than ten weeks apart, it’s a good idea to get at least one more. This second test can be performed after completing the Sperm Boot Camp in order to see what effect an optimized environment for sperm production has had on the semen.
If you’ve already had at least one semen analysis, start with "Semen Analysis- When, Where, Why, and How", to make sure that the testing was performed properly, and then the "Interpreting Semen Analysis Testing" section to review the interpretation of the results before embarking on the Sperm Boot Camp.
Normal Semen Analysis but Still Unable to Conceive
Sometimes a couple who has been trying to conceive for at least a year end up having completely normal fertility test results from both the male and female sides. Some of this inability to conceive may be due to pure chance (that is, bad luck) and simply trying longer will eventually result in success. Other times there may be hidden factors that are not uncovered by routine semen analysis. Certainly there are physiologic aspects of male fertility that have not been discovered yet by scientific research and so cannot be currently tested for.
If no significant abnormalities are discovered after two normal semen analyses, and if fertility testing for the woman has produced normal results, a couple has several options:
• Optimize the environment for sperm production. Even if the results of the semen analysis fall within the normal range, it is never a bad idea to try to optimize male fertility potential as much as possible. This process of improving the environment for sperm production starts with the "Male Infertility Testing" section to make sure that all of the appropriate testing has been performed before moving on to the Sperm Book Camp. Simple noninvasive measures (such as beginning antioxidant supplementation, quitting smoking, and making healthful changes in lifestyle and diet) are recommended for all couples having difficulty conceiving. More invasive interventions (such as varicocele repair) are typically not recommended in men with normal semen parameters unless other problems were found.
• Sperm DNA testing. The "Advanced Sperm Testing" section of this website reviews testing that can look for elevated levels of DNA fragmentation (abnormalities in the sperm’s genetic material). This type of testing is not routinely recommended for couples who are having trouble conceiving. However, if no problems can be found on standard semen analysis and female fertility testing, it may be useful to check sperm DNA fragmentation levels.
• Female fertility treatments. If no problems are found on standard testing of both partners, then a commonly used approach is to begin fertility interventions from the female side, which can potentially increase the odds of conception with each cycle. Options include medications for the female, intrauterine inseminations, and in vitro fertilization. The "Female Fertility Treatments" section of this website discusses the basics of these interventions from the female side.
If a couple proceeds with interventions from the female side, the chances of these interventions being successful are often higher if the man’s environment for sperm production is optimized. Often a lot of time, money, and emotion is invested in these interventions, and it makes sense to be sure that the man’s semen is as optimal as possible before getting started. I therefore recommend that the male partner proceed with the sperm optimization plan in order to increase the couple’s overall chances of fertility success.
Unable to Successfully Provide a Specimen for Semen Analysis
For most men, providing a sample for the semen analysis is not something they look forward to doing, but it’s not particularly problematic, either. However, some men have trouble producing a semen specimen for testing.
Sometimes men with otherwise normal sexual function are unable to provide a specimen for analysis because of problems with masturbation or an inability to “perform” in the strange environment of a collection room at the fertility lab. This is completely understandable and nothing to be embarrassed about, and it can usually be resolved successfully. The "Semen Analysis- When, Where, Why, and How" section reviews normal collection recommendations as well as suggestions for troubleshooting problems that can occur with specimen collections. Other men may have a known long-standing problem with erectile dysfunction or ejaculation. Separate sections of this website review management of erectile dysfunction as well as ejaculation problems.
Recurrent Pregnancy Loss
Sometimes couples do not have an issue with getting pregnant but do have problems with maintaining a pregnancy. Although often due to female factors, some male factor issues can also contribute to recurrent pregnancy loss. Examples include abnormal sperm DNA fragmentation.
The "Recurrent Pregnancy Loss" section reviews this subject in more detail and the "Advanced Sperm Testing" section discussed sperm DNA fragmentation in more detail.
Recurrent IVF Failure
Even in the best of circumstances, with good-quality embryos, failure rates for a cycle of in vitro fertilization (IVF) approach 50 percent due to persistently low implantation rates. Therefore, every effort should be made to improve sperm quality prior to an IVF cycle to increase the chances of success with the Sperm Boot Camp. Sperm DNA fragmentation testing may be indicated in couples who have failed two or three cycles of IVF for no apparent reason, or those who fail an initial cycle of IVF and had poor embryo quality or progression despite good egg fertilization. There is increasing evidence that elevated levels of sperm DNA fragmentation can contribute to recurrent IVF failure and especially impact embryo quality as well as miscarriage rates. See the "Recurrent IVF Failure" and "Advanced Sperm Testing" sections for more detailed information.
Previous Vasectomy
Approximately half a million vasectomies are performed every year in the United States, and between 3 and 8 percent of these men will change their mind and want to have more children in the future. Effective therapies are available to these men, including microscopic vasectomy reversals as well as sperm extractions combined with conventional in vitro fertilization or intracytoplasmic sperm injection. The "Fertility Following Vasectomy" section reviews these post-vasectomy fertility options in detail.