MALE FACTOR INFERTILITY

QUESTION

To dear Dr. Zavos,
Could you please help us?
My husband has been diagnosed as having a low sperm count (approximately 6-13 million) which we have been advised is satisfactory and substantial quantities to produce a viable pregnancy.(as told by our doctor) Apart from this, he has a large amount of abnormal sperm, with a total of between 43%-61% abnormal forms with regard to morphology. With regard to motility, the values range between 38%-66%. The volume of each collection was between 5.0- 5.5 ml, which is reasonable. The amount of sperm that "show good forward progression" are between 50-77%. He is currently taking Tribulex, Multivitamin and a Zinc tablet daily, along with a satisfactory diet- although he smokes and drinks alcohol on a regular basis. He currently works shift work in a paper mill driving a forklift truck. He worked in the pest control industry for several years before I met him and he remembers the smells of all the chemicals regardless of breathing apparatus. I have been tested, both surgically and via blood tests and have been informed that I am of good health and able to sustain a viable pregnancy. We having had unprotected sex for over three years now and no success. Can you help with any advice? Is there anyway that the morphology of the sperm can be improved? We would appreciate your assistance and guidance.
Thank you for your time!
Judi

ANSWER
Dear Judi

Regarding the abnormal morphology, we would recommend that the semen analysis be repeated and the morphology be evaluated according to strict criteria. These criteria can isolate abnormalities in sperm that cannot be detected using WHO guidelines. It is possible that the various factors that you mentioned above regarding the pesticide exposure, smoking, and use of alcohol could have an additive negative effect on the spermatogenic parameters. This presents a typical example of somewhat severe male infertility that need to be addressed in a very aggressive and methodologically correct manner.

When we look at the whole picture so far as all spermatogenic parameters, we see possibilities of a certain number of sperm can be recovered that is motile, morphological normal, healthy spermatozoa that can be used either in a IUI or ART program. Not knowing anything about your age, and knowing that you have already tried for 3 years with unprotected sex with no success, one must recommend an accelerated mode of treatment either via the use of IUI with aggressive ovulation induction and prediction or the use of IVF for the purposes of achieving a pregnancy.

When it comes to male infertility and sperm abnormalities, there is very little that can be done to improve sperm morphology. We are very concerned about any possible implications of the chemicals and their involvement in the sperm abnormalities that we see in your husband.

As a final piece of advice, please walk this line very carefully with a physician that know the ramifications of the use of severely deficient sperm and its involvement in fertilization and onset of pregnancy.

We see something wrong here that may be correctable. We wish you good luck.

Sincerely,

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

QUESTION

My husband had a SA done and we found out that he had high sperm count but low motility (20%) What are the chances of us getting pregnant without any medical intervention and if can still be accomplished. We were thinking of getting an IUI done because of his problem but we would like to try naturally first and I just want to know if there still is a chance that it can happen naturally.

Thank You

April

ANSWER
Dear April,

The information that is provided regarding your husband's semen analysis and the results obtained is not adequate to begin to offer you some solid directions as to how you should proceed with your infertility difficulties. One semen analysis without repeating and reconfirming data is not adequate for anyone to base its decisions to propose a mode of treatment. However, you need to consider the following:
1. Repeat the semen analysis and the laboratory or clinic that does this should follow the WHO guidelines for sexual abstinence (3-4 days). They should consider the use or employment of a seminal collection device at intercourse for you during the production of the specimen. This may bring about some improvements in the specimen, as we have shown in the past via a series of publications.
2. Make sure that your doctor is an infertility specialist (REI). He/she may be able to rule out any possible problems associated with the female factor in order to zero in and solve the male factor infertility associated with this couple.
3. One must remember that as long as there is sperm in the ejaculate, then there is a chance for success in establishing a pregnancy. If you are interested in trying to establish a pregnancy naturally first, then you should try on your own for 3-6 cycles and if you get no success, then you should solicit more advanced treatment with IUI and possibly going with assisted reproductive technologies (IVF). Of course, if there is an age factor involved with this couple, then things may have to be accelerated via the use of artificial means.

Please always remember that where there is a will, there is a way.
Sincerely,

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

QUESTION

I have been married for 13 months and have been having unprotected sex for the same period. I am 30 years old, while my husband is 37 next month. My husband has been diagnosed to have low sperm count. The two tests he has done revealed 3.5 million and 2.5 million respectively. He did the second test after he had been placed on a drug for a period of two months. The results said poor motility, something percent dead and something per cent sluggish, etc. He has stopped alcohol and has gone off coffee and other caffeinated things. He does not smoke. My question: Is it possible for me to get pregnant while he is still being treated? How long does it take to treat it? Can you offer any advice that can aid us?

ANSWER
Your problem is one of many prospective parents. It is very unfortunate that you are experiencing the types of problems that you do. If we were to assume that your husband's evaluation is done properly and his counts remain the same, along with all other deficiencies in motility and morphology, you would then need to consider going through IVF in order to overcome those deficiencies. Please understand that your husband can be perfectly normal and healthy and the low sperm count may be a difficulty that he developed due to a variety of experiences that he has suffered through his childhood and adulthood life. He does seem to be living a very healthy life and he may not need to be placed on drugs to improve his sperm counts unless he is found to have some hormonal deficiencies that can be treatable.

Yes, it is possible for you to get pregnant while he is still being treated. As to how long does it take to treat his infertility difficulties, that would be up to his doctor. As I noted above, your husband can only be treated for his deficiencies, if and only if he is found to have any deficiencies. At this time I would suggest that you do obtain a second opinion from an infertility specialist. I wish you good luck.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

QUESTION

My husband and I have been trying to conceive for almost two years. We recently had a sperm test done by his urologist. [Volume 1.0 / pH 8.1 / Motility 2-hour 30% / Count 2.6 million / WBCs 5 (million?)] The urologist felt the high white blood cell count indicated prostate infection. He started a 30-day treatment with Bactrim. Is it possible we can expect significant improvement with treatment of the infection, or should we go to an RE and investigate further? He has lost 75 pounds in the last year and weighs around 290 now. Will further weight loss also improve his results? Many thanks for your time.

ANSWER
Please remember that your husband has been evaluated by his urologist only once! A lot of men, and I mean a very large majority, take their testing very seriously, and, during their first attempt to be evaluated, fail miserably because they are nervous and very concerned. I feel that your husband needs to be counseled properly and be evaluated at least 2-3 times more, before we can tell with some degree of certainty that his problems are consistent and serious.

I definitely believe that going on antibiotics for his WBC difficulty is a must and we could expect some improvements especially in the qualitative aspect of his sperm (motility and morphology). In your question to us about going to see and RE for further investigation, it may indicate that you are not sure that you are seeing the right doctor for the treatment of your difficulties. Please remember that in your own mind, you must feel that you are seeing the right doctor and feel confident that you are "in good hands" for your overall infertility workup. Your husband has gone through a great deal of stress already by going through this and also his weight loss. Please remember that additional weight loss could bring about further improvements assuming that it is done under non-stressful circumstances. You may consider going to see an infertility expert unless you feel comfortable with your current circumstances.

You must continue to support each other during this very stressful experience. After all, it takes two to tango.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

QUESTION

My husband has been diagnosed with a low sperm count (first test = 2.8 million / 4cc / 60% motility). An infection was detected by the urologist. He was put on an antibiotic for two weeks, and it cleared up the infection. Next count = 3 million / 3.8cc / 60% motility. There was still "pus" present in his semen. The urologist again prescribed an antibiotic (a different one). The urologist has been very negative about the chances for a pregnancy to occur. He said the next step will be hormones for my husband. He also said that there is a 30 percent chance that the hormones or the antibiotics will increase his count, however, he continues to be very negative and suggests that an IVF will probably be the only way to conceive. What is your opinion?

ANSWER

It is rather confusing that your husband is diagnosed with a low sperm count, is suffering from an infection and he is showing a rather high percentage of motility. Normally, when a man has a low sperm count, he also has very poor qualitative characteristics (motility and morphology). It is also sad to see that after the first infection your husband showed a second infection and he was given an additional antibiotic prescription. Although it is a bit confusing, your husband may have not been receiving the proper antibiotic prescription which did not or does not treat the infection present within the specimen (reproductive tract). You may need to obtain a second opinion and make sure that the urologist that is treating your case also has some knowledge of andrology (male infertility).

Under the current circumstances, unless they change, you're a patient that would need to go through an ART program (IVF). Your husband would not need to go through any hormone treatments unless he is properly assessed and he is found to have hormone deficiencies that may be treatable. I also tend to believe that if your husband's picture remains the same, you are definitely an IVF candidate. However, before you proceed with any IVF procedure, you owe it to your husband and to yourself to get another opinion as to the etiology and possible treatment of his problem. Good luck with your efforts.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF


QUESTION

My husband and I have just completed our second insemination, after we have been trying to conceive for the last two years. When we first started my husband became impotent. Tests showed he had high estrogen. After six months and no treatment, he was back to normal. He recently had a sperm count and it was 500 million per cc. After his sperm was washed is count was 290 million per cc. My doctor says he may have too many sperm and may have to do a "hamster" test. He would not expand or explain the consequences. Why would too many sperm be bad? Are there more tests he can take? I have had all the tests and show to be normal. Is there a medication to get his sperm to be normal and healthy? He is taking vitamins with zinc -- would they affect his sperm?

ANSWER

This case needs to be documented a bit better in order for us to give you more accurate feedback. However, we will attempt to answer some of your questions to the best of our ability in spite of the missing "links." It seems that your husband is under a great deal of stress. The high sperm count, which is known as polyzoospermia, should not be a difficulty unless we see other spermatogenic deficiencies that are associated with this condition such as low motility, progressive motility, and most importantly, low critical morphology.

The hamster test or "hamster sperm penetration assay" (SPA) is used to determine whether sperm are capable in penetrating a membranous system such as the hamster egg and could be predictive of any problems that the polyzoospermia may have if the sperm lacks the conditions noted above i.e. motility, progressive motility, critical morphology.

Your husband is where most men wish to be and he does not need to suffer any more than he needs to for having good and plenty of sperm. A lot of men wish that they were sitting where he is sitting. If you don't believe me, please read the preceding five questions that have been presented in this e-zine. Although we can speculate on the issue of polyzoospermia, not enough data exist that would indicate that it is a medical condition that needs to be treated. There is no medication that your husband can take to get his sperm down from where it is now. He needs to continue with his vitamins and zinc, and good healthy living. Consider yourselves lucky.

As a final recommendation, you may need to be assessed more aggressively for any female factor infertility difficulties that you may have. Make sure that you see an infertility expert that would give you an expert opinion on the subject. Your infertility difficulties are very delicate but treatable. We wish you good luck.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IV


QUESTION

My question is regarding collection of semen for a test. Is it absolutely imperative to collect the entire amount of ejaculate? Is a test done without the whole amount not a valid test to trust? My hubby got all nervous and was able to get only the last bit in the bottle. The results were low. But the volume seemed okay. What does that mean?

ANSWER
The first portion of the ejaculate contains almost all the sperm, so it is imperative to collect this portion. If you have missed this portion, you will still have some sperm in the ejaculate but the numbers may be low, and it would not represent a true picture of your husband's condition . The volume would still be within normal range, but the sperm rich fraction would be missing. After collection the sperm rich fraction and the seminal plasma mix to give a very homogenous sample. If this mixing (or liquefaction) does not occur properly, the results of the semen analysis, especially the count, should be questioned.

It is imperative for your husband to have another semen analysis done and ensure that the entire specimen is collected. A semen analysis with only part of the sample collected is not representative of your husband's semen profile. In addition, the most proper way to collect a semen specimen is via intercourse using a non-spermicidal condom. This maximizes the overall effort by allowing maximal sexual stimulation, and therefore enabling the male to deliver the best and the most representative sample under circumstances similar to those when he performs with his sexual partner (you). I am quite sure that this has frustrated your husband immensely and has upset both of you, but you need to calm down and look ahead. Incidentally, if you both feel like it is rather difficult for you and your husband to go back to the same physician for additional evaluation, you may consider looking into the "Home Semen Analysis Kit" that is offered through the Andrology Institute of America. This may alleviate all possible stress symptoms.

Every man deserves a second chance. Give him one! We wish you the best.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

QUESTION

My husband is 42 and had his vasectomy reversed after 17 years. He has had numerous sperm counts that show his levels at 4 million per mL, low motility, and abnormalities. He has tried Proxeed and a fertility drug but nothing has improved the count. I am 28 and in good health. Is in vitro our best chance? What are the chances of retrieving good quality sperm from my husband to perform the procedure successfully? We want children badly and would appreciate any help you could offer. Thank you for your time.

ANSWER

Your story is very familiar and one must "tip-toe" very carefully through all the data that has been generated up to now in order to be able to give you a very accurate assessment of the situation as it is. It is difficult to critically assess your situation without all the semen analysis data. With repeated analyses showing 4 million sperm per mL, with low motility, chances of conceiving naturally via intercourse may be low. However, if you and your husband would want to attempt IUI (intra-uterine insemination), it would be possible to collect 2-3 specimens during the insemination time and pool them in order to get an adequate number of sperm to inseminate with (one sample may not be enough to do the job) and expect positive results.

Our recommendation would be to see an experienced infertility specialist who would be able to better advise you on your situation, and may even suggest that you opt for IVF if all other attempts fail. Not only do you need to properly evaluate and treat your husband for his difficulties, but you also need to have an infertility workup done for yourself as well. Do not forget that it takes two to tango in this business. The choice for IUI or IVF may also depend on you and your reproductive status.

We wish you the best for you and your husband. Keep up the faith and things may turn around for you.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF


QUESTION

I'm a 26 year old woman and my husband is 48. He had a vasectomy about 20 years ago, so from what I've been reading a reversal isn't likely. We have been discussing having a child. Is there a reasonable procedure that would allow me to be impregnated by his sperm? I have seen fleeting references online to invitro fertilization but I have found very little information on this subject. Could you supply some information? Thank you.

Rachael M.

ANSWER
Dear Rachael M.:

We have reviewed your case with a great deal of interest, and I must tell you that your case is not unique but rather common in the infertility market. There are a number of positive signs in this case as I see them. The husband is 48 years old with 20 years of being vasectomized, being married to a rather young female and, I take it, capable of reproducing. However, the fact that your husband has been vasectomized for 20 years could mean that even after vasectomy reversal, although successful, he may not yield the appropriate numbers and, most importantly, the quality of sperm necessary for your impregnation under natural conditions. We are not implying that you should not try to get pregnant via this mode, rather, we are stating that the chances for you getting pregnant will be relatively slim.

Under the current circumstances, we believe that the most promising mode of treatment for your difficulties will be via Microsurgical Epididymal Sperm Aspiration (MESA) and use of the sperm for IVF purposes. During this process, the sperm is microsurgically removed from the epididymis slightly above the site of the vasectomy and introduced via Intra Cytoplasmic Sperm Injection (ICSI) into your eggs. The overall success for this procedure lies in the ability to recover good viable spermatozoa, and also in the ability of the female factor to produce adequate number of high quality oocytes. More information on the MESA procedure may be found on our center's website at kcrm-ivf.com/services.htm#mesa.

We definitely want to wish you a great deal of luck and success in your efforts in accomplishing what your are aiming to do. Please remember that it takes a great deal of luck but also a great deal of love, understanding and consideration between the two parties to accomplish a pregnancy and take a baby home. You have all our support.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

QUESTION

My husband may have a low sperm count. The first test was not done properly, and we're waiting for results of the second. If he does have a low count, does this mean we have to resort to IVF?
Christine P.

ANSWER
Dear Christine P.:

Thank you for your very inquisitive question that concerns many, many couples like you. It is quite unfortunate when the investigator (physician's office or laboratory), for a variety of reasons, is not able to obtain and confirm the accuracy of their results and they begin to question the ability of the male or the female to reproduce. Let us focus on your case.

The term "low" is meaningless unless it is defined. According to the World Health Organization standards, a man is defined as oligozoospermic (low sperm count) if he has a sperm count of less than 20 million sperm per mL. However, in our own terms, and in the business of treatment of infertility, there is a significant difference between a man that has 19 million sperm and a volume of 5 mL (total sperm count of 95 million), versus one that has 19 million with only 1-mL volume (total sperm count of only 19 million). The two men, although they have the same deficiencies, could require a different mode of treatment (intrauterine insemination versus in vitro fertilization). Also, bear in mind that it takes more than just sperm numbers to achieve one's goal. The sperm has to be motile and morphologically normal to establish fertilization and subsequent pregnancy.

We have established that men's seminal characteristics can fluctuate quite significantly from time to time. Most importantly, we were the first ones to show that the mode of semen collection (natural intercourse versus masturbation) could yield different results in favor of intercourse. Therefore, under those circumstances, your husband should be given a second chance and possibly be given the opportunity to collect a specimen via natural coitus using the Male Factor Pak. This product is a non-spermicidal condom used during intercourse exclusively for semen collection for infertility purposes.

The bottom line in your case is as follows: Your husband's specimen has to be collected and assessed properly in order to establish very accurately as to whether he does or he doesn't have any deficiencies. On the issue of resorting to IVF, you need to wait and establish your husband's and your fecundity in order to plan things accordingly. Do not forget that in this business "it takes two to tango." I hope that all goes well with your husband's evaluation and that you get the positive results that you wish. We wish you good luck with all your efforts.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

QUESTION

My husband and I have been married for six years. Since we have been married, I have never been on any kind of birth control. We are just now researching the possible fertility problems that could be present. I am 25 my husband is 26. I have had regular periods and my gynecologist doesn't see any obvious indicator of a problem with me. My husband just agreed to get his sperm checked, and it was "low" with "low mobility." He is really hesitant in seeking treatment by a urologist. I was hoping you could give me an idea of what the process is from here so that maybe I can ease his mind somehow. Thank you.

Valerie W.

ANSWER
Dear Valerie W.:

We have reviewed your case very carefully. You're fortunate in that if you are to have problems of this nature, it is always better that you discover them at an early age and be given the opportunity to correct them while you're young and able to reproduce. As you may know, most couples postpone childbearing until later and they are faced with a multitude of problems, among others the most significant being the aging effect of the female factor that cannot be reversed. So consider yourself lucky.

Coming to your case, I must say that you need to review the previous case noted above addressed to Christine P. They are some similarities between your case and the previously reviewed case. Your husband must be given another chance or two and possibly a better mode of semen collection that could assist him in producing more sperm along with higher motility of spermatozoa in his ejaculate. I can understand and sympathize with your husband for being hesitant. After all, he may not be needing treatment but rather another chance for proper evaluation. If your husband remains hesitant to follow up with his case, our offices could offer him the "BioTranz" test (which you may access at http://www.aia-zavos.com/biotranztest.htm). This test is done on a long-distance basis where you collect the semen at the privacy of your home during intercourse using the Hygiene Kit and the semen is then forward to us in a special container for proper evaluation and interpretation (which is shared with your physician). This may ease both of your minds somewhat.

Because each couple's problems with infertility involves two people, the husband and wife, one must make sure that before we "accuse" the one party as being deficient, we must make sure that the other party is "doing its homework." I must know that your gynecologist, by his statement "doesn't see any obvious indicator of a problem with you," intends to impart that the proper testing and proper diagnosis of your reproductive ability has been done correctly and comprehensively. Whether or not this is an accurate evaluation can be accomplished by getting a second opinion from another OB/GYN infertility expert in the area. This is very important.

I hope that I have been able to assist you with your case. You must continue to think positive, and the fact that you're very young should be a point of optimism. We wish you good luck.

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

QUESTION

My husband suffers from klinefelter syndrome. We 've heard about ISCI after testicular biopsy but are seeking help and advice on what we should be doing to treat this.

Thank you,
Lisa and Emmanuel - french readers of the infertility E-zine

ANSWER
Dear Lisa and Emmanuel,

Klinefelter's Syndrome issue is a rather severe mode of male infertility with no definite mode of treatment. There have been several reports in the literature in which pregnancies have been achieved, although at a very low success rate via the use of testicular biopsy and use of ICSI. Unfortunately, there is no guarantee that when spermatozoa are retrieved from the testes and introduced into healthy oocytes via ICSI, it would yield subsequent fertilization and/or onset of pregnancy. However, as of today, the mode of testicular biopsy and ICSI seem to be the only possible treatment available that could yield fertilization and possible pregnancy.

A bit of a reminder, do not forget to check the clinic for any historical data and success rates or failures doing regular ICSI, ICSI with testicular sperm, and experience with Klinefelter's syndrome sperm.

We wish you good luck.
Sincerely,

Dr. Panayiotis Zavos
Director, Andrology Institute of America
Associate Director, Kentucky Center for Reproductive Medicine & IVF

310 South Limestone Street, Lexington, KY 40503 USA
P.O. Box 23777 " Lexington, KY 40523 USA
Phone: (859) 254-8108, (859) 226-7263, (859) 226-7264
Fax: (859) 226-0026
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