In Good Health: The Matter Of Male Fertility

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0:31When a couple struggles to conceive, the assumption is often that there is something wrong with the woman. Women are evaluated for infertility far more often than men, but male factor infertility accounts for about half of all infertility cases. And when it is the cause, men are less likely to talk about it, seek support, or even get tested in the first place. I'm Jen White. This is the 1A Podcast. Today, for the latest in our series, In Good Health, we're talking about male infertility, what causes it, what can be done about it, and what it's like to go through it. and we share some of your stories along the way.

1:06Stay with us.

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3:18Dr. Paul Shin joins us in studio. He's a urologist specializing in male infertility at Shady Grove Fertility. That's the largest fertility clinic chain in the country. Dr. Shin, welcome to 1A. Hi, it's super nice to be here. So first, just define male factor infertility for us. What is it? So male factor infertility carries a whole broad array of definitions, but put most succinctly, it's where either a shortage of sperm, either in terms of number or motility, causes a couple to have difficulty with naturally achieved pregnancies. So timed intercourse for six months to a year. And you said it's either the sperm count or motility, and just define motility for us.

4:00Motility is just simply the number of sperm that are actually moving and swimming. The way I kind of put it to patients is sperm have a job to do. They've got this massive Easter egg hunt to go on, and you need as many runners to start the race. How common is male factor infertility? So amongst the couples that we see, as you mentioned, the perception is that fertility is a female-only problem. But the reality of it is, again, you've got two people. It's a problem about 50 % of the time. In your experience, what are some of the most common medical causes? So the most common overall cause of male infertility is actually a very benign testicular condition called varicose veins of the testicle, or what's called a varicocele.

4:41It's something that many men have. They're oftentimes very asymptomatic, and it's the number one thing that we look to address. But other causes from a medical perspective can be anything from certain types of medications to hormones to underlying physical conditions. So it really runs the gamut of a broad array of different health conditions. You mentioned sperm count. How important is that count for fertility? So it's not only the sperm count that's important, but it's the number of sperm that are actually swimming and moving. So you can have all kinds of discrepancies with semen analyses where men have perhaps high sperm counts but lower motility.

5:19But at the end of the day, you want to have as many runners running that race as possible. We got this from Brian in our text club. Have there been any studies showing a link between obesity and issues with fertility? Dr. Shin? Yes. There can be a couple of different issues with being overweight. One of the more obvious issues is that with added body mass and added body fat, it makes the testicles warmer. And your testicles generally don't like to be too warm. They kind of want to be a little cooler than body temperature to operate most efficiently. So there's a body heat metric here. But there's also an endocrine metric or a hormonal metric where many men who are overweight within their fat cells will take testosterone and actually turn it into a form of estrogen called estradiol.

6:05And that conversion is enhanced in men that have added body fat to the point where sometimes that added estradiol can also impact how well a guy makes sperm. What do we know about the effect of lifestyle factors like exercise, drugs, and alcohol? So lifestyle factors are something that patients always ask about. And it's because there's that very human concern of, hey, I want to do something to make my fertility better. And these are the things that I have control over.

6:39So restrained moderate consumption of alcohol, for instance, or even the occasional cigarette or cigar if you're out with your friends is probably not that big of a deal. But higher levels of consumption can certainly be a factor both in terms of tobacco, marijuana, and alcohol. And so there's kind of a usage spectrum there. Well, male infertility has been a taboo topic for a long time, but that's starting to change. Tyler Teza is a content creator and shared a video before his own procedure to treat an enlargement of veins in his scrotum. I'm currently in Atlanta, Georgia for a procedure to help with a fertility issue that I have.

7:17I have a varicocele vein, and what they're going to do tomorrow is tie some of those veins up and allow proper blood flow into my, you know, area. Hopefully that helps with my fertility issues. But I wanted to make this video more for those guys out there that are having issues, whether it's a varicocele or whether it's sperm count or whatever the case is. I want you to know that it's normal. It's not just you. And it happens. When we talk about varicocele, which, again, you said is really the most common thing you see, how treatable is that type of infertility? It's very treatable. And it's almost like we set it up this way.

8:03That's beautiful. But it's the most common thing that we run into. It's one of the most common procedures that we do. And actually, somewhere in the ballpark of 60 to 70 % of men substantially improve their sperm counts and motility after a varicocil repair. The trick is just making the diagnosis because it's super subtle. It doesn't impact puberty. It doesn't change sexual functioning. So it really doesn't cross a guy's radar, usually until there's a problem with fertility. And so what does the procedure entail? How long does it take? So it takes about 30 to 45 minutes per side. The majority of men will have varicose seals, usually only on the left, but we do have some guys that have it on both sides.

8:44And what you're effectively doing is you are stopping the backflow of warm abdominal blood down to the testicle. So all these enlarged veins, like you've seen people with varicose veins in their legs, imagine those veins draped around a testicle, almost like a puffy coat. And so it's a layer of insulation that you're looking to basically thin out and allow for better heat transfer. And so you are basically tying off those veins? Correct. There's a ton of other veins. We're not choking the testicle off or anything, but you're selectively identifying these really abnormal veins. And we use a tiny ultrasound probe and a microscope to help us identify.

9:24And from a cost efficiency perspective, of almost all insurance companies will cover it too. Well, we got this message from another member of the 1A Techs Club. The worst part is providing specimens for testing. It's very humiliating, though I suspect it pales in comparison to what every woman has ever had to go through. Dr. Shin, what does that testing and evaluation process look like? So that is one of the primary complaints that has always plagued the notion of getting a semen analysis is, well, how do you get it? Where do you get it? How do you deliver it in? And then when you walk into a fertility clinic with a small brown paper bag with a container in it, everybody knows what you have in it, right?

10:01So there's a certain amount of stigma or almost shame that goes along with this. And one of the ways that we try to work around this is we have patients produce the sample at home and bring it in. So they can do it in the privacy of their home. They're not struggling to find a public bathroom to do it in or doing it in their car and trying to get it in. And the other real benefit to this is there's been an explosion of available at-home tests. So it provides a measure of discretion. The patient can produce the sample at home and just mail it into some of the companies that, and we work with a few of them.

10:38You know, there are a few limitations with doing that too, but in terms of lowering the barrier to entry, it is a huge plus when guys don't have to confront the whole issue of that interface. Well, here's another message from a member of our text club. My husband was sent to a urologist for fertility issues by my OBGYN. I went with him for support, and when we arrived, I felt the doctor was critical of me for expecting my husband to go through testing. Mind you, this was in 2005 or so, but it was horrifying to me that he implied I was some devil forcing him to do the testing. I ended up having more painful tests.

11:14We never got pregnant. We adopted two beautiful children from foster care and privately. all in good time. Women are often the first to be evaluated sometimes by many months or even years, even though men are statistically just as likely to deal with infertility issues. So, why are men less likely to be tested? I think that goes all the way back to just the way that men interface with the medical system. So, women from a very early age start seeing the doctor. They go to the doctor when they get their period. It's something that happens every month. I mean, can you imagine what would happen if a guy had a period?

11:56It would be kind of the end of the world, right? Well, it would also be a completely different healthcare system, but that's a different conversation. If men had menopause, we would have fixed it 50 years ago, right? Oh, yeah. But in truth, there's this perception that women have to carry babies. Women seem to have more complicated parts, so it's clearly a female problem. And that has its roots not only amongst the patients that we take care of, but amongst providers. People grew up in a medical system that trained them that this is a female fertility issue. This is a female problem. And that's changed.

12:30That paradigm in the last, I'd say, 20 to 30 years, I've got a little gray hair. I've seen this change occur. But there's this whole generation now of specialty care directed at male fertility acknowledging that it's a problem. Another member of the text club writes, My wife and I were told 37 years ago we would never have children. We adopted our son as a baby, and it was wonderful. Five years later, the doctor said my wife was pregnant, and we had a daughter by natural means. What a blessing. After a quick break, we'll hear from someone whose infertility forced him to confront why and whether he wanted to become a parent.

13:06That's in just a moment.

13:11Support for NPR comes from IBM. On Smart Talks with IBM, host Malcolm Gladwell speaks with leaders who are pushing the boundaries of AI and technology in partnership with IBM. Hello, hello. I'm Malcolm Gladwell, host of Smart Talks with IBM. I sat down with Alon Cohen, who leads research and development at UFC, to discuss the complexity of using technology to analyze fight data. With kick to the head, it makes contact with the outset of my arm, which I brought up. In our world, that's a blocked strike. Yeah. But teaching a computer what exactly that means and when and how. Like, when my arm is up, that's a block.

13:53When my arm is down and hits my shoulder, that's not. It's those nuances that proved incredibly difficult for machines to be able to handle for a very, very long time. That is, until IBM entered the octagon. Listen to Smart Talks with IBM wherever you get your podcasts. This week on Up First from NPR News, President Trump is at the G7 in France and is supposed to sign a peace deal with Iran. That deal, if it happens as planned, will have big effects on the global economy and more. and we will track the changes as they unfold. On a week of major geopolitical news, listen to Up First every morning on the NPR app or wherever you get your podcasts.

14:34This week on Wait, Wait, Don't Tell Me, we asked comedy legend Robert Smigel about the moment he first knew he was funny. When I was like four or five, I could draw really well. So I could draw Fred Flintstone and Snoopy. And then probably a couple of years later, I started drawing them having sex. Listen to the Wait, Wait, Don't Tell Me podcast in the NPR app or wherever you get your podcasts.

15:21at NPR Wildcard. On the next through line from NPR, the story of the World Cup and what happened when a tournament imagined to promote peace landed in a country primed for war. There's obvious reasons why neighboring countries will be rivals. This manifests particularly in football. Listen in the NPR app or wherever you get your podcasts. Let's get back to the conversation and add some more voices as we talk about what it feels like to live through a diagnosis of male factor infertility. Dr. Bill Petok is a psychologist specializing in couples and individuals dealing with fertility issues. He's a past chair of the American Society for Reproductive Medicine's Mental Health Professional Group.

16:06Bill, welcome to the show. It's a pleasure to be here. Thank you. And Renee Almaling is also with us. She's a professor of sociology at Yale University and author of the books Sex Cells, The Medical Market for Eggs and Sperm, and Gynecology, The Missing Science of Men's Reproductive Health. Renee, thanks for joining us. Thanks so much for having me. And we're hearing from you. Amy writes, my husband had a mild issue and the only way to address it was IVF. We were fortunate that it worked and we have two kids, but it was a long, expensive, and stressful process. Bill, you've been working for decades with individuals and couples facing fertility issues And of course, everyone experiences these challenges differently.

16:48But generally speaking, how do you see people react to getting a diagnosis of male factor infertility? Well, I think it's very similar to the way female infertility is experienced in that there's a lot of psychological distress, depression, anxiety, and a reduced quality of life. Those things are all felt and seen in individuals, both men and women. Dr. Shin, how do you approach sharing this news with your patients? I first like to demystify it by telling the couple that they're not a failure. So one of the things that is most rooted in our psyche is think back to what you were told initially when you were learning about sex ed in middle school with your gym teacher awkwardly teaching this to you.

17:33You're told, well, you need to use contraception or else you are going to get somebody pregnant. So the thought process is, well, all I have to do to get pregnant is stop using birth control, and it should happen. And if it doesn't, then I'm some sort of a failure. So it's reemphasizing that this is a very biological phenomenon. This is something that a lot of people go through, but aren't going to put on social media. So it's more prevalent than you think. And there's lots of ways to fix it and address it. It's just facing the demon first. You know, it's interesting in popular culture, we have lots of examples of women who share their fertility challenges and their use of IVF or donor eggs or surrogates.

18:10Michelle Obama, Mariah Carey, Celine Dion, there's just a few of the very high profile women who've shared stories about the fertility struggles. But when it comes to men, there are fewer examples. Bill, why do you think that is? Well, I think it's very difficult for men to talk about this because of shame and guilt and a sense that it's their fault. I mean, we're raised to be problem solvers, and here's a problem you can't solve. Oftentimes, as Dr. Shin indicated, it's nothing that the man did. It's just bad luck. And so when you can't solve it, it's difficult to talk about it. And it's embarrassing.

18:51And we're not trained to talk about that. Yeah. Renee, you're a sociologist. what connection do you see men make between their virility, so how strong, vigorous, and sexual they are, and their ability to conceive children? Yes. Well, there is a very longstanding association between masculinity and virility, sort of the ability to father a child. And as we have had more data come out about sperm counts, then the virility sort of gets quantified and people think about their sperm counts as a measure of their masculinity. And so I appreciate Dr. Shen sort of referencing these, you know, long-standing cultural beliefs, and they go back centuries.

19:36Hey, Dr. Shen, what does the science tell us about the connection or lack thereof between strength, sex drive, and fertility? There really isn't one. A lot of those things that we just mentioned and everything that you would think of in terms of sexual prowess really is more linked to testosterone. and it's two totally separate problems. So you can certainly have men who have little to no sperm, who have completely testosterone, who have completely normal testosterone levels. So the notion that strength or virility or sexual prowess guarantees fertility is really not a thing. Well, we're getting questions about testosterone.

20:15John emailed, as a urologist, I'm seeing more and more men with male factor infertility caused by supplemental testosterone use. Can you please address this? Now, we should mention here that this is part of this sort of looks-maxing movement, and they talk about maximizing testosterone, especially among young men. Dr. Shen, what are you seeing in your practice? We're seeing the same thing, and it's actually the reverse. When you go on some form of external hormone therapy, testosterone, or, you know, we have a fair number of trans patients that also because of higher estrogen levels, it suppresses your body's own need to make testosterone and along with that goes your sperm count.

20:56So it's a subtle thing and it's something that many people prescribing testosterone never even talk to their patients about. And there's this short-term end goal of, as you mentioned, looks maxing. And yeah, if you get on some testosterone, you'll probably feel great, but what it's doing in the background is really detrimental for your fertility. Well, we're seeing popular podcasters like Joe Rogan and Andrew Huberman, also Health and Human Services Secretary Robert F. Kennedy Jr., speaking publicly about their experimentation with testosterone replacement therapy. How much are you having to sort of combat this idea that this is a way to build muscle mass and vigor and that it might be affecting your fertility?

21:41I think a critical part of what I do when I talk to patients about this is just talking about the science. This is why testosterone impacts your fertility, but there are some other alternatives that we can use that both supplement testosterone but also allow you to have your sperm count. So, Bill, in your discussions with individuals or couples experiencing male factor fertility, how much of your work is about sort of rewriting the script around what it means to be masculine or about that individual's role in that partnership? If they feel like, you know, that's being challenged because I'm having issues with infertility.

22:29I think we're doing an awful lot. We have to do an awful lot to reduce that sense that masculinity and fertility are somehow related. And it's a problem because men are not brought up to understand reproductive health very well, as Dr. Shin alluded before. Or when the women are pulled out to talk about menstruation, the boys are pulled out to talk about how not to get somebody pregnant or not to get a sexually transmitted infection. And in fact, what ought to be happening is talking about reproductive health, what one must do to preserve your reproductive health. So stay out of hot tubs, don't use things excessively, be careful about where you work, those sorts of things.

23:17So that's one thing that we do as we talk about how to understand things a little bit differently. Secondly, it's giving men a different definition of what it constitutes to be manly. It isn't necessarily about strength. There are many different ways to define manliness. I mean, Renee, what I'm hearing is that part of this discussion is a cultural one in similar ways as when women are dealing with infertility and these questions about motherhood come up and the role that plays in your life or doesn't or if you choose not to have children, right? That's a very fraught discussion for many people.

23:56But there's something similar happening for men, but it's less public. It's less in the public eye. What do you think we lose when we don't have that discussion in a way that's visible? Oh, yes. Well, I think it's a wonderful question and really allows us to think about the ways that fertility is clinical and it is biological, but it is also deeply social and cultural and psychological. And so when we as a society code reproduction as something that happens in women's bodies, is women's responsibility, is tied to motherhood and femininity, we're missing an entire part of the conversation about how men understand their own reproductive bodies, how they experience their reproductivity, how they think and feel about fertility.

24:48And so, you know, from high school health education classes to, you know, clinical visits with physicians to conversations that men have with their friends, there's not a cultural infrastructure that exists to provide them with the information and support that they need. One of you asks, would your guests speak on boys who have mumps early in life and its impact? Are there other childhood illnesses that affect male fertility? Sure. Mumps is the prime example because young boys can get what's called mumps or chitus, which is essentially mumps inflammation of the testicle. And that is one of the viral mediators that can impact fertility later on down the line.

25:30And fortunately, it's pretty rare, particularly with the level of vaccination that's out there. We just don't have that many kids that get mumps anymore. But other childhood issues can be things that are surgical, testicular torsions, undescended testicles. And then there's the whole suite of other hormonal issues that kids can have that can later on influence fertility. Here's another question we got from Mason who writes, My son was born with a testicular hydrosol. Will that affect his fertility, or is there anything we should look out for when the time comes? No, a hydrocele in and of itself really shouldn't be that big of an impactful factor, but sometimes hydroceles can be associated with an undescended testicle, which can be a bigger deal.