COPING WITH INFERTILITY
Both females and males should be evaluated
Infertility is generally defined by the American Urological Association as the inability to conceive after having unprotected intercourse for one year.
Surprisingly, approximately one in six couples will struggle with infertility at some point. As many couples are now delaying pregnancy, infertility is becoming more common. Unfortunately, many couples do not feel comfortable discussing this struggle publicly and prefer to deal with it in private. This often creates a misperception that infertility is rare, which could not be further from the truth. As couples deal with issues surrounding fertility, they will often experience anger, anxiety, worry and depression. This can obviously lead to significant strife within the relationship, and it is important that physicians be aware of these issues.
Traditionally, it was believed that males rarely played a role in a couple’s infertility. Many times it was the female’s fault until proven otherwise. This is also a big misconception, and it is important for physicians and patients to be aware that approximately 50 percent of couples struggling with infertility will have a male component present as a contributing factor, and almost 20 percent of these couples will have a male factor present as the isolated cause.
These statistics obviously support the fact that both the male and female should be simultaneously evaluated to avoid unnecessary testing and delays.
When infertility concerns are present, females should consult their primary care physician, OB/GYN or a reproductive endocrinologist (female fertility specialist). The physician will generally begin by taking a thorough history and performing a physical exam. Several things important to note are the following: whether the female has regular menstrual cycles, her age, if she has ever been pregnant before, history of ectopic pregnancies, and if she has ever been diagnosed with polycystic ovarian syndrome or endometriosis. The physician will then generally perform hormone testing and may do an ultrasound of the uterus and ovaries. A more specialized test called an hysterosalpingogram may be indicated in certain circumstances. This is a dye test to make sure there are no blockages in the female reproductive tract.
Accordingly, when there are fertility concerns, males should also be simultaneously evaluated. They should consult their primary care physician, a urologist or a male fertility specialist. Similar to the female evaluation, a thorough history and physical exam need to be performed. Several hormones may also be evaluated including a testosterone and FSH. Testosterone is very important for sperm production within the testicle. Importantly, approximately 20 percent of men who are evaluated for infertility will be diagnosed with hypogonadism (Low T). These men cannot be given testosterone because this can potentially shut down sperm production. There are only two medications that are generally recommend for these men: clomiphene citrate (clomid) and hCG. Both of these medications help men to make their own natural testosterone. FSH is another important hormone to check. It is a hormone that is sent from the brain to the testicles to produce sperm. Normally, this value should be less than seven for most men. When the FSH is higher than seven, this can indicate there may be an issue with sperm production.
When performing a physical exam on the male patient, it is also important to evaluate males for clinically significant varicoceles (needs to be palpable by the physician). A varicocele is dilated veins that surround the testicles and are present in approximately 20 percent of men. Fortunately, most varicoceles will not cause fertility issues and do not need to be repaired. However, larger varicoceles that are palpable in the scrotum certainly can cause fertility issues. Thankfully, most of these can usually be repaired with an outpatient surgery, and about 70 percent of men will see improvements in semen testing over time.
Semen testing is vital to properly evaluate a male’s fertility.
The American Urological Association recommends at least two semen analyses. Two are recommended because semen parameters can have significant variability and isolated abnormalities are very common. These should generally be collected at the lab to ensure the specimen is of the highest quality.
Additionally, many men will also struggle with erectile and ejaculatory dysfunction when dealing with the pressure surrounding infertility. Thankfully, these issues are rarely permanent, but can be a significant source of added stress. Unfortunately, many men may not be comfortable discussing these issues, and it is often up to the provider to elicit. The good news is that medications and counseling are very helpful in combating these issues when they arise.
As couples continue to delay pregnancy, infertility will become more common. It is important that physicians and patients be aware that males and females both can contribute to infertility and should be evaluated simultaneously when possible. Thankfully, many of these issues can be resolved if the proper diagnosis is made in a timely fashion.
Jared L. Moss, M.D. is a urologist at Regional Urology. He earned his Fellowship in Male Reproductive Medicine and Surgery at Northwestern Memorial Hospital, Chicago.