“The Empty Chair”
Why men should be at the fertility Dr.’s appointment too
A female friend who is 40 recently went on a date. The conversation flowed, their jokes jibed, they made eye contact and it definitely seemed like a second date was destined. Instead, he never called and that night was the last time they saw one another. In lieu of a phone conversation, email or text, he did decide to relay through a friend that he thought she was too old for him. He wanted to have children, he explained, and he needed to date younger women. She would have been content with no explanation at all, but now she had this feedback to harp on. As attracted as he was to my friend, and as connected as they got on that date, her age was a factor that he mulled over after they said goodnight. Her age was a number that relegated her to the “fertility challenged” zone in his estimation. Incidentally, he is seven years her senior.
Speaking to another friend who froze her eggs in her 30s, the following question arises: “Do these men who want younger women know if they’re fertile themselves?” The ancient problem of an imbalance in fairness, a double standard and the biological pressures on women versus men, is a recurrent topic when it comes to fertility. Today however, we do hear about how men need to consider their own biological clocks. It was even the subject of a book by urologist Harry Fisch, M.D.
BIOLOGY AND FERTILITY
Dr. Fisch is a New York physician internationally renowned for treating male infertility and for vasectomy reversal. His first book, The Male Biological Clock, is often cited by those who discuss male infertility — and it was published way back in 2005. Since then, he has authored two more books, Size Matters (and yes, it matters for fertility! Think “walnuts, not cherries” for the look of healthy testes) and The New Naked. He is candid with me about the initial response of academic establishments to his first publication:
“They were taken aback when the book came out with this new term. People were in disbelief that men have a ‘biological clock’ at all. I still practice medicine at Cornell and I know men that still don’t understand that they can have a problem! Ultimately, what I’ve come to realize and what the data shows is that a ‘parental effects combination’ is key to conception and healthy offspring. In all my research, I can’t say ‘at this specific age for a man, things go wrong,’ but what I can say is that the male biological clock does begin ticking at age 30. That means one or two things can decline. We know that testosterone decreases by 1 per cent annually after age 30.”
He adds that a younger woman can increase a man’s chances of conceiving a healthy child because her “system is more guarded” — She will more likely miscarry when there’s a genetic abnormality, and more likely get pregnant from the scant healthy sperm, whereas an older woman might retain an unhealthy pregnancy, not having her body reject it, or, she may not be able to conceive at all. A potential solution for older couples is getting pregnant through IVF with PGD (Preimplantation Genetic Diagnosis), a highly sensitive way of testing embryos for anomalies. PGD has actually recently come under some scrutiny for just how extremely sensitive it is! See a doctor for more information about methods of assessing embryos for a successful, healthy pregnancy.
As a former fertility patient myself, I got to know many couples in the waiting room who were dealing with male factor infertility in their 20s and 30s. These couples, who I kept in touch with, were only able to conceive following methods of Assisted Reproductive Technologies.
ENVIRONMENT AND FERTILITY
In addition to biology, genetics and factors related to aging, there is much current discourse about the environment and toxins that may harm fertility.
“Awareness of male reproductive toxins dates back to early history,” says Jeanette R. Tomasino, MS, RNC, MNN, Director of Clinical Education and Quality at Progyny,www.progyny.com, “Lead was identified as a cause of male infertility during the days of the Roman Empire. In recent times, toxins (have been) categorized into heavy metals, agricultural chemicals, industrial chemicals and even the medications we take.”
With regard to younger men, adds Tomasino, “some of the issues that can affect their fertility include: illness/high fevers, childhood diseases, a genetic disorder, an un-descended testicle, surgery, trauma, infections, drug/tobacco/alcohol use, anabolic steroid use, testosterone supplementation and hot tub use/exposure to excessive heat.”
Mary Samplaski, MD, of the USC Institute of Urology adds that: “inflammatory events and even diet may negatively impact semen parameters, sperm DNA health and even live birth rates. Recent data have identified a variety of factors…even a high fat diet. It is advisable for all men trying to achieve a pregnancy to take a multivitamin, as this may help to negate some of these negative environmental effects and help men to produce healthier sperm.” (http://www.ncbi.nlm.nih.gov/pubmed/26252449,http://www.ncbi.nlm.nih.gov/pubmed/20378409)
In addition to the proper multivitamin (ask your doctor for a recommendation), physicians like Dr. Joshua M. Hurwitz, a reproductive endocrinologist at Reproductive Medicine Associates of Connecticut (RMACT), will prescribe regimens that include antioxidants. (http://menfertility.org/effects-of-antioxidants-on-male-fertility/)
“THE EMPTY CHAIR”
In light of all the information, the major problem that persists — according to Houston-based Dr. Michael Heard, a Reproductive Endocrinologist and OBGYN — is “the empty chair” in his examining room. “Women are made to feel that they are the ones with the issue when 40 percent of the time, male infertility is actually the case. Far too often women come to appointments and the men who should be there are not.” Dr. Heard sees men who are exposed to excessive heat in their jobs, who have smoked cigarettes and others who have used marijuana (Getting high makes sperm go low).
He sees those (with no medical degrees) who have self-prescribed supplements (some who picked what they wanted at GNC or over the Internet — definitely not the right course!) and protein regimens, and those who’ve self-selected oral “antidotes” to combat hair loss. Commonly, he sees men who haven’t gone to a general practitioner in years. ALL of these are factors that can put one’s fertility in jeopardy — and adversely affect the health of offspring.
THE IMPORTANCE OF ANNUAL CHECKUPS
“Men need to look closely at their health, see a general practitioner first. After that, they can have their sperm count checked too if they’re planning to have kids. More woman are freezing their eggs today and it’s a good idea to freeze sperm,” says Heard, “Most often men do this when faced with a cancer diagnosis, but while they’re healthy, they need to keep on top of their health with annual checkups. Before worrying about a woman’s fertility, they should look into their own because they are 40 percent of the infertility equation.”
Dr. Heard is not alone in expressing sentiments to raise awareness among men about sperm quality, count, morphology (the size and shape of sperm) and motility (movement, AKA the sperm’s ability to “swim”).
Most reproductive endocrinologists refer to the aforementioned “40–40–20” fertility ratio — the 20 attributed to “other” factors (one example is when combined sperm and egg of a given couple repeatedly show genetic incompatibility, something couples may not discover until multiple miscarriages result from chromosomal abnormalities, leading them to see a geneticist).
TREATING MALE INFERTILITY
Mike Hsieh, MD, Associate Professor of Surgery in the Department of Urology at UC San Diego adds: “Older men not only have decreased sperm count, their sperm quality also declines with aging. ‘Sperm DNA Fragmentation’ is a test that I use to assess sperm quality. There are many types of male factor infertility which are treatable such as Varicocele (varicose veins in the penis area that can impact fertility, for which there’s surgical treatment), low testosterone/hormonal abnormalities (there’s medical treatment) and diet and lifestyle modifications (we recommend weight loss, smoking cessation and avoiding hot tubs/saunas). It’s important to pick up these issues at a younger age because they are reversible and the difference can be conceiving naturally versus requiring complicated fertility treatments (i.e. IVF). Unfortunately, only 20% of male partners seek evaluation and not all doctors are well trained to evaluate male infertility.” (The Sperm DNA Fragmentation test is also called the Halotest or Halo Test. Following is a link to more information about this method of testing sperm quality: http://www.ncbi.nlm.nih.gov/pubmed/24947544)
In this video, https://youtu.be/9i3E5q6UB10, Dr. Hurwitz discusses treating male infertility and the process of ICSI. With standard IVF, sperm is combined with the eggs and the sperm naturally swims to the egg. With ICSI (Intracytoplasmic Sperm Injection), an enhanced type of IVF geared specifically towards male infertility, a single healthy sperm is injected into the egg.:
Dr. Natan Bar-Chama, like Dr. Fisch, is a urologist who practices in New York City. He is the Director of Male Reproductive Medicine and Surgery at The Mount Sinai Hospital and is on faculty in both the Department of Urology and the Department of Obstetrics, Gynecology, and Reproductive Science at Mount Sinai School of Medicine. According to the hospital website “His subspecialty clinical practice is exclusively dedicated to male reproductive medicine and microsurgical reconstruction for the treatment of male infertility (vasovasostomy, varicocelectomy, testicular and epididymal sperm retrieval, vasectomy) and penile reconstructive surgery including implants.” Here, Dr. Bar-Chama discusses treatments for male infertility: https://www.fertilityauthority.com/video/what-are-treatments-including-lifestyle-modifications-male-infertility
Research conducted with rats suggests that a surprising toxin affects sperm: it’sparacetamol (acetaminophen), found in analgesics: https://www.nih.gov/news-events/news-releases/high-levels-urinary-paracetamol-may-impair-male-fertility-nih-study-suggests
I.Male Contraceptives ― There are some that contain Testosterone. Doctor Heard explains that Testosterone supplementation takes a patient’s sperm count down to ZERO and this can take from 6–12 months to reverse through treatment.http://www.sciencedirect.com/science/article/pii/S0094014316000070.
II. Studies with canines (http://www.abc15.com/news/national/could-infertility-from-male-dogs-be-causing-infertility-in-humans andhttp://www.telegraph.co.uk/science/2016/08/09/chemicals-in-food-wrappings-could-harm-human-and-dog-fertility/) point to Plastic affecting fertility and more specifically, sperm count. It should be noted however, that we can only sum up so much from man’s best friend, but keeping a healthy home for both is prudent for best chances of overall health.
III. A study published in Fertility & Sterilityis one of the largest reviews of male fertility to date. Tomasino explains: “The authors found that between the ages of 30 and 50, the average man’s sperm declines by up to 30 percent in volume, swims up to 37 percent slower, and is five times more likely to be misshapen.” These findings further attest to Dr. Fisch’s Male Biological Clockhttp://www.ncbi.nlm.nih.gov/pubmed/11172821
IV. Work-related conditions showed an impact on fertility in another study, says Tomasino: “In a group of 446 men, with an average age of 31.8 years, the study showed that heavy exertion was consistently associated with lower semen concentration and total sperm counts. 13% of men who reported they have workplace exertion displayed low sperm counts compared with 6% of those who did not report workplace exertion. Shift work, night work, vibration, noise, heat and prolonged sitting were not associated with semen quality. In contrast there was an association between heavy exertion, hypertension and the number of medications a man was taking and his semen quality. These are potentially modifiable factors. Further research should be done to determine whether treatment or cessation can improve male fertility.” (Eisenberg M, Chen Z, Ye A, Louis GM. Relationship between physical occupational exposures and health on semen quality: data form the Longitudinal Investigation of Fertility and the Environment Study. Fertility and Sterility 2015; 103: 1271–1277.)
Reproductive endocrinologists emphasize time and again how a man’s general health and his fertility are not only interconnected, but indicators of one another. Dr. Paul Gittens, a Urologist at the Philadelphia Center for Sexual and Reproductive Health says: “In my practice I discuss all of the endocrine disrupters (i.e. testosterone supplements and the latest research on paracetamol affecting T levels) and what needs to be avoided. We also suggest adding dietary antioxidants, high omega fatty acids, and fertility supplements such as Proxeed to assist with improved sperm health.” (http://www.ihr.com/infertility/proxeed.html)
Dr. Peter Ahlering, Director of the Missouri Center for Reproductive Medicine, advises that “Men should also be screened for Prolactin and Thyroid abnormalities.”
OLDER MEN AND THEIR SPERM
The good news about older men with bad habits and those who’ve neglected their physicals, according to Jane Frederick, MD, a fertility specialist and OBGYN in Orange County, CA is that they do very well with treatment.
“Men can actually improve their fertility over time with supplements and lifestyle changes as their body produces new sperm ―approximately every 72 days.”
Coming back to my 40 year old female friend and her 47 year old date, I will highlight what Dr. Ahlering says about age and male infertility: “As men age, testicular function slows and is revealed as lower sperm counts, poorer sperm quality (like DNA fragmentation issues) and also Low T (Testosterone). Studies have shown that DNA Fragmentation is likely to increase as men age which is an indicator of poorer sperm quality. This leads to 1) an increase in the time to pregnancy, 2) an increased risk for miscarriages and 3) an increase in genetic abnormalities of the off-spring — including a possible association with autism.” He reiterates what Dr. Fisch and others say regarding optimal fertile years for men and women, how they’re “actually very similar, with reductions in time to pregnancy becoming evident in mid to late 30s, more prominent in 40s, very prominent after age 50.”
In general when it comes to fertility, men have an advantage.
Writes Dr. Michael Witt, Urologist/Male Fertility Specialist at Reproductive Biology Associates: “As opposed to women, men continue to make sperm as long as their health allows. As a result, the fertile window never closes physiologically like in women. In men, it does become more difficult the older they get, and like in women, the quality of the pregnancy can also decline, due to genetic and epigenetic factors that increase in incidence as the man ages.”
“PATERNAL AGE IS AN EVOLVING AREA OF RESEARCH”
The above quote is Dr. Samplaski’s.
She adds: “Men are fathering children later in life and we are seeing some changes in their reproductive capacity on a variety of levels. A recent meta-analysis of 93,839 men found that male age is associated with a decrease in semen volume, total sperm count, sperm motility, percent normal sperm and sperm DNA health. In addition, these declining semen parameters do seem to correlate with pregnancy rates; A 5-fold increase in time to pregnancy has been seen in men over 45 years of age.”
In addition to higher incidence of Down syndrome, Samplaski says: “Men with advanced paternal age have a higher risk of having children with “schizophrenia, autism, bipolar disorder and achondroplasia (which commonly causes dwarfism). There are also some data showing an increased risk of cancer among offspring conceived by older fathers, although data are conflicting. It is important to note that while these risks are increased in men of advanced age, the ‘absolute risk’ remains low.”
IN CONCLUSION — FERTILITY IS A UNISEX WORD!
There is more to say about infertility, but I have far exceeded my word limit here! What I can say is that when we hear about a celebrity becoming a father at 67, we need to forget what we think we know, and realize there’s a lot we don’t know(whether genetic testing was involved, whether frozen sperm was used, what surgeries took place, what treatments were administered and the steps that may or may not have been taken…).
“Fertility” may have a feminine ring to it, but doctors agree — and 40–40–20 indicates to us — men need to start considering this topic more seriously. The persistently “empty chair” bears witness to the following:
Despite the research, we still have a way to go.