Understanding Male Infertility

Understanding Male Infertility

Culturally, the burden of fertility—and infertility—falls on women. And so there are structures of support in place for women struggling to conceive. But while men struggle with infertility, too, it’s rare that they receive the same level of medical attention or the same emotional space to process.

This is something that reproductive urologist Paul Turek, MD, a leading male fertility and sexual health specialist, has found throughout his career: He’s often the first person his patients open up to about their infertility.

“Young men are wild animals when it comes to medicine,” Turek says. “We hardly ever see them.” So, he says, the first step is getting them in the room. The second is giving them space to process, feel, and speak. We asked Turek the requisite questions about fertility—how to preserve it if you have it, what to do about it if you don’t—as well as how he’s advancing a revolutionary vision for men’s health.

A Q&A with Paul Turek, MD

What are the most common causes of male infertility?

The most common cause is varicocele, an enlargement of the veins in the scrotum that can cause issues with fertility by keeping the temperature of the testicles too high. That covers roughly 40 percent of male infertility cases walking in the door. The good news is that most infertility from varicocele is resolvable by surgery.

Lifestyle factors, including stress, diet, exercise, and sleep—and we’ll go over these in more depth—I’d put at 25 percent of male fertility issues.

Hormonal issues come in at around 10 percent of cases, genetics at 5 to 10 percent, and the effects of infectious disease probably at 1 to 5 percent.

A good amount of the time, couples just aren’t having sex at the right time to conceive. If it’s your first time trying, it’s not always intuitive—especially for the male partner—where the female partner is in her cycle and at what point it’s possible to get pregnant. Sometimes all it takes is education on that.

How much of male infertility is preventable? How do you preserve fertility?

Right now, most physicians dealing with male infertility aren’t thinking in terms of prevention. But if we look at a really simple study that I did looking at lifestyle modifications for couples with fertility issues, we can get an idea of what’s involved.

There were a number of couples that came in to see me within a year and a half of experiencing infertility, and in each case, I cleared the male. He looked okay, in terms of his medical history and physical. Female partner’s fertility looked all right—everything checked out. So I told each of these couples, “You’re cleared. Here’s what I would do: Take a good antioxidant supplement. Lower your stress. Sleep better. Eat better.” This is all general health advice, so it’s not an answer a lot of patients like to hear. Then they would go home and say, “Turek couldn’t figure out what was wrong with us.”

“When it comes to preserving fertility, think in terms of preserving your health. Surround your system with good stuff.”

This was frustrating for everyone involved. So I decided to follow up: I had a student from USC call up all these couples a year after I’d seen them, even though I hadn’t operated or given them a prescription or anything. Sixty-five percent had conceived naturally in the year after I talked to them, and 20 percent more had had successful pregnancies with assisted reproduction technologies, like intrauterine insemination (IUI) or in vitro fertilization (IVF). This isn’t a see-I-told-you-so situation. It’s a lifestyle-modification study—not a controlled one, but by observation. If you can think of these resolvable fertility issues as preventable ones, I’d give it a rough guess that a quarter of male infertility is preventable.

That said, male infertility due to genetic causes is not fixable by lifestyle modification or surgical intervention. Genetics currently accounts for roughly 7 to 10 percent of men with low sperm counts and 15 percent of men with zero sperm count.

When it comes to preserving fertility, think in terms of preserving your health. Surround your system with good stuff.

What can you do about low or zero sperm count?

If you have a low sperm count, the options include IUI or IVF. If you have no sperm count, it’s a whole other conversation. I was part of a team that invented a procedure called sperm mapping—and of the men who come into my clinic with no sperm count, I can find sperm in the testicles of at least half of them. That sperm might be used IUI or IVF technology.

What are the most common myths about male fertility?

The first common misconception is that fertility is a women’s issue. That still seems to be the dominant myth in America, where most of the care for fertility issues is driven by and delivered to women.

Another myth we busted is that fertility is independent of overall health, that it’s just a problem handed to you. For a long time, we thought that if men’s health were a planet, reproductive health would be a moon that orbits it, maybe gravitationally associated with the planet but ultimately unaffected by its goings-on. But that’s not it. Now we know that men’s fertility is a biomarker—a key indicator—of overall health. If you want the best reproductive health, you need the best overall health.

“The real challenge is creating a network of support for men facing infertility.”

The third myth is that men don’t feel as bad about being infertile as women do, which is entirely wrong. Men just don’t often express how emotionally painful it is for them. We and others have published papers showing that infertility has just as strong an impact has on men’s quality of life as it does on women’s. I did an ad hoc study with my patients where I gave men who were infertile a survey asking, “How many years of your life would you give up to be fertile and have a kid?” And the average answer was about four and a half years. Similar questions are often asked of cancer patients—how many years of their life would they give up to not have cancer?—and their average answer is five.

Do you end up acting as a stand-in therapist for men dealing with infertility?

All the time. A lot of patients would rather talk to me than to a therapist. It’s amazing what men will tell you when you can get them to open up. But that’s the connection that’s actually the easiest to make. The real challenge is creating a network of support for men facing infertility. I’ve tried to run support groups, but guys don’t show up. What I’ve found works better is something anonymous. For a while, I had an online support group for my patients that was run by a therapist, and nobody had to reveal their names. It went on for a couple years. From what I’ve seen, the greatest amount of discussion is in open online forums.

I run a blog on male infertility, and each post has an area for comments. While most posts are on medical considerations, a lot of them deal with the emotional end of experiencing infertility. Those posts are often where the comments sections really take off. Some have hundreds of comments. These commenters aren’t always telling their whole stories the same way we’d encourage them to in a support group, but it’s something. And when I get those guys in front of me, I hear it all.

Why else is it important for men to see a doctor about fertility issues?

My field is based on fertility and reproductive issues, but it’s not that alone. Men need some parallel to a gynecologist. They don’t have one. They have a pediatrician, age out, and then medicine becomes very siloed for them. And when that happens, we miss a lot of critical information about men’s health that could be important indicators of their overall health later in life. My goal—since I was a professor at the University of California, San Francisco, and got a grant from the National Institutes of Health for this purpose—has been to develop men’s health programs that take care of men from the time they’re young all the way through their lives.

A lot of men come see me for the first time because they’re looking to solve erectile dysfunction. And I’m glad they do: Erectile dysfunction is often the canary in the coal mine for overall health. When men have significant erection problems in their forties, their risk of cardiovascular disease and cardiovascular events is an estimated two to three times higher. It’s as robust a risk as a family history of heart disease or a history of smoking.

“Men need some parallel to a gynecologist. They don’t have one.”

It’s similar with infertility. We’ve found that severely infertile men have much higher rates of certain cancers later in life. One of my buddies, Michael Eisenberg, is looking at the longevity of men who had infertility problems when they were young. His research reveals that infertility is associated with a shorter life span. A group in Milan has been measuring the disease burden of men who are infertile compared to that of fertile men. They’re finding that infertile men are more likely to have other adverse health conditions.

From that research, we’ve developed this concept that infertility might be the first problem of several. What we’re investigating now is whether infertility might be a biomarker of something gone wrong with a body’s ability to repair DNA from damage, which has the potential to explain those risks down the line. We’re still trying to come up with easier, quantitative ways to measure this risk—is it a semen analysis? testosterone level? body mass index?—but that could get us down to the why of the whole thing, both for infertility and for long-term health outcomes.

Paul Turek, MD, is a reproductive urologist and founder of the Turek Clinic, a male fertility and sexual health practices in San Francisco and Beverly Hills. Turek holds a BS in biology from Yale College, an MD from Stanford University, and board certification from the American Board of Urology. He is a past president of the American Society of Andrology, the inventor of FNA mapping (sperm mapping), and a leading surgeon in vasectomy reversal. Turek is also a recipient of a National Institutes of Health grant for male infertility research and a former professor in the Department of Urology, Obstetrics, Gynecology, and Reproductive Services at the University of California, San Francisco.

This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.