Male Infertility & Sperm Analysis: A Review for Gay Men Considering Surrogacy
One often overlooked and rarely discussed subject in the fertility world is male factor subfertility (less than normal fertility). As someone who regularly meets with gay men planning on parenting, I often surprise my patients when I tell them that it is possible to have a sperm problem.
Sperm represent small DNA packets, which are at risk for production problems, motility problems, and for breakdown of DNA. These factors often coalesce to affect a man's potential to generate a healthy embryo and to have a successful pregnancy. The reality is that gay dads-to-be have just as much risk of having mild to severe male factor infertility as the heterosexual population.
Fertility Sperm Production 101
Let's take a break to complete a little Fertility Sperm Production 101.
At the time of puberty when testosterone levels rise, sperm production begins. There are two cell lines in the testes, one that makes sperm and the other that makes testosterone. When very high testosterone levels are achieved in the testes, sperm production begins via a process called meiosis. This allows immature sperm stem cells to begin to divide in order to create mature sperm. The maturation time for sperm is about 72-90 days.
Once the process is working, the testes produce millions of sperm on a daily basis. In fact, the average semen analysis has more than 30 million moving sperm in less than a teaspoon of ejaculate. The components of a semen analysis include: volume, concentration of sperm (millions per mL), motility of sperm, and percentage of normal sperm. These four components are all measured and analyzed separately and together to assess a man's potential fertility. It is considered normal if 85-95% of sperm are abnormally shaped. It is considered abnormal to have 96% or greater abnormal sperm. The male reproductive tract is designed to generate billions of sperm with less than 15% of the sperm actually moving and normally shaped. For gay dads-to-be who are conceiving using in vitro fertilization, we actually need as little as 100,000 or fewer normally shaped moving sperm to work with under the microscopic conditions of the laboratory.
Semen Analysis | Male Infertility Test
When I meet with intended fathers who have never had a semen analysis, I advise them to go to their general practitioner or use our office to have a semen analysis performed. This is the first step in assessing whether they can be genetic fathers to a child that will be conceived using in vitro fertilization. The good news is that the vast majority (95%) of these men have an adequate semen analysis for use in the IVF lab. Occasionally we find someone who has a significant problem.
Male factor infertility is broken down into three categories: mild, moderate, and severe. Mild and moderate cases of male factor infertility usually can be treated or improved after evaluation with lifestyle modifications, medication changes, or, sometimes, surgery. Severe male factor infertility (having less than 5 million sperm in the ejaculate) requires evaluation by a reproductive urologist to define the cause of this process. It is important to remember that in the IVF laboratory we need very little sperm, sometimes as few as 20 moving sperm, so even a man with severe male factor infertility can be a genetic father using in vitro fertilization techniques and a process called intracytoplasmic sperm injection (ICSI).
Male Biological Clock
While many have heard about the female biological clock ticking, I want to confirm that there is also a male biological clock. Men's sperm count, and the overall quality of the specimens, begin to decline after age 40, and decline further after age 60. There is data to suggest that there are some small increases in risks for a child to have developmental problems at a higher rate if conceived using sperm from a man older than 60 years. Some researchers have recommended that men protect their fertility by cryopreserving sperm prior to their 40th birthday. This, however, is not commonly done. I regularly work with men between the ages of 40 and 60.
Causes of Male Infertility
There are definitely things men can do to protect their fertility. These include avoiding reproductive toxins, certain medications, and having regular physical exams with a primary doctor. While we all know that tobacco products are bad for our lungs, it is less commonly known that they're also very bad for reproductive health. Cigarette and marijuana cigarette smoking are documented to have negative effects on sperm function, motility and morphology, and reproductive performance. In fact, men who smoke have lower pregnancy rates even with in vitro fertilization and higher miscarriage rates. It is very important to remember that the sperm development cycle is approximately three months, so in a matter of three months quitting smoking can improve a man's potential to be a genetic father. Alcohol (more than seven drinks per week) has also been linked to lower reproductive outcomes. These simple modifications can sometimes overcome mild male factor infertility. Other reproductive toxins include exposure to petroleum products, herbicides, and pesticides.
If a man has mild to moderate male factor fertility we review their lifestyle choices to see if there are opportunities to make changes to improve overall quality of sperm in the ejaculate. Medications that can affect sperm count and function include, but are not limited to: Testosterone, medications to prevent hair loss, blood pressure medications, and medications which treat gout. Testosterone use is one significant problem as of late, secondary to all the marketing associated with using testosterone to treat men who have symptoms of tiredness and decreased sex drive. While it sounds counterintuitive, the use of testosterone will lower sperm count and actually has the potential to completely stop natural sperm production. The good news is that, for the most part, within 6 months of stopping testosterone usage sperm count recovers. A more significant issue is for men who have used injectable anabolic steroids in order to improve their physical performance and appearance. If anabolic steroids were used during the teenage years it is possible to have completely stopped any and all sperm production. I would strongly caution any man who is considering being a genetic father from using any testosterone/anabolic steroids type medications.
An anatomic issue that can affect male factor fertility is a collection of veins that is prolapsed through the inguinal ring (groin) called a varicocele. A varicocele increases the temperature in the testes and epididymis (anatomically the storage tubules for mature sperm) thereby damaging sperm function, number, and normal morphology. Men with mild to moderate male factor infertility may have a varicocele. This is evaluated by a urologist via physical examination of the testes and perhaps a testicular ultrasound. If the sperm count is significantly affected and there is a varicocele present, surgery is often recommended to correct the varicocele in order to maximize the opportunity for pregnancy. For gay dads-to-be, if there is enough normal sperm in the ejaculate and the varicocele is not associated with pain, we often have enough sperm to work in the IVF laboratory; therefore, surgery is often avoided.
Treating Male Factor Infertility | ICSI
The good news is that greater than 99% of men who want to be genetic fathers can do so through modern IVF laboratory technologies. There is a common process of assisted fertilization used in the IVF laboratory known at Intra Cytoplasmic Sperm Injection (ICSI). It has been used since the 1990s and now accounts for more than 60% of IVF cycles. ICSI involves the injection of a single normally shaped motile sperm into a mature egg. With this technique, even men with severe male factor infertility can create embryos for use in a surrogate.
In a nutshell, male factor fertility issues are fairly common. In order to evaluate sperm health, a semen analysis needs to be performed during a period of abstinence that is between 3 to 5 days. For men planning on using an egg donor and a gestational carrier, which is the typical process for most gay men, the vast majority of mild to severe male factor problems can be overcome using a technique call ICSI. In the situation of a good sperm count, a young egg donor and a proven surrogate, gay fathers-to-be have some of the best success rates in the field of reproductive medicine.