Male Infertility
Male Fertility: Are we overlooking 50% of the equation?
Written by Dr. Fiona Callender, ND
We use the term infertility to describe when a couple has been unable to fall pregnant after one year of trying. There are times when we investigate sooner, but often medical referrals to a fertility clinic happen around one year. As anyone who has gone through this process - or who has witnessed friends or family in this situation - knows, the burden of testing primarily falls on the female partner who will be carrying the baby. They are often the first ones in my office too - ready to do anything it takes to build their family. We make lifestyle changes, run tests, take supplements etc., while the male investigation (if one is done) often starts and ends with a semen analysis. Knowing that male factors contribute substantially to about 50% of all cases of infertility, we are often missing a big piece of the puzzle by not adequately supporting and prioritizing a male partner’s health.
Understanding the current state of male fertility
Sperm counts are actually declining globally at a fairly rapid rate. From the 1970s until now, we’ve seen about a 40% decrease - with accelerated declines in more recent years. Though we don’t fully understand why this is, some theories include more long-term exposure to environmental toxins and, paradoxically, increased access to medical care globally. Having better care and technologies has allowed men with poorer health (and perhaps advanced age) to access technologies. We may also see male aging playing a role - yes, male fertility is impacted by age too! As modern couples tend to delay family planning until later than their 1970s counterparts, male age may be playing a role in the sperm parameters we are seeing in the data. Ultimately, we don’t necessarily know exactly why semen counts are down, but it does highlight the need to assess and support men in the fertility process - perhaps more intentionally than many presumed!
What causes male infertility?
There are a number of possible reasons for male infertility - including both conditions that are reversible and those that are irreversible. These conditions can co-exist with factors that influence both partners, including age, medications, surgical history, environmental exposures, genetics, and other diseases. We want to be able to identify which factors are reversible and determine whether he may be a candidate for assisted reproductive techniques (ART) - such as IVF or IUI.
Underlying causes of infertility can be sorted into a few categories:
Hormonal conditions (eg. could be due to the testes ability to produce testosterone)
Sperm transport issues (eg. could be vasectomy or obstruction due to genetics or disease)
Testicular conditions (often leading to abnormal sperm parameters without identifiable cause)
Unexplained (where there are normal sperm parameters but we still don’t know why he’s experiencing infertility)
Studies report untreatable conditions to make up about 70% of male factor infertility cases - this is largely related to those abnormal sperm parameters with unidentifiable cause. With ART, we are able to get around a large portion of these cases. This is an amazing part of medicine that can overcome a large portion of male-factor fertility issues. That said, there are a number of lifestyle factors that can impact sperm parameters to sometimes improve these untreatable conditions.
How do we assess male fertility?
We always start by getting some a pretty comprehensive health history. This would include reproductive history, family history, history of injury to the pelvis or testes, concussion history (yes, this can impact!), a review of other conditions and medications (including cancer and treatment for cancer). We would also ask some more lifestyle questions like what does he do for work, how much does he drink or smoke, is he a cannabis user or ever used steroids. Asking about libido and sexual function/performance, as well as lubricant use is also important. Having a physical exam with his doctor is also helpful to assess for any concerns of the testes.
A semen analysis as well as some blood work is another great step. We have semen analysis reference ranges that are based on the bare minimum for fertility. We look at these numbers knowing that in this range, they can often be overcome with technology. As I said, ART often works really well for male factor infertility. That said, there are supports we can put in place to improve these numbers and improve chances of pregnancy - whether that’s IVF or without technology. A lot of this comes down to lifestyle and addressing any medical conditions that may be impacting his health.
So what can we do to support male fertility?
Fertility struggles can sometimes hold a mirror to the overall health status of a male patient. Supporting fertility potential is supporting overall health. We know that men with infertility tend to have worse overall health status - including higher risk of depression and diabetes. We look at nutrition/diet, exercise habits, medication use, cannabis and/or alcohol use, and stress as major contributors.
Nutrition
Eating in a generally healthful way, while increasing fish and nuts seems to be a fertility-friendly way of eating for men. If we can reduce red meat and trans fats, while increasing olive oil, fish, vegetables and nuts, we are going in the right direction! There’s no need to cut out all the foods you love - and you can keep your morning coffee! - as even a shift towards a more healthful diet has been shown to help. There’s evidence that even adding ½ cup of nuts per day to a regular diet improved sperm count, motility and overall health of sperm.
Exercise
Exercise can benefit a number of health outcomes - fertility is no different. Getting active about six months before trying for a baby (and being consistent with it!) seems to improve sperm quality. This has been shown over and over again in the research. What kind of exercise should you do? Probably a combined approach that includes moderate intensity continuous aerobic exercise and resistance training is best. If you aren’t doing anything right now, experimenting with what you enjoy or what will fit your lifestyle and routine would be a good start. Remember, consistency is more important than intensity! If you can aim for 150 minutes per week, that’s a pretty good start.
Medications
Discussing the medications you are on with your practitioner can be helpful as there are some pretty common ones that may be impacting sexual function and/or sperm production. SSRIs are one of the more commonly prescribed medications and some impact sexual function and sperm health more than others. This is something that many men feel uncomfortable bringing up with their health care provider, but knowing there are options can be helpful. We want to be able to continue managing mental health while addressing any fertility barriers - it’s a balancing act. It may make sense to have a conversation with your prescriber about which medications makes the most sense for you and your fertility goals. Other common medications that may impact sperm health/production include some analgesics (eg. tylenol) and some blood pressure medications.
What about Cannabis?
Cannabis competes with receptors in our endocannabinoid system in our brain. This is a system that regulates a whole host of bodily functions including hunger, pain, temperature etc. Cannabinoids in Cannabis mimic our own body’s cannabinoid system and can impact fertility. Cannabis has an impact on some of these receptors on sperm, which results in changes in motility. Even once a week seems to lower sperm concentrations and counts when compared to those who don’t smoke. The effect is even greater in those who use cannabis more than 10 times per week - this impacts both sperm and hormone levels. The effects are reversible within a few months of pausing use. If you are using Cannabis to relax and unwind, we can discuss other options to support you!
Alcohol
Alcohol also seems to have an effect when it’s consumed with regularity or when it’s considered binge drinking. Te definition of “binge drinking” is perhaps lower than you think - 3-4 drinks in one sitting. This amount decreases sperm quality and semen volume. Occasional light drinking doesn’t seem to have a big impact. One circumstance where we would suggest you completely abstain is prior to IVF. This is such a big investment for both partners - emotionally, financially, time commitment - alcohol in the weeks leading up to IVF has been shown to result in lower success rates.
Stress
Stress triggers our hypothalamic-pituitary-adrenal (HPA) axis - our stress response system - leading to downstream effects. We see lower testosterone production through both the impacts on the brain and the HPA axis, as well as the direct effects of stress hormones on the cells of the testes. We see more cell death in the testes with higher stress.
We know that all sorts of stress - including job, social, stressful life events etc - have been correlated with reduced semen parameters. Support and stress management is an important part of fertility care for both parties!
Next steps
There is so much more to supporting a male partner than just looking at a semen analysis. Research has shown that many men want to be more involved, but often feel overlooked in fertility appointments. There’s a lot we can do to support with changes to the lifestyle factors listen above, as well as supporting with supplements that have been shown to improve sperm parameters.
Curious about how naturopathic medicine can be a support on your fertility journey? I would love to meet you!