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Melanie Cole (Host): Infertility is a widespread problem. According to the American Society for Reproductive Medicine, about half of all cases of infertility involve an element of male infertility. My guest today is Dr. Robert Oates. He’s the vice chairman in the Department of Urology at Boston Medical Center. Welcome to the show, Dr. Oates. So, let's talk about male infertility, and how do you find out that it's the male, and when the couple comes to you – they’re having trouble —is it typically difficult to get the male to discuss whether or not it might be him?

Dr. Robert D. Oates, MD (Guest): Well, Melanie, it's a great question, and I think it's important to recognize that those of us in reproductive medicine don’t see it as either a male or a female issue. We view the two of them as a couple, and so for all couples, we want to look at all different aspects of his evaluation, her evaluation. Try to put that all together. Try to find as many issues or problems that we can and then try to deal with them on an individual basis, meaning that if I find something on him – that might improve their fertility potential. Let's improve that. If we find something on her part – let's improve that. And occasionally, we can’t improve them to the point where they get pregnant naturally so then we have to go ahead with all of our other advanced technologies such as in vitro fertilization. So, it's really not an either or – it's a both. So, we always want to look at both partners.

Melanie: So, do we know some of the causes of male infertility?

Dr. Oates: Well, it would be not male infertility to use that term. It would be sperm-production problems or sperm quality problems…

Melanie: …or blockage of sperm…

Dr. Oates: …exactly…

Melanie: …so you’re saying, yes, okay. So, do we know some of the causes of that?

Dr. Oates: Absolutely. There’s for instance, blockages, there's a lot of different types of blockages. Some have a genetic basis which we actually defined here many, many years ago at Boston Medical Center. Some have an anatomic basis from a prior infection or a prior inflammation or prior trauma. There’s other cases – not blockages – where the testes don’t make sperm, and there's just a problem in the production process, and there's a lot of genetics known about those – many of which we and others have figured out here at Boston Medical Center. So, the evaluation, then, starts with a history. So, you meet the couple. You go through her history and what data might be accumulated already from a reproductive endocrinologist, who’s a female fertility specialist. You go through his history – medical history, what medications, what other medical problems does he have, what toxin exposure might he have. Then you perform a physical exam, which is oftentimes absolutely critical. You cannot get by with just looking at a sperm count, for example, and then with the history and the physical, you’ll also pull into the equation his sperm count, maybe some other lab data that you have and then you start to figure out what might be the problems on his side that are contributory, and you’re also figuring out what might we do to correct them.

Melanie: With some women, Dr. Oates, there could be unexplained infertility. Does that happen with men or is there almost always – you can kind of figure this out?

Dr. Oates: No. It’s a great question. Again, because sometimes – but remember unexplained infertility is a term that we apply to the couple. So, it's really when, as a couple, his sperm look okay, and her ovulatory status looks okay, and her tubes look okay, and her uterus looks okay, and everything looks okay, but they're not getting pregnant. That’s when we define them as having unexplained infertility. But for most couples, we can figure out probably the reason – his count’s a little low; she doesn’t ovulate all that well. His sperm activity’s a little bit on the low side. Those kind of things most of the time – we’re probably correct. Now, a lot of the time, there's something very, very obvious. She does not ovulate; her Fallopian tubes are blocked; he does not have any sperm in the ejaculate. These would be absolutes that we're pretty confident his lack of sperm in the ejaculate is the reason or at least one of the most important reasons for the couple not getting pregnant. So, we look for both simple little things, and we look for these much more severe things.

Melanie: So before we speak about some treatments or corrections – things that you can do to help the couple – do you know is their age; lifestyle factors, alcohol, drug use, smoking; any of these kinds of things that would affect these ejaculate issues?

Dr. Oates: There's a lot of lifestyle factors, and it's something that I pay particular attention to because alcohol and smoking are not only just unhealthy habits – and we always want our patients to be healthy – but they also do, in a small way, impact on male fertility potential. One of the most common things that we're seeing nowadays, and we can call it a lifestyle habit or lifestyle issue, is the use of testosterone or anabolic steroids because there's a lot of men out there getting prescribed testosterone from urologists – my kind – endocrinologists, primary care physicians. As equally as many men out there getting a little bit of anabolic from Joe at the gym and Sam down at the health club try to build more muscle, try to look a little bit more fit and whenever you're taking testosterone from the outside world, your testicles shut off their production of testosterone themselves. They don’t need to. There’s plenty in the body circulating and then the testicles shut down their production of sperm. So, just the use of steroids – anabolic steroids – is one of the more common things we’re seeing in this day and age, and we have to attend to that because it's the only way to get the patient’s sperm production back on line. So, lifestyle factors an important part of that original history.

Melanie: So, then what treatment options are available and certainly what you are doing at Boston Medical Center? Speak about how you can help the couple and sort of the process that they go through.

Dr. Oates: Yeah, it's – the treatment options are always going to depend obviously on what the etiology or the cause was for the problem. So, we’ll just start with some of the more fancy ones. If the patient has very poor sperm production – to the degree that he's not even making enough sperm to been seen in the ejaculate – he still may have sperm here or there or over there in the testicle, and so we operate on the testicle itself, search around with an operating microscope and try to find little pockets of sperm production. The key to a surgery like that is that one, you have to have expertise in using the operating microscope, which obviously I've done that for years and years and years. Plus, you combine those types of therapies with the in vitro fertilization group because if you harvest sperm from the testicle, the only way you can use it is in conjunction with our very, very fancy in vitro technologies. So, the coordination between myself and the in vitro fertilization group is critical to the success for the couple. Fortunately, in Boston, we have several in vitro fertilization groups which are absolutely fantastic. So, I work with all of them and so the couples get great care, hopefully, from my standpoint, my side of the equation, but I definitely know they get great care from the IVF group. There’s other cases where sperm are being made, but we simply can harvest them. That’s the only thing we can do. We can’t reconstruct the blocked system. So, we harvest sperm again; we use that in conjunction with IVF. There's a lot of men who have had vasectomies in the past. Sometimes in the same relationship, and they just changed their mind – the couple does. But most often, his life changed – suffered a divorce, now is with a new partner – and so vasectomy reversal, we go ahead with, and a vasectomy reversal, when done by someone like myself who does these a lot, and it's a part of the practice – your practice -- is very, very successful in returning sperm to the ejaculate and helping those couples get pregnant naturally.
So, those are surgical options. And the final one I would mention is correction of a varicocele – varicocele is enlarged veins that drain the blood away from the testis on the left side, and sometimes when a person has a large varicocele, it can be impacting on sperm production and sperm quality, so we fix the varicocele microsurgically, but sometimes, the options that we use for the male specifically don’t involve a treatment for him as an individual person, but treatment for them as a couple. So, a very, very low sperm count that we can’t alter – it’s just that’s the way he is. Oftentimes, the correction of that or the way that we treat the couple is with in vitro fertilization. So, the in vitro happens to the woman. She’s the one who gets the shots, gets the eggs harvested, all of that, but the treatment’s being done for a very low sperm count which otherwise, is not correctable. So, we have great mechanisms to compensate for male reproductive deficiency that we can’t otherwise fix or correct, but we can compensate for really, really well with our in vitro technologies.

Melanie: Well, you’ve described it so well, Dr. Oates, and how some of the corrections that you're doing for the male really involve the female, so it is the couple as a situation of fertility, and that’s really what you're dealing with. So, wrap it us for us with your best advice about infertility in general and what you'd like people to know about what you're doing there at Boston Medical Center.

Dr. Oates: So, infertility in general always involves a workup for the male, a workup for the female, and really my thought has always been that those should be simultaneously performed instead of the old approach which is – well, we’ll do some testing on her; we’ll see what that shows, and then we’ll do some testing on him, and we’ll see what that shows, and maybe we’ll come back to her. That just delays things, and it takes much, much longer than it has to. The couple who is older in terms of the female age – 38, 39, 40, or above really should try to conceive on their own for only about six months before coming in to see us because their age is becoming a worry. The other couples that we like to see early are the ones who have a suspicion, well, I had chemotherapy when I was a teenager. They told me I’d probably have a problem conceiving. We don’t want those couples to try for six months or to 12 months. We want them to come right in because most likely their suspicions about a fertility decrease or decline or problem will be correct, and we can figure that out right off the bat.
The other part of it is to always see an expert. In this area, we have so many reproductive endocrinologists, who are female fertility experts, that we always want our women to go to see them and for me, this is what I do, and so I love seeing the male because this is what my expertise is. One of the additional things I do want to mention is about getting back to the genetics is that we have so much genetic knowledge now, and that’s accumulating and increasing every single day – the genetic basis of male infertility. So, it's important to be with someone who understands that who has that as a part of the practice because it's a necessary component of the proper evaluation and treatment and really strategies that we set up for the male which then transmits to setting up for the couple themselves. So, expertise and finding that expertise, I would say is the most important thing for the couple and as always with any medical problem, trying to have him stay as healthy as he possibly can is always good.

Melanie: Thank you so much, Dr. Oates. What a great segment and such great information. This is Boston Med Talks with Boston Medical Center. For more information, you can go to bmc.org. That's bmc.org. This is Melanie Cole. Thanks so much for listening.