Knocked Up Podcast - 'Sperm counts are falling faster than ever'?
Is what we read in the The Age true?
'Sperm counts are falling faster than ever'?
Is what we read in the SMH/The Age true? Read the article here.
If sperm count is falling, why is this? Are there workarounds? Can sperm be improved?
Other helpful resources:
What Can Be Done to Prevent Male Infertility?
Here are some past concerns that may cause male infertility now
Genetics of Male Infertility with Dr Sarah Catford
Let’s bust some myths about male fertility
How can IVF help male factor infertility
We've made sperm friendly lube! Find it here
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
Find us on Instagram - @knockeduppodcast
Have a question about women's health? Is there a specific topic you'd like us to cover? Email podcast@womenshealthmelbourne.com.au. We keep all requests anonymous.
TRANSCRIPT
Women's Health Melbourne is an innovative, holistic fertility and women's health practice. We are world leaders in IVF and egg freezing and provide our patients with every opportunity to achieve their goals. Our handpicked expert team provides the ultimate care experience for our patients. Reach us at women'shealthmelbourne.com.au and follow us at women's health melbourne and at Dr Raelia Lew. Hello, and welcome to Knocked Up, the podcast about fertility and women's health.
Jordi Morrison: You are joined as always by me, Jordi Morrison, and doctor Raelia Lew, CREI fertility specialist. Raelia, I've read in an article that was in the agent Sydney Morning Herald last week that sperm counts have fallen 52% in the past five decades, and the decline appears to be speeding up. Is this true?
Dr Raelia Lew: It's really a 100% hard to tell how much of this phenomenon is reporting bias, but, definitely, what we've seen is that sperm counts measured today show a lower count than the average sperm count measured years ago. We can ask ourselves the question, are we doing many more sperm counts? And probably the answer is yes. And we have a situation in our society, particularly in a first world context, where infertility is much more common than it used to be because we're all having babies a little bit later in life. We also know that malefactor infertility does increase with advancing age, and we have easier access than we used to to investigations to look into it. The question really is, is our population sperm count falling? And probably it is because environmental factors do come into it. But also, is the population of men having sperm test today extensively the same as the population that was having sperm test ten, twenty, thirty, forty, fifty years ago? Probably the answer to that question is no.
Jordi Morrison: So why are we doing more sperm counts?
Dr Raelia Lew: We're doing more sperm tests because we can and because infertility is more common, and we're less accepting of it. It used to be that back in the day, if someone was infertile, then potentially many people accepted their lot in life, and there wasn't until the late seventies a lot in the way of interventions for malefactor infertility. In 1978, '79, IVF was invented, and that changed everything for malefactor infertility. It used to be that men who couldn't have a baby with their own sperm naturally or with gentle assistance either needed a sperm donor to have a child or they just didn't have one. Today, in our world of IVF, we can help people have babies even with the absolute lowest amount of sperm possible, even if they have no sperm in the ejaculate at all, which is called azoospermia, some men can have sperm found for them through surgical techniques like open testicular biopsy and microtesse.
Jordi Morrison: Is there anything that can be done for someone before getting to microtesses?
Dr Raelia Lew: There's a lot that can be done because most people don't have a zero sperm count. Most people may have, with malefactor infertility, an impaired sperm production or a sperm quality problem. So it may not just be about the count. It might also be about what the sperm looks like, how the sperm is swimming, what proportion of sperm look like they are normal or have normal morphology. That is what I call the functional count, the number of sperm in the sample that look good and can swim, because those are the sperm that will have a chance of making a baby in the body and also in fertility medicine.
Jordi Morrison: This might be a bit TMI, Aurelia, but how do we get a sperm sample? What's the process?
Dr Raelia Lew: So that's a really good thing to talk about because I think a lot of men and people who make sperm don't actually have much experience in this department. When we have a sperm sample, the most common method of obtaining a sample for analysis is through masturbation and ejaculation, but we need to prepare for that. It takes a while to make sperm, about seventy days, and we like to see a fresh sample that has been not sitting around getting stale. We wanna see your sperm at its best. So what we ask you to do is ejaculate through any means you would like and then wait at least forty eight hours before providing another sample for analysis. You can do this at home. If you have a lab that accepts a drop off sample, what you will require is a little jar, a specimen collection jar. Some people call it a urine jar with a yellow lid. You can obtain this from most pharmacies or most pathology companies and then have a specimen drop off at the lab that's going to analyse your sperm as long as you can get the sperm to the lab for analysis within an hour of collection. Sometimes that logistically is challenging, and some people prefer to collect a sperm sample on-site where there is facility to do so, where they're having their sperm analysed, and that's also fine. Most IVF labs have a little room where you can provide a sample for analysis, and, certainly, that's where you provide a sample for treatment when you're doing fertility treatments. There are some circumstances where sperm samples will be provided in a different way. For example, some men do not have the facility to ejaculate or might have retrograde ejaculation and sometimes will sample sperm from a urine sample after a retrograde ejaculation. And, occasionally, there are cultural stipulations, and sperm can be collected from a specialised condom via intercourse as long, again, as it is a nonspermicidal condom and that it can be dropped off also in a urine jar to the lab for analysis within an acceptable period of time of less than an hour from collection.
Jordi Morrison: For someone with low but good sperm what am I saying? Low sperm count but good quality sperm what are the options when it comes to fertility?
Dr Raelia Lew: When we look at a semen analysis on paper, the parameters refer to the World Health Organisation guidelines, and how those were made was by getting about 5,000 men who had had natural pregnancies with their partners and looking at their sperm and graphing it and looking at the average parameters. And we know that in fertile populations, the lower limit of normal is considered 15,000,000 per mil. That is a statistical decision to draw the line there because that represents the fifth centile of the fertile population's sperm count. But with fertility, nothing is binary. What that means is that you don't have to be fertile and infertile. There's a whole spectrum of subfertile. Also, sperm production is not static. I often talk to my patients about humans being mammals, not machines. The way we make sperm is different on different days. Our environment and also our biology contribute to that. And if you study the way men make sperm, and this has actually been done serially by doing semen analysis over and over and over again, the graph does not look like a steady line. It looks like a very spiky line with lots of variation in all of the parameters that we look at on a semen analysis. So I say to patients when I look at a semen analysis, particularly if there's a problem on the result, that I don't know if it's a personal best or a bad day. And for context, to really understand their chance of making a baby with their partner naturally, I need to know more about them, and that's why it's really good practice to do some further investigations into male factor infertility. The kind of things we do are repeat semen analysis on different occasions so we can see a pattern, not just a static measure. We can also look at things like DNA fragmentation in the sperm to look at the level of oxidative stress the testes is under while making sperm. We can look at a man's hormonal profile. We can look at his metabolic markers, which are things like measuring his blood sugar and his cholesterol and looking at the sperm as kind of the canary in the mineshaft because his general health will reflect how good he is at making sperm.
Dr Raelia Lew: This is really an opportunity for many men because by changing diet and lifestyle, adopting antioxidant therapy and antioxidants in food, which are molecules that help our bodies make healthy cells, having a healthy diet, having a healthy body weight, having a healthy exercise routine, making sure we have enough fluid in our body, making sure we have enough rest, all of these things can help us make better sperm. There are also some physical parameters that can affect how a man makes sperm or a person with testes make sperm, and these are things like the environment of the testes itself. So lumps and bumps, varicose veins, otherwise known as varicoceles, our temperature regulation, which can be affected by our body mass, because when we are carrying a lot of extra weight, particularly around the abdominal area, which can cause some overheating in the testes, that can cause sperm parameters to fall. And, also, when we carry a lot of extra weight as a male, our adipose tissue, which is where we store our energy, actually is a hormonally active tissue, and it can make different hormones and different levels of androgens and and oestrogens that can affect how much sperm we make and how well we make sperm. So that can also suppress the sperm function and the sperm production, particularly the hormone oestrone. So there's lots and lots of options and opportunities to change the way we make sperm. We can cut out toxins. We can reduce smoking. We can eliminate alcohol if we're having too much. So many opportunities for change.
Jordi Morrison: Why would endocrine disruptors, what are they and why are they important when it comes to fertility?
Dr Raelia Lew: It's one of those things that actually endocrine disruptors have every, and probably to some degree, more potential to affect male infertility than female, even though they do, we think, affect both adversely because men are making sperm every day of their lives from puberty until they die, whereas women make all our eggs originally. We're the original gangsters. We make all our eggs when we're a foetus. But men make their sperm as they get older and age affects the way that men make sperm. But so does the environment, and endocrine disrupting chemicals are chemicals in our environment, often from plastics, that can act on our hormone receptors and cause unwanted post receptor effects. So famous examples of things like phthalate and BPA, but there are many, many different examples of potential molecules, all of them with long and complicated names that are found in things like plastics, household chemicals, the linings of tin cans, pretty much everywhere in our environment, in all of the lotions and potions we put on our bodies. There are lots of different potential molecules that can potentially upset our endocrine system. One of the things that we looked at when we made lovers products was to make sure that we had no nasties in our loo, and that's really important for fertility.
Jordi Morrison: You mentioned early on my Crotisi. That's probably the far end of the spectrum. What other interventions medically can be done before then?
Dr Raelia Lew: So the simplest intervention for male factor infertility is concentrating the sperm and delivering it closer to the egg, and that's the kind of technology we use for a technique called RUI or intrauterine insemination. That, for very mild sperm problems, can get the sperm over the line, certainly boosting its concentration and helping fertilisation potentially occur. Then we have ICSI, which is intracytoplasmic sperm injection, and that is something we can do in an IVF context where the sperm looks problematic. We can choose the best sperm available and inject it directly into an egg, and that was a game changer in the nineteen nineties for IVF, for malefactor infertility. Before that time, we used to have a lot more failed fertilisation situations in the lab where we were just dolloping sperm next to the egg. In itself, that is a massive intervention, giving the sperm direct access to the egg, but ICSI is when we pick a sperm and inject it right into the egg to really deliver that DNA package to the egg and make its life as easy as possible.
Jordi Morrison: We're quite good at taking a medicine when we want something fixed. Is there such a thing when it comes to sperm?
Dr Raelia Lew: Aside from antioxidant therapies and and really replacing the building blocks that men require to make healthy sperm, there are some hormonal treatments that can be helpful in some circumstances, but not all, to help men make sperm. There are different problems in making sperm. Sometimes it's a production problem, so there's a problem in the factory, the testes, where the sperm is made. But sometimes it's a hormonal messaging problem, and the testis in that situation may be normal, but the sperm count may be lower absent because of the messaging that should be coming from the brain to the testis being turned off. And we can use medicines in certain circumstances to correct those kind of problems. An example is if someone has used, for example, anabolic steroids for bodybuilding and they've turned off their sperm production, we can turn it back on again slowly. It takes a long time using hormonal measures. Another issue can be if someone has a pituitary lesional tumour that makes the hormone prolactin, and that can turn off sperm production. And, again, we can turn it back on by treating that overproduction of prolactin and potentially using some hormonal stimulation to get the testes working again. So those kind of therapies are very niche for specific situations. For most of the time, hormonal therapy does not improve the sperm count if there's not a hormonal problem underlying the issue.
Jordi Morrison: Rayleigh, you've got a special qualification called a CREI, which means you're a reproductive endocrinologist. Why is this something a couple experiencing infertility, especially with sperm, should be looking for?
Dr Raelia Lew: A lot of people working in the field of infertility, really good doctors, really wonderful people trying to help couples overcome infertility, Originally trained as gynaecologist, but didn't do much in the way of male factor infertility training. As a CREI subspecialist, I'm also a trained andrologist, meaning that I'm fully qualified to look after both male and female infertility. And, of course, couples come often with both. Often, about a third of the patients I see who have delayed a pregnancy have multiple problems that work together to make life difficult for them rather than one individual problem that's female or male in origin. It's really great to be able to optimise all aspects of fertility care as a CREI subspecialist because that is the way that we get the best outcomes for our patients.
Jordi Morrison: So does this mean the male needs to come to all of the appointments?
Dr Raelia Lew: Without naming and shaming, it's astounding how many patients are fully investigated as a female before the male is considered. The take home message is that male factor infertility is real. It's common. It's prevalent, and it occurs in fifty percent of cases where infertility is a presenting problem. In about a third of those cases, the malefactor is really the main issue. In about a third of cases, a male factor is a contributing issue. So we don't really get to the bottom of infertility without looking into the male very closely. We think a lot of problems with male factor infertility are in fact genetic, but some are environmental. Genetic problems can be passed on to a child when we use techniques like IVF to create children for people with malefactor infertility, and we have seen studies that show men who can save using ICSI are more likely to have male offspring who also require ICSI. We're not too worried about that finding. We think it makes sense. And as an IVF doctor, I also know that if today's technology can overcome a problem, tomorrow's technology will only be better, and all the babies that are conceived with ICSI are much loved and very wanted children. We know that there is a slightly increased risk of congenital abnormalities in IVF babies, but it's not very much and that most IVF babies are completely healthy and normal.
Jordi Morrison: How do men take it when you deliver the news that they have an abnormal sperm count?
Dr Raelia Lew: When a man finds that he has an abnormal sperm count, he often finds that news quite devastating. It can be very hard to hear. It's one of those things that sometimes men don't even have on their radar that it might be an issue. They assume normality. And I think humans in general are pretty optimistic, but I think females also, as a gross generalisation, assume infertility blame culture that it's our fertility is a female thing. It's gotta be a woman's issue. Sometimes when a woman finds out the partner is affected, there can be some emotional issues there because sometimes there's been a delay to attending a semen analysis, and that can bring with it some frustration. My take home message is that it's not a blame game. When a couple are trying to have a baby, it's a team effort, and nobody chooses to have a problem. It's nobody's fault. What we need to do is to identify the factors accurately so that I can help think of the best possible solution that's gonna be targeted to an individual and a couple's concerns and be solution focused because that's the way to get the outcome everybody wants, which is a healthy baby.
Jordi Morrison: Thank you, Raelia. We've got a few blogs on this topic and some other podcast episodes that go into more detail about things we've touched on today, so we'll link to all of those in the show notes. If you've got any questions, our next episode out in two weeks' time will be answering your questions. So send them through to us at doctor Raelia Lew at knocked up podcast or podcast at women's health Melbourne.
To support Knocked Up, leave us a review or recommend to a friend. Join us on Instagram at @knockeduppodcast and join Raelia at @doctorraelialew, and email us your questions to podcast@womenshealthmelbourne.com.au.