Improving the Patient Experience - Male

Male factor evaluation is essential in diagnosing infertility causes, enhancing ART outcomes, and improving patient confidence. Learn why this assessment matters.

So I'm tasked today to talk about the importance of the male factor evaluation. So how many of you have had a couple that you saw that had unexplained infertility and you asked yourself what is the explanation, right? There's got to be an explanation for all this infertility. How many of those couples had a hint at a male factor? And I don't mean an abnormal semen analysis but I'm talking about some mild abnormalities.

So we know that male fertility is on a continuum, on a long spectrum. Way over here is azoospermia and then you have the severe abnormalities and then the mild abnormalities and then you have the fifth percentile of normal fertility by the WHO criteria for any parameter and then you have everything else. So I'm talking about right in this zone where there's mild abnormalities, 17 million per milliliter concentration, 43% motility, maybe a low total motile count for whatever reason but it was a normal semen analysis.

We know this is extremely common. 50% of all couples coming in for infertility have a male factor, a contributing male factor and a third of all couples coming in for male factor, sorry, coming in for infertility have a primary male factor. So a third of a primary male factor and so why is the evaluation important then? So I'm going to go through several reasons.

Number one is we diagnose serious and life-threatening disorders. Number two, we diagnose reversible and treatable causes of male factor infertility. Number three, we actually improve ART outcomes.

Next, we identify untreatable causes of testis failure and provide appropriate consultation and referral. For azoospermic men, we actually enable the IVF process. Those men need a sperm procurement procedure and then lastly, evaluating the male is following the ASRM guidelines.

When I think of the importance of the male factor evaluation, I've got a patient story for you. This is a story I'll never forget. This couple came in, 30-year-old male with his 28-year-old female partner.

They had just failed an IVF cycle. Poor fertilization, no blasts, severe male factor, terrible SA on the day of egg retrieval and we reviewed his semen analyses. His initial one was mildly abnormal.

They were called unexplained. They had a couple of cycles of IUI and then the failed IVF and their semen analysis went down, down, down, down until it was really bad and that's when he came to see me and as soon as I got him in the exam room, we knew something terrible was wrong. Testicle was abnormal.

Of course, he did a scrotal ultrasound, testicular cancer. Probably the worst possible diagnosis a couple dealing with infertility in a moment could possibly receive. Now, this is uncommon.

This is not something we see every day but it certainly highlights the importance of the male factor evaluation. The semen analysis, some people say, is the canary in the coal mine. Others call it the barometer of men's health.

Testicular cancer is three times more common in men who have a history of infertility. Prostate cancer, two and a half times more common among men who have a history of infertility. Among azoospermic men, those men are three times more likely to subsequently develop any cancer.

I'm not talking about genitourinary cancers. I'm talking about colon cancer, brain cancer, pancreatic tumors. So, we know that male factor infertility is associated with life-threatening disorders.

Stan Honig looked at this data back in the 90s. Over a thousand patients coming into their clinic, one percent had a serious or life-threatening diagnosis. So, this is point number one, why the male factor evaluation is important.

The second reason is we identify reversible and treatable causes of infertility. I saw a young couple recently who came in with low-volume semen analysis, oligospermic, with high round cell count. I got to talking to them.

They had dyspareunia, not what you guys are familiar with as dyspareunia, but male dyspareunia. So, pain with erections, pain with intercourse on his side of things. His exam demonstrated something called phimosis, which is where the foreskin is tied over the penis.

Does anyone know the treatment for phimosis? Circumcision. Thank you, Dr. Crawford. So, the most common urologic procedure in all of the world.

Cures the infertility. Simple procedure. So, there's other common causes of male factor infertility that we see every day, including exogenous androgens.

So, this is men on testosterone, men previously on testosterone, took testosterone in college, took steroids in college, taking workout supplements, other exogenous androgens. The list goes on and on, but this is every day in clinic, and these men are easily treatable with sometimes just clomid, clomid HCG, but we're able to cure these men medically. And then there's the most common cause of an abnormal semen analysis, the elusive varicocele.

Such a storied history in reproductive medicine, the varicocele is because it's so common. Half of all couples coming in with abnormal semen analysis have a varicocele. Why is this important? When we treat it, 70% of men have significant improvements in their sperm quality.

A third actually conceive naturally. Flip that number around, two-thirds don't conceive naturally and still need ART. So, what about those couples who had a varicocele and still need ART? When I was at UNC, we did a big study, a meta-analysis, was published in Fertility and Sterility back in 2016, where we looked at all the couples who had a known varicocele and underwent IVF.

And the comparison was, was that varicocele treated, was that varicocele not treated? In treated varicoceles, the live birth rate with IVF is 1.7 times, in a meta-analysis, 1.7 times those with a known and untreated varicocele. So, that's point number two, why the male factor evaluation is important. We actually can enhance, I'm sorry, that's point number three, we can actually enhance ART outcomes.

Next, is we define untreatable causes of testis failure. So, this might be a couple who comes in with RPL and a history of failed IVF, maybe a hint at a male factor, slightly abnormal semen analysis. A reproductive urologist is going to check a karyotype on that couple, on that male, and he is going to, you know, if he has a translocation, that's not treatable, right? I mean, nothing we can do about that.

But what we can do is we can help provide closure for their prior ART failures. We can refer them on to genetic counseling. We can have them, we can refer them on to genetic counseling and let's see, so other causes, other untreatable causes of male factor infertility.

Sorry, I lost my train of thought. So, when couples come in, I can't even tell you how many couples come in and have a, have an untreatable cause of male factor infertility, we just need to tell them to undergo IVF. So, what happens to those couples? Well, they go into IVF more confidently because they know they don't have cancer.

They know they don't have a treatable cause of male factor infertility where they need medicine. They certainly don't need supplements. So, these men just need IVF and they need someone to tell them that they need IVF with their severe male factor and they go into their IVF cycle more confidently.

So, the next reason that the male factor evaluation is important is we provide the avenue for treatment at all for azoospermic men. So, if a young couple comes in with an azoospermic sample, low volume, acidic pH, that's almost always congenital bilateral absence of the vas deferens, CBAVD. And men with CBAVD, they just need a sperm retrieval.

We're also going to check them for cystic fibrosis mutations. We're going to do a renal ultrasound and make sure they don't have a congenital renal anomaly. But those men do really, really well with IVF and they just need a sperm retrieval.

So, that's another reason why the male factor evaluation is important. And then the last but not least reason is that it follows the guidelines. So, the American Urological Association published some guidelines with the ASRM back in 2020.

This is published in Fertility and Sterility. If you haven't seen it, it's an awesome document. It came out in two parts.

Download it tonight in your hotel room. Read it on the airplane going back. I'm going to focus on the first three guideline statements.

So, number one, the first guideline statement in the male factor evaluation guidelines from the ASRM states that the male and the female should be evaluated concurrently. So, when we evaluate the male concurrently, we get guideline statement number two, which is that reproductive history needs to be taken for the male and a semen analysis. Everybody's doing that.

Everybody's getting, everybody's doing the history on the male and is getting a semen analysis. Guideline statement three is practice changing. And what guideline statement three in this guideline states is that if a male is in abnormal semen analysis, they need to be referred for reproductive urology evaluation.

So, what are we going to do in that evaluation? So, we're going to see them. We're going to do the history. We're going to do a full physical.

We're going to do hormone testing. We're going to obtain specialized semen analysis. So, that can be retrograde if they have low volume.

That might be a DNA fragmentation test. And then we're going to have a treatment plan, usually in two visits. So, it's as simple as that.

And the goal of that visit is to actually dovetail with the ART plan. So, we want to optimize their ART outcomes. And that brings me to my very last point, which is that the male evaluation actually enhances the ART practice.

And so, how does that do that? Well, you know, yeah, we diagnose cancers occasionally and we diagnose serious problems and diabetes and, you know, we find treatable causes. We treat varicoceles, but it actually enhances the ART practice because it improves outcomes. Better sperm counts improve IUI success.

Better sperm counts improve IVF success. And then for the men with untreatable causes, it allows them to confidently go into their ART cycle knowing that they've done everything that they possibly can. And so, they're able to proceed with treatment with more confidence and it greatly improves our outcomes and patient satisfaction.

So, thank you very much for your attention.