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FirstHealth of the Carolinas
Infertility and the male By Dick Broom


There could be any number of reasons for that. But since Martha Washington had four children before the death of her much-older first husband, we can probably rule out two of the most common reasons couples can’t have children: ovulation problems or blocked fallopian tubes. A likely explanation, then, is that the problem was the president’s.

It used to be thought that if a woman couldn’t get pregnant, it had to be because of some problem with her reproductive system. Now we know better.

What physicians call “male factors” cause up to 40 percent of couples’ infertility. The most common male factors are low sperm count and low motility, which means many of the sperm are dead or inactive.

If a man and a woman are having trouble conceiving a child, they typically go first to the woman’s obstetrician— the physician who from a medical standpoint is the expert on having babies. The physician can examine the woman and run tests on her, as well as order a lab analysis of the man’s semen.

“Typically, we would expect to see a minimum of 20 million sperm (per cubic centimeter), and we would want to see at least half of those alive and moving around,” says Walter Fasolak, D.O., an obstetrician-gynecologist and infertility specialist with the Southern Pines Women’s Health Center.

If a man’s sperm count is low, the OB/GYN physician may refer him to a urologist.

Varicose veins
The most common cause of low sperm production is one or more varicose veins in the scrotum, says Greg Griewe, M.D., a urologist with Pinehurst Surgical.

According to Dr. Griewe, varicose veins are bigger around than normal, so they hold more blood, which increases the temperature around the testicles. If the testicles are too warm, they don’t produce as many sperm.

“About 15 percent of American men have a varicose vein in their scrotum, but most of them don’t have fertility problems,” Dr. Griewe says.

Walter Fasolak, D.O.

Greg Griewe, M.D.

For those who do, varicose veins can usually be fixed with a relatively simple surgical procedure.

Dr. Griewe defines infertility as the failure to achieve pregnancy after one year of sexual relations. Some men are infertile because of genetic factors or hormonal problems, and certain medications can interfere with semen production and normal sexual function. Anabolic steroids used by some athletes and bodybuilders cause fewer sperm to be produced.

“Various types of infections and other illnesses can cause a dip in the sperm count,” Dr. Griewe says. “The count usually comes back up to normal once the illness has been treated.”

Treatment options
Sometimes, there isn’t much that medical science can do to increase the number of healthy, active sperm. But there are ways to make the most of the healthy sperm that a man does have.

During a couple’s sexual relations, only 10 percent of the man’s sperm may get through the woman’s cervix, up into the uterus and close to a fallopian tube where fertilization of an egg can occur. To increase the chances of success, infertility specialists can insert healthy sperm directly into the uterus. But first they have to wash the sperm.

“With normal sexual relations, the sperm is filtered through the cervix,” Dr. Fasolak says. “If we bypass the cervix, then we are obligated to filter the sperm and separate it from the mucous and all the other proteins that are in the seminal fluid. That filtering is what activates the sperm so it can actually fertilize an egg.”

Dr. Fasolak has equipment in his office for washing sperm, a process that takes about an hour.

“Then we take that small amount of sperm that is now concentrated and insert it into the uterus,” he says. “It’s just a way of helping nature along.”

If that doesn’t work, there is a more complicated procedure for overcoming male infertility called intra cytoplasmic sperm injection (ICSI) that has been developed within the past 10 years. It is a modified version of in-vitro fertilization, a procedure that is sometimes used when a woman has ovulation problems.

With in-vitro fertilization, the woman’s ovaries are stimulated to produce eggs. Then the eggs are removed and fertilized before being inserted into the woman’s uterus. With the sperm injection procedure, eggs are removed from the woman’s ovaries and placed under a microscope along with a sample of the man’s sperm.

“We take the best-looking sperm we can find and use very sophisticated instruments to inject that sperm into an egg,” Dr. Fasolak says. “We place the fertilized egg in a culture medium and watch it grow for a day or two, until we know for sure that the embryo is dividing. Then we place the embryo in the woman’s uterus, and we have a pregnancy.”

Dr. Fasolak says this procedure has dramatically improved the chances of pregnancy in cases of male infertility.

“The whole process can cost upwards of $15,000 for just one cycle,” he says. “But if you’ve hit the end of the road with all other options, this could make the difference between no children and having a child.”

After a vasectomy
Some men are infertile by choice after having had a vasectomy. Some men change their mind, however, and decide they want to have children after all. Fortunately, vasectomies often can be reversed.

“The shorter the time period between the vasectomy and the reversal, the better the success rate,” says Dr. Griewe, who has performed many reversal procedures. “If it’s done within 10 years of the vasectomy, there is a good chance the man’s fertility will be restored. But, of course, that is still no guarantee of pregnancy.”

According to Dr. Griewe, the pregnancy rate is about 47 percent if the reversal surgery is done within eight years of the vasectomy. The rate is 40 percent if it’s done within nine to 14 years.

Many times, when a couple is unable to have children, the cause is unknown, Dr. Griewe says.

“The woman has a normal menstrual cycle and the man has a normal sperm count, but for some reason, it just doesn’t happen,” he says.