Better Fertility: Understanding Infertility with Scott Zeitlin, MD.

Better Fertility: Understanding Infertility with Scott Zeitlin, MD. Listen To This Episode on Apple Podcasts

In today’s episode, we discuss infertility, a problem affecting one in 7 couples trying to conceive. Dealing with infertility can be very stressful and confusing. Who better to help us better understand this issue than Dr Scott Zeitlin. We will discuss ways for men to maximize their fertility, how to recognize infertility, what diagnostic tests are needed to determine the causes of infertility, and the treatment options that are available for men with infertility.

This Episode's Guest:
Scott Zeitlin, MD

Dr Zeitlin is a board certified and licensed Urologist specializing in the treatment of infertility. Dr. Zeitlin graduated from Brooklyn College and then completed Medical School and his Urology training at the State University of New York Health Sciences Center in Brooklyn. He then completed a clinical fellowship at UCLA. He is now a clinical professor of Urology and Obstetrics and Gynecology at the David Geffen School of Medicine at UCLA.

Better Fertility: Understanding Infertility with Scott Zeitlin, MD. Transcript:

Better Man Clinics 

What can a man do to try to maximize his fertility or chances to conceive?

Dr Zeitlin 

Well, if you take care of yourself, you exercise, you sleep, you limit your stress, you follow a good diet, you maintain your cardiovascular health, you will benefit your fertility and your sexual health. There’s a lot of common sense that’s involved. One of the things that is also helpful is frequent ejaculation.

Better Man Clinics 

How does the frequent ejaculation help with fertility?

Dr Zeitlin 

When couples are trying to have children, and they’re having difficulty, oftentimes, sex becomes work. And so they start to have sex less frequently. And one of the things that we know about infrequent ejaculation is that the amount of abnormal sperm DNA increases with less frequent ejaculations. In contrast, ejaculating more frequently can thus be helpful to men.

Better Man Clinics 

Well, that’s interesting. Let me let me tease that apart for a second. So one aspect is just the frequency of the ejaculation. But I think that a problem that comes up a lot is, as you mentioned, the stress of trying to conceive. It becomes a full time job. On top of that, they are also doing technical things like checking temperatures to check for ovulation status. Do couples that are just getting started that don’t have any known fertility issues, need to be that technical? Should they rely on calculators and thermometers and ovulation tables? Or should they just try?

Dr Zeitlin 

They should just try depending on how old the female partner is. If the woman is young, let’s say tunder 35, that’s something where they should just try and see how they do.  The way we define infertility depends on the age of the female partner. If the woman is under 35 years of age, then we define infertility as a year of trying and not being successful. For women above 35, that timeline decreases to six months.

Better Man Clinics 

Are there any other factors that also impact fertility?

Dr Zeitlin 

First, I want to make a distinction when I use the words “young” and “old” or “older”. Women who are 40 years of age are young and healthy and vibrant, but their fertility potential isn’t what it was. If we see a couple, and the woman is 40 years of age, and the man is 30 years of age, we think they don’t have a lot of time. And if we see a couple and the man is 40 years of age, and the woman is 30 years of age, we think this couple has a lot of time. Maternal age is the biggest factor in general, in my practice. The other element, again, is stress.  Stress, itself, impacts sperm quality and the ability to conceive. I think that stress is huge. I think that stress affects all aspects of your life. It affects how you function, it affects your sleep (which is very important), it affects your diet. Some people are stress eaters while others don’t eat when they are under stress. And so if you’re under stress, it’s not just the feeling of stress, it can be physical, as well as emotional, and it’s very harmful.

Better Man Clinics 

What about medications? Anything to consider with regards to medications for men that are concerned about fertility?

Dr Zeitlin 

Number one is testosterone. A man often starts taking testosterone because he feels less virile. And he thinks intuitively that if he feels more virile, that his sperm count will be higher. However, if a man takes exogenous testosterone (meaning testosterone that his body is not creating), then that will suppress the sperm count, and some men will become azoospermic, which means that they will have no sperm in the ejaculate. This is the number one factor that we see as far as pharmaceuticals.

Better Man Clinics 

What about recreational drugs but like alcohol, tobacco, and marijuana? Do they impact fertility.

Dr Zeitlin 

I consider nicotine a drug just like all the other doctors and I think smoking is terrible. One of the things that a man with infertility can really improve upon is quitting smoking. I see patients that smoke a pack a day, or even more and I tell them that I think if they quit smoking, and quit drinking, they may be able to conceive within 6 months.   Unfortunately, some of them will invariably say, “What if I don’t want to quit smoking and drinking?”  Cigarettes are really a problem. With alcohol, if you have a few drinks a couple of times a week, it’s not a big deal with regards to fertility. What I don’t want to do to the patient is to torture them.  I don’t want them to be more stressed by eliminating everything that they potentially enjoy. So mild consumption of alcohol is fine. Marijuana, on the other hand, is problematic – it can affect reproductive hormones and it can affect sperm. The problem is also that not all the marijuana is the same.  Over the last 20 or 30 years, some strains of the marijuana have become much stronger and have a bigger impact on fertility. So while not fully quantifiable at this point from a from a sperm perspective, cigarettes, marijuana and alcohol do have a significant impact on fertility. I feel most strongly about eliminating cigarettes and marijuana when thinking about fertility.

Better Man Clinics 

What about medications like Propecia or Finasteride.  A lot of men in their 30s and 40s use this medication to treat hair loss and this is just around that time when they want to conceive.  What impact does this type of medication have on fertility.

Dr Zeitlin 

Finasteride (which is which the generic name for Propecia) is used to both treat hair loss and to shrink the prostate in men.  Studies have shown that a small number of patients who use this medication will have irreversible effects. These effects include erectile dysfunction and loss of libido. And even more rarely, there are small numbers of men who will develop gynecomastia, which is breast tenderness and potential breast enlargement that can occur with the with the drug. In the general population, there are a lot of people that take finasteride and have still achieved pregnancies. However, when they come to me after unsuccessfully trying to conceive for a year and their sperm parameters aren’t optimal, I’ll ask them to stop.

Better Man Clinics 

Any other medications to think about that you screen for when you see people with infertility?

Dr Zeitlin 

Some other prostate medications can cause a condition called retrograde ejaculation. These medications are in a class of drugs called alpha blockers and include medications like Flomax or Tamsulosin.  These drugs make it easier for men to urinate because they open the neck of the bladder, allowing the urine to flow out easier.  But, in so doing, they also cause semen (which gets deposited into the prostate just prior to ejaculation) to go backwards into the bladder rather than out of the penis.  As you can obviously imagine, if there is little or no semen leaving the penis and reaching the partner, the chances of a successful conception is low.

Better Man Clinics 

What about obesity?  Does that impact fertility.   When you see patients with infertility that are significantly overweight, do you recommend that they lose weight so as to improve their chances to conceive?

Dr Zeitlin 

I think weight loss is very, very important. I think overall health is important. I tell my patients “your goal is to live a long life so you can spend as much time with your kids and be there for them and enjoy them.”  This is not just a goal to achieve a pregnancy, but this is a goal for life. That said, from a fertility perspective, specifically, we see that obesity is a significant problem.

Better Man Clinics 

Lubricants used during sex have often been mentioned as a potential contributor to infertility. Some are supposed to be okay while others are not. Do you have any any comments on that?

Dr Zeitlin 

Many lubricants are spermatotoxic, meaning that they’re harmful to the sperm. If couples can avoid using a lubricant, it’s better to avoid using a lubricant. That being said, some people will need lubrication for intercourse. There are lubricants that are specifically not spermatotoxic on the market that couples can use in order to prevent toxicity to the sperm and still get lubrication to help with intercourse.

Better Man Clinics 

Once a couple has met the criteria for infertility (lack of success after trying for one year or 6 months, depending on the age of the female partner), what is the best plan of action?  In other words, once a couple start to see that they may have an infertility problem, where do they go from there?

Dr Zeitlin 

I think the least expensive and most effective start is actually a semen analysis, because it gives us a baseline lets us know where we stand from the perspective of the man.  In older couples, it is probably most efficient to have the female partner evaluated in parallel so as not to waste time.

Better Man Clinics

What should a man expect in seeing a doctor for suspected infertility?

Dr Zeitlin 

The evaluation starts with some basic questions: How old is he? Has he ever made anyone pregnant? If he hasn’t made anyone pregnant, sas he ever tried to make anyone pregnant? If he’s tried to make that someone pregnant, has that prior partner been able to conceive with someone else. I also try  understand the medical history of his present partner. They should also bring in any relevant tests that they have already had, particularly semen analyses.

Better Man Clinics 

What type of physical examination is done during an infertility consultation? What are you looking for?

Dr Zeitlin 

I think the most important part of the examination is the genital examination when it comes to fertility.  The testicles are sponsible for spermatogenesis, or the production of sperm, in addition to the production of the male hormone, testosterone. What we are evaluating is the size and the consistency of the testicles.  By consistency I mean the firmness of the testicles. Often times, when testicles feel softer than normal, they are not functioning appropriately. Occasionally we will also find a testicular cancer during this examination.

We also examine the epididymis, which is the structure that connects the testicle to the vas deferens. The epididymis is responsible for maturation and transport of sperm. The sperm is transported from the testis and matures in the epididymis.  It then proceeds to the vas deferens which brings the sperm up into the body from the testicles.  We examine these structures to make sure they are present and to look for any abnormalities.  As we are examining these structures, we are also looking for dilated veins.  A varicocele is a collection of veins which have valves, which are in competent, and so blood will pool within them.  The significance of this is that this pooling of blood can increase the temperature within the scrotum. The reason why the testicles live outside the body is because they function better at a lower temperature. When the scrotum (and testicle) is overheated, as in the case of a varicocele, it can interfere with spermatogenesis. And it can interfere with the number of sperm, but also the ability of the sperm to move or swim. In addition to the affect on sperm, a varicocele can affect testosterone production.  As we discussed before, a decrease in testosterone can also affect fertility.

Better Man Clinics

To what extent do varicoceles impart fertility in men?

Dr Zeitlin

A varicocele is the most common cause of male infertility. It’s also the most reversible.  A varicocele can be fixed surgically and we expect to see results (improvements) in three to six months after the procedure.

Better Man Clinics 

What about the penis?  An average guy does not know if there is any abnormality with his penis.  However, some guys have a condition called hypospadias – a problem in which the hole out of which the urine and the semen come out is not properly positioned- that can significantly impact fertility. Can you speak a little bit to that?

Dr Zeitlin 

A hypospadias is when the urethra (the tube in the penis carrying urine and semen) does not come to the very end or tip of the penis. There are different forms of hypospadias. In a mild form of hypospadias where the urethra ends around the head of the penis, there usually is not problem with infertility.   Typically, however, in hypospadias where the opening is further down near the shaft of the penis, it can be problematic for the sperm to find its way into and into the uterus.  This can result in infertility.

Better Man Clinics 

Anything else that a man can expect during the examination?

Dr Zeitlin 

In patients that are 40 and above, I’ll do a prostate exam, just to make sure that it’s normal. In men who have absent vast deference, the seminal vesicle is also often missing.  When examining the prostate, we can also feel for the presence of the seminal vesicle. That can sometimes help you confirm the diagnosis. All men over age 40 with a history of prostate cancer will receive a prostate examination and will also get a PSA blood test. Finally, the last group whose prostates we examine are patients who we think have prostate infections or inflammation. Prostate inflammation can affect  ejaculate volumes, erections.  It can also affect sperm quality because the inflammation can cause oxidative stress on the sperm itself.  Within the body, we have an equilibrium between oxidation and antioxidants.  Pro oxidants are important for processes of fertilization called capacitation, and the acrosome reaction.  However, if you have too much oxidation or oxidative stress, then  can negatively affect the sperm and can negatively affect the sperm DNA.

Better Man Clinics 

A lot of young men suffer from prostatitis. Do they have to have anything special in mind when they when they start trying to conceive? Do they need to seek any special treatment ahead of time? Do they need to take antioxidants or anti-inflammatory medication?

Dr Zeitlin 

Prostatitis is a condition that is intermittently bothersome to a lot of people. Depending on whether they’re symptomatic or not, we can evaluate them and sometimes treat them with antioxidants. One of the things that we look for on the semen analysis are white (inflammatory)cells. When a lot of white blood cells are seen on a semen analysis, it can either mean that they have prostatitis or immature sperms cells.  You really can’t make that distinction without actually staining the fluid. If we find the patient to have prostatitis, we will treat them with certain medications. If they have immature sperm cells, then we’ll also give them antioxidants because immature sperm can adversely affect normal sperm.

Better Man Clinics 

You had mentioned that one of the most important test for evaluating infertility is a semen analysis.  Men often provide these samples incorrectly. Any thoughts on how to make sure they are providing a good sample?

Dr Zeitlin

There are different opinions out there regarding the necessary length of abstinence before giving a sample.   I usually ask my patients for 48 hours of abstinence prior to the analysis. Sometimes men are  very nervous at the time of collection and sometimes they miss the cup and get an artificially low amount of semen. This is important because when we see low volume consistently, we think of  conditions like absence of the vas deferens or partial ejaculatory duct obstructions or inflammation related to prostatitis. That is why a complete collection is important.  For those men that live close to the lab and have problems providing a sample in the clinic, we provide them with a cup to take home.  That way they can be in more comfortable surroundings for the collection and simply drive in the sample.

Better Man Clinics 

How much is a normal amount of semen for a semen sample?

Dr Zeitlin 

That’s a great question. A normal amount of semen is somewhere around one and a half to two milliliters. Now, to put that into context, a teaspoon is five milliliters. So a whole teaspoon of semen is a lot.

Better Man Clinics 

What other factors are you looking for on the semen analysis to help guide you in understanding whether there is a fertility problem and, if so, what kind?

Dr Zeitlin 

One component of the semen analysis that I look at in conjunction with the volume is the pH or acidity of the sample. The acidic part of the of the semen comes from the prostate. If you see a small volume (less than 1 milliliter) and an acidic pH of like 6, then I think that the patient may have a condition such as absence of the vast difference or an ejaculatory duct obstruction. Those two anatomic issues will give you semen analyses that look essentially identical because you’re just seeing acidic prostatic fluid in their ejaculate.  So, in this example, a few parameters of the semen analysis can really help us understand the cause of infertility.

Better Man Clinics 

What is considered a normal sperm count on a semen analysis?

Dr Zeitlin 

The normal total number of sperm in the ejaculate should be about 40 million or about 20 million per milliliter of semen. But aside from the number of sperm, the percentage of the sperm that are moving is also very important.

Better Man Clinics 

What if no sperm at all are seen on a semen analysis? What does that mean?

Dr Zeitlin

If there is no sperm at all, we call that azoospermia. In that situation, we look at a number of factors. First, we consider what the physical examination tells us? Is this a patient who has normal size testicles but is missing his vas deferens? That tells us one thing.  If this is a patient with small testicles that have a soft consistency? That tells us something else.  We usually run hormonal tests on men with azoospermia.  One hormone we check is the follicle stimulating hormone (FSH), which is a chemical from the brain that tells the testicle to make sperm. If the FSH is elevated, then we call the condition non obstructive azoospermia. Meaning that there’s no sperm produced by the testicles. In contrast, if the FSH is normal, there may be a blockage that is preventing the sperm produced by the testicles from escaping the testicles.

Better Man Clinics

Are there any other hormones that are important to check in men with azoospermia?

Dr Zeitlin 

Typically, I’m going to check a total testosterone level on men under 60 years of age. Leutenizing hormone (LH) is the driver of leydig cells which live in the testes and make testosterone.  If the LH is elevated, then it tells us that the testicle is being driven harder in order to produce a normal amount of testosterone because they are not otherwise doing so.  That also has an impact on fertility.

Better Man Clinics 

When does genetic testing come into play in the infertility evaluation?

Dr Zeitlin 

Genetic testing really comes into play in men with non obstructive azoospermia or less than 5 million sperm per milliliter. One genetic test that is ordered in this situation is a karyotype. This helps us understand if the patient has a normal number of chromosomes. A normal number karyotype for a man would be 46x y. The second test is Y chromosome microdeletion test which looks at the DAZ (deleted in azoospermia) gene.  There are three regions of this gene that are important to us. There’s an A region, a B region and a C region. If you’re missing regions A or B, then those are incompatible with spermatogenesis- your testicles cannot produce sperm.  We will not do surgery to look for sperm in those patients tests. If you have a C deletion or partial C deletion, you still have a reasonable chance of having sperm found in the testis and the doctors may recommend a surgical procedure to look for them.

Better Man Clinics 

Is it safe to say that once genetic testing is involved, some form of assisted reproduction is going to be required to conceive?

Dr Zeitlin  

Correct.  In this situation, when we say assisted reproduction, we’re talking specifically about in vitro fertilization (IVF).   Also, men who don’t actually ejaculate any sperm are going to need to undergo sperm retrieval to obtain the sperm for the IVF.  Some men won’t have sperm at the time of the sperm retrieval- unfortunately, those men will not be able to conceive despite assisted reproduction.

Better Man Clinics 

Now lets discuss the possible treatments for the various causes of infertility that you previously alluded to.  Lets start with varicoceles.  What is the success rate of treating varicoceles?

Dr Zeitlin  

So classically, people will quote 40 to 70 percent success in treating varicoceles. What I tell my patients is, the bigger the varicocele, the more likely the improvement with surgery. The improvement you are likely to see is in sperm concentration (meaning the number of sperm), motility (meaning how well and fast the sperm swim).  Morphology (which is the shape of the sperm) is less likely to improve with varicocelectomy (surgical repair of a varicocele) then concentration and motility.

Better Man Clinics 

The other category we talked about was obstruction. Whether its obstruction of the tube that carries the sperm in urine or the vas deferens or the ejaculatory duct, is the best option to fix the obstruction or just proceed with assisted reproduction?

Dr Zeitlin  1:01:07

There are different levels of obstruction. One level of obstruction is at the level of the epididymis. In this situation, you would need to connect the vas deferens to the epididymis to overcome the obstruction. That is an operation where you’re trying to place sutures into something as small as the head of a small pin. Technically, these are these are operations that trained micro surgeons are able to do but it just depends on the location and cause of the obstruction. In men who have had significant scarring within their testicles have a lot of inflammation, then the surgery would be more difficult.  In contrast, if someone has an obstruction at the level of the ejaculatory duct or a cyst compressing the urethra, these are easier surgeries to perform but the potential side effects of those surgeries can be problematic.

Better Man Clinics 

What about men that have had a vasectomy in the past and now want to conceive?  Can the vasectomy be reversed?

Dr Zeitlin 

The ability to reverse a vasectomy successfully depends on the time that has transpired since the vasectomy. The shorter the time from the vasectomy to the vasectomy reversal, the more likely they are to be successful. In properly selected patients, the results are very good. Vasectomy reversal is less optimal for men with older partners because of the time it takes to heal from the reversal and the subsequent time to pregnancy.  It is time that the older partners may not have in terms of their fertility and window of opportunity.

Better Man Clinics 

Earlier we spoke about certain medications causing retrograde ejaculation, which can also lead to infertility.  As we discussed, this occurs when the semen gets ejected into the bladder rather than out of the penis.  Aside from stopping the medication causing the problem, what can be done to help men with infertility due to retrograde ejaculation? Specifically, what can be done when the retrograde ejaculation is not caused by medication?

Dr Zeitlin 

Men who have retrograde ejaculation can be treated with medications like Sudafed. We can use medications like Sudafed to cause the bladder neck to close or tighten and propel the semen out of the penis rather than backwards into the bladder.  There are different protocols that we use for patients to take these medicines over the course of let’s say 24 hours.

Better Man Clinics 

Earlier we spoke of hormones that can be related to fertility.  For example, we discussed how, in some men, a high LH or FSH level may mean that the testicles are not functioning properly. What about when the opposite is true?  What about when LH and FSH are low and we think that the brain hormones aren’t being produced properly?  Men often hear about a hormonal medication called Clomid with regards to infertility? When is it a consideration? And when is it not?

Dr Zeitlin 

Clomid is going to increase FS, LH and testosterone. It does it so by preventing the negative feedback of these hormones on the pituitary gland in the brain. The pituitary doesn’t sense the testosterone and therefore produces more FSH and LH.

Better Man Clinics 

Does Clomid just put the testicles on hyperdrive and, in so doing, causes them to increase sperm production?

Dr Zeitlin 

Yes, to an extent it does. However, everybody responds differently. Some people can take the medicine and feel great -their testosterone goes up and their sperm counts go up. And it can be dramatic. In others, you’ll see little or no response.

Better Man Clinics 

As we discussed, sometimes the only way to treat infertility is through assisted reproduction.  Can you explain the main methods of assisted reproduction and the differences between them?

Dr Zeitlin

The two main categories of assisted reproduction are intrauterine insemination (IUI) and in vitro fertilization (IVF).  Intrauterine insemination or IUI is what people often refer to as the “turkey baster method”.  In the process, the semen is ejaculated naturally and the sperm is collected and processed. Fluid with concentrated numbers of the processed sperm is then placed by a gynecologist through the cervix into the uterus. Thus, it is an in-utero insemination of the sperm. Ten million motile sperm on a semen analysis is really the minimum number of sperm required for success within uterine insemination. When it comes to IUI, the rates of success aren’t that high. In and of itself, IUI is no more effective than standard intercourse in the absence of cervical factors (meaning there is no issue with the cervix in the female partner). It is when there is a problem for the sperm to get past the cervix that IUI is helpful.

In contrast, In Vitro Fertilization(IVF) is the process of mixing eggs and sperm together in a dish in a laboratory. “In vivo” would mean doing this in the body while “in vitro” means it is done outside the body in the laboratory. In vitro fertilization also usually specifically refers to intracytoplasmic sperm injection (ICSI). That is a procedure done in the laboratory in which a single sperm is injected into a single egg, so that you bypass certain processes in order to help ensure that fertilization occurs.  There are certain advantages to IVF. First, it’s quite successful.  Second, it allows for testing the embryos to ensure that the complement of chromosomes is normal. When women get older, the rates of aneuploidy  (abnormal chromosome numbers within their eggs) increases. Testing in IVF prevents you from transferring embryos that have abnormal numbers of chromosomes which can often lead to miscarriage. Finally, testing during IVF also allows parents to know the sex of the child very early in the process and potentially select the sex of the child that you desire. So let’s say you have two girls and you want to have a boy or you have two boys and you want to have a girl, you can do the in vitro fertilization, do the testing, and then transfer the embryo that is the boy or that is the girl.

SUMMARY KEYWORDS

Sperm, ejaculate, testicles, obstruction, conceive, infertility, couple, prostate, fertility, vas deferens, testosterone, epididymis, ejaculation

Disclaimer

The conversation transcribed above is for informational purposes only. It does not represent a medical consultation nor medical advice. Rather, we hope that the information provided empowers men with the knowledge and confidence to address their issues with their health care providers. As with any medical or wellness issues, you should always consult with your health care provider before beginning any type of treatment or preventative intervention.