Sperm Meets Egg

Why me? My wife never had an infection, surgery or any other problem? I have no difficulty ejaculating and there’s plenty to work with so why can my friends, neighbors and coworkers get pregnant and we can’t?

I hear these questions daily and appreciate the frustrations, anger and stress felt by my patients expressing these feelings through such questions. There are many reasons why couples do not conceive. An infertility workup will identify some of these. A semen analysis will pick up a male factor in 50-60% of cases and in more than half of these cases the male has the only problem. An hysterosalpingogram will locate tubal disease in about 20% of cases. Another 20-25% of women do not ovulate or ovulate dysfunctionally preventing conception.

Even when a semen analysis is normal it is possible that a post coital test may identify that the problem is that the sperm is not reaching the egg. It may not be able to swim up the cervical canal into the womb and up the tubes where it should normally find an egg to fertilize. When these tests are normal a laparoscopy may be performed to identify the 20-25% of infertile women with endometriosis. However, even when the infertility workup is normal and there is no test that logically explains the lack of success in achieving a pregnancy; an IVF procedure may both identify the cause as failure of the egg to fertilize and treat it successfully by injecting sperm microscopically into the egg by a procedure called Intracytoplasmic Sperm Injection or ICSI.

What causes male factor infertility?

There are several potential causes of male factor infertility. Hormonal causes can be caused because of problems at the hypothalamic-pituitary level or at the testicular level. Normally, the hypothalamus regulates pituitary production of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). FSH and LH drive the testis to produce sperm and testosterone. Deficiency of FSH or LH can lead to lack of ability to drive the testicular production of sperm and testosterone just as lack of gas will prevent a car from being able to run. Today, the most common reason for a man to have FSH and LH production shut off is from his use of anabolic steroids such as testosterone, hcg (human chorionic gonadotropin) and clomiphene (clomid). These all may provide negative feedback on the pituitary turning off FSH and LH production. One can also see elevated testosterone shutting down the testis with congenital adrenal hyperplasia and adrenal tumors.

Pituitary tumors, infarction, surgery, radiation and infiltrative processes can also diminish FSH and LH production. In the presence of low FSH and LH it may be useful to check for elevated prolactin levels to rule out a pituitary prolactinoma and obtain an MRI to check for other tumors or pituitary pathology.

Isolated deficiency of LH and FSH can occur (Kallmann’s syndrome) and lead to diminished testis (hypogonadism). This occurs in 1 in 10,000 men. Less common defects are seen in hypothalamic stimulation of the pituitary and are usually associated with other congenital findings.

Abnormal thyroid and glucocorticoid (prednisone) excess can result in decreased spermatogenesis through effects on the hypothalamus and LH production or conversion of androgens (male hormone) to estrogens.

Testicular causes include the presence of tumor, chromosomal abnormalities, congenital absence of germ cells, drugs and radiation that are toxic to the testes, undescended testes and varicocoele.

Ten per cent of males with a sperm count under 10 million and 20% of men with azospermia have a chromosomal abnormality. Kleinfelter’s syndrome is a genetic disorder due to the presence of an extra x chromosome in the male. This occurs in 1 out of 500 males and is often seen in the mosaic form where some cells are 46 xy and some are 47 xxy. The testes tend to be small and these men have delayed sexual maturation, azospermia and gynecomastia (enlarged male breasts). There has been some success with ICSI of biopsied immature sperm cells.

Sertoli-cell only syndrome or germinal cell aphasia may have several causes including congenital absence of the germ cells, genetic defects or androgen resistance. Testicular biopsy shows complete absence of germinal elements. Men are azospermic yet virilize normally. Testes may have normal consistency but be slightly smaller in size. Testosterone and LH levels are normal but FSH is usually elevated. Men with testicular failure secondary to mumps, cryptorchidism or radiation/chemotherapy damage have smaller testes with a non uniform histologic pattern. The testes may have severe sclerosis and hyalinization. There is no treatment for this form of azospermia.

Gonadotoxic drugs like chemotherapy or radiation can effect the germinal epithelium because it is a rapidly dividing tissue and is susceptible to the interference imposed by these toxins on cell division. At radiation exposure below 600 rads, germ cell damage is reversible. Recovered spermatogenesis may take up to 2-3 years even when exposed to low doses of radiation. Elevated FSH levels reflect the impaired spermatogenesis and return to normal once the testes recover.

Orchitis occurs in 15-25% of males who contract mumps which is unilateral in 90% of cases. Testicular atrophy may take years to develop. At least two thirds of men with bilateral orchitis remain infertile for life.

Trauma either through accident or torsion of a testis is a relatively common cause of subsequent atrophy with potential diminished fertility.

Medical conditions such as renal failure, cirrhosis of the liver and sickle cell disease can all lead to low testosterone levels and decreased spermatogenesis.

Cryptorchidism occurs in 1 in 12 males. The undescended testis becomes abnormal after age 2. Even when unilateral, cryptorchid patients have reduced fertility potential.

The varicocoele is the most common finding in infertile men. It is the result of backflow of blood due to incompetent valves in the spermatic veins. 90% occur on the left and is found in 20% of males 40% of the infertile population. 50% of men with varicocoeles are fertile. It is thought that a varicocoele can cause infertility by elevating the temperature of the testis. Varicocoelectomies however are not universally helpful and remain somewhat controversial for many cases of infertility.

Unfortunately, at least 25-40% of infertile men have idiopathic infertility for which no cause may be identified.

Other causes of azospermia include congenital absence of the vas deferens or obstruction secondary to infection or surgery. These cases may be amenable to surgical reconstruction and/or ICSI with epididymal aspiration or testicular biopsy to obtain sperm. These are the most successful cases of ICSI associated with azospermia.

Sperm antibodies may be a relative cause of infertility in about 3-7% of cases. Treatment has been successful with intrauterine insemination and with ICSI.

Infections can affect sperm motility secondary to e coli, Chlamydia, mycoplasma, ureaplasma and trichomonas. Culture and treatment for asymptomatic infertile males remains controversial.

Sexual dysfunction is a presenting cause of male infertility in about 20% of cases. Decreased sexual drive, erectile dysfunction, premature ejaculation and failure of intromission are all potentially correctable causes of infertility.

Treatment of Male Infertility
Treatment depends on diagnosis. In cases where the FSH and LH are low with a normal head MRI, clomiphene may be of benefit. Clomiphene citrate (Clomid or Serophene) is one of the most widely used drugs in male infertility. It is a weak anti-estrogen that interferes with the normal feedback of circulating estrogens and results in an increase in GnRH that stimulates gonadotropin secretion. The resulting elevation in LH and FSH increases intratesticular testosterone levels and in theory should improve spermatogenesis. Gonadotropin therapy may be used if clomphene is unsuccessful in the face of low FSH and LH.

If a pituitary tumor is found, surgery or medications to lower prolactin may restore spermatogenesis to normal.

An obstructed vas may be microsurgically reconstructed. Surgery may also be performed in the presence of a varicocoele.

Intrauterine insemination may improve delivery of sperm to an egg or in the absence of any sperm, artificial insemination with donor sperm is often successful.

Intracytoplasmic sperm injection into the egg in an IVF procedure is highly successful when sperm may be obtained through the ejaculate and even through testicular biopsy. When normal mature sperm are rare such as in testicular failure, associated with elevated FSH, ICSI is much less likely to result in fertilization and pregnancy. Immature sperm cells rarely can result in a healthy pregnancy.

Naturopathic Treatment

Naturopathic treatment for male infertility focuses on improving sperm quantity, sperm quality, and overall male reproductive health. There have been reports that sperm counts have fallen almost 50% since the 1930s. Although some dispute these findings, it is generally accepted that sperm counts are declining. The cause may be environmental and dietary and lifestyle changes may interfere with men’s sperm production. If this is so, improving diet and making healthy lifestyle choices should positively impact male reproductive health.

Nutrition

The importance of a healthy diet cannot be overstated. To function properly, the reproductive system requires the proper vitamins and minerals. Nutritional deficiencies can impair hormone function, inhibit sperm production, and contribute to the production of abnormal sperm

• Eat a natural foods diet that focuses on fresh vegetables, fruits, whole grains, fish, poultry, legumes, nuts, and seeds.
• Drink 50% of body weight in ounces of water daily (e.g., a 150 lb man would drink 75 oz of water).
• Eliminate processed and refined foods (e.g., white flour), junk food, sugars, alcohol, and caffeine.
• Avoid saturated fats and hydrogenated oils (e.g., margarine); use olive oil.
• Pumpkin seeds are naturally high in zinc and essential fatty acids which are vital to healthy functioning of the male reproductive system. Eat pumpkin seeds to help maintain a healthy reproductive system.

Supplements

The following supplements may increase sperm count and/or motility. Allow 3-4 months for the supplements to work. The following is a list of supplements with their supposed benefit.

• Arginine – Take 4 gr daily. Needed to produce sperm. If the sperm count is below 10 million per ml, arginine probably will not provide any benefit.
• Coenzyme Q10 – Take 10 mg daily. May increase sperm count and motility.
• Flaxseed oil – Take 1 tbsp daily. Is a source of essential fatty acids.
• L-carnitine – Take 3-4 grams daily. Required for normal sperm function.
• Multivitamin-mineral – Buy a high-quality product and take one serving size (differs from brand to brand).
• Selenium – Take 200 mcg daily. May improve sperm motility.
• Vitamin B-12 – Take 1000 mcg daily. A B-12 deficiency reduces sperm motility and sperm count. Even if no deficiency exists, B-12 supplementation may help men with a sperm count of less than 20 million per milliliter or a motility rate of less than 50%
• Vitamin C – Take 500 mg 2 times daily. Is an antioxidant.
• Vitamin E – Take 400 IUs 2 times daily. Is an antioxidant and may improve sperms’ ability to impregnate.
• Zinc – Take 30 mg 2 times daily. Required for a healthy male reproductive system and sperm production.

Herbal Medicine

Herbal remedies usually do not have side effects when used appropriately and at suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset or headache. This may reflect the purity of the preparation or added ingredients, such as synthetic binders or fillers. For this reason, it is recommended that only high-quality products be used. As with all medications, more is not better and overdosing can lead to serious illness and death.

The following herbs may be used to treat male infertility:

• Ginseng (Panax ginseng) – Known as a male tonic (an agent that improves general health) and used to increase testosterone levels and sperm count. Siberian ginseng (Eleutherococcus senticosus) may also be used.
• Astragalus (Astragalus membranaceus) – May increase sperm motility.
• Sarsaparilla (>Smilax spp.) – Known as a male (and female) tonic.
• Saw palmetto (Serenoa repens) – Used for overall male reproductive health.

Other Recommendations:

Avoid alcohol. Alcohol consumption is associated with an increased number of defective sperm.
• Consider acupuncture.
• Do not smoke, or quit smoking. There is an association between smoking and low sperm count, poor sperm motility, and abnormal sperm.
• Proxeed – is a new nutritional supplement that may improve sperm health and fertility rates. The ingredients include L-carnitine and acetylcarnitine, two vitamin-like substances synthesized naturally by the body. These chemicals are involved in cellular metabolism and are found in semen at a rate that is proportionate to the amount of healthy sperm. Proxeed is purported to improve sperm count, concentration, and motility when taken orally for about 2 months. It is reported that approximately 30% of couples using it conceive. It is available without a prescription, although couples considering it should consult their physician.

This is one husband’s story about living with a woman on hormones. It is not always this dramatic but the stress can be very difficult for a couple and many relationships benefit from professional support when going through fertility treatments. Imagine dealing with the stress, frustrations and cyclic disappointment couples feel when trying unsuccessfully to start a family. Add to this that your wife is being pumped up with hormones that have the potential to lower her threshold of rationality and sanity. Outbursts of anger directed at especially those closest to them are very common. Under normal circumstances most of us can control our reactions without letting our emotions get in the way. Hormones can greatly diminish our ability to control our behavior when circumstances become tense and stressful. Hormones have even been used as a defense in murder cases. My recommendation is to get rid of any guns in the house and not respond to apparent emotional outbursts. This should pass when the cycle is completed and the hormones have faded from the system. If not…?

Before the tips, here’s a hopeful quip:

“Slow down and everything you are chasing will come around and catch you,” said John De Paola.

I don’t know if pregnancy will “catch” you if you slow down…but heck, it’s worth a try! To learn more about sperm, ovulation, and getting pregnant, click Fertility and Infertility for Dummies by Gillian Lockwood and others. And, read on for dozens of tips on reducing the stress of infertility….At East Coast Fertility, join our Mind Body Program where reducing stress and improving your odds is the name of the game.

Social Ways to Reduce Infertility Stress

- Tell your friends what you need. If don’t want people to keep asking if you’re pregnant (I hate that!), then tell them that you’ll give them the good news when you’re ready!

- Accept your way of dealing with infertility. You and your partner’s method of coping with infertility could be much different than mine, or your sister’s – and the sooner that you accept it, the better.

- Talk to your friends about your frustrations and joys.

- Have a relaxing glass of wine or a margarita with friends, but don’t overdo it (though some say you shouldn’t drink alcohol at all when you’re trying to get pregnant…that’s a personal choice).

- Prioritize invitations to reduce stress. Give yourself time to unwind and do what you want to do. Say no to parties or get-togethers, or just make a brief appearance.

- Don’t fall into the trap of comparing your life, situation, relationship, or family to other people’s.

Physical Ways to Reduce Infertility Stress

- Get a full-body massage – and tell your massage therapist that you’re trying to get pregnant.

- Spend time out in nature: walking, skating skiing in the winter, hiking in the summer.

- Take a warm bubble bath (but if you’re a female or male coping with infertility, make sure you check with your doctor first).

- Stop eating before you’re full – don’t gorge on chocolates, chips, or fast food.

- Get enough sleep.

- Reduce your caffeine intake (I’m sure you’ve heard that before!).

- Take your vitamins, supplements, minerals (you’ve heard that before, too, I bet).

- Drinks lots of water.

- Get a manicure or pedicure.

- Make love for the sake of making love.

Mental Ways to Reduce Infertility Stress

- Volunteer at a food bank, hospital, or animal shelter.

- Take downtime to snooze, read, relax.

- Play your favorite card and board games – laughing will reduce the stress of getting pregnant.

- Take a regular crossword puzzle or Suduku break.

- Pick your battles, choose your priorities.

- Let go of the little stuff.

- Watch your favorite TV shows or movies.

- Share your baking or meals with homebound people or lonely neighbors.

Emotional Ways to Reduce Infertility Stress

- Practice gratitude.

- Have realistic expectations.

- Laugh!

- Stay in touch with your authentic emotions.

- Cry, scream, or punch the pillow when you need to.

- Stop to take a deep breath every hour or so throughout the day.

- Let yourself grieve. Reducing stress involves expressing your emotions.

- Keep your old traditions and healthy habits alive, but be open to new ones.

Creative Ways to Reduce Infertility Stress

- Paint, draw or carve your thoughts and feelings.

- Visit a museum or art gallery to reduce holiday stress.

- Go to a movie in the middle of the day by yourself.

- Listen to music that relaxes and/or energizes you.

- Go for a drive in the country; stop for hot chocolate and muffins.

- Write in your journal to reduce stress.

Spiritual Ways to Reduce Infertility Stress

- Pray, and remember the big picture.

- Read the Bible, Torah, or other meaningful book.

- Seek the deep meaning behind church or mass services to reduce holiday stress.

- Remember that your God, Creator or Higher Power is working behind the scenes.

- Adjust your perspective to include peace, compassion, and forgiveness.

Family Ways to Reduce Infertility Stress

- Change your regular responses to aggravating family members, especially if your normal responses haven’t worked in the past!

- Shrug off challenges and criticisms.

- Let go of past betrayals, mistakes, failures – both yours and others’.

- Don’t expect people to change (unless you change first).

- Maintain healthy boundaries to reduce infertility stress.

Readers, how do you let go of the stress of trying to get pregnant? I find that walking in the woods out behind our house is hugely relaxing – it reminds me that life can be beautiful even without kids. There’s something about deep breaths of fresh air that energize me, no matter how bad I’m feeling…

At East Coast Fertility, we understand the emotional aspect that accompanies infertility, and we believe it is equally important to support our patients emotionally as well as physically. It is important to understand fertility holistically. In addition to treating the various physical etiologies of infertility, we must take into account the effects of stress and anxiety. Your mind and body work together, not separately. Therefore your thoughts have a direct effect on yourphysiology. When you are experiencing stress, your brain releases stress hormones. These stress hormones function in many ways. One of the stress hormones, cortisol, has been documented to interfere with the release of the reproductive hormones, GnRH (gonadatropin releasing hormone), LH (luteinizing hormone), FSH (follicle stimulating hormone), estrogen, and progesterone. In fact, severe enough stress can completely inhibit the reproductive system. Cortisol levels have also been linked to very early pregnancy loss. For this reason, it has been found extremely helpful when treating infertility, to include mind/body methods and strategies which help to alleviate the stress response that sets off a cascade of hormonal responses which may inhibit fertility.

The mind/body work we teach here at East Coast Fertility includes methods that allow the body to return to a calm and relaxed state, thereby turning off the biochemical stress response and allowing our hormonal physiology to function optimally.  Feelings of anxiety, depression, isolation, and anger are common themes in infertility.  Often, anger masks the feelings of loss experienced month after month of trying to conceive without success. Infertility impacts on one’s marriage, self-esteem, sexual relationship, family, friends, job, and financial security.

One study showed that women going through infertility experience as much depression as women who have been diagnosed with life-threatening illnesses such as metastatic cancer, heart disease, or HIV. When women face these other illnesses, they are likely to seek out the support of their friends and family. The sad aspect of infertility is that although these women are as depressed as those facing life-threatening illnesses, they are far less likely to seek out support from friends and family. Often, thoughts of not living up to the expectation to become pregnant, thoughts such as “why is this happening to me?!”, and the intense emotions of loss related to the thought that one may never have a child, lead to feelings of isolation, anger, and depression.

Although there is a correlation between stress and infertility, the relationship remains complex. However, the research does in fact suggest that psychosocial factors such as depression and anxiety correlate with
lower pregnancy rates following IVF. In addition, of the women who participated in Alice Domar’s Mind/Body program at the Mind/Body institute in Boston, 55% conceived pregnancies that resulted in the birth of a full term baby compared with 20% of the control group.

~ Mind/Body Support Group at East Coast Fertility ~

In our Mind/Body support group, patients experience the opportunity to share information, feelings, or their own personal stories. You may be surprised to see how your support can help others or you may be relieved
to hear others experiencing the same type of thoughts and feelings as you experience. Often, the supportive nature of this group, and the connection that develops between members, fosters a healing process.
Feelings of isolation, anger, and stress are slowly relieved.

Our Mind/Body program focuses on symptom reduction and developing a sense of control over one’s life by utilizing Mind/Body strategies and interventions which elicit the relaxation response. The relaxation
response is actually a physical state that counteracts the stress response. You can think of it as the physiological opposite of the body’s stress response. We cannot be stressed and relaxed at the same time.
Therefore when a person elicits the relaxation response, the body’s stress response is halted, stress hormones diminish. Stress responses such as heart rate, metabolic rate, blood pressure, and shallow breathing decrease. Breathing becomes slower and deeper, so we have more oxygen being delivered to all the cells in the body. The way in which you are taught to elicit the relaxation response is through methods such as: breath focus, guided visual imagery, muscle Relaxation and learned mindfulness, and meditation.

In Mind/Body work, we also work with “cognitive restructuring” which is examining our negative thoughts, seeing where there is distortion, and reframing our thoughts positively and realistically. Often, we have held on to certain negative thoughts and feelings we may have developed years ago. The thought pattern becomes so ingrained in us, that we take it for truth, when in fact, it is a distortion. Cognitive restructuring will help you examine your thoughts and see which are distorted, causing you needless worry, anxiety, or depression. Once you understand how a thought is distorted, you can change those thoughts and alleviate the anxiety attached to them.

Awareness of the mind/body connection allows us to use our minds to make changes in our physiology. This holistic treatment – combining bio-medical science with mind/body medicine deals with the treatment of the whole individual rather than looking only at the physical aspect.  The fact is, body and mind work together. We invite you to take advantage of this unique area of support provided at East Coast Fertility and join our Mind/Body group.