Initial Male Work Up - What You Should Be Prepared For

June 5, 2007 - Tuesday
7:30 PM to (EST)
Guest Speakers: Craig Niederberger
University of Illinois at Chicago

Categories
Infertility • IUI • Male Factor • PCOS

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Craig_Niederberger	Hello!
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Moderator_DBecker	Dana and Shaymer welcome to tonights Chat
shaymer01	thank you
Moderator_DBecker	The AFA is pleased to have Dr. Craig Niederberger
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Moderator_DBecker	Main Topic: Initial Male work UP - but general question welcome
Moderator_DBecker	Hi Omit welcome to tonights chat
Craig_Niederberger	Thanks, Dan.
Moderator_DBecker	OK who want to ask the first question??
Craig_Niederberger	Welcome, Dana, Shaymer and Omit.
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Moderator_DBecker	Hi Lori welcome to tonights chat
Craig_Niederberger	Welcome, Lori.
Lori_Belle	Thank you.
Moderator_DBecker	Remember no question is silly = knowledge equals power
Craig_Niederberger	My area of specialty is male reproductive medicine, and I'm happy to answer any questions you may have.
omitatrivedi	Hello Dr. Niederberger. Does a mumps infection lead to male infertilty?
Moderator_DBecker	I do have one question - do you heat your examining room year round??
shaymer01	I don't think I have any particular questions yet, just here to learn
Moderator_DBecker	Shay - that is always a good place - but feel free to ask away
Craig_Niederberger	That's an excellent question, Omi. Many children have mumps, but occasionally it can infect the testis. It's called "mumps orchitis" when it does, and the testis swells up like the cheeks.
Craig_Niederberger	When that happens, occasionally it may lead to lasting effects on the making of sperm in the testis.
omitatrivedi	Is it possible to tell later on in adult life if the infertility is due to mumps?
Craig_Niederberger	We ask in the initial evaluation whether a man has had any childhood illnesses, and that's one of the reasons why.
Moderator_DBecker	Also is it that adult exposure to MUMPS can be more problematic?
Lori_Belle	Dr. Niederberge, what is your opinion of the importance of morphology in evaluating male factor infertility?
Moderator_DBecker	BTW if you ask a question and it is not answered right away be patient - it is not always easy to type one answer while reading other quesitons
Lori_Belle	Niederberger*, I'm so sorry I misspelled your name
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Craig_Niederberger	One way to figure out whether mumps affected fertility is to do a physical examination, laboratory tests like testosterone and FSH, and of course, a semen analysis. But there's no way of knowing specifically if the mumps was the reason.
Moderator_DBecker	Mgagnon welcome to tonight's chat w/ Dr. Neiderberger, chief of Andrology at Univ Chicago
Craig_Niederberger	Lori, that's an excellent question. In general, most sperm look funny under the microscope. Some have big heads, some have small. Some may have more than one head, some two tails. But in general, it looks like with the exception of extreme cases, the overall look of the sperm--its morphology--matters little to fertilizing potential. Study after study has shown that men with morphology numbers that are in the abnormal range are as likely to conceive as men with morphology numbers in the normal range.
Lori_Belle	My husband had 4% Kruger morphology last July
Lori_Belle	we conceived in February, but miscarried at 10 weeks
Lori_Belle	He works outside
Lori_Belle	Is it possible that working outside where there is a lot of heat may lower morphology scores?
Craig_Niederberger	There is an exception, though, and that's when all of the sperm have the same morphology problem--all have perfectly round heads, which would be missing an acrosomal cap--the holder of the enzymes that help the sperm get inside of the egg. Or all have tiny heads. Or all have huge round heads. These are very rare conditions, but they do affect fertility.
Moderator_DBecker	Doc can you explain the Kruger
Lori_Belle	That would explain why we conceived in the winter. But actually, if morphology is not a factor, then maybe not
Craig_Niederberger	Many men conceive with Kruger morphology at 4%.
danaabney	Dr. Niederberger - is there anything you can do or take to increase ones motility levels?
Lori_Belle	Would you recommend IUI in such a situation? (with the low morph)
Lori_Belle	sorry dana didn't mean to interrupt
Craig_Niederberger	That's an excellent question, Dana. There's a theory that l-carnitine, a chemical found in the epididymis, helps sperm motility, and a drug based on that. But there aren't any good double blind, placebo controlled studies, so the jury's still out. You'll find carnitine in many foods, especially energy drinks--just read the labels at the grocery store!
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Craig_Niederberger	Thanks for the question, Lori. IUI is meant to hasten pregnancy by bypassing the cervical barrier, which lets only one in several thousand sperm through. It's used in a lot of circumstances to "speed things along".
Lori_Belle	I have heard a lot about washing in those situations - does it really improve the quality of the sample and if so, which parameter (i.e. motility, morph...)
Craig_Niederberger	As for heat affecting the making of sperm (what we call spermatogenesis), it does. Certainly concentrated heat, like the condition where the testis is inside of the body, called "cryptorchidism". But we don't know exactly what the threshold is--many studies have measured the heat from a laptop, or even crossing your legs, but we don't know the exact change in temperature that damages spermatogenesis.
Lori_Belle	My husband has a congenital absence
Lori_Belle	Ultrasound has verified that it is not cryptorchidism, supposedly
Craig_Niederberger	Washing is the standard procedure to concentrate sperm for IUI, Lori, and it mainly increases the motile fraction of sperm, hopefully improving odds of the IUI cycle.
Craig_Niederberger	As for morphology, unless there's a specific morphological problem, like all of the sperm having perfectly round heads, morphology alone probably doesn't mean much.
Lori_Belle	oh, that's good to know
shaymer01	My husband has had a semen analysis with all reports within normal range. We have had 4 miscarriages in the last year and a half, all early, the longest at 9 weeks. I have had extensive workup and my RE thinks it is likely an egg problem. My question is, should there be other tests done on my husband at this point? What other causes of early miscarriage could be attributed to the male?
danaabney	My husband has hypothyroidism how does this affect sperm levels? Do you think once this is regulated sperm level will increase?
Craig_Niederberger	Hi Shay, you've just hit on probably the thorniest issue currently in the field. Could it be the sperm's DNA? Possibly. The tests under investigation to figure out sperm DNA are Comet, TUNEL and SCSA. There's a lot of disagreement about SCSA, and we're not sure what it means yet. Comet and TUNEL are turning out great results, but aren't quite ready for prime time.
shaymer01	so, they are not readily used? My RE office has never mentioned any further male factor testing/possibilities/
Craig_Niederberger	Hi Dana, there is a classic relationship between hypothyroidism and spermatogenesis. Hypothyroidism may exist alone, or may be part of a larger pituitary issue. Treating hypothyroidism may improve spermatogenesis, but other endocrine issues should be evaluated.
mgagnon123	My husband also has morphology that ranges from low normal to abnormal, with excellent count (e.g., 180 million). Last SA indicated 3% Kruger and 41% motility. He had a vas-reverasal (after 8 years) in Nov 2004. He's undergoing a fertility work-up (e.g., scrotum sonogram). Could you briefly explain why an 8 year vasectomy would reduce his sperm quality (he fathered 3 normal kids with previous wife)? Also, would long bouts of travel (many hours in car several times a week for work) cause problems? Any recommendations? -- Thanks, Mich
Craig_Niederberger	Shay, you can order a SCSA, but there's a lot of disagreement over the results by scientists and clinicians that doesn't come through on the SCSA report. Comet and TUNEL aren't yet clinically available.
Craig_Niederberger	There's a lot of information in there, Mich, and your husband will probably want to talk to the surgeon that did the reversal. In general, men who have successful reversals often develop antibodies to their own sperm--a product of the original vasectomy, not the reversal.
Moderator_DBecker	These are great questions and very informative answers
mgagnon123	Tragically, the surgeon took his life after his nurse left a surgical sponge in a patient and he was successfully sued. How would his current urologist (who has special training in male infertility) evaluation for anitbodies?
danaabney	My husband has also had a vas-reversal(after 4yrs.) in july 2005. His SA results seem to change considerably from test to test. None so far seem to be very consist. Is there any thing that could cause this? Doesn't seem to have any blockage.
Craig_Niederberger	Wow, Mich, that is a horrific story. If you've hit on a urologist with special training in male infertility--you're lucky--we train Andrologists (male reproductive specialists) who then go to University programs to teach residents, as fertility may be overlooked. If his doctor has training in Andrology, he or she will likely order the classic test for antibodies, the immunobead test.
danaabney	Mgagnon123 this sounds like our surgeon out of Tampa. We are in the same situation.
Craig_Niederberger	Dana, that is a great question. Any man's semen analysis varies widely over time, and that's one of the reasons it's difficult to assess male reproductive potential. In one famous study, a medical student gave a semen analysis every two weeks for a year. Not only did the analysis vary from week to week, it varied over months--dropping really low, and going really high.
mgagnon123	Danaabney: Yes, he was in Tampa. We traveled to him because he had an excellent reputation.
Lori_Belle	small world
mgagnon123	Also, isn't one of the main criticisms of Kruger methodogy that the inter-rater reliability can be low, which can produce varying results lab to lab?
Craig_Niederberger	For me, the proof is in the pudding. If a man with abnormal strict morphology is as likely to conceive with his wife as a man with normal strict morphology, I can't rely on the test to predict whether a man will conceive with his partner, or conversely, if he has a problem. Study after study has shown that, the most recent presented at the Annual American Urological Association meeting this May.
Moderator_DBecker	DR. Actually that raises a question - from your perspective how important is it to use the same lab for SA and other tests like LH???
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Moderator_DBecker	kkf welcome to tonights chat
Lori_Belle	I am 23 years old. My husband is 26. I have PCOS but ovulation is restored with metformin. He has 4% morphology but all other semen parameters are normal. My OBGYN has referred me to a fertility clinic after my recent miscarriage. I cannot afford IVF right now. If I go, what do you think they will recommend? If I will not do IVF at this point, is there a point in seeing the fertility specialist at all?
Craig_Niederberger	That's a great question, Dan. For the most part, blood hormone levels are performed in machines that are highly reliable. (Free testosterone is the exception--it's meaningless using the generally available clinical assays.) But a semen analysis is a high complexity test, and should be performed by a lab that commonly performs them, and is CLIA regulated. Often times, hospital labs will rarely perform semen analyses, and do them incorrectly.
shaymer01	This might be a misplaced question. But, my husband only had one SA. And we froze this sample and have continued to use it for our attempts. I am told, as I said before, that this was a good sample. Does freezing affect the viability? Also, for IUI we use frozen the morning after HCG injection. Shouldn't this be done later (at 36 hours) as I have read that frozen sperm don't live as long? (sorry, suddenly finding many questions)
Moderator_DBecker	When I was a patient my urologist would not accept tests done except for his lab!
Craig_Niederberger	Lori, that's a great question. I hope that my answers tonight are somewhat informative, but there's no replacement for sitting face to face with a doctor who specializes in the condition about which you're concerned.
Lori_Belle	that's true
Lori_Belle	I'm just afraid I'll be wasting my time
kkf	My husband and I have a healthy 3 yr old daughter. We got pregnant with her very easily....naturally. We were having trouble getting pregnant the secod time around. In all of our tests we found that my husband only has 1% sperm motility. No one can explain why this was not a problem when we got pregnant the first time and it is now. Any thoughts??? We're just starting our third round of ivf.
Craig_Niederberger	Talking to a doctor, and just asking questions and having them answered, is never a waste of time.
Lori_Belle	That's true, now that I think about it.
Lori_Belle	Thank you.
Moderator_DBecker	KKF did they do ICSI as well???
kkf	yes, we did icsi. we had 7 eggs fertilize, out of 14.
Craig_Niederberger	Shay, those are great questions. Typically I think of semen analysis as being for analysis or therapy. I typically recommend at least two "analytic" semen analyses (done in a good lab) to get a handle on a man's current fertility status. But semen analyses done for therapeutic purposes--for example with an IUI, or for freezing, can add information to the picture.
Craig_Niederberger	Sometimes, though, the amount of sperm is so small that you don't want to waste it. In that case, the lab can pool frozen samples.
shaymer01	We use frozen samples mainly due to my husbands travel schedule. It is unpredictible.
mgagnon123	What about varicoceles, esp post vas-reversal. The urologist notes that he wouldn't even recommend repair (if any are found) unless they are quite significant.
Craig_Niederberger	Hi KKF, sperm can really change dramatically over time. Having a low motility can be caused by antisperm antibodies (a man is making antibodies to his own sperm,) white blood cells killing the sperm, and problems with the genes and proteins that make up sperm.
kkf	Thanks for the info. Can it change this dramatically over 3 years? Or did we just get really luck when we got pregnant w our daughter? Also, is there anything he can do/take to help reverse this motility issue?
Craig_Niederberger	That's a great question, Mich. There are three kinds of varicocele, those that only can be picked up on a test like an ultrasound (grade I), those that the doctor can feel (grade II), and those that you can see through the scrotal skin (grade III). Treating grade II and III varicoceles may help spermatogenesis, but in the current era, most don't treat grade I varicoceles.
Lori_Belle	is a varicocele obvious to a man who has one?
Craig_Niederberger	The thing to be careful about with treating a varicocele after a vasectomy is that during the vasectomy one of the two main blood supplies to the testis is often cut. If the varicocele operation cuts the other blood supply, the testis may have a problem.
Craig_Niederberger	KKF, semen analyses can really dramatically change over years. I've seen in in practice over and over again. From earlier tonight: Any man's semen analysis varies widely over time, and that's one of the reasons it's difficult to assess male reproductive potential. In one famous study, a medical student gave a semen analysis every two weeks for a year. Not only did the analysis vary from week to week, it varied over months--dropping really low, and going really high.
Craig_Niederberger	That's a great question, Lori. Most of the men that I see who have grade II varicoceles don't know that they have them. Many of the men I see who have grade III varicoceles do know they've got something squishy in their scrotum.
Craig_Niederberger	And KKF, "luck" brings up one big thing:
Moderator_DBecker	I hope all of you are "members" of the AFA with our NO BARRIER PROGRAM it is FREE
Craig_Niederberger	Reproduction is all about luck. It's like rolling a big dice. Sometimes it's not about anything being wrong--it's about taking a little extra time.
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Craig_Niederberger	But when people get older, especially women, that dice has many more sides. So we're a lot more aggressive in treatment when women are a little oler.
shaymer01	Can you find a way to turn back time? I would appreciate that!!!
Moderator_DBecker	Also, a have a few minutes but I want to thank Dr. Niederberger for taking the time out of his busy scheduale to "chat" with us tonight on this very important topic of Male Factor Infertility
Lori_Belle	Yes, thank you Dr. Niederberger. You've been very informative.
Moderator_DBecker	Welcome Luna to tonight's chat - we have a few more minutes so ask away!!
Craig_Niederberger	I wish I could, Shay. But then I'd have to live through the past again ::rolleyes
luna	when will I be able to see a transcript of tonight's chat? I had trouble with my pc and couldn't log on in time.
Lori_Belle	Why the aggressive approach with older women? Is it related to egg quality?
Craig_Niederberger	My pleasure, Lori, and everyone. Thanks for asking such wonderful questions!
Moderator_DBecker	Luna it is usually up pretty fast
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Craig_Niederberger	Yes, Lori, women have all the eggs they're born with.
Meltini	I have come lat. Sorry
Craig_Niederberger	And studies suggest they may ovulate the better ones at an earlier age.
Moderator_DBecker	Hi Meltini - welcome to tonight's chat - our time is short but we have time for a questio or two
Meltini	My husband's Dr gave him clomid for a low sperm count. How much will this improve his counts?
mgagnon123	Many Thanks, Dr. Niederberger! BTW: I think a doctor who acknowledges "luck" and timing as 2 of many factors related to fertlity / pregnancy is being very honest. Thank you for that.
luna	could diabetes affect sperm abnormality. My husband came back with 22% normal
Craig_Niederberger	That's a great question, Meltini. Clomiphene citrate increases testosterone production in the testis, and sperm are very sensitive to testosterone.
Craig_Niederberger	Interestingly, if you give a man a testosterone shot in the arm it's the opposite of clomiphene--the body thinks it has enough testosterone, stops making it in the testis, and sperm count goes down.
kkf	Thank you!!!
Craig_Niederberger	Some have investigated using exogenous testosterone as a male contraceptive.
Meltini	So his counts will go up with the clomid?
Craig_Niederberger	Hi Luna, diabetes can affect fertility in many ways. In one way, it can affect ejaculation.
Moderator_DBecker	ON behalf of the AFA, again I want to thank Dr. Nieerberger, Chief , Div of Andrology at the University of Chicago College of Medicine for joining us tonight - GREAT JOB!!!
Craig_Niederberger	Thanks, everybody!
Lori_Belle	No, thank you!
danaabney	Thank you !
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Moderator_DBecker	GOOD NITE and ALL THE BEST!!!!!!!!!!!!!!!!!
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shaymer01	Thanks!
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Initial Male Work Up - What You Should Be Prepared For

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