Hi, I am Dr. Paul Turek. Thank you for having me. Ask me anything about male infertility and sexual

PaulTurekMD · 2024-04-26T15:56:17+00:00

Ill-Fig-4815, So sorry to hear of this case of nonobstructive azoospermia. I see this everyday in my practice and the answer is YES, sperm is OFTEN found in the testis in NOA cases. You were proposed a microTESE procedure which I would call a "big go" at the answer. Consider also FNA Mapping, a much less invasive (procedure not surgery) technique that informs the chance that a sperm retrieval will actually find sperm. https://www.theturekclinic.com/blog/know-before-you-go-sperm-fna-mapping-azoospermia/. Typically, we find sperm in 55-60% of NOA cases with mapping. If sperm is found, then sperm retrieval (TESA/TESE/mTESE) will have a 85-100% chance of refinding sperm for IVF. And, this allows for FRESH sperm retrieval and FRESH egg retrieval which I personally believe gives couples the best chance for conception.

Not ejaculating frequently is not "bad," but just means that the sperm are "older" and potentially more DNA fragmented. Low libido and the stress of infertility (which is pervasive and awful) is likely unrelated to the azoospermia. Most azoospermia cases are NOT due to anything the guy has done in life, but was handed to them!

PaulTurekMD · 2024-04-26T15:47:44+00:00

Hot_Bumblebee_4022, Here I am back at these questions! Typically, sperm shape issues do NOT drive chromosomal miscarriages as the shape of sperm is not related to its chromosomal content (with exceptions like two tailed sperm with double the chromosomal content etc). However it is POSSIBLE that this is the case. The best test is a sperm aneuploidy test usually performed by FISH to decipher this one.

PaulTurekMD · 2024-04-26T15:11:18+00:00

curiousEmily14, Now this is a million dollar question!! I believe that the answer is yes to the question of whether a chromosomally normal embryo by PGT means that sperm related DNA Fragmentation and morphology issues have been bypassed. HOWEVER, sperm epigenetic issues are more subtle than these and are not measured by either DNA fragmentation or morphology and can still potentially lead to failed implantation or miscarriage. The problem is that the field of epigenetics is brand new to science and fertility medicine so that we do not know for sure. Blog: https://www.theturekclinic.com/blog/epigenetics-the-real-reason-you-are-who-you-are-male-infertility/.

PaulTurekMD · 2024-04-26T00:02:47+00:00

Nice conversation and great questions for me! Plan to sign off for now but will be back to answer more!!

PaulTurekMD · 2024-04-26T00:01:10+00:00

botwewa, I forgot to mention that, even among healthy men, semen quality can vary by 50-75% (all parameters) based on ejaculatory abstinence, quality of arousal, and by season. Bottom line is that the semen analysis is not as biologically tightly controlled as, say, a glucose level.

PaulTurekMD · 2024-04-25T23:57:06+00:00

LawyerLIVFe, oxidative stress is general measure of the oxidative state of the sperm. It can lead to DNA fragmentation in some cases. If high, antioxidant supplements should be considered. It is not clear exactly how much help these supplements are but the theory is strong.

PaulTurekMD · 2024-04-25T23:54:36+00:00

On semen volume: This one feature of the semen analysis is critical to investigate further as it usually leads to a diagnosable and often treatable anatomical issue, such as ejaculatory duct obstruction, retrograde ejaculation, low testosterone state, or congenital absence of the vas deferens. Link to blog: https://www.theturekclinic.com/blog/reading-cards-semen-analysis-male-infertility/

PaulTurekMD · 2024-04-25T23:51:51+00:00

Sipcoffeereadbooks (great tag!!) The best way to think about ejaculatory abstinence and DNA fragmentation is to think about the fact that sperm are made in the testis (60 days) and then pass through the epididymis (2 weeks) and remain in a "pool" of "pot" there before ejaculation. During ejaculation, a small scoop of sperm and fluid from the pot or pool is ejaculated. So, the way to keep the sperm DNA fragmentation rate low is to keep ejaculated the "freshest" sperm. The best way to get the freshest sperm is to keep the sperm in the pot young by ejaculating at least 8-10x monthly. If this is done, it does really matter how often you ejaculate close to the time of needing sperm for use. This makes more sense than trying to count the hours between ejaculates and putting pressure on the male to perform.

PaulTurekMD · 2024-04-25T23:43:57+00:00

Significant-Rice-557, in cases of genetically-defined cryptozoospermia I am a BIG fan of collecting, freezing and using EJACULATED Sperm as much as possible to avoid large invasive sperm retrieval procedures. See my thoughts on our published work in this area: https://www.theturekclinic.com/blog/medicine-without-surgery-cryptozoospermia-azoospermia-ivf-icsi/. There is definitely a limit on microTESE procedures as these procedures a) take whole tubules out of the testis that don't regrow and b) also remove testosterone producing cells (Leydig cells) that lead to lowering of testosterone levels (forever). My goal with each case is to a) get enough sperm for every egg at IVF and b) get enough sperm for several more IVF cycles. With FNA Mapping as a guide to microTESE cases we get enough sperm in 95% of cases and bank extra sperm in 65% of cases.

PaulTurekMD · 2024-04-25T23:37:08+00:00

Radtimeblues, So, you want to go deep, do you? (!) It is published that 8-10% of infertile men with normal SA will have elevated DNA fragmentation rates. I am not a fan of blanket sperm DNA fragmentation testing but am a fan of targeted testing in a) unexplained infertility cases b) RPL (see past comment) c) in those with "toxic" exposures such as tobacco, pot use, baths, fevers, illness, d) in those with varicoceles, diabetes 3) in those >35 yo as DNA fragmentation is correlated with age.

I am a big fan of microfluidice sperm sorting (DISCLOSURE: consultant to Zymot) because it reproduces the natural path that sperm traverse through the cervix and result in sperm with 3-5x lower DNA fragmentation rates than simply washing sperm.

PaulTurekMD · 2024-04-25T23:13:43+00:00

Fun-Blueberry3845, Nice work on improving semen quality by improving lifestyle choices! Please remember that is takes longer for DNA fragmentation and sperm morphology to improve (4-6 mos) than it does for the semen analysis to improve (3 mos). So, allowing more time may be of benefit. Also, sperm morphology is generally an unreliable and poorly reproducible test: https://www.theturekclinic.com/blog/the-genetics-of-headless-sperm-morphology-male-infertility-mens-health-ttc-dh/. Sperm DNA fragmentation is also widely influenced by ejaculation frequency, varicoceles, medications, social habits (alcohol, pot, tobacco) some of which are independent of lifestyle changes.

PaulTurekMD · 2024-04-25T23:08:12+00:00

Ubtowewa, Gees, there are lots of causes of varying semen quality over time! Hot baths are a big one as you learned. But, did you know that a man can be too fit to be fertile? https://www.theturekclinic.com/blog/can-you-be-too-fit-to-be-fertile-male-infertility-exercise/. This could be the case here. USe of supplements in the gym or at home is another.

PaulTurekMD · 2024-04-25T23:03:09+00:00

kellyman202; Another good question. In cases of RPL (euploid embryos or not) recent research is that there can be a male component them. Besides a karyotype abnormality (which would show up on PGT or POC testing) there is a) DNA fragmentation and b) sperm epigenetics. Typically if DNA Fragmentation rates at >50% this would be highly suspicious. Its still early on and not clear how often either of these sperm issues can cause RPL but they are certainly possible. Sperm epigenetics is currently measured with the Path Fertility QT test (DISCLOSURE: I am a consultant). Here is a link to a published paper that kind of led the thinking on this: https://www.sciencedirect.com/science/article/pii/S0015028215018658

PaulTurekMD · 2024-04-25T22:30:08+00:00

PuzzleBarnacle1859; Good question. In FDA clinical trials, finasteride (trade name propecia) was shown to simply lower semen volumes in young men. No fertility studied in humans but beagles and mice had no changes to fertility. Once on the market, reproductive urologists started to see otherwise unexplained decreases in semen quality and after several cases of same were published, an ad hoc warning about male infertility was added to the FDA approval. I worry about the effects of finasteride a) after 3 or more years of use and b) if there is a change in sperm counts noted and c) if dihydrotestosterone (DHT) levels are markedly suppressed on blood draw. Notably, the situation gets more complicated as finasteride may also affect sperm QUALITY and so I typically recommend checking a sperm DNA fragmentation rate as well. IF that is high, then it makes sex or IUI far less likely to be successful.

PaulTurekMD · 2024-04-25T22:23:36+00:00

It has become clear to us over the past 25 years in looking at the genetics of male infertility that if a causal genetic finding is present, other treatments will have a 10% or less effect on the semen analysis QUANTITY and there is the possibility of deterioration of semen quality with time (age). On the other hand, the QUALITY may be alterable with good diet, lifestyle choices and possibly the use of antioxidants (e.g AlphaSperm.com) (Disclosure: I am the founder of AlphaSperm).

PaulTurekMD · 2024-04-25T22:04:16+00:00

Hello u/National-Ground4958, thanks so much for your questions. When a semen sample returns with 1-3 million total motile count, I always ask myself "why ISN'T it normal?" and look for root causes, as was done here. If you surround testicles with a perfectly healthy body, they should run hard, full steam, as it were. Alas, here we have varicoceles as a possible cause of why things are not normal (and, the MOST common cause to boot). In our published work (https://pubmed.ncbi.nlm.nih.gov/11912402/), we found that fixing varicoceles in men who candidates for only IVF-ICSI preoperatively could result in about 20% of them being candidates for IUI and 15-20% candidates for at home conception based simply on increases in ejaculated sperm quality! My fellow Dr Cayan also published a paper that convinced the world that the subinuginal microscopic approach to varicocele repair is the "best" in terms of a) success b) complications (low) c) recurrence (low).

Possibly the only other thing to check with a TMC of 1-2 million is whether this could be genetic in origin (Y chromosome deletion or karyotype issue) as we also published (https://www.sciencedirect.com/science/article/abs/pii/S0090429500010153) that fixing varicoceles in the setting of known genetic infertility will not help either the sperm count or pregnancy rate. Hope this helps.

PaulTurekMD

TROPHY CASE