Infertility

What causes male infertility?

There are a large number of factors that can lead to male infertility.  These factors vary from sexual problems, poor timing of intercourse, prior childhood or developmental problems, medical conditions, prior surgery, infections, exposure to chemicals, genetic diseases, or even prior chemotherapy for cancer.  Some men are infertile because of a prior vasectomy and subsequently desire another child.  Recent publications have noted laptop computers left on the man’s lap may raise scrotal temperature.  Frequent hot tub use also raises the scrotal temperature, causing poorer production of sperm.  

Male infertility is a subspecialty that is involved in nearly 50% of all infertile couples.   Dr. Lowe has expanded operations to provide comprehensive fertility diagnostics and treatments for the male patient.  Many treatment options for men provide a lower cost approach to infertility than typical IVF.  However treatments can enhance the availability of couples to pursue IVF with success as well.  Patients previously found to have no sperm present on a simple testicular biopsy are ideal candidates for micro-dissection TESE, a procedure allowing for the recovery of small numbers of sperm for IVF in approximately 30-50% of patients.  This involves the use of an operating microscope and expertise on regions most likely to harbor foci of sperm.  Many men are finding themselves remarried after a previous divorce as well.  Often the idea of having a child together is limited by the man having had a previous vasectomy.  We offer patients the opportunity for vasectomy reversal (vasovasostomy or vasoepididymostomy) for future conception.  Other patients are found to have a varicocele that may inhibit testicular growth.  This is easily correctable with a simple microscopic operation after which the patient is able to return to normal activities in 4-5 days.  Finally, it is important for men to be evaluated if there are fertility problems as this can identify long-term health problems for the male partner.

Common causes of male infertility:

1. Varicocele (abnormal collection of veins around the testicle)
2. Vasectomy or obstruction of vas deferens
3. Testicular cancer (even before treatment)
4. Chemotherapy
5. Undescended (not dropped into scrotum) testicles at birth
6. Hormonal/low testosterone
7. Drugs
8. Prior radiation treatment
9. Trouble with ejaculation (common in spinal cord injury)
10. Genetic causes
11. Infection
12. Testicular failure

Even after a complete evaluation, up to 30% of men have unexplained infertility.

How is male infertility evaluated?

A complete history and physical exam is necessary to identify potentially correctable factors.  The most frequent test to evaluate male fertility is a semen analysis.  In this test, a man provides a semen specimen after 2-3 days of sexual abstinence.  The number of sperm, the concentration of sperm, the sperm movement and sperm shape are all evaluated to provide information.  Even in normal men, these levels can vary dramatically so it is often important to obtain more than one semen analysis.  A basic hormonal evaluation is performed including a blood testosterone and follicle stimulating hormone (FSH) level.  

Based on the findings of the above tests, further testing is directed at identifying reversible and irreversible causes.  A transrectal ultrasound may be performed.  At times, an evaluation of chromosomes is important.  A testicular biopsy may be used and a vasogram can provide further information in the appropriate patient.   The sperm can be evaluated for DNA damage or antibodies directed at the sperm can be identified as the problem.  

Are there treatments for male infertility?

There are a number of treatments that can successfully improved a man’s fertility and lead to pregnancy.  One of these is vasectomy reversal (vasovasostomy), a procedure where the healthy ends of the vas deferens are re-connected to allow the transport of sperm again after prior blockage.  For men with cancer, it is important to understand the goals of cancer treatment and efforts can be undertaken to maintain fertility options.  A varicocele can be treated with a simple microsurgical procedure (varicocelectomy) to decrease the backflow of blood toward the testicle.  Sexual problems or ejaculation disorders can be corrected.  Hormone levels can be returned to normal with the use of medications.  Even men with some genetic disorders, prior chemotherapy, or testicular failure can be found to have sperm in the testicle with microsurgical sperm extraction techniques.  With the success of assisted reproductive techniques (in-vitro fertilization and intracytoplasmic sperm injection), only a few sperm are needed for the possibility of a pregnancy.

Varicocelectomy

Varicocelectomy is a surgical procedure during which a small 1-2 cm incision is created in the groin.  The blood vessels and vas deferens leading to the testicle are brought to the skin level.  The veins are tied off individually to prevent the backflow of blood.  Using a microscope for this procedure limits the risk to the testicular artery and makes a hydrocele (accumulation of fluid around the testicle) less likely.  Most men notice an improvement in the semen sample after approximately 70-90 days.  Even for men who ultimately undergo assisted reproductive techniques, varicocele repair has been shown to be beneficial.

 

Vitamins/Antioxidants recommended to improve sperm motility and quality:

Recommended infertility antioxidants:

1. Co-enzyme Q10 (or Ubiquinol) 200-300 mg taken once daily

2. L-carnitine 1 gram taken once daily

If you are a smoker, consider adding glutathione 600 mg once daily

Vasectomy is a very common procedure with around 500,000 US men having this procedure performed each year.  Vasectomy involves blocking the flow of sperm out of the testicle.  It is most commonly done as a clinic based procedure with the patient able to return to work in several days.  Vasectomy does not produce immediate infertility, but requires a short period afterwards to clear residual sperm.  This procedure is as effective as any other type of birth control.   Men who have significant anxiety regarding the procedure have medication options to help them relax during the procedure.

Vasectomy should not decrease testosterone levels, change erections or decrease sex drive for patients.  If these occur following a vasectomy, it is important to look for underlying causes.

Approximately 1% of men will have scrotal pain that lasts longer than expected following a vasectomy.  If this does occur, there are treatments available and thankfully many men will ultimately have complete resolution of the pain.  

There are a number of treatments that can successfully improved a man’s fertility and lead to pregnancy.  One of these is vasectomy reversal (vasovasostomy), a procedure where the healthy ends of the vas deferens are re-connected to allow the transport of sperm again after prior blockage.  For men with cancer, it is important to understand the goals of cancer treatment and efforts can be undertaken to maintain fertility options.  A varicocele can be treated with a simple microsurgical procedure (varicocelectomy) to decrease the backflow of blood toward the testicle.  Sexual problems or ejaculation disorders can be corrected.  Hormone levels can be returned to normal with the use of medications.  Even men with some genetic disorders, prior chemotherapy, or testicular failure can be found to have sperm in the testicle with microsurgical sperm extraction techniques.  With the success of assisted reproductive techniques (in-vitro fertilization and intracytoplasmic sperm injection), only a few sperm are needed for the possibility of a pregnancy. 

 

Questions to ask your surgeon prior to vasectomy reversal (vasovasostomy or vasoepididymostomy):

1. How many vasectomy reversals have you done over the last 3-4 years?  How many do you typically do per year?  
2. Do you use an operating microscope?  How many microscopic surgeries do you do a year?
3. What is your success rate for getting sperm back to the ejaculate?
4. Are there other options I should consider prior to surgery?
5. What training have you received regarding vasectomy reversal?​

Home Care after Vasectomy Reversal

Follow these guidelines for your care after your surgery to help your recovery.

Activity

• Limit your activity for the first 5 days after surgery to light activity.

• You may return to work in a day or so.

• Limit lifting, pushing or pulling to less than 20 pounds for the next week. Also limit running and long walks. 

Swelling

Scrotal swelling from the surgery may take weeks to get better. You should call your doctor if the swelling is severe and the scrotum is larger than an orange.

• Use ice packs to the scrotum and penis for 15 minutes every hour for the first 48 hours when you are awake to limit swelling. Use a plastic bag with ice or a bag of frozen peas for the ice pack. Wrap a cloth or towel around the ice pack so the ice does not directly touch your skin.

• Wear a jock strap or tight underwear for the next week to support your scrotum and reduce swelling. 

Incision care

• Stitches will dissolve and do not need to be removed.

• Expect a small amount of blood may stain the dressings for up to 72 hours after surgery.

• For the first few days, apply two or three gauze pads to the site each day and as needed to keep the dressing dry. This will protect the incision and help keep your clothes clean.

• When you are no longer having any drainage, stop using the gauze pads over the site. 

Bathing or showering

• You may shower 48 to 72 hours after surgery. Allow the water to wash over the incision but do not scrub the incision. Dry the site gently by patting it with a clean towel.

• Tub baths should be avoided for 7 days after surgery.

• Swimming should be avoided for 14 days after surgery. 

Pain control

You will likely be sent home with a prescription for a few days of pain medicine. Use this only as needed. After 48 hours, most patients can take extra strength Tylenol (acetaminophen) or Advil (ibuprofen) for pain, following the label directions. Pain most often is eased after 5 to 7 days.

Sexual activity

You need to avoid ejaculating for 21 days after surgery.

Follow up

• You will have a follow up appointment in 6 weeks. Please call the office to schedule.

• You should have a semen analysis done 6 weeks after the vasectomy reversal. You will then need to have the analysis done every 3 months until pregnancy occurs.

• Please call the office for the script for the semen analysis if you wish to have this done closer to home. 

When to call your doctor

Call your surgeon’s office at 614-788-2870 right away if you have:

• Severe swelling, larger than the size of an orange

• A large amount of fluid drainage that soaks several pads per day

• Pain that is not controlled with pain medicine and use of ice packs

• Any signs of infection such as:

• Increased redness or tenderness around the incision site

• Pus type drainage from the incision

• Fever of greater than 101 degrees F 
　

You may also use MyChart to send a query or email Dr. Lowe at gregory.lowe@ohiohealth.com with concerns. This may require several days for a reply.

No sperm used to mean no children.  However with the introduction of in-vitro fertilization only a few sperm are necessary for a pregnancy.  Male factors play a role in up to 50% of cases of couple infertility.  Now, at OhioHealth, no sperm still allows options for men to become fathers.  

Dr. Gregory Lowe completed his urology residency at Ohio State prior to pursuing fellowship at the University of Virginia.  He trained in Mens’ Sexual Health and Male Infertility under Raymond Costabile, MD and Bill Steers, MD.  Dr. Costabile has performed nearly 2800 vasectomy reversals and he has been instrumental in the development of MUSE and Cialis.  His expertise and guidance rapidly advanced the training Dr. Lowe had previously received in male infertility.  Dr. Steers is one of the brightest minds in urology and provided research guidance in erectile dysfunction, especially following prostate surgery.  

Dr. Lowe grew up outside Cincinnati and went to Miami University (the one established before Florida was a state) for undergraduate studies.  He completed his medical school training in Toledo, Ohio prior to his residency at Ohio State.  Prior to fellowship, Dr. Lowe recognized there was very little male infertility care provided in central Ohio.  Unfortunately, this area is not taught in all residency programs and many practicing urologist are not comfortable with providing infertility guidance.   Dr. Lowe decided to return to central Ohio to become the first and only fellowship trained specialist to work full time in Columbus.

Infertility care for the male patient requires an understanding of the hormone influences and testicle role in sperm production.  Many of the male patients coming to see Dr. Lowe have not seen a physician in years.  At times, the infertility evaluation provides the opportunity to identify significant diseases such as testicular cancer, diabetes, genetic diseases or low testosterone.  Many of the surgical procedures in male infertility require specialized operating microscope training to be performed with the best chances of success.  Vasectomy reversal is most successful in the hands of a fellowship trained surgeon, and has success rates of greater than 95%.  Micro-dissection testicular sperm extraction is a surgical procedure to identify small areas of sperm production in men who do not have sperm in the ejaculate.  This procedure allows men with even 5-10 sperm to have a child through in-vitro fertilization.  Dr. Lowe enjoys seeing the ultrasound pictures and joy in the couples who achieve successful pregnancies.  He also knows the importance of sensitivity and care when telling couples they will not be able to have their own children.

Besides infertility, Dr. Lowe has an interest in low testosterone (hypogonadism) and hormonal imbalances in men.  Recent advertisements on tv and the radio for medications have made this a booming part of Dr. Lowe’s practice.  Testosterone has many effects in men.  Some men do not even realize how good they could feel with normal testosterone, and assume it is “old age”.  Testosterone treatment has many misconceptions and is difficult to study due to the normal fluctuations.  Testosterone does not cause prostate cancer and in some cases men with a prior history of prostate cancer are receiving testosterone therapy.  Testosterone also does not make men angry or aggressive.  In fact, most men on testosterone therapy have an improved and more stable mood.   There are many ways to replace testosterone and it is important to find the most appropriate for each patient.  Patients desiring maintained fertility/sperm production should not get testosterone injections because this will lower sperm counts.  There are treatments to help these men achieve higher testosterone levels without lowering sperm counts.

Many men presenting with low testosterone often complain of erectile dysfunction as well.  For most men, simply replacing testosterone will not restore normal erections.  Dr. Lowe focuses many clinical hours and research efforts into treating erectile dysfunction.  Many factors can lead to erectile dysfunction and it is now well recognized that the penis can act as “the canary in the coal mine”.  The arteries that supply the penis with blood are about half the size of heart arteries.  Therefore, men who present with erectile dysfunction have been found to have a higher risk of heart attacks in the next 10 years.  Usually the erection problems precede the heart attack by 2-5 years, and this provides an opportunity for intervention prior to an event.  Dr. Lowe takes this into account when treating his sexual health patients.  Often the evaluation is detailed to monitor blood sugar levels, cholesterol levels, blood pressure and medications used to treat each of these.  Men who fail the typical initial treatments of oral medication are offered penile injection therapy and surgical options.  The injection therapy works well and once men overcome the anxiety associated with a needle injection in the penis, the results are dramatic.  When men fail this approach, surgery to implant a penile prosthesis is a wonderful option.  Penile prosthesis is associated with very high satisfaction rates for patients and their partners.  The new penile prosthesis work well, last a long time and provide near normal feeling erections.  Surgery to place the prosthesis can be performed as an outpatient surgery and recent research has shown that success rates for this operation are highest when performed at a higher volume center.  With Dr. Lowe’s guidance, Ohio State’s volume has become one the highest in the state.  

Dr. Lowe enjoys one area of urology that has been notoriously difficult to treat, testicular pain.  He follows a protocol to allow a trial of conservative measures, followed by medication and ultimately resulting in surgery if needed.  Many of these men present requesting the testicle be removed because of their bother with the pain, however removing the testicle does not always resolve the pain.  Dr. Lowe offers microscopic spermatic cord denervation to remove the nerves travelling along the cord to the testicle and resulting in pain relief in 70% of men.  This is an area of active research for Dr. Lowe.  Many men struggle with this problem and few good solutions exist.  Dr. Lowe is ready to study a treatment algorithm to determine if a simplified way to address this problem is available for urologists.  

Dr. Lowe takes great pride in his clinical practice and works hard to ensure each patient feels respected and treated as an individual.  He provides new learning opportunities for the Ohio State residents and has been working to establish better care pathways for the patients being treated for all types of cancer.  Allowing men the opportunity to bank sperm prior to some surgeries or chemotherapy may be the only option for a patient to have children in the future.  

Dr. Lowe’s practice has grown very quickly in the last 20 months and he knows that involves more than just the care he provides.  “I love what I do and love treating men’s issues that are difficult for patients to discuss.  It’s not just me though; the staff surrounding me makes me look good.  Their care and compassion really shines.” 

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