David Shin, MD, Chief for the Center for Sexual Health and Fertility at Hackensack University Medical Center, Vice Chair of Urology at Hackensack Meridian School of Medicine at Seton Hall University, talks about male infertility and sexual dysfunction.
Talk to me about something dubbed secondary infertility. Could you explain to me and to our viewers what that is?
Well secondary infertility is couples who are having difficulty having a child after they’ve already conceived the first time. So they’ve been trying for a year and for whatever reasons it hasn’t been able to happen naturally, that’s what we define as secondary infertility.
How common is something like that?
It’s about 11 percent of the reproductive population that has secondary infertility. So it’s more common than probably what you think.
Usually if couples have no problem the first time around, what’s the thought when they try to expand their families?
Well I think when they’re having difficulty the second time around, the question is what is going on, right? They may have been just lucky that first time around and they really always had an underlying medical issue. For instance, the guy may have had a varicocele. What’s a varicocele you may ask? A varicocele is dilated veins in the scrotum. It’s almost like how women have varicose veins in their legs. Men can have in their scrotum and what it does is it creates a heat effect as if the testicles are in a sauna all day, every day. Now being in the sauna 10 to 15 minutes no big deal – 24 hours a day seven days a week, not so good. So what happens is that it can impinge upon sperm production for the testes. It doesn’t work as well. So a guy may be having a low sperm count but it progressively is declining as he’s getting older due to this varicocele effect.
Is that the most common reason for male infertility?
In about 40 percent of couples who present for fertility issues, varicoceles are the most common reason at least on the male side. So that is definitely something we evaluate and look for. It’s very important. In up to 50 percent of the time, there’s always what we call a male factor involved with fertility issues. So when couples are having difficulty getting pregnant, it’s traditionally thought to be only a female problem. That’s not the case. Up to 50 percent of the time, there is a male factor present.
That was my next question. Has there been a change over the last couple of years? While you’ve been practicing, are men more willing to take a look at whether or not the issue could be on their end?
I think so. Men are definitely becoming more comfortable coming in. I think it also helps that there are more specialists like myself who focus on the male reproductive side. 20 to 25 years ago there were only a few of us around. If you go around the country there’s always going to be at least someone who is really interested in the male partners.
So how do you treat it, the varicocele?
They first have to come in for a history and physical examination. We examine men to make sure that they have the varicocele. After that, I usually have these guys undergo an ultrasound of the scrotum, just to confirm that the presence of these enlarged veins are there. Once we have that confirmation, typically it’s treated by surgery; what we call the microsurgical varicocelectomy. What that is, is a very tiny incision, a one inch incision, just above in the groin. We use an operating microscope to look at about 25 times magnification of the enlarged veins so that when we look at it, we tie off the veins that are problematic or the varicoceles as we call it. It’s a microsurgical varicocelectomy or varicocele repair.
Fortunately I’ve been doing this for a little while, so yes surgery can definitely be helpful. I tell couples when I counsel them in terms of undergoing surgery, an improved semen parameter is seen in about 60 to 70 percent of the time. What I mean by semen parameters is improving concentration, motility or morphology; so concentration is the amount of sperm per milliliter in the ejaculate; motility is the percentage of moving sperm, and morphology is the percentage of normal shaped sperm. Typically, the average onset of pregnancy is usually about nine months after the surgery.
So, is this something that for some couples is not a lengthy process?
Absolutely. For some couples it may not be. It may be as quick as say in a couple of months or so but you also want to be realistic because it’s not only just the men. You know when couples are trying to achieve pregnancy, it takes two to tango. So we want to also take into account the female factors as well. That’s why I think nine months is usually a nice average onset and realistic in expectations.
Are there risks to letting a varicocele go? Not treated, is this something that could develop into something worse?
Right. It’s a question I get all the time. So the varicocele is by itself not harmful. In other words, it definitely can impinge on fertility. It can decrease sperm counts. It may even decrease a man’s natural testosterone levels. So correcting the varicoceles is beneficial. However, if a man does not do it, it’s OK. The goal in correcting varicoceles is just to try to help improve upon a man’s fertility so that couples can achieve pregnancy naturally.
Are there other conditions that would also make it difficult for a male to be fertile?
Well, any time men come in with infertility, we always try to stress that they get evaluated. I think the hardest part is for them to walk into the door because even though they know there may be an issue, I think for men it’s difficult because you have to now face that issue and own up to it. So I always try to set up a comfortable environment for men to come in because A, it’s already hard enough for them to walk in, and B, once they’re here, well how do we now fix a problem right? This is what men want to do. I think in general, men want to just have things fixed. If there’s something fixable, yes, like a varicocele is very easy, but we also don’t want to miss cancer in these men. For instance, testicular cancer may present like this for infertility. In other words they’ve been trying for a while or they already have a child which is secondary infertility. They come in wondering what’s the problem? On examination, instead they have a hard mass on their testicle which is typically not painful. So they would ignore it or not even realize that they have it until they come in, get evaluated by a urologist and see, OK, now we have something else that’s going on. Yes, you are initially here for fertility issues but now we have another bigger concern that we want to take care of first which is cancer.
What do you think when you see – I don’t want to say the fruits of your labor, but you see what families are able to do?
You know what? Every time I see a smiling baby it really gives me great joy knowing that you’ve helped a couple to start a family or helped a couple grow their family when they have secondary infertility. It just really makes me realize what a privilege it is to be able to help these couples achieve this pregnancy and yes, I had some part in it, but I’m privileged that they allowed me to do that and that we were able to find a solution for them so that they can create a new family and go on from there.
Is there anything I didn’t ask you that you want people to know?
We always want to make sure that it is very important for guys to be evaluated. I think that’s the biggest thing because infertility may be due to an infection of the testes. It may be related to medications that they’re taking. There are correctable treatments we can offer so it isn’t just all surgery but when guys come in, it’s really about getting a comprehensive evaluation. There’s been some recent studies showing that infertility may be a marker of cancer to come whether it’s prostate cancer, lymphoma or thyroid cancer. Especially for guys who come in for an evaluation with me and may not have a primary care doctor, I may be the first doctor that they’re seeing. At least I’ve helped them get into the healthcare system and realize, OK, you need to take ownership of your health. It’s not about you, You may have a little one that you’re going to have to take care of and you want to be around for.
Is there anything about the treatment for this particular issue that you would want to make sure people know?
You mean about the varicocele? No, I think that it’s definitely something that we can intervene upon and help correct surgically. It’s an outpatient procedure. Men go home the same day. It’s also typically covered by insurance plans because varicoceles are a medical condition. A lot of times our couples come in and they’re concerned that they don’t have coverage for infertility. That just depends on state by state but varicoceles are a medical condition so I don’t really remember the last time that I’ve ever had any issues in terms of having the surgery pre-approved.
Interview conducted by Ivanhoe Broadcast News in December 2019.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
David Shin, MD
David.Shin@hackensackmeridian.org
551-996-8090
Mary McGeever
Mary.Mcgeever@hackensackmeridian.org
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