Ranjith Ramasamy, MD, Director of Reproductive Urology, University of Miami Health System, talks about possible causes for male infertility and a particular treatment option.
Interview conducted by Ivanhoe Broadcast News December 2017.
When a couple is trying to conceive for the most part it always seems to fall on the woman if there is an issue. Do we need to be aware that sometimes it can be the man?
Dr. Ramasamy: Absolutely. In fact 50% of the time it is the man’s problem. But unfortunately in this society women get blamed for infertility and they often get presented to their doctor and after a lot of the workup in the woman the man finally says, oh maybe you should get checked out. And that’s when problems with the man in the couple who have infertility usually crop up.
Do we know on a national level about how many men suffer from infertility?
Dr. Ramasamy: Absolutely. One in six couples have trouble conceiving and, so do the math, about 50% of the time that is a male factor component involved in every couple that’s struggling with infertility.
What are some of the causes?
Dr. Ramasamy: The most common cause for male infertility is a condition called varicocele. This is a condition where the veins around the testes are dilated, the temperature of the testes increases and effects sperm production. Some of the other causes are genetic, smoking, using drugs, and also hormonal issues where men could have no testosterone leading to infertility.
Can that be related to age as well or no?
Dr. Ramasamy: Absolutely. The concept of having older men able to father children I think is a little controversial. I don’t think we have great data to say that older men are necessarily going to have infertility, very different from older women who we do know for sure have infertility. The only research that has been done is to show that when older men have children that it’s an increased risk of birth defects and autism and other psychiatric disorders in the kids.
Going back to varicocele again tell us what that is again and can it happen or is it something that someone is born with or is it something that can happen through trauma or an accident?
Dr. Ramasamy: So varicocele is basically dilated veins. It’s just like varicose veins that happens in the legs but it happens around the testes. Most of the time men have it around puberty and that’s when it gets first noticed. Some of the time it gets missed because either lack of examination or most men who have this condition are asymptomatic. And when they come to present with infertility it is the first time that it even gets discovered.
What can be done about it and how do you test for it?
Dr. Ramasamy: It’s basically tested using a physical examination. When a doctor sees a young man and has dilated veins around the testes, one of the conversations that they need to have no matter how young they are is to see if his sperm count needs to be checked. If the sperm count is abnormal, no matter what age they are, I recommend going ahead and fixing the varicocele. If the sperm count is normal and most men don’t have problems with their sperm count even though they have a varicocele, I usually just observe the varicocele.
You wouldn’t recommend something?
Dr. Ramasamy: You can check a scrotal ultrasound if there is a difficult scrotal exam
Describe the procedure, what you do and is it inpatient, outpatient, tell us a little bit about that.
Dr. Ramasamy: Sure, varicocelectomy is a same day procedure. It’s done under anesthesia and men will go home the same day after the surgery. The recovery is pretty quick most people go back to work in about two or three days and are up and about in about 24 hours. Now the varicocelectomy can be done either using the open approach or using the microsurgical approach. Here at the University of Miami Health System we use the microscope to fix the varicocele. Some of the side effects that can happen from the surgery itself are either recurrence where the veins come back after surgery or it can damage the testes or something called hydrocele which is fluid that can build up around the testes. Now using the microscope we’re able to avoid and minimize these side effects and also tie off all the veins as much as possible.
Once that procedure is completed that procedure opens up the veins? In other words this is like a varicose vein?
Dr. Ramasamy: Right, exactly. The procedure basically ties off the veins that cause this back flow of blood. The procedure is done so the blood gets rerouted through another venous system which does not have these leaky valves in these veins. So when the veins are tied off, the temperature in the testes cools off and it takes up to about three months after surgery for the sperm parameters to improve.
So you would maybe suggest to a couple that just went through this procedure wait three months and then start trying?
Dr. Ramasamy: Absolutely, absolutely. I don’t recommend that they wait for three months they usually can start having sex in about two weeks after surgery. But the best results following varicocele surgery will be seen at about three months after surgery.
How successful is this procedure?
Dr. Ramasamy: The varicocele surgery itself is very successful, up to ninety to ninety five percent of the time if that’s the couple’s only problem, then the couple can go on to conceive naturally. However if there are female factors involved, often that also has to get fixed so the couple can conceive naturally.
The couple that we’re going to meet tonight, obviously you probably have a very good bond with your patient, it seemed to work very well for him. What is believed to have caused varicocele with him?
Dr. Ramasamy: He could have had varicocele for a long time. I think one of the things that happened with John was that he had an accident and he was unable to conceive after that. And one of the things that we picked up on exam were these dilated veins which we were able to fix and he was able to conceive on his own after that.
Say they wanted to have a second child down the road would he possibly need another procedure or how does that work?
Dr. Ramasamy: Most likely not. I think the surgery is often successful enough that the sperm parameters improve at three months, they’re usually fairly durable and they remain high throughout the rest of their life as long as the surgery was successful and does not reverse with the blood flow. So if he wants to have another child he can certainly go ahead and have another child.
So for people around the country who see this story and they’re having trouble conceiving, and the woman has gone through the testing and they don’t think it’s an issue with her are you encouraging couples go seek help. Go see an urologist and look into this?
Dr. Ramasamy: Absolutely. If a female has gotten checked out and she does not have any problems or even if she has problems there could always also be problems with the male partner. At the least I recommend that the men get the semen analysis and if there is anything abnormal with the semen analysis they should see a urologist just for a consult to make sure that there is nothing else that can be improved.
Is this something that would be covered by insurance because of this issue?
Dr. Ramasamy: Most insurance companies actually cover the varicocele procedure. They deem it as a medically necessary condition and don’t look at it just as an infertility standpoint but more from a health standpoint because varicocele will not only improve semen parameters but also improve testosterone levels in men. So they look at it as a medical necessity and most insurance companies typically cover the operation.
So the condition itself what is it called?
Dr. Ramasamy: Varicocele is the condition. Repair is the operation, correct.
Could you describe the operation to us?
Dr. Ramasamy: Using a microscope, we identify these dilated veins that cause abnormal blood flow around the testes. We tie off the vein and more importantly we spare the blood supply to the testes. So we preserve the artery to the testes and we preserve the lymphatic to the testes which if tied off can cause testicular damage as well as hydrocele which are side effects from the surgery.
Say you’re a guy, but you’re not trying to have a child, if you do have varicocele is this something that could harm you or cause a problem?
Dr. Ramasamy: Absolutely. I see a lot of adolescent kids with varicoceles and I recommend a sperm analysis. If the sperm analysis is impaired I have a conversation with the kid as well as their parents about having it fixed and most parents because they want to have grandkids often rush to have the surgery right away.
How would you know you have it?
Dr. Ramasamy: It’s a physical exam.
But only a physical exam because as you said it’s asymptomatic?
Dr. Ramasamy: Correct. Yes.
You wouldn’t know.
Dr. Ramasamy: Some patients can have pain and you would pick it up that way, but most of the time it gets picked up just on physical pain.
When you were examining John it was like a bridge the sperm couldn’t get through?
Dr. Ramasamy: In John’s case he had already had two kids prior to his accident and following his accident he saw me, he could not conceive and he was not making any live sperm. So we diagnosed him with varicocele and we were able to fix the varicocele and he was able to produce motile and live sperm.
If you’re an older man and trying to conceive you probably write it off as old age?
Dr. Ramasamy: Absolutely, absolutely. There’s something called secondary infertility where couples have no problems having their first kid, and they go on and become older. The woman gets older, the man gets older and varicocele over time can cause his sperm parameters and sperm counts to come down. What happens then when you fix the varicocele then the sperm parameters improve and in fact it’s still the most common cause of couples that are trying to conceive for their second or third child and that still helps.
For the male, at what age would a man’s sperm not be motile anymore?
Dr. Ramasamy: No age. Producing sperm is like producing sperm from a factory. There is a machine that starts producing sperm as men go through puberty. The factory as the machines get older start producing lots of sperm but still damaged sperm. There is a decreased ability to repair when defects happen in the sperm and these damaged sperm start coming outside. So there’s lots of sperm as men get older but they’re just defective and damaged sperm. As men get older there is a risk of defects happening in the kids, but not really decrease in chance of conception as long as the woman is fertile.
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:
Ranjith Ramasamay
Joanna Palmer
Joanna@pitchperfectprmiami.com
Jose Boza
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