When couples cannot get pregnant on their own, it’s stressful. But when they continue to fail to conceive even with help of fertility specialists, it can be devastating. This happens more often than most people think — the expensive, emotional process is unsuccessful about 20 to 30 percent of the time, OB/GYN and Reproductive Endocrinologist Dr. Ralf Zimmerman says. “Most of the time with fertility treatments, people come in with a lot of hope,” he told Fatherly. “A lot of times physicians don’t do an adequate job of counseling them appropriately and helping them come to terms with the fact that they cannot have a child.”
Zimmerman explains what it’s like to tell men who want to be fathers that they are infertile, what their options may be (including getting a brother to donate sperm on the sly), and how couples can cope with male infertility.
So, how often is the man exclusively the problem?
I would say about 25 to 30 percent the time. Most of the time, both partners actually have some sort of infertility problems. There are different grades, but the most severe form is when you do not find sperm in the ejaculate, but then you’d do a testicular biopsy and hormonal studies to see whether there are any sperm available. Most of the time even if you have a very low sperm count, as long as there are a couple hundred sperm available, those men can probably conceive because they can use a single sperm and put it directly into the egg through a process called intracellular sperm injection. Many times this goes well.
What are the other grades of sperm levels and what are their options?
Based on the criteria from the World Health Organization, what you would like to see close to that is 15 million per milliliter. If they have relatively good motility, haven’t been trying long, and the couple is in their early 30s, we’d typically tell them to keep trying on their own. If they have been trying on their own longer or their sperm count is lower, you’d resort to intrauterine insemination where you would select the best sperm with the best movement ability and then you would like to see 3.5 to 4.5 million motile sperm, that would be enough for when we did the insemination. If the number of motile sperm is less than 3.5 million, then many times we would suggest IVF. As you inject a single sperm into the egg, there are good fertilization results that way.
Have you encountered any unique concerns from men about IVF?
Passing on a lower sperm count is one of them. There was a paper at the meeting of the European Society of Human Reproduction and they had looked at young men who were conceived from men with significant male fertility factors. And the good news was that the young men conceived through this procedure had higher sperm counts and better sperm than their fathers. It’s pretty new and a very important result because we, as reproductive endocrinologists and also urologists, were always afraid that it would continue to decline and decline [across generations], and thank god it doesn’t.
Do men ever refuse fertility testing?
There are cultural issues sometimes. I’ve seen couples where the man will not produce a sample, and that becomes difficult for the couple. We tried to talk to the man, but sometimes it’s still a no, and there’s not much you can do about it.
What’s the issue exactly? Providing the sample?
The question of masturbation, yes. It doesn’t happen very often, but on rare occasions you have situations. Maybe there’s some fear that there would be an abnormal semen analysis. I think in our culture is more accepted that men are not infallible but in other cultures it’s maybe less accepted if you would have a finding like that.
Then is the worst case scenario for men? Is it just no sperm in the ejaculate?
There can be a certain location on the Y chromosome, and if this piece is missing then the ability to produce sperm would not exist. Then if they wanted to have a child they’d have to use anonymous donor sperm or sometimes, and we have to be careful about suggesting this, but if they want to maintain the lineage of the family sometimes in a few cases (though not a lot) a brother could potentially step in who has a normal sperm count. Then you can maintain the genetic lineage of the family.
Wow. Are people disturbed by that option?
Oh, absolutely. Whenever you would present such an option, at first it has an incestuous flavor, to some extent. But then you give a couple time to really think about it and process it and know that the sperm will be in a lab and insemination will take place and that there’s a contractual agreement, then some people are OK with it.
How does this process compare to an anonymous donor?
You obviously have to pay a lot of attention to disclosure issues and how the child will relate to the genetic father. All this has to be clarified in detail. So couples going down this road will have to go through a lot of psychological counseling and there’d be a psychological evaluation of the brother to make sure that everybody really is in agreement. There also has to be a legal contract too, because sometimes something really unexpected happens, and the key to what you have to do as a reproductive endocrinologist is to protect the rights of the child. To do that you have to cover your bases with unforeseen events.
What sort of unforeseen events have you encountered?
Let’s say they agree that the child should not be told and all the sudden somebody tells. There have been studies, but not very current or scientific ones, about people who found out later in life that they were conceived through sperm donors by going through their parents’ records and a lot of them felt really deceived by it. They wish they had been told. So if you chose to not tell the child, it really has to be air-tight.
What are the conversations like when biological conception is just not going to happen?
What I do, because this is obviously a process, I’ll refer them out to a colleague of mine for counseling. It’s a very fine line, you want the couple to have hope, but you don’t want them to continue to be stuck in that. If you did 10 years of fertility treatment it would be so traumatic for the couple. They can have 70 eggs still and several embryos left and find out it’s just not meant to be. It’s incredibly hard, but it’s something we don’t talk about enough.
Is there a number of times where trying IVF becomes unethical?
Different physicians obviously have different approaches. For me, if somebody has done two or three IVF cycles and you’ve gotten like 30 eggs and some nice embryos, then you have to ask yourself ‘Well, what is the issue?’ Under those circumstances, I would send them to a second physician who would review the records and make sure there’s not something anyone has overlooked. And then they would either try one more time or come to terms with the fact that it may not work and decide to stop. It’s a very difficult decision to make. Childlessness is very hard to accept. But once patients are inside the infertility machine, on one hand we have to help them, and on the other we also have to make sure that they can deal with the loss of control from not being able to have children.