Infertility isn’t just a woman’s problem. In fact, male issues contribute to fertility struggles more often than you may think. Join Dr. Carrie Bedient from The Fertility Center of Las Vegas, Dr. Abby Eblen from Nashville Fertility Center and Dr. Susan Hudson from Texas Fertility Center as they speak with Dr. Chris Schrepferman, a Louisville urologist with specialized training in male infertility. Listen as they discuss why they recommend more than one semen analysis, how testosterone therapy can cause infertility and how they treat a sperm count of zero. Have questions about infertility? Visit FertilityDocsUncensored.com to ask our docs. Selected questions will be answered anonymously in future episodes.
Infertility isn’t just a woman’s problem. In fact, male issues contribute to fertility struggles more often than you may think. Join Dr. Carrie Bedient from The Fertility Center of Las Vegas, Dr. Abby Eblen from Nashville Fertility Center and Dr. Susan Hudson from Texas Fertility Center as they speak with Dr. Chris Schrepferman, a Louisville urologist with specialized training in male infertility. Listen as they discuss why they recommend more than one semen analysis, how testosterone therapy can cause infertility and how they treat a sperm count of zero. Have questions about infertility? Visit FertilityDocsUncensored.com to ask our docs. Selected questions will be answered anonymously in future episodes.
You're listening to the fertility docs , uncensored podcast, featuring insight on all things, fertility from some of the top rated doctors around America, whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.
Speaker 2:Hi everybody. We're back with another episode of fertility Datsun censored . I'm one of your hosts, Dr. Abby , Ablin from Nashville fertility center. And today I'm joined with my friends, Dr. Susan Hudson from Texas fertility center and Dr. Carrie BDS from the fertility center of Las Vegas. We're also joined with our special guest , Dr. Chris Shefferman from global Kentucky. And we're going to have some really interesting questions to ask him about male infertility, but first Susan is going to cover the question of the day to day .
Speaker 3:All right. So one of our listeners , um, has written in that her AMH was technically within normal range, but still well below the median for my age group. Should I be concerned about this? What do you think, Abby ?
Speaker 2:I don't exactly know what the number is. I know the number that I kinda like to see. Um, I tell patients that there's no number at which they can't get pregnant, but I kind of liked for it to be over two is what I would prefer. It just means that they have a good number of eggs , um, and a little bit better chance of pregnancy. What do you think carry ?
Speaker 4:So in this particular issue, I am definitely of the philosophy. That more is more , um, and so we can get the better, but I agree there's no, there's no level that you can't get pregnant and it's just, how hard are we going to have to work to get there? Um, I like it to be at least one or higher and the higher it is. That means the more likely we are to see a couple that are coming out of hiding people always ask, well, can you make more eggs grow? No, I can't make more eggs grow. I live in Las Vegas, but I am not a magician. I can't make something that's not there up here, but I can try and cook something out that otherwise would not have grown. So if you've got an AMH of three, then yeah, I might be able to pull something out. That's not otherwise showing itself to us. If you've got an AMH of, you know , 0.5, what you see is most likely what we're going to get. So, you know, it's not, it's not good or bad. It's what is, and we're just going to work with what we got.
Speaker 3:One thing that kinda caught me by the question is the technically within the right range, but not appropriate for my age group. I don't ever, usually I don't usually consider AMH something about an age appropriate. So what I generally tell patients is if it's between one to three, I feel warm and fuzzy. If it's less than one I'm concerned, but I've even seen spontaneous pregnancies with undetectable, AME four , over three, we have lots of eggs and you may not be obviating .
Speaker 2:I agree. I haven't really seen a specific AMH for age and I thought I was the only one . So I didn't say anything, but yeah, I agree. I like to be high to high, as high as good.
Speaker 4:I started to see the labs produce reference ranges. Now where on the AMH they'll put, if it's male and he's between ages, you know, zero in whatever. And they'll divide it up into like three age groups for the guys and they'll put corresponding levels. And then for the women, they'll do a ton of age groups and they'll put corresponding levels and that's something relatively new that I've only started seeing
Speaker 2:In the past. And does it change your management? Not at all.
Speaker 3:What do you think about those reference ranges? It's kind of like reference, trade just for HCG levels that are completely meaningless to anybody who actually see somebody that's pregnant.
Speaker 4:I'm just like, all right, well, you know, that's a nice number. That'll give us a starting point on our conversation. That is absolutely baseless and the rest of things, but okay. We can, we can talk about that. Um, it's , it's a starting point, but ultimately it's looking at how many eggs do you have and can we get them out?
Speaker 2:Exactly. So today, as I mentioned earlier, we're joined by Drucker Shefferman, and I'm really nervous about saying that name. So can I just call you Chris, because that's going to be much easier to say it's a very complicated name, but for those of you who are looking at MK , it's spelled S C H R E P F E R M a N. And he's a urologist in Louisville, Kentucky, and he's a little bit of a rare bird because he is subspecialty trained in infertility. And there are very few urologists that are actually fertility trained, have done sub specialties in infertility. And so he's a very rare bird and he is going to talk a little bit about before we get started about his experience in living and working in Louisville for several years now. So Chris, tell us a little bit about what it's like to live in Louisville. I've actually lived there too . Um , and Chris and I cross paths for about a year, I think when I lived there and it is definitely a special town. So tell me what's so cool about Louisville.
Speaker 5:Well, thanks for having me. I , but you can certainly call me Chris. No problem. Um , Louisville, as you mentioned, and I think it was 2002, when you and I were both on Louisville briefly, I had first started in practice. And , um, I think the thing that I've enjoyed about Louisville is , uh, I , I'm kinda the first second generation male fertility specialists , meaning that it's such a small and new field that when I came into practice, I took over a practice of a person retiring a man named Arnold Belker, who was one of the, probably top two or three people in the world at that time. And rather than starting a practice from scratch, I was able to come in and learn from him as well, almost a second fellowship in many ways. And we had a lot of things set up here. Um, since that time we've grown our footprint in the region, for sure. Um, but the city is great. It's , uh , it's a wonderful place to live. It's close to where I grew up in Northern Indiana and my wife and family loved being here , um, around our , uh, the Darphin family is close by. And we've got Churchill downs here with horse racing, which is a big interest of ours
Speaker 3:At the horse races and all that type of stuff.
Speaker 5:Yes. In fact, my wife probably say we have too many of those. We've got boxes all over the house with big Derby hats that where all of our , all our family comes in. So it's a big, it's a big event Louisville for sure.
Speaker 2:Poorly. Do you wear a Derby hat, Chris , some men do actually wear
Speaker 5:No, they do. They do. Um , I , I do not. I do not. And I'm actually going the other way. I'm kind of almost starting to argue that we don't have to wear a tie even every year, cause it's sometimes pretty warm, but , uh , it's really an interesting event and we have 170 580,000 people day . So it's a really neat,
Speaker 3:Yeah, Chris, you're talking to some of us who live in Texas and Las Vegas, how warm really is one .
Speaker 5:Well, no, but I, but when you have a , when you have a coat and tie on 85 with 180,000 people feels pretty warm, so it can be pretty warm here,
Speaker 4:Like a seersucker suit. So it's designed for that kind of heat and that kind of humidity and to make you more comfortable. And you've got a mint Julep in your hand. And so it's designed for comfort.
Speaker 5:It's designed for comfort. Yeah, sure. Is. And in the spring, admittedly , we get some beautiful weather sometimes for sure. So it's a great time of year for us here and a wonderful event for our city.
Speaker 2:The more Midtjylland she drank, the more comfortable it gets, Carrie ,
Speaker 3:When I was in , I love hats. And when I was interviewing for residency, yeah. I interviewed in Lexington, Kentucky. And I remember like when I was checking out the city and everything like that, I went to into this amazing hat store. I'm like, you know, we don't have hat stores in Texas . If you go into a hat store in Texas it's cowboy hats, it's not ladies' hats. And it was, it was just an absolutely amazing place to be. It's just one of those unique,
Speaker 2:I'll tell you the other interesting thing about living in Kentucky in Louisville, you know, if you didn't know anything about horse racing , racing before you moved there, you learn it. And so I lived there for about six years and as it turned out, we had a few people who were really involved in the horse racing industry that were our patients. And the thing I really liked about the jockeys and their wives were I could look at them eye to eye . Let me just mention if I haven't already, I'm five feet tall and I could look at all of them out of it. And you see these big muscular guys, but they were exactly my same height. And so I'm sure Chris doesn't have that problem because I can't remember exactly how tall he is, but he is about a foot taller than I am or more , more than
Speaker 5:More . Yeah. Well, and I will tell you for this, for their size pound, for pound, they're probably the strongest athletes in the world, shaking hands with a jockey. You're going to your it's going to hurt for sure. They're really strong
Speaker 4:As they had to be so strong. Like I thought the whole point was to be as light as possible because they're trying to go as fast as they can.
Speaker 2:They do have a weight limit, but they're really muscular. They're really built and really muscular, but they have a hybrid Chrome and the weight requirements . So
Speaker 5:I mean, you're trying to, you're trying to steer a thousand plus pound animal, 40 miles an hour in a circle with 15 other horses. It's it takes a lot of power. And , um, even the exercise , if you've ever listened to an interview with a jockey, one of the major races they're out of breath and these guys do this multiple times, these men and women do this multiple times per day. And they are they're short of breath after a two minute ride. It's very difficult.
Speaker 4:The impact of jockeying on male fertility, just the up and down and the bouncing, like we get this about bike riding all the time out in Vegas because there's a ton of bike riders here for sport. And I hear it about jacuzzis and spas and all of those types of things. But I , I have never gotten the question of my husband likes to ride horses frequently. And is that contributing to his burn county ?
Speaker 5:I've not seen anything published. We, we certainly have tons of exercise writers that live in Louisville that ride and exercise horses in the morning. I have not seen a patient like that. I will say I did see a patient who fell in an accident, got stepped on by a horse and split at one of those festivals . And that probably impacted his fertility, but moving forward .
Speaker 3:So in Texas we have bull riders and I think there's some decent evidence that bull riding. I can understand bull riding and riding a horse completely different issue, but bull riding can have issues on fertility more
Speaker 4:Than just when they step upon your parts.
Speaker 3:Yeah. Cause they're like, like the amount of like impact is, is significantly more. It's a long seven seconds,
Speaker 4:But she said, sorry, I digress continue .
Speaker 5:Uh, as a most common you see a horse riding a jockey, riding a race. They're not actually sitting at a Saturday . They stay on for the most of the race. There's very little sitting. Um, so it's a very challenging thing to do athletically, but I don't know that anything published.
Speaker 3:So, so Chris kind of back to kind of , um, your background. So fertility trained urologists, like Abby said are , are pretty rare breed. I mean, in our area in central Texas, I know of two currently. Um, there's a few others in Texas. Like how, how many of there are y'all? I mean, even reproductive endocrinologists , there's only about 35 new ones each year for the entire United States. What what's kind of the population of fertility trained urologists.
Speaker 5:I'd say our society trains, let's say five to 10 new people per year. Um, I would estimate there are probably 150 to 200 out of us in the U S um, so it's, it's a new, you know, until say the mid nineties, when Etsy came about for really low sperm counts, there really wasn't much of a specialty. I mean, there were certainly microsurgical cases from secondary reversal. Uh, but uh, at that time, until that development, if you have low sperm count, we had a few things to try to make it better. Um , but if we could make it better than that, probably wasn't gonna work out for you. And now that we need only a single sperm per egg for in vitro fertilization, the whole, the whole specialty of testicles farm harvesting and microdissection of the test tool looking for even tiny amounts of sperm in people with the most profound problems with male fertility have led to successful pregnancies. So the snow field really grew from there. Chris was
Speaker 2:Saying earlier that that's been an issue that he's seen in a lot of patients around and they don't really know what to do. So what do we do, Chris? What do patients do when they have from their sperm count zero?
Speaker 5:Well, I think that the first thing that needs to be determined is whether the count is zero because the patient is making no sperm or extremely low numbers from, or whether it's because they have an obstruction to the outflow of that sperm. And that's an important distinction. Um, the term is called [inaudible] , which is a generic term. That just means we did a sperm sample on you and you don't have any sperm there, but it doesn't tell us anything about why. And so the difference between a patient who is obstructed and isn't producing any sperm in the ejaculatory versus a patient who is not obstructed and has a profound problem, making sperm to begin with inside the testable are two completely different patients for us. So it is important that you have a professional evaluation with somebody who knows how to handle this problem, particularly if you're told, Hey, it doesn't look like there's much we can do. That's not a truthful statement most of the time. Um, there are certainly times where that is true, but the number of people that we'd say now have complete sterility is a very low number of the people that we see
Speaker 3:Based on a single semen
Speaker 5:Analysis. No, I do not. Um, I always have people get to now, you guys have touched on this in your podcast before there's some reticence on the part of male partners on occasion to collect and whether that's a machismo bravado, whether it's embarrassment , um, whether it's just , uh , kind of an uncertainty of the process. Um, if that happens, I can live with one generally. I will say when, when you're told you have a zero sperm count, the point of the second sperm count is not to see if it's normal. The point of the second sperm count is what if there's just one because to a male fertility specialist one's from is a completely different patient than zero sperm. And so getting a second count where you see that is really valuable information,
Speaker 2:Chris, why's that? Why is it one sperm important to see? What does that tell you ?
Speaker 5:Sure. If you're in a situation where you have profound problems making sperm and you have a zero sperm count, ultimately a treatment down the road might be to look inside the testicle to see if there's any usable sperm for fertility treatments. And if you see no sperm of any kind, the chance of retrieval of sperm, surgically is around 55 or so percent. If you see one sperm or two sperm or fives from the , you can't use those necessarily for your treatments, but the fact that you're making some tells me that I have a 95 or 98% chance of findings from at the time of surgical harvest, it also tells me some interventions that I might provide may give you a chance to have improved sperm from a sperm image acculate , which would allow you to avoid surgery altogether .
Speaker 3:So kind of breaking up causes. So I think we have the obstruction causes and we have the kind of not making enough causes. Okay. So let's, let's start with the obstruction causes. Cause I think those are a little easier to grasp. What, what are causes of obstruction that you see ?
Speaker 5:Well, the most common cause of a zero sperm count is a previous disectomy and most men are going to know that they have that problem. And so they've had a previous surgery of having that done. I have had one patient that claimed he didn't know. Um,
Speaker 4:I tell you though, like I have gotten to the end of a good many consultations, and I was asked , you know, any surgery on penis testicle scrotum. And I'm like, no , Nope , nothing. And at the very end, I'll start going through and I'll say, okay, well, male evaluation , we need to see save analysis and then go, oh, you're not going to find anything. He had a vasectomy. You could all led with that.
Speaker 3:I had a patient once before that had had of the sec to me in a reversal, which he told me about the partner didn't know. And needless to say it was, he didn't have a completely successful reversal. And so obviously that was an important piece of information to be shared.
Speaker 5:I've certainly had patients who prefer their new partners, not to know some of that back history, which puts us in a little bit of a difficult position. Like you, we see patients together as a couple. And so when we have unexpected findings, it can get a bit, a little bit delicate in the room on occasion.
Speaker 2:I'm impressed, Chris, I didn't know. You guys saw both partners together. Very impressive. Yeah , I do . I like that. It takes two to tango. I think
Speaker 3:Mentality as a team.
Speaker 5:It is, it is. And it doesn't mean , you know, some of our guys kind of get hung up on, is it my fault or her fault? And
Speaker 2:Although I will kind of say, when you see a guy right before he's going to leave his specimen, he's just convinced it's his problem. And so you've never seen a more relief guy when you call him to tell him or tell him face-to-face that he has a good sperm count. It's like just the way that the world's come off his shoulders ,
Speaker 5:It is. And it also makes their life a little lives, a little easier moving forward. Most likely if it is normal. Cause certainly if you can isolate to mainly one side, it does make the path forward. Maybe a little more obvious sometimes.
Speaker 2:So going down, what we were just talking about, you had mentioned previous vasectomy is one of the causes for obstructive alias . Permia give me some other causes of that.
Speaker 5:Uh, we have a condition called ejaculatory duct obstruction. So if there's an obstruction at the level of the prostate gland, which is one of the male fertility glands that prevents the outflow of not only sperm, but of the semen as well. So one of the clues to that is when you see a really low amount of semen on your semen sample, if that volume is low, then and you see nose from then that's one of the considerations is that there may be a blockage at that duct level, Get the clogged pipe type right down right before the semen comes out. Correct . We usually unclogged that surgically, but the good news about that is that as a correctable cause of the problem , um , and then we see patients who are born without their duct work, that there's a duct called and Baton , the vast deference that carries sperm from the Tesco where it's made up to the evacuation center by the prostate gland. And there are people who are born either without those ducks or they're born with just portions of them, meaning they're partially blocked or incapacitated with thick fluid. And those patients , um, have a zero sperm count with normal semen volume. So that's one of our abilities to distinguish. Now, if they don't have any of the duct on either side, those patients may also have low semen volume because they also don't have the gland that they SEMA to begin with as part of that condition.
Speaker 2:And Chris , sorry to interrupt, but that's kind of a big deal for all of us. And , and can you explain how the genetic reason why that might happen to have a clogged or duck that's not?
Speaker 5:Yeah, there , there are two reasons that people have the Baz development problems. The most common that we see is that they are carriers for a disease called cystic fibrosis. And that's an important condition if you are a carrier for that condition. And honestly, most men who have no VAs on either side are NAR more than carriers. They're technically very mild versions of the disease because they have usually both, both genes are affected . They are going to pass on that gene. One of the, two of the pair to any offspring they have, where that becomes particularly relevant is if their partner is also a carrier. So if the female partner is a carrier than one out of four of their children with our assistance , I might add is going to have a child with cystic fibrosis, which is a very difficult and life threatening condition. And in young adulthood now ,
Speaker 3:Just to clarify, so even if they're only a carrier, they have an increased risk of having issues with their paths or if they own, or only in a situation where they,
Speaker 5:You actually see both in , in , in part because some of the genes aren't known. So you'll get a , I mean, I've seen people with , um, with that where you , they only have one positive and you think , I always tell him , Hey, you probably have one on the other side, that's small. Um, but yeah, it's , most of those people have one large deletion on one of their, one of their pairs and then maybe a smaller one on the other. Again, if they had the largest and most common deletion on both sides, they would actually have physical manifestations of that disease themselves. Most of the people I find are asymptomatic.
Speaker 2:So if there's a guy out there listening right now, who's kind of in this situation and he's been told that he has no sperm is it was in for him to get a test, to make sure he doesn't have cystic fibrosis, or should he see a urologist first? Or should he do both?
Speaker 5:I think one of the challenges is that it's, you don't know whether you're blocked or not, and if you're blocked and there's, somebody can determine that for you. And that can be on an examination. Sometimes it's on a needle biopsy. Once you can determine that, then those people definitely need to have cystic fibrosis testing. And that's true, even if they have a vast F-bombs on each side and we can't tell why they're blocked, if you don't know idiopathic obstruction, patients need CF testing as well. And so the difficulty which you don't want to get into is having people get all the testing for all the causes of zero sperm count. Because a lot of times that's an out-of-pocket expense for them. And so if you have obstruction, you need cystic fibrosis testing. If you don't, you don't need that testing, you need a different type of genetic testing that we can get into a bit later,
Speaker 2:We covered obstruction. Or is there anything else that's right up there on the list of obstructive causes of,
Speaker 5:Yeah, I'll say one more. Um, there are occasionally people who are born without one vest deference, so they won't necessarily have a zero sperm count, but if you're missing a vast difference, they're often missing the kidney on the same side. And we'll sometimes see patients who have a zero sperm count because they have a partial block on one side and a completely absent as on the other. And occasionally they have kidney development problems as well.
Speaker 2:I didn't know that that's interesting. It's sort of analogous in women when women have , uh , an abnormal abnormality on one side with their uterus. A lot of times they also are missing a kidney. I didn't realize there was a nail correlate of that. That's kind of interesting. Very cool.
Speaker 5:Yeah. It's a fetal it's , it's a fetal development problem with the meds . Whenever done .
Speaker 4:Can you pick up most of these obstructive abnormalities just on physical exam has done by?
Speaker 5:I would say that , um, yeah , I , I practice with 28 urologists, so not all of my partners can, but definitely male fertility people can. And so some of the cues we look for is what does the epididymis gland feel like? Which is the gland behind the testicle . If that gland is enlarged and from that are used, that the patient's still making a lot of sperm and it's kind of getting hung up there and it's not able to go downstream. So I can tell that , um , if the testicles are normal size, you can't really rule out a non obstruction problem there, but if they're quite small or soft and abnormal feeling, you can say pretty certainly they're not obstructed. So obviously if I can examine them and feel they don't have a vest deference that gives them the clue right away, that they have an obstruction problem on almost every case. I'd say probably 10% of the time. I can't tell. And I'm , if you can't tell on examination, then we move on to the other parts of the evaluation.
Speaker 3:I know you kind of mentioned something that you referred to as a needle biopsy. And I know a lot of times guys are really not excited about just the way that sounds. Could you maybe explain that a little bit to take the mystery out?
Speaker 5:Sure. I'm a needle biopsy. Everyone has the same. All the guys had the same reaction. Oh man, I don't want to do that. That's understandable for sure. Um, but
Speaker 4:The mildest version of that reaction, then I may have brought them to a patient.
Speaker 5:Yeah. I've heard profanity and the response for sure. But we actually do have them in here in the office and we do that with a local block, much like all of our prospective new patients, it's the same block we do. It actually stops all the pain fibers coming from the testicle and uniformly. I can give you lists of patients that say, I can't believe that's how you do that load . It's a very, very straightforward process. And we actually do two things. We do the needle biopsy in an effort to see whether people are blocked or not. And then secondly, while we're there we go ahead and collect and freeze this from. So the used to be that a diagnostic biopsy was performed in the operating room. That's almost never done by anybody who has experience in this field. Now we do diagnostics and , and treatment, meaning freezing and collection of sperm in the same procedure that's done in the office for an obstructed patient. We get enough sperm for as many IVF cycles as most people would ever care to try. Uh , and it's about a 20 minute procedure with the two day recovery.
Speaker 2:And let me, let me just throw one funny thing up there. Not only does he do that in the office, he gives it to him and they deliver it themselves to our is , which is a few hours away and it saves them a lot of money. So it's great. The patients love that part of it.
Speaker 5:Yeah, they do. Cause I think the whole thing in our office is a very, very low cost compared to involving an operating room, for example, and the sperm , uh , sperms quite Hardy. I mean, you could even spar book fine the next day in the right fluid . So , um, there's plenty of time to transport it a few hours away if needed. Um, there are, there are causes that are inborn and certainly we have genetic explanations for that. We probably know a fraction of the genes that are responsible for male fertility. Currently, there are some that we know of and test for. Um, there are things that happen to patients throughout their lives that also impact their fertility. One of the biggest ones we see now , uh , which is a real shame, unfortunately it's temporary. Most of the time is that patients are placed on testosterone therapy. And so it's a very difficult process to understand. So I always draw it out for patients and a lot of my partners,
Speaker 2:Chris, in testosterone in that didn't that make men more virile and more fertile. That's what people think.
Speaker 5:And it does, you know , certainly helps libido and sexual function and energy levels and staying fit and keeps protects bone health. It's a very important hormone. Um, it's just the way the pituitary gland, the testicle were together. If you give testosterone directly into the bloodstream by injection or gel, those patients will turn off their pituitary hormones, which then turn off their own production on the testable . And if you're not making your own testosterone in the testicle, you can't produce any sperm. So the typical story we'll get is somebody had a lowish sperm count. They were placed on testosterone to make it better. And in reality, it made it worse, comes down to zero and then I get them on full freakout mode , um , as you would. And if it was an important thing to you, the last thing you want to hear is, Hey, I gave you a treatment and now you're zero. Um, so the nice thing about that is within a few months, now it takes a little bit of time, but within a few months we can treat you and improve your testosterone analyte and make sperm count often better than before.
Speaker 3:That's in the situation of somebody who was on it for relatively short period of time. I think all of us sitting here, I've seen those gentlemen, who've been on testosterone for five, 10 years and that's , that's a different ball game. Isn't it, Chris?
Speaker 5:Yeah. I think if you look at dose and you look at duration, so if you have people on gala , for example , um, teenage boys who fail to develop puberty, then they'll go on testosterone therapy. And so they can be on therapeutic replacement for many years and we can recycle them and get pituitary hormones going when they're interested in fertility. I think the trouble we see is the long-term abusive levels that are occurring in many of these cash clinics that you'll see around. Uh , people are treating outside the therapeutic window and it's , um, we do have trouble recovering sperm in those men. Sometimes we recovered none . I will say most of the time we get them to where we have something , uh , where they can get a few of the ejaculatory where we can harvest them. Um, but yeah, you definitely make your life a lot harder by using high dose testosterone. What
Speaker 3:Do you consider as the therapeutic window? I mean, I've had, I know I had someone recently that it was like over a thousand. That seems really high to me, but you know, I'm a female doctor for the most part.
Speaker 5:Yeah. Well , um, it depends a little bit on how you replace it. So let's take the most common way of replacing. And that is a weekly testosterone injection. When you give the injection, the highest level that you have is the day after the shot and the lowest level you have will be the day you give your next shot. And so there's a, there's a declining range for seven days. So we consider the mid cycle testosterone level, which I check on day three should be between five and 800. So if you check the day after a shot, you could have the over a thousand. If you check the day before a shot, it shouldn't be over about 300. That makes
Speaker 3:Sense. That makes sense. It's interesting.
Speaker 2:I did not know that.
Speaker 4:So what other testing do you, do you want to do when you, you're not suspicious of obstructive [inaudible] you think this is an underlying hormonal functional condition? What, what other testing do you want?
Speaker 5:We start with a full hormone panel, which would include pituitary hormones, testosterone levels , thyroid studies. And honestly, I'm hoping that the pituitary tests are abnormal because if you have a really poorly functioning pituitary gland there, I can easily replace those hormones and you'll begin making sperm. That's good quality in a relatively short time, three months or so if those are not the, and that's not usually the case, by the way, I mean, most of the time we'll find that that is not a pituitary condition, so that's not a pituitary condition. Then we also get genetic testing performed. We do a test called a Y chromosome micro deletion passe . And we do a karyotype, which is a way to look at whether you have the proper pairing of chromosomes. Yeah . Prolactin is on our initial hormone panel.
Speaker 3:So what types of, what types of abnormalities do you find with the Y chromosome microdeletion test or the, or the karyotype w what are some of the possibilities and what do you do?
Speaker 5:Well, I think that that is part of the problem we come into is that we can't always change those. So if you have an abnormal karyotype, for example , uh , one of the most common will be something called Kleinfelter syndrome where a male patient has been granted or has inherited an extra X chromosome that can have fairly profound impact on the testicular size and the sperm production. And it can have fairly mild impact. Really. There's actually a condition called mosaic Kleinfelter syndrome. That actually, you were almost made me feel very confident that you have a chance of findings from in those patients. Whereas , um, the other thing we see is something called a Robertsonian translocation. So if you see a translocation in the karyotype, that will predict, even if you find sperm that you may have difficulty with recurrent miscarriages, and that's very, it's valuable to know going into the, to the IVF cycle in that case, because you could then do PGD and maybe identify embryos that are at risk for that
Speaker 2:Filters. Do you find , um , situations where couples can actually have a healthy pregnancy if the male patient
Speaker 5:Yeah. We'll , we'll find sperm , uh, 40 to 50% of the time, and then you'll end up with the IVF pregnancy that's depending on the lab you use, can it be anywhere from 40 to 60% pregnancy based on that even a really, really small testicles, actually, sometimes they're easier to harvest because they tend to tend to have very small testis volumes . So if you have a tubule that happens to have sperm in it, it's a very obvious tube , much, much easier to get.
Speaker 2:Great. This has been really interesting, Chris. Um, thank you so much for being here and , uh, I think it'd be great to have you back, cause I think there's plenty of other questions and things we could talk about related to malefactor fertility. So we really appreciate your time. Are there any kind of closing statements that you'd like to make, or, you know, one, one piece of information you'd like for our listeners to really , um , take home with them?
Speaker 5:Yes. I think if , if you are told that you don't have any sperm and you need to move on to non-genetic alternatives and you don't necessarily feel comfortable with that, be sure that you've spoken to a male fertility specialist. Many of us will do teleconference visits for out of town patients. Uh , we'll give second opinions on the testing that's been done. And while it may not be an easy process at times, you can certainly achieve genetic pregnancy in , unless you've been told that by one of us. Now, if we do a search and we don't find anything, and that does happen on occasion that we can help, but I would not take that for an answer unless you've spoken to somebody who does this for a living.
Speaker 2:Very good information. Thank you so much, Chris. Thanks for having me. You're welcome to our audience. Thanks for listening and tune in next week. For more also be sure to subscribe and leave us a review in iTunes. We really love to hear from you
Speaker 3:Also visit fertility DocSend censored to schedule an appointment with any of us there . Submit specific questions you have about infertility . All questions will be answered on the podcast anonymously in our ask the doc second . So don't hold back. We can't wait to hear your questions. All right .
Speaker 2:All right. We'll talk to you all soon. Have a wonderful week.