Dr. Philip Cheng was recently interviewed on the Healthcare Strategies podcast, discussing male infertility, a growing concern that affects 1 in 5 couples in the US. Listen to the podcast below or read the full episode transcript below.

Alivia Kaylor:

Hi, and welcome to Healthcare Strategies. I'm Alivia Kaylor, senior editor of Life Sciences Intelligence and Pharma News Intelligence. Today we are speaking with Dr. Philip J. Cheng, a urologist at Reproductive Medicine Associates and Peak Men's Health.

Dr. Cheng, thank you so much for joining us today.

Dr. Philip J. Cheng:

Hi. Thank you for having me.

Alivia Kaylor:

Of course. As we start, if you will briefly share your educational and or career background that led you to specialize in male fertility.

Dr. Philip J. Cheng:

I'm happy to. So I went to college and medical school in Houston, Texas. I did a combined program with college and medical school. I went to Rice University and Baylor College of Medicine. And during medical school, I always knew I wanted to be a surgeon of some kind, and my urology rotation in med school led me to really loving the field and the variety of surgeries and the different problem issues, and I liked dealing with kind of more sensitive issues. And so I went to residency at Harvard Medical School in Brigham and Women's Hospital in Boston. And during that time I decided to further specialize, and I did a one-year fellowship at the University of Utah in male infertility, sexual medicine and reconstructive urology.

So very specific kind of niche field. And it was at that time where one of my program directors actually showed me this job opportunity here at Reproductive Medicine Associates of New Jersey. And now I'm the head of the urology department at this large fertility group doing mostly male infertility.

Alivia Kaylor:

Excellent. What a background. Thank you so much for sharing.

Unfortunately, it's often assumed that women are responsible for a couple's fertility problems when actually men are just as likely as women to be the cause. Can you please explain male infertility? What causes it? How common is this?

Dr. Philip J. Cheng:

Absolutely. Infertility in general in the United States is very common. Roughly 15% of couples in the US will experience fertility issues. Over 50% of the time, there is a male infertility issue. So we generally say that about 30% of these cases is solely due to a male issue, and the other 20% of the time there's a combined issue of male and female. So 50% of the time there's going to be a male issue.

Male infertility can be caused by a lot of different factors such as an abnormality with sperm production, such as low sperm production or abnormal numbers of normal sperm or modal sperm, moving sperm. There could be an issue with an obstruction, so sperm not making its way out. One aspect of fertility that a lot of people don't think about is sexual dysfunction. So a man could have totally normal sperm parameters, but if he has issues with erectile function or ejaculation, then couples can have issues getting pregnant.

Alivia Kaylor:

Gotcha. Yeah, that's an issue I feel like most people don't consider.

Moving into my next question then, what treatments are available for couples with male infertility issues and have erectile dysfunction as you mentioned? And then moving on, the next question is, what about for same-sex couples instead of heterosexual couples?

Dr. Philip J. Cheng:

In general, there are a lot of different treatment options for male infertility, and it ultimately depends on the underlying cause. So if there is a hormonal issue, and male infertility is very closely tied to hormonal issues, testosterone production, things like that. And so if there's an issue with someone's testosterone production and that's the cause of sperm production, then I can prescribe some medications that can help with that. So optimizing someone's hormones, optimizing someone's testosterone levels can certainly help.

Some people have an issue with the hormones that are necessary for stimulating sperm production. One of such hormone is called FSH follicle-stimulating hormones. So I can prescribe the sexual medication to stimulate the testicles to produce sperm. For some men, the solution is going to be surgery. If someone has a blockage of sperm or is unable to ejaculate, then I can do a testicular sperm extraction where I'm getting sperm directly from the testicle itself. And then we use that sperm for assisted reproduction such as IVF, in-vitro fertilization.

A lot of men out there who've undergone vasectomies ultimately changed their mind at some point in time and want to have kids again. And there are also plenty of men out there who've gotten vasectomies and never had children before. So about 6% of men who've undergone vasectomies do change their mind, and so that's not an insignificant number given how popular the procedure is. And so for these men, there are a coupled surgical options. One is a sperm extraction that I mentioned before, and you can use that sperm for IVF. And another option is a vasectomy reversal, which is a surgery that I do putting the two ends of that tube that was previously cut, putting them back together again and allowing couples to try naturally.

One of the most common causes of male infertility is a varicocele. Varicoceles are dilated veins in the scrotum. They're very similar to varicose veins in the legs that a lot of people know about. These are veins in the scrotum that can essentially increase the temperature of the testicles and negatively impact sperm. So for these men, fixing the varicocele surgically through a small procedure in the groin is a way to potentially improve chances of getting pregnant. And so that's one of the most common surgeries that I do.

And one of the last surgeries is a microTESE or microsurgical testicular sperm extraction. And this is a surgery that's specifically for men who are not producing any sperm in the semen. And so about 50% of the time in these men, they're producing very small numbers of sperm in the testicle themselves, and I can do a procedure to actually look for that sperm and help them achieve pregnancy through IVF.

So yeah, we have medications, surgeries. Another category of treatment is lifestyle changes. So these are things that men can do to try to improve their fertility, improve the numbers of sperm they're producing or the quality of the sperm. And so that can be anything from exercising more to eating healthier, losing weight, avoiding exposures to anything that I call it gonadotoxics. Or things that are really bad for the testicles, such as excess heat, hot tubs saunas, seat warmers, laptops on the lap, or substance use. Basically any use of substances that you can think of is probably bad for your sperm. So that includes alcohol, tobacco products, nicotine, cannabis, opioids, illicit drugs, all of these can negatively impact sperms. So just making these sorts of lifestyle changes can certainly help with fertility.

And I had mentioned before that sexual dysfunction such as erectile dysfunction can be the cause of infertility. So if that is the cause, I treat those issues all the time. About 50% of men age 40 and older have some element of erectile dysfunction. So it's very common, particularly among my patients who are trying to conceive. The longer it takes, sometimes the more performance anxiety men will develop. And couples are also having sex around the time of ovulation, which could be at a time where they may not be in the mood and it may be harder for them to perform, so to speak. So I prescribe medications to help with improving erectile function and other sort of sexual issues such as premature ejaculation or difficulty ejaculating, things like that.

All of the treatment options that I mentioned before can apply to same sex male couples. These couples can also experience the same hormonal issues or sperm production or sperm blockage issues that heterosexual men experience, the same sexual dysfunction. The main difference is that these couples, or even single men are going to be unable to achieve pregnancy without the help of either an egg donor or a gestational carrier if the route they want to take is to have kids using their sperm. And so that's something that our fertility center helps patients with all the time, helping these men find egg donors where we can do IVF using their sperm and an egg donor and then they can achieve pregnancy using a gestational carrier. A lot of people call it a surrogate.

Alivia Kaylor:

Excellent. Thanks for that awesome explanation. It's really cool that there's a wide range of treatments for these males out here who experience infertility or subfertility.

In a review in meta-analysis published in Human Reproductive Update, researchers found that the global average sperm count dropped 51.6% between 1973 and 2018. Additionally, the publication notes that the decline became steeper after the year 2000. And in 1972, the decline per year was 1.16%, but after 2000, the yearly decline was more than double that at 2.64%. Do you believe that this trend will continue in future populations? Should we be concerned yet?

Dr. Philip J. Cheng:

Thanks for bringing up this paper. It definitely made a lot of headlines for obvious reasons, and I do think that it has a lot of really important points. I think in general, the study was well executed. It's a very comprehensive meta-analysis including data from 223 studies.

And so overall, it's very comprehensive and I think that there's a lot of accuracy to it. I do think that infertility rates among men are on the rise. And although the study itself doesn't go into evaluating like the causes of this decline in sperm counts, we can make a lot of educated guesses about why, and it's probably multifactorial. I think that some potential causes are rising rates of obesity in the global population. There's definitely a decrease in physical activity. And diets are getting worse, we're starting to eat a lot more processed foods around the world. And there's also an increase in exposures to environmental toxins, pollution, chemicals in our environment. As the world becomes more industrialized, I think this is affecting communities that didn't previously see this rise in infertility. And some of these exposures are to mothers while they're pregnant, and we're finding out that these sort of substances and chemicals can affect the developing fetus, including the reproductive tract, and so that could be a cause of why fertility rates are rising as well.

I don't think that there's reason to panic yet. The average sperm counts are still really high, still in the millions, in the double-digit millions, which is what we want to see at a minimum. But I do think that we need to take this data seriously because I wouldn't be surprised if this rising rate of sperm count decline continues to get worse and worse as time goes on, particularly as we start to get exposed to even more chemicals and diets get even worse and obesity rates rise even more. So all the reasons that I mentioned for why sperm counts are declining, none of these things are improving right now. And so I think it's a bit of a wake-up call for us to really do something about this. I'm definitely seeing a lot of pieces of infertility that could be linked to some of these things.

Alivia Kaylor:

Thank you for that explanation. I like that you added the aspect about environmental surroundings as well as the obesity. I feel like those both are very huge concerns that you pointed out. So it'll be interesting to see, especially if we adopt any type of sustainable practices or healthier health measures for the populations to see if that affects this decline in any way, shape or form.

And unfortunately, there is still a stigma that surrounds male infertility and low sperm counts. How can health providers such as you tackle this social construct and help normalize this condition?

Dr. Philip J. Cheng:

That's a great question. I think that in general when it comes to healthcare for men, we know that healthcare is underutilized by men. Men are less likely to have primary care physicians. They're less likely to initiate infertility care. They're less likely to see physicians like myself, rather than the female side that is more likely to initiate this evaluation and seek out a female reproductive specialist. And I think that a lot of that does have to do with stigma. I think that there is definitely a concern with masculinity and dealing with these issues. A lot of my patients who do come in for these evaluations feel a lot of shame if the primary issue is a male infertility problem, it's a sperm issue.

And I just try to explain to these patients that ultimately... Particularly the heterosexual couples that are coming in, that it's a couples issue. I'm trying to do everything we can to help these couples get pregnant. There's no like finger pointing or blame like, "This is her fault," or "This is his fault." I think the most important thing is that we're trying to optimize everything on both sides to help these couples get pregnant. And that's ultimately the goal for these patients who come in to see us. And so if it means doing something to improve the sperm or doing something to improve the fertility side with regards to the female partners, then that's what we're going to do.

So I think it's helpful for providers to frame it a little differently so that there isn't this stigma. I think that once patients come in to see me, they realize that it's not as scary as they expected, but I do think the difficult part is getting them into the door. There are a lot of patients that get referred to me that are very reluctant to see me. They get really scared about the exam and what I'm going to do with the evaluation, and they expect something to be very invasive. Or they expect to get news that they don't want to hear that maybe it is primarily a sperm issue. But fertility care is very time sensitive. So the earlier people are seen, the earlier we can manage these issues and help these patients get pregnant.

What I hate seeing is couples that have been on a fertility journey for a very long time, and we don't hear from them for years, and then they come back and they haven't done anything differently and nothing was really addressed. They just maybe had initial evaluation and kind of ignored some of these issues. And then by the time they come in to see us, sometimes it is too late because these things are so time sensitive, and so that can be really tough.

So I think it's important for providers to let these men know, in these couples that are coming in, that senior fertility specialist is not that scary. I would say the vast majority of patients when they leave will say that it wasn't as bad as they expected, unless it's indicated I'm not doing prostate exams on everyone. That's what people are so terrified of seeing a urologist. These are generally younger guys. There's no reason to be doing those types of things. The exam's a very quick and painless part of the evaluation, and a lot of the rest of the evaluation is going over things like blood work and semen samples and just education, just counseling. And then in the more serious cases, going over situations that can be treated with surgery, medication, things like that. And so ultimately our goal is always to help these patients with building their families. And so once people realize how common these issues are and that it's not too scary to see a fertility specialist, I think that it puts them at ease.

Alivia Kaylor:

Thank you. I want to move back to something that you said kind of framing it as not just a one person issue, that they're tackling this issue as a couple. And I like to think of that... like as a team, with your teammates tackling this issue, it's not one against the other. So I really like that little representation that you put out there.

Dr. Cheng, in your opinion, how can the healthcare industry achieve health equity when it comes to the male infertility space?

Dr. Philip J. Cheng:

When it comes to male infertility, I think that it's really important for everyone in the field of infertility to realize that male infertility affects 50% of infertile couples. A lot of male patients don't necessarily have coverage for fertility procedures. And so that's something that is starting to change. I think that's a really important part of creating equity in this space. Progyny, for instance, is an insurance company for fertility care that as of January 1st of this year started to cover male infertility, not just the female side. And so I think that that's really important. And they're cover covering services provided by male infertility specialists.

I think that this field also needs to continue to grow. There are certainly a lot more reproductive specialists on the female side than there are on the male side. So a lot of patients just don't have access to a male fertility specialist. And so that starts with residency training and exposure to this area, and also increasing the number of fellowship positions for this specialty. And as it grows and the field is growing, I think there'll be a lot more specialists in the country. It's a field that's growing every year and more people will have access.

And then lastly, I think that research in this area is really important, and there's a lot more money going into research for female fertility and the male side is often ignored. And the more studies that are done on the male side, the more treatment options we'll have, the more specialists we'll have going into the field and the more patients that can be seen.

Alivia Kaylor:

Dr. Cheng, thank you so much for setting aside the time today to join us on Healthcare Strategies. I had a great conversation.

Dr. Philip J. Cheng:

Yeah, my pleasure. It was great talking to you. Thank you so much for your time.

Alivia Kaylor:

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