Sperm Morphology & Male Fertility (Episode 320)

Full Transcript: Episode 320

Lisa Hendrickson-Jack: Welcome to the fertility Friday podcast, your source for information about the fertility awareness method and all things fertility. I’m your host, Lisa Hendrickson-Jack. I’m the author of the fifth Vital sign and the fertility awareness Mastery charting Journal. I’m a certified fertility awareness educator and holistic reproductive Health practitioner with nearly 20 years of experience teaching women to connect to their fifth Vital sign through menstrual cycle charting, balancing hormonal health, and optimizing the menstrual cycle without hormones. I’m outspoken about hormonal birth control and its impact on fertility and overall health because you have the right to know how your body works and how artificial hormones disrupt that natural process. I host live coaching programs to help you achieve optimal fertility and health because it’s important to have healthy menstrual cycles regardless of whether or not you want to have babies. I’m also a wife and mother of two beautiful boys. I know, I know, I’m a busy girl, but I managed to fit it all in. This podcast is designed to empower you to take full control of your Cycles, your fertility, and your overall health, and I’m so excited that you’re here with us today. I have an exciting episode to share with you today. In today’s episode, I’m sharing my interview with Dr. Thinus Kruger, and in case you’re not familiar with his work, you can’t really study sperm quality morphology without running into his work. So just to give you an example, if you’ve ever had your partner’s sperm analyzed or you’ve interacted with a health professional related to a sperm analysis, and you’ve noticed on the sperm analysis it’ll say, you know, strict and morphology strict, and it’ll give you a percentage of, you know, the abnormal or normal sperm — that standard related to sperm morphology was actually developed by Dr. Thinus Kruger. So I was really excited to have the opportunity to speak with him and to really go in depth into sperm quality, morphology, and what prompted him to develop those standards and how they then became kind of accepted worldwide for how we look at sperm and kind of how it changed the way that sperm was even looked at and thought of and how quality was thought to be related to your chances of conception. So I’m sure you’ll find this episode interesting, particularly if you are trying to conceive or if you have concerns about sperm quality. And so with that said, let’s jump right into my conversation with Dr. Kruger. And I’m very excited and honored today to be here with Dr. Thinus Kruger. Dr. Kruger is the founder of the first IVF clinic in South Africa, and he’s also the proud co-founder and partner of Aevitas Fertility Clinic. Prof. Kruger acted as leader of the team at Tygerberg Fertility Clinic, which led to the first test-tube baby in South Africa in 1984, the first frozen embryo pregnancy in South Africa in 1988, the first baby born from ICSI in South Africa in 1995, and also the standardization of international sperm morphology guidelines by the World Health Organization from research conducted by his team. So I’m very happy to have you here with us, Dr. Kruger. Thank you for coming on the show.

Dr. Thinus Kruger: Thank you. It’s really an honor.

Lisa Hendrickson-Jack: Well, I mean, you’ve done so much work in the field of fertility. So as I was going through the short summary of some of the highlights of your work, obviously you’ve been incredibly involved in artificial reproductive technologies and really at the forefront of those developments. But in particular, I asked you here today to talk about the standardization of the international sperm morphology guidelines. I’ve read a number of your research papers, and you know, this is an area that I’m always talking about on the podcast and a particular area of interest for myself. And so the first question that I have for you is, what brought you to focus on fertility challenges and, in particular, challenges of sperm morphology?

Dr. Thinus Kruger: Yeah, thank you very much for the question. Perhaps I can just give a little background also on my love for the USA and the fact that I did my fellowship there, and the story that I’m going to tell you is a story between Cape Town, South Africa, and then the USA, later at the Jones Institute in Norfolk, Virginia, and it dates back to 1985, ’86 — a long time ago. What happened is that I’m a gynecologist with an interest in male infertility. The reason, in those years, was that the male was very neglected, and I just became interested because we could do so little for the men and could explain very little. So I’ve observed, during time of laparoscopy where I did some smears inside the pelvis of the female, and then saw — sometimes saw — spermatozoa, and I stained them and observed that there’s one specific type of sperm that you will find in the body of the female. But when you look at a raw sample of semen, there are many varieties in shape — shapes and sizes are different. What I’ve observed, and what my fellow colleagues observed — there was a specific scientist working with me, Dr. Menkveld — we saw that the head of the sperm in the body looks like an acorn. Are you familiar with the acorn tree? Yes, yeah. So that shape, the acorn — that’s what we saw. So we stained and counted them and measured them, and then we developed a theory. And I was busy with my PhD at that stage, a post-Gynecology study on aspects affecting IVF results, and one of the aspects that I wanted to study was the male. So we then saw, in men, that some men will only have 2% of the so-called acorn type, or oval-shaped sperm, and others will have 14, 15, 16, 20%. And in the IVF laboratory, then, you can standardize your number of sperm that you fertilize — so you will have 10 oversized… in one couple, you standardize the number of sperm that you fertilize the egg with, but the morphology, of course, will vary dependent on the male. And then we saw — and you must ask me now — we saw a linear improvement in fertilization: that the higher the morphology, so example, if the morphology was 1 and 2 and 3%, we saw very few eggs fertilized — a rate of about 15%. If we deal with a male with 18 or 19 or 20% of the oval sperm, we saw that there was 80, 90% fertilization rate. So very different. And we, of course, did statistical analysis on the data set, and in the first study we saw a drop in pregnancies at the level of below 14%, but the study was not very big, and our statistician clearly said that we’ll have to enlarge the numbers. But there was no doubt in our minds that the morphology is playing a role in fertilization, and also then in pregnancy rate, because if you are dealing with less embryos, you’ll have a lower pregnancy rate. And that is what we’ve seen. So I’m going to stop here, but the story is now going to the USA — but I want you to ask me questions because I want to be sure that your listeners understand what I try to say.

Lisa Hendrickson-Jack: Well, thank you for sharing that. So it sounds to me that you were analyzing the sperm, and you noticed that the sperm of a certain shape — so the sperm of more of a normal morphology — you found a connection between the number or percentage of normal sperm and the pregnancy rates.

Dr. Thinus Kruger: Yeah, also in fertilization, because the power of that study — published, I think, in ’86 — was that we could see the impact on fertilization, because you’ve got one dish, one egg, 50,000 sperm inside, but in one patient morphology will be 1%, and the other one it will be 15%. One could clearly see that there was an impact on fertilization, so the lower the morphology, the lower the fertilization — sometimes no eggs fertilized. And I just want to underline that, at that stage, in the world literature, there was total agreement that morphology is not playing a role at all in the fertilization process. It was considered not important, and count and the movement of sperm was said to be important. I would say that was a first phase in the research, but because no one else believed it — I published it, but then moved to the States for my postdoc fellowship at the Jones Institute in Norfolk, Virginia, and perhaps I must tell the story. I arrived there, I was of course, um, ’86, I was much younger, and coming out of Africa. And I observed, in the mornings, when the doctors sat around, Dr. Howard Jones, that sometimes they said, “No fertilization in this patient,” or “very poor fertilization — it must be an egg factor.” Those were the words. I looked at those patients, and then I saw, “But it’s a morphological problem.” It’s the morphology that’s low — good count, low morphology. And I told Dr. Howard Jones, “I think it’s morphology.” I’ve observed that in Cape Town — I was not sure if what we’ve observed was applicable to other parts of the world. But I then said, “Let’s do a blind prospective study.” That meant that I didn’t know what is going to be reported — I just reported the morphology, and then gathered the information on the patient fertilization later, so it was totally blind for me. But within a few days — actually a few weeks — the scientists, that was Lucinda Veeck and Dr. Howard and others, said, “But they think I can predict what is coming” — because I’m now like a little witch doctor from Africa — because I could tell them, before they even told me, what’s going to happen: “This patient will fertilize less than 25%,” and “that one should fertilize, if the eggs are normal, 80, 90% of eggs.” So that’s the story, and that led to a publication, almost a repeat of the work in Cape Town, and then we described the first patterns. What is a pattern? It is where the fertilization was very low in the low morphology groups — we call that the P pattern, or poor prognosis pattern. That was in cases with 0 to 4% normals. And then we described a G pattern, or good prognosis pattern, and in that study the fertilization rate was 63%. And then the third pattern was above 14% normal forms — that was called the N pattern, or normal pattern, and the fertilization there was like 90%. So you can clearly see, in those studies, a stepwise, upward improved fertilization the higher the morphology was.

Lisa Hendrickson-Jack: Well, this is very interesting. So this is specific, then, to artificial reproductive technology, when you’re looking specifically at the fertilization and the link between the morphology and how successful the fertilization is going to be. And for the listener who isn’t really sure about morphology — so it’s the word to describe the sperm, whether the sperm is normal or not, and the sperm, if you look at it under a microscope, some of them don’t have a head, some of them, you know, they have all kinds of different issues with how they look. And what you said, which I found really interesting as well, was that before you had done this work and focused on “could morphology be affecting fertilization,” it was assumed that if fertilization didn’t take place, that there was an issue with the egg, instead of looking at that. So that is really just interesting, and I think even to this day there’s still a lot of that, because when a couple is trying to conceive and it’s not happening, the assumption is often the default that it must be the woman. So because your research was focused on fertilization, within this context, could you tell us the impact that this could have on a couple’s chance of conceiving naturally?

Dr. Thinus Kruger: Yeah, I think there was a long-time misconception that if we classify a patient in the P pattern, poor prognosis pattern, morphology of 3 or 4% normal, that they cannot impregnate their wife — and that’s not true. So one must immediately say that if the morphology is read correctly, even by the top experts in the world, and you are sure that the report is accurate, I never — and I’m repeating, never — tell a patient that you cannot impregnate your wife. You can — it can happen. But we know that in those first studies, the rates of success are lower in the morphology. But if you are dealing with a male factor, the doctor must always make sure about the female, and when I lecture on the male, on infertility, it takes two to tango — so one must look at the male, and you must correct him. And we will perhaps talk about factors that can affect the outcome of the male factor and improve it. And you must focus on the female — you know, weight, smoking, cycles, is she ovulating well — and you must always correct it. So the misconception is: if the morphology is low, now you must have ICSI, you must have in vitro. We always try at home, and will only move to other treatment modalities if they’ve tried long enough.

Lisa Hendrickson-Jack: Well, so you shared, with the two studies that you described, that you listed a level of 14% or higher as normal, and that had the highest chance of fertilization within that context. And also a really important point — because when you go through the research about morphology, there are researchers who would still argue that morphology doesn’t really matter, because it is always possible, provided that the male partner has some degree of sperm, it is possible, as you said, for their partner to become pregnant.

Dr. Thinus Kruger: Yeah, I totally agree, and I think there’s definitely a misconception that people are so dogmatic — and doctors can be so dogmatic about the male — that they then don’t give them a chance. And that’s not true, and I underline again: even if you’re in the P pattern group, you can still have a natural pregnancy. It’s a marker — let’s say it’s a red flag. It tells you something is not right, and you must then go into the history of that male and correct what you can. And often there will be an improved morphology if the smoking stops, marijuana — it’s important, you know, overweight is important, lose weight — and so on. And medication, self-medication — all those things must be excluded, so that you get a healthy male and female lifestyle. Very important.

Lisa Hendrickson-Jack: Well, so I’ve noticed a trend with the women who I’ve worked with, who’ve had their partner’s semen analyzed, and one of the trends that I’ve noticed is that regardless of what the analysis says, unless it’s below the World Health Organization guideline in one of the three main areas, they’re often just told that it’s “normal,” you know, period, full stop. And so, for example, unless the morphology is below 4%, they’re not told anything. And so, you mentioned a few things that could impact sperm — but for the woman who’s listening, you know, what would you want her to know about morphology? Is there — should we be looking at when the morphology is in a subfertile or suboptimal range, and then is that an opportunity to involve the male partner to make some changes to try to improve?

Dr. Thinus Kruger: As you mentioned, again, with respect to the physicians — as you know, there’s still debate, and in certain centers they don’t believe in morphology, often they don’t have the scientist trained to do a good, strict morphology. But whatever the case — let’s say they are in our clinic, and we confirm that it’s a P pattern — we will not, I’m repeating, again, not jump to ICSI. We will make sure about the natural fertility, to get it as high as possible on the female side, and if it’s a young couple, we will encourage them to try at home. But correcting the female — sometimes it’s something simple, like she’s not totally ovulating so her cycles can vary between 22 and 33 days — so in those cases you can give them a fertility medication to stimulate the ovulation, find the fertile day, and give them an opportunity to fall pregnant, in spite of the so-called low morphology — he can impregnate her. I think, again, takes two to tango — important to look at the male, correct what is wrong, we can also talk about supplements here, and then correct the female and see if you can’t make her more fertile, and that will compensate for any male factor, low count, lower motility. So important to look at both.

Lisa Hendrickson-Jack: Well, for the listener who may not be familiar with ICSI — intracytoplasmic sperm injection — that’s when, if they’re going through artificial reproductive technology, the sperm is directly injected into the egg and then placed in the uterus. Just so, for the listener who may have heard you say ICSI and wasn’t sure what that is — could you share with us, then, if you do identify that the male does have the P pattern, as you said, so the lower morphology number — you mentioned a few things that can be done. So your practice — it’s kind of a two-part question — what are some of the things that men can focus on when we have identified that they have a low morphology and there could be some degree of male factor, and how long can a couple expect it to take before some of those changes actually take effect?

Dr. Thinus Kruger: If the morphology is low — now we’re getting a little technical, but I always ask, in our lab, at least three scientists to read the morphology, because you must be trained to do it. So make sure that the lab that you are using is not overly strict. But let’s assume the morphology is low — then, if your lifestyle is good, the only other thing that you can do is — and there’s a lot of literature on that — eat a lot of healthy food. Junk food not indicated, not good for morphology. I want to talk a little bit about that — in the African green monkey model, I’ll tell you now, it’s an interesting one — but there’s good literature saying lots of greens and vegetables, and free of pesticides, that is good, and also free-range chickens and that type of thing will enhance fertility. There’s interesting work on that. But can I just deviate for a second? In the ’90s there was a study at the Medical Research Council here in Cape Town on heart conditions and the effect of diet on the cholesterol, and so on, of the African green monkey. So it was totally ethically cleared, and half of the monkeys received an African ordinary — let’s call it bush diet, normal, healthy — berries, and things that they usually eat — and half of the monkeys received more a Western diet, with more fat intake, and so on. And the morphology of the African green monkey from the bush — you test the sperm, almost all the sperm are like acorns. Isn’t that interesting? Almost every sperm — so if you count 100 sperm, 99 will look perfectly normal, in contrast with the human male. So it’s a very good model to study diet, and it was done, and it was clearly seen that in the Western, unhealthy diet, the morphology was affected. That study was done blind, and the slides were read by my colleague Dr. Menkveld, who’s a scientist, and he didn’t know which ones were which — and could clearly see the impact of the diet on the African green morphology. So, indirectly, one can then extrapolate and say the studies on the human — where they showed better pregnancy rates where you eat healthily — it’s got some merit. Something else that I want to just tell you — the cheetah. We are working with veterinarians here in South Africa, and the listeners will know about lions and cheetahs, and there’s a veterinarian studying the fertility of these animals, because the cheetah is endangered. If you inbreed the line, or inbreeding in the cheetah, their morphology goes down tremendously — so I’m wondering if there’s not also a genetic factor in the human. So it’s just — I’m just telling it because I found it fascinating and interesting, and it tells you something — nature can always teach you something. So, diet — important, and we have the African green monkey model, but there’s also very good clinical study showing the value of lifestyle change and good diet, infertility, male and female.

Lisa Hendrickson-Jack: Yeah, that’s very interesting. It leads me to a question that I wanted to ask you, which is: could you share your perspective on why there’s been this decline in male sperm count and quality? So I know that there’s a bit of debate, but when you look at different research papers from different periods of time — the 1940s — I found a few studies that had samples from men in the 1940s, and if you find samples from men today, there’s a significant decline just in the count, specifically in the concentration. If you can find morphology numbers, you’ll know that they’ve declined, as well as the motility numbers. So do you have a comment on why it’s been such a significant decline?

Dr. Thinus Kruger: It’s Scandinavian work — a lot of Scandinavian work — and, you know, they’ve got very good data records. Skakkebaek is one of the leading scientists in the field. They speculate that there’s more estrogen in the water, water pollution, plastic, that type of thing. I am not an expert in this field, but, like you, quoting the literature — I can quote about the literature, we see the trends, but I think it’s possibly toxins.

Lisa Hendrickson-Jack: Well, and is there — so there’s some research on the sperm DNA damage, so whether the sperm is damaged, and how that could relate to morphology — so if the male has been exposed to more oxidative stress, or if that’s had a negative impact on his sperm — so do you have a comment on whether there is a link between morphology and the quality of the sperm in terms of the actual integrity of the DNA?

Dr. Thinus Kruger: Yeah, very important question, and the short answer is yes. We’ve done studies in the ’90s on different aspects — oxygen species, DNA damage, and sperm morphology — and we did see a correlation. I think, as part of full evaluation of the male, one must actually — in all men, but all labs and clinics can’t do it — do a DNA evaluation, a TUNEL assay, we call it — it’s one of the tests, because that will give you sometimes DNA damage in a subfertile male. But if you’re asking trends, the P pattern, the poor prognosis, the low morphology, will have more DNA damage than the male in the N pattern, or high G pattern. I just want to share with you — I think very interesting data, recent data — where there were single… we’ve done population studies, and what I’ve just said was on big semen samples, but there’s a scientist — when ICSI came, the injection of one sperm at a time — the first person to report an impact on embryo quality and pregnancy outcome was a lady with the name of De Vos, and she’s from Brussels, one of the big clinics there. And she saw that if there is a male where she could not find healthy oval-type sperm, that the morphology of the embryos were poorer, and the pregnancy outcome was poorer. And that gave a hint that even morphology becomes very important in the lab, in the ICSI arena, because when ICSI came, I was sitting in a conference in Paris, and there was a scientist saying, “Now that we have ICSI, sperm is not important anymore, you can inject any sperm and you get an embryo, and the pregnancy” — and of course he was totally, totally wrong. It was not a very thoughtful statement, because as things progressed it became important that the DNA damage can be in sperm, and that you must select the sperm very well. I can talk a little bit about a guy from Yale called Professor Huszar’s work, if you want me to, because it illustrates this point. Yeah, so he observed that a mature sperm develops a hyaluronic acid receptor, so that sperm can bind, if it’s mature and healthy, to hyaluronic acid, and he saw that the morphology of those sperm were also, interestingly, more oval-type sperm. So that observation led to more detailed studies on single sperm, and there’s a study where they’ve looked at two groups — one sperm at a time — that was fascinating — testing for DNA fragmentation, testing for mitochondrial damage, testing for DNA abnormality, and they describe the sperm — they say, a sperm with no defect, that’s the oval type, or, in the other group, a sperm with vacuoles and other — we call it amorphous, misshapen sperm — and they saw a clear difference: the oval shape, with no vacuoles, were healthier, from a DNA fragmentation point, from mitochondrial damage, compared to those misshapen amorphous sperm. And I thought that was one of the most elegant studies, where they’ve isolated sperm and then tested sperm by sperm, and not populations. We could not do it in the ’90s — we did population studies, we saw trends — but here it was very clear that you must select your sperm well, even if you do the injection of sperm into the egg, which we call ICSI.

Lisa Hendrickson-Jack: Well, so that’s very interesting — I mean, there’s this idea, which isn’t entirely wrong, but I think it’s helpful to question it a little bit — that all you need is one. So there’s kind of this idea that, you know, men have millions of sperm, but all you really need is one. And so what you just shared, where the study was done and they were testing the individual sperm, and the normal morphology of the sperm was related to the quality of the DNA — it’s interesting, because then, does that suggest that if a man has a higher percentage morphology, does it suggest that overall the DNA, or the sperm in general, might be a better quality, compared to a man who has a lower morphology, or do you think it’s not necessarily related, and it’s more on an individual sperm basis?

Dr. Thinus Kruger: No, I think it’s the population that’s important, but then you’re talking about natural fertilization, and the body’s got the capability — the cumulus cells around the oocyte — to select sperm. And we don’t know, but I assume that the oval type will go in. Why do I assume it? Because we’ve done studies — hemizona assay — so we cut eggs in half, and then compared low-morphology men with normal-morphology men, and we looked at the binding, and we developed an assay in the ’90s, and noted that less sperm could bind successfully on the eggshell — that’s the zona pellucida, the eggshell — in the low-morphology men, where there were sperm in abundance that could bind. So, for the listener, one can then say that it’s like a key in a lock — so there’s a lot of potential in the morphology that is normal to unlock the lock and enter the egg, where the low-morphology men, perhaps due to amorphous sperm and so on, very few sperm bound on the egg. One could clearly see that — so it’s all direct and indirect evidence that one mustn’t just brush morphology aside. Even at the cellular level it becomes important — we started off with an observation on fertilization, we started off with an observation of the type of sperm inside the female body, and still we see the trend — the same trend. So the scientist in the lab must be also very careful when they do the ICSI treatment, which they are aware — most clinics are very aware of that.

Lisa Hendrickson-Jack: And by that you mean — are you saying that the scientist has to be aware of this, so that they are intentional about which sperm that they’re selecting?

Dr. Thinus Kruger: Yeah, because — you said they used to believe it wasn’t relevant, but there’s enough evidence now. Yeah, absolutely. What we do in our lab is we select the sperm with hyaluronic acid — there’s a little dish called PICSI, it was developed by Huszar from Yale — and then we fish those sperm that’s got the ability to bind on the hyaluronic acid, we fish them out, and put them in a little dish, then we look at the morphology, and we try to find the ideal sperm based on all the things that I’ve told you, then we inject them. And our reasoning is: we have physiological data behind us, so why not do that — why must one just take a sperm randomly? You can make bigger mistakes with that. Well, by doing that, you would be increasing the chance of — not successful fertilization, but quality embryo — because that man in Paris was right, you can inject any sperm and you get an embryo, but often they are chromosomally abnormal. When you are working with morphology and so on, do your best to find the best sperm, and that produces the better quality embryos.

Lisa Hendrickson-Jack: Well, this is all very fascinating. I wanted to go back to when you were talking about the fertilization and what you said about the key and the lock, and how the lower morphology numbers — there were fewer successful — basically the sperm connecting with the eggs. So what’s interesting — I mentioned to you that in the work that I do, I help women to understand the menstrual cycle, and so with fertility awareness charting, cervical fluid is essential to most of the main methods of fertility awareness. And so the research around cervical fluid is fascinating — women are producing it before they’re ovulating, in that fertile window, and the cervical fluid has the ability to filter out abnormal sperm. And so there’s different studies — some of them are showing the quality of the sperm after they’ve passed through the mucus, and some of them are analyzing the action of it — but I just thought that was an interesting addition to what you said, because even though I think a lot of women are kind of shocked to discover that even the healthiest man typically has a huge percentage of abnormal sperm, and it’s fairly normal and common for the majority of sperm that men produce to be actually abnormal — but we do have this natural screening process within our bodies that then helps to select the better quality sperm. I’m not sure if you have a comment on that.

Dr. Thinus Kruger: Yes, I have — you’re absolutely correct, and I think that’s why, later on, we also looked at morphology in the mucus. We even took mucus and then put sperm on this side in a dish, and see what comes out, in the end, what type of sperm — and it’s that selection process. So the mucus is definitely helping, and the amorphous sperm do not do as well as the oval-shape sperm — and that is what we’ve observed in the body, and when you trace it back, it starts with the selection of the mucus.

Lisa Hendrickson-Jack: Yes, so interesting — I could just talk about this all day. Yeah, so I wanted to go back to something also that you mentioned when you were talking about the testing — so at the very beginning of our conversation, when I introduced you, I mentioned that your work was an integral part of creating a standardized process for classifying sperm morphology, and that was crucial for developing the World Health Organization guidelines. And so you mentioned that individuals have to be trained, and when you’re doing it you have three scientists looking at it — so could you share with us, then, for a woman who’s listening, who’s had a semen analysis — so it sounds like there’s different ways to do this semen analysis, and different labs are doing it differently — so is there any, I suppose, information that women should have in these situations, when they’re getting this information from their doctors about morphology?

Dr. Thinus Kruger: I think, number one — let me just say, if you’re living in Switzerland, the whole of Switzerland is totally standardized, disciplined, standardized, and when you do a morphology reading in Basel, and you take that same slide and give it to someone in Bern, the reading will be very, very similar — so the reports are very reliable. Now, sometimes a scientist can make a fertile male — can put him in the P pattern — and then the patient gets a fright. And I think perhaps that’s the biggest message today: even if your morphology is low, relax about it — make sure that your lifestyle is good, if your count is good, your motility is good, you can impregnate your wife if she is in top condition. So I think that’s principle number one. To ask a scientist for the slide and get a second opinion from another clinic is also valuable, and they should not feel threatened, because then, if two people say, “Yes, we agree, it’s definitely a P pattern,” then you know it — but you know it with insight. So no doctor must give you a fright — that’s definitely not on. If you’re young, 28, and you’ve got a low morphology, and you’ve corrected your lifestyle, and the doctor corrected your wife’s fertility — hang in there, wait a little bit, wait a year, follow this natural way, the American Old West way, to impregnate your wife — it can happen. So often there’s this misconception that some doctors say — if it’s a P pattern, they must go immediately to IVF — and that is not true. So I hope I’m clear on the broad picture.

Lisa Hendrickson-Jack: Well, I mean, it sounds like what you’re saying is that it’s possible for the scientist who is looking at the sperm specifically to be too strict, and possibly make it seem like — if they’re really following the guidelines a little bit too strict — that it could seem as though the man has lower sperm parameters than he really does. And also, I hear what you’re saying — that there’s this tendency to assume that if there’s a problem you’ve got to go straight to IVF and ICSI, which is very expensive. So I would be interested to hear your comment, because, you know, when looking at the research, there would be an indication that if a man has lower sperm parameters — so if he has lower morphology, or if he has a higher level of the sperm DNA damage — that it could potentially, in some cases, take a longer duration of time to conceive, but it doesn’t mean that conception is impossible.

Dr. Thinus Kruger: That is true, that is absolutely true. I also want to say that if there’s ever an uncertainty about a slide, a morphology — I get requests from all over the world, so people ask for a second opinion, and they send the slides by mail, or by just post, with a semen report — and then can ask for a second opinion on the morphology through their doctor, or directly. And we ask $50 to read the slide, because it takes time on top of our other work, but we will gladly do that if there’s ever a difficult case.

Lisa Hendrickson-Jack: Well, I think that’s interesting, between that aspect of it and what you said earlier about having a number of scientists look at the results — it suggests that you could have two different people looking at the results and have two different outcomes. And so, for example, you developed the strict — so for any of the listeners who are pulling up their morphology tests, or pulling up their sperm analysis right now, and looking at them — typically some of the labs will actually say “Kruger strict” morphology beside it, and give the number — so is it possible, then, that if the lab is not using the specific, say, Kruger strict guidelines, that number could be overestimating the number of healthy sperm?

Dr. Thinus Kruger: They usually underestimate — they usually take a G pattern patient and they’re too strict, and put them in the P pattern group. Okay, that is what usually happens.

Lisa Hendrickson-Jack: Okay, so it’s much less common for it to be the reverse.

Dr. Thinus Kruger: They’re not using it — it’s a very, very severe P pattern, you cannot miss it, you know, all the sperm amorphous — that’s it. Now we become very technical, but I think that in certain cases certain labs are too strict, and then — but the listener must know, even if my morphology is low but my count is good, I have a chance of a pregnancy. I think that’s perhaps our message of the day. And then, lifestyle, lifestyle, lifestyle — very important, because you are affecting your DNA by doing the wrong things. Sport is important — cycling does not affect the morphology. Long-distance running, even marathons, will bring the count down a little bit, but not in the subfertile range, and people can run and can do cycling — because there’s this misconception also in the literature. I’ve written a chapter in a book on sport and the effect of sport on morphology — I’ve reviewed the literature quite extensively, and there’s very few sports that really impact on the morphology. Of course, the bodybuilders — that’s a big problem — and if they are using anabolic steroids, the biggest impact is no sperm — you know, they become azoospermic.

Lisa Hendrickson-Jack: Well, you know, one final question for you — you bring up an important point, and I find it interesting, so from both sides — that provided that your male partner has sperm, men are not identified as sterile.

Dr. Thinus Kruger: Yeah, so these parameters, the quality of the sperm — there’s, like, provided that there’s sperm, yeah, your partner will not be classified as sterile, because there is a chance of conception when he has sperm.

Lisa Hendrickson-Jack: But could you share with us, like, in what cases are men actually classified as sterile?

Dr. Thinus Kruger: I think the easy one is — you do a semen analysis, there’s no sperm, and you must, of course, examine the male and understand why, and do blood tests and so on — do chromosomal test, doal test — and then repeat it again, and if it’s a second time, a month later, and if it’s a second time and a third time azoospermic, then one can say, at that point, that male is sterile. Then one must consider a testes biopsy, and see if there’s sperm in the testes, or this micro stuff — you know, there’s another road to follow with those men, that they are sterile. If there’s — the World Health Organization threshold values say you’re in the subfertile range — hear the word subfertile, not sterile — you’re in the subfertile range when the count is below 10 million per milliliter, when the motility is below 30%, and your morphology is below four — subfertile, that doesn’t mean you cannot impregnate your wife. And, of course, if you fall in the subfertile range, one must look at the factors that I’ve talked about — the lifestyle factors — and any drug or medication must be looked at carefully to see if that’s not impacting, and then see if you can’t improve the quality by changing lifestyle or habits or medication. All depends. And I always like to give antioxidants — like vitamin C, 300 milligrams a day, 40 milligrams of zinc, and folic acid — those vitamins, those three, have been researched, and they’re cheap, and you can buy them over the counter and make your own fertility vitamin concoction. And there’s good evidence that that can help you. There are many medications on the market that are very expensive, that I think one must be very careful — you must look at the evidence, if there’s no evidence, don’t use that. But you can do what I’ve just said — lifestyle, lifestyle, lifestyle — plus, if you want a supplement, use the zinc, the vitamin C, and the folic acid, which is a good choice.

Lisa Hendrickson-Jack: I feel like there’s a few main messages that have come out in our conversation today, but, you know, one thing that I’m taking away from it is that even if there is an issue that is detected with the male side, there’s so many very practical — some common sense — things you can do, but there’s much that you can do to improve the quality, which I think is really helpful for couples who are struggling specifically with male factor issues.

Dr. Thinus Kruger: Exactly. I’m very clear with the patients that we handle: stop alcohol — that’s number one. Or, if you drink a glass of wine now and then, it’s fine — binge drinking, very bad for sperm, so stop that. You know, five, six, seven, eight beers on Saturday, and next week again, and next week you’re affecting your fertility — so stop that. Second, stop smoking. And number three — when I worked in the States, I was surprised how many marijuana-related medications and smoking is happening, and if that is the case with an individual, it’s not healthy, not good for sperm — stop. So there are certain things that we can be very clear about, and then your diet — adapt that, your weight — get that down so that you’re slim and fit, and all those things can assist. I think the other message is: if you have a male problem, make sure the female is fine — she must have regular ovulation — and the things that you do for them is very important, to find the fertile day, to be sure that the mucus secretion is there at the time of the LH peak, and so on. Those things are small things, but it’s actually big things, because often women do not know when they’re fertile — they must know it, they must find it.

Lisa Hendrickson-Jack: Well, I want to just — you know, we’ve covered a lot, and I really appreciate your time, and I appreciate you for going through in such detail everything that we spoke about today — that was a very nice summary as well — but is there anything else, given everything that we’ve spoken about today, that you’d like to leave the listeners with?

Dr. Thinus Kruger: No, I think I’ve repeated the important issues, and, you know, we must always think small, we must think about home — that is, I always tell the patients, there are many roads to Rome, symbolically speaking, but I prefer this small road, which is the home pregnancy, and it can be achieved. So one must never forget that, because we are often inclined to go for the high tech, and then you don’t even correct the lower level. So I always correct the home situation before I even think about any other treatment. You will find that sometimes people will come to a fertility setup, and the male is still smoking, the female is perhaps smoking, her weight is not correct — now they do ICSI, her chances to fail is high. So correct everything, and then, if you deserve it, you can start looking at IVF treatment.

Lisa Hendrickson-Jack: Well, I think those are very wise words to end on. Thank you. Well, Professor Kruger — Dr. Kruger, both titles — thank you so much for being here. Could you let the listeners know where they can go to learn more about you and what you do? And I think we’ll also link some of your research papers to the PubMed site, so that the listeners can also read up more on sperm.

Dr. Thinus Kruger: Yeah, they can look at the website of the clinic, Aevitas — A-E-V-I-T-A-S — Aevitas.co.za, or they can just search “Aevitas” and they will get to the web address. There they get some information, you know, and if there’s ever a question, welcome to write, email, and we’ll respond.

Lisa Hendrickson-Jack: Okay, well, I’ll be sure to link your website in the show notes page for the listeners who are on the go, and just thank you once again — this was really informative.

Dr. Thinus Kruger: It’s been a privilege, and, as I’ve said, I’ve got this line in my life, and I’ve been working with the colleagues at the Jones Institute for over 30 years — we’ve done wonderful research together, so this partnership was special. But my experience in your beautiful country, and the beautiful people that I’ve met, and still friends — many of them came to visit us here in Cape Town, and I took some friends to the Kruger National Park, which is one of my favorite places in the world. So, yeah, I’ve got a soft spot for your country. Thank you, and also for the opportunities that I got by going to the Jones Institute — I’ve brought some information to them, and they’ve sharpened me and my career and helped me — so thank you for that also.

Lisa Hendrickson-Jack: Oh, well, thank you again.

Dr. Thinus Kruger: Yeah, and have a wonderful day — I say good day, and perhaps we’ll talk again in future.

Lisa Hendrickson-Jack: Okay, well, thank you so much. Welcome.

Dr. Thinus Kruger: Good day, bye.

Lisa Hendrickson-Jack: Thank you for listening. If you enjoyed today’s show, please share it with a friend — you’ll find the show notes page for today’s episode over at fertilityfriday.com/320. I hope that you enjoyed my interview with Dr. Kruger. I found it fascinating to learn about the history of sperm analysis and how Dr. Kruger’s work influenced the way that we look at sperm morphology. I thought it was interesting that there was a time when they didn’t even look at it, didn’t even think it was important — but I suppose, you know, on the other hand, it’s not that surprising to hear, because even to this day I’ve worked with so many women whose partner’s sperm analyses fall below the optimal range and they’re not really advised or told about it. So it’s interesting to see that there was a time when they barely even looked at it at all, and even though we’ve made a lot of progress, it is interesting to reflect on that, because one of the topics that I bring up whenever I’m talking about conception is the importance of understanding where your partner’s at in terms of sperm quality — because even though, even with all the work that Dr. Kruger did over the years to bring this topic to the forefront, we’re still at the stage where many times couples aren’t being advised of whether or not there’s an issue. And my favorite word is thrown in there — you know, “it’s fine,” sperm is fine, everything’s fine — but we’re not really provided with the information that would help us to understand the difference between what is optimal for natural conception versus the bare minimum for procedures like IVF and IUI, and ICSI, and all of those different artificial reproductive technologies. So with that said, if you can think of a friend or somebody that you know who would really benefit from listening to this episode, please do share this episode — the link again to share is fertilityfriday.com/320. And of course, I want to thank you for taking some time to tune into the show. I appreciate all of you for spreading the word about Fertility Friday and sharing the podcast with your friends. I see you tagging me on social media and sharing, and I appreciate it so much. So thank you so much for being a part of the Fertility Friday community, and, of course, as always, until next time — be well and happy charting!