Hepatitis B and C May Compromise Male Fertility
In 2019, a man with hepatitis B was referred by his fertility specialist to Su Wang, M.D., an internist and expert on the viral infection that causes liver inflammation and can lead to liver disease, failure or cancer. The patient emigrated to the United States from Haiti, a highly endemic area for hepatitis B, which is caused by the hepatitis B virus (HBV).
Wang explained a couple of points to the man, whose name she withheld due to patient confidentiality. First, the most common source of hepatitis B transmission is perinatal infection, from mother to child during birth. Second, another common mode of transmission is horizontal transmission as a young child. This mode could occur among people living in the same household who are exposed to blood sharing via an open cut.
Wang tested the man's hepatitis B DNA (viral load) and his liver enzymes. The viral load was fairly low and the enzymes were normal. Wang determined he did not need medication and was in the chronic inactive phase of hepatitis B. Thus, it was at low risk of being infectious.
She ordered imaging of his liver, which revealed no signs of fibrosis, the thickening or scarring of the tissue.
How hepatitis might affect male fertility
Wang, who serves as the medical director of the Center for Asian Health at Cooperman Barnabas Medical Center in Florham Park, New Jersey, often gets contacted for fertility consultations. These are usually for mothers with hepatitis B who want Wang to clear them so they can undergo in vitro fertilization (IVF).
"This was a case where the dad had hepatitis B," she said. "They were worried about whether or not he could donate his sperm and if there was an issue during transmission."
After reviewing medical literature, Wang determined no conclusive evidence indicated there was any chance the patient's sperm could be infected given his stage of hepatitis B.
"I think there's a lot more focus paid to women in terms of childbearing risks for hep B and not a lot to men," Wang said. "Although, there's clear evidence that fathers can pass on the infection to their kids."
A study that analyzed data from 681 infertile couples indicated hepatitis B affected men's sperm quality. However, it did not affect the outcomes of assisted reproductive technology (ART), which includes IVF.
IVF is considered safe for using sperm or eggs from male and female hepatitis B carriers. A mother with hepatitis B can pass it to her baby, but that would likely happen during birth, not in utero. Studies show both hepatitis B and hepatitis C, an infection caused by the hepatitis C virus (HCV), can impact a man's sperm, which could potentially lead to infertility.
Both hepatitis B and C have been found to be associated with a lower sperm count, decreased sperm motility (movement) and abnormal sperm morphology (shape), according to Paul Kwo, M.D., a professor of medicine and the director of hepatology at Stanford University.
Kwo added that men with chronic hepatitis B and C seem to have lower testosterone and prolactin levels. Both are hormones that affect libido, erections and other areas of sexual function. Kwo is not aware of any studies that examined whether curing hepatitis C would improve semen parameters.
"Many other aspects of overall health improve when you cure hepatitis C, so it wouldn't surprise me if it gets better," he said.
Differences and similarities between hep B and C
While hepatitis B and C tend to reside in the liver, they are completely different conditions.
"Those of us in the field will bemoan the fact that they're both called hepatitis," Wang said. "It almost would have been better if we had named them two different things."
The major difference between hep B and C is how they are transmitted. People may get hep B from contact with the bodily fluids (blood, semen, vaginal secretions) of sex partners who have the infection. Hepatitis C, on the other hand, generally only spreads through blood-to-blood contact.
Hep B and C can both become chronic, long-term infections with side effects. When people are exposed, their immune system cannot fight it off, Wang explained, and chronic infection leads to inflammation (acute hepatitis).
"Like if you keep getting bumped over and over again, eventually, you develop a scar," Wang said. "Your liver might eventually develop cirrhosis and, potentially, liver cancer."
Chronic infection with hepatitis B or C is the most common cause of liver cancer worldwide, according to Chari Cohen, Dr.P.H., president of the Hepatitis B Foundation, a global nonprofit organization based in Doylestown, Pennsylvania.
"It always amazes people that we don't talk about it more and that there's not more of a public outcry to do something about it, because after tobacco, hepatitis B is the number one carcinogen for humans and causes the most deaths from cancer," Cohen said.
Worldwide, it's estimated that 296 million people have chronic hepatitis B and 58 million have hepatitis C, according to the World Health Organization (WHO). In the U.S., up to 2.4 million people have chronic hepatitis B, and roughly the same number have chronic hepatitis C.
"We may not know the true extent of the fertility issues just because this is probably not the highest priority," Kwo said.
The best thing you can do to prevent liver cancer is to get a hep B or hep C test. And get a hep B vaccine if you need it, said Wang, who has hep B herself.
"Sometimes people just think it's like a weird STD when, in fact, the majority of people who have hep B actually don't get it as an STD at all," Wang said. "It's mother-to-child transmission or some other way. I think it's good to try to promote it as not just a sexually transmitted disease, but it also helps destigmatize it, too."
Managing fertility in men with hepatitis
Helen Bernie, D.O., a urologist and the director of sexual and reproductive medicine at Indiana University Health, said of the few patients she's seen who had hepatitis, she worked on restoring their hormone levels.
"If someone comes in with liver dysfunction or any causes of infertility, we assess all of those free variables," Bernie said.
Whenever a man has liver disease or dysfunction, it impairs the liver's capability to metabolize estrogens, Bernie explained. The liver disease could be due to hepatitis, an autoimmune disease or alcoholism.
"If you can't metabolize estrogens, you're going to have higher estrogen levels," she said.
In the body, testosterone gets converted to estrogen and dehydroepiandrosterone (DHEA).
"Whenever you have high levels of estrogen, it works in a negative feedback to tell the body, 'Whoa, stop making as much testosterone,'" Bernie said. "So it lowers your testosterone levels."
If a man has low testosterone, he's not going to be able to produce sperm, because intratesticular testosterone works with follicle-stimulating hormone (FSH) to tell the body to produce and make sperm.
"It makes sense from a physiological standpoint of how hepatitis or any liver dysfunction can predispose men to infertility," Bernie said.
According to Bernie, men have three primary ways to improve or maintain their fertility:
- Behavioral and lifestyle modifications
- Medications and supplements
- Surgical intervention
Cutting back on alcohol consumption, quitting smoking, eating a healthy diet, minimizing caffeine intake, and avoiding hot tubs and saunas may all help improve fertility.
"We start them on fertility supplements, which are just minerals and vitamins that have been shown to help decrease DNA oxidation and sperm fragmentation in men," Bernie said.
Physicians also have medications that can increase a man's natural testosterone levels if they have low-T.
Cohen said she thinks hepatitis and male infertility is understudied because the greatest fear from having hepatitis is the development of liver cancer.
"A lot of the research focuses on the virus itself and what happens to the liver when someone has it," Cohen said. "And how do we prevent them from developing liver cancer? A lot of it focuses on the virology of the virus and developing treatments and hopefully a cure [for hepatitis B]."
If you're worried about a potential hepatitis infection but don't have a primary care provider or would rather begin the conversation through a phone or video visit, Giddy Telehealth has options available for you.