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News flash: Around half of all infertility cases are due to a male factor. One-third are attributed to the female partner, one-third are attributed to the male partner, and one-third are a combination of both, or unexplained.
This math should be intuitive since sperm is half of the baby-making equation, but it still comes as a surprise to many people. In fact, a recent survey showed that 35% of men and 40% of women underestimated the prevalence of male factor infertility, and 1 in 10 respondents believed it had little or no impact on conception.
While the medical community is well aware that male fertility does, in fact, greatly impact conception, in around one-quarter of infertility investigations, men are not examined by a doctor. Not testing men means that women are serving as treatment surrogates, and couples are spending thousands on procedures that may not be necessary. It's time we change that.
The shame and stigma of male infertility
Let’s back up and talk about how we got here. One reason is the culture we live in: We are often bombarded with stories of male celebrities who sire children (with much younger partners) well into their 70s and 80s. But men experience age-related fertility decline after 35, too. In fact, one study showed that even when controlled for the age of the female partner, pregnancy rates for fathers over 35 years old were less than half of those under 35.
A man’s virility is also still, somehow, a yardstick for a man’s overall worth, so talking about sperm with anyone, even close friends, doesn’t usually happen. Not to mention there are few online forums for men who need anonymous support; and men don't utilize healthcare services at the same rates as women, which means that they often avoid being seen until there is something glaringly wrong.
Barriers to diagnosing and treating male fertility issues
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Male factor infertility can be tricky, as it is often asymptomatic, so most couples don’t know it’s an issue until they cannot conceive. A diagnosis requires a physical examination and semen analysis, which men do not often seek proactively, or at all in some cases. And this problem starts early, as there is little to no reproductive health education for young boys and men.
Further, reproductive endocrinologists, the doctors who test and treat infertile couples, are OB/GYNs, trained as experts in women’s bodies. They perform basic screenings and can order a semen analysis, but otherwise must refer out to a male fertility specialist. The practitioner that should test and treat men is a reproductive urologist, but there are simply not enough of them to fill the ever-growing need. There is a known shortage of reproductive endocrinologists — around 1,300 total in the U.S. — but there is an even more serious shortage of reproductive urologists — just 200 — and not enough fellowships to train new providers in either category.
The existence of a technology developed to help treat male factor infertility is ironically a barrier to providers caring more about the underlying problem, too. Intracytoplasmic sperm injection, or ICSI, allows an embryologist to select a single sperm that looks high quality under a microscope and insert it directly into an egg using a micropipette to create an embryo during an IVF cycle. It allows sperm to bypass the natural barriers to fertilizing an egg and gives the perception of control for doctors, and patients. While it works well if used in cases of male factor infertility, it does not raise the live birth rate — the only metric in IVF that matters — universally outside of that use case. But because ICSI only requires a single motile sperm, the presence or absence of sperm is the only metric reproductive endocrinologists have to care about.
Breaking the taboo surrounding male infertility
Allowing male factor infertility to go untreated carries real impacts on women and children beyond unnecessary, invasive treatment. For pregnant women, low-quality sperm can increase the risk of preterm birth and preeclampsia. For future children, issues with sperm can drive an increased number of genetic mutations and mental health conditions. And for families and society at large, there is a financial, emotional, and physical burden to caring for unhealthy men. Men die 5 years younger than women on average, and sperm can be an early indicator — a biomarker — for other health conditions like cancer. Better management of men’s health would give them more well years and allow them to be more involved, active partners, and parents, too.
Women are born with all the eggs they will ever have, and once chromosomally abnormal, they cannot be repaired. There is no test to glean the quality of a single egg, either, as eggs are single cells, and testing an oocyte would destroy it. Egg quality can only be indicated once that egg is fertilized and becomes an embryo. Men regenerate sperm constantly and, in around three months, produce an entirely new supply. With appropriate lifestyle changes, men can upgrade their sperm parameters and optimize their odds of conceiving.
Encouraging your partner to test his fertility
If you’re reading this and wondering how to support your male partner, here are a few ways:
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Book a couple's preconception appointment: If it’s been a while since he’s seen a primary care physician, the months before you plan to conceive (or even if you’re in the throes — it’s never too late) is a great time to check in. If you see the same primary care provider, go together. If not, make a pact to be seen separately and trade notes.
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If you’re working with a fertility specialist, ensure your partner is checked at the same time you are: This may sound obvious, and although all medical organizations agree this should be the standard of care, it isn’t always. Even if you suspect the underlying cause of infertility resides in your body, that doesn’t exclude your partner. Sometimes it’s both.
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Assess the fertility impacts of prescription drugs: Some medications, including steroids, hair loss products, and even drugs to treat conditions like type 2 diabetes, can impact sperm parameters. Prescription drugs don’t come with a male reproductive health label as they do for pregnant and lactating women, so while this will hopefully come up in a preconception appointment, encourage him to book a chat with the prescribing provider, too.
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Change lifestyle factors that impact sperm parameters: At a high level, follow a Mediterranean diet and cut processed foods and sugary beverages whenever possible, avoid saunas and steam rooms or any other heat near the testicles, get moderate exercise (but stop cycling), avoid endocrine-disrupting chemicals, smoking, and cannabis use, and get more sleep.
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Use a fertility-friendly lube: If you’re actively trying to conceive, check the packaging for spermicide, which, as you can probably imagine, is not good for sperm. There are several fertility-friendly brands designed specifically to help sperm on its journey to the egg.
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Leslie Schrock is a founder, investor, and advisor to some of the top companies at the convergence of health and technology. She is also the author of Fertility Rules: The Definitive Guide to Male and Female Reproductive Health. Leslie was named one of the Most Creative People in Business by Fast Company, and her work has been featured in publications including The Economist, Fortune, NPR, GQ, CNBC, and The New York Times.
