Male in­fer­til­ity

In­fer­til­ity is a real and painful is­sue

The Observer Magazine - - NEWS - Il­lus­tra­tions FRANCESCO CICCOLELLA

Why is so lit­tle be­ing done about this wors­en­ing health is­sue?

It’s like a judg­ment on your mas­culin­ity,” says Glenn Bar­den. “You do feel like less of a man.” Bar­den, a 48-year-old TV di­rec­tor from Lon­don, is talk­ing about an is­sue that is lit­tle dis­cussed in pub­lic or the me­dia, but which af­fects a grow­ing per­cent­age of the pop­u­la­tion: male in­fer­til­ity. He spent most of his 30s try­ing to have a child, and the fail­ure to do so left him de­pressed, he says, some­times in tears, and “hid­ing un­der the du­vet”. In his case, his sperm count – the main marker of male fer­til­ity – was not even deemed prob­lem­atic. But he avoided al­co­hol, stopped smok­ing dope, wore loose un­der­pants, and fol­lowed the ap­proved ad­vice to max­imise sperm pro­duc­tion, all to no avail – no spe­cific is­sue was di­ag­nosed and yet his wife did not get preg­nant. He felt as if he was fall­ing short of what was re­quired of him as a man. And that fail­ure made him para­noid, frus­trated, en­vi­ous and an­gry.

He de­scribes the mind­less ba­nal­ity of go­ing along to clin­ics and giv­ing sperm sam­ples, but also the ner­vous feel­ing that he had to give it his best shot. Then came the or­deal of wait­ing for the re­sults with his wife.

“I re­mem­ber go­ing to see the doc­tor to get the an­nounce­ment of the test and hop­ing that it wasn’t me. Hop­ing that it was her fault.”

For Gareth Down, the sit­u­a­tion was more dis­turb­ing. At the age of 21, when he was al­ready mar­ried and af­ter an un­suc­cess­ful pe­riod of try­ing to have chil­dren, he took a se­men test. He learned the re­sult when his GP phoned him at work.

“He told me: ‘You’ve got no sperm. You can’t have a fam­ily.’ That was just a five minute-con­ver­sa­tion. He knew I was at work but he didn’t think twice about de­liv­er­ing the news and hang­ing up. There was no of­fer to come in and have a chat, to ex­plain or help with what the im­pact might be.” The im­pact was life-chang­ing.

Bar­den and Down are far from alone. A com­pre­hen­sive study pub­lished last year by the He­brew Univer­sity of Jerusalem sug­gests that sperm count among western men has more than halved over the past 40 years. There have been sev­eral other stud­ies that have reached sim­i­lar con­clu­sions, but this was by far the largest. Ac­cord­ing to ex­perts in the field, as many as one in five young men have low sperm counts, and about one in two are below the op­ti­mum.

“I don’t like the word cri­sis,” says Richard Sharpe, pro­fes­sor at the Univer­sity of Ed­in­burgh’s Cen­tre for Re­pro­duc­tive Health and one of the world’s lead­ing au­thor­i­ties on male in­fer­til­ity, “but I think it’s fair to say that there is an un­ac­knowl­edged prob­lem.”

Sperm count varies enor­mously, from zero sperm per millil­itre (spm) of se­men to 250 mil­lion or more. Above 40m spm there is lit­tle gain in fer­til­ity but, below that fig­ure, the fer­til­ity graph plum­mets. Ac­cord­ing to the World Health Author­ity, a count of less than 15m spm is low, de­fined as what’s called oligo­zoosper­mia – which means that there is likely to be dif­fi­culty in con­ceiv­ing, and that dif­fi­culty steeply in­creases as the count moves to­wards zero.

One study held in Ed­in­burgh showed sperm counts de­clin­ing from an av­er­age of 100m spm in 1950 to 50m spm in 1990. An­other con­ducted among sperm donors in France sug­gested that healthy sperm lev­els were drop­ping by 2% a year. It’s fig­ures like these that en­cour­age the pos­tu­la­tion of dooms­day sce­nar­ios, fa­mil­iar from sci­ence fic­tion, in which hu­man­ity risks ex­tinc­tion.

Male in­fer­til­ity ac­counts for roughly half of all in­fer­til­ity, yet fer­til­ity has his­tor­i­cally been per­ceived both in the pop­u­lar imag­i­na­tion and within med­i­cal prac­tice as largely a fe­male mat­ter. While women have gy­nae­col­o­gists and ob­ste­tri­cians, spe­cial­ists trained in fe­male re­pro­duc­tion, there is no equiv­a­lent for men.

In­deed, as Sharpe says: “The re­mark­able thing about ART (as­sisted re­pro­duc­tive tech­nol­ogy) is that even when it’s the male prob­lem, it’s the fe­male that has to un­dergo treat­ment. What sort of equal­ity is that?”

Most ex­perts agree that the de­cline in fer­til­ity is real, but no one re­ally has a clear idea of what’s caus­ing it. There have been sev­eral the­o­ries put forth: obe­sity, smok­ing, stress, as well as the sug­ges­tion that oe­stro­gen in the wa­ter supply (sup­pos­edly from the con­tra­cep­tive pill and HRT) has neg­a­tively af­fected sperm qual­ity.

“That’s al­most cer­tainly rub­bish,” says Al­lan Pacey, pro­fes­sor of an­drol­ogy (the field of male health) at the Univer­sity of Sh­effield.

Pacey is some­thing of a scep­tic about di­min­ish­ing male fer­til­ity. He ques­tions the ac­cu­racy of many of the stud­ies, par­tic­u­larly those that com­pare against ear­lier sta­tis­tics, when tech­niques were less de­vel­oped and re­sults less re­li­able. He also points out that sperm lev­els can drop a long way with­out af­fect­ing most men’s fer­til­ity.

But there is a cri­sis devel­op­ing, he feels, though it is one brought about be­cause of the in­creas­ing age of par­ents, rather than of di­min­ish­ing fer­til­ity.

“Men and their part­ners are wait­ing un­til they are older be­fore they think about hav­ing chil­dren,” says Pacey. “The com­bi­na­tion of an older woman and an older man means that their prob­a­bil­ity of suc­cess is re­duced. There­fore they are more re­liant on as­sisted con­cep­tion.”

How­ever, Pacey was im­pressed by the rigour of the He­brew Univer­sity study, and he ac­knowl­edges that there is ‹

‹ good ev­i­dence that sperm count in­creases as you move east across the Baltic, which sug­gests there are en­vi­ron­men­tal fac­tors in­volved in the dis­tri­bu­tion of fer­til­ity rates.

“There could be a com­bi­na­tion of causes,” he says. “Richard [Sharpe] pro­poses that there is a dis­rup­tion of the early testos­terone in the devel­op­ing foe­tus. That the­ory seems a good one to me. An ex­am­ple might be, preg­nant women tak­ing parac­eta­mol dur­ing preg­nancy, and the parac­eta­mol cross­ing the pla­centa and caus­ing prob­lems. Com­pounds present in make-up, sham­poos? No­body re­ally knows the true an­swer. There was a story of women who dur­ing preg­nancy ate lots of beef from cows that had been given hor­mones and they were cross­ing the pla­centa. Lots of po­ten­tial things out there. It may just be modern life.”

Sh­eryl Homa runs An­drol­ogy So­lu­tions in Wim­pole Street, Lon­don, the only clinic li­censed by the Hu­man Fer­til­i­sa­tion and Em­bry­ol­ogy Author­ity in the UK that is de­voted to male re­pro­duc­tive health. She worked as a clin­i­cal em­bry­ol­o­gist in IVF lab­o­ra­to­ries and was shocked at how lit­tle at­ten­tion was given to male in­fer­til­ity. “I think that far too many men who have poor sperm qual­ity are sent off to IVF units with­out hav­ing proper in­ves­ti­ga­tion,” she tells me. “They could be man­aged in other ways.”

The lead­ing cause of male in­fer­til­ity is a com­plaint called varic­o­cele, which is a knot of vari­cose veins in the testes. About 40% of in­fer­tile men have varic­o­cele, al­though it doesn’t al­ways im­pair fer­til­ity – 15% of fer­tile men also have varic­o­cele. It cre­ates an en­gorge­ment of blood that heats up the testes as much as four de­grees, which can cause sig­nif­i­cant dam­age to sperm.

A phys­i­cal ex­am­i­na­tion can iden­tify varic­o­cele, and it’s eas­ily ruled out by an ul­tra­sound scan. But very of­ten men go un­di­ag­nosed, and ul­tra­sound scans, which are stan­dard in in­ves­ti­gat­ing fe­male in­fer­til­ity, are very rarely em­ployed on men. In­stead, di­ag­nos­tic work on men sel­dom goes be­yond the stan­dard se­men anal­y­sis.

That anal­y­sis gives lim­ited in­for­ma­tion – es­sen­tially, the sperm count and motil­ity (the abil­ity of the sperm to move around). These are im­por­tant fac­tors, and a lack of ei­ther can lead to in­fer­til­ity. “But,” says Homa, “it’s a very su­per­fi­cial test. There is a great mis­con­cep­tion about the value of se­men anal­y­sis. There is a false be­lief that if you have nor­mal se­men pa­ram­e­ters, the man is fine. He’s told this: you’re fine, you’re not the prob­lem. But we have to re­alise se­men pa­ram­e­ters are re­ally poor in­di­ca­tors of fer­til­ity.”

She be­lieves that fur­ther tests, like assess­ment of ox­ida­tive stress and DNA frag­men­ta­tion tests, which can show dam­age to sperm not picked up in se­men anal­y­sis, should be much more widely used. She also says that 35% of her clients with in­fer­til­ity is­sues carry un­der­ly­ing in­fec­tions that are not de­tected in stan­dard STI (sex­u­ally trans­mit­ted in­fec­tion) screens. And just as women are re­ferred to gy­nae­col­o­gists when be­ing treated for fer­til­ity, so men should see con­sul­tant urol­o­gists spe­cial­is­ing in an­drol­ogy.

There is a re­luc­tance to im­ple­ment fur­ther test­ing, she says, be­cause it’s deemed ex­pen­sive. Yet women are sub­ject to a bat­tery of ex­pen­sive tests, and cou­ples are sent off to IVF, at a far higher fi­nan­cial cost, with­out a proper un­der­stand­ing of the male’s re­pro­duc­tive health.

Sharpe ac­knowl­edges the prob­lem. “Se­men anal­y­sis is a very im­per­fect tool. If you’ve got a nor­mal, or even high, sperm count it doesn’t guar­an­tee you are fer­tile and, cor­re­spond­ingly, if you have a very low sperm count, it doesn’t guar­an­tee that you are in­fer­tile.”

How­ever, these ques­tions cen­tring on the male con­tri­bu­tion to re­pro­duc­tion tend to be over­looked be­cause ART of­fers an an­swer, even if it still only works for a mi­nor­ity of peo­ple. This has been par­tic­u­larly so since the de­vel­op­ment of in­tra­cy­to­plas­mic sperm in­jec­tion (ICSI) in 1992. ICSI, which is avail­able on the NHS, is like a more re­fined IVF pro­ce­dure, in that a sin­gle sperm is picked up and in­jected into an egg. It’s of­ten used when the sperm count and/or motil­ity is low.

“ICSI,” says Sharpe, “has cre­ated an il­lu­sion in the minds of many peo­ple: we don’t have a prob­lem with male fer­til­ity be­cause we’ve got a so­lu­tion – send them for ICSI, de­spite the fact that we know that it doesn’t work for the ma­jor­ity of cou­ples, and you need re­peated cy­cles, which is emo­tion­ally, phys­i­cally and fi­nan­cially pretty bruis­ing.”

Those bruises were suf­fered by both Bar­den and Down, and their ex­pe­ri­ence of them was all the more pun­ish­ing be­cause both felt that, as men, it was their job to ap­pear as if they were cop­ing, es­pe­cially as it was their wives who were un­der­go­ing the pro­ce­dures. “All I had to do was jerk off into a pot,” says Bar­den. “But it ab­so­lutely de­stroyed my life in my 30s. I had ter­ri­ble de­pres­sion.”

An­other vet­eran of fer­til­ity test­ing, a TV pro­ducer who wishes to re­main anony­mous, found that the only way he could deal with the “grim­ness” of the pro­ce­dures and the mourn­ful wait­ing rooms was through hu­mour.

“I used to tell anec­dotes about hav­ing to go toss your­self with an old copy of Raz­zle in some slightly dirty toi­let and peo­ple would laugh and I would laugh too, be­cause it was ridicu­lous. They’d lit­er­ally give you some crappy old porn mag­a­zine and a jar and that was it. Off you go. And you’d think, I can’t go back into the wait­ing room, it’s too soon. I’ll leave it a cou­ple of min­utes, other­wise they’ll think I’ve got pre­ma­ture ejac­u­la­tion. I mean, it was funny.”

But Bar­den couldn’t bear to be around friends with chil­dren and nor did he feel able to talk about his prob­lems with any­one. In­stead, he hid, avoid­ing sit­u­a­tions that would make things worse. It has to be said that an aching de­sire to have chil­dren is not some­thing that is pub­licly

‘My fail­ure at fa­ther­hood ate away at me but I couldn’t talk about it’

as­so­ci­ated with man­hood. In modern life, men are the ones who re­luc­tantly ac­cede to fa­ther­hood – not ac­tively seek it. Bar­den in­ter­nalised his frus­tra­tion.

Years later, he dis­cov­ered that two male friends he reg­u­larly played poker with were hav­ing sim­i­lar prob­lems, but they, too, kept it quiet. To make sense of it all, he wrote a ro­man­tic com­edy novel about his ex­pe­ri­ence, en­ti­tled My Lit­tle Soldiers. But the re­al­ity was of­ten de­spair­ing.

“My fail­ure at fa­ther­hood ate away at my very be­ing,” he says. “Friends later told me that my body was phys­i­cally hunched from the emo­tional weight of my baby wait. I didn’t want to talk about it to any­one. I would walk past chil­dren play­ing in the park and I’d feel my heart break­ing into tiny pieces. I would os­cil­late wildly be­tween anger and de­pres­sion. Af­ter learn­ing a friend of ours was preg­nant, I didn’t leave my bed­room for two days.”

For Down, who is the man­ager of an HGV garage in Dorset, it was the ar­rival of chil­dren within his ex­tended fam­ily that was most dif­fi­cult. There were seven new­borns while he and his wife were try­ing – through do­nated sperm and IVF – to have a baby. “That was very hard,” he says. “We had a few fam­ily dis­agree­ments.”

Be­cause he had zero sperm, he had to un­dergo a chro­mo­some test to es­tab­lish that he was male. “Ap­par­ently,” he ex­plains, “you can have all the anatomy of a man and still have a fe­male chro­mo­some mix­ture. You think, ‘I’ve spent 21 years be­ing a man.’ So it was a shock to be tested.”

The worst as­pect of the whole process, how­ever, was the “dreaded wait” be­tween the cy­cles of the var­i­ous ART pro­ce­dures his wife un­der­went – nine in to­tal.

“You have to wait to see if the em­bryo takes or not.” The un­cer­tainty, and then grow­ing ex­pec­ta­tion of dis­ap­point­ment, ex­erts great stress on a mar­riage. Bar­den be­lieves that the process brought him and his wife closer to­gether, but it also re­sulted – af­ter seven years – in a child.

“We had a girl,” he says. “We’re over­joyed with her. Gen­uinely feel blessed. But I re­ally feel for any­one who doesn’t come out the other side. I wanted to go for more but my wife was adamant that she wasn’t go­ing to do it again.”

He ac­knowl­edges, though, that things could have turned out very dif­fer­ently. “I think if we hadn’t had a child, we wouldn’t be to­gether now.”

Down and his wife reached their fi­nal at­tempt al­most three years ago. His wife did not want to go through with this last at­tempt to fer­tilise her re­main­ing frozen em­bryos. But Down thought they’d re­gret it if she didn’t. He wanted to speak to other men in the same sit­u­a­tion. So he set up a closed Face­book group, Men’s Fer­til­ity Sup­port, be­cause all other fer­til­ity groups were fe­male based. “They’re much bet­ter at talk­ing about these things,” he says.

The group is flour­ish­ing. And Down now has a two-yearold boy. The pro­ce­dure worked. But the mar­riage did not sur­vive. They split up a year ago. His wife wanted an­other child, and he, as he says, “didn’t have the strength to go through it all again”.

He thinks they could prob­a­bly have sur­vived that dif­fer­ence of opin­ion, but the legacy of stress and all the ten­sions their at­tempts to have a baby in­curred proved too much. They now live sep­a­rately and have joint cus­tody. His wife had al­ways wanted to carry a child, so adop­tion wasn’t for her. But he is un­con­cerned that his son is not his bi­o­log­i­cal off­spring. “Genetics don’t make you a dad,” he says. “It’s how and where you are in his life.”

Male fer­til­ity is a large and mostly con­cealed sub­ject. But all the par­tic­i­pants I spoke to, both ex­perts and prospec­tive fathers, agreed on one thing: the need to change at­ti­tudes. For sci­en­tists like Sharpe and Homa, the level of re­search re­quired to un­der­stand the mys­ter­ies of male fer­til­ity will not come about with­out so­cial pres­sure. In this, Sharpe be­lieves, women have a key role.

“They’re much more ef­fec­tive in get­ting things mov­ing like this, and it’s time to start say­ing, when it is the male prob­lem, why can’t you do some­thing about this?”

For Down and Bar­den, and many other men like them, it would be a help­ful start if the med­i­cal au­thor­i­ties be­gan to take a more ac­tive in­ter­est, and view them not just as faulty sperm donors, but a key part of the re­pro­duc­tive process.

As Homa says: “I think that by by­pass­ing male in­fer­til­ity, as if it’s sec­ondary and unim­por­tant, you’re los­ing half the pic­ture.” ■ ■

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