Infertility is a real and painful issue
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.” ■ ■