Why treatment for male infertility is failing both men and women

Male infertility is a really, really important issue  that simply doesn’t get enough recognition.
The world of fertility is geared around women — despite the fact that male infertility is now the most common reason for couples to have IVF.
And we really, really should be paying more attention.
Last year, an apocalyptic study by the Hebrew University of Jerusalem found that sperm counts in the West have more than halved over the past four decades, and are continuing to decline — which the authors of the study say could lead to the ‘extinction of the human species.’
And scientists say we don’t really understand why.
Despite all the incredible advances in reproductive technology, in some ways the approach to male infertility seems to have barely progressed at all.

Diagnosing male infertility

The standard semen analysis hasn’t really changed since the 19th century — looking at a sperm sample under a microscope to assess three key parameters: sperm count (how many are there?), motility (can they swim?) and morphology (what do they look like?).
And that’s….well, basically it.
If the results of this basic semen analysis indicate a sperm issue, the couple will be referred to a fertility clinic for IVF treatment (specifically, ICSI, a form of IVF where the embryologist injects the sperm directly into the egg), where they will be treated by a gynaecologist.
So far so good? Yes…and no.
The evidence suggests that ICSI is the most effective treatment to help a couple with a diagnosis of male factor infertility to have a baby. So in that respect this pathway makes total sense.
But does this approach really address patients’ needs?

Let’s break it down.

• A man with an diagnosis of male factor infertility is referred to a specialist in women’s reproductive health.
• His female partner will normally undergo numerous investigations — even though she may not actually have any fertility issues.
• Meanwhile, his actual medical problem is completely ignored once the semen analysis is done. Thereafter the man is frequently relegated to the role of ‘doing the easy bit’, to come up with the goods on demand.

OK, but isn’t that just how the IVF process works — it’s necessarily centred on the woman’s body?

Yes, the physical realities for the female partner during fertility treatment are unavoidable — but it takes two people to make a baby. It’s an experience that a couple go through together, and decisions should be made jointly.
But lots of men have said they felt sidelined from the process by clinicians who would often barely acknowledge their presence — as James describes in his fertility story.
It wasn’t helped by the fact that whenever we went to appointments it was very much like I was just there — the conversation wasn’t directed at me.
IVF is really bloody tough for both partners — and that’s before adding in the impact of a male infertility diagnosis: which Richard describes in his fertility story as humiliating, emasculating, isolating, and causing deep self-loathing.
So in terms of emotional care, yes there’s definitely more that could be done to support patients from the outset.

But let’s take another look at the overall process.

In the past, clinical aspects of male infertility were primarily dealt with by urologists. But once ICSI came along, fertility medicine became almost exclusively the domain of gynaecologists.
Which means infertile men are now being treated by clinicians with little to no training in diagnosing or treating male patients:
• Gynaecologists don’t perform physical examinations on men to check for any testicular issues that could be affecting his fertility (that might be easily resolved).
• Or take a full clinical history — which might indicate an underlying health problem, or potential lifestyle factors that might be affecting his fertility (that if addressed, might improve sperm quality).
• Or undertake further tests to identify additional sperm defects (such as DNA damage) that can cause infertility and miscarriage, but which aren’t picked up by a basic semen analysis (that if diagnosed, might be treatable).
While NICE guidance doesn’t recommend expensive additional tests, simply taking a history shouldn’t be too much of an ask, surely?
And if a couple are paying in thousands for physically, emotionally and financially demanding fertility treatment, shouldn’t they at least be given the option to discuss the pros and cons of more advanced diagnostics?

Treating male infertility

The result of inadequate diagnosis of male infertility is inadequate treatment of male infertility. In that there, er, isn’t any.
At least, not treatment for men.
The idea of choosing to put a patient with no medical issues through invasive treatment, in order to treat someone else’s medical issue, sounds ridiculous, right?
But that’s exactly what happens with male infertility. Rather than diagnosing the cause of the problem – in order to determine the best way to treat it—the default solution is simply to use ICSI to bypass the problem. Job done.
And yes, the goal is to have a baby — and if that’s going to achieve the desired result, then great.

But women are bearing the physical burden of potentially unnecessary fertility treatment, all because their infertile partners are being ignored by the medical profession — and opportunities to actually treat their problem are being missed.
Some scientists have even argued that this infringes upon the ‘basic human rights and dignity’ of women.
For example, a man with infertility problems who’s overweight and smokes might, if he adopts a healthier lifestyle, improve his sperm quality enough to be able to conceive naturally.
Yet low-cost and effective interventions may be overlooked, simply because no one ever bothered to take a proper history. (see below for more examples)
And looking at the bigger picture, the unintended consequence of ICSI’s success is that any attention into understanding the causes of male infertility has been diverted into researching treatment for the female — with many experts arguing that since ICSI was introduced 25 years ago, it has effectively roadblocked any further scientific advancement in male infertility.
Still, it’s not like male factor is a really common cause of infertility, or a massively growing worldwide problem, is it? Oh no, wait. Ah. Doesn’t sound great, does it?
Inadequate infertility care is failing men, and it’s failing women.
How much unnecessary time, money and heartache might be saved if men were actually acknowledged as more than just a sperm donor?
They deserve better. Their partners deserve better.
Male infertility is a growing problem on a global scale — so when are clinicians going to start taking it more seriously?

 Male infertility: Moments in history

16th Century fertility diagnostics
Early diagnostic tests for male infertility weren’t exactly bulletproof. And mainly involved peeing on plants.
One option was for both partners to pee into a pot that had been planted with barley, and whichever seed sprouted first demonstrated the fertility of the person who had watered it.
For a more rapid-turnaround test result, both parties would pee on a lettuce leaf, and the person whose urine evaporated from the leaf first was thought to be infertile.

Presidential potency
For hundreds of years any inability to conceive was blamed on the woman — as long as the man wasn’t impotent, he was assumed to be fertile.
US President George Washington was ‘mystified why, year after year, he and [his wife] Martha could produce no Washington heir’. Obviously as the leader of a great nation, there couldn’t possibly be any question of his virility, so the issue evidently had to lie with Martha.
Except that Martha was a widow, and had given birth to 4 children with her late husband, before she married George.
So, er, yeah, the woman with 4 kids is definitely the infertile one…

Sperm under the microscope
In the 1860s, American gynaecologist James Marion Sims decided to have a quick look at a semen sample under the microscope (he was investigating infertility, it wasn’t just for kicks. At least, you’d hope not).
And, wait for it…..he saw ACTUAL sperm with his own eyes! Voila, the semen analysis was born.

A dedicated male fertility laboratory
In 1945 the Family Planning Association (FPA) opened a dedicated seminological centre — Britain’s first purpose-built laboratory for investigating semen samples.
It was established in part specifically to help women, aiming to spare them from ‘unnecessary operative procedures’ if it was the husband who was ‘partly or even wholly responsible’ for the couple’s infertility.

A 1940s fertility story

In the 1940s a couple went to see a doctor about their inability to conceive: over the course of two years, the woman underwent a catalogue of invasive — and expensive — investigations and treatments.
Only after all this invasive treatment was unsuccessful did someone suggest that perhaps her husband’s fertility should be tested.
One simple semen analysis later, and the verdict was in. Not a single sperm was found in the sample. Not one. Neither in any of the subsequent tests.
Every single procedure the woman endured was totally pointless — all because male factor simply wasn’t a priority.

A modern day fertility story
A couple trying since 2013 to get pregnant had seen many doctors and visited multiple clinics. All had focused on the woman’s reproductive system – she had invasive tests, pelvic scans and many months of guilt and crushing disappointment as she ‘failed’ to get pregnant.
Days before she was about to undergo an HSG – where dye is inserted through the cervix into the uterus using a catheter in order to check its shape and make sure the fallopian tubes are not blocked – that a doctor suggested her husband might have his sperm tested.
A 5 minute test later, it was found her husband had problems with sperm motility and count. After successful IVF they now have a baby girl, but as she was by now 41, she felt she had run out of time to have the two children she had dreamed of. An earlier diagnosis would have been possible with even the most basic of sperm tests. In many ways, very little has changed since the 1940s.

2018 Male Fertility Stories

The surgical procedure

Naomi and Jonathan were referred to a fertility clinic following a diagnosis of male factor infertility. Jonathan already knew that he had a varicocele (a varicose vein in the testicles), however their clinic advised them that going straight to ICSI was the best option. They had 3 failed cycles, finally succeeding on their 4th cycle. When they decided to start trying for a sibling, Jonathan went to see a urologist to discuss removing the varicocele, in the hope of improving his sperm (and increasing their chances of a successful ICSI cycle). A few months after his surgery, they conceived their daughter naturally.

The hormone treatment

Priti and Raj were advised to have ICSI due to Raj’s low sperm count. Priti became very ill with ovarian hyperstimulation syndrome during their first (and unsuccessful) cycle. In addition to the shame Raj felt about his diagnosis, he felt enormously guilty that Priti had endured such physically gruelling treatment as a result of his infertility problem.
Desperate to find any way to avoid putting Priti through another cycle, he trawled Google looking for advice, eventually making an appointment with a male fertility specialist.
Blood tests revealed that Raj had a hormonal imbalance, which was the likely cause of his low sperm count. After a course of hormone tablets, his sperm count improved enough to attempt a less invasive form of fertility treatment (IUI, or intra-uterine insemination) — which was ultimately successful.