A couple that fails to conceive after one year of frequent, unprotected intercourse is described as infertile. Infertility affects around 1 in 6 couples all around the world, and male factor infertility is responsible for 50% of these cases. The rate of infertility is constantly increasing, as well as the decline in sperm quality among males around the globe. Even though this decline in semen quality has been investigated since 1938, male factor infertility has yet not been sufficiently researched and studied.

Clinical Evaluation

The clinical evaluation of male infertility is supported by semen analysis and physical examination. Semen's volume, pH, sperm count, motility, morphology, and vitality are the main parameters that get tested in a routine semen analysis. The WHO manual of 2021 indicates that the normal semen volume is 1.4 ml, the normal sperm concentration is 16 million spermatozoa per ml with a total motility at 42% and normal morphology at 4%. However, it is necessary that most, if not all, the values are within the fertile range for one to be fertile. Generally, low motility, poor concentration, or abnormal morphology, or a combination of them are known to be the cause of male infertility. Of course, the reference values have changed over the years as semen alterations have increased and more and more men become infertile. Another important test for infertility is the physical examination where further abnormalities may be discovered. To be more specific, examination of gynecomastia, sexual dysfunction, and the anatomy of the male genitals such as the testicle size can show abnormalities that can affect infertility.

Factors that Can Lead to Male Infertility

Male fertility and sperm health

Many factors can lead to male infertility:

1. Hormonal deficits: Deficiency in hormones such as FSH and/or LH can lead to low levels of testosterone, which is responsible for the production of sperm.

2. Genetic factors: Chromosomal abnormalities or mutations in the DNA may cause azoospermia (the absence of sperm) or oligospermia (severely reduced sperm numbers). Genetic abnormalities are found in 15% of infertile males. They are either inherited or acquired.

3. Free radicals: An increase in free radicals leads to higher levels of oxidative stress, which can cause cell damage, with sperm being particularly sensitive to this type of damage, causing them to become less functional. A healthy lifestyle and supplementary doses of antioxidants may alleviate the effects of oxidative stress.

4. Physical factors: Enlargement of the sperm vessels (varicocele), impaired testicular circulation (testicular torsion), and other abnormalities in the genital area may cause physical impairment to sperm production.

5. Infections/Illnesses: Genital tract infections such as chlamydia or gonorrhoea, although often treatable with medication, can cause irreversible damage to the male reproductive system.

6. Environmental factors: Pesticides, mercury, and radiation are some environmental toxins that can lead to reduced sperm production.

7. Lifestyle:Increased temperatures in the genital area, overuse of therapeutic medications, recreational drugs, anabolic steroids, smoking, alcohol, obesity, and age can negatively affect semen quality.

Infertility is a public health problem, and most people are unaware why infertility rates are rising. Delaying parenthood is a trend attributed to more recent generations, especially among people in the Western world. Of course, social and individual variables might influence a couple's decision to have children, but by lacking accurate information on fertility issues, people unwillingly contribute to such a trend of delayed childbearing.

To be more specific, according to some studies, many medical and non-medical students seem to have had a poor understanding of fertility issues and that there were gaps in knowledge on the impact of age on fertility. Additionally, it is known that adults of reproductive age have insufficient fertility awareness about fertility, infertility risk factors, and the implications of postponing parenting.

Furthermore, a population-based survey among men that tested the awareness of factors that lead to male infertility showed that males are not sufficiently aware of environmental, physiological, and medical factors that may lead to male infertility. Another study conducted in Bangladesh showed that not only did both healthcare professionals and medical students lack the knowledge on male infertility, but they also had a negative attitude towards it.

Finally, according to other studies, it appears that men are less aware of infertility issues than women.

Most men have never questioned their fertility. The taboos and misconceptions linked with male fertility mean men are less likely to visit a fertility clinic, and if and when they do, are less likely to be as involved with the fertility journey of their partner. This is attributed to the lack of trusted and available support and online resources focusing on male fertility education.

There is an association between infertility and failure on a personal, interpersonal, or societal level. Often these associations are due to societal norms such as gender inequality and perceived religious tenets that alter a medical problem into a social one.

Men are thought to be masculine, strong, virile, and many other stereotypical characteristics that influence their role in society. This influence has led to the concept of 'reproductive masculinity,' which places men in a secondary role in addressing infertility compared to women. The absence of focus on men even when they are infertile makes them feel less important.

Additionally, infertile men feel less masculine, virile, and are embarrassed to talk about their situation, as infertility is known to be a women's problem. It is a social stigma, as it is still less explored and understood than female infertility.

To conclude, male infertility is less advertised because men try to hide their infertility issues mostly due to patriarchy and the high expectations society has brought for them. This may be addressed if we fill the gaps of knowledge. They will no longer feel embarrassed or less masculine. This will ensure better guidance for men struggling with infertility and their partners. They won't face infertility-related stigma. A change in this area would resume society's prejudices, and males would feel equal to women as far as infertility is concerned. Infertility is a disease, and no disease is a shame. Patients should be treated accordingly.

By Theofano Kotrotsiou

References

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Bhongade, M.B., Prasad, S., Jiloha, R.C., Ray, P.C., Mohapatra, S. and Koner, B.C. 2015. Effect of psychological stress on fertility hormones and seminal quality in male partners of infertile couples. Andrologia 47(3), pp. 336–342. doi: 10.1111/and.12268.

Boeri, L. et al. 2022. The impact of different WHO reference criteria for semen analysis in clinical practice: Who will benefit from the new 2021 thresholds for normal semen parameters? Andrology 10(6), pp. 1134–1142. doi: 10.1111/andr.13213.

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Iktidar, M.A. et al. 2022. Knowledge, attitude and perception among medical students and healthcare professionals regarding male infertility: a cross-sectional survey from Bangladesh. BMJ Open 12(11). doi: 10.1136/bmjopen-2022-062251.

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Miner, S.A., Daumler, D., Chan, P., Gupta, A., Lo, K. and Zelkowitz, P. 2019. Masculinity, Mental Health, and Desire for Social Support Among Male Cancer and Infertility Patients. American Journal of Men’s Health 13(1). doi: 10.1177/1557988318820396.

Ravitsky, V. and Kimmins, S. 2019. The forgotten men: rising rates of male infertility urgently require new approaches for its prevention, diagnosis and treatment. Biology of Reproduction 101(5), pp. 872–874. doi: 10.1093/biolre/ioz161.

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