Male Infertility from Science to Societal Issues

Male factor infertility makes up approximately 40% of South African couples struggling to conceive. Fortunately, most cases can be relatively easily rectified by the use of assisted reproductive technologies (ART). Moreover, most male infertility cases present as sub-fertile. This means that with most male infertility cases, there are one or more sub-optimal semen parameters causing the lowered chances of natural conception (Wijnland Fertility 2024). So what is infertility? According to Boitrelle et al. (2021), infertility is defined as the “inability to achieve spontaneous pregnancy within one year of regular unprotected sexual intercourse”. In recent years, there has been a growing concern about the declining sperm concentrations around the world, which could be attributed to various lifestyle factors such as obesity and exposure to environmental chemicals/radiations (Boitrelle et al., 2021). Male infertility is due to low sperm production, abnormal sperm function or blockages that prevent the delivery of sperm. Illnesses, injuries, chronic health problems, lifestyle choices and other factors can play a role in causing male infertility. There are few cases due to there being no sperm present at all, however, this can also be ‘rectified’ by making use of donor sperm (Wijnland Fertility 2024) in some cases. It is for this reason that there are numerous analysis that one will have to take to evaluate the semen – but also the medical history of the patient.     

There are methods that can be used to test for male infertility known as the semen analysis. Thus,  the semen analysis (SA) represents the most basic evaluation of male infertility. The evaluation of semen parameters is currently based on the standards defined in the laboratory manual for the examination and processing of human semen created by the World Health Organization (WHO).  The WHO laboratory manual for the examination and processing of human semen 1st Edition was published in 1980 to the current 6th Edition, there have been significant advances with the incorporation of recent developments in semen examination techniques, methods of sperm preparation and cryopreservation, and new technologies to improve quality control and assurance (Boitrelle et al., 2021). Recent scientific advances in the understanding of sperm DNA fragmentation (SDF), seminal oxidative stress (OS), and reactive oxygen species (ROS) testing have shed additional light on the prognosis of reproductive outcomes in terms of natural conception and assisted reproductive technology (ART). Given the growing awareness that chromosomal abnormalities and gene mutations often underlie a diverse spectrum of male infertility, genetic and genomic testing are gaining attention in this new 6th Edition (see chapter “Extended examinations”). In the chapter “Advanced examinations”, some other tests used in research are described, such as sperm acrosome reaction, functional analysis of transmembrane ion flux and transport in sperm, and methods for the evaluation of chromatin condensation (Boitrelle et al., 2021). Even with these new advances in semen analysis the problem with male infertility remains and exacerbate societal issues.

One of the social issues concerning male infertility is its connection to Intimate Partner Violence (IPV) particularly in low-income and middle-income countries. Intimate partner violence IPV is the most common form of violence against women, defined as any form of violence by a current or former male intimate partner within a union, and can present as physical, psychological or emotional, or sexual violence, or as economic coercion and controlling behaviours (Wang et al., 2022). I can only imagine how important this matter is especially in patriotic sociaties and/ or where (toxic) masculinity is high and men think that only the women are responsible for sexual and reproductive health. For example, where men believe that it is only the women that can be infertile and never the men – as it may be so due to some cultural ideas in South Africa and possible Africa. The most recent estimate from WHO indicates that, worldwide, 27% of ever-married or ever-partnered women aged 15–49 years have experienced physical or sexual violence (or both) committed by intimate partners at least once in their lifetime, whereas the prevalence over a 12-month period was 13%. This poses a problem, seeing that De Jonge et al., (2023) mentions that literature database contains many publications demonstrating that in comparison with women, men are characteristically less likely to seek routine healthcare unless intervention for an acute medical issue presents. The reason for this is that men tend to associate seeking medical care with weakness and/ or a threat to their masculinity and/ or  because an underlying health issue may be revealed. So, to fill that void, women make up to 80% of health care decisions for their family and the male partner. They further explain that, in the field of Medically Assisted Reproduction (MAR)  it is frequently said that women provide the primary motivation for an infertility investigation including for that of her male partner. However, it is difficult to find any specific evidence in literature data to confirm or refute this assertion, and thus must be considered as anecdotal. Inference of men taking a ‘passenger’ role in the investigation of infertility for the couple comes from one study showing that both men and women felt that fertility is a woman’s issue (De Jonge et al., 2023). This is obviously a problem, because as research indicates many of the sexual and reproductive issues are not always or only the women’s problem. Therefore, one can notice how it is important to have a more male inclusive sexual and reproductive health.  

As the saying goes: prevention is better than cure! Therefore, how do we prevent or rather help lessen male infertility. The more obvious way is to have awareness campaigns around this matter.  To develop community (public) education and from as early as male puberty starts so that no one is left behind.  Starting early can help lessen the stigma that also comes with male infertility and decrease the burden on IPV. The focus on education and public awareness on women fertility has not particularly solved the injustices that are linked to sexual and reproductive health. Hence, we need to also think and strategise how we can have these programs aligned or be complementary to those existing men’s health and/ or Gender Based Violence (GBV) awareness campaigns program. For example, non-profit organisation such as the men’s forum or men imbizo could be used for dialogues on this matter from a community based model. In addition, promotion of healthier lifestyle is imperative since there are many behavioural and environmental factors which can have a direct or indirect impact on how a man’s body ‘produces’ semen. Therefore, one can adopt the following healthy lifestyle habits:

• Avoid drug and tobacco use and drinking too much alcohol, which may contribute to male infertility.
• Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm production and motility.
• Avoid exposure to industrial or environmental toxins, which can affect sperm production.
• Limit medications that may impact fertility, both prescription and non-prescription drugs.
• Exercise moderately. Regular exercise may improve sperm quality and increase the chances for achieving a pregnancy. However, avoid excessive exercise.
• Avoid wearing very tight underwear for prolonged periods of time
• Cut back on caffeine consumption. (Two cups of coffee a day is fine)
• Avoid steroids used in body building. These compounds disrupt hormone production, and can actually stop your body producing sperm.
• Eat more antioxidant-rich foods like fresh fruit and vegetables. Not only can this assist in conditions like high levels of ROS (Reactive Oxygen Species) in semen, but will improve your overall health too! (Winjland Fertility 2024).

In conclusion, male infertility is a serious matter and can affect the individual and couple in question. Not addressing this matter is an injustice. An injustice that needs to be ratified and addressed. Therefore, we can start rectifying these injustices by developing policies that are inclusive of male sexual and reproductive health, then develop some education and advocacy campaigns to raise awareness on this matter, and promote healthy lifestyle amongst men. This will not only ensure human rights, i.e., rights to health, but will also aid in helping to address some of the short comings that may be found in science and technology for male sexual and reproduction in terms of  analysis, health promotion, diagnostic tools, affordability, accessibility, and specialist in this research field.  

 Written by: Fikile M Mnisi

References:

Boitrelle, F., Shah, R., Saleh, R., Henkel, R., Kandil, H., Chung, E., Vogiatzi, P., Zini, A., Arafa, M., & Agarwal, A. 2021. “The Sixth Edition of the WHO Manual for Human Semen Analysis: A Critical Review and SWOT Analysis”.  Life. Vol. 11 (1368): p. 1- 13.

De Jonge, C. J., &  Gellatly, S.A., Vazquez-Levin, M. H., Barratt, C.L.R. 2023. “Male Attitudes towards Infertility: Results from a Global Questionnaire”. World J Mens Health. Vol 41(1): p. 204-214.

Wang., Y, Fu., Y, Ghazi, P., Gao, Q., Tian, T., Kong, F., Zhan, S., Liu, C., Bloom, D.E., & Qiao, J. 2022. “Prevalence of intimate partner violence against infertile women in low-income and middle-income countries: a systematic review and meta-analysis”. Lancet Glob Health. Vol. 10 (8): p 20-30.

Wijnland Fertility.  2024. “What is Male Infertility”. Accessed: 8 June 2024.  Accessed from: https://www.wijnlandfertility.co.za/male-infertility/#:~:text=Male%20factor%20infertility%20makes%20up,African%20couples%20struggling%20to%20conceive.