Guilt, stress, expense... the physical and mental impacts of male infertility
According to International journal , more than 56 million men suffered infertility up to 2019 globally — a growth rate of 76.9% compared to 1990
Plastic is everywhere: from flotillas of toy ducks on the ocean to micro-plastics in anything from blood to breast milk, from instant rice to breaded shrimp.
But earlier this year, two studies indicated something more insidious.
In May, in the journal Toxicological Sciences, a report showed the presence of microplastics in all 23 human testes that were analysed, suggesting it may have a role in the decades-long decline in sperm counts around the world.
In June, in another study, microplastics were detected in all 40 semen samples from men undergoing premarital-health assessments in Jinan, China.
The suspected link between microplastics and declining sperm quality may be real, but beyond doubt there is an issue with male fertility.
According to International journal BMC Public Health, 56m men were infertile up to 2019 — a growth of 76.9% compared to 1990. The issue was particularly pronounced in certain regions, such as Western Sub- Saharan Africa, Eastern Europe, and East Asia, and the 30–34 years age group had the highest prevalence.
According to the World Health Organization, male infertility may be caused by obstruction of the reproductive tract, resulting in dysfunctionalities in the ejection of semen, due to injury or infection of the genital tract, alongside hormonal disorders and testicular failure to produce sperm, for example due to varicoceles or medical treatments that impair sperm-producing cells, such as chemotherapy. Likewise, the use of anabolic steroids could result in abnormal sperm function and quality.
Graham Coull, scientific director of Sims IVF in Ireland, says that factors include sedentary jobs and long trousers, the commonality being heat.
Testicles are designed to exist at 35°C, lower than the rest of the body. An increase in testicular temperature affects sperm production, so professions where heat is a factor — such as working in kitchens or bakeries — can have an adverse impact on sperm quality. Lifestyle can also be a significant reason for poor sperm quality or quantity.
Coull says: “The biggest thing is smoking, and there is more and more evidence that shows vaping is just as bad.” Moderate alcohol intake can actually benefit sperm quality, but excessive alcohol intake is damaging, while cyclists are likely to have sperm problems because of all those hours in the saddle.
It says much about the wonders and mysteries of procreation that even a fertility expert such as Dr Coull sometimes turns to phrases such as “the way the wind blows” and “the phases of the moon”.
Sims IVF has three fertility clinics, which deal with around one-third of all infertility cases in Ireland.
Coull acknowledges the many successful cases, but there is no sugarcoating the difficulties faced by couples struggling to conceive.
Coull cites an old study that repeatedly trying and failing to conceive has similar stress levels to stage-4 cancer. And for men, still more buttoned up when it comes to discussing these things, it can cause misplaced guilt.
“Rather than angst between couples, though it can cause that, I would say the biggest feeling is guilt — ‘is it my fault?’ The guilt becomes massive for him — wrongly. It’s a tough journey.” Birth rates globally are declining and, according to Coull, one likely factor is the later age at which couples try to have their first child. Some 50 years ago, a first baby might arrive in the parents’ early 20s or even in the late teens, whereas now it is likely to be at 33.
This is a function of economics, he says — couples want to be financially secure, ideally not renting any more and living in their own home, with a career in progress.
All that takes time, and time is the issue: the later that fertility problems emerge, the shorter the time window to address them. The average age of people attending SIMS is 37 to 38, with 30% of cases related to problems with the woman, 30% relating to problems with the man, another 30% relating to issues with both, and the final 10% “totally unknown... everything looks fine and we don’t know why,” Coull says. This element of chance, the unknown variable they can’t pinpoint or control, Coull says “could have been the way the wind blows or the phases of the moon”.
Irish researchers are working on possible solutions.
Dr Eoghan Cunnane is a lecturer in biomedical engineering and is principal investigator on an ERC starting grant at the University of Limerick, and is leading the way in terms of Irish reproductive biology research. The ERC grant is targeted at developing representative, reliable, and reproducible in-vitro models of the human testes, to develop male infertility treatments.
Cunnane is looking at how the cells and tissues of the testicles interact, and how to accurately represent those interactions outside of the body in a pre-clinical model that could then be used to help develop treatments for male infertility prior to clinical trials.
“We are seeking to develop a platform that can be used to investigate the causes of male infertility, and also to assist in the development of treatments for currently untreatable forms of male infertility,” Cunnane says.
“In order for such a platform to work effectively, it must accurately replicate the key functions of the human testes, which are to produce hormones and also to produce mature sperm. This has been a persistent research hurdle for many years in the field of male reproductive health.
“We are seeking to overcome this hurdle by extensively characterising the properties of testicular tissue harvested from men who exhibit a wide range of testicular pathologies. We then utilise this information to inform the development of the platform which utilises testicular cell and tissue components. Our hope is that the platform can utilise high-throughput fabrication and automated analysis in order to produce scientific data that is reliable and reproducible, as well as being representative of human physiology.”
Cunnane believes male infertility has been “a little bit neglected” and that addressing it is vital; particularly given the complexities of the male reproductive organs, the unknown as to why some people experience fertility issues.
And then there is the stigma.
Around 6,000 couples engage with fertility support services every year in Ireland, and the National Infertility Support and Information Group (NISIG) has a range of services, including a helpline, workshops, live web chat, support meetings, resources, and information for parents and intending parents, as well as undertaking advocacy on behalf of couples experiencing fertility issues.
According to its spokesperson, Caitríona Fitzpatrick: “The vast majority of people who engage with our services are women; mostly, men will attend our support meetings with a female partner and may or may not disclose their fertility issue.” Fitzpatrick said stigma is “a significant issue when it comes to fertility”, referring to a survey conducted by SIMs IVF earlier this year, which found that more than one in three adults (34%) had experienced stigma or judgment in relation to their fertility, either directly or through a friend or family member.
At the time, Karen Ferguson, director of nursing and clinical services at Sims IVF, said that stigma was “a hidden burden” for people undergoing fertility issues, whether through humour or sarcasm or unsolicited advice.
Or, as Coull puts it, the unwanted words are seldom malicious, but are generally unhelpful, such as references to ‘when are we going to hear the pitter patter of tiny feet?’ For both Cunnane and Coull, education is key, ideally making people, particularly young men, aware that testing could be available while they are in their 20s, even if it might not be top of their agenda at that age. Again, it’s with one eye on the clock: just as women would be encouraged to freeze their eggs, men could get ahead of any possible future issue.
According to Fitzpatrick: “The publicly funded IVF which was announced [by government] last September has been a welcome progression in the provision of services in Ireland, but this is a first phase and we look forward to seeing the criteria expanded and a much broader provision of services through the public health system, now that the AHR [assisted human reproduction] legislation has been passed.” For Coull, this policy advance is likely to mean more people, previously priced out of seeking IVF assistance, looking for advice and support, all the way up to the highly technical processes that might, some day, result in the birth of a baby — so worried over, so longed for.
As for those treatments, they are wide and varied: for example, intracytoplasmic sperm injection, or ICSI, which is very similar to conventional IVF, in that gametes (eggs and sperm) are collected from each partner.
This is used when the sperm count is very low, or the sperm cannot move properly, or the sperm are in other ways abnormal and when sperm has been retrieved surgically from the epididymis or the testes. Other male-orientated treatments include TESE, a surgical sperm- retrieval procedure used in fertility treatment for men who have no sperm in their ejaculate, and IMSI, or intracytoplasmic morphologically selected sperm injection, a variation of ICSI that uses a higher-powered microscope to select sperm.
As Coull points out, fertility treatment is a peculiar form of medicine, one where people repeatedly return with no positive result — until just maybe there is one.
He recalls one couple, where the issue was with the male, who underwent so many treatments involving the freezing of embryos that the clinic told them they didn’t want to take any more of their money: “They begged us to do one more cycle and it was chalk and cheese compared to the previous ones. There was a beautiful embryo and they ended up with twins.”
It is this case that prompted him to muse on the unknown element of infertility — “it could have been the way the wind blows or the phases of the moon”, but for when it all works out, he has the perfect phrase: “The successful couples disappear into the sunset.”
