Written evidence submitted by Mr Ibrahim Samy, Mr Tet Yap and Ian Stones (IMH0087)
How does infertility affect men’s health?
I am a Urology fellow, researcher, and psychosexual therapist in training, with a particular focus on Andrology and men's health. My interest in this field has grown significantly since I began collaborating with Mr. Yap, the head of the only Klinefelter's Clinic in the country. Their ongoing efforts to understand this syndrome's impact on men and male infertility are commendable. One of the challenges we face is that individuals can receive a late diagnosis, which can hinder their access to proper care.
It is worth noting that many men who struggle with infertility also experience sexual dysfunctions. However, there is still a need for extensive research to determine the extent of this correlation. This has sparked our interest in delving deeper into this area, examining existing relevant literature, and identifying the challenges men encounter in receiving the appropriate care. Our goal is to not only help men access the care they require but also to raise awareness about this critical issue.
Introduction:
Infertility is a vital component of sexual and reproductive health and rights (SRHR), but it has often been overlooked within the broader global SRHR agenda. Infertility brings about substantial societal and health-related consequences, including social stigma, financial burdens, instances of gender-based violence, and adverse effects on mental well-being.
In this paper, we will delve into an extensive review of existing literature concerning infertility. We will explore its prevalence, the obstacles encountered when dealing with and addressing male infertility, the emotional toll that infertility takes on men, and the relationship between male infertility and sexuality.
What is infertility?
The World Health Organization (WHO) specifies a 12-month duration, defining infertility as “a disease of the male or female reproductive system characterized by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse”.
Infertility can be primary or secondary. Primary infertility is when a pregnancy has never been achieved by a person, and secondary infertility is when at least one prior pregnancy has been achieved.
What is the prevalence of infertility?
In a study reviewing the prevalence of infertility worldwide by the WHO in 2013 showed that 17.5% of the population estimated lifetime prevalence of infertility, which means the proportion of a population who have ever experienced infertility in their life. While 12.6% estimated period prevalence of infertility, which means the proportion of a population with infertility at a given point in time which may be current or past (WHO, 2023).
Period and lifetime measures of infertility prevalence provide different types of information, both of which are important. Contemporary estimates of period infertility prevalence help countries identify service needs and target resources, whereas estimates of lifetime infertility prevalence provide an understanding of the burden of infertility over people’s lifetime.
Challenges faced when addressing male infertility
Male infertility often remains concealed or receives insufficient attention, with women frequently taking on the primary role in the diagnostic and treatment process However, even when men actively engage in infertility assessment and treatment, the complexity of this issue persists. (Johnson, K.M et al, 2012; Gerrits & Shaw et al, 2010; Inhorn & Patrizio et al, 2015).
For instance, within an ethnographic exploration of male infertility in the United States, Barnes (2014) described how healthcare providers in clinical settings frequently employ metaphorical language and indirect communication techniques when informing infertility diagnoses and treatment alternatives to male patients. In numerous cases, this approach is so subtle that men do not recognize infertility as an issue they personally face. (Sherry et al., 2016)
It is also important to note that male infertility is in fact a symptom of disease (see table below).
In fact, one of the most common genetic abnormalities which remains very much undiagnosed, Klinefelter Syndrome, is a major genetic cause of male fertility issues. This unfortunately often never gets picked up and other sequelae of this genetic condition never gets addressed or treated appropriately (such as osteoporosis, low Testosterone and risk of male breast tumours).
What is the relationship between infertility and sexuality?
“Interactions between infertility and sexuality are numerous and complex. As a result, infertility could be considered as both, a cause or consequence of sexual dysfunctions (SD)” (Mimouna et al, 1993).
Although organically caused sexual dysfunction plays a relatively minor role in male infertility, accounting for only about 0.4%-5% of the causes (Brandes et al., 2010; Rantala,M. L et al., 1988), conditions like erectile dysfunction and ejaculatory disorders are associated with increased difficulties in achieving conception. Moreover, sexual dysfunction can sometimes emerge as a secondary consequence of an infertility diagnosis or during the course of in-vitro fertilization (IVF) treatments. Additionally, the utilization of assisted reproductive technology can create a perception that sex is solely for reproductive purposes, potentially leading to a decline in non-conceptive sexual activity. Furthermore, the use of medical terminology related to infertility can be perceived as intimidating, causing anxiety in infertile men and potentially resulting in temporary sexual dysfunction. As noted by Reder et al. (2009), "many men may view their infertility as a loss of masculinity and virility, potentially leading to feelings of low self-esteem and depression."
Sexual dysfunction in male infertility
Throughout the Assisted Reproductive Technology (ART) process, men may encounter sexual dysfunction due to various factors. These include the expectations set by the medical team, the medical examinations involved, and the anticipations of their female partners. For example, a study conducted by Saleh et al. (2003) discovered that 11% of males reported experiencing issues related to erection or orgasm when diagnosed with altered semen parameters.
Moreover, the pressure to produce a semen sample in a clinical laboratory as part of the fertility assessment can be quite stressful for men and may result in difficulties achieving an erection due to anxiety. Research has also indicated that the time it takes to ejaculate can be linked to semen parameters and may reflect the detrimental impact of acute stress during sample collection through masturbation at a clinic.
Male infertility often intersects with sexual dysfunction, and this can manifest in various ways:
- Erectile Dysfunction (ED):
Numerous studies have highlighted a higher prevalence of ED in male infertility patients when compared to the general male population (Jain et al., 2000; Monga et al., 2004;
O’Brien et al., 2005; Shindel et al., 2008; Lotti et al., 2012; Gao et al., 2013).
The incidence of ED in infertile males (22%) surpasses that observed in males of the same age group (7-9%) (Shindel et al., 2008). Additionally, Jain et al. (2000) reported a 15% rate of ED in 175 infertile couples.
Recent reports indicate that one in six infertile men suffers from ED.
During Assisted Reproductive Technology (ART) procedures, some men may experience temporary ED. Furthermore, in cases of non-obstructive azoospermia (lack of sperm in the ejaculate), unsuccessful testicular sperm extraction may negatively impact erectile function due to hormonal and psychological factors.
B. Ejaculatory Disorders:
- Premature Ejaculation (PE):
Research has shown that 50-66% of men dealing with infertility also experience premature ejaculation (PE) (Jain et al., 2000; Shindel et al., 2008). In a study by Hurwitz (1989), among 40 couples facing primary infertility, 75% of the male partners had PE during sexual intercourse or during the fertile window of the menstrual cycle. PE is more prevalent among infertile men compared to the general population with rates of 15.6% and 19.01% observed in infertile men, respectively (Lotti et al., 2012; Gao et al., 2013). This condition can lead to frustration and unsatisfying sexual experiences for the female partner, exacerbating the impact on the couple's well-being (Huyghe et al., 2013).
- Anejaculation:
Psychogenic anejaculation is relatively common among the infertile population (Barazani et al., 2012). Anejaculation can be observed in patients who refuse fatherhood due to various reasons such as financial, psychological, or social concerns resulting from the infertility diagnosis (Huyghe et al., 2013). Typically, deep-seated psychological conflicts underlie cases of anejaculation.
- Sexual Desire Disorder:
Sexual desire disorder is the most prevalent sexual dysfunction among infertile couples. Often, sexuality becomes disconnected from sexual desire and becomes limited to sexual intercourse and intravaginal ejaculation (Mimoun et al., 1993; Wischmann et al., 2010; Huyghe et al., 2013).
This approach implies that sex is primarily intended for procreation (Mimoun et al., 1993; Wischmann et al., 2010; Huyghe et al., 2013).
The treatments and medical requirements associated with infertility can contribute to a decrease in sexual desire (Mimoun et al., 1993; Reder et al., 2009).
In a clinical investigation, it was revealed that, compared to their recollection of past sexual desire and satisfaction, slightly over 40% of men experiencing infertility reported a decrease in desire, and more than half reported a reduction in satisfaction (Ramezanzadeh et al., 2006).
The emotional impact of infertility on men
Bearing children can significantly contribute to one's social standing. Likewise, societal expectations regarding gender roles frequently emphasize procreation as a fundamental indicator of adult masculinity and femininity. A universally observed phenomenon across diverse cultural settings is that the inability to conceive may be perceived as a personal and societal shortfall in conforming to the expected definitions of being a "man" or a "woman." (Bell,A.V et al., 2019)
In societies where cultural norms emphasize that women must bear children as a fundamental aspect of their role within the institution of marriage, the inability to conceive or give birth can result not just in societal stigmatization and verbal harassment but, in certain instances, even escalate to physical violence.
(Aduloju et al., 2015; Akyuz et al., 2013; Ardabily et al., 2011; Fledderjohann et al., 2012; Liamputtong et al., 2009; Morse et al., 2012; Stellar et al., 2016)
The inability to conceive is widely recognized as a distressing and uncertain phase experienced by numerous individuals and couples worldwide. Research has consistently indicated that individuals facing infertility often exhibit elevated levels of stress, depression, and anxiety, along with reduced life satisfaction and self-esteem when compared to those who are fertile. (Cousineau & Domar et al., 2007; Hanson et al., 2017; Luk & Loke et al., 2015).
Men often tend to conceal their emotions in the context of infertility, and healthcare providers have been observed using indirect language and euphemisms to shield men from being labeled as infertile, as highlighted by Barnes (2014). This approach may contribute to fewer men identifying themselves as infertile and potentially experiencing less stress related to infertility. Even though infertility's emotional burden may be more pronounced in women, men grappling with infertility tend to report higher levels of psychological symptoms, particularly when the infertility is attributed to male factors. (Fisher & Hammarberg, 2012; Fisher et al., 2010; Luk & Loke, 2015).
Disparities in access to infertility treatment
Inequalities in accessing infertility diagnostics and treatment can stem from various factors. These include limited geographic access to clinics and specialists, financial constraints, unintentional bias or discrimination by healthcare providers, time constraints for pursuing treatment, and psychosocial barriers like stigma, which can discourage individuals from seeking the help they need. (Bell, 2014; Ceballo et al., 2015; Fledderjohann & Roberts, 2018; Inhorn et al., 2009; Inhorn & Fakih, 2006; Mehta et al., 2016).
When taking all these disparities into account, it becomes clear that fertility services are predominantly utilized by middle- and upper-class couples living in urban areas. Conversely, working-class individuals, racial and ethnic minorities, sexual minorities, and those residing in more remote areas face significant barriers and are notably less likely to access these treatment options.
Many couples undergoing fertility treatments experience a significant dropout rate, with the most prevalent reason for discontinuation being the psychological burden associated with the treatment. (Domar et al., 2018).
Another significant obstacle for people dealing with infertility is the substantial expense associated with both assessment and treatment. Frequently, the cost of fertility care is prohibitively high, causing many individuals to forgo seeking or receiving medical intervention or to explore alternative therapies, which can sometimes be ineffective, unsafe, or even delay proper medical treatment. (Bardaweel, S.K et al., 2014; Connolly et al., 2010; Eisenberg et al., 2010; Read et al., 2014; Weiss et al., 2011).
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