Male factor infertility affects one-third of the 7 million US couples struggling with infertility. While the conversation around this fact is increasing, in part due to all the new male fertility-related startups, there are still challenges to be overcome. Dr. R. John Aitken, Co-Director of the Priority Research Centre in Reproductive Science at the University of Newcastle, NSW, spoke about this topic at the recent American Society for Reproductive Medicine (ASRM) conference. During his talk, he identified three areas contributing to underdiagnosing male factor infertility.
1. Lack of Guidelines to Test for Male Factor Infertility
The U.S. Preventative Services Task Force (USPSTF) is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services.
This is the body that provides recommendations for BRCA risk assessment, diabetes screening, and folic acid supplementation, as an example.
Not a single recommendation exists for male fertility screening.
If male fertility is not part of this screening, even though at least 30% of infertility cases are due to male factor, it is no wonder that men are often not screened or screened too late in the process. In fact, Dr Aitken stated, “25% of couples bypass initial semen analysis.”
2. Men typically don’t visit doctors
Dr. Aitken stated that one-third of men don’t have primary care physicians (PCP). As a result, many aren’t even seeing a doctor to be regularly checked out for their general health much less for infertility. However, even if they did see a PCP, as stated above, the guideless do not suggest fertility assessments need to be conducted.
Even if men do have primary care physicians, Dr. Aitken reminded us of what typical behavior is. He described, “a period where mom takes the [young boy] to the pediatrician and then his girlfriend gets him to go to the doctor.” However, without that, men typically don’t visit the doctor. As a result, the first intervention for fertility assessment is often with the fertility specialist because his wife trying to get pregnant but struggling to do so. However, as stated earlier, 25% of couples with fertility struggles, bypass the semen analysis.
3. Too much red tape in the healthcare system
Should a man decide to have a semen analysis, it is challenging. Based on interviews with couples who have gone through assessments that test for male factor infertility, there seem to be two options for couples:
Get referred to Urologist
Assess Semen with the Reproductive Endocrinologist
Women tend to have two doctors – primary care physician (PCP) and OB GYN. However, men, if they have a doctor at all, only have a Primary Care Physician, who can’t do a semen analysis and would conduct only basic assessments of potential issues with his reproductive system.
If he were to ask for a semen analysis or detailed work-up, he’d have to visit a urologist, where it could take months to get an appointment. As one patient said, “It is important for my wife and I to have a child, but I don’t have time to make another appointment much less visit another doctor.”
Should the female be seeing an OB GYN who identifies a potential concern with infertility, the OB GYN may not even consider this urological evaluation. If fact, according to Resolve, The National Infertility Association, a recent study showed that only 41% of OB GYN physicians even considered a urological evaluation of the male partner and only 24% would routinely refer men to the urologist before ordering a semen analysis.
If the couple is past the stage of seeing an OB GYN for fertility struggles, they would be referred to a fertility clinic, where they would see a Reproductive Endocrinologist. However, the focus here is on the woman’s reproductive health and only a semen analysis is conducted on the man. Should he need a further workup, that would require a urologist, which, again, requires a referral and possible wait time to be fit in for an appointment.
What can men do to better understand fertility?
Several companies, such as YO, now offer convenient testing in the privacy of one’s home. Some, like Dadi, enable men to send in their sperm for both testing and storage. However, the Mayo Clinic suggests that “relying on a home sperm test might lead to delays in seeking appropriate fertility evaluation and treatment.” The reason is that a full male fertility workup includes several other tests, which are recommended by ASRM and the Urology Care Foundation.
Additionally, some of the at-home tests only assess sperm concentration. However, a typical semen analysis performed by an infertility specialist assesses:
Total sperm number
Vitality (percent alive)
Thus, it is important to understand what the kits test for and how accurate they are, but even more importantly, to be mindful that a semen analysis is only part of the story.
Dr. Aitken wisely stated that “fertility depends on the fertility of the potential couple.” This is not a “woman’s problem” or a “man’s problem.” We have a long way to go with setting up both male behavior and the healthcare system to bring an assessment of male factor fertility to the forefront.