On both the societal and individual level, there are often stigmas associated with male infertility because it is a condition that prevents men from contributing to a common goal and expectation of many couples—having children.
To address these stigmas, Peter N. Schlegel, MD, discusses why male infertility should be normalized not only in the field of urology, but throughout society. He also advises clinicians on how to counsel their patients regarding this difficult condition, including the recommendation of lifestyle changes and the general education of various reproductive options. Schlegel is a James J. Colt Professor of urology at Weill Cornell Medicine in New York City, New York.
Younger men tend not to seek medical care to begin with. The stigmas from male infertility, specifically, are concerns about a man's core identity. In addition, fertility issues are often confused with sexual issues. And so, men often avoid having any evaluation to begin with because of fear that something is going to be found that would be devastating, at certain levels, to their core and to their psyche. This can result in substantial delays in being able to receive effective care or treatment for their infertility – simply because they are concerned about having a semen analysis.There are many examples where men do not seek care, they do not even have the preliminary evaluation of a reproductive history and semen analys, and almost try to deny that there's any potential of a problem that could be male-related.Contributing to this denial is the observation that women are the individuals who are not getting pregnant in a couple. So, even when it's male fertility, sometimes there is a blame that occurs on the female side. And certainly, female evaluation is most typically the way that couples initially have evaluation for fertility issues.
Obviously, if you don't have any evaluation, you don't even have a semen analysis or a reproductive history, then you can't begin the male evaluation. So, it tends to delay evaluation, it tends to delay identification of treatable male factors, and sometimes that can be for months or years that it occurs in terms of a delay.Further, male infertility treatment may be difficult for men – at some level, men ask, “Why would I have surgery (or other intervention) for a condition that doesn’t give me any symptoms – and often was unrecognized prior to fertility evaluation.”
The urologist's role is to try to normalize what is going on and provide easier access to care. I have observed, particularly in the last year and a half, we have seen much more extensive reach out and telehealth to facilitate evaluation and male infertility treatment. Often, couples are more comfortable seeking advice and information when they're in their own homes rather than having to go into a medical or clinic-type environment for a urologist to explain some of the basics in terms of both the evaluation, and what can be done to optimize male fertility. And I think most younger couples are very interested in what they can do to enhance their own health. They may not be as good at seeking medical care, but again, in terms of enhancing their own health, whether it's through diet or exercise or other lifestyle changes, urologists can provide specific information about what may affect male fertility from an environmental or lifestyle standpoint. Even though our guidelines point out that we don't have absolute proof that lifestyle interventions really increase fertility, it certainly is clear that there are lifestyle effects on male fertility. That's important for couples to know and for urologists, who typically are providing information evaluating males, to be able to give that information to couples.
It is a difficult process. You can often see men in couples struggling with the concept that they are responsible for this fertility problem, when fertility is expected to occur naturally for almost all couples—that they would have children when they wanted to have children. I think for a urologist to be patient, understanding, [and] recognize that this can be a difficult process for men, is important. It is a little bit different from a lot of disease states we deal with where patients have a symptomatic problem, you typically address the problem and fix it, and there's usually little question from the patient in terms of knowledge about the medical consequences of the problem and focus on fixing it. For male fertility issues, it tends to be a little more of a process—understanding the problem, understanding the options or potential management approaches, what that means, what it involves, and the expected outcomes from that, require a lot more education. And again, oftentimes, urologists are central to helping the couples understand what their fertility problem is and how they can improve their chances of reaching their goals of having a family with male fertility treatment.
Over the last 10 or 20 years, we've gained a much greater understanding not only of factors in the male that can be identified and treated specifically, but even factors in the male that affect the outcomes of assisted reproduction that is provided primarily to women. So, for example, the impressive role of male obesity, smoking, and other factors that we didn't previously recognize have now been shown to affect the results of in vitro fertilization and other assisted reproductive techniques. [They] are things that urologists are now increasingly aware of, able to counsel couples about, and that's of great benefit for couples who are seeking to start or grow their families.