Why men need to be a bigger part of the infertility conversation

May and Dan* had been trying to get pregnant for over two years when May first visited her general practitioner for help. Over the next six months, she underwent a battery of ultrasounds and blood tests, all of which came back normal. Finally, her fertility doctor recommended checking Dan’s sperm. Dan, it turned out, had low sperm motility and count along with abnormal morphology (sperm size and shape)—factors that all affect a couple’s ability to conceive. May and Dan were told to consider using donor sperm.

While Dan went to an andrologist (a male hormonal specialist) for more testing, May looked into natural treatments to improve Dan’s sperm quantity and quality. They changed their diets, began seeing an acupuncturist twice a week, and started taking Chinese herbs. In less than four months, May found out she was pregnant with her son Dylan, who is now 6 months old. “I wish that we had looked at our health in a more holistic way sooner,” says May. “I honestly think it might not have taken so long to get pregnant and we could have avoided a lot of stress and invasive tests.”

Stories like May and Dan’s aren’t uncommon. According to the Centers for Disease Control and Prevention (CDC), 35 percent of couples struggling with infertility are dealing with both male and female reproductive issues (and 8 percent are struggling with male-specific reproductive issues). Yet that’s not often brought up in conversations surrounding infertility—which is largely perceived as a women’s issue. And when it comes to knowledge about infertility and its causes, “there’s a gender gap,” adds Amin Herati, M.D., a urologist and the director of male infertility at Johns Hopkins School of Medicine.

Those assumptions and knowledge gaps play out at home, in doctor’s offices, and in the marketing of solutions. Most fertility apps, for example, are geared towards women, and infertility assessments usually begin at a woman’s OB/GYN or family doc. “I think most women are going to assume it’s them until proven otherwise,” says Samantha Pfeifer, M.D., an OB/GYN and reproductive endocrinologist who’s on the board of directors for the American Society for Reproductive Medicine. But given that it takes a sperm and an egg to create a child, why are we collectively overlooking male contributions to infertility?

Unpacking the fertility gender gap

First things first: Male reproductive issues can absolutely affect a person’s ability to have children. Sperm count, which affects the probability that a sperm will be able to fertilize an egg, has declined for men of all ages by an estimated 50 percent since the 1970s; up to 15 percent of men with infertility don’t produce sperm at all. Varicocele, swollen veins in the scrotum that can cause low sperm count, affects an estimated 40 percent of men with infertility. There can also be issues with the shape or movement of sperm, as in Dan’s case.

Yet despite these factors, male fertility issues are often treated as a secondary concern. A 2018 study found that men whose infertility was due to varicocele—which is correctable with surgery—waited an average of nearly two years of trying for a baby before getting a fertility workup. And Dr. Herati estimates about 80 to 90 percent of couples who come to his urology clinic for fertility issues have already seen the woman’s doctor for a checkup, often because women are more inclined to seek medical care. “They’re typically the ones encouraging their husbands to make the appointment and show up,” he says. This isn’t just a gendered stereotype; research by the CDC consistently shows that men are less likely to seek all kinds of medical care than women. Women are also used to regularly seeing their OB/GYNS (and thus are having regular checkups of their reproductive health), while men rarely have a reason to visit the urologist.

“I think the fear is if there’s inadequate or no sperm production, that’s associated with less virility, manhood, or power.” —Samantha Pfeifer, MD

There are also some cultural issues at play. From an early age, women hear about the tick-tock of their biological clocks (which, ugh)—but men’s fertility rarely comes up in health classes or pop culture. “Male infertility is starting to come up in social media and movies and shows, but the female side is still better portrayed,” Dr. Herati says. This doesn’t just create an unfair burden on women; it also leads to men not fully understanding their own fertility. Many men, for example, (incorrectly) think that just because they ejaculate, there must be sperm, says Dr. Herati—so they might not even know that having a low or nonexistent sperm count is a possibility.

Certainly women struggle with the brunt of infertility stigma—the ability to have children was long considered to be an essential part of being a woman, and women report feeling more social exclusion than men because of infertility—but men struggling to have children face their own stigmas, too. “I think the fear is if there’s inadequate or no sperm production, that’s associated with less virility, manhood, or power,” says Dr. Pfeifer. Providing the sperm sample is uncomfortable as well, since it requires masturbating in a hospital-like environment; in some cultures, masturbating into a cup is seen as unacceptable. All of this makes some men to avoid getting evaluated at all, she says.

The IVF bias

Fertility specialists say most couples should check in with their doctors after 12 months of trying for a baby without success; if the woman is 35 or older, or if either partner has had pelvic surgery or chemotherapy, the couple should schedule an appointment after six months, says Dr. Herati. The doctor will usually refer the couple to a female reproductive endocrinologist for a full fertility workup—which includes a basic sperm analysis for the man. If a man’s sperm count is lower than expected, he then should see a male fertility specialist or urologist, say both Drs. Herati and Pfeifer. (This isn’t just for fertility; Dr. Herati says sperm count is a barometer of overall health, and low levels could signal numerous underlying problems such as a hormonal imbalance, an inflammatory state in the body, or even cancer.)

This is what should happen. However, some practitioners jump straight to in-vitro fertilization (IVF) treatment, since it addresses both male and female infertility factors. (Basically, IVF takes mature eggs and combines them with your partner’s sperm in a lab; if your partner has low sperm count or sperm motility issues, the sperm can be injected straight into the egg to facilitate fertilization.) “Because of IVF, not as many men are being referred for an evaluation as may benefit them,” says Dr. Pfeifer. In the 2018 study referenced above, nearly one in five men with varicocele sought assisted reproductive technologies (like IVF) before seeing a male fertility specialist. That’s a pricey alternative: One round of IVF can cost upwards of $25,000—and it isn’t necessarily covered by insurance.

Dr. Pfeifer caveats that a mild abnormality in sperm count doesn’t necessarily warrant seeing a male fertility specialist—especially when time is of the essence. “A 38-year-old woman can’t necessarily wait six months [for her partner] to recover from varicocele repair. Some treatments for the male may have marginal effect, and the couple may still end up getting IVF,” she says.

Addressing male-specific fertility problems like varicocele, however, can increase the odds of having a successful pregnancy, Dr. Herati says. “If women have to go through the process of hormone treatments, testing, and egg retrieval, they should have the best chance at a positive outcome,” he says. And that should include testing (and, if necessary, treatment) for their partner’s fertility.

Changing the conversation

With all the focus on female fertility, many fertility-tracking apps and devices are geared towards women—think Glow, Ovia, or Ava. And it makes sense, says Dr. Pfeifer, since most track a woman’s cycle, which is key to timing sex correctly (and getting pregnant). But there is a growing recognition of the man’s role in conception being reflected in some new startups.

Tom Smith, the CEO of the sperm testing and storage startup Dadi, came up with the idea for his business four years ago after his friend found a lump in his testicle and learned that he had cancer. Smith’s friend knew that he needed to go through invasive surgery and chemotherapy, but he wanted to bank his sperm first so he could potentially start a family in the future. However, between the pressure of ejaculating in a hospital-like environment and the stress of his diagnosis, it took Smith’s friend three to four hours to produce sperm. Smith, who notes that his friend is in remission today, saw an opportunity to update the procedure.

Enter Dadi, which provides men with kits that they fill with sperm at home and send back to the company via FedEx. Within 24 hours, the sperm is safely frozen for the future, and men receive a fertility report and a video of their swimmers in action. Smith is careful to note that Dadi doesn’t diagnose fertility issues; if sperm counts are low, the company suggests men contact their primary care providers. The kit costs $100, and sperm storage costs $100 annually.

“Our mission at Dadi is to normalize the conversation around male infertility and help society understand the facts behind fertility,” says Smith, whose app launched in January of this year. He hopes that by creating an informed dialogue, men can be more proactive with their reproductive health and futures. Several other new companies are focusing on male infertility with home sperm count tests, including Trak Fertility and YO.

Dr. Herati says these startups have a good premise. “They have decent accuracy, but not to the same extent as semen analysis. But the information it yields can prompt a visit to a urologist,” he says. And in many cases, just getting people in the door is half the battle.

“Fertility is a team sport,” says Dr. Pfeifer, and both men and women should take their reproductive health into account when trying to have children. “It took a while for people to believe earth wasn’t flat…These misperceptions were perpetuated over years, but slowly with science we’re moving on to things that are closer to scientific truth.”

*Names were changed to protect privacy.

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