Vardit Ravitsky is an associate professor of bioethics at the University of Montreal.
Sarah Kimmins is an associate professor at McGill University and Canada Research Chair in Epigenetics, Reproduction and Development.
Forty years ago last month, the first in vitro fertilization (IVF) baby, Louise Brown, was born. Since then, the performance and social acceptability of assisted reproduction has increased tremendously. To date, over eight million babies have been born using these technologies. With infertility on the rise, one in six couples is unable to conceive without such clinical intervention.
Indeed, these technologies are one of medicine’s greatest success stories, but they have continuously focused on women. Men have been largely neglected in terms of research, diagnosis and treatment.
For instance, diagnostic methods for male infertility are based on outdated assessments of semen that have remained essentially unchanged for the past half century. But over the past 40 years, sperm counts worldwide have halved and sperm quality has declined alarmingly. One in 20 men currently faces reduced fertility. Potential causes include environmental exposure, rising rates of obesity and delayed parenthood. There is urgent need to place the forgotten male centre stage in infertility care.
The primary intervention currently offered is intracytoplasmic sperm injection (ICSI), whereby a single sperm is injected directly into the egg in vitro. This procedure is non-invasive for the male partner, since sperm is collected through masturbation. However, the female partner is subject to numerous invasive procedures, including blood tests, hormone injections, surgical egg retrieval and embryo transfer. Some of these procedures are painful and carry medical risks. Women are exposed to these risks even when they are fertile, because ICSI is the only option for their male partners. As a result, they carry a disproportionate and unjust physical and psychological burden.
On the backdrop of this ethically challenging reality, the paucity of attention to male infertility, in terms of research and clinical alternatives, is so scandalous that some have called it an “infringement of basic human rights and dignity” of female partners.
Assisted reproductive technology is often not covered by health insurance. Couples undergoing treatments spend upwards of $30,000. About 75 per cent of IVF/ICSI cycles fail, requiring multiple treatments, with the required number increasing with maternal and paternal age. With each cycle, health risks increase.
Moreover, due to the continuing and pervasive nature of treatment, women miss numerous days of work and carry a heavy emotional burden, with documented elevated rates of stress and depression and even more so in cases of failed treatment.
The emotional burden of infertility is not borne by women alone. Men suffer the painful and isolating effects as well. In the past, male infertility was heavily stigmatized and often socially hidden or even taboo. This is gradually changing. Men desire a more inclusive process in the fertility clinic. Most would welcome better methods of preventing, diagnosing and treating their infertility.
Additional research is urgently needed. In-depth assessment of sperm quality is required. Potential screening tests are under development, some based on sperm genetics or epigenetics. Once validated, such tests may offer feasible approaches to better assess male fertility, streamline clinical treatment and improve the health outcomes for offspring. This would not only improve outcomes for couples, but also reduce the unjust toll it takes on women.
Moreover, sperm quality and quantity can be predictive of men’s overall health since they are directly linked to morbidity and mortality. Incorporating sperm screens into primary-care check-ups is advisable. Sperm tests should be performed at an early age, to allow men to adopt lifestyle changes to abrogate a fertility crisis.
Much ink has been spilled in recent years regarding “social egg freezing” to tackle the female biological clock. However, evidence shows that sperm counts and quality decline in men over 40. Older men also face increased DNA damage and mutation rate, which augment the risk of disease in offspring. It is therefore relevant and timely to consider “social sperm freezing” as well.
We need educational tools and public-health campaigns to inform men and their partners about environmental and behavioural risks to their fertility and how lifestyle changes can improve sperm quality.
Information about reproductive health and fertility must be responsibly and widely disseminated to boys and men beginning in school sex-education programs and throughout their adult lives. This will lead to increased understanding of the crucial role men can play in taking preventive measures, preserving their fertility, and promoting the health of their future children.
We need political will to put research dollars toward male infertility. We also need the engagement and commitment of researchers and clinicians. It is time to focus on men in preconception education and in the development of better methods to diagnose and treat infertility. It is time to challenge the status quo and promote a culture that puts as much emphasis on male as on female reproductive health.