Male infertility clinics are filled with fertile men. At least, that’s what they tell themselves.
So found Cambridge University sociologist Liberty Walther Barnes who set out in 2007 to study male infertility. Barnes spent more than 100 hours tracking urologists and infertility experts in five U.S. male fertility clinics, observing daily interactions with patients and interviewing reproductive endocrinologists, embryologists, nurses, genetic counselors, and psychologists. Barnes also followed 24 heterosexual married couples diagnosed with male infertility due to low or zero sperm counts. To her surprise, despite trying to impregnate their wives for more than a year and visiting a male infertility clinic, more than half of the men did not consider themselves infertile.
Where, she wanted to know, are all the infertile men?
And so for the next six years, Barnes tried to unpack the gender assumptions that influence male perceptions about fertility, infertility treatment decision-making, and the medical community’s reaction to infertile men. The result, Conceiving Masculinity: Male Infertility, Medicine, and Identity will be published in May 2014, and reconsiders two major gender myths that Barnes argues pervade the $3 billion dollar fertility industry and ultimately do a disservice to both infertile men and women.
The first stereotype, she says, is that women will do anything to get pregnant. The second is that men will avoid infertility treatment at any cost. Yet Barnes found that when couples were given the choice to pursue a female-focused treatment like in vitro fertilization (IVF), or a male-focused remedy like surgery, they unanimously chose the male course first, even if the man didn’t necessarily consider himself “infertile.”
There was, in fact, a strong sense among both men and women that male-focused solutions were a more “natural” way to get pregnant, explains Barnes, and that physical participation in fertility treatments was a “manly way” for husbands to “protect their wives.” The problem, she says, is that many doctors tiptoe around a man’s fertility issues, and that specialists often push IVF on infertile couples—so that men aren’t really given a choice in the first place.
According to Dr. Marc Goldstein, professor and chief surgeon of male reproductive medicine at NewYork-Presbyterian/Weill Cornell Medical Center, male infertility is as common as female infertility. For one-third of couples the problem is the man’s, another third deal with a female’s issues, and the remaining third struggle with a combination of both. But Goldstein says he regularly sees couples where a woman has already undergone an invasive and expensive fertility procedure like IVF before a simple semen analysis is even done on her partner—and it’s zero.
Doctors are much more comfortable talking about infertility with their female patients, Goldstein says, mostly because of the deep social stigma surrounding male infertility. Men, he explains, tend to falsely associate infertility with impotence and see reproduction challenges as an assault on their masculinity.
“Going back to biblical days, infertility was always blamed on the woman,” Goldstein says. “Only within the past 25 years or so has attention been paid to men.” And when a woman doesn’t conceive, she usually consults her gynecologist, who applies a gynecological knowledge base— female-focused treatments—and often only checks a man’s fertility as a “last resort.”
According to a recent report discussed at a meeting of the International Federation of Fertility Societies and the American Society for Reproductive Medicine, 5 million IVF babies were born in the past three and a half decades—with 2.5 million of them born in just the past six years—evidence of how socially mainstream IVF is now and how far female reproductive technology has come.
But men lag behind. When it comes to male infertility, we’re only now emerging from the dark ages, says Dr. John Jain, a reproductive endocrinologist at Santa Monica Fertility in Los Angeles. For example, scientists are just starting to study how environmental factors may impact the quality of semen. Jain finds that men are reticent to talk about their own fertility and naïve about how common male infertility is. Though, he admits, the most critical fertility factor is undeniably the age of the woman.
“The focus on women and infertility is warranted,” Jain explains, “especially in an industrialized population like the United States where women are increasingly delaying childbirth for longer and longer to pursue their education and careers.”
Convincing men that they, too, have a biological clock would be a key step in changing social attitudes about male infertility. A man’s fertility does decline with age, just like a woman’s does, as does the genetic quality of his sperm, explains Dr. Harry Fisch, professor of urology and reproductive medicine at NewYork-Presbyterian/Weill Cornell Medical Center and author of The Male Biological Clock: The Startling News About Aging, Sexuality and Fertility in Men.
Unfortunately, when men see actors in their 60’s and 70’s fathering children, they make incorrect assumptions about a man’s biological capabilities, according to Fisch. The truth is, a 70-year old father may be using someone else’s sperm. Schools, he says, should be teaching kids about their biological clocks in sex education— so infertility isn’t a social taboo from the start. Physicians too, he believes, should remove the stigma around infertility and talk to men in their 20’s about how obesity can impact sperm quality, and the kinds of fertility treatments available to them, from improving blockages to treating infection.
“My daughter is in college, and I would tell her to have a baby before she’s 30,” Fisch says. “Nobody talks about it really, but I would tell a son in college the same thing. Have a baby early.” We’ve been told that 35 is a pivotal number in female fertility. Men 35 or older, he warns, have half the chance of fathering a child within a year, compared to someone younger than 30.
But the medical community doesn’t spend much time or energy training doctors to talk about or treat male infertility. It’s just like contraception, says Dr. Florence Comite, a reproductive endocrinologist, who spent 25 years as a professor at Yale School of Medicine, and is the author of Keep It Up, a book for men about andropause, or what’s known as male menopause. There are a lot of options for women, but male fertility treatments are much more limited.
No surprise, she says, given the historical context of medical education, which has always focused on the reproductive system for female health. Training for male health, on the other hand, has always focused on well-known things like heart disease and prostate cancer. As Comite points out, most medical schools don’t have a department of andrology, while they often have departments of endocrinology.
To remove the secrecy and stigma, male infertility may need a high profile advocate and a public health campaign, Barnes says. After all, erectile dysfunction had Bob Dole. Testicular cancer had Lance Armstrong. But male fertility lacks a celebrity to raise awareness that infertility is a “normal” medical condition that “manly men” deal with too.
“Before Viagra was invented,” Barnes explains, “men felt deep shame about their impotence.” But when impotence was reframed as “ED,” a physical condition with a reliable medical solution, it became less stigmatized. In her interviews, men often told Barnes that “infertility is just a medical condition.” This, she says, allowed them to describe their condition as something beyond their control— and not a reflection of their strength or masculinity. Perhaps, this is the first step to getting men to admit that they’re infertile and eventually, to make male fertility treatments as mainstream as they are for women.