Why aren’t we dealing with the last infertility taboo... it might be him?

There once was a couple, let’s call them Meg and Steve*, who wanted a baby. They tried for a year. Eighteen months. Two years. Nothing happened. They started down the road of medical intervention. Months of invasive testing on Meg followed; thousands of pounds of fertility treatment ensued. It was only well into this procreation journey that anyone even thought to test Steve’s fertility – which turned out to be the real reason they weren’t getting pregnant.

Though their dream of parenthood was eventually realised, the process to get there left them disillusioned and furious. Why, they asked, had the assumption been that Meg was the problem? Especially when it would have been easier to look into Steve’s side of the baby-making equation. (After all, it’s considerably less demanding to, ahem, “make love” into a cup than it is to have your internal reproductive organs examined.)

Meg and Steve’s story was relayed to me recently by a friend of the couple while discussing the pervasive notion that anything to do with fertility is a “women’s issue”, with the blame laid unquestioningly at the female’s feet whenever problems arise – guilty until proven innocent. Meanwhile, long-ingrained beliefs persist that men’s fertility, unburdened by the same biological clock constraints as women’s, remains forever unchanged – that men are as “potent” at 80 as they were at 18 (stories about Mick Jagger and Robert De Niro becoming OAP dads hardly help). Aside from being patently untrue, these mythologies are dangerous, ultimately hurting men as well as women.

Waning fertility is far from being a female-only problem. Over the past 40 years, sperm counts worldwide have halved and sperm quality has declined “alarmingly”, with one in 20 men currently facing reduced fertility, according to a 2019 paper titled “The Forgotten Men: Rising rates of male infertility urgently require new approaches for its prevention, diagnosis and treatment”. And the phenomenon seems to be speeding up. A 2022 review of global trends concluded that sperm counts had fallen by 1.2 per cent per year on average, from 104 to 49 million per ml, between 1973 and 2018; this drop more than doubled to 2.6 per cent a year from 2000 onwards.

As is often the case when attempting to reduce science to broad, sweeping statements, it’s not possible to definitively say that a drop in sperm counts equals a drop in men’s fertility. But the experts I speak to largely agree with the theory that male infertility is on the rise, including Sarah Kimmins, a professor at the University of Montreal’s Hospital Research Institute and CEO of male infertility diagnostic company His Turn. As well as sperm counts, she says, “there is an increased dependence on medically assisted reproduction. That’s increasing at 5 per cent a year, and it’s increasing worldwide.” While Jonathan Ramsay, one of the few consultant urologists specialising in male fertility in the UK, stresses that “it’s not that the end of the world is nigh”, he agrees that the evidence does suggest an overall decrease in male fertility globally.

The reasons behind this modern dip in fecundity are pretty well established. Many of them are lifestyle-related: obesity and smoking, for example. Age is also having an impact, as men as well as women increasingly delay parenthood. Forget those celebrity outliers – “Sperm quality starts to decline after the age of 40, and that goes along with changes in testosterone levels,” says Kimmins. “When you have older dads with a high body mass index (BMI), you also have double the risk of having a child with autism. Older dads have a higher risk of having a child with schizophrenia, and they have more DNA damage in their sperm.”

The other major element affecting sperm is environmental: exposure to endocrine-disrupting chemicals that interfere with our hormonal systems. Sometimes known as “forever” chemicals because they stick around in the environment, these chemicals – such as flame retardants, plasticisers, pesticides and fungicides – are found on much of the food we eat and the packaging it comes in.

All of the above factors can lead to sperm showing “epigenetic changes”. Quick science lesson: epigenetics refers to the layer of information that controls how DNA is used, regulating whether genes are turned on or off, without changing the sequence of DNA itself. Disruption to the epigenetic layer during the making of sperm or at the embryo fertilisation stage – which could be a consequence of ageing, obesity or toxins in the body – can “alter development” of the embryo, resulting in “higher rates of miscarriage”, warns Kimmins.

The risk of infertility posed is also twofold, Ramsay explains. Firstly, lifestyle and environmental components can damage a man’s sperm, making it harder for him to get a woman pregnant; secondly, if he does succeed, these effects might “reduce levels of testosterone in the developing foetus and then infant. So not only does a man have a lower sperm count, but when and if fertile he may be passing on that tendency to the next generation. It can be quite a toxic mix – a perfect storm.”

Yet men have more control over many of these elements than they might think. The key timeframe is three months before a couple tries to conceive, as this is the length of time it takes to produce new sperm. During this window, men can increase both the chances of making a baby and that that baby will be healthy through their own lifestyle choices: cutting out smoking and drinking, eating healthily and avoiding ultra-processed foods with a high calorific and sugar content, losing weight if they have a high BMI. Even exposure to those “forever” chemicals isn’t completely unavoidable; simple steps like removing food from a plastic container before you heat it up in the microwave can help, as can thoroughly washing fruit and veg to remove pesticides. Better yet, “buy organic, even if you can only afford to do it in those months before pregnancy,” advises Kimmins.

In around half of the one in six couples affected by infertility worldwide, the issue will solely or partly stem from the male partner. And yet, just as Meg and Steve experienced, between 18 and 27 per cent of the time the man is not even evaluated initially. If tested, he will get nothing more than a basic semen analysis looking at the number of sperm he has and, if he’s lucky, how they move – an “outdated” assessment that has “remained essentially unchanged for the past 50 years”, according to the aforementioned 2019 paper. If semen is analysed and found to be subpar, “very little further information or testing is offered to the man at this stage to try and ascertain why his sample is suboptimal, meaning [the couple] move forward with treatment with no other help or focus on the man,” says charity Fertility Network UK.

Ciaran Hannington, host of The Male Fertility Podcast

Even when it’s discovered that the issue lies with the male partner, the only main intervention other than IVF is intracytoplasmic sperm injection (ICSI). It’s non-invasive for men, but guess what? The procedure requires women to undergo blood tests, hormone injections, surgical ova retrieval and embryo transfer. These can carry short and long-term medical risks (as well as clearly being no picnic to go through). As Kimmins puts it, “the only treatment currently offered is treating women for a disease in men.” One could cynically argue that it’s in fertility clinics’ financial interests to keep recommending IVF cycles instead of looking too closely at the root causes of infertility; at up to around £5,000 a pop in the UK, baby-making is big business.

Behind these women having to bear the emotional and physical brunt of it all are their male partners, frequently left feeling isolated and pushed out, forced to watch from the sidelines. This was certainly the case for Ciaran Hannington and Shaun Greenaway, who teamed up to create The Male Fertility Podcast after both enduring gruelling infertility experiences that severely impacted their mental health.

“I ended up suicidal. I just didn’t want to live any more,” says Hannington. “A man’s ego and self-perception is hugely affected by infertility – and mine took the biggest hit it’s ever taken.” He’s speaking of the period when he and his wife Jen were approaching their third – and likely final – round of IVF. He had turned to alcohol and cut himself off from friends and family; it was Jen who pulled him back from the brink. “She pushed me to get support and I ended up having counselling, which saved my life.”

Hannington’s story will be horribly familiar for men with fertility issues. Once he and his wife sought help, only Jen was examined for the first six months. Then, just before she was due to start taking medication to stimulate ovulation, Hannington’s sperm was tested – almost as an afterthought. He assumed there was nothing to worry about.

A couple of weeks later, they were called in to see the consultant, who assured Jen that they could get her ovulating, no problem. “And then he turned to me and said, ‘but there’s not much we can do for your situation, so you’re going to have to move straight to ICSI,’” recalls Hannington. He had no idea what his “situation” was – no one had bothered to tell him. It turned out that he had an extremely low sperm count, only around 1,500 per ml, with less than 1 per cent of these deemed “viable”. “That was the start of a very difficult time for me, not just going through IVF, but also mentally.”

Greenaway has a similarly debilitating tale. Unlike many men, he was tested upfront, having mentioned a severe case of mumps in his early twenties that caused his testes to swell. Again, the news of his infertility was delivered “in the most horrendous of ways” – as if it were something casual, not earth-shattering – with a member of his GP’s admin staff phoning him up and stumbling over the word “Azoospermia”. She had no idea what it meant, forcing Greenaway to google it for himself – only to discover that he had zero sperm in his semen. “It was a life-changing moment, quite frankly, and I went into shock.”

What followed was a period defined by grief and shame. Once he and his wife started down the route of IVF with a sperm donor, Greenaway felt reduced to a spectator, as well as acutely guilty that his wife was the one having to undergo invasive treatment when the problem had originated with him.

It’s a phenomenon that Ramsay recognises. “Every kind of focus tends to be on the woman,” he agrees. “Men are often left in limbo. GPs don’t even really understand what semen analysis means – they’re not equipped to deal with it. But think about a man in his late twenties getting told he has no semen at all: it’s like getting a cancer diagnosis.”

Jonathan Ramsay, male fertility specialist

Both Greenaway and Hannington’s stories have a happy ending: each now has two children. But the journey to get there was needlessly traumatic, and left them feeling helpless, lost and silenced. Part of the reason they launched the podcast was to fill a gaping hole, both in terms of information for men about their own infertility, and in terms of emotional and mental health support.

Despite lifestyle changes having the potential to significantly improve their fertility, men are rarely informed about this at any stage in the assisted reproduction process. Having done his own independent research, Hannington embarked on a programme of nutrition and exercise that within months had boosted his sperm count from 1,500 to 4 million per ml; his viable sperm leapt from 1 to 4 per cent.

There is some hope, at least, that things are changing. Kimmins’s company, His Turn, has spent 20 years developing a diagnostic tool that goes way beyond the crude analysis of simply how many sperm there are and how they move. Instead, it assesses the epigenome to determine if fertility is being affected by being overweight, by environmental factors like toxicants, by age, and by things like cannabis use.

“The idea is that this test will be able to give information that’s actionable, so the couple will know: what are the chances of conceiving with his sperm quality as it is right now, and of having a healthy pregnancy? What factors are driving his low fertility score, and are they addressable?” says Kimmins.

But the biggest change that needs to happen is a shift in attitudes – a shift which sees men included in the entire process as equal parties. “It can feel very cynical,” Greenaway says of the fertility industry. “Like you’re a walking, talking pay cheque. That needs to stop. It needs to be patient-centred, care-focused treatment – with men brought in from the start.”

*Names have been changed