Avradeep and Emma met in 2010, when they were both in their thirties and living in Bristol. “My late father was the youngest of 13 children,” Avradeep says. “Growing up, I saw the joy that raising me gave my father. My parents’ dream was to have children, and they were great parents. I wanted something like that.”
Given Emma’s age, the couple didn’t feel that they had the luxury of getting to know each other over many years before planning a family, so they started trying for a baby just a year into their relationship. “We did what you’re supposed to do,” recalls Avradeep. “A slots into B, and Bob’s your proverbial uncle.” However, despite months of trying, Emma did not become pregnant. Concerned, they went to their GP, and both partners were given several blood tests. Avradeep was also asked to do a semen test. “I had to produce a fresh sample and get it to the hospital lab within an hour,” he says. “Which is no mean feat, considering
the traffic in Bristol.”
A week later, the results arrived while Avradeep was playing squash. Emma collected them and rang him to say they needed to talk. He returned home, and it was then that he learned the reason why Emma was failing to become pregnant: Avradeep had zero sperm. He was infertile.
It is estimated that infertility affects one in six heterosexual couples and, in 40% of cases, the cause lies with the man. Despite advances in health science, the problem is only getting worse – a study published last year showed that among men from Europe, North America and Australia, sperm counts have halved in less than 40 years. “Men’s fertility and reproductive health seem very much to be under threat in our society,” says Sheena Lewis, emeritus professor at the Centre for Public Health at Queen’s University Belfast. “A large meta-analysis published 20 years ago claimed that sperm counts had dropped in the previous 50 years. Everybody said the statistics were wrong, but the paper that came out last year confirms the data.”
Despite this, the global conversation around conception still largely centres on women. “The medical and scientific study of reproduction has historically focused on women’s bodies,” says Liberty Barnes, author of Conceiving Masculinity: Male Infertility, Medicine and Identity. “So it’s no surprise that when we started dealing with infertility, this continued to be the case.”
There is, perhaps, a correlation between this tendency and the way we seem to know so little about our declining sperm counts. It’s something we rarely think about as individuals, unless it becomes a problem. As for the medical community, it’s aware that sperm counts are declining – but it’s not sure exactly why.
“I often compare sperm production to an assembly line in a car factory,” says Tim Child, medical director of Oxford Fertility, one of the UK’s largest IVF treatment centres. “It just takes one bit to go wrong and the end product won’t be as good as it should be. It’s the same with sperm: if there’s one enzyme missing, one protein that’s not quite right, then it could affect the end result.”
That this seems to be a predominantly Western phenomenon suggests that the problem isn’t entirely natural. “It has something to do with our lifestyle and our diets,” says Lewis. “We know this because in countries such as India, richer people who adopt a Western lifestyle end up having more issues.”
Many of these Western maladies should come as no surprise: obesity, lack of exercise, and so on. Environmental pollutants are a probable factor, with multiple studies linking air pollution with “abnormal sperm shape”. We are also having children later, and sperm quality is significantly poorer in those over 45. But there is, as yet, no smoking gun, no definitive cause. All we have is speculation.
When a couple are experiencing fertility issues, their GP will most likely suggest a variety of tests for the woman and possibly a semen test for the man. They will then be recommended IVF treatment.
“The reason for my lack of sperm was never discovered,” says Avradeep. “In effect, I was discounted as being ‘useful’ by the fertility unit.” According to clinical embryologist Sheryl Homa, “The triaging is wrong if a man with poor semen analysis is simply sent to an IVF clinic. The IVF clinic offers IVF – it doesn’t offer an investigation. If you go to a butcher’s, don’t expect to find oranges.”
Homa used to run IVF labs for both the state and private sectors, but she quit after becoming disillusioned with the persistent marginalisation of men. In 2007, she set up Andrology Solutions in a clinic off Harley Street, in order to focus on men’s health – particularly in relation to their reproductive system. Her hope is to offer a level of investigation, diagnosis and explanation that she feels is missing from the NHS.
The men who visit the clinic come alone and are given a detailed health questionnaire that is used to assess the cause of their low sperm count. “If we can find out what is behind it, we might be able to treat it,” says Homa. The leading known cause of male infertility, she says, is a varicocoele – a clump of abnormally enlarged veins around or above a testicle. “This leads to an engorgement of blood that heats the testes. If you raise the temperature of the testes too high, you can destroy sperm development.”
Homa is convinced of the potential benefits of varicocoele repairs. “There is a lot of evidence that this will improve sperm DNA damage and increase your chances of pregnancy, naturally and with IVF,” she says. So why isn’t it more commonly practised? In this and other respects, the medical community is divided. “In studies where men were randomised either to have the varicocoele repaired or not, the results showed their fertility did not improve,” says Child. “So the national guidance in the UK is that men should not have it repaired purely for fertility reasons, as there is no evidence that the treatment will help.” Child continues, “In general, there are no drugs, surgeries or medications that can ‘fix’ men’s fertility problems.” For now, he believes IVF remains the best option.
Avradeep and Emma opted for IVF using donor sperm. “I felt bad for Emma because I was the reason she could not conceive naturally, and why we needed to go down this route,” he says. “She would have to undergo various uncomfortable procedures and blood tests, whereas my lack of sperm ruled me out immediately.” Sometimes, on the drive back from work, he would cry. “I felt useless.”
This sense of personal failure is a very common response, explains Homa. “How would I describe the emotional state of the men who come to see me? I think the word is ‘dire’,” she says. “They feel guilty about how they cannot provide what their partner wants most and yet she is stuck with them. I have had men tell me it would be better to divorce, so she could find somebody else. I have had plenty of men break down during a consultation.”
Homa sees her clients without their partners, so they are, perhaps, more comfortable about revealing their emotions. In other environments, many of them feel they have to “be strong”. “Men often hide their feelings in front of their partners,” says Lewis, “even if
they are heartbroken inside.”
Richard Clothier is a marketing manager in Bedfordshire who married his wife in 2011. After learning he had fertility issues that would make natural pregnancy unlikely, his wife started IVF treatment in early 2016. “I kept quiet about my feelings in order to be the ‘knight in shining armour’ who every man wants to be for his partner,” he says. “But it took its toll. Every morning on the drive to work, I would pull up on the same stretch of the A41 and find I was punching the steering wheel with both hands. I was filled with rage and raw emotion, making noises that I had never heard myself make.”
That those like Clothier feel they have no outlet for their frustration is a sign that men still feel uncomfortable about discussing their feelings openly. “Men have fewer social support networks,” says Barnes. “[Male infertility] is something that has been taboo for many years, and men don’t have the same resources available to them.”
Some are trying to change this. In 2015, Gareth Down set up a Facebook group focused on male fertility. After discovering he had no sperm as a result of testicular lumps during his teenage years, Down and his wife, Natalie, began fertility treatment. The couple had multiple rounds of intrauterine insemination (IUI) and IVF, and Natalie frequently went online in search of support and advice.
When Down tried to do the same, however, he came up against a wall. “The people on the pages were predominantly female, and I couldn’t find anything to relate to,” he says. “I couldn’t speak openly about how I was feeling.” So, he decided to start his own page. “After I set it up, I had a place where I could post about what I was going through. The strength of the Facebook group is that it is only men – so it seems that [on issues] where men might normally stay silent, they feel able to speak out.”
Avradeep and Emma also noticed an imbalance in support. “Compared to the thousands of female infertility blogs, male blogs are in a minority, because men don’t tend to share their feelings much, let alone write about them online for all to see,” says Avradeep. He started his own blog in 2014 to verbalise his concerns. One anxiety repeatedly mentioned by men with fertility issues relates to how a lack of sperm affects their sense of masculinity. “I have spent my whole career trying to separate fertility from virility,” says Lewis. “Men’s self-esteem is dented when they find they have a low sperm count. They think it makes them less of a man.”
The Next Generation
Last year, scientists at the Francis Crick Institute announced they had created healthy offspring from genetically infertile male mice. It was a ground-breaking result, pointing to a potential new approach to tackling infertility. The technique requires further development before it can be tested on humans, and even then it would need a change in UK law, which currently bans the use of artificially produced sperm to make babies. Still, it offers some hope.
“The research being done in genetics is the most promising thing for the future of fertility,” says Barnes, “and the lab scientists who are studying male infertility are finding really interesting answers. I think in 20-30 years, we will know a lot more about what causes infertility and how it can be solved.”
In the meantime, while there are no medical fixes, there are things that men can do to improve the quality of their sperm – and thus the chances of being able to father children naturally (see box on page 99). That you are reading this magazine – and therefore presumably taking an interest in your health – is a good first step. “Men produce new sperm every 70 days,” says Lewis. “So if you were to change your lifestyle for just three months, you might be able to improve your sperm quality.” It’s worth keeping in mind, too, that the world’s Mick Jaggers are the exceptions and not role models: men do have biological clocks.
Avradeep and Emma spent seven years and £35,000 on fertility treatment. After three rounds of IUI and five rounds of IVF, in April this year Emma gave birth to a girl they named Matilda Bea. “Matilda means mighty in battle,” explains Avradeep, “and Bea means bringer of joy.” Avradeep’s and Emma’s baby offers living proof that infertility need not mean childlessness. “Where donor sperm is used, the big thing that many men like myself have to understand is that this donor sperm is just DNA,” says Avradeep. “The donor is not the father. Once you get over that hurdle, it’s easier to progress.”
For Barnes, the story of Viagra offers some clues about how progress might be made. “Viagra and erectile dysfunction are now commonly talked about in popular discourse, but that wasn’t always the case,” she says. “I don’t know what it would take for us to be able to acknowledge male infertility as openly as we do erectile dysfunction.”
Funding new research is a separate battle – sperm studies are viewed as unattractive, given that they require large sample groups over many years and rarely give clear answers. But the first step towards greater understanding is simply to talk, to encourage men to vocalise their experiences honestly and to allow their voices to be heard. “The more we share, the more it becomes acceptable,” says Homa. “If people understand they are not alone, then the taboo is broken – and the real conversation can start.”
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