Men's perception and understanding of male-factor infertility in the UK

Infertility is a disease of the reproductive tract that results in the inability to become pregnant after 1 year of well-timed unprotected intercourse (Zegers-Hochschild et al, 2009). Around the world, 15% of couples are affected by fertility challenges, and a cause affecting the male partner (male-factor infertility (MFI)) is identified in 30–50% of cases (Chandra et al, 2013).

Semen quality may be influenced by lifestyle choices such as smoking, heavy alcohol consumption, obesity and the use of anabolic steroids as fitness supplements (Kühnert and Nieschlag, 2004; Anifandis et al, 2014; Jurewicz et al, 2014; Pacey et al, 2014). Furthermore, male fertility declines with age (Fisch and Braun, 2013; Johnson et al, 2015).

Men with MFI experience emotional issues during and after fertility treatment that can impact their daily functioning. They experience more sexual dysfunction during fertility treatment (Ferraresi et al, 2013), and men with MFI whose partners require assisted reproductive treatment such as in-vitro fertilisation are more likely to experience depressive symptoms than the general population (Li et al, 2013). Longer treatment periods worsen maladjusted psychosocial behaviours (Johansson et al, 2010). The experience of grief and loss can continue after a couple abandons unsuccessful family-building efforts (Webb, 1999).

Because the treatment of infertility focuses on achieving a pregnancy, the majority of interventions revolve around the female partner, even in the setting of a male diagnosis. This marginalises men during the process and can lead to feelings of detachment and uncertainty (Hinton and Miller, 2013). Men with MFI often do not disclose their fertility issues to their social network (Stevenson et al, 2019) because disclosure can cause significant stress (Gradvohl et al, 2013). Non-disclosure and avoidance, however, put men at a greater risk for depression (Martins, 2014). Avoidance is related to the stigma attached to infertility and the negative self-perception that infertility has on masculine identity (Arya and Dibb, 2016; Bechoua et al, 2016).

Public perception of health challenges drives acceptance and mobilisation of resources, research and support, but infertility is a complex issue, and public knowledge of it is inadequate in general and about MFI specifically. One study found that only half the general population had adequate information about fertility, with women having more accurate information than men (Bunting et al, 2013). Additionally, appreciation of the true incidence of MFI is poor. This lack of knowledge may prevent men from seeking early treatment, which could lead to them missing out on comprehensive assessments that could identify significant underlying conditions (Hanna and Gough, 2016).

Therefore, an understanding of what the public believes about this often-stigmatised medical condition is needed.

The aims of this study were to:

• Assess the UK male public's understanding and awareness of male fertility issues compared to female fertility issues
• Identify the best ways to provide emotional/information support for men with fertility issues
• Examine the impact of lifestyle on male fertility issues.

Methods

Design and sample

This exploratory, descriptive, cross-sectional study is a secondary analysis of a dataset collected by Infertility Network United Kingdom (now called the Fertility Network United Kingdom), a national charity that supports people with fertility problems.

The anonymous data were collected via an online survey and presented during the UK's National Fertility Awareness Week in November 2015. Atomik Research, a UK-based market research agency, was used to reach men from across the UK to complete this survey online. Men who met the inclusion criteria (aged 21–50 years and living in the UK) logged on to the survey site and completed the study questions.

This study received ethics approval by the Duke Health Institutional Review Board.

Data analysis

All data were originally captured in Excel and then analysed using SPSSv23.0. Descriptive statistics were used to support all study aims. Participants' perceptions about support and lifestyle were compared by age group using chi-squared and residual analyses.

Results

Demographics

A total of 2006 men responded to the survey. Over half were aged >30 years. More than one in four (28.17%) already had children and 32.9% of those who did not thought that having children in their lives was important to them. Just under two-thirds (64.66%) considered infertility to be both a male and female problem, while 18.34% considered infertility an exclusively male problem. Of the total sample, 30.16% (n=605) had male fertility problems and, within this group, 58.35% (n=353) thought male infertility would affect marriage and 40.17% (n=243) thought it would affect mental health.

Public perception about male fertility issues

More than half (59.3%) of the participants (n=1189) thought male fertility was more hidden or less talked about than female fertility. The majority of the sample (n=1297; 64.66%) considered infertility to be both a male and a female problem. The majority (n=1389; 69.24%) also felt that 21–60% of all infertility cases involved both a male and a female problem. More than one-third (736; 36.69%) considered they may unknowingly have a male fertility issue and 605 (31.16%) had a diagnosed male fertility problem (Table 1).

Public preferences for emotional/information support for those with fertility issues

Around half of the participants would discuss fertility with their GP (n=1087; 54.2%) and partner only (n=966; 48.2%); 626 (31.2%) thought medical professional support was the most helpful form of support while 464 (23.1%) thought family support was the most helpful. More than half (54.4%) perceived that there was already enough support and information about fertility issues for men (Table 2).

There were age-related differences in perceptions and support preferences. Residual analysis showed that men in the 31–40 age group most often felt male fertility was hidden and less talked about than female fertility. They mostly preferred the idea of support from family. Younger men (26–30 years), were slightly less likely to state that MFI was hidden and be talked about than female infertility (17.4%). Their preferred format for emotional/educational support was online (23.8%). The oldest group in our study (41–50 years) were the least likely to see MFI as hidden and not talked about (16%), and most preferred seeking support from medical providers (>25%) and peer groups (>28%) (Table 2).

Public understanding of lifestyle influences on male fertility issues

More than half the participants thought that excess alcohol consumption (n=1291; 64.4%), smoking (n=1283; 64.0%), being overweight or obese (n=1076; 53.6%) and increasing age (n=1023; 51.0%) had negative effects on fertility.

However, 30.4% (n=610) of the participants were regular smokers, 28.8% (n=578) were overweight or obese, and 11.2% (n=426) consumed excessive amounts of alcohol. Additionally, 36.2% of them would not change (n=405; 20.2%) or did not know whether they would change (n=321; 16.0%) their lifestyles, even if such changes would have a positive impact on their fertility (Table 3).

Specifically, residual analyses showed that, compared to other age groups, men aged 26–30 years significantly disagreed that excess alcohol consumption, smoking, being overweight/obese, ageing, recreational drugs, sexually transmitted infections and anabolic steroids would impact fertility, whereas men aged 26–35 significantly disagreed that anabolic steroids would impact fertility. Men aged 21–25 years were significantly more likely to have experienced a sexually transmitted infection than older men. A significant proportion of men aged 31–35 would change their lifestyles to improve their fertility, whereas older men aged 46–50 years would not.

Discussion

Men were recruited from all over the UK, with a robust sample of more than 2000 and a wide range of ages. Additionally, those with and without children as well as those with a diagnosis of MFI were well represented in the final sample.

These data found that men perceive that the general public largely does not acknowledge male fertility problems. Close to 60% of participants thought that male fertility was more hidden or less talked about than female fertility. The data suggest that men who are of reproductive age are most aware that the issue is hidden. This may be because they are experiencing it themselves; one-third of the sample reported a diagnosis of MFI, a far higher prevalence than in the general population.

Stigma by the public also contributes to avoidance behaviours because men report threats to their perceived masculinity (Arya and Dibb, 2016; Bechoua et al, 2016). This avoidance caused by stigma places men at a greater risk of negative psychological outcomes such as depression (Babore et al, 2017; Martins, 2014). Conversely, when men feel acknowledged by their social network, they may be more likely to disclose their fertility status and treatment experience (Arya and Dibb, 2016).

Furthermore, while the stigma around MFI keeps men from disclosing their fertility status, those who are open about it receive benefits such as being better able to cope with the complex emotions that fertility problems elicit (Bechoua et al, 2016).

Despite the perception that MFI is a hidden issue among the general public, most of the sample thought that the public is aware that fertility issues can affect both men and women. Given that one-third thought they may unknowingly have a male fertility problem and another third had a diagnosed problem, this may not be surprising and may reflect selection bias in the participants.

While research indicates that most people lack adequate knowledge about both female and male infertility, most men place significant value on fatherhood (Hammarberg et al, 2017). This sample may have a greater awareness of male fertility than the general public. Nevertheless, younger men in our sample were more likely than older men to disclose to friends. One study found that men who felt that there was stigma associated with their infertility were less likely to disclose their status and seek support (Slade et al, 2007). Stigma associated with MFI continues to be an issue that affects how men emotionally navigate the diagnosis, treatment and outcomes of infertility.

There were differences in our sample's preference for emotional and educational support for MFI according to age group. Younger men (aged under 30 years) tended to prefer online support. This may be because younger men are more familiar with using the internet as a source of answers to a range of everyday problems. Younger people are more likely to seek health information online than older counterparts; the difference in access to technology between age groups is termed the digital divide (Cotten and Gupta, 2004). Access to the internet has given men opportunities to find information and connect with others experiencing similar problems.

Many men are open to talking about the emotional side of infertility with other men. This process is called ‘inclusive masculinity’ (Hanna and Gough, 2016). Online discussion boards have been found by some men with infertility to increase their social network and thereby to gain emotional support from peers (Richard et al, 2017; Hanna and Gough, 2018).

While this is beneficial, options for support are limited, and information found online is often poorly regulated and disconnected from healthcare teams. There is a significant opportunity to bridge this gap by creating formats that allow men to connect with peers virtually, while specifically trained moderators can allow evidenced-based information to be made available.

Men aged 31–40 years tend to prefer family as their source of support. Some evidence shows that men derive most support from their partners during family building. The quality of the man's relationship with his partner can also impact the perceived quality of support and may be directly associated with their level of marital satisfaction (Keramat et al, 2014). Having high levels of infertility-related stress levels before starting fertility treatment can negatively affect the quality and longevity of relationships with a partner (Martins, 2014). Therefore, assessing relationship quality and making referrals to mental health professionals as needed are essential parts of the care plan during fertility treatment.

The oldest group of men in the sample prefer to receive support from peers or medical professionals. The ability to seek support from the care team during diagnosis and treatment of infertility was seen as essential, yet this aspect of care is often missing. One study found men would like treatment information to be delivered verbally during their visit instead of through literature such as leaflets, and that their emotional support came from their fertility team (Fisher and Hammarberg, 2012). Men reported that they desire information about both practical and emotional components of treatment from healthcare providers (Read et al, 2014). Infertility clinicians are in a position to assess the need for emotional support during complex medical appointments.

Overall, the sample in this study had a good understanding of the potential controllable influences on fertility, including excessive alcohol consumption, smoking, adiposity and increased age. This to an extent is supported by data showing that, across most demographic groups, men are most aware of the controllable risk factors of infertility, though they have much more limited knowledge of fixed risk factors such as delayed puberty and chronic health issues (such as cardiovascular disease and diabetes) (Daumler et al, 2016).

Although this study did not specifically inquire about men's awareness of fixed risk factors, campaigns focused on improving overall public awareness offer opportunities to educate broadly to improve men's fertility awareness. Broad-based health initiatives should ensure that campaigns bring attention to lesser known associations with male infertility, particularly those that are common and amenable to being addressed through lifestyle modification.

Furthermore, increasing evidence supports that semen quality (a central component of MFI) is a potential reflection of male health in general (Eisenberg et al, 2015a; 2015b; 2016), and impaired semen quality is linked to a number of long-term conditions including cystic fibrosis, endocrinopathies and certain cancers (Doria-Rose et al, 2005; Eisenberg et al, 2013; 2015b). The scientific community is just beginning to understand the significant effect of overall male health on fertility. Public health campaigns are critical in ensuring that efforts to increase awareness translate into appropriate screening and treatment in healthcare settings.

It is important to note that, despite having an awareness of the modifiable lifestyle behaviours on male fertility, the men in this study still engaged in some of these behaviours; more than one in four were smokers and overweight or obese. Furthermore, one-third indicated that they were unwilling to change their behaviours even if they knew it could improve their fertility. This is not surprising given healthcare trends. For example, it is well known that in developed countries, such as the UK, obesity is a growing problem and is common among men of reproductive age (Craig et al, 2017). Smoking rates in men in the UK are about 14% (Office for National Statistics, 2020); reports indicate that national efforts are resulting in improved cessation rates nationally (Public Health England, 2017). Younger men in the sample (aged <36 years) were not aware that anabolic steroids negatively affected fertility, although the inverse relationship between anabolic steroid use and male fertility is well documented (Windfeld-Mathiasen et al, 2021). Men are known to place significant value on fatherhood (Hammarberg et al, 2017), but this does not always mean appropriate choices are made to meet this goal.

There is public resistance to lifestyle changes because these changes are often perceived as difficult. Messages that seek to promote a healthy lifestyle need to take account of current public knowledge and gaps in this knowledge (Lignowska et al, 2016).

Strengths and limitations

The strengths of this study include that men were sampled from a wide geographic range across the UK and there was a wide age distribution. Furthermore, the survey style provided anonymity, which could encourage truthful responses on a sensitive topic.

A limitation was that ethnicity and cultural backgrounds, which may influence help-seeking behaviours, were not captured as part of the survey. Another limitation was potential selection bias because one-third of the sample thought they may have a fertility issue and another third had a diagnosed fertility problem.

Conclusion

While men in this study understand male fertility issues are common and are as likely to contribute to a couple's fertility problems as female problems, overall, they feel the issue of male fertility is hidden from the general public, and this contributes to the stigma associated with MFI. They feel multiple support opportunities are helpful, from both their healthcare team and social circle; younger men have a marked preference for accessing support online. Finally, this sample have a good awareness of lifestyle behaviours that could affect their fertility.

This is an opportune time for healthcare team members and nurses in particular to influence public perceptions about MFI. Public campaigns that increase health literacy could, by advocating lifestyle interventions, improve fertility in the short term and chronic illness in the long term. For example, the Fertility Education Initiative was developed by a group of UK stakeholders who have developed tools and information aimed at children, adults, teachers, parents and healthcare professionals, with the goal of improving knowledge of fertility and reproductive health (Harper et al, 2017). Increasing public awareness can reduce some of the stigma associated with MFI. If stigma is reduced, men may be more willing to share their journey and seek the support they very much need during this complex time.

KEY POINTS

• Male-factor infertility is common but stigmatised. Men feel male infertility is not discussed by the public as much as female infertility
• Lifestyle issues affecting male fertility are not well understood
• Men with infertility problems desire more support, including online, from health professionals and through peer support
• Public health professionals can offer programmes to reduce stigma and help increase public knowledge about infertility
• Practitioners are well placed to provide more emotional support to men with infertility problems

CPD reflective questions

• How would you describe the understanding of male-factor infertility among the general public? Could this be improved in your setting?
• What patient teaching would you include in your care of men about lifestyle choices that may improve fertility?
• Considering the stigma men often feel about infertility, how does your clinical team meet the emotional and educational needs of men during family building?