O

ne in six Australian couples is infertile, and

male infertility is the sole or a contributory

cause in half of these. Treatment sought by

infertile couples leads to 70,000 assisted repro-

ductive technology cycles each year at a cost

of $600 million, with each couple paying approximately $

per cycle out of pocket.

A less readily quantified cost of infertility is the psychosocial

and relationship stress resulting from the inability to father a

biological child. Male infertility is a deeply personal affliction

for which disclosure to family and friends, or support groups,

is often declined or unavailable.

Failure to produce adequate numbers of motile and func-

tional sperm is the most common presentation of male infer-

tility, yet for most men no specific cause can be identified. As

such, no effective treatment can be provided.

Our current inability to make a precise diagnosis compounds

the sense of frustration for patient and clinician alike. Semen

and hormone testing provide insights into the severity of the

underlying disorder, but usually not the cause of disease.

In an effort to rectify this situation, studies are underway

to identify the genetic causes behind about 50% of infertility

cases. A potentially far more challenging task is identifying

environmental causes of infertility and the interplay between

genetics and environmental exposures.

For many men, assisted reproductive technology approaches,

such as intra-cytoplasmic sperm injection, provides a bypass

for sperm functional deficits. But assisted reproductive tech-

nologies place a disproportionately heavy burden on the female

partner, and can carry substantial treatment-associated risks

and financial burdens.

Added to this burden is that infertility remains “women’s

business” in many countries, with the focus of infertility assess-

ments being the female partner. This apparent gender bias is,

however, gradually receding with the Fertility Society of Australia

recently mandating the routine evaluation of male partners

within all clinical infertility programs.

Despite this overwhelming clinical and social need, rela-

tively little research is conducted on the mechanisms under-

lying normal or disordered male fertility. This lack of

prioritisation is tied up in complex taboos and narrow-minded

perceptions that unless you die of something, or patients are

openly complaining, it does not deserve funding.

Rather, we would argue that male infertility is such a personal

issue it will be the very rare patient who will stand up in public

and proclaim themselves to be infertile and become a” crusader”

in the way we have seen with several types of cancer. Until

infertility is “normalised” as a disease like any other in the

community, it will be left to those who know the breadth and

depth of this condition to advocate for increased service and

research effort.

In constructing the case for an enhanced focus on male

reproductive health, we present three perspectives:

1. male infertility is extraordinarily common, affecting men
   you know or it could affect you;


2. male contraception represents a largely untapped means of
   increasing fertility control options; and


3. infertile men die younger than their fertile brothers.
   Currently men play a major but often under-recognised role
   in natural family planning through the use of condoms
   and sterilisation. There is, however, a need for a new
   male contraceptive for couples for whom existing
   methods (including female-based methods) are
   unacceptable. The ideal contraceptive needs to
   be efficacious, reversible, safe, cheap and easy
   to use, but ultimately the development of a
   contraceptive akin to the female pill also involves
   a business case.
   An effective male hormone-based contraceptive strategy has
   been developed, and several non-hormonally-based methods
   are in development. The male hormonal contraceptive approach

20 | JAN/FEB 2016

The Boys Are Not OK

MOIRA O’BRYAN & ROB McLACHLAN

Not only is male infertility a determining factor

in a couple’s ability to start a family, it is also

associated with a higher risk of early death.