Are men struggling through a mother-focused health system?

AS a male reproductive specialist (andrologist), every week I have the satisfaction of finding the likely explanation for why a man and his partner have been struggling to conceive. It is a rewarding moment because more often than not, the condition is manageable and paves the way for them either having a healthy baby naturally or using assisted reproduction. Sadly, sometimes no solution is possible, yet even then I can help them understand why, put to rest uncertainties, talk about “why me?” or “why us?”, and assist in their plans.

However, the diagnostic process might also explain why my infertile patient has been suffering in other ways.

He might also have type 2 diabetes with erectile dysfunction limiting their intercourse frequency – a problem that he and his partner have been too embarrassed to raise with their respective GPs. We might discover a pituitary or testicular disorder that has also slowly depleted his testosterone over years, causing him to be fatigued with reduced libido. Perhaps he’s been living with Klinefelter syndrome and never understood why he was different to his peers.

Whatever it may be, providing a diagnosis and explanation usually triggers a sense of relief. Most have had a nagging concern that something wasn’t quite right, but they never saw an opening to raise it. These guys often say to me: “This is the first time someone has listened to me, examined me, included me in the process.” And by that stage, some have paid thousands for unproven “natural therapies” or for in vitro fertilisation (IVF) with their partners under the care of a gynaecologist whose focus has largely been on her. Some have only really seen a laboratory and a semen jar in the process.

It should not be this way. While there’s still much to learn about male fertility, we know enough to take it seriously both before a man starts trying for a baby and when he reaches a fertility clinic. There’s research to show that men can improve their fertility before they start trying for a baby and that lifestyle factors during the pre-conception phase can adversely affect their offspring’s health. We can advise that if they’re smokers, they should quit at this critical time, or if they’re obese, they should attempt to lose weight. And if they’re using androgenic steroids, they should be told it’s a contraceptive. Cumulatively, the issues mount up to a considerable and preventable health burden.

Similarly, when a man and his partner are struggling to conceive, one cannot presume it’s a female problem. One in 20 Australian men have impaired fertility and half of all IVF treatments are partly or solely due to the male. Male infertility also can be the “canary in a coal mine” and point to other health risks, not just in his reproductive system, such as testicular cancer or androgen deficiency, but more broadly. While more research is needed, there are epidemiological data pointing to higher rates of cancer and premature death in infertile men (here, here, and here).

It is time for a rethink about how we deal with male infertility and what it means in the short term for the couple and offspring, and in the longer term for the man.

Yet research by Healthy Male (formerly Andrology Australia), a national organisation providing up-to-date evidence-based information on male reproductive and sexual health, suggests men are getting lost in a mother-focused health system. A 2018 survey of 300 GPs found many were not discussing fertility with their male patients. While the majority thought that they should discuss reproductive health plans with men, half said they would only do so when being consulted specifically on such matters. Nearly all agreed that they should raise factors that affect male infertility with their male patients, but four out of five said they did this only occasionally.

More than half of GPs said a lack of knowledge about the subject was a barrier and more than a third said it was a difficult subject to bring up unless specifically asked. Almost half felt that fertility was generally perceived as a female issue.

One GP said:

“I routinely have a conversation about fertility and conception with my female patients, even when not prompted by them, but I admit I don’t routinely bring this up with my male patients unless they state they are planning to conceive. This is both due to [my] lack of detailed knowledge of male fertility factors and the perceived lower importance of male factors on fertility compared to females”.

It seems we have a cultural reluctance to evaluate male reproductive health disorders. Consider the fact that over half of Australia’s 15 000 adult men with Klinefelter syndrome will never be diagnosed; if genital examination were part of general medical reviews, the small size of the testes would be immediately evident. This diagnosis changes their life course, explains past experiences, raises possible fertility options and provides the restorative effects of lifelong androgen replacement. While genital examination is routine in male infertility evaluation guidelines, it also applies to men with hypogonadism or erectile dysfunction; how can evaluation be complete without examination of the testicular size, or of the penis for Peyronie’s plaques?

The 2018 survey results suggest primary care can improve and I’m grateful to the GPs who offered their honest thoughts.

Then, of course, there’s fertility treatment. I know from my own experience in IVF clinics that men can feel overlooked during early investigations of a couple’s problem. Many men do not undergo a full evaluation of their fertility concerns when they first present to a clinic, even though it might prevent expensive and invasive treatment. I’ve seen some spectacular missed diagnoses for men who feel rightly frustrated that they were treated like an accessory in the process. The collection of detailed data on male factor aetiology will shortly be required of all Australasian IVF units and this will necessitate improvements in the review of infertile men.

And what becomes of men when their partners are pregnant? Who supports him if they lose a baby or has a sick child? Whose job is it to ask him how he’s travelling? Healthy Male recently consulted people working in health services that deal with men expecting babies and new fathers. Despite up to one in 10 men experienced post-natal depression, the overwhelming view was that very few services focused on men.

Across the participants, there was clear agreement that Australia’s health system does not proactively engage men as they plan for and become fathers. Instead, across many reproductive health services, men are viewed as secondary to the childbearing process – welcome, but not a significant focus. This mindset, and the system that supports it, leaves men feeling undervalued and ignores their fertility needs and the mental health and wellbeing issues they may face as they become fathers.

To study this further, Healthy Male recently launched two surveys as part of its Plus Paternal project. We’re asking men about their experiences of the health system when they tried to father a child or became fathers. We’re asking if their health needs were discussed and/or addressed and whether they felt supported on their journeys to fatherhood.

There’s a separate survey for health professionals from general practice, fertility support, midwifery, obstetrics and gynaecology services. It asks about current practice, systems and processes for engaging men and the barriers and enablers to creating a truly father-inclusive health system.

If you are reading this, I invite you to please take the survey. We know that most young men want to become fathers at some point in their life. We also know their understanding of pre-conception health and fertility is poor. I hope this work will lead to meaningful change that helps them become healthy, happy fathers.

Professor Robert McLachlan is the Medical Director of Healthy Male, formerly Andrology Australia.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.