“Not this month anyway.”
Those were the words with which Kevin’s wife, Kate*, let him know that he wasn’t going to become a father. Not yet. It became their shorthand; a secret, poignant code that masked a pain they couldn’t discuss.
Every month, as the months rolled into years, Kate would say those words and Kevin would feel it almost as a physical sensation, “a kick in the guts. I pushed it out of my mind and I buried myself in work, but at the end of the day, I couldn’t stop the thoughts coming into my head. The loneliest hours were 1.30 or 2.30 or 3.30 in the morning, when I was lying there feeling like I had failed my wife with the one thing that she really wanted, and the one thing that I wanted more than anything else. Everyone else seemed to be having babies all around us. So why couldn’t we?”
We're put on this earth to facilitate childbirth and when you can't, it's a huge blow
Talk to men about their infertility problems – not an easy feat in itself: of the men contacted for this article, only one agreed to use his real name – and some common themes emerge. Some of them are the same feelings women who have struggled to become mothers describe: sadness, loss, grief. But where women sometimes describe their longing as a physical ache, men are more likely to talk about guilt, failure and loneliness.
For decades, women have been harangued by the media and society not to delay childbirth. But the elephant in the room has been the growing issue of male infertility.
Looming crisis
The evidence is now clear that there is a looming crisis in male fertility in the developed world. Research published in 2017 revealed that sperm counts in men from America, Europe, Australia and New Zealand fell by more than 50 per cent in less than 40 years. A meta-analysis of four decades of sperm count studies, published in the journal Human Reproduction Update, showed a 52.4 per cent decline in sperm concentration and a 59.3 per cent decline in total sperm count.
"It's a global trend we're seeing right across western societies. There are medical conditions that can cause someone to have a compromised semen analysis. But it seems that environmental pollution and lifestyle are certainly factors and it's really as vague as that," says consultant urologist and andrologist Ivor Cullen, who is based at the Waterstone Fertility Clinic in Cork and University Hospital Waterford.
The analysis did not explore reasons for the decline, but researchers at Hebrew University – Hadassah Braun School of Public Health and Community Medicine in Jerusalem, who co-led the study of 185 sperm count studies from 1973 to 2011 with experts in the US, Brazil, Denmark, Israel and Spain, pointed out that falling sperm counts have been linked to various factors such as exposure to certain chemicals and pesticides, smoking, stress and obesity.
Though the crisis in male fertility had been warned about before, the extent of the “sharp ongoing drop” hadn’t previously been illustrated quite so starkly. It was, they said, an “urgent wake-up call”.
Paternal age
Despite high-profile examples of older fathers like Mick Jagger, Steve Martin and Billy Joel, there is evidence to suggest, too, that the biological clock is not an exclusively female phenomenon. A small number of studies have highlighted the risks of delaying fatherhood, finding that older fathers were more likely to have children with a range of psychiatric, social and educational problems.
A study in 2001 at Columbia University, for instance, found that one in four cases of schizophrenia is linked to advanced paternal age. Another study at the same university in 2006 found there was a 60 per cent higher risk of miscarriage when the father was aged over 40. A large-scale Swedish study of 90 per cent of births over 28 years found that children born to fathers over the age of 45 were at greater risk of autism, bipolar disorder, suicidal behaviour, drug abuse and ADHD.
And yet, the notion that men who want to become fathers might need to start actively planning for it, and making the kind of lifestyle changes women are routinely advised to adopt, is rarely discussed outside the confines of the consultation rooms in fertility clinics. Often, treatment is focused on women in the first instance.
“Most couples I see start down the route of a female factor assessment, and it can be months before they go and look into the male factor assessment,” says Cullen. He suspects there is an element of taboo at play, but also points out that traditionally fertility was managed by gynaecologists, whose experience is predominantly in dealing with women.
“Ultimately, we didn’t realise quite how big the male factor was until the last 10 or 15 years.”
Informally, too, men tend not to talk to each other about fertility, other than in embarrassed sniggers. “Men’s role in having children does define them in a lot of ways. We’re put on this earth to facilitate childbirth and when you can’t, it’s a huge blow,” says Kevin, who talks openly and movingly about his experience of infertility, but who prefers not to use his real name.
When they got married in 2005, he and Kate decided right away “not to prevent” a pregnancy. He was 31 and she was 26, they were healthy, and they had no reason to think they’d have any trouble conceiving. And yet, 18 months on, they began to realise there might be a problem.
Reluctance
“I was very reluctant to go down the assisted fertility route. I wanted to try everything else first. You hear all these stories of couples who are on their sixth cycle. Wrongly maybe, I saw it as the end of the road and I felt that if it didn’t work, what would we do.”
They tried charting, which didn't work, and acupuncture and reflexology, which did, at least in helping them to deal with the stress of infertility. "Your close friends are looking at you with that look, and they don't realise they've got it on their faces. Or they say 'someday it'll happen for you', and that's even worse."
Kevin was adopted, so it felt natural to apply to become adoptive parents, a gruelling process that took around five years. "We were certified as adoptive parents but there were no children at that time in Ireland. And all the international countries were closing their doors. So you sit and wait for the phone call that never comes. That was six years ago and the phone call still hasn't come."
The question of IVF was still there, lingering in the background. “She wanted to go for it, but I didn’t, and it put a huge strain on the relationship. Everything in your life becomes about trying to have a baby – even down to something as simple as will we go away for the weekend, or should we save our money in case we decide to go for it?”
Eventually, one day over coffee, Kevin “had an epiphany. I just thought, ‘this is it, we have reached the end of the road’.” They chose a clinic in Prague and were advised to try intracytoplasmic sperm injection (ICSI), a process in which a single sperm is injected directly into an egg.
They were sitting in another coffee shop, this time in Prague, when a phone call came to say the sample Kevin had given had no sperm in it. He was offered two options: donor sperm or the more complex procedure microsurgical testicular sperm extraction (Micro-TESE).
Lowest moment
He opted for micro-TESE and through the procedure, 10 sperm were retrieved. Two were injected into eggs and the rest frozen. After all of that, the first attempt at IVF failed, possibly because the eggs had been harvested too soon. “That was the lowest moment of the whole thing. It just didn’t take.”
Four months later, they tried again – and this time they were successful. Just under nine months later – nine years after they had started trying for a baby – they had “two lovely little girls”.
“My whole 30s were taken up with trying to have a baby. I regret now not going for IVF sooner. I think now that whatever the result is going to be, get to the place where you can deal with it quicker.”
My body is simply 'broken' when it comes to fertility, there is nothing that I can do to fix it
Kevin and Kate’s story is by no means unique. Currently, one in six couples in Ireland has problems conceiving. It used to be said that in one-third of cases, the male factor was at play; in one-third it was female; and the remaining third was a combination. These days, says Cullen, there’s some element of male factor infertility in half of the couples who need fertility treatment.
Like Kevin and Kate, Paul Bradley and his wife, Kristel, started trying for a baby early, when they were both in their late 20s.
Fertility drugs
A year in, Kristel began taking fertility drugs and injecting herself with hormones. “It’s tough seeing her taking injections every day and all these drugs, and dealing with the side effects like bloating.”
They kept it to themselves at first, he says. “You don’t talk about it. I was only 27 when we started, and none of my friends were there yet – half of them were single and worried about the next night out. So it’s not the kind of thing you can bring up over pints.”
But after their wedding in 2014, people started asking questions, “and we started being more open about it. We’d say, ‘yep, we’re trying and it’s not happening for us’.”
The first fertility clinic they went to said they were too young for IVF. So they switched to the SIMS clinic in Dublin. “They were very blunt with us. Because we’d been trying for five years at that stage without success, they said we had only a 2 per cent chance of conceiving naturally, and they put us straight on IVF.”
At around the same time, they took part in a TV3 documentary, The Baby Makers. "We'd come to terms with telling our story by then. When I was doing research, I didn't have any men giving their side of the story to help me and I thought if I had the balls to put myself out there, it might make a difference to someone else."
In the first round, they harvested 11 eggs, and nine successfully fertilised. But on day nine there was bad news. All of the eggs had arrested; none were viable for implantation.
Success stories
As it turned out, they were to be one of the success stories of the programme. Paul went for a simple “DNA fragmentation” test, which tests for DNA damage in the sperm sample. If a sperm cell containing damaged DNA fertilises an egg then necessary genetic information may be missing which can lead to poor fertilisation rates. “It should have been 15 per cent, and it came back at 49 per cent.”
Paul and Kristel made a series of lifestyle changes. “We took eight nutritional supplements, cut out alcohol, stopped eating processed foods, cut down smoking, tried to get plenty of sleep. It was a process of just calming down and copping on.” They went on holidays in January 2016, and when they came back, Kristel was pregnant. Their daughter, Zoe, was born later that year. Kristel is currently 16 weeks pregnant with their second child, also conceived naturally with the help of the same lifestyle changes.
Of the couples deemed suitable for micro-TESE, about one in seven cases will lead to the birth of a baby
For Ed and his wife, Laoise*, who started trying for a baby in 2015, it took five rounds of IVF to achieve a positive result on a pregnancy test. They have both male and female factor infertility, but the male factor is “the inhibiting one”. Despite this, they are now in the early stages of pregnancy, and feeling nervously hopeful, he says.
He was, he says, surprised by the speed at which he processed the fact that he had fertility issues, and moved on to trying to solve the problem. “Our counsellor said nine out of 10 men she spoke to quickly turned away from emotional responses, and focused on problem solving. By and large, my low moments are caused by the fact that I don’t yet have children, and will be 38 soon.
“There are still moments where I think about the fact that my body has failed me physically in this respect, and wonder what that says about me. But my body is simply ‘broken’ when it comes to fertility, there is nothing that I can do to fix it. On an intellectual level I know it’s not my fault, I do occasionally struggle with the thought that I am failing to hold up my end of the process.”
Lifestyle factors
The good news is that we have a better understanding of the lifestyle factors that contribute to male infertility.
Cullen points out that the lifestyle changes that can lead to an improvement in semen analysis don't have to be dramatic. "Essentially, it's avoiding smoking, marijuana, not drinking to excess, taking some of the nutritional supplements that have been shown to have a positive effect. There are magic underpants you can buy on Amazon to keep your groin cool, and people tend to get very excited about these, but the sensible advice is really just to keep laptops off your groin, and avoid an excess of saunas and steam rooms."
But, he adds, since semen has a 90-day life cycle, the lifestyles changes will been seen in it only after a few months. He advises couples who are having trouble conceiving not to delay having semen analysis done, and not to get too caught up on the absolute numbers in a single sample. Trends over time are more important.
When lifestyle changes aren’t enough, scientific treatments are advancing all the time.
The first baby conceived with the help of micro-TESE performed in Ireland was born in 2016. Cullen carried out the surgery. Aimed at men who ejaculate, but don’t produce any sperm in their ejaculate, and don’t have a physical obstruction such as scarring – following, for example, a medical procedure or sexually transmitted infection – it involves opening the testis and using microsurgical techniques to try to find pockets of sperm production within the testis for retrieval and use with IVF.
Around 50 per cent of the time, some sperm is retrieved but, as Cullen points out, that is not a guarantee of a healthy full-term pregnancy, and there are many other factors at play.
Of the couples deemed suitable for micro-TESE, about one in seven cases will lead to the birth of a baby. “I’ve now done it on 22 Irish males, and we’ve had two babies born and one ongoing pregnancy as a result,” he says. So it’s not a magic bullet, but for the right couple, it might be their best hope of having their own genetic offspring.
Secrecy and shame
Ed points out that the secrecy and lingering air of shame surrounding male infertility makes it harder to cope. “Most people, I think, generally assume that where there are fertility issues, it is a ‘problem’ with the woman. Even though I know it’s not my fault, and that my fertility issues are beyond my control, I wouldn’t yet be comfortable to talk about it in front of people who I don’t know. I suppose I have a fear of being judged ‘inadequate’, even though I know that’s not the case,” he says.
“It’s hard for men to talk about this, but I don’t know how it will change other than more people talking about,” says Paul Bradley.
“It takes more people being a bit more understanding, more supportive rather than joking about it. There’s room for humour too. But we need to start the conversation. Men need to know this is something that affects them.”
*Some names have been changed at the request of interviewees
