Men an Afterthought in Infertility Evaluation

Marcia Frellick

May 10, 2019

CHICAGO — Male factors are responsible in 50% of infertility cases, but men's needs are largely unmet in evaluations, counseling, and available resources, according to new research.

Those factors can often be addressed and corrected, but too often that step is skipped, so couples might be undergoing unnecessary in vitro fertilization (IVF) cycles and incurring significant emotional and financial costs, Akanksha Mehta, MD, from the Emory University School of Medicine in Atlanta, told Medscape Medical News.

Mehta and her team gathered two focus groups. One had four women and three men who discussed individual experiences, and the other had 10 couples experiencing male-factor fertility.

The 27 participants, 26 to 38 years of age, were recruited from a community-based fertility-awareness nonprofit organization, from an outpatient urology practice, and over social media. All were undergoing infertility evaluation or treatment.

The researchers did a qualitative investigation with interpretive phenomenologic analysis.

"A large proportion of the males in the focus groups didn't believe that it could be a male problem until they went to a physician," said Mehta. And the physician the men reported seeing initially was, in most cases, the wife's physician and almost always a primary care physician, not a urologist.

Websites, available counseling, and printed information for men are primarily geared toward female-factor infertility, Mehta explained. Support groups geared toward men experiencing infertility are practically nonexistent.

The infertile men in the focus groups said they want a central repository for evidence-based information and access to physical and mental health services geared toward infertile men, she said.

Physicians should refer infertile couples to a urologist early on, Mehta advised, and tell couples that their infertility could come from either partner, or both. Couples should also know that infertility is common; it affects 8% to 10% of those trying to conceive, she said.

However, insurance coverage for infertility can be an issue.

Inequities in Insurance

"Ultimately, I would like to see better insurance coverage for men," said Mehta. "That has lagged far behind."

In a handful of states, insurance is mandated for infertility workup and diagnosis and treatment, "but if you look at the fine print, it's mandated for the female side and not the male side," she said.

"So they may cover IVF but they won't cover semen analysis. They may cover IVF but they will not cover sperm retrieval," she noted. "How are you supposed to get the sperm?"

In Atlanta, there is no coverage for male infertility surgical procedures, she said. Therefore, costs for surgical sperm retrieval, diagnostic evaluation, and testicular biopsies, for example, are paid out of pocket.

Even the most severe male infertility conditions - for example, when sperm production is so low that no sperm appear in the ejaculate - can be safely and effective treated.

"There really is a limited amount of evaluation typically done of men prior to treatment," said Peter Schlegel, MD, from the Weill Cornell Medicine in New York City, who is president of the American Society of Reproductive Medicine (ASRM).

The historic view has been that "there are no treatable conditions for men beyond doing in vitro," he told Medscape Medical News. In addition, "a lot of the experts evaluating couples have a female focus; they are mostly reproductive endocrinologists who, of course, are gynecologists by training."

Often, because men are not initially considered part of the treatment, women undergo months of medical treatment or other interventions before there is any recognition that the problem might be low sperm levels, or even no sperm production at all.

"Even the most severe male infertility conditions — for example, when sperm production is so low that no sperm appear in the ejaculate — can be safely and effective treated," said Schlegel.

ASRM guidelines recommend that men and women be evaluated at the same time to avert inappropriate treatment. The society is moving toward better communication with men and improving its website to make information geared toward men more visible, Schlegel reported.

"One of the most searched areas on the website is on sperm morphology, the shape of the sperm, and how it affects both fertility and treatment," he said.

Funding was provided by the American Society of Reproductive Medicine and the National Institutes of Health.

Mehta and Schlegel report no relevant financial relationships.

American Urological Association (AUA) 2019 Annual Meeting: Abstract PD29-04. Presented May 4, 2019.

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