mercredi 31 mai 2017
Maybe It's Him and Not Your Biological Clock
When Jane Smith* couldn't get pregnant, she assumed it had something to do with her body. She was wrong.
Jane and her husband, Joe, spent most of their 20s thinking about how not to get pregnant. By their early 30s, they were ready to start a family. Soon, they learned it wouldn't happen on demand. Months and eventually years went by until they were able to conceive with assistance from IVF. Jane says she now has "enormous empathy" for others who deal with fertility struggles and that the experience taught her a lot about how we view women's bodies. For so long, Jane points out, women are made to believe we can get pregnant at the drop of a hat. "The minute you'd like it to happen, you assume it will be easy." And if it isn't, you figure it's probably your fault. But through their fertility journey, Jane and Joe discovered that their troubles were caused by an issue with Joe.
Male infertility leads to trouble conceiving just as often as female infertility.
About 10 percent of American couples of childbearing age experience infertility, according to the American Pregnancy Association. But as famous and everyday women alike open up about their struggles, women still shoulder much of the "blame." In reality, male infertility leads to trouble conceiving just as often as female infertility, as was the case with Jane and Joe. And issues with a man's reproductive health don't just impact the ability to get pregnant. They can also cause miscarriages. As we become more open about infertility, it's important we don't assume it's all about the would-be mother. Such assumptions put emotionally draining pressure on women, and they're also counterproductive. Research and clinical observations show that environmental and lifestyle factors affecting men could be decreasing sperm quality as we speak.
Why We Often Assume It's the Woman's "Fault"
Infertility is defined as the inability to conceive after one year of unprotected sex or the inability to carry a pregnancy to live birth. "Honestly, most often couples assume that a conception or miscarriage problem is caused by the woman," explained Dr. Paul Turek, a leading specialist in men's reproductive health. "It's been this way since time immemorial, largely because women are more proactive and responsible about their health care." Turek finds that it often takes pain or a life-threatening event to get men to see a doctor.
"Most often couples assume that a conception or miscarriage problem is caused by the woman."
It's true that even when they're not planning to conceive, women are more regularly in touch with their reproductive health than men. Once a month, we know if our periods are regular and often bear responsibility for avoiding pregnancy when sexually active and not trying to conceive. Unlike men, most of us also see an ob-gyn at least once a year. That means we get face time with a doctor who specializes in reproductive health.
If a woman has tried to have a baby for a while without success, she already has a built-in relationship with a doctor. And when she brings up fertility challenges with that doctor, there's a good chance the physician will focus on potential female factors causing infertility, since they specialize in women's health. There may be a passing mention that the male partner should be checked out too, but that's not the doctor's area of expertise. So it's up to the man to find his own specialist to talk to. Dr. Heather Rupe, an ob-gyn and author in New York City, said she observes a discrepancy between the sexes. "I think women are more proactive to seek treatment and answers, whereas men typically have the 'let's just keep trying' approach." This difference could leave couples ignorant of how the man's health may be impacting their chances to start a family.
For Jane and Joe, it was a male factor that lead to their challenges conceiving, but Jane admitted that at first, she assumed it might be a problem with her. "I was aware of so many more instances of the issue being with the woman. After trying for a while and doing all the research that process inspired, I knew that there were quite a few things that had to work correctly for me to conceive even if everything was fine with my husband. I could have issues ovulating regularly, issues with quality of eggs, blocked tubes, uterine fibroids, problems with implantation. I just didn't know much about male infertility or how common it was."
Constant attention on the "biological clock" also sends the message to women that our bodies and life choices put us at risk for infertility. Yet the impact of a woman's age has been exaggerated as the main hurdle to conception. A 2013 piece in The Atlantic examined research and found that the mainstream media has largely misinterpreted studies about maternal age and reproduction. One stat - that 30 percent of women age 35 to 39 won't get pregnant within a year of trying - is based on data collected in France between 1670 and 1830. More reliable studies have found something different: that fertility of women in their late 20s and early 30s is practically the same and that there is not a major drop in fertility until age 40.
The impact of a woman's age has been exaggerated as the main hurdle to conception.
And then there are messages we hear from health officials. The Centers for Disease Control's (CDC) "faststats" on infertility track the number of women who have used fertility treatment in their lifetimes, with no mention of men. And the agency's public awareness campaigns about reproductive issues are often targeted toward women. In an especially paternalistic recommendation, the CDC recently told women to stop drinking alcohol if they were trying to get pregnant or simply not using birth control. The idea was that half of pregnancies are unplanned, so drinking without using contraception could put an unborn baby at risk. (The tone-deaf recommendation also ignored gay women.) Women are constantly told that it's our actions that can get in the way of a healthy pregnancy, when in fact men play a role, too.
Jane's experience made her more aware of the expectations society and women themselves put on the female body. "Women probably feel the pressure more because they feel the clock ticking. I think we are also very in tune with our bodies when we are trying to conceive and looking for every possible symptom or problem, which sort of exacerbates that pressure. We watch what we eat, how much we exercise, our mental health. We can easily fall into an obsession over our bodies not being able to do the thing 'we were designed to do.' I can't speak for men, but they just seem to be a bit less neurotic about the whole process. They've got one job, and once it's done, there's not much they can do to change things so stressing about it all doesn't do any good."
Society's view of reproduction as a woman's job, and hence infertility as a woman's failing, reveals an undercurrent of sexism. Just like the burden of child care is still placed squarely on many women, conception has historically been considered a woman's responsibility. England's King Henry VIII and his wives infamously dealt with fertility woes. Historical studies suggest it was an anomaly with his blood group that caused his reproductive challenges, yet his wives took the blame and even paid the price with their lives. While we've certainly seen progress since then, today male infertility is still considered a threat to a man's masculinity. We see this manifested in the rate of elective sterilization procedures. A couple in America who is finished having children is much more likely to pursue a tubal ligation (tube tying) for the woman than a vasectomy for the man. Since a vasectomy is a much less invasive procedure, this suggests men feel pressure to maintain their fertility even when they're done having children. This same underlying pressure could discourage men who are trying to conceive from exploring potential problems.
Jane's husband, Joe, compared confronting his fertility challenges with the feeling some may have about seeing a psychologist - it's difficult to take the first step. "There is a stigma for men, like we are lesser men if we can't 'sow our wild oats' and reproduce." The process taught Joe to see the experience as a physiological challenge instead of a personal failing. "I learned that there are medical issues that thankfully we could get around." Joe's experience working with fertility specialists made him see great value in overcoming that initial stigma. "The medical professionals made us feel that there were a whole bunch of possible pathways. If we were committed and open-minded about how we would move through the journey, we were going to have kids one day."
Infertility: It's a Two-Way Street
As Jane and Joe learned, various factors lead to infertility, many of which can impact both men and women at any age. When you break down cases of infertility, one-third are attributed to the male partner and one-third to the female partner. The rest are due to unknown factors. Here's what these factors and causes look like.
- Female Factors: The most common female-driven reasons for infertility include blocked or damaged fallopian tubes, endometriosis, polycystic ovarian syndrome, uterine or cervical abnormalities, and a decrease in egg quantity or quality. The underlying causes of these issues can include age, hormonal issues, past sexually transmitted infections, and lifestyle factors like smoking, drinking, and weight.
- Male Factors: Male-driven reasons for infertility can include low sperm count or quality, a lack of sperm production, testicular abnormalities, and trouble reaching climax. Underlying causes include past illnesses, infections, physical trauma, age, genetic disorders, hormonal problems, varicoceles, and lifestyle habits like smoking and exposure to heat or toxins.
- Underdetermined Factors: If all tests for known female or male factors come back clear but a couple still cannot conceive, the cause is unknown.
Why We Need More Awareness About Men's Fertility
While we hear a lot about a woman's biological clock, it's a shame there isn't more awareness about male-factor issues because many of them can be easily solved. Turek said the more we learn about genetics and the hard science of male infertility, the more environment and lifestyle issues appear to matter. Risk factors that can be reduced include obesity, poor diet, recreational drug use, and exposure to heat, industrial solvents, or medications.
"Environmental reproductive toxins like BCPs, Bisphenol A, phthalates [chemicals that often show up in personal care products or plastics], and air pollution are also a serious consideration," Turek noted. These tend to impact the future fertility of male babies if their pregnant mothers are exposed to them more than adult men but still could have an impact on male fertility overall. A March 2017 New York Times op-ed by Nicholas Kristof laid out how these endocrine-disrupting chemicals may be impacting male fertility on a broader basis. Kristof cited stats that show sperm counts have dropped in the last 75 years and wrote, "human and animal studies suggest that a crucial culprit is a common class of chemical called endocrine disruptors, found in plastics, cosmetics, couches, pesticides and countless other products." Kristof recommended that both men and pregnant women avoid plastics (even those plastic-y receipts you get at ATMs and gas stations) and pesticides. He also called for more regulations of endocrine-disrupting chemicals in our personal care and other products. Turek, who works with male patients every day, isn't convinced these chemicals are causing a widespread sperm quality crisis yet, but he does think the potential long-term consequences are cause for concern.
In addition to harmful chemicals, seemingly harmless ways of relaxing could be holding men back from becoming fathers. A three-year study led by Turek when he was at the University of California, San Francisco, found that hot tubs, jacuzzis, and hot baths could put men at risk for infertility by decreasing total motile sperm count. The good news was that the effects were often reversible within three to six months of avoiding the hot water.
The trend toward legalized marijuana is another reason for more awareness about male fertility factors for couples trying to conceive, since cannabis use can also get in the way. Turek conceded that marijuana likely has some medical benefits but said evidence suggests sperm can be negatively impacted by THC. We already knew that smoking of any kind was bad, but the issues with THC suggest it's not just smoking that could hurt male fertility, but also consuming edible marijuana.
Many people wrongly assume that a man's job in reproduction ends once the sperm fertilizes the egg.
Low-tech solutions like avoiding marijuana and hot tubs could not only improve a couple's chance of conceiving, but also lower the risk of miscarriage. Many people wrongly assume that a man's job in reproduction ends once the sperm fertilizes the egg. But in the days following conception, the egg determines whether or not the sperm is good enough. After the two meet, the egg will "inspect" the sperm's genetic material and either fix imperfections or reject the sperm, leading to an early miscarriage. This sort of "quality control" of the embryo happens multiple times during early development and can depend greatly on the quality of the sperm. Sometimes the issues with the sperm are chromosomal, but other times it's poor DNA integrity. The latter can be caused by lifestyle factors - like smoking and hot tubs - which also means changing those habits could prevent future miscarriages. Men have the benefit of creating their sperm as they go, which means they can also improve it.
It Makes Sense to Start With the Man
Common sense would suggest that infertility testing should start with the man. Recall that one-third of infertility cases can be traced back to male factors, no fewer than female-factor-related cases. Now consider that a semen analysis costs anywhere from $50 to $300, while diagnostic tests for a woman can costs thousands of dollars and are much more invasive. If a man's semen analysis suggests low a sperm count or quality, he first can turn to basically free lifestyle changes in an attempt to improve it. And if the couple still doesn't conceive, they can explore other options, including further testing for the man or testing for the women. If simple lifestyle changes do work and the couple conceives, they may have avoided costly procedures like intrauterine (IUI) and in vitro fertilization (IVF), both of which can be used to address male-factor infertility. Considering the low cost of a preliminary semen analysis, there's little reason not to start there.
On the other hand, preliminary fertility testing for a woman includes a blood test to look at hormones, an intravaginal ultrasound to examine ovarian reserves, and an uncomfortable hysterosalpingography (HSG) dye test that involves injecting dye into the uterine cavity to make sure the fallopian tubes are open. The latter alone typically costs $1,000 and is rarely covered by insurance.
Overall, Turek has hope that the mainstream conversation around reproduction issues will expand to include men. Recently, the National Institute of Health (NIH) announced plans to research how a man's fertility could be a marker for overall health. The government-funded studies would look into how infertility is tied to later occurrences of cancers or lower life expectancies in men. The results could lead to more men getting tested for potential fertility issues as part of their overall health care. "With the recent realization that a man's fertility may be a good biomarker of his overall and future health. I am pretty sure that this will change." It can't happen soon enough, he said, and we agree. Meanwhile, by opening up about their journeys, couples like Jane and Joe help others feel less alone and more informed.
*Names have been changed to protect anonymity.
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