Why does the infertile man get such poor quality treatment ?

As an IVF specialist , I have noticed that infertile men often get very poor quality treatment. There are many of reasons for this.

The first is the infertile couple themselves. Having a baby is usually considered to be the woman's problem , and she is the one who seeks medical attention which means she usually goes to her gynecologist. Many men have a fragile ego, and while some refuse to go for sperm testing , others postpone this, because they are worried they will find that they have a problem. Many men still blissfully resume that if their libido is normal , this automatically means that their fertility is fine , and that they do not need to check their sperm count.

By default, it is usually the gynecologist who then becomes the primary care physician for infertile couples. Unfortunately, most gynecologists are clueless about male infertility. Many have never examined a man in their entire professional career . They usually ask for a semen analysis; and if this is abnormal, they refer the man to a urologist. However , sometimes they do not interpret the semen analysis report properly , and this causes its own set of problems. For example some gynecologists still believe that a count of less than 60 million is abnormal - which means that men with a completely normal semen report are overtreated with medication , wasting valuable time.

To make a bad problem worse, most laboratories don't even know how to do a basic semen analysis properly. Because it is an inexpensive test, it's often done badly. This causes a lot of heartburn and confusion, as sperm counts vary widely all the time, and patients cannot make sense of what their problem is !

What happens when the infertile man is referred to the urologist ? While the urologist is a specialist , many of them do not have a special interest in treating the infertile man; and there are very few specialised andrologists ( male infertility specialists). This is why many urologists continue to provide many ineffective tests and treatments for the infertile man. They will often try empiric medical therapy to improve a low sperm count; and because this rarely works, patients get fed up and frustrated. The trigger happy urologists diagnose a varicocele for practically all men referred to them, by doing a color Doppler ultrasound scan. Once they find a varicocele , they are happy to treat it - and when this doesn't help to improve the patient's fertility status, they throw up their hands and say – Sorry – there is nothing else we can do ! The other problem with a referral to a urologist is that the care of the infertile couple gets fragmented. Often the gynecologist has no idea what the urologist is doing , and vice versa, which means the couple is not treated as a unit. This often causes them to lose confidence in medical treatment.

Another weak link in the medical system is the fact that many laboratories do not know how to perform a semen analysis properly. Since it is such a cheap test, they often do it badly, resulting in wrong reports - and therefore , the wrong treatment.

Compounding this problem is the underlying fact that the basic sciences understand very little about male infertility. We really still don't know enough about normal sperm production; and since we cannot pinpoint what the problem in sperm production is in the infertile man , there is very little effective treatment we can offer him. This is why the standard treatment for a man with a low sperm count today is ICSI
( intracytoplasmic sperm injection ) – a treatment which is conceptually crude, but works amazingly efficiently. We still do not have good tests for analyzing sperm function, so that a lot of our treatment consists of bypassing problems , rather than identifying them and solving them. This is a sad testimony to the fact that the infertile man has been relatively neglected !

About 15 years ago , it was felt that strict morphology testing using Kruger criteria would help us to identify which infertile men had functionally competent sperm. Unfortunately , we now realize that these criteria are not always reliable. The new generation of sperm function tests are supposed to check for DNA integrity. Unfortunately , these are equally unreliable, even though they are presently very fashionable. This is because while they do generate valuable information in research studies, they are not very good at providing clinically useful information for the individual patient. Thus , while we know in general that infertile men will have higher sperm DNA fragmentation levels than fertile men, there is no number at which we can tell the infertile man whether or not his sperm are capable of fertilizing his wife's eggs.

This sad truth is that male infertility treatment still leaves a lot to be desired. And this is why , ironically , the most effective treatment for the infertile man it to treat his fertile partner !