Educating Men: Gender Bias in Preconception and Fertility Education
Jaclyn Chasse, ND
When it comes to preparing couples for pregnancy and treating couples with infertility, statistics show that there is a gender bias. A survey of 15 000 men and women in Britain found that women are slightly more likely to have and seek treatment for infertility than men.1 There is also far more research on the psychological consequences of infertility in the females than in males.2
I would argue that the gender bias goes even deeper. When couples seek treatment for infertility or look to prepare themselves for pregnancy, this process is typically driven by the female partner. In fact, in my years of clinical experience in this specialty, I can think of only 1 couple out of hundreds for whom the process was driven by the father-to-be. This bias can lead to a focus on infertility as a women’s issue, and more education targeting a female audience on topics such as preconception, timing of intercourse, and human fertility. This clinical observation is borne out in research. One study published earlier this year in the American Journal of Preventive Medicine showed that, in federally funded clinics in the United States that deliver family planning services, 81% provided education around preconception care for women, while only 38% provided the same education for men.3 While men and women both play essential roles in contributing gametes to a future child, it seems that far less than half of men receive education to prepare them.
When it comes to research on male fertility, there is a wealth of knowledge available. Semen analysis provides an easy, non-invasive way to assess fertility before and after treatment. Many studies focus on therapeutics to enhance fertility; however, this article will focus on foundational preconception considerations and modalities to help men prepare for a growing family.
Why Men Need Preconception Education
In 1992, a landmark study published in the British Medical Journal revealed that, over a 50-year time frame, the average sperm concentration in healthy men had declined from 113 million sperm per mL of semen to 66 million per mL. Compounding this problem was an observed decline in seminal volume, resulting in an overall 52.8% decrease in sperm count per ejaculate during the 50-year study period.4 While some may argue that the lower sperm counts seen in healthy men today do not pose a risk for fertility, the observed decline is nothing short of concerning. In the face of rising rates of both infertility and genetically-linked chronic diseases in children and adults, I believe greater concern should be raised over the steady decline in the quality of these gametes, which are the blueprint for our offspring.
Over the years, adjustments have been made in normal ranges for measures of semen quantity and quality based on findings from 3 major studies. The first study, by John MacLeod and published in Fertility & Sterility in 1951, was the basis for the World Health Organization (WHO) first edition of the normal values for semen published in 1980. These standards set the normal range for sperm concentration at 20 million sperm per milliliter of semen; motility at better than 50%; and, appropriate morphology (shape and size) at better than 80.5%. There were many flaws in the study, including the use of manual assessment of samples by 1 individual, collection by withdrawal from intercourse, and as much as 5 hours between semen collection and assessment, now known to have a significant impact on sample quality.5 Over time, the WHO updated their parameters by decreasing normal morphology to better than 50% in 1987, better than 30% in 1992, better than 15% in 1999, better than 4% in 2010, using a stricter measure of morphology.
A second major study in 2001 established a range of fertile semen parameters with an improvement in study quality, although research flaws, such as not evaluating the female partner, still existed. This study defined fertile semen (concentration >48.0 million/mL; motility >63%; morphology >12% normal) and subfertile semen (concentration <13.5 million/mL; motility <32%; morphology <9% normal), with an indeterminate range in between. The study also calculated odds ratios for infertility based on combinations of these parameters.6
The 2010 WHO parameters were established using data from 4 different populations, including 4500 men across 14 countries in 4 continents. This included men who had fathered children in the last 12 months, unscreened men of unknown fertility, fertile men with no report of when they fathered children, and men who were chosen based upon passing 1999 WHO standards. Rather than calculate the mean value and upper and lower limits for each parameter in men who had achieved pregnancy within the last 12 months (which was used in previous research), the 5th percentile was used as the lower threshold for normal values.7 While this may be a more accurate statistical methodology, the results do not necessarily provide the most useful information, as there is still a failure to look at the production of ideal sperm, with good motility and morphology, and absent of genetic markers that render the sperm incapable of fertilization and maintenance of pregnancy.
With these changing definitions of normal for these parameters, clinicians should focus on restoring optimal fertility to all men who are preparing for pregnancy or are of childbearing age by considering key components of a preconception program consisting of lifestyle strategies as well as targeted nutritional therapeutics.
Components of a Preconception Program
Preconception education should include counseling on diet, exercise, stress management, and toxin avoidance for both men and women.
It is essential to ensure that men considering conception are a healthy weight. Higher BMI and central adiposity have been associated with lower sperm concentrations, numbers, motility, and morphology, as well as lower testosterone levels,8 and restoration of healthy weight is associated with improvement in these parameters.9 Furthermore, a higher rate of miscarriage has been observed in couples in which the male partner is obese, whether they became pregnant through assisted reproduction or spontaneous conception.10
A study of 209 healthy Spanish men demonstrated that higher consumption of omega-3 fatty acids was associated with increased testicular volume, and intakes of trans-fatty acids and omega-6 polyunsaturated fatty acids were inversely related to testicular volume. Trans-fat intake was also inversely associated with free and total testosterone levels.12 In addition, a low intake of antioxidants has been associated with poor quality semen.11 A Mediterranean diet, which is plant-based and rich in antioxidants as well as omega-3 fatty acids, may be a good choice for improving fertility.
While we’ve known for some time that exercise improves fertility (likely due to its impact on overall health and weight management), a recent study in the journal Reproduction compared 3 types of exercise and their impact on sperm health in 280 healthy male volunteers. Each participant was assigned to 1 of 4 groups: moderate-intensity continuous training (MICT) (30-45 minutes of moderate speed running 3-6 days per week), high-intensity continuous training (HICT) (60 minutes of vigorous running 3 days per week), high-intensity interval training (HIIT) (20-30 minutes of alternating sprinting and walking 3 days per week), or no exercise. All types of exercise led to an improvement in markers of oxidative stress and inflammation and these changes were correlated with improvements in semen quality and sperm DNA integrity. Men in the MICT training group experienced the greatest benefit. During follow-up, semen parameters were found to return to baseline values after 1 week to 1 month in men who discontinued their exercise regime.13 These findings suggest that a long-term exercise program involving moderate intensity activity may be most helpful in men wanting to enhance their fertility.
Exposure to environmental toxins through diet, topical exposure, and inhalation is nearly ubiquitous. Exposure to toxins, specifically endocrine-disrupting chemicals (EDCs), has been associated with decreased sperm quality and increased incidence of reproductive organ anomalies in men.14 EDCs have been found not only in serum, urine, and breast milk, but also in secretions of the male and female reproductive tracts, including the seminal fluids that carry sperm out of the body.
A growing body of evidence has shown that EDCs act through multiple pathways: In addition to modulating gene transcription, they may promote actions that directly compromise sperm function. EDCs that are most likely to have a negative impact on male fertility include oxybenzone (a common ingredient in sunscreens), phthalates (plasticizers used in food containers and beverage bottles, personal care products, pharmaceuticals and supplements, and many other products), triclosan (an antibacterial and antifungal agent), and bisphenols (additives to plastics and epoxy resins, like bisphenol-A and bisphenol-S).15 Others that have been identified include polychlorinated biphenyls, pesticides, and more. Avoidance of these sperm toxins is an essential part of a preconception program, as consistent exposure may contribute to poor sperm health and decrease fertility.
In addition to lifestyle factors, several key nutrients can be considered as part of a comprehensive preconception program for men. Early research has indicated that infertile men have lower levels of omega-3 fatty acids,16 zinc,17 and coenzyme Q10.18 In 1 of these studies, food intake of coenzyme Q10 reached an average of only 19.2 mg per day, while the supplemental dose demonstrated to positively impact male fertility is 200 mg per day.18
Participate in Equal Education
A male-centered preconception program should provide education to men on the relationship between lifestyle and fertility. In addition, basic supplementation with a daily multivitamin, as well as 100-300 mg of coenzyme Q10, 25-30 mg of zinc, and 1000-2000 mg per day of omega 3 fatty acids can be recommended.
Let’s ensure that, as health care practitioners, we support a level playing field when it comes to preparing couples for pregnancy, keeping male partners involved, and keeping in mind that it always takes 2 to tango!
- Datta J, Palmer MJ, et al. Prevalence of infertility and help seeking among 15 000 women and men. Hum Reprod. 2016;31(9):2101-2118.
- Culley L, Hudson N, Lohan M. Where are all the men? The marginalization of men in social scientific research on infertility. Reprod Biomed Online. 2013;27(3):225-235.
- Robbins CL, Gavin L, Zapata LB et al. Preconception Care in Publicly Funded US Clinics that Provide Family Planning Services. Am J Prev Med. 2016;51(3):336-343.
- Carlsen E, Giwercman A, Keiding N, et al. Evidence for decreasing quality of semen during past 50 years. 1992;305(6854):609-613.
- MacLeod J, Gold RZ. The male factor in fertility and infertility. Sperm morphology in fertile and infertile marriage. Fert Steril. 1951;2(5):394-414.
- Guzick DS, Overstreet JW, Factor-Litvak P, et al. Sperm morphology, motility, and concentration in fertile and infertile men. N Engl J Med. 2001;345(19):1388-1393.
- Cooper TG, Noonan E, von Eckardstein S, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010;16(3):231-245.
- Sermondade N, Faure C, Fezeu L, et al. Obesity and increased risk for oligozoospermia and azoospermia. Arch Intern Med. 2012;172(5):440-442.
- Hakonsen LB, Thulstrup AM, Aggerholm AS, et al. Does weight loss improve semen quality and reproductive hormones? Results from a cohort of severely obese men. Reprod Health. 2011;8:24.
- Boots C, Stephenson MD. Does obesity increase the risk of miscarriage in spontaneous conception: a systematic review. Semin Reprod Med. 2011;29(6):507-513.
- Mendiola J, Torres-Cantero AM, Vioque J, et al. A low intake of antioxidant nutrients is associated with poor semen quality in patients attending fertility clinics. Fertil Steril. 2010;93(4):1128-1133.
- Minguez-Alarcon L, Chavarro JE, Mendiola J, et al. Fatty acid intake in relation to reproductive hormones and testicular volume among young healthy men. Asian J Androl. 2016 Oct 28.
- Maleki BH, Tartibian B, Chehrazi M. The effects of three different exercise modalities on markers of male reproduction in healthy subjects: a randomized controlled trial. Reproduction. 2017;153(2):157-174.
- Phillips KP, Tanphaichitr N. Human exposure to endocrine disruptors and semen quality. J Tox and Environ Health. Part B, Critical Reviews. 2008;11:188-220.
- Schiffer C, Muller A, et al. Direct action of endocrine disrupting chemicals on human sperm. EMBO Rep. 2014;15(7):758-765.
- Safarinejad MR, Hosseini SY, Dadkhah F, Asgari MA. Relationship of omega-3 and omega-6 fatty acids with semen characteristics, and antioxidant status of seminal plasma: a comparison between fertile and infertile men. Clin Nutr. 2010;29(1):100-105.
- Chia SE, Ong CN, Chua LH, et al. Comparison of zinc concentrations in blood and seminal plasma and the various sperm parameters between fertile and infertile men. J Androl. 2000;21(1):53-57.
- Tiseo BC, Gaskins AJ, Hauser R, et al. Coenzyme Q10 intake from foods and semen parameters in a subfertile population. Urology. 2016; doi: 10.1016/j.urology.2016.11.022. Epub only.
Jaclyn Chasse, ND, is the founder of Perfect Fertility, a clinical telemedicine practice and educational training program for patients and practitioners. She also works as the Vice President of Scientific and Regulatory Affairs for Emerson Ecologics, holds an adjunct faculty position at Bastyr University, and is honored to serve as the current President of the American Association of Naturopathic Physicians. In her spare time, Dr. Chasse enjoys cooking, traveling, and playing outside with her lovely family.