Discover more from Fertility Rules
👨⚕️ Where are all of the reproductive urologists?
Plus synthetic embryos, the emotional toll of infertility, possible trigger for endo, and how childhood obesity may affect fertility
If you missed the epic fertility industry breakdown Chrissy Farr and I coauthored, catch up over on her excellent Substack Second Opinion. Over here, we’re going deep into one of the biggest unsolved issues in fertility care today: the dearth of reproductive urologists to manage male factor infertility.
Male factor is the underlying cause of around half of infertility; around 1/3 is exclusively men, 1/3 is exclusively women, and 1/3 is either a combination or unknown. Sperm parameters seem to be dropping globally for reasons we don’t completely understand, and this news is beginning to alarm men. A recent survey of 1000 men aged 25-54 revealed that 39% of those polled were concerned about their fertility. Around the same number made moves and tested their fertility via semen analysis. For those that tested, a full 57% received an abnormal result.
Insurance reimbursement rates for semen analysis are low, and until recently, fertility benefits didn’t cover men equally, so many continue to pay out of pocket to test. At-home kits from companies like Legacy are preferable for men who can’t shake the visual of a clinic’s ostensibly sticky black leather couches/magazines or for those optimizing for privacy and convenience. Regardless of where it is done or who pays, when an abnormal result is found, more tests and consults are required. For 10-12% of men, so is a surgical procedure to treat conditions like a varicocele (swollen vein in the testicles). The cost to treat male factors varies but starts between $600-2500, and microsurgery can be anywhere from $8000-15,000.
The person who manages infertility for men is a reproductive urologist (RU), a urologist that does a fellowship in male fertility. They are the mirror specialty to reproductive endocrinologists (RE), the ob-gyns who pursue specialized training in female fertility. While there is a well-known shortage of REs, for a sense of how scarce RUs are, there are around 1300 REs and only 200 RUs in the US. Many are retiring, and there aren’t enough fellowships to grow this group quickly enough to fill the demand.
As the maestros of infertility care, REs refer out to specialists when the need arises. But their training is in women’s bodies, not men’s, and in nearly 1/4 of cases, couples undergo infertility treatment before a man is ever tested. Even if they receive an abnormal semen analysis, the RE often skips straight to ICSI (intracytoplasmic sperm injection = shooting a single specially selected sperm directly into an egg to create an IVF embryo) and men do not pursue the matter further. The existence of ICSI has reduced interest in male factor generally since it requires only one sperm. It is now used in most IVF cycles even though it does not raise the live birth rate when the underlying cause is not male factor. (This journal preprint sums up many of my thoughts on the state of sperm selection and overuse of ICSI.) Potentially reversible causes of male infertility like testosterone use (doesn’t have the effect you think it does!) and 5α-reductase inhibitors (treatments for male pattern hair loss) are not caught either, leaving some couples who may otherwise conceive naturally on the hook for expensive, invasive treatments.
The standard of care for a couple facing infertility should be to test men and women together at the very beginning of an exploration. But for the reasons above, combined with the economic incentive to treat women, male factor is often ignored. Perhaps this changes if those holding the purse strings—fertility benefits and loan providers—demand it before approving a course of treatment. While standard-issue urologists (there are around 13,000) can handle some issues, we are still short thousands of RUs with training specific to infertility.
Pam Pure, the CEO and cofounder of Posterity Health is here for this problem. The company is an online male fertility clinic and the largest group of RUs in the country. Posterity offers direct-to-consumer services and second opinions, and they partner with fertility clinics and ob-gyns to scale clinical access to RUs. In a recent chat, she shared that in two years, she went from struggling to get meetings with clinics and benefits providers to signing several national contracts, including one just announced with CCRM. Pam noted that via their partnership with Progyny, more men are initiating fertility conversations before women. Many who show interest have a family history or health history that indicates they could have trouble conceiving, while others are just fertility-curious.
Even if you don’t believe in the sperm quality drop or care about the correlation between sperm parameters and a man’s overall health, male factor infertility impacts women too. Experts I’ve spoken to believe that, conservatively, as many as 20% of IVF cycles could be avoided by just addressing male factor consistently up front. Men who present with oligospermia (low sperm count) and are treated can often conceive naturally—no invasive retrievals or hormone shots are required. Right now, it takes an average of three IVF cycles to achieve one live birth. So earlier evaluation and treatment of men could reduce the number of cycles required, shift the treatment burden off of women, offer enormous savings for employers and individuals who currently pay out of pocket, and increase the number of patients fertility clinics can serve.
📖 Fertility Rules: spotted in the wild
If you’ve been here awhile, you know my second book, Fertility Rules, is out. And as a serious book nerd, it never gets less cool seeing it in bookstores.
👀 What I’m reading
💥 Most advanced synthetic human embryos created Achievement unlocked: scientists used stem cells to make synthetic human embryos. The intent behind their creation is to better understand the earliest days of human development, genetic disorders, and the possible causes of recurrent miscarriage. But as with all scientific developments that involve the potential for human life, the ethics are complicated, and questions related to the potential of synthetic embryos to grow into viable life remain.
💙 Yearning to be a father, but still waiting This poignant read features men who share the rarely discussed but very real emotional struggles they experienced while attempting to start a family. Stories range from failed IVF cycles and unexplained infertility to the flawed systems that stand in the way of LGBTQ+ couples who wish to adopt.
👦 Overweight boys are more likely to be infertile men We still have a lot to learn about the impacts of weight on fertility. But in this study, boys of normal weight were found to have a 1.5x higher testicular volume than those that were overweight. It’s estimated that 60% of children today will be obese by age 35.
🦠 Invasive bacteria may trigger endometriosis Endo is a multifactorial disease that is notoriously difficult to diagnose. Treatments are often ineffective and can cause adverse side effects, and lesions can recur even after they are surgically removed. Though much more research is needed, a recent study out of Japan shows a strong correlation between the presence of Fusobacterium, a bacterium now considered a pathogen, and endometriosis.