Well, here’s a news flash. Male-related fertility issues are behind half the cases of couples struggling to have babies. This could be on account of low sperm count, sperm that are not shaped properly, sperm motility problems or a blockage in the male reproductive tract that keeps sperm from getting out.
The irony: Sometimes it is efforts by men to look more masculine that cause these problems. In any case, male infertility is not discussed often enough but it is an issue that needs to be addressed because, in many cases, it can be prevented if the right information is disseminated.
So what are the medical issues that need to be addressed?
In a local study comparing 218 infertile men with 240 fertile men whose wives were pregnant at the time of the study, it was found that the infertile men had a much lower concentration of sperm – 14.8 million/ml – compared with their fertile counterparts, who had an average sperm concentration of 44 million/ml.
At the National University Hospital (NUH), preliminary data from a study of 900 couples undergoing assisted reproductive techniques revealed that about 85 per cent of men had one or more abnormalities on semen analyses, such as abnormal sperm concentration, motility and morphology.
Although the statistics are real, male fertility issues remain a taboo and are rarely discussed openly. Why is this so? Both ignorance and embarrassment play a part.
Mr J, a 36-year-old finance adviser, has been planning to start a family with his 33-year-old wife, Ms L. They have been married for two years but they have both been busy with planning for their new home and career progression.
To de-stress, Mr J goes to the gym regularly, and finds that keeping in top form with a muscular physique boosts his confidence at work and intimate moments with his wife, while trying for a child. However, the couple have not been successful despite regularly trying over the last 14 months.
They signed up for a fertility health screening at a private clinic and Mr J was devastated to learn that his sperm count was low and the sperm were not moving normally.
The masculinity myth
“I never thought I would be the one with the problem. I am in good form, I take protein shakes, work out, eat clean and have no intimacy issues with my wife,” Mr J shared. “I wonder if I can ever be a father.”
Most men, presumptively more than 90 per cent, feel guilt and shame driven by public perceptions shaped by unrealistic portrayals surrounding masculinity and fertility in entertainment and social media.
Importantly, men often feel that masculinity is linked to virility, a concept that does not always equate to fertility. This is partly due to social and cultural stigma, and a lack of awareness and understanding about the causes and effects of, and treatments for, male infertility.
Furthermore, media images depict muscular men to convey idealised notions of masculinity. This has led many young men to pursue the perfect physique, by using sex steroids-adulterated products to enhance muscle growth and metabolism.
Unfortunately, this can hurt sperm production. Long-term use of sex steroids in healthy men can even cause sperm production to cease completely, leading to male sterility and atrophy of the testes.
“The fertility doctor asked me detailed questions about my lifestyle and exposure to potential risk factors that can affect my sperm count and quality.
“I shared about the supplements I bought online to boost energy, muscle growth and performance, as well as wearing overly fitting underwear and tights during my workouts,” Mr J recalled.
Such misconceptions and misinformation are further aggravated by the lack of open discussion among men on their reproductive health.
A conventionally greater focus on female reproductive health issues may overshadow men’s concerns about their contribution to the fertility journey.
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Additionally, limited awareness of the signs and symptoms associated with male infertility makes it more challenging for men to identify their reproductive health problems.
A 2023 white paper found that 76 per cent of respondents from Singapore expressed a low to moderate level of knowledge about conception and infertility, including how it affects both genders.
In Singapore, the Ministry of Education’s sexuality education programme has expanded significantly over the years, to also address topics like sexual assault, the prevention of sexually transmitted infections and responsible decision-making.
Expanding the scope of the sexual education curriculum for youth to incorporate the topics of infertility and sexual dysfunction can help raise awareness and normalise these conversations.
“I wish I had discovered earlier in my life about the need to be careful about my reproductive health. I stopped taking those supplements totally and also changed my gym attire completely. I hope this will improve my sperm count and motility,” Mr J said.
He remains motivated to optimise his lifestyle choices to improve his fertility, before the couple decide whether to move on to assisted reproductive treatments.
Normal function does not mean fertile
Achieving erection and ejaculation may suggest that one’s male reproductive anatomy and function are normal. However, being able to produce semen does not necessarily mean there are no fertility issues.
This misconception has resulted in many men falsely believing that if they can perform functionally, they have no problems. This complacency often means that men need convincing before they agree to undergo fertility assessment with their spouses.
Mr J is still feeling guilty that he is the cause of the couple’s inability to conceive.
“I am functioning normally, and there are no signs that there is something wrong with my fertility,” he said. “I only managed to find out, opportunistically, because we are trying for a child together.”
Appropriate and adequate sexual health education can help men understand the causes and effects of male infertility and seek help when needed.
Open discussions and access to dependable, well-curated resources by hospitals and fertility clinics, including the NUH’s National University Centre for Women and Children, as well as national associations such as the Family Planning Australia and American Society for Reproductive Medicine, can enable early diagnosis and treatment. This improves the chances of successful fertility outcomes for men.
Essentially, breaking this taboo will help reduce the shame and fear associated with male infertility, allowing men to feel more comfortable seeking support and treatment in a timely manner.
This can also help men’s health in other ways. Many large population studies show that normal results from semen analyses in men are associated with improved healthy longevity and reduced risks of cardiovascular diseases.
A 2017 study showed that having an infertility diagnosis among men increased the risk of developing diabetes or ischaemic heart disease by 30 per cent and 48 per cent, respectively.
This is all the more reason to educate young men and help them understand why it is important to care for their reproductive health.
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Maintaining a healthy lifestyle, avoiding smoking and excessive drinking, eating a balanced diet, managing a healthy weight, as well as optimising mental health and reducing stress are essential for male reproductive health.
These steps seem simple but require discipline. That is why men who don’t consider that their general health can impact their reproductive health realise this only when they try to have children.
It’s also important to note: Men suffering from any cardio-metabolic conditions such as hypertension, diabetes and hyperlipidaemia, if left uncontrolled, are at risk of suffering from poor reproductive health such as erectile dysfunction, ejaculatory disorders, libido issues and poor spermatogenesis.
“I will continue to exercise, keep fit to look good the natural way through well-curated exercises suitable for me, improve dietary habits and avoid all quick fixes to look bulky and macho,” Mr J said. “Having my wife as my pillar of support during this journey humbles me tremendously.”
Ultimately, raising awareness of male reproductive health can lead to earlier diagnosis, better support, shared responsibility and greater involvement of men in their journey to conception with their spouses.
Mr J said: “Having all this information beforehand would have made me more conscious of my choices in life. Importantly, knowing that there are specialists and doctors who manage patients with men’s health issues can be enlightening and empowering.”
Adjunct Assistant Professor Huang Zhongwei is a consultant at the Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, National University Hospital.
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