This week is UK Fertility Week — and today’s theme is #FertilityFellas.
Fertility is not solely a female issue — men are half the fertility equation too, but are often ignored. To understand a bit more about how we got to this point, I thought it would be interesting to take a trip down memory lane, and have a look at some highlights in the history of male factor infertility.
Let’s jump back a few hundred years…
Don’t be silly, of course men don’t have fertility issues — it’s the woman who’s barren
Fertility and virility have historically been central to masculinity —so to be impotent or infertile was to be a failure as a man. So it’s not surprising that in years gone by, any inability to conceive was blamed on the woman — as long as the man wasn’t impotent, he was assumed to be fertile.
Daniel Sennert summed this up in his 1664 page-turner Practical Physick; The Fourth Book:
Hence we may gather, that Barrenness is oftner from a fault in the women then the men: for in men there is nothing required but fruitful Seed spent into a fruitful womb.
Jolly good — so as long as he got his rocks off, job done. If babies didn’t immediately spring forth it was definitely his barren wife’s fault.
Unsurprisingly, blokes were pretty happy with this theory, so it becomes a bit of a recurrent theme…
No doubt for James McMath in his 1694 banger The Expert Mid-wife: A Treatise of the Diseases of Women with Child:
‘the vile Imputation of Barrenness, rests almost, solely upon them [i.e. women]’
Or William Salmon in his 1686 blockbuster Systema Medicinale, A Compleat System of Physick, Theoretical and Practical :
‘Here we shall only examine Barrenness, so far as it concerns a Woman alone.’
One of my favourite examples of the ‘nope, definitely not the man, it’s absolutely, definitely the woman who’s got the problem’ assumption is US President George Washington. He and his wife Martha were happily married but “mystified why, year after year, he and Martha could produce no Washington heir”. Obviously as the leader of a great nation, there couldn’t possibly be any question of his virility, so the issue evidently had to lie with Martha.
Except that Martha was a widow, and had given birth to 4 children with her late husband before she married George.
So, er, yeah, the woman with 4 kids is definitely the infertile one…
Alright, maybe the male partner might be worth checking out, just to be sure
Whilst the barren women assumption dominated, the notion that the problem might lie with the male partner wasn’t totally inconceivable (no pun intended).
In his study of barrenness in The Hidden Treasures of the Art of Physick (1659) surgeon John Tanner stated that there might be merit in considering male infertility
Before you try these uncertain conclusions upon the Woman, examine the man, and see if the fault be not in him.
The 1668 edition of Lazarus Riverius’s Practice of Physick went further by acknowledging that failure to consider the possibility of male factor could inflict unnecessary treatments on the female partner:
‘diligently consider and inquire, whether Conception and Generation be not hindered by fault of the Man, or any deficiency in him. For in such a Case, It were vainly done to torment the Woman with a multitude of Medicines.
The contribution of sperm quantity and quality to successful conception was recognised even in 1662:
‘the mans Seed, when it is not sufficient in quantity, or fit for Generation; and though a Woman receives it, either there is no Procreation, or its in vain’
And varicoceles had been identified as a possible root cause of male factor infertility as early as 1687
They who have their Testicles varicous are barren, because the Spirits of Generation pass to the Varices, and so leave the Seed unfruitful, being deprived of Spirits’
It’s clear that there was in fact a relatively sophisticated level of understanding of male factor infertility, even in the 17th century — but that there was little appetite to attribute any blame to the male.
OK, so how can we test for male factor?
If a man was willing to have his virility challenged, there were a couple of ways of investigating male infertility:
Male vs female fertility blame game
In 1545 one handy midwifery guide advised that both partners should pee into a pot that had been planted with barley, and whichever seed sprouted first demonstrated the fertility of the person who had watered it.
Or for a more rapid-turnaround test result: both parties would pee on a lettuce leaf, and the person whose urine evaporated from the leaf first was thought to be infertile.
Urine + horticulture — they both sound pretty bulletproof fertility tests, no?
Solo male testing (strap in for this one)
But wait, there’s even a fertility test for the blokes in their own right.
Instead of knocking one out in a clinic masturbatorium, yep, you’ve guessed it — it’s pee-in-a-pot time again.
But be prepared, it’s a doozy.
In his 1605 smash hit, The General Practise of Physicke, Christopher Wirtzung suggested this approach to determining a man’s fertility:
‘let him pisse in a pot, and let the urine stand awhile, if wormes grow therein, then is that urine barren’
Leave your warm piss in a cup and see if any worms start growing? If worms grow in your piss then I think you’ve got more than subfertility going on to worry about!
And let’s face it, the likelihood of worms magically emerging seems somewhat slim (at least, you’d hope so). Therefore the man was guaranteed to pass with flying colours regardless.
Bonus male fertility top tip
Whilst reading up on the history of male infertility, I ended up down some pretty freaky rabbit holes, discovering certain stuff I can never un-see.
And now I’m going to share this delightful fertility sex tip with you too.
Jane Jackson’s recipe book included a fertility enhancing remedy that had to be applied to the male genitalia:
‘Take the braine of a crane and medle it with ganders grease and fox greaseand keepe it in a vessell of silver or of gould and at what time thou wold have knowledge annoynt therewith thy yard and shee shall conceave’.
Right, so kill a crane, mix up its brain with some goose and fox grease, smush it together and smear it on your cock, BOOM. Up the duff.
Suddenly those fertility lubes like Pre-Seed are looking remarkably appealing in comparison…
We’ve invented semen analysis! But nah, let’s not bother with it, it’s probably a waste of time
So in the 1860s, American gynaecologist James Marion Sims is investigating ‘sterile marriages’ and decides to have a quick look at a semen sample under the microscope. And, wait for it…..he can now see ACTUAL sperm with his own eyes! Voila, the semen analysis is born. Examination of sperm count, motility and morphology is now possible. No more peeing on lettuce leaves.
Zoom forward a few years: in 1945 the Family Planning Association (FPA) opens a dedicated seminological centre — Britain’s first purpose-built laboratory for investigating semen samples.
It was established in part specifically to help women, by sparing them from ‘unnecessary operative procedures’ — when it was the husband who was ‘partly or even wholly responsible’ for the couple’s infertility.
Awesome! Finally infertility is treated as a couple’s issue!
Er, not quite.
One medical journal reports the case of a couple who were struggling to conceive, and over the course of 2 years, the woman underwent:
2 D&C operations
a tubal insufflation
an endometrial biopsy
a host of tablets, injections and vaginal douches
Only after all this invasive treatment was unsuccessful did someone suggest that perhaps her husband’s fertility should be tested.
One simple semen analysis later & the verdict is in.
Not a single sperm was found in the sample. Not one.
Neither in any of the subsequent repeat tests.
Every single procedure the woman endured was thus totally pointless — all because male factor simply wasn’t a priority.
Let’s deliberately avoid diagnosing a male factor issue so we don’t hurt the man’s feelings
Although in theory the new concept of ‘infertile marriage’ gave equal weight to women and men, in practice few English doctors paid the same amount of attention to both partners.
Some men felt so threatened by the prospect of having to take a semen test, that they attempted suicide. Therefore one doctor argued that the risks of upsetting a sensitive man by asking him to undergo a semen test far outweighed those of unwarranted surgery on his wife.
Sometimes it was even the wife who objected to the test ‘either because she is afraid of the effect the knowledge of his infertility may have on their relationship, or because she believes that male infertility cannot be treated successfully and she prefers to live in hope rather than know the truth.’
How much progress have we actually made?
Male infertility is a really, really important issue — that simply doesn’t get enough recognition
It’s now the most common reason for couples in the UK to have IVF, according to the latest HFEA data.
And we really, really should be paying more attention.
Last year, an apocalyptic study by the Hebrew University of Jerusalem found that sperm counts in the West have more than halved over the past four decades, and are continuing to decline — but we don’t really understand why, or what to do about it.
Despite so many cutting edge advances in assisted reproductive technology, the way we approach male infertility isn’t really that dissimilar to 150 years ago.
Women are routinely undergoing IVF — even if there’s nothing wrong with their own fertility — because their infertile partners are being ignored by the medical profession.
Leading fertility expert Prof Sheena Lewis — chairwoman of the British Andrology Society — says the lack of focus on male infertility within the health system is an “urgent” problem:
Men are not being looked after properly, not diagnosed, and not cared for.
The woman actually acts as the therapy for the man’s problem. We are giving an invasive procedure to a person who doesn’t need it, in order to treat another person. That doesn’t happen in any other branch of medicine.
A couple with a male factor infertility diagnosis will be referred to a fertility clinic, where they will be treated by a gynaecologist. It’s the male partner who has the medical issue — but yet they’re sent to a specialist in women’s reproductive health.
Dr Jonathan Ramsay, a consultant urologist specialising in male fertility sees many couples who’ve undergone multiple rounds of failed IVF, where the underlying pathology was never identified and treated — rendering the treatment utterly futile.
Which sounds rather like the 1945 case mentioned above, where no one had bothered to look at the man’s sperm until 2 years of harrowing treatment down the line.
What gynaecologists don’t do is look at the bloke and say, let’s do some old fashioned doctoring with you. Let’s do a few more tests. A physical examination could reveal a varicocele, for example: a varicose vein in the testicle that can overheat the sperm, yet be eliminated by a quick operation under local anaesthetic.
Or it could be that he’s obese and drinking too much. If that guy loses weight, stops drinking and just does sensible exercise, he may well get over the threshold where she gets pregnant. We need to treat the man and the sperm, ignoring half of the picture is just not sensible.
We saw above that varicoceles had been identified as a cause of male factor infertility in a medical text from 1687 — and yet in 2018 a couple may be referred for ICSI without anyone even bothering to examine the man to see if this might be a treatable issue?
How much unnecessary time, money and heartache might be saved if men were actually acknowledged as more than the sperm donor?
They deserve better. Their partners deserve better. We might have moved on from peeing on lettuce leaves in 2018, but in many ways we haven’t really moved on at all.
How you can help & have your say
Thanks so much for reading — all and any feedback is very gratefully received.
I’m currently trying to write a book that challenges the fantasy infertility narrative of endless positivity and happy endings, by sharing real women’s and men’s stories about what it’s really like to struggle with infertility and pregnancy loss. It’s a club that no-one wants to join: but knowing that you’re not alone can provide solace and support in the darkest times.
My goal is to represent as many different perspectives as possible — including the male perspective. If as a couple you’ve experienced infertility or pregnancy loss (regardless of which partner has received the infertility diagnosis, if any)— whether your journey is current or past, whether successful or not — I’d be honoured if you’d consider sharing your story anonymously. There are questionnaires for both the female and male perspective — and I’d love to hear more from the guys!