Men contribute to and suffer from infertility.

KEY MESSAGES

* Infertility affects men as well as women.

* Infertile men suffer stigmatization.

* Men can protect themselves and their partners from STIs and possible infertility by practicing abstinence, being faithful to one partner, or using condoms.

"Any man who has no children is considered a dead man."

--Second-century Talmud writings

When a couple cannot have children, the woman is usually blamed. However, men can be infertile, too--a situation that causes them embarrassment and disappointment.

Infertility affects about 8 percent to 12 percent of the world's population and--in about half of the cases--men are either the single cause of, or contribute to, the couple's infertility. (1)

Various myths exist about causes of male infertility. A survey of 120 residents of an urban slum area of Bangladesh, for example, found that male infertility was often attributed to God's will or psychological problems. (2) In Nigeria, some women and men correctly suggested in a study that sexually transmitted infections (STIs) can cause infertility, but others said male infertility was the result of eating sweet foods, having a small penis, or engaging in sexual intercourse with older women. (3)

However, true causes of male infertility are abnormal sperm production or sperm function, obstruction of the genital tract, or disorders of the sex organs. (4) Many of the root causes of male infertility, such as infectious and parasitic diseases or toxins (see table, page 4), are preventable. While research on the link between STIs and male infertility is conflicting, some studies suggest that gonorrhea or chlamydial infection can spread from the urethra to the epididymis, sometimes generating infections that block the sperm ducts or cause disorders in sperm production. (5)

The use of male condoms can reduce STI risks for men and--more importantly--for their partners, thus protecting fertility. Yet, many individuals incorrectly believe that condoms--as well as other contraceptives--cause permanent infertility. In Botswana, participants in a recent study said they did not want to use family planning methods because they thought the methods damage the body's immune and reproductive systems. "Contraception, condoms, pills, they all block the bloods.... For men, if the blood is blocked, he will not be able to have a child, and then people will think that he is sick.... What woman will want you if you are known to be sick, to not be able to give any woman child?" (6)

Men, attitudes, and risky behaviors

To protect themselves against STIs--and the possible consequences of infertility--men can practice sexual abstinence. Or, they can be faithful to one partner. The African Proverbs Project, which applies traditional wisdom to modern-life circumstances, has used the Kiswahili proverb "better a curtain hanging motionless [than] a flag blowing in the wind" to caution young people about the risks of having multiple sexual partners. Finally, using male condoms offers protection.

Ironically, in trying to prove their virility and fertility, some men may behave in ways that put them at greater risk of acquiring and transmitting fertility-threatening STIs.

An FHI study of youth ages 15 to 24 years in the Kakamega, Vihiga, and Bondo districts of Kenya found that young men saw sexual activity as a sign of manhood. Many young men reported that they had sexual intercourse to gain community recognition and to test their virility. Others said intercourse was essential to preserving fertility and health. "Most men say it is not right for a man to stay for one to two months without having sex. If there are too many sperms in the body, the man becomes shapeless or too fat.... If the sperms take too long in the body ... one cannot make a woman pregnant because his sperms are expired," a young woman explained. (7)

Although study participants recognized the dangers of STIs, many said men were reluctant to use condoms to prevent infection because condoms also prevent pregnancy. "Young men usually compete over one girl. To win a girl, the man has to make her pregnant," one young man said. (8)

Studies conducted in other countries confirm that attitudes about what is natural or appropriate masculine behavior encourage men to be sexually active, often with little regard for the possible consequences of that activity. A study in Nigeria found that nearly one-third of the 1,527 young men surveyed said they wanted to have sexual intercourse to feel like "real" men. (9) In Brazil, young men said they felt pressure from their fathers and friends to be sexually active. (10) A study of approximately 800 men in Latin America found that nearly one-fourth of men surveyed in Argentina, Cuba, and Peru said that men are incapable of saying no to sexual intercourse; more than half of the men surveyed in Bolivia gave the same response. (11) Research in Thailand and Haiti found that married men were expected to have affairs with girlfriends or prostitutes, (12) while research in Grenada and St. Lucia showed that having multiple sexual relationships was considered permissible for men. (13)

Expectations that men be virile and strong also may make them reluctant to seek treatment when they notice STI symptoms, such as urethral discharge or a burning sensation during urination.

Infertile men stigmatized

Men and women who cannot bear children often face terrible consequences, including loss of status within the family and community.

For women, infertility can be particularly cruel. Women may be ostracized in their families and communities, ridiculed by friends and neighbors, or abandoned or beaten by husbands. Infertile women may not be allowed to touch babies and may be feared as witches. Some women who have no children cannot inherit property and may find themselves without financial support in old age. They may be denied a proper burial. Among the Yoruba tribe in Nigeria, infertile women are called "agon," from a word that means to hold in contempt or to despise. (14) Even when male infertility is the reason a couple cannot have children, women may still face the threat of divorce. (15) In Bangladesh, remarriage often was suggested as a remedy for infertility in the family. "Whoever stays with an infertile wife, people call him bad," one man explained. (16)

Men who are infertile also face ridicule and stigmatization--although to a lesser degree than women. In some cultures, children are an indicator of a man's wealth and prosperity; men without children do not receive the same respect as fathers. In research conducted in Zimbabwe, some men said they were denied work because they did not have children or that they were excluded from leadership roles in their communities. Other men said their inability to father children brought shame to their extended family, and some men, determined to prove their fertility, had sexual intercourse with multiple partners hoping to impregnate one. (17)

Men who learn they are infertile may perceive themselves as less masculine. A small study of 36 couples in the United States found that men felt "disabled" or "emasculated" when they learned they were infertile. Some men described themselves as "losers." (18)

Yet, in some countries, men may never learn they are infertile. A participant in an Egyptian study explained, "Usually when it's [infertility] known to be from the husband, they don't tell him anything, because it would make him feel embarrassed, and his manhood would be shaken." (19)

Men who do recognize that they may be infertile may be reluctant to seek counseling about the condition. "Men do not want their personal lives to be known, especially when it comes to infertility problems," says Betty Chishava, the director of Chipo Chedu Trust, a nongovernmental organization in Zimbabwe that provides education and counseling about infertility and its consequences. "In Zimbabwean society, a man is recognized as a man only if he has some children. Without a child, men would think that after their death, no one will inherit their property and carry their name in the future."

References

(1) Cates W, Farley TM, Rowe PJ. Worldwide patterns of infertility: is Africa different? Lancet 1985;2(8455):596-98; Program for Appropriate Technology in Health (PATH). Infertility. Overview/lessons learned. Reproductive Health Outlook 2002. Available: http://www. rho.org/html/infertility.htm.

(2) Papreen N, Sharma A, Sabin K, et al. Living with infertility: experiences among urban slum populations in Bangladesh. Reprod Health Matters 2000;8(15):33-44.

(3) Okonofua FE, Harris D, Obebiyi A, et al. The social meaning of infertility in southwest Nigeria. Health Transit Rev 1997;7(2):205-20.

(4) International Planned Parenthood Federation. IMAP Statement on Infertility. London, UK: International Planned Parenthood Federation, 1995.

(5) Berger RE. Acute epididymitis. In Holmes KK, Mardh P-A, Sparling PF, et al., eds. Sexually Transmitted Diseases. New York, NY: McGrawHill, 1990.

(6) Upton RL. Perceptions of and attitudes towards male infertility in northern Botswana: some implications for family planning and AIDS prevention policies. Afr J Reprod Health 2002;6(3):103-11.

(7) Family Health International. Dual protection study: formative research qualitative report. Unpublished paper. Family Health International, nd.

(8) Family Health International.

(9) Oladepo O, Brieger WR. Sexual attitudes and behaviors of male secondary school students in rural and urban areas of Oyo State, Nigeria. Afr J Reprod Health 2000;4(2):12-34.

(10) Simonetti C, Simonetti V, Arruda S, et al. Listening to boys: a talk with ECOS staff. In Zeidenstein S, Moore K, eds. Learning about Sexuality: A Practical Beginning. (New York, NY: Population Council and International Women's Health Coalition, 1996)324-32.

(11) Pantelides EA. Male involvement in prevention of pregnancy and HIV: results from research in four Latin American cities. Programming for Male Involvement in Reproductive Health. Meeting of WHO Regional Advisers in Reproductive Health, Washington, DC, September 5-7, 2001. Geneva, Switzerland: World Health Organization, 2002.

(12) Tangchonlatip K, Ford N. Husbands' and wives' attitudes toward husbands' use of prostitutes in Thailand. In Ford N, Chamratrithirong A, eds. UK/Thai Collaborative Research Development in Reproductive and Sexual Health: Proceedings of the Symposium on Mahidol-Exeter British Council Link. (Nakornpathom, Thailand: Mahidol University, 1993)117-34; Ulin PR, Cayemittes M, Metellus E. Haitian Women's Role in Sexual Decision-Making: The Gap between AIDS Knowledge and Behavior Change. Research Triangle Park, NC: Family Health International, 1995.

(13) Caribbean male: macho and insensitive? IPPF/WHR Forum 1991:31.

(14) Pearce TO. She will not be listened to in public: perceptions among the Yoruba of infertility and childlessness in women. Reprod Health Matters 1999;7(13):69-78.

(15) Inhorn MC. "The worms are weak": male infertility and patriarchal paradoxes in Egypt. Men Masculinities 2003;5(3):236-56.

(16) Papreen.

(17) Runganga AO, Sundby J, Aggleton P. Culture, identity, and reproductive failure in Zimbabwe. Sexualities 2001;4(3):315-32.

(18) Nachtigall RD, Becker G, Wozny M. The effects of gender-specific diagnosis on men's and women's response to infertility. Fertil Steril 1992;57(1):113-21.

(19) Inhorn.

Helping Men Understand Infertility

Reproductive health programs and clinics can play an important role in helping men understand and prevent infertility. They may be able to:

* Educate men about the prevalence and causes of infertility. They can explain that infertility can affect men as well as women, and that preventing sexually transmitted infections (STIs) may be one of the best ways of preserving fertility.

* Challenge attitudes and customs that encourage men to prove their fertility and manhood through unsafe sexual behaviors.

* Counsel men about how to protect both their own fertility and that of their sexual partners by reducing risky sexual behaviors.

* Offer STI screening, when resources are available. Providers should encourage individuals with STIs to ask their partners to seek treatment as well.

Reproductive health programs and clinics may also be able to help men and their partners cope with infertility. Some can:

* Offer infertility information and counseling to infertile couples or make referrals to organizations that offer such services.

* Encourage both men and women to seek diagnoses and treatment for the condition. Diagnostic tests for men are less complex than those for women. And these tests can uncover reasons for infertility that may be easily treatable, such as low sperm counts due to excessive heat1 or to diabetes. (2)

* If no treatment is available, counsel both men and women to help them accept their infertility.

In India, the Comprehensive Reproductive Health for All project has a goal to "leave no man out" when screening and treating couples for infertility. (3) The program, administered by the Family Planning Association of India, offers a special reproductive health clinic for men that includes condom distribution, education, and counseling, as well as infertility screenings that include STI testing, semen analyses, blood tests for testosterone levels, and a physical examination. In addition, the program encourages men to accompany their wives who seek treatment for infertility.

In Zimbabwe, the nongovernmental organization Chipo Chedu Trust promotes income-generation projects to help infertile women and men earn enough money to pay for medical treatments, in addition to offering programs to educate the community about infertility. (4)

Betty Chishava, director of Chipo Chedu Trust, says it is important to educate men about infertility so that they can protect themselves and their partners from STIs. "Men are left out of infertility programs because the blame is always pointed to women,"she says. "Reproductive health programs can encourage men to prevent STIs by organizing and conducting health education [efforts].... Both [members of the] couple must seek treatment at the same time."

Chishava suggests infertility education efforts should begin early. "Since infertility is an ongoing thing, and the rate is always increasing, there is a need to impart the knowledge to school children. The education sector should write school books on infertility so as to encourage early treatment and to [help people] accept whatever has come across their lives."

* Barbara Barnett

References

(1) Datta B. "What about us?" Bringing infertility into reproductive health care. Quality/Calidad/ Qualite 2002;13:3-29.

(2) Gunaratne M. Childlessness: The Laymans' Guide. Peradeniya, Sri Lanka: University of Peradeniya, 1987.

(3) Datta.

(4) Cohen P. Overcoming the stigma of infertility in Zimbabwe. Changemakers.net J 2001. Available: http://www.changemakers.net/journal/01june/ sango.cfm.