By Jonathan Ramsay
The fertility road may seem endless, winding and strewn with potholes, but perhaps its worst features is a lack of signposts. In fact, there is only one signpost and it says ‘this way to the IVF clinic’. Already the scene is set for a difficult, exhausting and often confusing journey.
The trouble is that mainstream medicine does not acknowledge that (or at least prefers to ignore) any treatment to explore fertility in both men and women is possible, or even exists. Therefore, the absence of a child inevitably leads straight to IVF and of course, the implication of this radical approach can be very damaging psychologically and even physically.
I often see the bad effects in couples waiting for IVF – even before they have started. Because this seemingly drastic intervention has been offered, both partners usually think it must be the only solution, that no treatment is possible, and that ‘doing it naturally’ just isn’t going to work.
The effect on the man is variable as he takes one of two positions depending on what he has been told about his sperm – and usually this is after only one or two tests. Either he has been told that his sperm is OK, or that it is not, and that therefore the issue is male factor or his problem. So straight away, without realising it, we, the doctors, have created a potentially bad situation because the man told that he is ‘normal’ may dissociate himself from the process, or, he may blame himself for the whole situation. This risk reinforces the couple’s belief that nothing can be done, and if the IVF doesn’t work, then certainly doing it naturally is a lost cause.
As far as men are concerned there are three almost equally unhelpful diagnoses.
The first male diagnosis for men in ‘unexplained’: This is when the sperm count is normal and the female’s investigations are normal. It is perhaps the worst position to be in. It’s bad enough not to have a child, but in many ways worse to have a label which seems to accept from a medical point of view, that we are not going to try to explain it and therefore the only solution is seemingly endless ICSI.
The second diagnosis for men is male factor: Simply put, this just means that some feature of the sperm test – numbers, motility or shape, or morphology – is not normal. Although this conclusion is often true, it equally often may be giving entirely the wrong impression to the couple.
For example, if on a semen analysis the morphology is ‘low’ at 2%, it can hardly be confidently diagnosed as the reason if the sperm numbers and motility are normal, and when only one or even two tests have been done. Even when morphology is persistently low, it may be possible to explore this. In the meantime, this man’s partner has been told that all her tests are normal, but often the real impact of her age – let’s say she’s 37 – has not been explained.
In fact, the 2% diagnosis may be of equal significance as female age. Meaning that this could actually be a problem shared, rather than being designated purely ‘male factor’ alone without all the baggage that comes with it.
The third diagnosis for men is an absence of sperm, or azoospermia: This, of course, does mean that this is male factor, and definitely so. But we manage this badly as well, because we, and I include almost all doctors in this statement, do not, unless we have first-hand experience of this, stop to think what a devastating thing this is.
Let me expand on this awful gap in our training. If ever there was bad news almost equivalent to a cancer diagnosis (and most cancers are at least treatable), then the diagnosis of no sperm rates or Azoospermia is high with the sorts of bad news that doctors commonly give. But Azoospermia is much rarer than cancer, so we are not used to talking about it. In the fertility unit, the condition has usually been diagnosed previously, and so a rather superficial view is taken along the lines of either, ‘we’ll just go with surgical retrieval’ – as if that was going to solve everything – or worse, ‘better start thinking of donor sperm’.
So for the man, whichever of these three situations exists, it’s all pretty horrible, and in my experience is thoroughly badly handled by doctors at all levels.
So enough about how bad it is.
What can we do to improve the fertility road?
First, we need to put some signposts on the fertility road
The first signpost should say, ‘men, this way for diagnosis, explanation and where possible, treatment’
The second signpost should say, ‘we are going to treat you as a couple and try, with or without IVF to help you through this’
The third signpost should say, ‘keep trying naturally, because IVF can rule your lives’
Now that we’ve got some signposts on the fertility road, we need to try to fix the potholes. This is the most difficult bit because the road is naturally rough and bumpy, and no-one really knows what it’s like until they have travelled along it.
As far as the men are concerned, the worst pothole can be the business of producing specimens to order – and we do need to be more sensitive to this. We also need to be a little less negative about sperm in general. Overall, it’s the process of IVF (and ICSI) which for too many reasons is not as successful as it perhaps should be. And to constantly blame the sperm and therefore the man, is usually unhelpful.
And what about the windiness of the fertility road – the twists, turns, roundabouts and ‘no exit’ signs? Can we straighten it out?
Well, I think we can, and I think we should. The terrible disappointments are often about our failure to properly manage expectations. In our attempts to realise that unfulfilled human yearning to have a child, we have created a very ‘first world’ problem where success overall is no better than 30% and in which we have chosen (all of us) to ignore biology and just leave it too late.
So the fertility road is not straight because we (all of us, doctors and would be parents alike) are conspiring to make hope triumph over reality. It’s a human failing, it’s hard-wired into our DNA, it’s part of the survival instinct – but it certainly makes that fertility road very twisty.
About the author
Jonathan Ramsay has developed a large practice in male fertility for over 30 years. He has been a Consultant Urologist at Hammersmith, Charing Cross and Chelsea & Westminster Hospitals since 1988 and is a visiting urologist to fertility clinics in Buckinghamshire, Sussex, and Central London.