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Infertile ground

Every year 25,000 British men undergo fertility treatment amid rising fears of falling sperm counts. But are we right to be concerned? And are we being told the truth? Jonathan Gibbs exposes the flaws in an inexact science

Standing alone in a hospital toilet cubicle, my penis in one hand and a small plastic pot in the other, I find myself contemplating my predicament in a new light. I’m doing what hundreds of thousands of men in Britain have found themselves doing: producing a semen sample by masturbation for the purposes of sperm analysis. It’s a faintly risible position to be in. After all those years of being told it’ll make me go blind, that it’s a “waste”, that I’ll somehow “run out”, here I am, limbering up for my first, fully approved, government-funded wank. And you know what? It’s just not happening.

I’m not doing it for laughs, of course; I’m doing it because I’m worried. My wife and I have reached that stage in our lives where perfectly rational grown-ups decide to slash their sleep cycle, decimate their bank balance and do away with a social life, all in order to have children. But after more than a year of unprotected sex, nothing has happened. Nada. Zilch. No babies.
We’re one of many. A sixth of all British couples seek help in conceiving at some point in their lives. In my case, desperation led to a dour toilet cubicle. Two weeks later I’m sat opposite my GP, swiveling in his comfy chair and scanning my sperm test results. “You’re sub fertile,” he says. And just like that, I’ve become the one-in-six.

It’s shocking to hear, almost impossible to believe. After all, I’ve always had a healthy sex life. Everything works (why wouldn’t it work?) But check out the dark logic: if you were infertile, how would you know? For most of my adult life, avoiding pregnancy has been the issue. The decision to start a family is a momentous one and, like most men, it was a resolve I accepted only gradually. To make that leap, only to find out you’re not up to the job, is a brutal reversal.

Sub fertile? Infertile? What do these words mean? My results come with five sets of scores. Volume: a normal score is 2-5ml and I have an ample 2.3m1. Viscosity (the way my sperm flows): again, normal. But just producing the stuff isn’t enough. Density records the number of sperm per millilitre of semen. Anything from 40 to 100 million sperm per ml is average.

Anything below 20 million per ml you are, in medical terms, subfertile (not infertile though, that means zero chance of conceiving naturally). Subfertile means I’m likely to have problems fathering a kid. My results say a woeful 2 million sperm per ml. Moreover my sperm morphology (the percentage of healthily shaped sperm, capable of fertilisation) is just 9%. A healthy, normal score for morphology is at least 15%. Finally my sperm motility (the forward movement or `progression’ of my little tadpoles) should come in at about 50%, but only 45% of my sperm show good progression.

Fertility is a numbers game, but for me it’s there in black and white. The odds are too long.
A second test confirms the results and my GP pushes me in the direction of my local NHS fertility clinic. Only I’m not going to take this lying down. It’s time to ask some questions. I track down Professor Chris Barratt, head of reproductive medicine at the University of Birmingham, who has some revelations for me. Perhaps my results aren’t as rock solid as they first seem.
“Can you rely on a sperm count done in England? The answer’s probably not,” says Professor Barratt, who has helped produce the World Health Organization’s manual on sperm analysis. Barratt is pessimistic about results British men get back from the labs. For a start, the timing of your test can be crucial. Sperm density naturally varies, occasionally dipping a normally fertile man into the subfertile zone, and shooting him high into the charts at other times.

Other experts question the method used to count sperm. “When doing the count there are three main measurements,” explains Dr Allan Pacey, senior lecturer in andrology at the University of Sheffield. First, sperm have to be killed to perform a count, second, an assessment of how sperm are swimming needs to be done on a separate live sample; and finally, a smear of killed sperm is evaluated for size and shape. “You can never be sure if the sperm with good size and shape were actually swimming,” says Pacey.

Another reason to question my results is that different labs measure what they see in different ways. Most sperm samples aren’t actually analyzed in a specialist lab, but in the closest one to hand, which will often specialize in another medical field entirely.

It’s a problem that first came to light 10 years ago when 24 identical sperm samples were sent out to over 100 UK labs. The results were all over the place. In one case a sample assessed by one lab was said to have 240 million sperm per ml. But another lab scored it at just 3 million.

Standards have improved since but as Dr Pacey concedes, “There’s still variability in the quality of semen analysis.” Recent checks suggest only 2% of labs produced sperm concentration results outside the acceptable limit of variation. When it comes to testing the sample’s morphology — the shape tests — the standard is more worrying. Eight in every 100 labs produced morphology results outside the boundaries of acceptability.

Salvation from lab errors comes from an unexpected source: the aviation industry. To eliminate human error from the count Dr Pacey has teamed-up with aerospace engineers at the University of Glasgow on a computer-aided sperm analysis (CASA) programme. The team have discovered the same technology used to measure the flow of the smoke particles in a wind tunnel over an aero plane wing can be used to measure the movement of sperm swimming in semen.
But for the time being your sperm remains in the hands of the lab technicians, so to speak. Of course, you could ask your GP if the lab he’s sending your sample to is a UK National External
Quality Assessment Service (NEQ_AS) member ¬and if the staff are specifically trained in semen analysis.

But, chances are your
GP will have his hands tied as to which labs he can use. If you do need to give a sample, resist the temptation — which is sometimes offered to produce it at home, because the longer it’s left lying around before someone looks at it, the worse condition it’s going to get in. Grit your teeth and do it on site. If you’re lucky, you might get a special room. Otherwise it’s the toilets.
You could go private. But it’ll set you back upwards of£100 for a test and consultation, and there’s no guarantee the staff there are any better trained.

men-and-woman-fetility

You can even buy DIY kits online that allow you to play scientist at home, but these are far less precise. You just get a blunt yes/no on whether you are above or below the 20 million sperm-per-ml low-fertility threshold — and that at only an 87% accuracy rate.

For Dr Pacey a GP’s ability to interpret sperm analysis data is another weak link “For a doctor to look at a semen analysis and say ‘No chance’ is just rubbish. The poorer your sperm quality, the longer you have to try.”

For me and my misfiring sperm it seems absurd that, at a time when more and more people are rushing into the often expensive, always intrusive arms of the fertility industry, we can’t be sure the results are accurate. Of course, this quite specific and remediable problem also clouds a much larger issue: that of declining male fertility in general.

We were first alerted to the potential biological catastrophe of falling male fertility rates in 1992. Back then statistics for 15,000 men from the US and Western Europe showed a drop in sperm concentration from 113 million sperm per ml to 66 million. In a little over 50 years the amount of sperm a man can produce has almost halved. Several studies have tried to replicate the results since, some showing a similar drop, others showing no change. But if it’s hard to prove that sperm counts are actually falling, the question of what might be causing such a drop is even more convoluted. My sperm genesis (sperm production) and yours can be adversely affected in three ways: genetic damage, damage in the womb or environmental damage as an adult. Genetic damage could be a rising cause of infertility in young men since those who couldn’t father babies 30 years ago are now able to — thanks to techniques such as Intracytoplasmic Sperm Injection (ICSI), where a single sperm is injected directly into the egg. As a result these men may be passing on their genetic defects to their children, who may need to undergo fertility treatment in order to have children themselves.

Professor Richard Sharpe of Edinburgh University, an expert in human reproductive health, believes in utero damage is significant. “We now know that for sons whose mothers smoked during pregnancy, sperms counts can be up to 40% lower,” he says. Furthermore, the rise in testicular cancer over the last 100 years is being increasingly linked to damage to the male foetus in its mother’s womb. Scientists think a key cause could be chemicals, known as endocrine disruptors, which are unborn baby. These endocrine disruptors could come from pesticides getting into food or even from chemicals in cosmetics. It’s a scary scenario but, as Sharpe says, “There’s an awful lot of debate ¬none of it very conclusive.”

And then there’s stress, mobile phones and tight underwear — they all could have done my sperm in. At least that’s what the papers say.

But an example of how clouded this final factor is — and how confusing the whole debate has become — is a story linking fertility and mobile phone use in June 2004. Scientists from the University of Szeged in Hungary reported carrying your phone in your pocket could reduce sperm density by a third — as well as reducing their motility. Alarming, yes. But on closer inspection the study followed just 221 men over 13 months — which in statistical terms makes it practically useless.

So I’m subfertile — but I didn’t really know why or what to do about it. Nor does anyone else it seems. Professor Sharpe is cautious about how to deal with the growing scare over male fertility. “A lot of us think something is going on, but we don’t want to alarm people,” he says, summing up the stance of the scientific community. “Firstly, we don’t know it is the case; secondly, we don’t have a solution.”

It is the fertility industry, primarily, that benefits from alarm. Over 25,000 couples undergo treatment in the UK every year, with only a quarter fully funded by the NHS, though even here there are strings attached. Couples should have been trying to conceive naturally for three years, which, in our present culture of late-starting families, will inevitably decrease success rates.
To go private costs between £2,000 and £4,000 depending on the treatment and the clinic. Then there’s another £1,000 for the drugs. But even after all this outlay you still only have a 25% chance of success.

So, should we be panicking? Certainly, couples should be aware that the longer you leave it to have kids, the harder it’s going to be and that this — more than the effects of endocrine disrupters and mobile phones — is the decisive factor. At present, GPs won’t suggest fertility tests for an eager but unlucky couple unless they’ve been trying regularly for at least a year, or are well into their thirties.

Figures show that most will conceive naturally during a year of regular, unprotected sex (that’s 2-3 times a week). One couple in seven won’t. And half of those will conceive during a second year of regular sex.

And what about my useless sperm? Well perhaps my story is the best example of how inaccurate the whole process is. We eventually conceived twins through ICSI fertility treatment and were grateful for the happy ending. But it was an equal and opposite shock, then, to find out that we were to be parents again, quite naturally and by accident less than two years after the twins were born…