Low semen quality and experiences of masculinity and family building

A Grounded Theory Approach to Understanding Men Confronting Infertility

Purpose: This study aims to delve into the process of men confronting infertility. Design: This research employed the Straussian grounded theory approach. Methods: The study encompassed interviews with 16 participants from a private fertility center in Isfahan, Iran, between March 2023 and March 2024. The interviews were semistructured. Data analysis was carried out concurrently using constant comparative methods and standard grounded theory techniques. the participants' main concerns were identified, culminating in developing a substantive theory centered around a core category. Findings: The primary category for men struggling with infertility was "forced concealment." This was exhibited through the suppression of emotions, maintaining secrecy about infertility, hiding treatment, and attributing infertility to their wives to counteract threats to their masculinity. Factors such as partners, family, societal surroundings, care providers, and beliefs influenced the adopting of the "forced concealment" strategy. Conclusions: The "forced concealment" theory offers insights into the experiences of men struggling with infertility. The study highlights the necessity of formulating culturally sensitive strategies that enable healthcare providers, nurses, and health system managers to effectively fulfill their roles and address the challenges and needs of couples confronting male infertility. This can be realized through a comprehensive approach that integrates nursing skills and competencies.

Reproductive late effects and testosterone replacement therapy in male childhood cancer survivors: A population-based study (the Fex-Can study)

Childhood cancer survivors are at risk of various endocrine late effects affecting their quality of life. The aim of this study was to assess the prevalence and predictors of endocrine and reproductive outcomes in young adult survivors. A secondary aim was to assess possible associations between testosterone replacement therapy (TRT) and other endocrine, cardiovascular and psychosocial late effects. This nationwide study comprised 1212 male childhood cancer survivors aged 19-40 years, identified through the National Quality Registry for Childhood Cancer in Sweden. Median age at diagnosis during 1981-2017 was 7 (range 0-17) and at study 29 (19-40) years. The study combined self-report survey data with cancer treatment data from the national registry. Hormone-induced puberty was self-reported by 3.8% of the survivors and ongoing TRT by 6.0%. In separate logistic regression analyses, these treatments were associated with hematopoietic stem cell transplantation and cranial radiotherapy. Hormone-induced puberty was additionally associated with younger age at diagnosis. Men with TRT had a higher prevalence of other endocrine deficiencies, cholesterol medication, depressive symptoms and fatigue as well as a lower probability of living with a partner, having a biological child or current occupation. In the total male cohort, 28.2% reported having a biological child. Reassuring reproductive outcomes after less intensive therapies and low frequency of TRT were observed in young adult male childhood cancer survivors treated in the most recent treatment era. However, men with TRT suffered from several other endocrine, cardiovascular and psychosocial late effects, indicating a need for long-term monitoring of this high-risk group.

The psychosocial impact of male infertility on men undergoing ICSI treatment: a qualitative study

BACKGROUND

Male infertility is in 20-70% of cases the cause of a couple's infertility. Severe forms of male infertility are best treated with Intracytoplasmic Sperm Injection (ICSI). The psychosocial impact of infertility and ICSI on men is unclear because the focus is socially, clinically, and scientifically on women. However, there is evidence that it can affect the psychological well-being of men, but these studies are mainly quantitative. Qualitative research needed to explore the experiences of infertile men in-depth is limited. Therefore, the objective of this study was to clarify the psychosocial consequences of male infertility on men undergoing ICSI to understand their experiences with reproduction problems more comprehensively.

METHODS

In this generic qualitative study, men who were undergoing or had undergone ICSI after a male factor infertility diagnosis were included. A purposive sample with maximum variation was sought in a fertility clinic of one university medical centre in the Netherlands. Data were collected through individual face-to-face semi-structured interviews. Thematic analysis was used to identify themes from the data.

RESULTS

Nineteen Dutch men were interviewed. The mean duration of the interviews was 90 min. An everyday contributing backpack was identified as the main theme, as men indicated that they always carried the psychosocial consequences of infertility and ICSI with them. Different world perspective, Turbulence of emotions, Changing relation, and Selective sharing were the psychosocial consequences that men were most affected by. Moreover, men indicated that they were Searching for contribution during ICSI because the focus was entirely on the woman.

CONCLUSION

Men with male infertility experience psychosocial problems due to infertility and ICSI treatment. Healthcare professionals need to recognize the impact of infertility on men and create room for a role for them during ICSI.

Maternal pre-pregnancy BMI and reproductive health in adult sons: a study in the Danish National Birth Cohort

STUDY QUESTION

Is maternal pre-pregnancy BMI associated with semen quality, testes volume, and reproductive hormone levels in sons?

SUMMARY ANSWER

Maternal pre-pregnancy BMI was associated with an altered reproductive hormone profile in young adult sons, characterized by higher levels of oestradiol, LH, and free androgen index (FAI) and lower levels of sex hormone-binding globulin (SHBG) in sons born of mothers with pre-pregnancy overweight and obesity.

WHAT IS KNOWN ALREADY

Evidence suggests that maternal pre-pregnancy BMI may influence reproductive health later in life. Only one pilot study has investigated the association between maternal pre-pregnancy BMI and reproductive health outcomes in sons, suggesting that a high BMI was associated with impaired reproductive function in the adult sons.

STUDY DESIGN, SIZE, DURATION

A population-based follow-up study of 1058 young men from the Fetal Programming of Semen Quality (FEPOS) cohort nested within the Danish National Birth Cohort (DNBC), 1998-2019, was carried out.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 1058 adult sons (median age 19 years, 2 months), born 1998-2000 by mothers included in the DNBC, participated in FEPOS. At a clinical examination, they provided a semen and blood sample, measured their testes volume, and had height and weight measured. Maternal pre-pregnancy BMI was obtained by self-report in early pregnancy. Semen characteristics, testes volume, and reproductive hormone levels were analysed according to maternal pre-pregnancy BMI categories and as restricted cubic splines using negative binomial and ordinary least square regression models. Mediation analyses examined potential mediation by the sons' birthweight, pubertal timing, fat mass, and BMI. Additional analyses investigated the role of paternal BMI in the potential associations between maternal BMI and reproductive health outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

We found no consistent associations between maternal pre-pregnancy BMI and semen characteristics or testes volume. Sons of mothers with higher pre-pregnancy BMI had higher oestradiol and lower SHBG levels, both in a dose-dependent manner. Sons of mothers with pre-pregnancy obesity (≥30 kg/m2) had higher LH levels and a higher FAI than sons born by mothers with normal pre-pregnancy BMI (18.5-24.9 kg/m2). The mediation analyses suggested that the effect of maternal pre-pregnancy BMI on higher levels of oestrogen, LH, and FAI was partly mediated by the sons' birthweight, in addition to adult fat mass and BMI measured at the clinical examination, whereas most of the effect on lower levels of SHBG was primarily mediated by the sons' own fat mass and BMI. Paternal BMI was not a strong confounder of the associations in this study.

LIMITATIONS, REASONS FOR CAUTION

This study was based in a population-based cohort with a low prevalence of overweight and obesity in both mothers and adult sons. Some men (10%) had blood for reproductive hormone assessment drawn in the evening. While several potential confounding factors were accounted for, this study's inherent risk of residual and unmeasured confounding precludes provision of causal estimates. Therefore, caution should be given when interpreting the causal effect of maternal BMI on sons' reproductive health.

WIDER IMPLICATIONS OF THE FINDINGS

Given the widespread occurrence of overweight and obesity among pregnant women, it is imperative to thoroughly examine the potential consequences for reproductive hormone levels in adult sons. The potential effects of maternal pre-pregnancy obesity on sons' reproductive hormone profile may potentially be partly avoided by the prevention of overweight and obesity in the sons.

STUDY FUNDING/COMPETING INTEREST(S)

The project was funded by the Lundbeck Foundation (R170-2014-855), the Capital Region of Denmark, Medical doctor Sofus Carl Emil Friis and spouse Olga Doris Friis's Grant, Axel Muusfeldt's Foundation (2016-491), AP Møller Foundation (16-37), the Health Foundation, Dagmar Marshall's Fond, Aarhus University, Independent Research Fund Denmark (9039-00128B), and the European Union (ERC, BIOSFER, 101071773). Views and opinions expressed are, however, those of the authors only and do not necessarily reflect those of the European Union or the European Research Council. Neither the European Union nor the granting authority can be held responsible. The authors declare that they have no conflict of interest.

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Understanding the Male Perspective: Evaluating Quality of Life and Psychological Distress in Serbian Men Undergoing Infertility Treatment

The experience of an infertility diagnosis and treatment imposes a profound burden on affected individuals, encompassing not only physical and medical aspects but also a plethora of psychological, social, and emotional factors. By employing a multimodal assessment featuring validated self-report questionnaires, physical measurements, and clinical records, the present study aimed to explore the quality of life and psycho-emotional distress of men undergoing infertility treatment in Serbia, thereby addressing the dearth of research on the underrepresented male perspective in this domain. Findings revealed diverse semen abnormalities among participants (n = 96, average age 37.69 ± 5.72), with significant associations between longer treatment durations and reduced sperm motility. The observed rates of men surpassing predetermined DASS-42 questionnaire thresholds for depression, anxiety, and stress in the analyzed cohort were 13.54%, 11.46%, and 22.92%, respectively. Summary scores in conceptual areas comprised in the SF-36 questionnaire ranged from 49.00 ± 6.25 for the mental health dimension to 90.16 ± 17.75 obtained in the physical functioning subscale. Patients with a longer treatment duration demonstrated lower scores in the role emotional domain, indicative of a less favorable emotional state. Expectedly, inverse correlations were found between the SF-36 mental health score and DASS-42 subscales. By addressing the existing knowledge gap and highlighting the unique needs of infertile men, the finding of this study may contribute to a more inclusive and holistic approach to infertility research and management.

Maternal age at menarche and reproductive health in young adult men: a cohort study

STUDY QUESTION

Is maternal age at menarche associated with reproductive health in sons measured by semen quality, testes volume and reproductive hormone levels?

SUMMARY ANSWER

Later maternal age at menarche was associated with impaired semen characteristics, lower testes volume and altered levels of reproductive hormones, while earlier maternal age at menarche was not strongly associated with reproductive outcomes in sons.

WHAT IS KNOWN ALREADY

Both earlier and later maternal age at menarche may be associated with altered male reproductive health outcomes. This is the first study to investigate the potential association between maternal age at menarche and semen quality, testes volume and reproductive hormone levels in sons.

STUDY DESIGN, SIZE, DURATION

In this population-based cohort study, we used data from the Fetal Programming of Semen Quality Cohort nested within the Danish National Birth Cohort. In total, 5697 sons born in 1998-2000 were invited to participate in the cohort in 2017-2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 1043 (18% of the invited) young men with information on maternal age at menarche provided a semen and blood sample, measured their testes volume, and filled in a questionnaire on health behavior and pubertal development. Maternal age at menarche was reported by the mothers during pregnancy and examined categorically (as earlier, at the same time or later than their peers), continuously and modeled as splines. We estimated relative percentage differences in the reproductive outcomes using negative binomial regression models. Further, we did a mediation analysis to investigate the potential mediating role of timing of the sons' pubertal development.

MAIN RESULTS AND THE ROLE OF CHANCE

Sons whose mothers had age at menarche later than peers had 15% lower (95% CI: -27%; 0%) sperm concentration, 14% lower (95% CI: -28%; 1%) total sperm count, 7% higher (95% CI: 0%; 14%) proportion of nonprogressive or immotile spermatozoa, 6% lower (95% CI: -11%; 0%) testes volume, 6% lower (95% CI: -12%; 1%) luteinizing hormone, 6% lower (95% CI: -12%; 1%) sex hormone-binding globulin and 5% lower (95% CI: -9%; 0%) testosterone levels compared with sons whose mothers had age at menarche at the same time as peers. Our study did not suggest that earlier maternal age at menarche was strongly associated with semen quality, testes volume or reproductive hormones in sons. However, the spline analyses indicated a potential inverted U-shaped association for sperm concentration and testes volume, and levels of sex hormone-binding globulin and testosterone. We found no strong evidence of mediation by timing of the sons' own pubertal development.

LIMITATIONS, REASONS FOR CAUTION

There was a rather low participation rate in the Fetal Programming of Semen Quality Cohort and we tried to counter it by applying selection weights. Maternal age at menarche was recalled during pregnancy, which may introduce misclassification, most likely nondifferential. Inaccuracy of the sons' recalled pubertal development years after the event may result in underestimation of the possible mediating role of pubertal timing.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings may represent a degree of shared heritability of reproductive health or be a result of an underlying epigenetic profile or unknown shared environmental, cultural or dietary exposure, causing both altered age at menarche and impaired reproductive health outcomes in sons. However, the exact mechanism for the investigated association remains unknown.

STUDY FUNDING/COMPETING INTEREST(S)

This article is part of the ReproUnion collaborative study, cofinanced by the European Union, Intereg V ÖKS (20200407). The FEPOS project was further funded by the Lundbeck Foundation (R170-2014-855), the Capital Region of Denmark, Medical doctor Sofus Carl Emil Friis and spouse Olga Doris Friis's Grant, Axel Muusfeldt's Foundation (2016-491), A.P. Møller Foundation (16-37), the Health Foundation and Dagmar Marshall's Fond. Additionally, this study received funding from Aarhus University. There are no competing interests.

TRIAL REGISTRATION NUMBER

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The future of sperm: a biovariability framework for understanding global sperm count trends

The past 50 years have seen heated debate in the reproductive sciences about global trends in human sperm count. In 2017, Levine and colleagues published the largest and most methodologically rigorous meta-regression analysis to date and reported that average total sperm concentration among men from 'Western' countries has decreased by 59.3% since 1973, with no sign of halting. These results reverberated in the scientific community and in public discussions about men and masculinity in the modern world, in part because of scientists' public-facing claims about the societal implications of the decline of male fertility. We find that existing research follows a set of implicit and explicit assumptions about how to measure and interpret sperm counts, which collectively form what we term the Sperm Count Decline hypothesis (SCD). Using the study by Levine and colleagues, we identify weaknesses and inconsistencies in the SCD, and propose an alternative framework to guide research on sperm count trends: the Sperm Count Biovariability hypothesis (SCB). SCB asserts that sperm count varies within a wide range, much of which can be considered non-pathological and species-typical. Knowledge about the relationship between individual and population sperm count and life-historical and ecological factors is critical to interpreting trends in average sperm counts and their relationships to health and fertility.

Characteristics and independent predictors of self-disclosure among male patients undergoing in vitro fertilization: A cross-sectional study

PURPOSE

To investigate the levels of self-disclosure in men undergoing in vitro fertilization and analyze the effects of communication and personality on self-disclosure.

DESIGN AND METHODS

This cross-sectional study included 210 men undergoing in vitro fertilization. Self-disclosure was measured using the Chinese Distress Disclosure Index Scale.

FINDINGS

Participants with high self-disclosure exhibited lower neuroticism, higher extraversion, better partner communication, higher educational levels, and were likely to have a child; these factors were independent predictors of self-disclosure.

PRACTICE IMPLICATIONS

These findings highlight the factors influencing self-disclosure and can aid in developing guidance programs for infertile men.

Beyond Mum and Dad: Gendered Assumptions about Parenting and the Experiences of Trans and/or Non-Binary Parents in the UK

Within UK society, there are gendered assumptions about mums and dads and what they do. Existing research has explored the experiences of parents who diverge from such assumptions, but limited research has focused on trans and/or non-binary (TNB) parents specifically. Research on non-parent TNB populations suggests that individuals with different gender identities may have different experiences. This study therefore aimed to understand the way in which gendered assumptions about parenting shape the experiences of TNB parents, paying particular attention to the distinct experiences of parents with different gender identities (i.e. trans men, trans women and non-binary parents). Reflective thematic analysis was conducted on interview data from 13 TNB parents within the UK. Three themes were identified: ‘Motherhood: essential and exclusionary’; ‘Fathers as uninvolved parents: negotiating fatherhood’ and ‘Mum, Dad and nothing in between: parenting beyond the binary’. Parents with different gender identities were impacted differently by gendered assumptions, and generally, parents negotiated with and transcended restrictive norms. Findings highlight the analytical benefit of distinguishing between parenting identity (e.g. mum/dad/parent) and parenting practice (e.g. mothering/fathering/parenting). The findings expose the limitations of such terms as participants were found to go ‘beyond mum and dad’, in both their identities and practice.

Exploring male perceptions regarding the need to engage in preconception care - a mixed-method study amongst Dutch (prospective) fathers

PURPOSE

While most preconception care (PCC) interventions are aimed at women, men are also in need of PCC to reduce risk factors affecting the spermatozoa quality. The objective of this study is to explore male perceptions regarding the need to engage in PCC.

MATERIALS AND METHODS

In a mixed-method cross-sectional study, 229 men participated with a questionnaire and 14 individual semi-structured interviews were conducted. Questionnaires data were analysed using multiple regression analyses. The interviews were analysed using thematic analyses.

RESULTS

Most men did not retrieve preconceptional information (n = 135; 59.0%) nor visited a preconceptional consult (n = 182; 79.5%). Men who categorised their preconceptional lifestyle as unhealthy (score ≤6 out of 10) less often retrieved information (adjusted OR 0.36 [95% CI 0.14-0.93]) than men with a healthy preconceptional lifestyle. While several men expressed their fear for infertility, this did not lead to an increased uptake of PCC as men felt they were healthy enough already.

CONCLUSION

Despite high awareness of the positive influence of a healthy lifestyle, the perceived need for preparing for pregnancy among men remains low. Tailoring preconceptional information towards male needs provides a window of opportunity to improve men's reproductive health and possibly the health of future generations.

Adolescent attachment to parents and peers in singletons and twins born with assisted and natural conception

STUDY QUESTION

Does adolescent attachment to parents and peers differ between singletons and twins born with ART or natural conception (NC)?

SUMMARY ANSWER

Adolescent attachment anxiety with the father was higher among NC singletons than among ART and NC twins, whereas attachment avoidance with the father was higher in ART singletons than in NC singletons and NC twins. No differences were found in attachment to the mother, best friend or romantic partner.

WHAT IS KNOWN ALREADY

Most studies have not found differences between ART and NC singletons in parent–adolescent relationships, but twin relationships may be more at risk. No previous study has examined all four groups in the same study, or specifically looked at attachment relationships.

STUDY DESIGN, SIZE, DURATION

This was an 18-year, prospective and controlled longitudinal study with families of 496 ART singletons, 101 ART twin pairs, 476 NC singletons and 22 NC twin pairs. Families were recruited during the second trimester of pregnancy; the ART group was recruited from five infertility clinics in Finland and the control group was recruited from a hospital outpatient clinic during a routine visit.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mothers and fathers gave background information for this study during pregnancy, and during the child’s first year and early school age (7–8 years). For the ART group, infertility characteristics and prenatal medical information was also obtained from the patient registry of the infertility clinics. Children (originally 50% girls) filled in electronic questionnaires related to their attachment to mother, father, best friend and romantic partner (Experiences in Close Relationships—Relationship Structures) at 17–19 years of age.

MAIN RESULTS AND THE ROLE OF CHANCE

Adolescent attachment anxiety to father was higher in NC singletons than in ART twins, P = 0.004 and marginally higher than in NC twins, P = 0.06. Adolescent attachment avoidance to father was higher in ART singletons than in NC singletons, P = 0.006 and marginally higher than in NC twins, P = 0.055.

LIMITATIONS, REASONS FOR CAUTION

The sample size was small especially in the NC twin group and there was drop-out over the 18-year time period, especially among boys and families with lower parental education level. The study only included native Finnish-speaking families. The results could differ in a more diverse population. ART singletons were younger and had fewer siblings than ART twins and NC children, and ART and NC twins had more newborn health risks than ART and NC singletons.

WIDER IMPLICATIONS OF THE FINDINGS

The study adds to a growing body of evidence that neither ART treatments nor being a twin places mother–child relationships or peer relationships at long-term risk. However, in our study, which was the first to examine both ART and twinhood simultaneously, we found that there may be more problems in father–adolescent relationships, but only in ART singletons and only related to attachment avoidance. Our findings suggest that men, as well as women, should receive enough support in pre- and peri-natal health care during and after infertility treatments.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Academy of Finland (grant number 2501308988), the Juho Vainio Foundation and the Finnish Cultural Foundation. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

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How do young men want to receive information about fertility? Young men's attitudes towards a fertility campaign targeting men in Copenhagen, Denmark

STUDY QUESTION

What are young men’s attitudes towards the Danish fertility campaign ‘How’s your sperm?’ and how do they want to receive fertility information in the future?

SUMMARY ANSWER

The young men found that the campaign had limited impact because it was not relevant to their current life situation and they believed general fertility awareness should be a mandatory part of education, while more targeted information would be helpful through web-based venues when it was more relevant to their lives (e.g. when ready to have children).

WHAT IS KNOWN ALREADY

It is estimated that 16–26% of the Danish population who want children will experience infertility at some point in their lives. In Denmark, 25% of young healthy men have decreased sperm quality, and 20% of 50-year-old men are childless. Men play an important role in the fertility decision-making of couples, thus, it is important to target men and ensure that they have sufficient fertility knowledge. However, fertility awareness is limited among men and there have been few fertility awareness initiatives targeting men. In October 2018, the Municipality of Copenhagen launched the campaign ‘How’s your sperm?’ as a tool to increase fertility knowledge among men. To identify potential barriers for the effect of fertility campaigns targeting men, evaluations of such campaigns are needed.

STUDY DESIGN, SIZE, DURATION

This study was a cross-sectional, qualitative study of six focus groups including a total of 27 currently childless young men from the Capital Region of Copenhagen, Denmark. Data collection took place between April and October 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The interviewed young men were currently childless and were all residents in the Capital Region of Copenhagen. They were between 23 and 32 years old with an average age of 26 years, and almost all were university students or had a university degree. The focus group discussions were audiotaped, anonymized and transcribed in full. Data were analyzed using qualitative content analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, the campaign had limited influence on the young men because they believed the campaign was not relevant to their current life situation. Furthermore, the young men were confused about the aim and message of the campaign, as they thought it encouraged them to have their sperm quality tested. The young men also criticized the campaign for making a link between sperm quality and masculinity. They recognized the importance of knowledge about reproductive health but they wanted access to accurate information about fertility and risk factors for infertility. According to the young men, future initiatives should prioritize clear communication of accurate, reliable and understandable fertility information in web-based venues. In addition, the young men suggested that general fertility information should be a mandatory part of the (sexual) education curriculum in primary and secondary schools.

LIMITATIONS, REASONS FOR CAUTIONS

Participants were young and highly educated; thus the findings cannot be generalized to all men of a similar age group or to men at older ages.

WIDER IMPLICATIONS OF THE FINDINGS

Different strategies that are relevant to the lifespan are needed to increase fertility awareness in the male population. The young men’s responses underscored that any fertility awareness strategy or campaign must convey respect for the individual’s autonomy. The findings highlight that how information is communicated and the quality or type of information that is disseminated are both important in acceptability by target users.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study. No conflicts were declared for all authors.

TRIAL REGISTRATION NUMBER

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Relationship between coping/attachment styles and infertility-specific distress in Iranian infertile individuals: A cross-sectional study

BACKGROUND

Infertility has been recognized as a stressful clinical condition, significantly affecting couples' emotional functioning.

OBJECTIVE

To investigate the relationship between coping/attachment styles and infertility-specific distress (ISD) in infertile participants.

MATERIALS AND METHODS

Atotal number of 240 infertile participants (120 women and 120 men) who attend the Outpatient Infertility Clinic in Sari, Iran between February and October 2017 were selected using the convenience sampling method. Data were collected using a questionnaire addressing sociodemographic variables. In addition, coping and attachment styles were evaluated via the Coping Strategies Questionnaire and the Revised Adult Attachment Scale by Collins and Read (1990); respectively. Ultimately, the Infertility Distress Scale was used to assess ISD.

RESULTS

The mean ISD score was 42.53 ± 9.63. Secure and insecure attachment styles were observed in 37.9% and 62.1% of the cases, respectively. There was a significant difference among ISD and different groups of attachment styles (p = 0.001) and emotion-focused coping style (p = 0.021). However, no significant relationship was found between problem-focused coping style and ISD (p = 0.985).

CONCLUSION

Considering the relationship between coping/attachment styles and ISD, it was recommended to implement stress prevention and coping education within the framework of coping/attachment theories for infertile individuals.

A qualitative study on couples' attitudes and concerns regarding a freeze all strategy in ART treatment

The freeze all strategy has become a promising alternative to fresh embryo transfer in fertility treatment almost eliminating late ovarian hyperstimulation syndrome (OHSS) in the segmented cycle. There is a lack of in-depth knowledge regarding patients' attitudes towards the freeze all strategy. The aim of this study was to explore the attitudes towards a freeze all strategy compared with fresh embryo transfer in assisted reproductive technology (ART) treatment among couples in a public health care setting. We conducted semi-structured qualitative interviews with ten couples already participants in a randomised controlled trial (RCT) and undergoing ART treatment. The couple's responses showed five themes: (i) Starting treatment provides needed relief; (ii) Treatment must be provided with humanity; (iii) Provision of information instigates positive attitudes towards treatment; (iv) Fresh treatment - 'The normal way'; and (v) Freeze all treatment - 'The new black'. When thorough information about treatment procedures and safety aspects regarding both the freeze all and fresh embryo transfer strategy is given prior to initiation of treatment, couples feel secure and content, regardless of which treatment strategy is finally applied. This qualitative study found that starting treatment could prompt longed-for relief, as professionals would now 'take over' and assist in meeting the couple's family building goals.

A qualitative study of factors influencing male participation in fertility research

BACKGROUND

Although fertility is a couple-based outcome, fertility studies typically include far fewer males than females. We know little about which factors facilitate or inhibit male participation in fertility research. In this study we aimed to explore factors that influence male participation in fertility research among North American couples trying to conceive.

METHODS

We conducted a qualitative research study of male participation in Pregnancy Study Online (PRESTO), a prospective preconception cohort of couples actively trying to conceive in Canada and the United States. Between January-August 2019, we carried out 14 online one-on-one in-depth interviews and one online focus group of males and females with varying levels of participation. The in-depth interviews included females who enrolled in PRESTO but declined to invite their male partners to participate (n = 4), males who enrolled in PRESTO (n = 6), and males who declined to participate in PRESTO (n = 4). The focus group included 10 males who enrolled in PRESTO. We analyzed the transcriptions using inductive content analysis.

RESULTS

Male and female participants perceived that fertility is a women's health issue and is a difficult topic for men to discuss. Men expressed fears of infertility tied to masculinity. However, men were motivated to participate in fertility research to support their partners, provide data that could help others, and to learn more about their own reproductive health.

CONCLUSIONS

Male participation in fertility studies will improve our understanding of male factors contributing to fertility and reproductive health issues. Results indicate a need for more education and health communication on male fertility to normalize male participation in fertility and reproductive health research. Men are much less likely than women to participate in research on fertility and pregnancy. However, it is important for men to participate in fertility research so that we gain a better understanding of male factors that impact fertility and pregnancy outcomes. In this qualitative study, we interviewed men and women from Canada and the United States who were trying to become pregnant to understand why men choose to participate in fertility research, why men choose not to participate in fertility research, and why women choose not to invite their male partners to participate in fertility research. We found that both men and women believe fertility is a woman's health issue. Men find it difficult to talk about pregnancy and fertility and have fears of infertility tied to masculinity. However, men are motivated to participate in fertility research to support their partners, to help others, and to learn more about their own reproductive health.

Taking fertility for granted - a qualitative exploration of fertility awareness among young, childless men in Denmark and Sweden

Most previous studies about fertility knowledge and attitudes among men have been based on quantitative methods using questionnaires with fixed-choice response options. The aims of this qualitative study were to explore childless young men's reflections on fertility and infertility through semi-structured interviews. Danish (n = 17) and Swedish (n = 12) young childless men aged between 20 and 30 years in their last year of education were interviewed. Data were analysed using qualitative content analysis. Few informants had considered their own fertility, and most were positive towards fertility treatment. The young men had inadequate knowledge about factors that can potentially impair male and female fertility. On average, the young men each mentioned three different factors they believed influence male and female fertility: (i) health behaviour; (ii) factors beyond personal control; and (iii) age. None mentioned sexual transmitted infections (STIs) but most appeared aware of the effect of increasing age on fertility. The results of this study highlight the need for educational strategies to improve young men's knowledge about fertility and the factors that influence it, particularly about the potential adverse effect of STIs on fertility.

Recurrent pregnancy loss: couples' perspectives on their need for treatment, support and follow up

STUDY QUESTION

What do couples referred to or attending a recurrent pregnancy loss (RPL) clinic believe they need in terms of treatment, support and follow up?

SUMMARY ANSWER

Men and women wish for more information, earlier access to treatment, support and follow up that is sensitive to their history of pregnancy loss (PL), includes both members of the couple, and acknowledges the psychological impact of RPL.

WHAT IS KNOWN ALREADY

Previous research has highlighted women's dissatisfaction with medical care provided post-PL and their desire for medical professionals to have increased awareness about PL and recognition of the psychological impact of PL. Less is known about the needs of the male partner, the needs of those experiencing RPL and whether the needs differ during different reproductive stages.

STUDY DESIGN, SIZE, DURATION

Over a 2-month period in 2017-2018, 13 couples who were referred to the national RPL program in Copenhagen, Denmark were qualitatively interviewed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria were heterosexual couples with at least three consecutive PLs before 12 weeks' gestation with no children or one child prior to the PLs, not currently pregnant, and willing to be interviewed in English. Couples were interviewed together in a semi-structured format. Data were analyzed using thematic analysis. Invitations (n = 30) were sent to couples recently referred to the RPL program who indicated an interest in participating and 17 couples contacted the interviewer to schedule an interview. Due to cancellations, 15 interviews were held. Data from 13 interviews that met the study criteria were used for the current analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The participants had experienced a median of three PLs (range 3-6). Both men and women described the cumulative effect of RPL with an increase in pressure and exhaustion by the third and subsequent losses. Inclusion of the male partner in consultations and treatment was seen as important. Men felt pressured to remain positive and support their partners despite their own feelings of loss. The findings showed that couples desired reliable and accurate information about RPL. They wished for recognition from the medical community that RPL has a significant psychological impact, and stressed that effective treatment should include both members of the couple, with attention to both physical and psychological aspects of the RPL and should be tailored to their current reproductive stage, in order to help them cope with the negative impact of RPL and the anxiety associated with conception and another pregnancy.

LIMITATIONS, REASONS FOR CAUTION

Participants were self-selected thus findings cannot be generalized to all couples with RPL.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study addressing the needs of the female and male partners in couples suffering from RPL. The findings highlight a disconnect between couples' perceived needs and their experience of medical care after RPL. This may be partly due to a discrepancy in couples' and medical professionals' perceptions of the PLs. The findings highlight that medical professionals need to take a holistic and couple-focused approach in their treatment of RPL and include attention to the psychological impact and cumulative effect of the multiple PLs on the couple. The results underscore the need for informational resources and psychological support for couples experiencing RPL, tailored to their reproductive stage.

STUDY FUNDING/COMPETING INTEREST(S)

EK was funded by a Travel/Training Fellowship from ReproUnion, co-financed by the European Union, Interreg V ÖKS. No other competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

Depression among men in ART treatment: a register-based national cohort study

STUDY QUESTION

Are male factor infertility or remaining childless risk factors for unipolar depression among men in assisted reproductive technology (ART) treatment?

SUMMARY ANSWER

Male factor infertility was not associated with a significantly increased risk of unipolar depression and men remaining childless did not have a significantly increased risk of developing unipolar depression compared to men in ART treatment who became fathers.

WHAT IS KNOWN ALREADY

Men in medically assisted reproduction due to male factor infertility are more distressed and have more negative emotions such as feelings of loss, stigma and low self-esteem compared to men in fertility treatment due to other infertility diagnosis. Stress is in general a risk factor for depression. However, previous studies show conflicting results whether male factor infertility is a risk factor for depression.

STUDY DESIGN, SIZE, DURATION

This national, register-based cohort study consisted of 37 913 cohabitant male partners of women in ART treatment recorded in the Danish IVF register (1994–2009). Via a national register, the men’s personal identification number data were linked to the Danish Psychiatric Central Research Register (PCRR) (1969–2009) which records psychiatric diagnoses including unipolar depression, based on the ICD-8 and ICD-10 classification system.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The full cohort of male partners (n = 37 913) was included in the initial analysis on prevalence of unipolar depression before or after ART treatment initiation. The association between male factor infertility and unipolar depression diagnosis after initiating ART treatment was analysed with Cox regression analysis in a sub-study population of men with the exclusion of men having a depression prior to ART treatment or not having full data on educational level and infertility diagnosis (n = 34 817).

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 1.2% (n = 446) of the men were diagnosed with unipolar depression either before initiating ART treatment (n = 146) or during follow-up (n = 300). In all, 76.0% of men with depression prior to or after ART treatment achieved fatherhood compared to 82.3% of men without depression (P < 0.001). In the sub-study population (n = 34 817, which included 266 men with a unipolar depression diagnosis), male factor infertility was not associated a significantly increased risk of depression (adjusted hazard ratio (aHR) = 1.04, 95% CI: 0.79–1.36, P = 0.804), and ART-treated men who remained childless did not have a significantly increased risk of developing depression compared to ART treated men who became fathers (aHR = 1.13, 95% CI: 0.87–1.48, P = 0.355).

LIMITATIONS, REASONS FOR CAUTIONS

Only severe cases of depression are recorded and included in this national register-based study given that only men with clinically diagnosed unipolar depression recorded in a psychiatric hospital (in-patient and out-patient) are included in the Danish PCRR. It is difficult to completely rule out an association between the exposures and depression as this outcome is so rare, and therefore the results are still statistically uncertain despite a large cohort. Furthermore, only men in ART treatment were included in this study, and caution should be taken in generalising findings to the total population of men in all areas of medically assisted reproduction or infertile men who have not sought treatment.

WIDER IMPLICATIONS OT THE FINDINGS

This large national cohort study suggests that despite evidence showing that male factor infertility is a potential severe stressor for men, which can increase psychological distress and negative emotions, infertile men in ART treatment and men remaining childless after ART are not at a significantly increased risk of developing clinically diagnosed unipolar depression.

STUDY FUNDING/COMPETING INTERESTS

C.S.S. was funded by unrestricted research grants received by Lone Schmidt from The Danish Health Insurance Foundation (J.nr. 2008B105) and Merck Sharp & Dohme (MSD). The sponsors had no influence on how data were retrieved and analysed or on the conclusions of the study. C.S.S. and L.S. have declared conflicts of interests; the remaining co-authors have no conflicts of interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

The social construction of male infertility: a qualitative questionnaire study of men with a male factor infertility diagnosis

Although recent research has highlighted the distressing impact of infertility for men, fertility issues are still routinely seen as a 'women's issue' - even when male factor infertility is highlighted. This article reports findings from a qualitative questionnaire study focusing on a sample of men with a male factor infertility diagnosis; an under-researched and marginalised group in the context of reproductive medicine. Our analysis suggests that male factor infertility is viewed by men as a failure of masculinity, as stigmatising and silencing, and as an isolating and traumatic experience. It is also clear that these themes are shaped by wider societal discourses which present men as (unproblematically) fertile, uninvested in parenthood and stoic in their approach to emotional distress. Such norms also ensure that reproduction continues to be presented as a 'women's issue' which burdens women and marginalises men. In understanding male factor infertility experiences, the damaging nature of the social construction of male fertility is then more clearly illuminated.

'One of the good guys': sperm donor masculinity and the falling Danish sperm count discourse

Sperm banks in Denmark produce and export donor semen worldwide. The role of the sperm bank is to provide high-quality, safe semen from desirable donors. However, over the last 20 years, global sperm counts are reported to be falling. Along with these discourses comes the implication that poor fertility is a personal failing, which implies a conflation of 'fertility' with 'potency'. This paper draws on qualitative research with Danish sperm donors to explore how donors construct their identities as donors and as the producers of 'good sperm'. Accounts of the drive to produce the best sperm possible and the resultant confidence boost are bound up in ideas about masculine potency and potential and bodily performance and set against a backdrop of a moral panic surrounding the apparently declining Danish sperm count.