Introduction: The Silent Epidemic
Say "biological clock," and most people think "women." Most people know that a woman's ovaries stop producing eggs at some point and that natural fertility ends with menopause. But conventional wisdom holds that men can father children as easily at seventy-five as at twenty-five. Stories of people such as Saul Bellow, who became a father at age eighty-five, and Tony Randall, a father at seventy-two, help sustain a widespread myth: women have a gun to their heads that men never have to face.
Unfortunately, the conventional wisdom is wrong. Men have biological clocks too. This fundamental fact about life has been very slow to reach the public for many reasons, not least because an entire industry has arisen in the past decade for "fixing" female infertility with high-tech procedures such as in vitro fertilization (IVF). By and large, treating female infertility is much more financially lucrative than treating male infertility. The focus (by both women and their doctors) on the female side of infertility, and the urgency with which many couples come to the fertility industry, combine to shove male infertility to the sidelines and to launch couples into IVF prematurely. Sadly, millions of dollars are spent each year on IVF and other sophisticated procedures that could have been avoided if the male side of infertility had been properly diagnosed and treated. Most people -- and even many doctors -- don't know the startling facts about aging, male sexuality, and male infertility, in part because the studies that reveal these facts are so new.
The male biological clock isn't like a woman's. It "ticks" at a different rate, it causes an entirely different set of bodily and behavioral changes over the course of a lifetime, and it doesn't strike a "midnight" toll of an absolute end to fertility. But male fertility, testosterone levels, and sexuality all definitely decline with age. Men older than thirty-five are twice as likely to be infertile as men twenty-five or younger. In addition, as men age, the genetic quality of their sperm declines significantly. Every couple should know these facts because they affect two of the most important things in their life: their ability to have children and their capacity to have good sex.
The reality of the male biological clock and the ways the ticking of this clock can result in numerous problems with fertility or sexuality are facts that have not yet reached the men and women on the street. On the contrary: myths about male infertility and sexuality abound. Here are the myths I come across most often.
1. Infertility is rare and is mostly a women's problem.
Wrong. Each year about 6 million American men and women realize they have a fertility problem. In about 40 percent of these couples the problem lies with the man. In another 40 percent, it's the woman with the problem, and in another 20 percent either both partners contribute or the cause is unknown. Roughly 10 percent of men trying to father a child -- roughly 2.5 million men in the United States alone -- are either infertile or subfertile. Many of these men don't know they have a problem because they haven't been tested; others have been tested but not thoroughly enough. Hence their problem remains undetected and medical attention shifts to the female.
2. Although older women are at higher risk of having children with Down syndrome, the man's age doesn't matter.
Wrong. Down syndrome is a pattern of mental retardation and altered physical features caused by an extra chromosome 21. It has long been known that a woman's chance of having a baby with Down syndrome rises dramatically after age thirty-five, but it had been thought that the man's age had nothing to do with it. Now we know that this is false -- men also have a higher likelihood of fathering a Down syndrome baby as they get older. The incidence of genetic problems in their sperm increases with age, which leads to many problems, including Down syndrome. In fact, a recent study found that half the cases of Down syndrome in children born to women older than thirty-five are likely to be sperm-related.
3. Men with no sperm in their semen are sterile.
Wrong. In the past, this statement was true, but today numerous methods exist for extracting sperm from the testicles or other parts of the male reproductive tract and using the harvested sperm to fertilize a woman's eggs, using advanced reproductive technologies.
4. A vasectomy is final; it cannot be reversed.
Wrong. In fact, every year roughly 5,000 men with vasectomies change their minds, and today, with the advent of microsurgical techniques, the success rate for vasectomy reversal in the hands of a competent surgeon is 85 to 97 percent.
5. We conceived our first baby without any problem; the next baby will also be easy.
Not necessarily. A prior conception is no guarantee that future conceptions will be possible. In both men and women, many factors can intervene to compromise fertility after a successful pregnancy and delivery. For example, a man may develop reproductive tract infections that reduce his sperm quality or ejaculatory function, or the process of labor and delivery may subtly alter the anatomy of a woman's reproductive tract in ways that make a future pregnancy less likely.
6. If we haven't conceived after one year of trying, we will never get pregnant without IVF.
Wrong. A couple's inability to conceive is often related to relatively simple or easily corrected problems on the part of either the man or the woman. Couples often wrongly assume that their only option for having children after trying for a year is IVF, when in fact a host of other possible treatments is available, such as clearing up an infection, unclogging the man's ejaculatory ducts, or repairing distended blood vessels in a man's testicles that harm sperm quality. Most of these options are less expensive than IVF. Indeed, in many cases, when these options are pursued first, IVF is more likely to work.
7. Most couples using IVF end up with a baby.
Wrong. The unfortunate truth is that the majority of couples undergoing IVF will not have a baby. The chance of successful conception and delivery of a baby in a single round of IVF is about 27 percent. The chances of having a baby after two cycles of IVF are about 47 percent -- and most couples try for only two cycles because of the expense and emotional strain of the process. The chance of having a baby with IVF after three cycles is about 61 percent, and only after four cycles does it reach about 72 percent.
8. A man can't do anything to increase his sperm count.
Wrong. Both the number of sperm (sperm count) and the quality of that sperm (its shape and function) can be improved. Many men have undiagnosed problems with their testicles or reproductive tract that impair their fertility. Fortunately, such problems are often easily treated, and sperm numbers and quality increase as a result. In addition, moderate exercise, a healthful diet, and avoidance of substances such as cigarettes that are known to erode sperm quality can also improve fertility.
9. The size of a man's testicles has nothing to do with his fertility, testosterone, and sex drive.
Wrong. Although the size of a man's penis has little to do with either sexuality or fertility, the size of his testicles does. Testicles are composed of sperm-making and testosterone-producing cells, and generally speaking the larger the testicles, the more sperm and testosterone are produced, which increases sex drive and the chances that a man can get a woman pregnant. Normal testicles are at least the size of walnuts and have the firmness of a ripe plum. Small testicles are the size of cherries or smaller.
10.Using donor sperm to get pregnant is rare and is certainly used less often than IVF.
Wrong. Roughly 40,000 babies in the United States (slightly more than 1 percent of all births) are born each year to couples who have used in vitro fertilization techniques of one kind or another. But many more -- I estimate about two and a half times as many babies, or about 100,000 -- are born to women who have conceived using donor sperm, meaning sperm from a sperm bank.
11. IVF does not increase the chance of birth defects.
Wrong. The rate of birth defects in babies born via IVF can be more than two times that of babies conceived naturally.
12. A low sperm count is not related to a medical condition.
Wrong. Testicular cancer, varicoceles, undescended testicles, infection, and chronic illnesses such as diabetes are all associated with low sperm counts.
The unfortunate reality is that infertility is almost always viewed as a "woman's problem" by both the public and many doctors. For academic and business reasons, the entire field of fertility treatment is locked into a mind-set that ignores or marginalizes the male role. A man's fertility is often checked only by a simple semen analysis. If a man seems to have enough sperm and those sperm seem healthy, he is presumed fertile. This kind of cursory "exam" fails to detect a host of problems that could contribute to a fertility problem -- most of which can be fixed relatively easily and inexpensively.
The lack of attention to male infertility, the lopsided media and advertising attention paid to female infertility, widespread ignorance about the medical realities of infertility, and the profit motive at work in the infertility industry have combined to create a silent epidemic of infertility. It's probably true that the male ego is involved here too. The possibility of being infertile is deeply threatening to any man's self-esteem and sense of masculinity. This can lead to denial that a problem could exist, defensiveness if the subject is brought up, and a general reluctance to take steps to properly diagnose a potential problem. All these forces have conspired to create an epidemic of male infertility that is going largely unnoticed. Most couples never realize the true dimension of their problem and the often simple steps they could take to remedy the male side of the equation.
The male biological clock affects more than fertility, of course; it affects sexual performance, overall physical health, mental function, and intimate relationships. This book focuses on fertility and sexuality because these are my particular areas of expertise. As the director of male infertility at Columbia University and a board-certified urologist with a large private practice, I have successfully treated many thousands of men with fertility and sexuality problems. I am also a leading researcher on these topics and have participated in dozens of research studies on male infertility over the years. I am privileged to be on the cutting edge of new developments. Over the decades that I have been in this line of work, I have seen firsthand that the male biological clock can be slowed down or even reversed and that problems with sexuality or fertility that arise at any point in a man's life can usually be fixed. This book is about understanding how the clock works, how it can sometimes go awry, and how it can be fixed so a man and his partner can have children or return to an active, satisfying sex life.
A Growing Problem
Men and women are waiting longer to have children and thus have a greater chance of having fertility problems. According to the Centers for Disease Control and Prevention, the number of births to parents older than thirty-five years more than doubled from 1970 to 1999. As the chart below illustrates, over the thirty years, the percentage of live births to women between the ages of thirty and thirty-four doubled, from
12 percent in 1970 to 24 percent in 1999, the last year for which data were available as of this writing. The percentage of live births to women older than thirty-five more than doubled, from 6 percent to 13 percent.
Men are waiting longer to have children too. As the chart below illustrates, the percentage of live births to fathers ages thirty to thirty-four rose from 19 percent to 26 percent from 1970 to 1999. The percentage of births to fathers older than thirty-five rose from 14 percent to 21 percent in the same period.
This trend, coupled with the reality of the male biological clock, have led to the rise in the rates of infertility in the past decade. Each year about 6 million American men and women realize they have a fertility problem. Sadly, most of these couples assume, first, that the problem must be with the woman and, second, that their only option is assisted reproductive technology such as in vitro fertilization. Now, don't get me wrong: I'm not against IVF and other assisted reproductive technologies -- they are terrific for the right couple at the right time. I help couples through the IVF process all the time, and I've seen many beautiful children come into the world this way. It's just that I've also seen too many couples jump into IVF before they need to, before they've understood all their options, and before the male side of the equation has been thoroughly explored for possible problems.
What Is the Male Biological Clock?
Men don't face the absolute end of fertility that women face with menopause. When the female biological clock strikes midnight, a woman's estrogen levels drop precipitously and her ovaries shut down for good. The male biological clock ticks slower and more steadily, and its effects are less obvious. The male equivalent of menopause is "andropause," the steady drop in the levels of androgens (male sex hormones) accompanied by related declines in sperm count, sperm health, sexual desire, and sexual performance. Testosterone is the best-known male hormone, but several others play important roles as well. Changes in male hormones are just as important as changes in female hormones, but currently little attention is given to these changes. The term "andropause" is a somewhat unfortunate one because a man's fertility doesn't, in fact, "pause" the way a woman's does. But "andropause" is better than "hypogonadism in the adult male," which is the technically accurate but fairly clumsy term for what we're talking about. Since "andropause" is commonly accepted and understood by urologists, that's the term I'll use in this book.
How fast and how well a man ages -- how fast or slow his "clock" ticks -- is governed by his genes, his environment, and how well he takes care of himself. Exactly how the male biological clock works -- why some men's clocks run faster than others, for example, or how a man's body "knows" when it's time to move from, say, boyhood to adolescence -- is still not entirely clear, but recent research has pinpointed a likely mechanism. The "ticking" of the biological clock of both sexes appears to be linked to cell division. Each time most cells divide, certain caplike sections on the chromosomes inside the cell get a bit shorter. These caps are called telomeres, and they're the subject of intense research around the world, not just because they seem to be involved in the timing of various life stages (such as puberty) but because they may hold the key to aging itself. Certain key cells in the brain are particularly important "timekeepers," and when the telomeres in these cells are whittled down to a certain length, they acquire the ability to turn one's genetic machinery on or off, triggering, for example, the hormonal cascades of adolescence or the shutdown of a woman's ovaries.
Regardless of the actual details, however, neither your genes nor the clock itself fully determines your destiny. How a man's reproductive tract and sex organs age has everything to do with his overall health: what he eats, how much he exercises, what illnesses and accidents he has sustained in life, whether he smokes or abuses drugs, what chemicals he is exposed to at work or home, and a host of other external factors. The same factors affect female fertility as well, but women usually get years of warning bells about declining fertility, such as irregular periods and hot flashes. (These years are called "perimenopause" and are the lead-in to menopause, which is defined as a year without a menstrual period.)
Problems with sex or fertility are surprisingly common among men and arise from both normal and abnormal functioning of the biological clock. Between 20 and 30 million men have some degree of erectile dysfunction, for example, and despite the huge success of erection-enhancing drugs such as Viagra, Levitra, and Cialis, millions of men continue to suffer. The sex lives of millions of other men are eroded by problems such as premature ejaculation, lack of sexual desire, or the inability to have an orgasm.
This book will help men and their partners understand such problems, determine their source, and lay out a clear path to rewind the biological clock or fix the problems caused by it. Sometimes the steps will be simple and straightforward, such as using an erection-enhancing pill or clearing up an unrecognized infection with antibiotics. Other times more invasive measures must be taken, such as surgery to correct problems in the testicles that affect sperm formation. And sometimes the latest high-tech reproductive technology must be used to overcome obstacles of one kind or another. Regardless of the strategy required, couples should know that most problems with sexuality or fertility can be surmounted.
Viewing male sexual health as the workings of a male biological clock is a new and helpful way of approaching these problems. First, it reminds couples that difficulties with sexuality or fertility are as likely to arise on the male side as the female side of the equation. Acknowledging the reality of the male biological clock creates a level playing field at the outset. No longer is the man merely a bystander, cooling his heels in the waiting room and assuming that his anatomy and physiology are perfect while his partner is poked and prodded to uncover a problem assumed to be hers. And even if a problem is found on the woman's side, simply recognizing that it could as easily have been with the man makes it more likely a couple will feel united in their effort to conceive a child.
The facts of the male biological clock also destroy the myth that men of all ages have an equal chance of fathering children. That's simply not true. Recent studies have clearly demonstrated that as men age, the amount and quality of their sperm decline. The declining quality of sperm translates into a lower chance that any particular act of unprotected sex will lead to pregnancy -- and that means a longer average time required to get a woman pregnant.
Thinking of male sexual health in terms of a clock also helps clarify the notion that problems can occur at every stage of life and some problems get progressively worse with time. Infertility or sexual performance problems typically do not happen overnight. They are the end results of circumstances that might have begun at the moment of conception, in childhood or adolescence, or sometimes in adulthood. Time, in other words, is a vital part of an accurate view of both the problem and the solution. Problems take time to occur -- and they take time to correct. If you are trying to slow or reverse the male biological clock, you have to work with the clock; you can't pretend it doesn't exist.
Finally, it's helpful to use a mechanical metaphor for problems of male sexual performance and fertility. Although I realize it's a generalization, I think it's fair to say that most men can relate to machines. Machines can have design flaws that make them likely to break down. Machines also need maintenance if they are to perform well. Both notions apply to male sexuality and fertility problems. And even if a problem is related to choices a man has made about diet, exercise, or drug use, by the time a problem with sexuality or fertility is diagnosed, it's a medical issue -- a mechanical breakdown of one sort or another, whether it's as simple as an infection or as subtle as a genetic alteration that is crippling testosterone and sperm production. It is never a matter of "manliness" or "machismo."
Every man I've ever known who has learned he has a fertility problem has felt bad -- deflated, angry, depressed, or some combination of all of these emotions. That's perfectly normal, given the biological forces driving men to sex and reproduction and the cultural messages supporting those instincts, which are constantly reinforced in the media. But as more men and their partners recognize that they are dealing with a mechanical problem, they'll be able to resist their own (and sometimes others') insinuations that they are somehow to blame for the situation or that they're less of a "man." It's as ludicrous to blame oneself for a low sperm count or hormonal abnormality as it is to blame oneself for having impacted wisdom teeth or being color-blind.
Of course I don't mean to imply that men themselves are machines, just their sexual and reproductive systems. And I'm certainly not saying that sexual performance or fertility problems have no emotional or psychological dimensions. They almost always do -- and the emotional knots that can arise from a mechanical breakdown can sometimes be tougher to solve than the breakdown itself! As will be seen throughout this book, I firmly believe in looking at the entire man when dealing with any particular problem. Mind and body cannot be separated. Yes, the specific issue may be a blockage in a man's testicles, but that tiny blockage may be wrecking the emotional and physical intimacy of a previously solid marriage. On the other hand, mental or psychological problems, such as depression or anxiety, can lead to behavior changes (such as exercising less or abusing drugs) that directly erode both sexuality and fertility. Even though in this book we must necessarily concentrate on the mechanical aspects of fertility and sexual performance, and even though I believe the biological clock metaphor is helpful, I don't ever forget that the machinery is inextricably connected to the man as a whole.
Problems with sexual performance or fertility (or both) don't affect just men -- they affect their partners as well. Even though the man may have a medical issue that interferes with sex or fertility, his partner is always affected.* Hence this book is aimed at women as much as men. It's women who most often persuade men to seek treatment for infertility or sexual problems. In fact, women persuade men to seek help for practically every physical and mental illness. Women also need to know the facts about male sexual health to be good partners, just as men need to learn the basics of female sexual health. Women may be more objective than their mates in judging the degree to which lifestyle or physical issues can be increasing a man's risk of infertility or sexual performance problems.
I hope that both men and women will find the information and personal stories in this book helpful or perhaps even inspiring. In my daily practice I see much needless suffering caused by a lack of understanding, inaccurate information presented in the media, and misleading claims by fertility clinics. We are in an epidemic of unrecognized male infertility and performance problems, but I, for one, am not going to remain silent about it.
Copyright © 2005 by Harry Fisch