Stressful Life Events and Male Factor Infertility
A COMPARISON OF LIFE STRESSORS IN MEN WHO ARE EXPERIENCING INFERTILITY TO MEN WHO ARE ABOUT TO BECOME FATHERS
The study “Psychological stress, stressful life events, male factor infertility, and testicular function: a cross-sectional study” is ultimately about mental health.
It’s the first study comparing men who are just starting out treatment for male factor infertility to men whose partners are at least in their second trimester of pregnancy. The authors of the study expected that the less fertile men would report more psychological stress symptoms and that their stressful life events would be associated with reduced fertility.
BACKGROUND
This study took place in Copenhagen, Denmark from 2013 to 2016. Of the 423 men ages 20-45 who were voluntarily recruited, 274 were fertile and had a pregnant partner, whereas 149 men were seeking fertility treatment.
For the participants with male factor infertility, they could participate in the study if they had poor semen quality and intended to use a process called intracytoplasmic sperm injection (commonly known as ICSI) to inject sperm into an egg to ensure in vitro fertilization. The study included men with low sperm motility or abnormal sperm morphology, as the study authors hypothesized these men might have lower fertility due to higher stress.
Men were excluded if their fertility issues were believed to be unrelated to stress, so men with azoospermia (10-15% cause of male factor infertility), epididymitis, vasectomy, radiation or chemotherapy were excluded from this study.
All participants were given a series of tests. The first test was a reputable questionnaire asking about recent symptoms of psychological stress. The test asked about the physical, emotional, and cognitive symptoms coming from stress as well as burn-out.
The second test was another questionnaire, this one asking about stressful life events. These events included serious illness or death of a loved one, relationship issues, legal or economic woes, and job loss. Most importantly, men were allowed to write in what they considered to be a personally stressful life event so it could be counted if the category didn’t already exist.
The third test was a physical exam, where the men’s testes were palpated and their testicular volume was assessed by scrotal ultrasound. These tests were included because the study authors believed that stress from the adrenal glands would ultimately impair testicular function.
The fourth tests were blood draws for hormones, including testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH), inhibin B, and estradiol. The authors suspected that there would be differences in testosterone levels based on the reports of stress.
The fifth and final test was the semen sample, which was supposed to be taken after >48 hours of abstinence.
RESULTS
From the questionnaires about stressful life events - 50% of the less fertile men and 36% of the definitely fertile men had experienced at least one stressful life event in the past three months. That’s a LOT of men who had recently experienced something very stressful!
Also, 6% of the less fertile men vs. 1% of the fertile men reported having serious relationship problems.
These were only two areas where statistical differences were meaningful. For all other questions about burnout symptoms and stress on the questionnaires, there were no meaningful differences, which surprised the people conducting the study. They even tried breaking up the participants into smaller sub-groups based on alcohol intake, smoking, BMI, and socioeconomic status, yet the results still did not show an association between male infertility and stress.
The specific write-in answers to the questionnaire about Stressful Life Events (SLEs).
The results of the semen samples did not show that stress was associated with the quality of semen.
Regarding the hormones, they had found that testosterone and estradiol were similar in both groups, but the less fertile men had higher levels of luteinizing hormone and follicle stimulating hormone and lower levels of inhibin B. The less fertile men also had smaller testicles, higher rates of erectile dysfunction, and were less likely to be fathers or to have previously contracted a STD.
AUTHORS’ THOUGHTS
While the authors were not surprised about the hormonal results or erectile dysfunction, they had been especially surprised about the lack of difference in stress symptoms and their lack of association with fertility. They wondered if they should have measured cortisol, which is an unreliable yet long-used test for stress response.
Other than not measuring the controversial cortisol, the setup for this study was strong. They tested reproductive hormones and conducted testical exams. They asked numerous validated questions and even allowed the participants to write in their own personally stressful events. Though the results weren’t what they were expecting, they were consistent with the results found on stress and testicular function in a 2019 study involving 708 American men.
KEY TAKEAWAYS
1. We don’t yet have a strong grasp on how stress impacts male fertility.
The study expected to see that stress was associated with lower semen quality and testicular function, but this wasn’t the case. They also thought there would be differences in stress symptoms between men of higher and lower fertility, but this wasn’t seen either.
On the plus side, the finding that psychological stress is not associated with testicular function should be encouraging to both men and their partners who are trying to work through male factor infertility. Given that we are now living in a world that’s been turned upside down by coronavirus, it is a comfort to know that the new emotional and mental stress caused by the pandemic is probably not contributing to male factor infertility.
2. Men experiencing male factor infertility likely need additional emotional support while trying to conceive. Half of the men in this study experienced stressful life events in the three months before seeking fertility treatment. Looking at what these men wrote in as stressful events, they were stressed out the most by work or school deadlines, infertility itself, and the serious illness/death of a loved one (maybe this illness = partner’s own fertility issues?). These burdens may be difficult to work through alone or just with a spouse. Support options include:
Seeking couples or individual counseling
Seeking out a fertility support group
Online support
Reddit - “A Place for Infertile Males”
Facebook- “Mens Fertility Support- IVF/IUI/ICSI”
RESOURCES
Bräuner EV, et al. Psychological stress, stressful life events, male factor infertility, and testicular function: a cross-sectional study. Fertil Steril, 113 (2020), pp. 865-875. https://www.fertstert.org/article/S0015-0282(19)32615-9/fulltext
Coward RM. Stress does not appear to negatively affect testicular function in infertile men. Fertil Steril, 113 (2020), pp. 771. https://doi.org/10.1016/j.fertnstert.2020.01.011
Coward RM, Stetter C, Kunselman A, Trussell JC, Lindgren MC, Alvero RR, et al. Fertility related quality of life, gonadal function and erectile dysfunction in male partners of couples with unexplained infertility. J Urol 2019;202: 379–84.
ICSI, https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/what-is-intracytoplasmic-sperm-injection-icsi/
Questionnaire, http://www.mentalhealthpromotion.net/resources/english_copsoq_2_ed_2003-pdf.pdf
