• Male infertility is as prevalent as female infertility, but there are fewer resources and information on the topic
• Stigma, denial and ego may prevent men from discussing their fertility woes and seeking help early
• Low sperm count, poor sperm movement and abnormally shaped sperm are the most common fertility problems among men in Singapore.
• Experts said men seeking fertility treatment need emotional support as well
• Two men in their 30s talked about their experiences and the stress they faced

SINGAPORE — After trying for a baby for three years and being unsuccessful, Singaporean couple Samuel Yeo and Esther Tan went for a fertility check in 2018.

The results hit them hard, especially Mr Yeo, who was told he has abnormally shaped sperm, a condition called teratozoospermia.

The 34-year-old, who works in the public sector, said: “It is not something you think would happen to you. When I first heard about my condition, I did not feel like a man — to put it bluntly… maybe it was an ego thing.

“My next thought was, ‘So can we still have children or not?’”

Ms Tan, 33, a civil servant, was found to have thin uterine lining, which makes it more difficult for a fertilised egg to be implanted.

Both conditions reduce their chances of conceiving although it is still possible for them to do so naturally.

After learning about their fertility issues, the next few years were fraught with stress as they tried to conceive.

When they finally managed to do so in 2019, a miscarriage in the first trimester of Ms Tan’s pregnancy led to heartbreak and grief.

Speaking to TODAY as part of an annual fertility wellness campaign by I Love Children this year, Mr Yeo said that he is taking “a risk by opening up” about his personal fertility struggles and challenges, but he hopes that his experience will let other men with fertility issues know they are not alone.

“It makes me vulnerable. And if you have friends who like to tease, then it can feel personal even if they may be joking. But I want to encourage other men going through similar issues not to give up,” he added.

I Love Children is a voluntary welfare organisation that educates couples on fertility wellness and advocates parenthood. Similar to past years’ campaign, the group reiterated the importance of early awareness and access to fertility health checks.

When it comes to discussions on fertility, the spotlight is often on the women.

However, fertlity problems in men are why a third of couples in Singapore have trouble conceiving.

Dr Janice Tung, a consultant with Thomson Fertility Centre, pointed out that in another third, both the man and woman have difficulties having children.

With few avenues for men to talk about infertility, experts as well as men with fertility issues told TODAY that stigma and denial may prevent men from discussing their woes and seeking help early.

Dr Ee Tat Xin, a consultant with the department of reproductive medicine at KK Women’s and Children’s Hospital, said that low sperm count, poor sperm movement and abnormally shaped sperm are the most common fertility issues among men in Singapore.

Others include problems with maintaining an erection or achieving ejaculation, Dr Tung said.

Dr Ee said that many health conditions can affect male fertility. They include advanced age, obesity, sexually transmitted infections, birth defects, autoimmune disorders and enlarged varicose veins.

Prolonged or repeated exposure of the groin area to high temperatures is another possible risk factor, he added. For example, going to saunas, wearing tight underpants or jeans, or spending a long time under the sun.

THE STRESS OF GETTING TREATMENTS

For many couples, the fertility treatment process itself can be stressful.

During a fertility check, the doctor examines the couple’s medical history and orders tests to check sperm, fallopian tubes, ovarian reserves and ovulatory function.

The main test for male fertility is a semen analysis test, and further testing may be considered depending on its results, Dr Ee said.

For a semen analysis, the man is required to produce a semen sample.

Dr Tung said that there may be pressure to repeatedly produce semen specimens on demand in “artificial settings”.

Mr Yeo’s experience of having to produce a sample in a clinic “as if I were a robot” was a major source of stress for him. He had no prior knowledge of how fertility checks for men worked.

“In the clinic, they give you a bottle, show you into a room and expect you to produce semen. Inside the room, I was shocked because there were videos of scantily clad women, just to stimulate you to produce a semen sample,” he said. 

“It was a no-no for me. I really struggled because the only intimacy I wanted is with my wife.”

Last month, the couple was scheduled to start on a fertility treatment called Intrauterine insemination, which is a type of artificial insemination.

Then, when Mr Yeo could not produce a semen specimen due to the stress and anxiety, the couple had to call it off. 

“I just could not produce a sample, no matter what I did. But Esther (my wife) was supportive and decided to call off the treatment,” he said.

“She had been taking medication, monitoring herself for the day of the treatment. She could have said, ‘What’s wrong with you’ but she didn’t and that encouraged me.”

When Mr Yeo raised the issue with the doctor, he learnt that there were other alternatives, albeit less common, methods to collect a semen sample such as the use of a specially made condom.

Dr Tung said that a medical-grade condom, which does not contain any spermicide, can be worn during sexual intercourse to collect semen but the specimen has to be taken to the lab within an hour.

Other methods include vibro-ejaculation (the use of vibrators to stimulate the penis) or electro-ejaculation (application of electrical pulses to cause ejaculation), she added.

Another alternative method includes freezing and storing sperm in advance. This is one of the alternative methods of semen collection available at KKH.

Dr Ee said that the husband could produce his sperm sample in advance to freeze it before the assisted reproductive technology procedure as a “backup” in the event of non-production on the day of the procedure.

Mr Yeo believes that if there had been more open conversations on male infertility in Singapore, he would have learnt about these alternative methods earlier and save himself the unnecessary stress.

STIGMA, SOCIAL EXPECTATIONS, EGO

A 37-year-old working in the health services sector, who had male infertility, said that resources on male infertility in Singapore are limited. This makes it challenging for men to get information on the topic.

He did not want to be identified due to concerns about the stigma surrounding male infertility. He does not want his wife, in her early 30s, to be reminded of the tensions that had surfaced earlier in their marriage due to the fertility problems.

Married since 2019, he experienced difficulties consummating his marriage due to erectile dysfunction and phimosis, a condition in which the foreskin cannot be retracted from the tip of the penis.

“While women in Singapore have ready access to online forums and parenting support groups, few avenues exist for men,” he said.

“Men may not display their vulnerable side openly due to social expectations and this makes face-to-face doctor-patient interactions unsettling.

“Even if one seeks a medical opinion, gynaecological services are usually set up with the woman in mind. Men’s fertility often comes as an afterthought among the services offered.”

Mr Yeo agreed: “I think men generally tend not to open up and talk about such issues as naturally as women.

“It’s difficult for a man to talk to another man and say things like, ‘Eh, your sperm got problem or not?’ It takes a lot of tearing down of pride to just talk about something so personal.”

Dr Tung said that men in general will need emotional and mental support when tackling fertility problems.

“They may feel guilty that their wives have to ‘suffer’ because of their problem. It is important to emphasise that there are other men like them,” she added.

Having said that, Dr Tung also pointed out that women tend to bear greater physical burden of fertility treatments, which may lead to a “disproportionate amount of blame and burden” on them.

Ms Frances Yeo, a psychologist at Thomson Medical, said that like women facing fertility issues, men may also feel frustrated, angry, depressed and inadequate.

Even when the problem does not lie with them, they may also experience stress when they see their spouse having to go through challenging fertility treatments, Ms Yeo added. 

For couples going through fertility treatments, she advised them to seek professional mental health support when they feel that the stress, anxiety and depressed feelings are taking a toll on their relationships and work.

MORE INTEREST AND AWARENESS

Although male fertility problems may not be openly discussed, there are people such as Mr Yeo who are starting to see that such health conditions cannot be resolved without professional help and attitudes are gradually changing.

Dr Tung has seen more men coming forward for fertility checks, which she attributed possibly to greater awareness on fertility issues.

Mrs Joni Ong, president of I Love Children, which runs a fertility support group, said that the number of enquiries through emails and phone calls from men asking where they can go for a semen analysis has increased in the past two years — typically during its fertility campaigns.

There is also greater interest in male fertility resources and information. For instance, a webinar on fertility wellness organised by I Love Children on Nov 12, which includes a segment on male fertility, saw more than 1,000 sign-ups for the event. 

Dr Tung said that no matter what is causing the fertility issues, couples who are trying to conceive must face the problem together.

“It requires cooperation between partners for best outcomes.”

Ms Yeo from Thomson Medical said that it is important for couples to support each other since the decision to have children is made together.

Dr Ee advised couples hoping to conceive to seek specialised medical attention if they do not conceive after a year of regular, contraceptive-free sexual intercourse.

Couples above 35 may want to consider seeking help earlier, after six months of trying.

Dr Tung said that this can be done even earlier — whether or not couples intend to start a family yet, they may consider going for a fertility health check.

This is because common conditions that may affect fertility have no symptoms and may go undetected for a long time. Some of these conditions may have better options of treatment if they are detected early, she explained.

Dr Ee said that treatment of male infertility depends on the cause. If it is due a previous vastectomy (male sterilisation), for example, it can be reversed.

“Men with poor sperm due to chronic diseases such as obesity or diabetes will often see their sperm improving after optimising their chronic conditions,” Dr Ee added.

“However, causes such as testicular failure, genetic disorders or congenital absence of vas deferens (a long muscular tube that propels sperm into the urethra during ejaculation) are not reversible. Men with these conditions will likely be recommended to look towards in-vitro fertilisation for their best chance at conception.”

The 37-year-old who had phimosis and erectile dysfunction has since overcome his sexual health issues after undergoing surgery and engaging a sexologist. He revealed that he and his wife are now expecting a baby.

He said that awareness on infertility should not just be a “women’s issue”. Having more online resources available for men with fertility issues will be a good starting point.

Mr Yeo and Ms Tan are still trying for a baby. They have changed their diet and switched to taking more wholesome, plant-based foods and less processed foods to improve their health and fertility.

On her part, Ms Tan said that she has stopped charting her ovulation cycle to reduce stress on their baby-making efforts. 

“Emotionally, it was a challenge for me to stop charting. There are only 12 chances a year to (ovulate and possibly) conceive and you would want to catch the ‘golden window’. But I know this is also causing a lot of stress,” she said.

“I think it’s important for couples to not only think about baby-making, but to really enjoy their time together.”