University of Dundee The Present Crisis in Male Reproductive Health

Background: There is a global crisis in male reproductive health. Evidence comes from globally declining sperm counts and increasing male reproductive system abnormalities, such as cryptorchidism, germ cell tumors, and onset of puberty. Male factor infertility occurs in ~40% of couples experiencing infertility. Data demonstrate an association between male infertility and overall health. Associated significant health conditions include diabetes mellitus, metabolic disorders, and cardiovascular disease. Adding to the complexity is that men typically do not seek health care unless there is acute medical need or, as in the case of the infertile couple, the male goes for a reproductive examination and semen analysis. However, 25% of the time a reproductive health examination does not occur. Couples are increasingly utilizing IVF at more advanced ages, and advanced paternal age is associated with increased risk for (i) adverse perinatal outcomes for both offspring and mother; (ii) early child mortality, cancer, and mental health issues. In addition to age, paternal lifestyle factors, such as obesity and smoking, impact not only the male fertility but also the offspring wellness. Objectives: The purpose of this paper was (i) to spotlight emerging and concerning data on male reproductive health, the relationship(s) between male reproductive and somatic health, and the heritable conditions father can pass to offspring, and (ii) to present a strategic roadmap with the goals of increasing (a) the awareness of men and society on the aforementioned, (b) the participation of men in healthcare seeking, and (c) advocacy to invigorate policy and funding agencies to support increased research into male reproductive biology. Conclusions: The Male Reproductive Health Initiative (MRHI) is a newly established and rapidly growing global consortium of key opinion leaders in research, medicine, funding and policy agencies, and patient support groups that are moving forward the significant task of accomplishing the goals of the strategic roadmap. INTRODUCTION Men’s health is globally in crisis and worsening due, in part, to limited healthcare policies, ebbing research funding, and underdeveloped societal awareness and education. Global health care initiatives by the World Health Organization (WHO) and the United Nations (UN) serve as meaningful and representative examples for how policy enactment can act as a catalyst for globally increased social awareness and education to support healthier lives. For example, the WHO announced (September 2018) that over USD$35 billion in financial commitments were made to the “Every Woman Every Child Global Strategy for Women’s, Children’s and Adolescent’s Health” (2016–2030) program. This substantial financial resource has supported a highly successful educational outreach program through which 377 million women, children, and adolescents were reached. The UN’s 2030 Sustainable Development Goals (SDG) program is showing steady progress toward achieving SDG 3 on health and well-being by, for example, demonstrating global improvement in nutrition, reducing mortality, and ensuring reproductive health and rights for women and children. The success of these programs helps to reinforce what can also be accomplished for men’s health. These initiatives also help to shed light on the presence of a gender gap in healthcare policies and, thus, a need for more gender-inclusive healthcare strategies (Hawkes & Buse, 2013; Rovito et al., 2017). A recent publication (Baker, 2019) provides a comprehensive report on the global state of men’s health, and © 2019 The Authors. Andrology published by John Wiley & Sons Ltd on behalf of American Society of Andrology and European Academy of Andrology. Andrology, 1–7 1 This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ISSN: 2047-2919 ANDROLOGY some factors that contribute to and that are needed to be overcome in order for men’s health to improve. The field of reproductive biology, while a component of, for example, the WHO and UN initiatives, has received less attention in policy, funding, and societal awareness and education than other areas of the health sciences, for example, cancer and cardiovascular disease. In spite of these limitations, researchers have made remarkable progress in gaining a better understanding of female reproduction, diagnosing associated disease states, and developing effective therapies. This paper will specifically focus on the critical state of men’s reproductive health and how it is intimately connected with their overall health, how men’s reproductive health can impact their female partner and future generations, and it concludes with some current initiatives and recommendations for advancement. WHY IS MEN’S HEALTH IMPORTANT? Globally, men on average have a shorter life expectancy as compared to women (69.1 vs. 73.8 years, respectively)—“males across the globe live sicker and die younger than females” (Rovito et al., 2017). Contributing factors include reluctance of men to seek healthcare advice and treatment and, in general, unhealthy lifestyle factors. These are readily correctable factors that could help to erase the live sicker die younger label. The disparity in life expectancy between male and female has tremendous impact not only on the family but also on the economy. In the United States, many hundreds of billions of dollars are spent by federal, non-federal, and employer-supported health plans to support male chronic disease (Brott et al., 2011). Effecting change in male attitude from reluctance to active and regular participation in healthcare seeking would likely result in lower morbidity and mortality and, as a consequence, a very substantial monetary savings to national and global economies. Leone et al (2017) conclude “it is in the US economy’s best interest, in addition to being the morally correct position, to invest in understanding how to augment men’s health through access, participation, and prevention, with access being the linchpin to action. ” Economics is not the only benefit to come from men more actively seeking health care. For couples experiencing infertility, the male factors into 40% of the cause of infertility yet very often he lacks a current health and lifestyle profile much less a reproductive health profile. Absence of early diagnosis and treatment for a reproductive health issue or comorbidity can result not only in greater healthcare cost but, importantly, often place the burden of infertility treatment solely upon the woman. Thus, men’s health extends beyond just the individual; men’s health is very much a women’s health issue and a baby-born health concern as well. WHAT ARE SOME FACTORS THAT INFLUENCE MALE PARTICIPATION IN HEALTH CARE? Men characteristically fall second to women in seeking health care. Male participation in health care is predominantly influenced by the presence or absence of illness or injury, social norms, and feelings of vulnerability to one’s masculinity (Mahalik et al., 2007; Mahalik & Backus Dagirmanjian, 2018). For example, in the event of illness or workplace injury, a man may adopt a “tough it out” attitude in an effort to retain and maintain one’s sense of masculinity (Mahalik & Backus Dagirmanjian, 2018). If a man feels that a physical examination might reveal known or hidden illness, he may be reluctant to go because he identifies that as a sign of weakness and contrary to his sense of masculinity. Following along the same hegemonic masculine ideals, a man may feel his masculinity threatened if there is question regarding his fertility. Social norms can play a positive role in help-seeking if, for example, a partner or family member suggests that the man has a routine physical examination and he sees other men doing the same (Mahalik et al., 2007). This scenario may exist as it relates to a couple’s pursuit of a remedy to childlessness through assisted reproduction. The female partner is often said to be the instigator and motivator for the male seeking help to investigate his fertility potential. However, while the examination serves a purpose for fertility evaluation, other pre-existing medical issues may simultaneously be diagnosed for which the man was unaware because of his “caveman” attitude regarding participation in health care. Reassuring, however, is a study by Farrimond (2011), in which middle-class professional men were interviewed for their thoughts and feelings on health, illness, and help-seeking. The results were surprising in that any anticipation of a threat to masculinity as being a deterrent to help-seeking was not revealed. In contrast, the men reflected a “take action” attitude regarding health and healthy lifestyle. Thus, perhaps there is a change emerging regarding male self-awareness that will be promotive of repealing the historic “caveman” attitude of men toward help-seeking. If there is such an evolution, then it is deserving of affirmation and support because there is a global crisis in male reproductive health that demands urgent attention. THE PRESENT GLOBAL CRISIS IN MALE REPRODUCTIVE HEALTH A portent of potentially significant male reproductive health issues is the global decline in sperm count being reported in a growing number of scientific reports (Carlsen et al., 1992; Levine et al., 2017). While the studies are retrospective, the consistency in findings between them provides strong indication that sperm counts are changing and trending negatively. These exemplar reports serve as foundation for designing prospective, longitudinal studies to investigate possible cause(s) of the historical decline and to forecast what might be anticipated for the future. In parallel with sperm count, decline is an equally unsettling and persisting upward trend in male reproductive system abnormalities, such as c