The Case for Including Male Fertility in the UK Male Health Strategy

Lalana Songra, Jonathan Ramsay

This follows on from the previous Fertility Action charity blog.

Jonathan Ramsay  MS FRCS FRCS(Urol).  A Urologist in full-time clinical practice specialising in male fertility.  Formerly, an NHS Consultant at Imperial College in London, and now a visiting Honorary Professor in Life and Biomedical Sciences, at the University of Ulster.

Lalana Songra is a young doctor who has recently completed core surgical training with a urology focus and a Masters in Public Health at London School of Hygiene and Tropical Medicine.

Our submission is based on our shared experiences.  Lalana, with a background in public health, can take a view of the compelling data about a steady decrease in male fertility and the impact of this on male health-span and life-span.

Jonathan has managed more than 10,000 infertile and sub-fertile men in the past 20-years, both in the NHS at Hammersmith Hospital, and in the private practice.  It is worth pointing out that 10,000 sub-fertile men means 20,000 unhappy and disadvantaged people, and many more if we consider their extended families.

Introduction from Jonathan Ramsay

So, what is the size of the problem in the UK? In 2023, over 50,000 couples had an IVF treatment. If half of these treatments were due to male factors, that is 25,000 men every year, but this does not include those yet to be diagnosed, and those who may have ‘given-up’, often with a broken relationship, and those who either do not ‘qualify’ for IVF, or who cannot afford it. I see the clinical and psychological consequences of men who blame themselves for infertility every day. These consequences are often hidden, when underlying health and lifestyle issues have not been addressed, because they have often been told that there is no ‘diagnosis’ and that ‘nothing can be done’ except to have more IVF, or use donor sperm. So, for them it is like having an incurable disease.

The first step towards a solution is simply to treat them as ‘patients’ rather than, as we generally do now, as less than adequate ‘sperm vehicles’.

This submission is to encourage the inclusion of male fertility as a condition worth of diagnosis, investigation, and treatment, and this approach should start in Primary Care. ‘Fertility Units’ delivering IVF cycles are not equipped to manage men – their co-morbidities remain undetected, and the opportunity for the diagnosis of preventable conditions and therefore the potential economic benefit to the Health Service is lost.

You should read this submission if you are interested in:

  1. The physical and mental health of this generation, and the next, and the relationship of these big questions to couples’ fertility, particularly men.
  2. The increasing costs of healthcare which can be offset by preventative measures for men who are infertile.
  3. The reduction in UK fecundity (failing birth rates) and the economic and political effects of this dramatic change.

Executive Summary:

As the UK develops its first ever Men’s Health Strategy, there is an opportunity to define what matters in men’s health. Male fertility is not a niche concern – it is a powerful lens through which we can address some of the most pressing public health challenges we face: chronic disease prevention, early engagement with health services, and the long-term wellbeing of future generations.

Fertility is one of the few health concerns that young men actively care about1, and it offers a rare motivational hook for lifestyle change. Fertility is also an overall marker for male health, predictive of future risk for conditions such as cardiovascular disease, diabetes and cancer. Moreover, growing evidence now links sperm quality and advancing paternal age with increased risks of miscarriage, childhood cancers, autism and psychiatric illness – issues that not only affect families deeply but are already placing substantial pressure on the NHS and public finances.

By incorporating male fertility into the UK Male Health Strategy from the outset, a modern, preventative, evidence-based approach can be created that promotes healthier outcomes across our wider society.

  1. Male fertility as a powerful opportunity for behaviour change

One of the greatest challenges in public health is achieving sustained behaviour change in men. Men have a lower life expectancy than women. They are twice as likely to die prematurely from preventable diseases such as cardiovascular disease, lung cancer and liver disease2. While there is widespread knowledge that factors like smoking, obesity, and alcohol excess contribute to long-term conditions such as cardiovascular disease and cancer, these often feel abstract or distant, particularly for men in their 20s and 30s. Fertility, by contrast, is an immediate and emotionally compelling concern.

There is extensive research that shows that lifestyle factors impact male fertility in real time – cigarette smoking, high BMI and increased alcohol intake, amongst others, all are associated with poorer semen quality3.  A man trying to conceive today therefore may be directly affected by poor health behaviours, and this reality offers a unique and timely motivation for lifestyle change. If positioned strategically, male fertility could act as a gateway issue, prompting men to engage with healthcare services and adopt healthier behaviours with immediate personal relevance, while also benefiting their long-term health outcomes. 

  1. Reframing male fertility as a public health issue

Currently, male fertility is siloed within reproductive medicine, with little connection to public health strategy. Even within reproductive medicine, once diagnosed male infertility is rarely treated – rather, the problem is bypassed using ART procedures such as IVF / ICSI / Surgical Sperm Retrieval. This is a missed opportunity. Male infertility is often a biomarker of overall health, not a standalone issue. It correlates with increased rates of diabetes, cardiovascular disease, cancer and early mortality4,5. By integrating male fertility into the Male Health Strategy, we not only improve outcomes for families facing fertility challenges but also engage men earlier in preventive health interventions and enable earlier detection of at-risk men. Keeping working age men healthier, for longer, has obvious implications for society, in reduced NHS and social care costs and reduced working days lost to ill health.

  1. Outdated perceptions of fertility overlook the male contribution

Research showing the gender gap in GP consultations regarding reproductive health (239,594 female consultations vs 829 male consultations) highlights the current framing of reproductive health as a female issue6. This historical view that fertility is primarily a “woman’s issue” is no longer tenable. Male factor infertility is implicated in up to 50% of cases of infertility7, and the male role in successful live birth outcomes extends far beyond just fertilisation. 

Advances in male fertility testing remain overlooked despite compelling evidence to show that the standard semen analysis test is insufficient in accurately discriminating between fertile and infertile men, and yet this test remains the mainstay of male fertility diagnosis8. Developments in male fertility testing have largely focused on the DNA quality of the sperm, through studying markers such as Sperm DNA Fragmentation (SDF), or the causes of SDF damage such as the semen microbiome or oxidative stress. Sperm with high levels of SDF damage has been shown to affect not only the likelihood of conception, but also implantation success, embryo development, miscarriage risk, and long-term offspring health8.

Moreover, high levels of sperm DNA fragmentation damage are strongly associated with recurrent miscarriage9, a devastating condition affecting 1 in 100 couples that remains unexplained in 50% of cases10. Beyond the significant psychological and physical consequences of recurrent miscarriage, it also has been estimated to generate an economic cost of £471 million based on the short-term consequences alone11. By failing to evaluate the male factor beyond the standard semen analysis test, a significant proportion of recurrent miscarriages go without diagnosis or appropriate intervention. Currently only those patients with the means to pay for private fertility treatment can benefit from these advanced male fertility tests and, aside from the obvious benefits to the patients and to society generally, arguably it is the NHS which stands to gain the most from improved ART success rates and reduced miscarriage rates via better use of their resources (finance, personnel, time, …) and the resulting improved outcomes for patients.

  1. Sperm quality is a predictor of child health and long-term outcomes

There is increasing evidence that advanced paternal age is linked to adverse outcomes in offspring8,12-14, including higher risks of:

  • Neurodevelopmental conditions, such as autism spectrum disorders
  • Childhood cancers
  • Psychological and psychiatric conditions, such as schizophrenia
  • Increased hospitalisation rates in early childhood

These associations are particularly pronounced with increasing paternal age, which is associated with higher levels of sperm DNA fragmentation15. While men can technically father children at any age, the risks to the health of their offspring rise significantly with age and poorer sperm DNA quality. Public messaging has lagged behind the science; a balanced and informed campaign is needed to raise awareness of paternal age and fertility-related health risks. This is no longer just a clinical concern, it’s a growing societal issue. The Office for Budget Responsibility has said the rising cost of supporting children with high special educational needs is putting pressure on the finances of councils and other services, with the current cost estimated at £12 billion a year16.

  1. Conclusion

Advancing male fertility awareness, diagnostics, and counselling represents a vital opportunity to drive meaningful, large-scale change in reproductive health. Normalising conversations around male fertility, promoting evidence-based lifestyle improvements, and increasing understanding of the male role in fertility outcomes are long overdue. Prioritising male fertility not only supports better health and fertility outcomes for the men themselves but also contributes to the long-term wellbeing of their children. Crucially, it helps to rebalance the emotional and psychological burden of infertility – which too often currently falls solely on women – and creates a more inclusive, equitable approach to fertility care that recognises and addresses the needs of male and female patients equally.

 

References:

  1. Karin Hammarberg, Veronica Collins, Carol Holden, Kate Young, Robert McLachlan, Men’s knowledge, attitudes and behaviours relating to fertility, Human Reproduction Update, Volume 23, Issue 4, July-August 2017, Pages 458–480, https://doi.org/10.1093/humupd/dmx005
  2. The King’s Fund. Inequalities in men’s health: why are they not being addressed? Deborah Fenney and Veena Raleigh. 12 June 2024.
  3. Rotimi DE, Singh SK. Implications of lifestyle factors on male reproductive health. JBRA Assist Reprod. 2024;28(2):320-330. Published 2024 Jun 1. doi:10.5935/1518-0557.20240007
  4. L Priskorn, R Lindahl-Jacobsen, T K Jensen, S A Holmboe, L S Hansen, M Kriegbaum, B S Lind, V Siersma, C L Andersen, N Jørgensen, Semen quality and lifespan: a study of 78 284 men followed for up to 50 years, Human Reproduction, Volume 40, Issue 4, April 2025, Pages 730–738, https://doi.org/10.1093/humrep/deaf023
  5. Choy JT, Eisenberg ML. Comprehensive men’s health and male infertility. Transl Androl Urol. 2020;9(Suppl 2):S239-S243. doi:10.21037/tau.2019.08.35
  6. Wang Y, Hunt K, Nazareth I, et al Do men consult less than women? An analysis of routinely collected UK general practice data. BMJ Open 2013;3:doi: 10.1136/bmjopen-2013-003320
  7. The British Association of Urological Surgeons. https://www.baus.org.uk/patients/conditions/4/fertility_problems/
  8. Sheena E.M. Lewis, R. John Aitken, Sarah J. Conner, Geoffry De Iuliis, Donald P. Evenson, Ralph Henkel, Aleksander Giwercman, Parviz Gharagozloo,

The impact of sperm DNA damage in assisted conception and beyond: recent advances in diagnosis and treatment, Reproductive BioMedicine Online, Volume 27, Issue 4,2013, Pages 325-337, ISSN 1472-6483, https://doi.org/10.1016/j.rbmo.2013.06.014.

  1. Ribas-Maynou J, García-Peiró A, Fernandez-Encinas A, Amengual MJ, Prada E, Cortés P, et al. Double Stranded Sperm DNA Breaks, Measured by Comet Assay, Are Associated with Unexplained Recurrent Miscarriage in Couples without a Female Factor. PLOS ONE. 2012 Sep 17;7(9):e44679.
  2. Royal College of Obstetricians and Gynaecologists. Recurrent Miscarriage. https://www.rcog.org.uk/for-the-public/browse-our-patient-information/recurrent-miscarriage/
  3. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss Quenby, Siobhan et al.The Lancet, Volume 397, Issue 10285, 1658 – 1667
  4. Kaltsas A, Moustakli E, Zikopoulos A, et al. Impact of Advanced Paternal Age on Fertility and Risks of Genetic Disorders in Offspring. Genes (Basel). 2023;14(2):486. Published 2023 Feb 14. doi:10.3390/genes14020486
  5. Urhoj SK, Raaschou-Nielsen O, Hansen AV, Mortensen LH, Andersen PK, Nybo Andersen AM. Advanced paternal age and childhood cancer in offspring: A nationwide register-based cohort study. Int J Cancer. 2017 Jun 1;140(11):2461-2472. doi: 10.1002/ijc.30677. Epub 2017 Mar 23. PMID: 28257590.
  6. M C Guglielmo, J J Fraire-Zamora, E Bartoli, M Valerio, E De Ponti, A Rodriguez, M Popovic, J Buratini, M R Mignini Renzini, M Dal Canto, O-015 Advanced paternal age affects miscarriage and live birth outcomes following the first transfer in oocyte donation cycles, Human Reproduction, Volume 40, Issue Supplement_1, June 2025, deaf097.015, https://doi.org/10.1093/humrep/deaf097.015
  7. Gonzalez DC, Ory J, Blachman-Braun R, Nackeeran S, Best JC, Ramasamy R. Advanced Paternal Age and Sperm DNA Fragmentation: A Systematic Review. World J Mens Health. 2022;40(1):104-115. doi:10.5534/wjmh.200195
  8. High Needs Funding: 2025 to 2026 operational guide. https://www.gov.uk/government/publications/high-needs-funding-arrangements-2025-to-2026/high-needs-funding-2025-to-2026-operational-guide