Anthropologist Emilia Perujo discovered that infertile men are hard to hear, even if your thesis is about listening to them.
I was a 24 year-old woman becoming an anthropologist when I chose male infertility as a research topic. After having a first insight into the world of infertility experienced by heterosexual “traditional” couples in Mexico City, I felt male infertility in particular was the next step to understand the dynamics of assisted reproduction. My interest was always guided by what was missing about infertility: missing children, a missing legal framework, missing information and knowledge about the treatments, and what I will focus on here, the missing voices of men.
After getting acquainted with the literature about fathers to be, male access to reproductive technologies, and male infertility, and not finding a satisfactory representation of men´s experiences—sometimes not finding men at all—I had the impression social sciences were ignoring half of the population who suffers infertility. Infertility is caused by diverse factors, and it is told 40 percent of them can be attributed to male causes alone. I tried to address why this 40 percent of the cases remains invisible, at least locally, drawing from my impressions and personal experience.
A brief introduction
The research was conducted in Mexico City in 2010, with six heterosexual couples diagnosed as infertile due to a male factor. They all used homologous artificial insemination as fertility treatment. Four of them had successful results, and two did not, but decided not to use IVF when it was offered as the next step. Five of them had children already and were accessing technologies for their second pregnancy. All couples were situated in middle-high and high class positions and shared religious beliefs.
(The absence of) Male experiences in infertility
Approaching masculinity and fatherhood desires in Mexico City through what had been written about the topic highlighted an absence of men as main actors in reproductive issues. One of the more striking discoveries I made was that some reproductive decisions were made “even if the men didn’t agree.” Later I would find out this was not specific to the Mexican culture, that men´s experiences and decisions, if not ignored, are at least underrepresented in reproductive health literature, which becomes more clear and problematic when one takes a look at the variety of situations where men actually take part or wish to take part regarding reproductive health.
Female bodies are treated in every step of a couple´s trajectory to overcome infertility, but in some cases, male bodies are not even examined. This sets the scene for the contradictory fact that while not involving men in a men´s health issue—perhaps due to a protection and avoidance of stigma related to virility and masculinity—it erases them from the experience, not allowing for a space where men themselves can express a hurtful and complex experience. Social and medical institutions, starting from how infertility diagnosis are made, seem to protect them while leaving them unprotected.
Approaching infertile men
Studying male experiences regarding sexuality and events considered shameful, means great difficulty of gaining access to subjects, which can impact the findings in many ways. I was aware that choosing male infertility as a research topic would mean facing various barriers, but didn´t think the barriers would become part of the research topic itself. At some point, though, how men were “hidden” from me became more intriguing than what sometimes came up in our actual conversations once the barriers were overcome. Instead of limiting the study, the gatekeeping which limited my access to subjects enriched it.
The topic and participants were narrowed by several denied attempts to gain access to volunteer subjects at three fertility clinics in Mexico City. In some cases, clinics refused “to protect patients from an intruder in their privacy”. In others, no reason was given. Given the fact that usually, the first infertility diagnosis is made by gynecologists and starts in the female reproductive body, a gynecologist agreed to participate and asked some of his female patients if they would be interested to take part in the research. The only criterion to recruit the participants was that the couples had to be facing or have faced an infertility diagnosis caused by a male factor.
As a result of these two first encounters with barriers, only five women met with me to explore the experiences of men throughout fertility treatments, and they would later become gatekeepers themselves. Later on, I met another woman who was willing to be interviewed. From this total of six women, I could only interview two couples together, and one man alone. One couple had just separated due to the treatments. The other women said their husbands did not have time in this period of the year, or said they would ask their husbands and then never answered my calls or emails.
It was under women´s decisions whether or not I could access the couple´s relationships and interview both members. Once the access was gained, it was also women who organized the times and spaces for the interviews, the ones who introduced some topics and even encouraged their husbands to speak more about certain issues. Those men willing to participate were open to answer all questions and introduced themselves to me using comparisons to other men who could feel threatened by talking about certain topics or going through certain experiences and sharing them with a woman.
It seemed like men were willing to share their testimonies, but I could only find that out once we were finally able to sit down and talk. It seemed to me they found some comfort in speaking about their condition on a personal level—in many cases it was their first opportunity to do so. This fact made me wonder if the social and institutional secrecy surrounding the topic and the strategies used for making the problem invisible were not harmful and a contributing factor in turning the infertile condition into an even more stigmatizing issue.
Couples facing infertility
Roberto characterized his experience through the treatments as out of the norm, and explained:
…The doctor told me, “You are the second man I know who has gone to a fertility check up before getting married. I am the other man.” The advantage for us was that we knew about the possibility beforehand. Because of my brother (who had low sperm count and couldn´t conceive even with artificial insemination), we knew there was a chance of having trouble having children. If we had faced it not knowing that chance, perhaps we would have reacted differently.”
As Roberto describes it, he was one of the few men who went for a sperm evaluation before facing any problem, and even more unusually, before his wife had had any evaluation. The case of Roberto stands apart from the rest of the cases, not only in terms of male involvement in fertility treatments and parenting wishes, but also in his approach to the diagnosis.
By contrast, Eduardo and Fernanda remember the first months they were trying to get pregnant:
Eduardo: After the spontaneous abortion she had, we began trying, and every month we had hope and were being disappointed. So we looked for treatment. In the examinations it showed that she had developed a spermicide [a natural substance that rejected or killed his semen] and therefore my sperm couldn´t reach the ova.
Fernanda: But you also had slow mobility.
Eduardo: Oh, yes, it was also me, and I am glad because then no one gets to blame himself for the disappointment.
In the diagnosis of all the six couples, no emphasis was made on who was the person holding the health problem. The diagnosis of male factor infertility tends to be misinterpreted given the fact that for all fertility treatments, the female body is medically attended and observed. This leaves a space for patients to interpret or find other explanations for their difficulties to get pregnant.
Although I was introduced to them because they were patients due to a male factor, secrecy surrounding the subject increased the perceived importance of other factors, and the couples did not mention male infertility as a clear cause of their difficulties for becoming parents.
They don´t make a diagnosis for every person, it is the couple who is facing difficulties. Maybe if we had asked…I think the problem is me, because after having my children I never used contraceptives again and didn´t get pregnant—even in the relationships I had between my marriages. But he has diabetes and maybe that could also affect the sperm mobility. (Elisa)
Elisa was never sure if infertility was caused by her—although she had two children in her previous marriage. Both she and her husband, Alan, mentioned his diabetes as a likely cause of his infertility, but the doctors did not give importance to that in the diagnosis. In the case of Eva and Roberto, and Ignacio and Lola, the fact that they both gained weight before going to the fertility examinations was of great importance in their stories. It was something they could control.
Lorena and Miguel, after having one child with no treatments, were diagnosed with infertility when trying to conceive their second child. Lorena attributes their difficulties to the stressful episode they were both going through:
It was probably the stress he was put through, because of his job promotion, and also my stress of living in such a small apartment with one child and not being able to work at that time.
In other cases, where such tangible reasons were not present, spiritual and emotional causes were considered of central importance when facing the doctors´ results. This was the case of María and Fernanda, who both had miscarriages. María had gone to her 12-week pregnancy consultation and she was going to take the triple marker test. The day before, she prayed and asked God not to test her with a disabled son. She miscarried before the appointment. She and Oscar knew that her prayers were heard and, since they were not prepared to raise a disabled child, the pregnancy was naturally interrupted.
Fernanda and Eduardo were told about Fernanda´s brother sudden death several days after finding out she was pregnant. Fernanda then had a spontaneous abortion. Her brother was supposed to be their child‟s godfather, and his absence as such, is the reason she gives to explain the miscarriage. However, Eduardo thinks the miscarriage—and the several unsuccessful attempts that followed—were due to the fact she was emotionally unprepared to become pregnant and raise a child.
During most of the interviews and conversations we had, the reasons couple´s gave regarding their difficulties to become pregnant, were placed outside the reproductive system, which of course is proven to have an impact on reproductive health, but can also be a strategy to avoid talking about the medical reason: male infertility.
One fertility doctor told me, “In general, we try not to make one of the members of the couple feel guilty”, leaving doubts if female infertility is causing the diagnosis. For me, it was always surprising how, even though couples knew the reason I was referred to them (and my whole thesis subject) was male infertility, they presented and elaborated narratives that never focused on male bodies, where men were not infertile individuals.
A need for vindication
It is difficult for me to conceive a reproductive issue without considering every participant´s voice. Not paying attention to men´s voices in reproductive health topics has risks for everyone: women carry a heavier burden, and men are not even allowed to explore what their burdens are.
The few men I was able to speak with were willing to share their experiences and spoke about important issues: guilt, anger, genetics, fatherhood, medicalization, making it clear that men´s experiences on infertility are not only specific to men, but determining and very important when exploring assisted reproduction.
After speaking to them, my feeling of missing men in social research looking at reproduction has grown. What I wished to answer—why infertile men are missing or ignored—instead raised many questions. How do the context, medical institutions, couple´s dynamics, and notions about masculinity affect this usually stigmatized topic? Sometimes it seems as though men are being “protected” by diminishing their role, but are men really comfortable with such strategies if they obstruct and silence the expression and representation of their own experiences and emotional and physical involvement?
Photo— Robert S. Donovan/Flickr