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Male infertility in Zimbabwe
Patient Education and Counseling 59 (2005) 239–243 www.elsevier.com/locate/pateducou
Male infertility in Zimbabwe Sigurd Folkvord *, Oystein Andreas Odegaard, Johanne Sundby Institute of Tumor Biology, The Norwegian Radium Hospital, Montebello, N-0310 Oslo, Norway Received 20 April 2005; received in revised form 5 August 2005; accepted 17 August 2005
Abstract Objectives: There are very few studies on male infertility in sub-Saharan Africa. Sub-Saharan countries tend not to research male infertility because of economic reasons and, possibly, the psychological denial of the problem. Methods: The participants in the present study were 311 men with infertility problems who had been referred to the Andrology Clinic of the University of Zimbabwe. They were investigated by means of a clinical interview, a clinical examination, semen analysis and various endocrine tests. Results: It was found that 78% of the respondents had ever had a sexually transmitted disease. Most of the respondents reported that their infertility caused them stress and reported signs of mild depression. Most men mentioned also to seek treatment based on traditional methods. Men blamed that their wife was the reason of their childlessness. Conclusion: This study shows the importance of understanding both the cultural and the medical aspects of male infertility. Male infertility is a significant medical and psychological problem in Zimbabwe. Practice implication: Men should promptly be diagnosed and treated for STIs. Health education and teaching people about STDs and HIV in general about this are essential to the process of preventing male infertility. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Male infertility; Behavioural; Reproductive and medical aspects; Zimbabwe
1. Introduction Worldwide, there is great concern about population growth. Several methods have been used to reduce women’s total fertility rate, especially in developing countries. As a consequence, childlessness has received little attention. This is reflected in the lack of attention aid programmes in developing countries pay to this issue. However, it is well documented that infertility is a problem of global proportions [1]. It is estimated that 8–12% of all couples worldwide experience unwanted infertility [2]. In some African countries, however, the infertility level is as high as onethird of all couples [3–5]. Some authors have called these countries the ‘infertility belt’ of central and southern Africa [4–6]. The high infertility rates in some parts of developing countries have several causes, such as tubal infertility
* Corresponding author. E-mail address: [email protected] (S. Folkvord).
resulting from sexually transmitted diseases (STDs) and postpartum, post-abortive and iatrogenic infections [2]. In male-dominated societies, where the man has a strong social and political position, the woman is almost always blamed for a couple’s infertility [6,7] and often the scarce treatment resources are directed towards her. High expectations of having children may cause psychological distress [8]. Little attention has been paid to diagnosing and treating male infertility. It is, however, important to focus on male infertility, because such infertility might be treated or at least prevented. Many women suffer unnecessarily because they lack knowledge about the issue. This is especially important in sub-Saharan Africa because of the high rates of potentially treatable sexually transmitted infections (STIs) that may lead to infertility among both males and females. Earlier studies have shown that male infertility among the Shona in Zimbabwe is dealt with in a ‘secret way’ so that neither the man nor the society perceives the problem [9]. In 2000, Jacobus [9] studied infertility in general among the Shona people (the largest ethnic group) in
0738-3991/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2005.08.003
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Zimbabwe. The traditional Shona culture is male dominated, with the power centred on the head of the clan. This is also reflected in the pluralistic view in the Zimbabwean legal system, where traditional laws exist side by side with modern, human rights based treaties. Traditionally, land is almost exclusively inherited by the man or his children, and the barren wife is denied land rights. Thus, having children is a must for men, even if this implies polygamy [10]. Zimbabwe has few medical or economic resources to deal with the male infertility problem. However, in 1982 the Obstetrics and Gynaecology Department of the University of Zimbabwe established a male infertility clinic at the Spilhaus Family Planning Centre, Harare. This was done in order to develop a structured opportunity for the increasing number of infertility patients who seek care at the hospital, and to make it clear that also men are required for thorough infertility examinations. The counselling sessions that are given as part of the services are well attended, and it has been established that men too suffer greatly from their inability to produce offspring. They mostly want to find a ‘biological’ (i.e. biomedical) solution to their problem. This solution involves using the wife’s ova and husband’s sperm to bring about pregnancy, through medication or a surgical intervention, or sometimes with the help of a traditional healer. No one is interested in a condition that cannot be treated. There is a lack of information on male infertility in Zimbabwe. In one study Mbizvo et al. [11] studied male infertility in Zimbabwe, focusing mainly on biological and aetiological factors. The overall of the present study was focusing on male infertility in Zimbabwe and to explore the reproductive and medical factors associated with male infertility, and to examine the kind of distress these men suffer and to explore what kind of treatment to seek other than treatment from a biomedical perspective.
information collected by means of the interviews and the clinical examination for publication in a medical or sociological journal. All respondent (N = 311) gave their permission. 2.2. Instruments Data on the social demographic aspects and the medical history of the respondents were collected by means of a precoded questionnaire and clinical examination, respectively. As mentioned before, men were interviewed by the infertility nurse, and then referred to one of the specialists for a clinical examination. Data on the kind of distress men felt about their situation and information about what kind of other treatments they used, were collected with an openended question during the interview that was held by the infertility nurse. With permission of the respondents the infertility nurse took notes about the answers of the respondents on this open-ended question. The clinical examination included a review of their masculine body pattern of hair and fat distribution, a genital examination with measurement of testicular volumes (using an orchidometer), and palpation of testes, epididymis and vas deferens. Semen analyses were carried out after 2–7 days of sexual abstinence. The investigation covered semen volume, sperm concentration, motility, morphology, viability, viscosity, appearance and pH. Blood serum was assayed for luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone. The clinic analysed the sperm quality in an automatic sperm analyzer. LH and FSH are hormones produced by the hypophysis gland, and they control the production of sperm and testosterone in the male. Pathological levels help in the diagnosis of male infertility and its cause. 2.3. Analyses
2. Methods 2.1. Procedure Between 1993 and 1995, all infertile couples registered at one of the public hospitals in Harare were referred to the Family Planning Clinic at the Spilhaus Centre. Some men were referred to this Centre by general practitioners, while others come on their own having heard about the clinic. At the time of our study, male infertility had been diagnosed according to international criteria in 311 of the men. The quantitative data in this study were collected between 1993 and 1995, but additional field work was conducted in 2001. The Centre is run as a weekly specialist unit. In addition to a nurse specialized in group and individual counselling, the Centre has some core equipment for sperm and hormonal analyses. Men were interviewed and by the infertility nurse, and then referred to one of the specialists for a clinical examination. Men were asked to give permission to use the
With respect to the social demographic aspects and the medical history of the respondents descriptive analyses were used. Data from the open-ended questions (type of distress men felt about their situation and information about what kind of other treatments they used) were analyses using a thematic analysis approach. Thematic analysis is the process of identifying emerging themes through a careful reading and rereading the answers of the open-ended questions. The methodology of thematic analysis approach is a frequently used method in studies with an explorative characteristic and it has an inductive methodology.
3. Results 3.1. Characteristics of the respondents The infertile men included in the present study came from different parts of Zimbabwe. Most men (92%) came from
S. Folkvord et al. / Patient Education and Counseling 59 (2005) 239–243
urban areas. From the 311 men 31% were Protestants, 22% Catholics, 18% Apostolic Faith and 27% other religions. Their age varied from 22 to 59 years (median 31 years). Median time in school was 11 years. Ninety-nine percent were married, and 28% had had two or more wives. Only 112 (46.3%) reported that they had not fathered any children (primary infertility), while 78 (32.2%) had fathered one child and 52 (21.5%) had fathered two or more children (secondary infertility). The youngest child of 85% of those with secondary infertility was 4 years or older. The infertility had lasted at least two years in 98% of the cases. Mean age at first intercourse was 19.3 years; 47% were 18 years or younger when they first became sexually active. Their mean frequency of intercourse was 4.4 per week; 25% had intercourse every day. One hundred and one (33%) had sexual problems, such as ejaculatory or erectile problems. 3.2. Medical histories 3.2.1. General medical conditions The medical histories revealed no important differences compared to the general populations in respect to the patients general medical conditions. They are nevertheless important to understand and explain the causes of the infertility and to explain the findings in the semen samples. Twenty-two percent drank at least seven pints of alcohol each week. Sixty-four percent did not smoke. One percent had diabetes mellitus, 3% had TB, 5% had chronic respiratory tract disease, 9% had had fever in the previous 6 months, 30% had ever had urinary tract infection, 7% had maldescended testis, 21% said that they had had orchitis and 7% had ever had mumps. 3.2.2. Sexually transmitted diseases (STD) There were an interestingly high proportion of the men that had had any STD. Of the total group, 244 (78%) had ever had or had been treated for a STD. Forty-nine percent had had one episode, 22% two episodes, 8.4% three episodes and 5.3% four or more episodes. One hundred and twenty seven (49%) had had an episode lasting 2 weeks or more. Of the total group (311):
19 (6%) had been diagnosed with syphilis; 149 (48%) had had gonorrhoea; 1 (0.3%) had chlamydia; 36 (12%) had chancroids; 128 (41%) had other urinary tract/genital tract infection, including unspecified urethritis.
3.2.3. Clinical examination As expected, the clinical examinations did not give us much information about the infertility in these men. Only 10–15% of the men showed some abnormal findings. This included five subjects (2.6%) did not have palpable testes, 19 (11%) had testes volume < 10 ml. Twenty (10.5%) had abnormal findings in their epididymis (thickened, tender,
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cystic or non-palpable), 7 (3.6%) had abnormal vasa deferentia, 1 (0.5%) had a hydrocele, 1 (0.5%) had a hernia and only 1 (0.5%) had a palpable varicocele. 3.2.4. Semen analysis The most important method of diagnosing male infertility is semen analysis. Very few of the men had normal semen parameters (35 out of 260 semen samples). In most of the cases this analysis gave the men their ‘‘diagnosis’’. Many of these men with abnormal semen samples had impaired semen quality, often sub-levels in several parameters, but not low enough to be classified into one of the lower classes. The spermiograms in the remaining 225 patients were classified according to the recommendations of the International Committee of Andrology [11]. The largest subgroup of patients (78) had no motile sperm in their semen (azoospermia). Twenty-three of these patients also had hypospermia (volume 1 ml). The second largest subgroup (43 patients) comprised those who had only reduced motility (asthenozoospermia). Of these, 11 had hypospermia and six also had teratozoospermia. Asthenozoospermia was defined as <50% progressive motile sperm or <25% rapid progressive motile sperm. Thirty patients had combined asthenozoospermia and oligospermia (sperm count <40 million sperm/ml). Twenty-four patients had hypospermia with the other parameters being normal. Fourteen had oligozoospermia, with a sperm count of 0–40 million sperm/ml. Failure of semen to liquefy after 60 min was found in 15 cases. Eight patients had both a low count and poor motility with abnormal morphology (oligoteratoasthenozoospermia; OTA syndrome). Abnormal morphology or teratozoospermia was defined as <25% of the sperm with normal morphology. Five patients had this isolated. One patient had 10.50 ml sperm in his ejaculate and also had asthenozoospermia. Non-viable spermatozoa (necrozoospermia) were found in only one patient. 3.3. Distress on infertility Most men (70%) said that they felt uncomfortable about their situation of infertility. Thirty percent mentioned signs of mild depression such as sleeping problems. One-third of the respondents reported to have relational problems with their wife caused by their infertile status and also one-third mentioned to have problems with the rest of the family who had high expectations of having a child. Although most men mentioned that they felt uncomfortable about their infertility, most men (82%) were not really interested in alternative solutions to their infertility, such as donor insemination. This because of their strong beliefs about ancestral spirits improving clan communication and marital agreements, the idea of bringing in alien ‘sperm’ or biology was not readily accepted. Although accepting that the reason for their infertility was a low sperm count, a few men argued that they had fathered a child with another women a long time ago. Other
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explanations given by the infertile men was to claim that the reason for their childlessness was that their wife was born with ‘too few lumps inside her’ for making babies, or that her ‘womb was tired and turned its back against the semen’. 3.4. Treatment seeking behaviour Many of the men combined their treatment in the Centre with treatment based on traditional beliefs, and almost all the couples (80%) had tried ‘‘traditional treatment’’ before they came to the infertility clinic. Sperm donation within the family seemed to be acceptable. It was mentioned that they knew about the tradition of families arranging private ‘donations’ of semen through a secret affair between the infertile man’s wife and his brother, but no one knew if this had happened to themselves.
4. Discussion and conclusion 4.1. Discussion Less than half of the infertile men claimed to suffer from primary infertility. There are two possible explanations for this high reported level of secondary infertility: the woman has become pregnant with another man (false secondary infertility) or the man has become infertile during his marriage, for example after a gonorrhoeal infection. As explained, there is a traditional way to cope with male infertility in Zimbabwe. The previously reported traditional informal sperm donation may be a reason for this low primary infertility. The high proportion of care sought even for secondary infertility also shows the expectation of having and the need to have more than one child in Zimbabwe. In our study we found a large number of infertile men who had had gonorrhoe. Only one case of chlamydia was found, but many had suffered from unspecified urethritis. However, it might be that due to the poor diagnostic possibilities the number of men with a chlamydia infection is larger without realising it. In a study among asymptomatic women in Harare that was published in 2001 [11], a possible association between chlamydia infection and male infertility was established, but further analyses are needed to confirm this link. The prevalence of STD (and HIV) is also high in women in Zimbabwe (a recent study found a HIV prevalence of 30%), and a prevalence of other STDs as high as 20–40% for any reproductive tract infection [11]. Men felt uncomfortable about their situation of infertility. Although men were informed about their medical situation, it revealed very common to blame the women for the childlessness. Zimbabwe is, like many other African countries, a male-dominated society [9]. In many of these countries the power is centred on the head of the tribe, which is always a man. This male-dominated culture puts pressure
on the man to be a faultless person. For a man, being labeled as infertile would be an admission of not being faultless. Anonymous sperm donation is not readily culturally acceptable in Zimbabwe, and with high levels of HIV infections among adults, this is not a method of choice for infertile women and men unless a very tedious and proper HIV testing routine is applied and frozen semen is utilised. Wealthy patients may go to neighbouring countries (South Africa) for advanced treatment, but as the majority of the Zimbabwean population is poor, this is not an option for most infertile couples. The consequence of the fact that infertile men get very little help from health professionals is that the traditional manner of dealing with the problem will continue, and women will still be blamed for the infertility problem. Many men will continue to live with low selfesteem and depression. Most men in the present study did suffer on their infertility and also seek treatment based on traditional beliefs. Findings from other studies carried out in Zimbabwe also found that it was very common to visit a traditional healer as well as a medical doctor in cases of childlessness [9]. It was also shown in that study that infertile men are more satisfied about the treatment they received from traditional healers than about the biomedical treatment [9]. Possible explanations for this are might be the limited medical access, few medical treatment options, scepticism about whether doctors can cure infertility, a fear that the medical profession will not treat the couple according to their expectations, and the patients’ subjective view of the problem. This lack of options is real, and because modern forms of infertility technology are virtually inaccessible to the majority of the Zimbabwe society, men has to cope with his infertility without much hope of a solution. Traditional treatments and continuing to blame their wife for most of the problem, might be seen as ways to cope with the diagnosis of infertility. 4.2. Conclusion The results of this study and of other studies on infertility in sub-Saharan Africa [11–15] show that the problem of male infertility deserves more attention. Most men involved in the present study had a medical history were they had been treated for a STD. Although men were informed about their infertility and their medical diagnosis, many of them blamed that their wife was the reason of their childlessness. Most men mentioned also to seek treatment based on traditional methods. This study shows the importance of understanding both the cultural and the medical aspects of male infertility. Male infertility is a significant medical and psychological problem in Zimbabwe. 4.3. Practice Implications As mentioned before we found in the present study an accumulation of STIs, especially gonorrhoea among men.
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To prevent male infertility, men should promptly be diagnosed and treated for STIs, especially gonorrhoeal infections. Treatment for STI is also an important factor in reducing HIV transmission. Knowledge that chlamydia and gonorrhoeal infections may cause infertility and increase the risk of transmitting HIV, and that gonorrhoea can be treated, would probably prevent more male infertility. Health education and teaching people in general about this are essential to the process of preventing male infertility.
References [1] Van Balen F, Inhorn MC. Introduction. Interpreting infertility: a view from the social sciences. In: Inhorn MC, Van Balen F, editors. Infertility around the globe. New thinking on childlessness, gender, and reproductive technologies. Berkeley: University of California; 2002. p. 3–32. [2] WHO. Laboratory manual for the examination of human semen and semen-cervical mucus interaction. Geneva: World health organisation; 1980. [3] Reproductive Health Outlook. Infertility: Overview and lessons learned. Retrieved from the World Wide Web on January 10, 2005 from http://www.rho.org/html/infertility.htm. [4] Larsen U. Sterility in sub-Saharan Africa. Popul Stud 1994;48:459– 74.
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[5] Larsen U. Infertility in Central Africa. Trop Med Int Health 2003;8:354–67. [6] Inhorn MC. The worms are weak. Male infertility and patriarchal paradox in Egypt. Men Masc 2003;5:236–56. [7] Lwange C. Abortion in Mulago Hospital, Kampala. East Afr Med J 1977;54:142–8. [8] Pook M, Rohrle B, Tuschen-Caffier B, Krauser W. Why do infertile males use psychological couple counselling. Patient Educ Couns 2001;42:239–45. [9] Jacobus A. Options for the management of infertility in a sociocultural context of Shona people in Zimbabwe. Oslo: Thesis, University of Oslo; 2000. [10] Hellum A. Women’s Human rights and legal pluralism in Africa. Mixed norms and identities in infertility management in Zimbabwe. Oslo: Tano, 1999. [11] Mbizvo EM, Msuya SE, Stray-Pedersen B, Sundby J, Chirenje MZ, Hussain A. HIV seroprevalence and its associations with the other reproductive tract infections in asymptomatic women in Harare, Zimbabwe. Int J STD AIDS 2001;12:524–31. [12] Mbizvo M, Chimbira TH, Mkwananzi JB. Aetiological factors of male infertility in Zimbabwe. Cent Afr J Med 1984;30:233–8. [13] Mbizvo M, Chimbira TH, Gwavava NJ, Luyombya JS. Azoospermic infertile men. Br J Urol 1989;63:423–7. [14] Mbizvo M, Danso AP. Male reproductive function: a review on Sperm fertilising ability and infertility. Cent Afr J Med 1991;37:40–7. [15] Mbizvo M, Msuya SE, Stray-Pedersen B, Sundby J, Chirenje ZM, Hussain A. Determinants of reproductive tract/STI in asymptomatic women in Harare, Zimbabwe. Cent Afr J Med 2001;47:57–69.
Male infertility in Zimbabwe Sigurd Folkvord *, Oystein Andreas Odegaard, Johanne Sundby Institute of Tumor Biology, The Norwegian Radium Hospital, Montebello, N-0310 Oslo, Norway Received 20 April 2005; received in revised form 5 August 2005; accepted 17 August 2005
Abstract Objectives: There are very few studies on male infertility in sub-Saharan Africa. Sub-Saharan countries tend not to research male infertility because of economic reasons and, possibly, the psychological denial of the problem. Methods: The participants in the present study were 311 men with infertility problems who had been referred to the Andrology Clinic of the University of Zimbabwe. They were investigated by means of a clinical interview, a clinical examination, semen analysis and various endocrine tests. Results: It was found that 78% of the respondents had ever had a sexually transmitted disease. Most of the respondents reported that their infertility caused them stress and reported signs of mild depression. Most men mentioned also to seek treatment based on traditional methods. Men blamed that their wife was the reason of their childlessness. Conclusion: This study shows the importance of understanding both the cultural and the medical aspects of male infertility. Male infertility is a significant medical and psychological problem in Zimbabwe. Practice implication: Men should promptly be diagnosed and treated for STIs. Health education and teaching people about STDs and HIV in general about this are essential to the process of preventing male infertility. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Male infertility; Behavioural; Reproductive and medical aspects; Zimbabwe
1. Introduction Worldwide, there is great concern about population growth. Several methods have been used to reduce women’s total fertility rate, especially in developing countries. As a consequence, childlessness has received little attention. This is reflected in the lack of attention aid programmes in developing countries pay to this issue. However, it is well documented that infertility is a problem of global proportions [1]. It is estimated that 8–12% of all couples worldwide experience unwanted infertility [2]. In some African countries, however, the infertility level is as high as onethird of all couples [3–5]. Some authors have called these countries the ‘infertility belt’ of central and southern Africa [4–6]. The high infertility rates in some parts of developing countries have several causes, such as tubal infertility
* Corresponding author. E-mail address: [email protected] (S. Folkvord).
resulting from sexually transmitted diseases (STDs) and postpartum, post-abortive and iatrogenic infections [2]. In male-dominated societies, where the man has a strong social and political position, the woman is almost always blamed for a couple’s infertility [6,7] and often the scarce treatment resources are directed towards her. High expectations of having children may cause psychological distress [8]. Little attention has been paid to diagnosing and treating male infertility. It is, however, important to focus on male infertility, because such infertility might be treated or at least prevented. Many women suffer unnecessarily because they lack knowledge about the issue. This is especially important in sub-Saharan Africa because of the high rates of potentially treatable sexually transmitted infections (STIs) that may lead to infertility among both males and females. Earlier studies have shown that male infertility among the Shona in Zimbabwe is dealt with in a ‘secret way’ so that neither the man nor the society perceives the problem [9]. In 2000, Jacobus [9] studied infertility in general among the Shona people (the largest ethnic group) in
0738-3991/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2005.08.003
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Zimbabwe. The traditional Shona culture is male dominated, with the power centred on the head of the clan. This is also reflected in the pluralistic view in the Zimbabwean legal system, where traditional laws exist side by side with modern, human rights based treaties. Traditionally, land is almost exclusively inherited by the man or his children, and the barren wife is denied land rights. Thus, having children is a must for men, even if this implies polygamy [10]. Zimbabwe has few medical or economic resources to deal with the male infertility problem. However, in 1982 the Obstetrics and Gynaecology Department of the University of Zimbabwe established a male infertility clinic at the Spilhaus Family Planning Centre, Harare. This was done in order to develop a structured opportunity for the increasing number of infertility patients who seek care at the hospital, and to make it clear that also men are required for thorough infertility examinations. The counselling sessions that are given as part of the services are well attended, and it has been established that men too suffer greatly from their inability to produce offspring. They mostly want to find a ‘biological’ (i.e. biomedical) solution to their problem. This solution involves using the wife’s ova and husband’s sperm to bring about pregnancy, through medication or a surgical intervention, or sometimes with the help of a traditional healer. No one is interested in a condition that cannot be treated. There is a lack of information on male infertility in Zimbabwe. In one study Mbizvo et al. [11] studied male infertility in Zimbabwe, focusing mainly on biological and aetiological factors. The overall of the present study was focusing on male infertility in Zimbabwe and to explore the reproductive and medical factors associated with male infertility, and to examine the kind of distress these men suffer and to explore what kind of treatment to seek other than treatment from a biomedical perspective.
information collected by means of the interviews and the clinical examination for publication in a medical or sociological journal. All respondent (N = 311) gave their permission. 2.2. Instruments Data on the social demographic aspects and the medical history of the respondents were collected by means of a precoded questionnaire and clinical examination, respectively. As mentioned before, men were interviewed by the infertility nurse, and then referred to one of the specialists for a clinical examination. Data on the kind of distress men felt about their situation and information about what kind of other treatments they used, were collected with an openended question during the interview that was held by the infertility nurse. With permission of the respondents the infertility nurse took notes about the answers of the respondents on this open-ended question. The clinical examination included a review of their masculine body pattern of hair and fat distribution, a genital examination with measurement of testicular volumes (using an orchidometer), and palpation of testes, epididymis and vas deferens. Semen analyses were carried out after 2–7 days of sexual abstinence. The investigation covered semen volume, sperm concentration, motility, morphology, viability, viscosity, appearance and pH. Blood serum was assayed for luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone. The clinic analysed the sperm quality in an automatic sperm analyzer. LH and FSH are hormones produced by the hypophysis gland, and they control the production of sperm and testosterone in the male. Pathological levels help in the diagnosis of male infertility and its cause. 2.3. Analyses
2. Methods 2.1. Procedure Between 1993 and 1995, all infertile couples registered at one of the public hospitals in Harare were referred to the Family Planning Clinic at the Spilhaus Centre. Some men were referred to this Centre by general practitioners, while others come on their own having heard about the clinic. At the time of our study, male infertility had been diagnosed according to international criteria in 311 of the men. The quantitative data in this study were collected between 1993 and 1995, but additional field work was conducted in 2001. The Centre is run as a weekly specialist unit. In addition to a nurse specialized in group and individual counselling, the Centre has some core equipment for sperm and hormonal analyses. Men were interviewed and by the infertility nurse, and then referred to one of the specialists for a clinical examination. Men were asked to give permission to use the
With respect to the social demographic aspects and the medical history of the respondents descriptive analyses were used. Data from the open-ended questions (type of distress men felt about their situation and information about what kind of other treatments they used) were analyses using a thematic analysis approach. Thematic analysis is the process of identifying emerging themes through a careful reading and rereading the answers of the open-ended questions. The methodology of thematic analysis approach is a frequently used method in studies with an explorative characteristic and it has an inductive methodology.
3. Results 3.1. Characteristics of the respondents The infertile men included in the present study came from different parts of Zimbabwe. Most men (92%) came from
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urban areas. From the 311 men 31% were Protestants, 22% Catholics, 18% Apostolic Faith and 27% other religions. Their age varied from 22 to 59 years (median 31 years). Median time in school was 11 years. Ninety-nine percent were married, and 28% had had two or more wives. Only 112 (46.3%) reported that they had not fathered any children (primary infertility), while 78 (32.2%) had fathered one child and 52 (21.5%) had fathered two or more children (secondary infertility). The youngest child of 85% of those with secondary infertility was 4 years or older. The infertility had lasted at least two years in 98% of the cases. Mean age at first intercourse was 19.3 years; 47% were 18 years or younger when they first became sexually active. Their mean frequency of intercourse was 4.4 per week; 25% had intercourse every day. One hundred and one (33%) had sexual problems, such as ejaculatory or erectile problems. 3.2. Medical histories 3.2.1. General medical conditions The medical histories revealed no important differences compared to the general populations in respect to the patients general medical conditions. They are nevertheless important to understand and explain the causes of the infertility and to explain the findings in the semen samples. Twenty-two percent drank at least seven pints of alcohol each week. Sixty-four percent did not smoke. One percent had diabetes mellitus, 3% had TB, 5% had chronic respiratory tract disease, 9% had had fever in the previous 6 months, 30% had ever had urinary tract infection, 7% had maldescended testis, 21% said that they had had orchitis and 7% had ever had mumps. 3.2.2. Sexually transmitted diseases (STD) There were an interestingly high proportion of the men that had had any STD. Of the total group, 244 (78%) had ever had or had been treated for a STD. Forty-nine percent had had one episode, 22% two episodes, 8.4% three episodes and 5.3% four or more episodes. One hundred and twenty seven (49%) had had an episode lasting 2 weeks or more. Of the total group (311):
19 (6%) had been diagnosed with syphilis; 149 (48%) had had gonorrhoea; 1 (0.3%) had chlamydia; 36 (12%) had chancroids; 128 (41%) had other urinary tract/genital tract infection, including unspecified urethritis.
3.2.3. Clinical examination As expected, the clinical examinations did not give us much information about the infertility in these men. Only 10–15% of the men showed some abnormal findings. This included five subjects (2.6%) did not have palpable testes, 19 (11%) had testes volume < 10 ml. Twenty (10.5%) had abnormal findings in their epididymis (thickened, tender,
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cystic or non-palpable), 7 (3.6%) had abnormal vasa deferentia, 1 (0.5%) had a hydrocele, 1 (0.5%) had a hernia and only 1 (0.5%) had a palpable varicocele. 3.2.4. Semen analysis The most important method of diagnosing male infertility is semen analysis. Very few of the men had normal semen parameters (35 out of 260 semen samples). In most of the cases this analysis gave the men their ‘‘diagnosis’’. Many of these men with abnormal semen samples had impaired semen quality, often sub-levels in several parameters, but not low enough to be classified into one of the lower classes. The spermiograms in the remaining 225 patients were classified according to the recommendations of the International Committee of Andrology [11]. The largest subgroup of patients (78) had no motile sperm in their semen (azoospermia). Twenty-three of these patients also had hypospermia (volume 1 ml). The second largest subgroup (43 patients) comprised those who had only reduced motility (asthenozoospermia). Of these, 11 had hypospermia and six also had teratozoospermia. Asthenozoospermia was defined as <50% progressive motile sperm or <25% rapid progressive motile sperm. Thirty patients had combined asthenozoospermia and oligospermia (sperm count <40 million sperm/ml). Twenty-four patients had hypospermia with the other parameters being normal. Fourteen had oligozoospermia, with a sperm count of 0–40 million sperm/ml. Failure of semen to liquefy after 60 min was found in 15 cases. Eight patients had both a low count and poor motility with abnormal morphology (oligoteratoasthenozoospermia; OTA syndrome). Abnormal morphology or teratozoospermia was defined as <25% of the sperm with normal morphology. Five patients had this isolated. One patient had 10.50 ml sperm in his ejaculate and also had asthenozoospermia. Non-viable spermatozoa (necrozoospermia) were found in only one patient. 3.3. Distress on infertility Most men (70%) said that they felt uncomfortable about their situation of infertility. Thirty percent mentioned signs of mild depression such as sleeping problems. One-third of the respondents reported to have relational problems with their wife caused by their infertile status and also one-third mentioned to have problems with the rest of the family who had high expectations of having a child. Although most men mentioned that they felt uncomfortable about their infertility, most men (82%) were not really interested in alternative solutions to their infertility, such as donor insemination. This because of their strong beliefs about ancestral spirits improving clan communication and marital agreements, the idea of bringing in alien ‘sperm’ or biology was not readily accepted. Although accepting that the reason for their infertility was a low sperm count, a few men argued that they had fathered a child with another women a long time ago. Other
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explanations given by the infertile men was to claim that the reason for their childlessness was that their wife was born with ‘too few lumps inside her’ for making babies, or that her ‘womb was tired and turned its back against the semen’. 3.4. Treatment seeking behaviour Many of the men combined their treatment in the Centre with treatment based on traditional beliefs, and almost all the couples (80%) had tried ‘‘traditional treatment’’ before they came to the infertility clinic. Sperm donation within the family seemed to be acceptable. It was mentioned that they knew about the tradition of families arranging private ‘donations’ of semen through a secret affair between the infertile man’s wife and his brother, but no one knew if this had happened to themselves.
4. Discussion and conclusion 4.1. Discussion Less than half of the infertile men claimed to suffer from primary infertility. There are two possible explanations for this high reported level of secondary infertility: the woman has become pregnant with another man (false secondary infertility) or the man has become infertile during his marriage, for example after a gonorrhoeal infection. As explained, there is a traditional way to cope with male infertility in Zimbabwe. The previously reported traditional informal sperm donation may be a reason for this low primary infertility. The high proportion of care sought even for secondary infertility also shows the expectation of having and the need to have more than one child in Zimbabwe. In our study we found a large number of infertile men who had had gonorrhoe. Only one case of chlamydia was found, but many had suffered from unspecified urethritis. However, it might be that due to the poor diagnostic possibilities the number of men with a chlamydia infection is larger without realising it. In a study among asymptomatic women in Harare that was published in 2001 [11], a possible association between chlamydia infection and male infertility was established, but further analyses are needed to confirm this link. The prevalence of STD (and HIV) is also high in women in Zimbabwe (a recent study found a HIV prevalence of 30%), and a prevalence of other STDs as high as 20–40% for any reproductive tract infection [11]. Men felt uncomfortable about their situation of infertility. Although men were informed about their medical situation, it revealed very common to blame the women for the childlessness. Zimbabwe is, like many other African countries, a male-dominated society [9]. In many of these countries the power is centred on the head of the tribe, which is always a man. This male-dominated culture puts pressure
on the man to be a faultless person. For a man, being labeled as infertile would be an admission of not being faultless. Anonymous sperm donation is not readily culturally acceptable in Zimbabwe, and with high levels of HIV infections among adults, this is not a method of choice for infertile women and men unless a very tedious and proper HIV testing routine is applied and frozen semen is utilised. Wealthy patients may go to neighbouring countries (South Africa) for advanced treatment, but as the majority of the Zimbabwean population is poor, this is not an option for most infertile couples. The consequence of the fact that infertile men get very little help from health professionals is that the traditional manner of dealing with the problem will continue, and women will still be blamed for the infertility problem. Many men will continue to live with low selfesteem and depression. Most men in the present study did suffer on their infertility and also seek treatment based on traditional beliefs. Findings from other studies carried out in Zimbabwe also found that it was very common to visit a traditional healer as well as a medical doctor in cases of childlessness [9]. It was also shown in that study that infertile men are more satisfied about the treatment they received from traditional healers than about the biomedical treatment [9]. Possible explanations for this are might be the limited medical access, few medical treatment options, scepticism about whether doctors can cure infertility, a fear that the medical profession will not treat the couple according to their expectations, and the patients’ subjective view of the problem. This lack of options is real, and because modern forms of infertility technology are virtually inaccessible to the majority of the Zimbabwe society, men has to cope with his infertility without much hope of a solution. Traditional treatments and continuing to blame their wife for most of the problem, might be seen as ways to cope with the diagnosis of infertility. 4.2. Conclusion The results of this study and of other studies on infertility in sub-Saharan Africa [11–15] show that the problem of male infertility deserves more attention. Most men involved in the present study had a medical history were they had been treated for a STD. Although men were informed about their infertility and their medical diagnosis, many of them blamed that their wife was the reason of their childlessness. Most men mentioned also to seek treatment based on traditional methods. This study shows the importance of understanding both the cultural and the medical aspects of male infertility. Male infertility is a significant medical and psychological problem in Zimbabwe. 4.3. Practice Implications As mentioned before we found in the present study an accumulation of STIs, especially gonorrhoea among men.
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To prevent male infertility, men should promptly be diagnosed and treated for STIs, especially gonorrhoeal infections. Treatment for STI is also an important factor in reducing HIV transmission. Knowledge that chlamydia and gonorrhoeal infections may cause infertility and increase the risk of transmitting HIV, and that gonorrhoea can be treated, would probably prevent more male infertility. Health education and teaching people in general about this are essential to the process of preventing male infertility.
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