Delays in male infertility evaluation and their financial and emotional impact on couples

Introduction

The American Society for Reproductive Medicine (ASRM) defines infertility as any condition causing the inability to achieve a successful pregnancy with or without medical intervention in an individual or a couple having frequent, unprotected intercourse for 1 year when the female partner is under 35 years old. This timeframe decreases to 6 months when the female partner is over 35 years old, highlighting the intrinsic link between fertility potential and age (1). Past research has well-established that both male and female factors contribute to a couple’s inability to conceive, with data demonstrating relatively equal rates of male and female pathologic etiologies (2). Despite this knowledge, historical data reveal a concerning discrepancy in the perception of infertility causes, where an enduring assumption persists that infertility is primarily attributed to the female partner. These misconceptions have led to global delays in seeking urologic care for male-factor infertility, thereby potentially exacerbating the already complex journey of infertility for many couples (2).

The attribution of infertility to women dates back to before the Medieval Period. This historical perspective has persisted into modern medicine, where male infertility remains underrepresented in research, underscoring the need for a more inclusive approach to understanding and addressing a couple’s infertility. From 2016–2019, the National Institutes of Health (NIH) funded 76 male-based reproductive research projects totaling about $60 million compared to the 99 female-based reproductive research projects funded totaling about $83 million, reflecting a gender gap of over $20 million in research investment (3,4).

Diagnostic and treatment processes for female patients with infertility are often risky, invasive, time-consuming, and expensive. Identifying the etiology of female-factor infertility may require cycle tracking, frequent blood testing, biopsies, and procedures such as hysteroscopy or exploratory laparoscopy. Medical treatment for women depends on the underlying etiology, ranging from hormone replacement therapy to ovulation induction with agents like clomiphene, which increases the risk of adverse outcomes such as multiple pregnancies, ovarian hyperstimulation syndrome, vascular thrombosis, and ovarian cancer (5). Moreover, in vitro fertilization (IVF) frequently subjects women to a range of physical and emotional stressors and has been shown to increase depression, anxiety, and negative self-esteem in the short term (6).

Gendered care-seeking patterns not only affect individual patients and couples but also carry significant implications for public health. The delayed diagnosis of male-factor infertility contributes to inefficient use of reproductive resources, prolonged time to conception, and increasing emotional and financial burden for both partners (7,8). In a global context of declining fertility rates, failure to adequately address male infertility risks compounds reproductive health disparities and limits access to care in already vulnerable population, particularly those in low income or rural communities, those that lack access to male fertility experts, and populations where stigma or lack of awareness limits male engagement in reproductive care (9,10).

This study assessed how delayed urologic care affects the emotional well-being of couples navigating infertility. By quantifying the effects of delayed male evaluation, this study sheds light on how gendered assumptions can shape, and often hinder, fertility care. Although this study is United States (US)-based, these findings reflect global patterns in male reproductive underdiagnosis, especially in resource-limited settings (9-11). As global fertility rates decline, early recognition and treatment of male-factor infertility will be critical to ensuring equitable and effective reproductive care (12). We present this article in accordance with the SURGE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0246/rc).

Methods

The study evaluated the impact of delayed care for male-factor infertility. An anonymous electronic survey, administered through Research Electronic Data Capture (REDCap) software, was distributed to all male patients seeking infertility services at two high-volume male infertility clinics within in our university hospital. Eligible patients were identified retrospectively through the Epic SlicerDicer function using International Classification of Diseases, 10^th revision (ICD-10) diagnostic codes for male factor infertility (E29 and N46) (13). The survey was designed to capture quantitative and qualitative aspects of participants’ reproductive care experiences before deciding to pursue urologic evaluation. Participation was voluntary and responses were collected anonymously. No incentives were provided and no follow-up reminders were sent.

The instrument included both binary response options and open-ended questions, allowing participants to elaborate on their experiences. Data collection took place from January 2023 to June 2025 and was emailed to 6,166 couples. Informed consent statements were included at the start of the survey. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Baylor College of Medicine (No. H-52819). All participants provided informed consent.

Statistical analysis

Descriptive statistics, including central tendency and dispersion measures, were used to summarize the quantitative data and provide an overview of patient-reported experiences. In parallel, qualitative responses were analyzed using thematic analysis to identify key patterns and concepts. Associations between categorical variables were assessed using Chi-square tests. Binary logistic regression models were constructed to evaluate predictors of regret regarding delayed urologic evaluation. All data were analyzed using IBM SPSS Statistics (version 27).

Results

Quantitative analysis

A total of 226 couples completed the anonymous REDCap survey (response rate =3.67%). Of these, 26.0% reported having sought gynecologic care before seeing a urologist for infertility evaluation, while 10.2% had consulted a reproductive endocrinologist before pursuing a urologic assessment (Table 1). Among those who had initially pursued non-urologic specialties, respondents indicated they had spent between 2 months and 6 years focusing solely on female-factor infertility [median =12 months, interquartile range (IQR) =5–24 months]. Additionally, 40.8% of respondents described their prior treatments as invasive and costly. The 38.3% of respondents expressed a wish that they had specifically sought out urologic evaluation sooner.

A subgroup of surveyed male patients had previously undergone chemotherapy and were referred to a urologist preemptively due to the increased risk of treatment-induced infertility. These patients were excluded from repeated analysis due to the confounding nature of their early referral. After excluding this subgroup, the proportion of respondents who regretted not seeking earlier urologic care rose to 44.0%. Furthermore, participants described the financial consequences of delayed male infertility diagnosis. While pursuing alternative medical pathways, patients reported paying between $1,500 and $300,000 before receiving urologic care, with several noting they had to take out loans to afford treatment (median =$3,000, IQR =$2,000–$20,000).

A Chi-square test showed a significant association between seeking female fertility care first and regret about not pursuing male evaluation earlier (χ²=26.54, P<0.001). Those who initiated care with a female-focused provider were more likely to express regret. Another Chi-square test found a significant link between reported financial burden and regret about delayed urologic evaluation (χ²=4.28, P=0.04). This analysis highlights that participants who experienced financial strain were more likely to report regret.

A binary logistic regression was conducted to examine whether initiating fertility care through female-focused providers predicted regret about not seeing a urologist sooner. Results showed that seeking female-focused care was significantly associated with increased odds of regret (β=1.1604, P=0.04). Participants who initiated care through an obstetrics and gynecology (OBGYN) or similar provider had approximately 3.2 times higher odds of regret [95% confidence interval (CI): 1.04–9.83] compared to those who initiated parallel partner workup. This suggests that female-first care pathways may delay appropriate male infertility assessment, leading to dissatisfaction with the process. A separate logistic regression model evaluated whether experiencing financial burden was associated with regret about not seeking male fertility evaluation earlier. Reporting financial burden was significantly associated with increased regret (β=1.5342, P=0.03). Participants who reported financial strain had approximately 4.6 times higher odds of regret (95% CI: 1.15–18.75) than those who did not. These findings highlight the economic consequences of delayed male evaluation and suggest that earlier male factor testing may reduce unnecessary financial and emotional strain on couples.

Qualitative analysis

Textual analysis of the free-response survey identified three major themes that emerged most frequently among respondents:

• The complexity and length of the infertility treatment process;
• The ambiguous role of urologists in male infertility care, as perceived by non-clinicians;
• High costs and financial strain (Table 2).

These themes were mentioned 35, 29, and 21 times, respectively. Additional concerns cited by participants included the need for non-gendered, comprehensive infertility testing and diagnosis, the impact of previously diagnosed medical conditions, and a desire for increased public outreach and educational support.

Discussion

Cost and access to treatment

The long-standing notion that infertility primarily resides within the female partner has created a system wherein the burden of diagnosis, treatment, and stressors brought on by medical procedures is disproportionately placed on women. This phenomenon not only impacts the lives of these women but also adds to the overall healthcare costs and resources allocated to unnecessary procedures and treatments (7,8).

In contrast, the initial workup for male infertility typically begins with a cost-effective and minimally invasive screening tool: the semen analysis. Yet, a recent study found that only 41% of OBGYN physicians considered a urological examination for a male partner, and only 24% would routinely refer out to urologist before ordering a semen analysis (14). As a first-line assessment for couples experiencing unexplained infertility, it is significantly less expensive and less invasive than many female-focused evaluations. However, male-factor infertility should not be dismissed based solely on a single semen analysis, as this can be misleading and may not accurately reflect current fertility status. While a single semen analysis has its limitations and may not fully capture a man’s current fertility status, it can still provide clarity for healthcare providers as an initial diagnostic step. However, an overreliance on female-oriented diagnostics can lead to a misallocation of resources, with significant financial and psychosocial consequences. Moreover, because male-factor optimization often requires several months to achieve measurable improvement, initiating this evaluation concurrently with the female-partner workup—rather than sequentially after it—may allow couples to avoid additional delay altogether and, in some cases, may improve the success of assisted reproductive technology by addressing modifiable sperm parameters before treatment begins.

In low-resource settings, where access to specialized urologic care is restricted, and culturally entrenched norms discourage men from seeking fertility evaluation, disparities in diagnostic pathways and access to reproductive treatments may be even more pronounced (11). Even in higher resource settings, such as in the United States, male fertility specialists are in short supply. In 2010, only 197 of these specialists were identified nationwide and only 390 advanced reproductive centers were in existence. Furthermore, at the time of that study, 13 states had no male infertility specialist, making it necessary for patients to cross state lines to receive this specialized care (15). In the context of increasing legal and political restrictions on reproductive healthcare following Dobbs v. Jackson Women’s Health Organization, including threats to IVF, it is more critical than ever to advocate for early, equitable, and cost-effective evaluation of both partners (16).

Emotional burden

Due to spending time on unnecessary treatments, female partners may experience the emotional turmoil associated with unknown causes of infertility (17). This emotional strain is compounded by concerns about advancing age as time goes by, as female fertility is intrinsically tied to age. With our patient data showing many couples waiting months to years to seek male infertility care, this delay can both narrow the potential window for effective treatment as well as increase the psychological burden associated with prolonged uncertainty.

However, infertility-related distress also significantly impacts male partners. Recent literature suggests that men may be more concerned with the financial and social aspects associated with infertility. In contrast, their female partners attribute higher stress to the number of clinic visits, social concerns, and sexual concerns (17,18). These differences highlight the complex emotional toll that infertility can have on both partners. Notably, the growing body of evidence shows that delays in infertility care are associated with poorer outcomes and increasing burdens, including financial, emotional, and clinical (19).

Social stigma

Our results indicate that many patients who delayed seeking urologic care later expressed regret for not doing so, highlighting the importance of public education and awareness surrounding male-factor infertility. While male infertility has been widely stigmatized in the past, a more inclusive process, spearheaded by public health efforts, may allow for the dismantling of these previous notions (20,21). Targeted educational campaigns can play a vital role in normalizing discussions about male infertility and available treatments, as well as dispelling existing myths (22).

Consistent with existing literature, survey responses indicate that many women view their gynecologist as a primary care provider, often due to the frequency of routine visits. In contrast, men are significantly less likely to receive regular urologic care, making it more burdensome to establish care (20). This lack of consistent care may limit feelings of social support among men facing infertility and contribute to delays in seeking treatment. Promoting regular urologic care through public education efforts could inform individuals about the importance of early evaluation and foster greater understanding and acceptance of male reproductive health, ultimately benefiting both partners.

Male fertility as a reflection of general health and modifiable risk factors

In addition to healthcare system factors and gender bias, previous research has identified environmental and lifestyle contributors that impact male fertility. These factors include exposure to endocrine-disrupting chemicals, poor diet, obesity, and chronic stress as significant influences on male fertility potential (23,24). When left unrecognized or untreated, these modifiable risk factors not only impair reproductive outcomes but may also delay appropriate diagnosis by obscuring the male contribution to a couple’s infertility.

Concurrently, male infertility is increasingly regarded as a potential biomarker of overall health. Impaired male fertility parameters have been associated with increased cardiovascular disease, metabolic syndrome, and endocrine dysfunction (25,26). Thus, prompt urologic evaluation may yield broader clinical insights, offering opportunities for early detection of underlying health conditions while guiding fertility treatment.

Infertility may serve as an early clinical indicator of more serious health risks, with studies linking male-factor infertility to elevated rates of testicular cancer, hypogonadism, and even premature mortality (27,28). Integrating male reproductive health into routine medical evaluations could, therefore, yield substantial health benefits, supporting both reproductive and systemic health, and reducing the downstream burden on female partners who might otherwise be subject to prolonged and avoidable interventions.

Global impact and ramifications

Neglecting male-factor infertility has global consequences, particularly in low-resource settings where access to fertility care is limited and gender norms often discourage male evaluation (29). This leads to delayed diagnoses, unnecessary female interventions, and inefficient use of scarce healthcare resources. As sperm counts decline worldwide and environmental risk factors increase, male reproductive health is becoming a critical public health concern (30). Standardizing early, equitable assessment of both partners can reduce disparities, improve outcomes, and promote more balanced, cost-effective fertility care across diverse populations.

Limitations

The single-center design of this study limits its generalizability to broader or international populations. Self-reported data introduces the possibility of recall and response bias, and voluntary participation may have led to selection bias, with individuals experiencing greater emotional or financial burden more likely to respond. Additionally, we had a relatively small sample size for data analysis, which may have limited the diversity of themes captured. Despite these limitations, the findings provide important insight into the consequences of delayed male infertility evaluation and highlight the need for more balanced and equitable reproductive care. This is further compounded by a low survey response rate (3.67%), which likely amplified the representation of respondents with strongly negative experiences and limits the generalizability of our findings. Additionally, because participants were recruited exclusively from patients already referred to a male infertility specialist, couples whose infertility was ultimately attributable to female factors alone—and who therefore never required male referral—are not represented in our sample, which may overstate the perceived benefit of earlier male-factor referral relative to real-world practice patterns in which female-only or concurrent pathways are appropriate.

Conclusions

Our findings underscore the need to reassess how infertility is evaluated and treated. A shift toward evaluating both partners early, supported by education for both patients and healthcare providers, can promote more balanced and effective care.

As the field of reproductive medicine continues to advance, innovations, such as integrated couple-based fertility evaluation models, offer promising avenues for improving the early detection and management of male-factor infertility. For providers, adopting these couple-centered models could be key to improving outcomes and reducing inequities in the face of a growing global fertility crisis.

Acknowledgments

The Abstract was presented at ASRM 2024 and SMSNA 2024.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0246/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0246/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0246/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0246/coif). L.I.L. serves as an unpaid editorial board member of Translational Andrology and Urology from November 2025 to December 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Baylor College of Medicine (No. H-52819). Informed consent was obtained from all participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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