10th Postgraduate Course for Training in Reproductive Medicine and Reproductive Biology
Male reproductive health research needs and research agenda: Asian and Pacific perspective
Yi-Fei WANG
Area Manager for Asia and the Pacific
UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and
Research Training in Human Reproduction, Department of Reproductive Health
and Research
World Health Organization
20 Avenue Appia, CH 1211 Geneva, Switzerland
Key words: male reproductive health, research needs, research agenda, Asia and the Pacific.
Abstract
Male reproductive health, including increasing men’s participation, involves encouraging a range of positive reproductive health and social behaviour by men to help ensure women’s and children’s well-being. More intellectual work including research programmes is urgently needed to clarify the conceptual framework for male reproductive health. At the Asia and the Pacific Symposium ‘Intra-regional Cooperation in Reproductive Health Research’ (Shanghai, China, 12-13 October 1998) the Symposium participants identified the regional research needs, as well as recommended a regional reproductive health research agenda, among which there are six key issues related to male reproductive health: i) male contraceptive technology; ii) reproductive tract infections (RTIs)/sexually transmitted diseases (STDs) and male infertility; iii) male involvement in reproductive health; iv) male adolescent reproductive health; v) male reproductive ageing; and vi) environment and male reproductive health. One of the major challenges now facing us is the elaboration of a comprehensive, yet realistic, male reproductive health research agenda that reflects the needs and demands of Asian developing countries. To this end, to make full use of an interdisciplinary approach is of strategic importance.
At the 1994 International Conference on Population and Development (ICPD), held in Cairo, Egypt, representatives from more than 180 countries formally recognized the importance of men to women’s reproductive health and also recognized the importance of men’s own reproductive health.1 The ICPD Program of Action urges all countries to provide men and women with reproductive health care that is ‘accessible, affordable, acceptable, and convenient’.2
The ICPD Program of Action encourages reproductive health care programmes to move away from considering men and women separately and to adopt a more holistic approach that includes men and focuses on couples. It also draws attention to the unfairness inherent in many men’s and women’s gender roles, calling for men to take more responsibility for household work and child-bearing. Similarly, the report of the 1995 United Nations Fourth World Conference on Women, held in Beijing, China, encourages men to take steps toward achieving gender equality and better reproductive health.3
Profoundly life-affirming and life-threatening conditions make up reproductive health for both men and women. Estimates of reproductive ill-health worldwide indicate an unacceptably high prevalence of preventable conditions, unnecessary suffering, and often devastating consequences for individuals and families:- Every year, at least 120 million women who do not want to become pregnant do not have the means to prevent it;
- Every year, 20 million women put their health and lives at risk because they seek unsafe abortion;
- Every year, there are more than 330 million new cases of curable STDs and one in 20 adolescents become infected;
- Every year, the HIV infects 5.2 million people, over half of them young people below 24 years old.
Between 5% and 15% of the global burden of disease is associated with failures to address reproductive health needs. These figures are alarming in themselves - but they are still only the tip of the iceberg. The total burden for men and women remains inadequately documented and measured.4
Increasing men’s participation involves more than programme activities conventionally associated with men, such as preventing and treating STDs, promoting condom use, or opening male clinics. It also involves encouraging a range of positive reproductive health and social behaviour by men to help ensure women’s and children’s well-being. As the new thinking has evolved, a consensus is forming. To improve women’s and men’s reproductive health, policies and programmes must:- Encourage men to take more responsibility for their sexual behaviour;
- Increase men’s access to reproductive health information and services;
- Help men to communicate with their partners and make contraceptive choices together; and
- Address the reproductive health care needs of couples. More intellectual work including research programmes is urgently needed to clarify the conceptual framework for male reproductive health.5
- male contraceptive technology
- RTIs / STDs / HIV / AIDS and male infertility
- male involvement in reproductive health
- male adolescent reproductive health
- male reproductive ageing
- environment and male reproductive health
- Asia has the highest population of all the regions – with two countries (China and India) accounting for more than 40 per cent of the world population. There are still large segments of the Asian population whose fertility regulating needs are not met by the current available methods and services;
- In many Asian countries, STDs rank among the top five conditions for which men and women seek health care services. Multiple sex partners, the primary risk factor for STDs and RTIs, are far more common among men than women;
- It is estimated that by the year 2000, more that 10 million men, women and children are likely to become infected with HIV within the WHO South-East Region, accounting for over 25 per cent of the global cumulative infections;
- In several parts of Asia, ‘infertility’ services do not exist, and accessibility and availability of general health services are very limited, while in some other countries of Asia, infertility consumes a large proportion of reproductive health services resources, in terms of detailed, sophisticated and costly clinical and laboratory examinations and treatments stretched out over a period of months, even years;
- Surveys in Asian developing countries show that between 9 - 48 per cent of the pregnancies and births to women under age 20 are mistimed or unwanted; in most Asian countries, up to one-third of STDs occur among adolescents below the age of 20 years;
- Increases in the older population by up to 300 per cent are expected in many Asian countries within the next 30 years. There will be 274 million people over the age of 60 years in China alone – more than the total present population of the United States;
- Asia is the world’s most polluted and environmentally degraded region. It has been hypothesized that environmental exposure to pesticides, industrial chemicals, synthetic products and some metals has the potential to disrupt the endocrine system of men, resulting in declining semen quality and increased abnormalities of the male genitalia, including testicular cancer, hypospadias and cryptorchidism.
Male Contraceptive Technology
The Programme is involved in the development of both improved versions of existing methods (in order to make them safer, more effective and more acceptable) as well as of new technologies and interventions that will fulfil an expressed but a yet unmet need.
Contraception options for men are extremely limited. By far, the most common male contraceptive methods in use today are the condom, vasectomy and withdrawal. Many of the changes in the fertility regulating environment have been the result of the HIV epidemic and the increase in STDs and RTIs and have resulted in calls for methods that not only protect against pregnancy but also protect against STDs, so-called ‘dual protection’. Both new male methods and barrier methods are among the high-priority research and development areas. For the time-being, there are two male contraceptive technologies that have been identified as high priority leads by the Programme: 7
1. A three-monthly injectable levonorgestrel butanoate plus testosterone buciclate; or testosterone buciclate alone
A number of studies in animals and men have shown that the administration of androgen alone, combinations of gonadotrophin-releasing hormone and androgen, and progestogen and androgen combinations can suppress gonadotrophin secretion and spermatogenesis either completely to azoospermia or to a sufficiently low level of oligozoospermia to render the treated individuals infertile. Furthermore, discontinuation of treatment leads to full recovery of gonadotrophin secretion and spermatogenesis and return of fertility. The objective of ongoing studies is to establish the minimal doses of the progestogen required to ensure consistent inhibition of spermatogenesis and of the androgen required for testosterone replacement, and to evaluate contraceptive efficacy, reversibility and user acceptability of the approach.
2. Non-surgical vas occlusion (silicone plugs)
It will be a reversible method by occluding the vas deferens that does not require surgery for application nor complicated microsurgery for reversal. The objective of ongoing studies is to assess the safety (local tolerableness and side-effects), efficacy, reversibility (ease of removal of the silicone plugs) and the return to fertility after removal of the plug.
In addition to the endocrine feedback loops referred to above, there are many cellular and molecular events in the male reproductive activities that are unique to the male reproductive tract, which could be considered as the potential targets for male contraceptive development.8
RTIs/STDs/HIV/AIDS and Male Infertility
RTIs, including STDs, have been a neglected area in public health in may Asian countries, in spite of overwhelming evidence of their impact on health, particularly that of women, young people and neonates. The burden of disease is particularly severe in South and South Eastern Asian developing countries, characterized by high incidence and prevalence, a high rate of complications, the problem of antimicrobial resistance, and the increased risk of HIV infection. STDs and RTIs are often easily detectable in men than women and, with prompt and complete treatment, complications in self and female partner could be avoided. In many Asian countries, the problems of infertility in men and women arise primarily because of untreated genital infections. To meet existing demands, emphasis has to be put on prevention and management of RTIs/STDs/HIV/AIDS and infertility, starting at the primary health care level, supported by adequate and efficient referral systems.9
Male Involvement in Reproductive Health
Whereas the process of reproduction entails mutual responsibility, men’s participation in reproductive health is mostly negligible and neglected in many Asian developing countries. Thus, research that address the behaviour of men is seen as essential. In many Asian societies where men are the key decision-makers within the home and community, they can also be key advocates or opponents of contraceptive use and/or reproductive health decisions, with consequences for self, partner, community and society at large. The aim of research in this area is to assist in identifying strategies that create an enabling environment; to establish ways of reaching men with the view to positively influencing their reproductive health care seeking behaviour, including participation in fertility regulation, the practice of safe sex, the early seeking of clinical care for diagnosis and treatment of STDs/RTIs, men’s support for maternal health and prevention of unwanted pregnancies and unsafe abortion; to establish acceptable options for regulation of male fertility and be responsive to their specific reproductive and sexual dysfunction problems.
Male Adolescent Reproductive Health
Research in this field should identify the best approaches for reaching the young men, especially the male adolescents. It is important to influence social norms before they take hold. As men become adults, behaviour patterns, values and susceptibility to peer pressure become difficult to change. Although less likely to be targeted in reproductive health services, young men are more likely than young women to be sexually active, to have multiple partners and to begin sexual activity early. The aim of research in this field is to establish or strengthen, through research, the national capacity to develop, implement and evaluate policies and programmes, including services in Asian countries, that support healthy sexual development and maturation, and sexual and reproductive health behaviour for male adolescents.10
Male Reproductive Ageing
In Asia, there are more than 200 million men between the ages of 40 and 55 who are now going through the so-called male menopause. In less than 25 years, the number of men going through male menopause will grow to approximately 400 million in Asia. The aim of research in this field is to improve understanding of the physical, mental, sexual and reproductive health consequences of male reproductive ageing and promote effective management of male menopause.
Environment and Male Reproductive Health
Although quite a few studies point out that the semen quality has deteriorated over the past 50 years in some western countries, the hypothesis that men has impaired fertility because of exposure to environmental pollution has had no scientifically sound evidence yet. In addition, these findings have been contested by some authors, who suggested that these studies may have been flawed by inappropriate research methods or that the differences could be geographical. In considering that there are nearly no systematic and well-designed studies conducted in Asia, Africa and Latin America, the Programme is developing a multicentre study ‘Sentinel Surveillance on Waiting Time to Pregnancy and Semen Quality’ in Asia, Africa and Latin America. The overall objective of this programme is to investigate the possible association of defined semen parameters and other reproductive characteristics of men from geographically different settings with achieving a pregnancy.
One of the major challenges now facing us is the elaboration of a comprehensive, yet realistic, male reproductive health research agenda that reflects the needs and demands of Asian developing countries. To this end, to make full use of an interdisciplinary approach is of strategic importance. The most creative insights and productive leads are most likely to emerge from a research team that is interdisciplinary, especially in the field of reproductive health.
REFERENCES
1 United Nations Population Fund (UNFPA) (1995) Guidelines on reproductive health for the United Nations resident coordinator system. UNFPA Task Force on ICPD Implementation, p.89, UNFPA, New York
2 United Nations (UN) (1995) Programme of Action of the International Conference on Population and Development (Cairo). p.115 , UN, New York
3 United Nations (UN) (1995) Report of the Fourth World Conference on Women, Beijing, China. p.180, UN, New York
4 Drennan, M. (1998) New perspectives on men’s participation. Population Reports. Vol. XXVI, No. 2
5 World Health Organization (1999) Statement by Dr Gro Harlem Brundtland, Director-General, World Health Organization at ICPD + 5 Forum, The Hague, 8-12 February, 1999. World Health Organization, Geneva, Switzerland
6 Wang, Y.F. (1999) Male reproductive health research needs and research agenda: Asian and Chinese perspective. Asian Journal of Andrology (1):13-20
7 UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development & Research Training in Human Reproduction (1999) Annual Technical Report 1998. World Health Organization, Geneva, Switzerland
8 Wang Y.F., Zhu Y.F. (1998) Basic science research leads toward novel male fertility regulation approaches. Chinese Journal of Andrology, 12:177-182
9 UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development & Research Training in Human Reproduction.(1998) Report of the consultation meeting on strategies for research on reproductive tract infections, Geneva, Switzerland, 18-20 November 1998. World Health Organization, Geneva, Switzerland
10 Adolescent Health & Development Programme, WHO (1998) Considering the special needs of adolescent boys. World Health Organization, Geneva, Switzerland