Infertility and perceived chance of conception among men in Malawi

Abstract Infertility is a common experience among individuals and couples worldwide, but few studies focus on men’s reports of infertility or perceived chance of conceiving, particularly in high-fertility, pronatalist contexts where infertility is highly stigmatized. Using data from the fourth wave of the Umoyo wa Thanzi (UTHA) cohort study in rural Central Malawi (2017–2018), we examine the relationship between self-reported infertility, the perceived chance of conceiving within one year, and sociodemographic characteristics among men (N = 484). While 13% of men reported that they had experienced infertility, just 4% of men perceived that they were unlikely or there was no chance they would conceive with their partner within one year of having sex without contraception. In multivariable logistic regression models, older age was associated with experienced infertility (AOR: 1.06, p < 0.05) and higher parity was associated with lower odds of reporting that conception was unlikely or there was no chance of conception (AOR: 0.08; p < 0.05). We argue that additional research on infertility focusing on men is critical in gaining a more holistic and gender-equitable understanding of infertility. Including men in infertility research may also contribute to destigmatizing infertility among both women and men by acknowledging men’s roles in infertility.

Much of the research on the experiences and consequences of infertility has focused on women.Studies have shown that women face unique and severe consequences of infertility, stemming from expectations around motherhood in heteropatriarchal societies the world over (Cui, 2010;Fledderjohann, 2012;Miall, 1986;Remennick, 2000;Tabong & Adongo, 2013).Women's identities are often tightly linked to motherhood, particularly in settings where there are few social or economic alternatives to childbearing.Women's infertility is also more visible than men's infertility (Bornstein et al., 2020), as the absence of a desired or expected pregnancy in women is visible to others.However, the stigma and consequences women face for infertility do not exist in a vacuum.Infertility-related stigma is produced by norms around gender, power, and hegemonic masculinity (Connell & Messerschmidt, 2005).Thus, understanding men's experiences and perceptions of infertility may be an important factor in addressing infertility-related stigma and consequences for both women and men.While the impact of infertility on men is not well understood, several studies have shown that, similar to women's identities being tied to motherhood, men's identities may be tied to fatherhood, with severe consequences resulting from infertility, including social isolation and discrimination (Bornstein et al., 2020;Dhont et al., 2011;Hanna & Gough, 2017;Parrott, 2014).Such consequences may be exacerbated for men in pronatalist societies with relatively high fertility rates and where childbearing is highly valued and a marker of masculinity (Dyer, 2007;Nauck, 2007).
In general, research on sexual and reproductive health from men's perspectives is lacking (Greene & Biddlecom, 2000).In addition to issues around gender and power in society, the justification for focusing on women is demonstrated by three common assumptions: (1) men are not involved in matters of sexual and reproductive health and decision making, despite evidence that they do have a significant role (Gipson & Hindin, 2009;Kululanga et al., 2011;Miller et al., 2001;Shattuck et al., 2011), (2) men are unreliable research participants because their reports of sexual and reproductive health behaviours and outcomes (e.g.contraceptive use, time-to-pregnancy) are often incongruent with the reports of their female partners (Koffi et al., 2012;Miller et al., 2001;Shakya et al., 2018), and (3) reproductive health is more salient for women than for men, as women frequently carry both the blame and consequences for unfavourable reproductive outcomes (e.g.infertility, unintended pregnancy) (Dyer et al., 2004;Inhorn, 1996).
Despite the dearth of research on men's experiences with infertility and historical focus on women's bodies as the predominant source of infertility, evidence demonstrates that men contribute at least equally to the occurrence of infertility within couples.Clinic-based studies have attributed as much as 24-70% of infertility to male factors (Agarwal et al., 2015;Hull et al., 1985).A review conducted in 2020 found that 21% of infertility is attributable to male factors alone and an additional 20% is attributable to both female and male factors in the Africa region (Abebe et al., 2020).Studies conducted outside of infertility clinical care seeking often cannot differentiate between male and female factor infertility within couples.For example, a survey-based study in Malawi found that 20% of men reported ever experiencing difficulty conceiving with a partner (Barden-O'Fallon, 2005).However, studies also show that men are unlikely to perceive themselves to be infertile.For example, another study in Malawi that examined men's perceived likelihood of infertility found that 8% of men ages 21-29 years perceived they may be a little, somewhat, or very likely to be infertile, while the remaining 92% said they were not at all likely to be infertile (Polis et al., 2020).Notions of masculinity as tied to the ability to produce children, along with assumptions that equate male factor infertility with impotence, may contribute to low reports of perceived infertility among men (Moyo, 2013;Parrott, 2014).
The present study aims to describe the prevalence and characteristics of a cohort of men in Central Malawi who (1) report experiencing infertility and (2) report that they have low or no chance of conceiving with their partner within one year.Understanding characteristics of men who have experienced infertility and who perceive they may have low or no chance of conceiving is a first step in research that delves into men's experiences with infertility.

Data
Data for this study come from the Umoyo wa Thanzi (UTHA) research programme, a cohort study focused on sexual and reproductive health decision making among women and their male partners in Central Malawi.The cohort was recruited from the catchment area of a rural, non-profit hospital in 2013.The 68 villages in the catchment area were collapsed into 43 clusters based on size.Eleven clusters (19 villages) were randomly selected for inclusion in the cohort (Huber et al., 2017).All women ages 15-39 years residing in households within the selected villages were eligible to participate.Women could also refer their male partner(s) for enrollment and there were no age restrictions on male partners.At Wave 1, 1034 women and 442 of their male partners participated.Women who recruited their male partner(s) in Wave 1 were more likely to be married to their partner (97% vs. 66%) and less likely to be in a polygamous relationship (16% vs. 30%) than women who did not recruit their partner(s).Women who recruited their partner(s) also had slightly more children than women who did not (2.4 vs. 2.1) and fewer years of education (4.9 vs. 5.7 years) (not shown).These differences may indicate that men selected into the sample were in more stable and monogamous relationships than men not selected into the sample.At Wave 4 (2017-2018), enrollment efforts were expanded so that all men living within the cohort villages were eligible, whether or not their partner was in the cohort.In Wave 4, 75% of the 442 men who participated in Wave 1 were retained in the cohort (n ¼ 328) and an additional 293 men enrolled.There were no sociodemographic differences at Wave 1 between men who were retained in the cohort and those who were not.This study was approved by the Institutional Review Boards at The Ohio State University, the Malawi College of Medicine, and the University of California Los Angeles.

Analytic sample
The analytic sample includes men who participated in Wave 4 (N ¼ 621).Two participants were excluded because of missing data on the majority of variables and 82 men were excluded because they reported that they or their partner was sterilized.We also excluded 2 men who were over the age of 70 years and 51 men who had missing data for both main outcome variables in the analysis.This resulted in a total sample of 484 men.

Variables
We examined two variables related to infertility: selfreported infertility and chance of conception within one year (Table 1).We also examined several sociodemographic covariates, including age, number of living children, marital/cohabitation status, ever divorced, years of education, desire for another child ever and within the next 12 months, and household wealth.Wealth was determined by conducting principal component analysis on nine household assets, which loaded onto a single factor.We then split wealth into quintiles (Table 1).
Table 2 shows the full distributions of variables.In bivariable and multivariable analyses, chance of conception was recoded into two categories (certain/likely vs. unlikely/no chance) to account for a skewed distribution.Men who responded that they did not know their chance of conception (n ¼ 9) were excluded from bivariable and multivariable analyses.Small cell-sizes with respect to chance of conception limit our interpretation of those results.

Analysis
We conducted descriptive analyses examining characteristics of men associated with self-reported infertility and chance of conceiving within one year.We used Chi 2 tests and F-tests to examine differences in distributions and means.We then constructed two multivariable logistic regression models predicting the odds of reporting experienced infertility (vs.not experienced infertility) and the odds of reporting that conception within one year was unlikely or there was no chance (vs.conception is likely/certain).The multivariable models included independent variables with biological associations with infertility and chance of   et al., 2016;Deyhoul et al., 2017).The model predicting chance of conception also included desire to conceive within the next year as an independent variable because one's desire for an outcome (e.g.pregnancy) and assessment of the chance of that outcome occurring may be related (Sharot, 2011).

Results
Men in the sample ranged in age from 17-56 years (mean/median ¼ 31 years) with an average of less than six years of education (mean ¼ 5.7 and median ¼ 5.5 years) (a primary education in Malawi is 8 years).The majority of men were in monogamous (81%) or polygamous (8%) relationships.Among men in the sample who had ever been married (n ¼ 443; 91%), one-third of men had been divorced at least once (32%).A minority of men did not have any children (13%).Three-quarters (78%) wanted another child, although 73% strongly did not want to conceive within the next year.Thirteen percent of men reported that they and a partner had ever tried to conceive for two years or longer without conceiving in that time (experienced infertility).A small proportion of men (4%) reported that they and their partner were unlikely to conceive or there was no chance they would conceive within a year of having sex without contraception (Table 2).Among men who had experienced infertility, 13% reported that conceiving within a year was unlikely or there was no chance of conception compared to 3% of men who had not experienced infertility (p < 0.001) (Table 3).
From the variables we assessed, only older age was associated with experienced infertility (p < 0.05) (Table 4).A larger proportion of men who had experienced infertility were over the age of 45years (11%) than men who had not experienced infertility (4%).In bivariable analyses, there were no significant associations between sociodemographic variables and chance of conception.

Multivariable models
Older age was the only variable associated with experienced infertility after controlling for number of living children, marital status, household wealth, and education.For every year older, men in the sample had 6% higher odds of reporting having experienced infertility (AOR ¼ 1.06; p < 0.05) (Table 5).
After controlling for sociodemographic variables and desire to conceive in the next year, we found that men with four children had significantly lower odds of reporting that conception was unlikely or there was no chance of conception compared to men with one child (AOR ¼ 0.08; p < 0.05) (Table 6).The interactive association between age and number of children in a sub-analysis was not statistically significant (not shown).

Discussion
Our study reveals important insights into men's experiences and perceptions around infertility and chance of conception.Although a meaningful proportion of men reported that they had ever tried for two or more years to conceive with a partner without conceiving in that time (13%), very few reported that they were unlikely to conceive or there was no chance they would conceive with their partner within the next year if they did not use contraception (4%).Even among men who had experienced infertility, just 13% reported that they were unlikely or there was no chance they would conceive in the next year.These findings reflect community norms of pronatalism and general fertility optimism in this population (Garver, 2016).Notably, because our measure of experienced infertility was not partner nor time specific, it is also possible that men had experienced infertility with a previous partner, or infertility that had since resolved, explaining some of the incongruence between past experiences of infertility and the projection of future chance of conception.
Notions of masculinity may play a role in how men reported chance of conception.Previous studies in Malawi and the Africa region show that men's identities and social standing depend on their ability to have children and that men who experience infertility may be assumed impotent and thus not fulfilling masculine norms and cultural ideals (Inhorn, 1996;Moyo, 2013;Parrott, 2014).The stigma of male infertility in Malawi may cause some men who are infertile to discretely arrange for their partner to become pregnant by another man so as to give the impression that he himself is fertile (Bornstein et al., 2020).It may be socially or personally difficult for men to report low chance of conception.A study conducted in Mangochi district, Malawi where the majority of people identify as Muslim and as belonging to the Yao tribe (an area and population culturally different from our own study) found that almost 20% of men reported difficulties getting their partner pregnant, but only 5% of men reported themselves or their partner as infertile, indicating that perceived infertility (or self-labeling as infertile) may be influenced by social stigma of infertility (Barden-O'Fallon, 2005).Taken together with our study findings, pronatalist norms in Malawi appear so   strong and widely prevalent that even when men and couples have experienced infertility/difficulties conceiving, they are still hopeful they can conceive a future pregnancy or are unwilling to disclose that they are uncertain of their chance of conception.
Given the highly skewed distribution of the chance of conception variable, we must consider if the measure is relevant in our study population.However, our finding may be a valid representation of men's perceptions and realities, as the majority of couples (90%) will conceive within a year of trying to become pregnant or having sex without contraception (Taylor, 2003).We found no association between men's age and their reported expected chance of conception.Men remain fecund at older ages than women, meaning that their chance of conceiving within a year, as long as their partner is fertile, remains high over much of their life course; we lack the data in this analysis to assess the age of our participants' female partners.While studies suggest that men's fecundity declines as they age (Hassan & Killick, 2003;Kidd et al., 2001), most research focuses only on lower fertility rates among older men, which are likely due to norms around the timing of family formation and women's fecundity rather than men's (Harris et al., 2011;Matorras et al., 2011).
At first look, it may seem odd that we found that men with more children were more likely to perceive a low chance of conception, even when controlling for age.Men with more children may have a better sense of their typical timeline for conception than men with fewer or no children.Indeed, among men with no children in our study, 94% were under age 26 years, 65% had never been married, and 100% wanted children.These men were likely optimistic about their chance of conceiving because they had not yet begun having children and, perhaps, because they did not have much experience trying to conceive.
Our study lacks certain data that might be helpful in contextualizing certainty of conception.For example, we do not have data on relationship duration.Length of a relationship with a current partner would likely impact how certain one would be about their ability to conceive within a year.It is possible that men in shorter relationships would be more likely to be unsure of their ability to conceive with their partner in one year than men who had been in their relationships longer.Although just 9 men in our sample stated that they did not know their chance of conceiving within one year, a deeper look into this group shows that the majority had never been married (n ¼ 5) or were not currently married (n ¼ 1).
Unlike chance of conception, reports of experienced infertility among men in our study did vary by age.Along with fertility declines at older ages (Hassan & Killick, 2003;Kidd et al., 2001), men who are older have had a longer exposure to the possibility of conceiving, and, therefore, a longer exposure to the possibility of not conceiving, than younger men.Additionally, 8% of men in our study were in polygamous relationships.Although multiple concurrent partners should not impact men's reports of ever experienced infertility with a partner, it is possible that men were less likely to report that they experienced infertility if they were in a concurrent relationship where at least one of their partners became pregnant in less than two years.We did not find differences in reports of infertility by relationship status, although the small sample size of polygamous men may have impacted our ability to detect differences.
A limitation of our study is the relatively small and select sample.Unlike the women's UTHA cohort, the men are not a representative sample and are, indeed, select in many ways.Participants in the study had to be available for data collection, meaning that men who travelled for work are likely disproportionately excluded.In the first wave, men had to be invited into the cohort by their female partner.Of note, women with partners who had more than one wife were less likely to invite their partner to participate, meaning that polygamous men may be underrepresented.Women who were not married to their partner were also less likely to invite their partner to participate and, as such, unmarried men are also likely underrepresented in our data.Moreover, the relatively small sample size overall, and small cell sizes with respect to the certainty of conception variable, temper our ability to draw conclusions.On the whole, we found few significant relationships within our data.We suggest that future population-based surveys that include men should incorporate infertility and certainty of conception questions so that the field may gain a clearer picture of these phenomena.
A unique strength of our study is its focus on men, which is uncommon in infertility research (Culley et al., 2013;Fledderjohann & Roberts, 2018).Studies that measure infertility typically do so using women's reports.It is even common for studies to ask women if their male partner is infertile, rather than asking men themselves (Boivin et al., 2007;Fledderjohann & Roberts, 2018).There is little evidence to suggest that men are unable to accurately report on their own experiences, although women's reports are conventionally considered more accurate (Koffi et al., 2012;Miller et al., 2001;Shakya et al., 2018).Dismissing men's accounts of their own experiences with sexual and reproductive health and infertility in particular reinforces harmful gender norms that impact both women and men (Fledderjohann & Roberts, 2018).Women are frequently tasked with controlling reproduction and are therefore blamed for infertility.By asking men about their own experiences, researchers can reinforce men's shared responsibilityboth biologically and sociallywithin the realm of sexual and reproductive health.Research is increasingly recognizing the importance of a rights-based approach in sexual and reproductive health, which should implore us to ask men about their own bodies, just as we ask women about their own bodies.

Table 1 .
Infertility-related constructs and survey items.
aWe dichotomized response options for chance of conception into 'no chance/unlikely' vs. 'likely/certain' based on distribution of responses (shown in Table2).

Table 3 .
Associations between experienced infertility and chance of conception (N ¼ 460) a .

Table 4 .
Bivariable associations between participants' sociodemographic characteristics and experienced infertility and chance of conception a .Ã p < 0.05; NS: not significant; p-values are for Chi 2 tests (categorical variables) and F-tests (continuous variables). a

Table 6 .
Logistic regression model predicting that conception is unlikely or there is no chance (N ¼ 454) a .