Tailing off: Inside Kenya's male fertility crisis

When everyone was celebrating New Year’s Day, Wekesa Wasike was on the road in a bus from Kitale to Nairobi because his entire existence depended on it.

He had come to the conclusion that everything about his virility was wrong after his girlfriend fell into another man’s arms who wasted no time in getting her pregnant.

“That made me realise that all along the problem was not with her but me,” the 32-year-old mechanic opens up to Healthy Nation.

Heartbroken and frustrated, he shared his predicament with a relative who would recommend that he make the journey to Fertility Point, a fertility clinic in Upper Hill, Nairobi.

When we visited the centre, we established that Wekesa was not alone. We counted 12 men and 36 women queueing to be served.

Distressed by the inability to procreate, they all looked anxious and even the sight of our press cards was vividly a nerve-racking feeling as they turned away their faces.

But Wekesa remained confident to speak. He questioned county governments’ incapacity to invest in access to affordable fertility treatment in rural Kenya, which coerces many Kenyans to travel hundreds of kilometres to see fertility experts in the city.
Low sperm count

His National Health Insurance Fund cover expired and because he could not afford to part with Sh500 every month or pay for the fertility treatment, his uncle came to his rescue and after a series of tests at the clinic, the experts told him what he had all been suspecting. He had a very low sperm count.

“I have observed that it is not easy to find a woman who understands this type of situation when her friends are giving birth,” a distraught Wekesa says.

The male fertility issue characterised by a low sperm count is called oligozoospermia.

The World Health Organization (WHO) classifies sperm counts at or above 15 million sperm per millilitre (mL) of semen as average. Anything below that is considered low and is diagnosed as oligozoospermia.

In Nairobi’s Central Business District, a 35-year-old female business manager who begged for anonymity reveals that she dated a man for three years until he told her that he had a fertility problem.

After a while he told her he wanted to get checked and agreed because “I could see he was shooting blanks.”

The first time they went for the test he was told he had poor quality semen. That was the end of their relationship.

“He knew he couldn’t give me children and his family wouldn’t understand he was the problem,” she narrates.

She was dispirited by that reality she thought she had finally met someone she would have a future with “but his low fertility changed everything.”

She remains glad he told her about it as most men would go silent about it and watch as their female partners get blamed for childlessness.

“Others won’t even go to get tested and opt to leave their female partners moving from one doctor to another trying to find out the problem,” she says.

She even tried to follow a stereotypic advice from her therapist that she focus more on the pleasure of sex rather than the ejaculation of her partner but nothing changed.

But according to Dr Rajesh Chaudhary, the lead in-vitro fertilisation (IVF) specialist at Fertility Point the quality of sex does not in any way affect the quality of sperms, and having a low sperm count can make it more difficult to conceive naturally though successful pregnancies can still occur.

He says about one third of infertility cases diagnosed today are due to male factors and in Kenya, sperm morphology, motility and volumes have all been on the decline.

Declining sperm quality

“We have analysed samples from 2,500 Kenyan men aged between 30 to 60 years in the past three years and our findings show 2,000 of these men had a low sperm count,” he discloses.

He adds that when men hit 45 years of age, their sperm quality declines because of DNA fragmentation but that is now evident in young men.

Word Bank data shows that Kenya’s fertility rates have declined from 7.3 children per woman in 1960 to 5.1 in 2000.  In 2020, it waned to 3.3 children per woman.

Adolescent fertility rates stood at 107 births per 1,000 girls but that has reduced to 73 births per 1,000 girls aged between 15 and 19,  the data discloses. 

Dr Chaudhary points out that in many cases, it is not obvious what causes a low sperm count.

“Sometimes problems with sperm count and quality are associated with hormonal imbalance, such as hypogonadism (reduced hormone production), a genetic problem such as klinifelter syndrome.”

Klinifelter syndrome is a condition where men are born with an extra X chromosome, having had undescended testicles as a baby, a structural problem , previous surgery to the testicles or hernia repairs.

It also manifests itself when testicles become overheated, or when men sink in excessive alcohol consumption, smoking, using drugs such as marijuana, cocaine or miraa and medications including testosterone replacement therapy, long-term anabolic steroid use, cancer medications including chemotherapy, some antibiotics and antidepressants as well as being overweight or obese.

The expert adds that there is a possibility of low sperm count being a hereditary issue but the cases are very few.

“It is advisable to do a genetic test as well as a microdeletion test that provides information about the health of your still- developing baby, he says.

As a first step of a man’s fertility investigation, he is asked to undergo a physical examination and fertility experts evaluate his medical history, taking into account his personal and family background, social and environmental factors that can influence your fertility.

A semen analysis is usually ordered to measure any abnormalities in the morphology and motility of the sperm. 

He explains that a specialist helps to diagnose the issue and recommend treatments or procedures that can result in conception.

“Most of the time people are in a hurry but these treatments take months to bear fruit. Couples are not usually willing to wait for long yet sometimes there can be totally no sperm in the semen and so we try to find out whether the testes are manufacturing sperms or not, the sperm is being delivered to the urethra because maybe the ducts are faulty and once we have identified the problem, we then recommend the procedure needed.”

Dr Chaudhary says the clinic offers four treatment options.

The first is the Testicular Sperm Aspiration (TESA) which is a surgical procedure performed under local anaesthesia that includes passing a tiny needle directly into the testicles to retrieve seminiferous tubules.

TESA is generally performed in men where there are no spermatozoids in the ejaculate (also called azoospermia).

The seminiferous tubules are later checked in a laboratory to check for presence of sperm later to be used in an IVF-ICSI cycle.

The second procedure is known as Testicular Sperm Extraction (TESE) which is a surgical procedure to remove a small amount of testicular tissue or epididymal fluid in the testicle.

“These tissues are later transported to the laboratory to extract viable sperm from biopsy specimen that can be used for Intracytoplasmic Sperm Injection (ICSI) or In Vitro Fertilisation (IVF),” he explains.

TESE is performed under local anaesthesia and is done in men who have a blockage in the ducts that are supposed to carry sperm from the testicle and there are no sperms in the ejaculate to succeed with IVF.

The third procedure is Percutaneous Epididymal Sperm Aspiration (PESA) which is a technique used to insert a syringe into the epididymis and then aspirating the fluid.

The epididymis is a coiled tube in the back of the testicle that carries sperm from the testes to the ductus deferens in the male reproductive system.

“PESA is used on men who have had a prior vasectomy, congenital abnormality or infection. The procedure can be done either under a local anaesthetic or sedation.”

The fourth is Microsurgical Epididymal Sperm Aspiration (MESA) which is a surgical procedure to retrieve high number of sperms with optimal quality from a fully formed or only partially formed epididymis.

Dr Chaudhary explains that a small incision is made in the scrotum exposing the epididymis so that the sperm can be aspirated directly from the epididymis.

“An operating microscope is used to locate an epididymal tube to extract sperm,” he says.

The retrieved sperm, he delineates, can be used immediately for IVF/ ICSI cycle or cryopreserved for future use. MESA is recommended for men with a total absence of sperm in ejaculation and reproductive tract blockage.

“MESA is the best way to retrieve sperm when sperm retrieval through TESA fails.”

The IVF expert discloses that a microsurgery procedure at their facility costs Sh100,000, a huge amount for the average Kenyan man.

Four main IVF treatment options exist.

They include IVF using own eggs and a partner’s sperm, IVF using own eggs and donor sperm, IVF with donor eggs and a partner’s sperm and IVF with donor eggs and donor sperm.

The procedure is the most effective fertility treatment available and has high chances of success according to the expert.

Fertility Point officials disclosed to Healthy Nation last year that they get 20 to 25 patients per day, which works out to 400 a month but the number has increased this year to between 30 and 40 patients per day.

Sperm freezing, the process of collecting, analysing, freezing and storing a man’s sperms, costs Sh40,000 at the facility.

The frozen samples are later used for fertility treatments or donated to couples or individuals, including same-sex female partners.

“This overall process is known as cryopreservation and is sometimes referred to as sperm banking,” he says.

The cryopreservation process involves routine screening for infection (HIV, hepatitis and rapid plasma reagin test for syphilis), providing a semen sample or undergoing a sperm extraction, lab analysis of sperm quantity and quality, freezing of viable sperm and storage of the sperm indefinitely.

The benefits of freezing sperms is to allow a man to preserve his fertility by using his sperm at a later date.

Gonadotrophin medicine

If it is found that a man has very low levels of gonadotrophin hormones (which stimulate the production of sperm), he is treated with gonadotrophin medicine to improve fertility.

But if no cause has been found for the abnormal sperm count, he is offered hormone-based medicines .

Dr Chaudhary adds that a couple has to part with a total of Sh450,000 for an IVF procedure, an amount only wealthy families can afford.

“The injection costs between Sh100,000 and Sh150,000, depending on the ovary in reserve while pre-IVF assessment scans and blood tests can cost up to Sh100,000,” he says.

He urges men to make a habit of getting their sperm count checked.

“Fertility problems affect men and women. It is important you do a semen analysis if you have not managed to conceive after a year of trying to make a baby.”

Researchers observe that thousands of men have been cured of oligospermia with the help of Ayurveda treatment.

According to Johns Hopkins Medicine, Ayurveda is a natural and traditional system of medicine that originated in India more than 3,000 years ago.

Based on the idea that disease is due to an imbalance or stress in a person’s consciousness, Ayurveda encourages certain lifestyle interventions and natural therapies to regain a balance between the body, mind and the environment.

They treat patients through medication, diet plans, and exercises.

“All these factors are combined and work as an effective treatment to cure oligospermia. Our treatment works on the spermatogenesis process and enhances sperm concentration in semen,” Dr Narendra Goyal, a lecturer and wellness researcher in Udaipur, India, told Healthy Nation.

“It also improves sperm morphology and motility. Advanced Ayurveda treatment helps patients to reverse infertility symptoms like low sperm count, sperm motility, poor sperm morphology, asthenozoospermia, premature ejaculation and erectile dysfunction,” he says while pointing out that Ayuverdic treatment clinics currently operate in Nairobi.

Legal hurdles

Stephanie Musho, a human rights lawyer based in Nairobi who is also a sexual and reproductive health rights expert says assisted reproduction operates in a vacuum in Kenya – bringing up legal and ethical considerations, as there is no law to govern it even as 4.2 million men and women in Kenya need some form of assistance with reproduction. 

As it stands, various services are available but are the preserve of the rich because procedures such as rounds of IVF cost millions of shillings.

“The courts have held that despite the genetics belonging to the man who gave of his sperm and the lady of her ovum, parental rights and responsibilities remain with the surrogate mother until a time where a process of adoption has been successfully completed,” she elucidates.

Recently, the Reproductive Health Bill 2019 led by Nakuru Senator Susan Kihika did not see the light of day due to ‘technicalities’.

Ms Musho says Part Three of the proposed law focused on assisted reproduction with Section Nine giving every person in the country the right to assisted reproduction.

“This would have been effectuated by the national government in collaboration with the county governments to provide affordable, accessible, acceptable and quality assisted reproduction services,” the lawyer believes.

In 2014, a similar bill sponsored by Senator Judith Sijeny was shot down in parliament. Two years later, the Assisted Reproductive Technology Bill 2016 fell through.

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