Abstract
Addressing male infertility issue before marriage, at least to the mate and her family, seems reasonable to avoid several psychosocial, economic, and biological consequences. Here, we intended to comprehend whether fertility testing (i.e., semen analysis) for men before marriage is acceptable and can be applied in Jordanian society. To achieve this contribution, we designed a questionnaire that shows the opinion of a sample of the Jordanian population in applying fertility testing for men before marriage. 740 adult individuals (> 18 years old, 364 males, 382 females) were selected randomly from different martial, economic, social, ethnic, religious, and education statuses to fill the questionnaire. A 523 (70.11%) of participants had a positive attitude toward applying fertility testing for men before marriage. This opinion was found not to be affected by gender (P = 0.305), age (P = 0.329), body mass index (P = 0.061), smoking (P = 0.059), monthly income (P = 0.094), education level (P = 0.131), and family members with infertility (P = 0.074); while, it is found to be affected by the social status of the participant (P = 0.004). In conclusion, applying fertility testing for men before marriage appears to be acceptable in Jordanian society.
Keywords: Fertility testing, infertility, men, Jordanian, marriage
Introduction
In 2013, infertility has been defined as a disease in the reproductive system, in which couples are unable to conceive or achieve a clinical pregnancy for more than 12 months or more following continuous intercourse (Practice Committee of American Society for Reproductive, 2013). In general, the male factor in this disease accounts for approximately 50% (Banihani, 2016; Kumar and Singh, 2015); while, the distribution of male infertility varies (~ 20% – 70%) between regions around the world (Agarwal et al., 2015). For example, in 2015, the lowest male fertility was registered in Africa (~ 20 – 40%) (Agarwal et al., 2015).
Worldwide, according to the results by Agarwal et al. (2015), at least 30 million men were infertile (Agarwal et al., 2015). In Jordan, currently, no explicit published percentages on male infertility as a separate factor. While, in general, in the Middle East including Jordan, male factor infertility, as one of the multiple factors involved in infertility among couples, reached approximately ~ 60 – 70% (Agarwal et al., 2015).
As a disease, male infertility is due to poor semen quality, which is a measure of the ability of semen, typically sperm quality and quantity, to achieve fertilization (Banihani, 2018; Vander Borght and Wyns, 2018). Therefore, semen analysis is the topmost indicator of semen quality, and hence the best assessment of male infertility.
Actually, infertility after marriage has a broadband of different psychosocial (e.g., abortion, divorce, remarriage, marital dissonance, etc.), economic, and biological consequences (Luk and Loke, 2015; Mitsi and Efthimiou, 2014; Rouchou, 2013; Sami and Ali, 2006). Currently, in Jordan, such consequences are pronounced due to increased rate of infertility in both genders (Daibes et al., 2018). Therefore, at least in part, avoiding the unnecessary psychosocial or biological trauma associated with the male barrenness seems reasonable and could be ethical; however, the ethics of such issue required to be comprehensively addressed considering all contributing factors (e.g., religious, social, economic, etc.). In this work, we intended to examine whether fertility testing (semen analysis) for men before marriage is acceptable and can be applied in Jordanian society, especially, that human semen test has become available at low cost in almost all public and private laboratories.
Methodology
This study was conducted in various regions in the north of Jordan during the period from June 2016 to April 2017. A sample of 746 adult individuals of both genders was selected randomly from different martial, economic, social, ethnic, religious, and education statuses. Participants were approached at their homes, classes and work places.
A questionnaire was given to each selected individual to answer certain questions related to his opinion of considering fertility testing for men before marriage. All aims, terms, and questions were explained to each individual before he/she fill the questionnaire. The questionnaire was anonymous, and all personal information about recruited subjects were confidential. The Institutional Review Board approval of Jordan University of Science and Technology the protocol of this study. Data were gathered into groups and only the investigators were allowed access to the data.
The questionnaire collected information that included demographic data, whether the participant agree (or not) to men’s fertility-testing before marriage, causes of the agreeing or disagreeing, and applicability of the men’s fertility testing and its impact on marriage decision.
The obtained data was analyzed using the SPSS (Statistical Package for the Social Sciences, version 21.0, SPSS Inc., Chicago, IL, USA). Frequency analysis of responses was carried out, and the results were tabulated, and compared using the chi-square goodness-of-fit test. For all statistical analyses, the significance level was set at P < 0.05.
Results
As illustrated in Table 1, male to female ratio was 49:51 in the study sample. Of the participants, 35.6% were ≤ 25 years old and 27.6% were 25–35 years old, the remaining participants were > 35 years old. About 53.4% (399) of the participants had a bachelor degree. In addition, 42.7% of the participants were single and 34.9% were smokers. In addition, 19.3% of the participants have family members with infertility.
Table 1:
Demographic variables of the sample.
| Variable | N(%) |
|---|---|
| Gender | |
| Male | 364(48.7%) |
| Female | 382(51.1%) |
| Age | |
| ≤25 | 266(35.6%) |
| 25–35 | 206(27.6%) |
| ≥35 | 275(36.8%) |
| BMI | |
| ≤24.99 | 344(45.9%) |
| 25–29.99 | 238(31.7%) |
| ≥30 | 167(22.3%) |
| Smoking | |
| Yes | 261(34.9%) |
| No | 486(65.1%) |
| Income | |
| ≤400 | 244(47.8%) |
| >400 | 266(52.2%) |
| Education | |
| Less than high School | 53(7.1%) |
| High School | 132(17.7%) |
| Diploma | 88(11.8%) |
| Bachelor | 399(53.4%) |
| Graduate degree | 72(9.6%) |
| Social Status | |
| Single | 319(42.7%) |
| Married | 428(57.3%) |
Table 2 shows the attitude towards fertility testing and causes for agreement or positive attitude towards fertility testing as per demographic variables of the studied sample. As shown in the table, 523 (70.11%) of participants agreed to apply the fertility testing for men before marriage. This opinion was not affected by gender (P = 0.305), age (P = 0.329), body mass index (P = 0.061), smoking (P = 0.059), monthly income (P = 0.094), and education level (P = 0.131), family members with infertility (P = 0.074); while, it is found to be affected by the social status of the participant (P = 0.004).
Table 2:
Attitudes toward fertility testing and causes for agreement or positive attitude towards fertility testing as per demographic variables of the studied sample.
| Agree to fertility testing | Causes for agreement | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Avoid future marriage issues | Divorce or separation | Infertility is not an issue due to the presence of assisted reproductive technologies |
||||||||||
| Variable | Yes N(%) | No N(%) | P- value |
Yes N(%) | No N(%) | P- value |
Yes N(%) | No N(%) | P- value |
Yes N(%) | No N(%) | P-value |
| Gender | 0.305 | 0.086 | 0.166 | 0.722 | ||||||||
| Male | 254(48.6%) | 110(49.1%) | 187(45.6%) | 177(52.5%) | 115(44.4%) | 249(51.0%) | 63(45.3%) | 300(49.4%) | ||||
| Female | 269(51.4%) | 113(50.4%) | 223(54.4%) | 159(47.2%) | 144(55.6%) | 238(48.8%) | 76(54.7%) | 306(50.4%) | ||||
| Age | 0.329 | 0.250 | 0.112 | 0.017 | ||||||||
| ≤25 | 195(37.3%) | 71(31.7%) | 222(36.8%) | 44(30.6%) | 88(34.0%) | 178(36.5%) | 40(28.2%) | 226(37.2%) | ||||
| 25–35 | 139(26.6%) | 67(29.9%) | 169(28.0%) | 37(25.7%) | 63(24.3%) | 143(29.3%) | 32(23.0%) | 173(28.5%) | ||||
| ≥35 | 189(36.1%) | 86(31.3%) | 212(35.2%) | 63(43.8%) | 108(39.3%) | 167(34.2%) | 67(48.2%) | 208(34.3%) | ||||
| BMI | 0.061 | 0.276 | 0.423 | 0.081 | ||||||||
| ≤24.99 | 282(48.0%) | 61(38.3%) | 228(47.2%) | 116(43.6%) | 126(44.0%) | 218(47.1%) | 68(48.8%) | 275(45.3%) | ||||
| 25–29.99 | 184(31.2%) | 55(34.0%) | 156(32.4%) | 82(30.8%) | 99(41.4%) | 139(30.1%) | 34(24.4%) | 204(33.5%) | ||||
| ≥30 | 122(34.8%) | 44(27.7%) | 99(20.4%) | 68(25.6%) | 61(21.4%) | 106(22.8%) | 38(26.8%) | 130(21.2%) | ||||
| Smoking | 0.059 | 0.010 | 0.019 | 0.737 | ||||||||
| Yes | 194(37.1%) | 67(29.9%) | 160(39.0%) | 101(30.0%) | 105(40.5%) | 156(32.0%) | 50(36.0%) | 211(34.8%) | ||||
| No | 329(62.9%) | 157(70.1%) | 250(61.0%) | 236(70.0%) | 154(59.5%) | 332(68.0%) | 89(64.0%) | 396(65.2%) | ||||
| Income | 0.094 | 0.005 | 0.103 | 0.265 | ||||||||
| ≤400 | 163(45.8%) | 81(52.6%) | 123(54.4%) | 121(42.6%) | 76(43.7%) | 168(50.0%) | 45(44.6%) | 199(48.7%) | ||||
| >400 | 193(54.2%) | 73(47.4%) | 103(45.6%) | 163(57.4%) | 98(56.3%) | 168(50.0%) | 56(55.4%) | 210(51.3%) | ||||
| Education | 0.131 | 0.106 | 0.082 | 0.553 | ||||||||
| Less than high School |
30(5.7%) | 23(10.3%) | 21(5.1%) | 32(9.5%) | 15(5.8%) | 38(7.8%) | 11(7.9%) | 42(6.9%) | ||||
| High School | 87(16.6%) | 45(20.1%) | 68(16.6%) | 64(19.0%) | 58(22.4%) | 74(15.2%) | 36(25.9%) | 96(15.8%) | ||||
| Diploma | 61(11.7%) | 27(12.1%) | 47(11.5%) | 41(12.2%) | 34(13.1%) | 54(11.1%) | 17(12.2%) | 71(11.7%) | ||||
| Bachelor | 294(56.2%) | 105(46.9%) | 228(55.6%) | 171(50.7%) | 126(48.6%) | 273(55.9%) | 62(44.6%) | 336(55.4%) | ||||
| Graduate degree |
48(9.2%) | 24(10.7%) | 44(10.7%) | 28(8.3%) | 25(9.7%) | 47(9.6%) | 13(9.4%) | 59(9.7%) | ||||
| Social Status | 0.004 | 0.170 | 0.262 | 0.221 | ||||||||
| Single | 240(45.9%) | 79(35.3%) | 182(44.4%) | 137(40.7%) | 106(40.9%) | 213(43.6%) | 53(38.1%) | 266(43.0%) | ||||
| Married | 283(54.1%) | 145(64.7%) | 228(55.6%) | 200(59.3%) | 153(59.1%) | 275(56.4%) | 86(61.9%) | 341(56.2%) | ||||
In addition, about 55.0% of the participants agreed to apply the fertility testing for men before marriage to avoid psychosocial problems after marriage, whereas 34.7% of participants chose this opinion as to avoid divorce or separation. On the other hand, 18.6% of participants agreed that men’s fertility testing before marriage is not an important issue due to the presence of assisted reproductive technologies.
Table 3 represents the reasons for disagreement towards “before marriage fertility testing”, attitudes towards its applicability, and its effect on marriage decision. About 13.4% (n = 100) of participants owed their negative attitude toward men’s fertility testing before marriage to religious, ethical, and societal factors. These factors were found not to be affected (P > 0.05) by participants’ gender, age, body mass index, smoking habits, monthly income, education level, and family members with infertility. Whereas, social status was found to affect religious (P = 0.007) causes of disagreement toward the men’s fertility testing.
Table 3:
Reasons for disagreement towards before marriage fertility testing, attitudes towards its applicability and effect of on marriage decision.
| Causes for disagreement | Do you think this testing is applicable? |
Do you think that result of this test could cancel a marriage decision? |
|||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| religious | Ethical | Societal | |||||||||||||
| Variable | Yes N(%) | No N(%) | P | Yes N(%) | No N(%) | p | Yes N(%) | No N(%) | P | Yes N(%) | No N(%) | p | Yes N(%) | No N(%) | P |
| Gender | 0.426 | 0.925 | 0.040 | 0.207 | <0.001 | ||||||||||
| Male | 43(43.0%) | 321(49.6%) | 49(49.0%) | 315(48.7%) | 48(47.5%) | 316(48.9%) | 235(50.5%) | 129(45.7%) | 287(53.1%) | 77(37.2%) | |||||
| Female | 57(57.0%) | 325(50.2%) | 51(51.0%) | 331(51.2%) | 52(51.5%) | 330(51.1%) | 230(49.5%) | 152(53.9%) | 252(46.7%) | 130(62.8%) | |||||
| Age | 0.227 | 0.218 | 0.975 | 0.073 | 0.432 | ||||||||||
| ≤25 | 28(28.0%) | 238(36.8%) | 29(29.0%) | 237(36.6%) | 36(35.6%) | 230(35.6%) | 155(33.3%) | 111(39.4%) | 189(35.0%) | 77(37.2%) | |||||
| 25–35 | 30(30.0%) | 176(27.2%) | 27(27.0%) | 179(27.7%) | 27(26.7%) | 179(27.7%) | 141(30.3%) | 65(23.0%) | 156(28.9%) | 50(24.2%) | |||||
| ≥35 | 42(42.0%) | 233(36.0%) | 44(44.0%) | 231(35.7%) | 38(37.6%) | 237(36.7%) | 169(36.3%) | 106(37.6%) | 195(36.1%) | 80(38.6%) | |||||
| BMI | 0.248 | 0.626 | 0.841 | 0.250 | 0.252 | ||||||||||
| ≤24.99 | 24(41.2%) | 320(46.3%) | 41(41.4%) | 303(46.6%) | 24(43.8%) | 320(46.1%) | 271(47.5%) | 72(40.7%) | 276(45.8%) | 68(46.5%) | |||||
| 25–29.99 | 24(41.2%) | 214(31.0%) | 34(34.5%) | 204(31.4%) | 17(31.3%) | 221(31.9%) | 167(29.2%) | 71(40.1%) | 194(32.2%) | 44(30.2%) | |||||
| ≥30 | 10(17.6%) | 156(22.7%) | 24(24.1%) | 143(22.0%) | 14(25.0%) | 153(22.1%) | 133(23.3%) | 34(19.2%) | 201(22.0%) | 34(23.3%) | |||||
| Smoking | 0.662 | 0.375 | 0.460 | 0.696 | 0.004 | ||||||||||
| Yes | 228(35.2%) | 33(33.0%) | 230(35.5%) | 31(31.0%) | 229(35.4%) | 32(31.7%) | 160(34.4%) | 101(35.8%) | 172(31.9%) | 89(43.0%) | |||||
| No | 419(64.8%) | 67(67.0%) | 417(64.5%) | 69(69.0%) | 417(64.6%) | 69(68.3%) | 305(65.6%) | 181(64.2%) | 368(68.1%) | 118(57.0%) | |||||
| Income | 0.183 | 0.507 | 0.350 | 0.082 | 0.334 | ||||||||||
| ≤400 | 39(53.4%) | 205(46.9%) | 32(48.5%) | 212(47.7%) | 35(50.7%) | 209(47.4%) | 164(50.3%) | 80(43.5%) | 183(48.5%) | 61(45.9%) | |||||
| >400 | 34(46.6%) | 232(53.1%) | 34(51.5%) | 232(52.3%) | 34(49.3%) | 232(52.6%) | 162(49.7%) | 104(56.5%) | 194(51.5%) | 72(54.1%) | |||||
| Education | 0.009 | 0.073 | 0.600 | 0.249 | <0.001 | ||||||||||
| Less than High School |
12(12.0%) | 41(6.3%) | 8(8.0%) | 45(7.0%) | 12(11.9%) | 41(6.3%) | 35(7.5%) | 18(6.4%) | 36(6.7%) | 17(8.2%) | |||||
| High School |
29(29.0%) | 103(15.9%) | 19(19.0%) | 113(17.5%) | 18(17.8%) | 114(17.6%) | 69(14.8%) | 63(22.3%) | 72(13.3%) | 60(29.0%) | |||||
| Diploma | 11(11.0%) | 77(11.9%) | 15(15.0%) | 73(11.3%) | 11(10.9%) | 77(11.9%) | 55(11.8%) | 33(11.7%) | 62(11.5%) | 26(12.6%) | |||||
| Bachelor | 41(41.0%) | 358(55.3%) | 41(41.0%) | 358(55.3%) | 51(50.5%) | 348(53.9%) | 259(55.7%) | 140(49.6%) | 312(57.8%) | 87(42.0%) | |||||
| Graduate degree |
7(7.0%) | 65(10.0%) | 17(17.0%) | 55(8.5%) | 9(8.9%) | 63(9.8%) | 45(9.7%) | 27(9.6%) | 56(10.4%) | 16(7.7%) | |||||
|
Social Status |
0.007 | 0.129 | 0.158 | 0.145 | 0.120 | ||||||||||
| Single | 31(31.0%) | 288(44.5%) | 37(37.0%) | 282(43.6%) | 38(37.6%) | 281(43.5%) | 206(44.3%) | 113(40.1%) | 223(41.3%) | 96(46.4%) | |||||
| Married | 69(69.0%) | 359(55.5%) | 63(63.0%) | 365(56.4%) | 63(62.4%) | 365(56.5%) | 259(55.7%) | 169(59.9%) | 317(58.7%) | 111(53.6%) | |||||
In terms of test applicability, 62.3% of participants thought that fertility testing for men before marriage can be applied in Jordanian society. Such thinking was found not to be significantly affected (P > 0.05) by any of the tested demographic variables. In terms of the marriage decision, approximately 72.3% of participants think that applying this test may cancel the marriage decision. This thinking was found to be significantly influenced by participant’s gender (P < 0.001), and education level (P < 0.001).
Discussion and conclusion
To the best of our knowledge, this is the first study that aims to probe the applicability of fertility testing for men before marriage in Jordan. Given that the consequences of male factor infertility are manifold and can include personal suffering as well as societal repercussions (Dooley et al., 2014), then there was a need to provoke this study in this society.
In this study, majority of participants of both genders had a positive attitude to apply the fertility testing for men before marriage to avoid primarily the psychosocial problems after marriage, and secondarily the divorce or separation. This attitude was found to be affected by the social status of the participant. In addition, the religious causes of disagreement toward men’s fertility testing were found to be influenced by the social status of the participant. Moreover, the majority of participants felt that applying this test may cancel the marriage decision.
In general, infertility is still one of the most stressful problems along the marriage journey for both partners (Sormunen et al., 2018). In his systematic review, Luk and Loke (2015) showed that infertility in general affected couples and their life in many aspects such as psychological well-being, sexual relationships, marital relationships, and quality of life (Luk and Loke, 2015).
Studies have shown that male infertility factor causes greater mental breakdown for both partners, but its intensity is higher in women compared to men (Wright et al., 1991). It has been reported that there were more concerns regarding male factor infertility compared with female infertility and unidentified causes of infertility (Wright et al., 1991). In addition, female members of partners in which both male and female were infertile expressed less sexual and marital satisfaction than their husbands (Lee et al., 2001). While, in unexplained infertility, no differences in sexual and marital satisfaction were found between both couples (Lee et al., 2001).
In fact, in Arab Muslim societies, male infertility may have more impact on the woman more than the man. This may be because the man is religiously permitted to marry more than one woman, regardless that this permit requires specific circumstances. Additionally, the majority of women in that society prefer to keep their marriage, even under such circumstances to avoid the guilty society’s perception of the divorced women, or sometimes because of the financial issues as many women in Arab Muslim societies are financially dependent (Esposito, 2001). Therefore, studying such issue among Jordanians would have more impact, given that the main religion in Jordan is Islam.
A study conducted in China by Che and Cleland (2002) revealed that infertile married partners were 2.2 times more likely to divorce than were the fertile partners (Che and Cleland, 2002; Luk and Loke, 2015). Another study in Iran showed that there is a negative attitude toward infertile subjects, and the interference of other persons increases the encouragement of divorce (Amiri et al., 2015). A recently published study in Turkey by Ergin et al. (2018) confirmed that there is a very significant familial attitudes and social stigma related to infertility, including divorce (Ergin et al., 2018). Such results are in line with current findings; that the fear of separation or divorce was found to be a factor behind the positive attitude of participants to apply men’s fertility testing.
In the current study, the majority of participants thought that applying men’s fertility testing before marriage may cancel the marriage decision. Actually, such thinking, according to the participants, was to avoid the social stigma that, in particular, the female may experience after marriage. This marriage cancelation or disagreement, most of the time, comes from the female’s side, either by the female’s decision herself, or by her guardian, or sometimes by interferences from other persons in her family (Amiri et al., 2015).
In fact, many people in Arab Muslim societies derive their central life decisions/motives such as marriage from Islam. One important hadith that encourages men for marriage as attributed to prophet Muhamad is that “Whoever among you can afford it, let him get married, for it is more effective in lowering the gaze and guarding chastity. And whoever cannot afford it, then let him fast, for it will be a restraint for him.” (Abdul-Rauf, 1993). According to many scientists in Islamic religions, the term “can afford it”, refers to the physiological as well as the financial abilities to support the wife and family after marriage. While the physiological ability is not yet well determined in terms of fertility as it refers, according to many religious scientists, to sexual ability. Accordingly, it is very important to revisit the exact meaning of physiological ability for the man who desires to marry by the consensus of the Islamic-religion scientists. Such consensus decision is very important to consider before applying the fertility testing for men before marriage.
In conclusion, current results suggested that applying fertility testing for men before marriage appears to be acceptable in Jordanian society; however, a national study that considers larger sample size and link this application to the religions seems very important to ethically and fully permit this test among Jordanian society. The results of this study may consequently be extrapolated in other societies, particularly Arab Islamic societies.
Acknowledgment:
Work on this project was supported by grant # 5R25TW010026-02 from the Fogarty International Center of the U.S. National Institutes of Health.
Footnotes
Conflict of interest: The authors declare no conflict of interest.
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