Discussion
To our knowledge, this study is the first in the literature to evaluate
the effects of the COVID-19 pandemic on male fertility by comparing the
demographic structure and spermiograms of patients presenting to a
urology clinic due to infertility before and during the pandemic. The
impact of the pandemic on semen parameters in men is a controversial
issue, and may occur in two ways. The first is the effect of the
infection itself, while the second involves the possible
psychophysiological effects of pandemic-imposed social restrictions on
male reproductive health.
In the pathophysiology of COVID-19 infection, host ACE2 receptors
facilitate intracellular entry and replication of the SARS-CoV-2 virus.
This process is much easier in cells with high ACE2 expression. In many
studies, ACE2 expression level was found to be high in the seminiferous
tubules and in Leydig and Sertoli cells. This potential affinity of the
SARS-CoV-2 virus for the testicles is the main basis for the researchers
who support this view. However, studies evaluating the effect of
infection on semen parameters have yielded different results. In fact,
it remains unclear whether the testicles and other male reproductive
organs are susceptible to SARS-CoV-2 infection. Temiz et al. found that
sperm quality decreased in the acute period of COVID-19 infection but
did not differ from controls after treatment. They attributed the
decrease in semen parameters during acute infection to high fever, but
noted that SARS-CoV-2 was not detected by PCR in the semen during this
period.8 In another study, SARS-CoV-2 was detected by
PCR in the respiratory tract but not testicular tissue in postmortem
evaluations after COVID-related deaths.9
Levels of sex hormones in individuals infected with COVID-19 have also
been investigated due to their direct effect on semen parameters. Male
sex hormones vary dramatically with acute illness or physiological
stress, so it should be kept in mind that these early results are may be
disputable.10 In a study of 119 patients, Ma et al.
determined that luteinizing hormone and prolactin levels were higher in
COVID-19 patients compared to the control group, but did not detect a
significant difference in testosterone or estradiol
levels.5 In another study, pretreatment levels of
follicle-stimulating hormone, leutinizing hormone, and testosterone
levels were lower in 30 COVID-19 patients compared to the control group,
while posttreatment levels did not differ significantly from those of
controls.8 In a study of 31 patients, Rastrelli et al.
reported that testosterone levels were significantly lower in COVID-19
patients who required intensive care than in those with mild
disease.11 It seems that the conversation on the
effect of COVID-19 infection on testicular functions cannot be closed
yet.
Another important aspect of the COVID-19 pandemic is the major lifestyle
changes that have occurred for many individuals. Social isolation due to
the pandemic has led to increased feelings of loneliness as well as
increased use of mobile devices and laptop computers. These devices may
adversely affect semen parameters due to the low-level radio-frequency
electromagnetic fields they produce.12 In addition,
obesity that can occur due to a sedentary lifestyle may also be an
important risk factor. A meta-analysis study showed that semen quality
was lower in obese men than in men of normal weight.13Psychosocial stress caused by the pandemic also constitutes a
significant public health problem. The effect of psychosocial stress on
semen parameters has actually been a topic of debate for a long time.
Hjollund et al. determined in a prospective study that there was no
relationship between stress and sperm parameters14,
whereas Janevic et al. found a negative association between stress and
sperm concentration, motility, and morphology.15 As
the duration and degree of stress experienced by a lonely man cannot be
measured with objective parameters, the effect of stress on semen
parameters remains uncertain. The results of the present study suggest
that these pandemic-related risk factors are not severe enough to
disrupt sperm parameters. Of course, these one-year results can also be
seen as a preliminary study. If the pandemic continues, future studies
of larger series will offer more insight into this issue.
It is also necessary to question the sex life of patients who present
due to male infertility during the COVID-19 pandemic. Analyzing semen
parameters alone may not be enough in these patients. It has been seen
in pandemics that patients affected by mental disorders far outnumber
the infected patients.16 Therefore, it should be kept
in mind that increased anxiety or depression in men during the pandemic
can also cause erectile dysfunction (ED) and loss of
libido.17 An individual’s psychological state may
trigger or exacerbate ED. Depression has been found to double the risk
of ED.18 ED may in turn cause a loss of self-esteem,
which can adversely affect their partner relationship. Therefore,
performing a psychological evaluation is recommended before seeking an
organic cause for ED, especially in men under the age of
40.19
Another issue that may be important during the pandemic is loss of
libido.20 Although this condition (also known as
hypoactive sexual desire disorder) is less common in men than women, it
can lead to important problems between couples.21 In a
prevalence study by Carvalheria et al., loss of libido lasting more than
2 months was most commonly seen among men aged 30 to 39
years.22 Clinicians should bear in mind that low
libido is not only caused by low testosterone levels, but can also occur
as a side effect of antidepressant and antipsychotic
drugs.23 Furthermore, sexual performance anxiety,
relationship problems between couples, and depression/anxiety are known
to reduce sexual desire.24
One of the important findings of our study was that the mean age of men
presenting due to infertility during the pandemic was 33.1±6.3 years,
significantly younger than in the previous two years. This difference
may reflect an increase in future anxiety in these patients during the
first year of the pandemic. A study in the literature demonstrated that
the prevalence of anxiety/depression during the COVID-19 pandemic
increased significantly more among participants under 35 years of age
than in participants over 35 years of age.10 According
to the definition of infertility, pregnancy is not achieved for 12
months despite timed or regular sexual intercourse. Therefore, a
detailed history should be obtained from infertile couples to understand
the frequency of sexual intercourse during the COVID-19 pandemic. The
lack of difference in the number of patients presenting to the clinic
due to infertility compared to the previous two years indicates that
there was no change in couples’ desire to have children, despite the
adverse circumstances brought about by the COVID-19 pandemic.
In summary, the available data suggest that for patients who present due
to infertility during the pandemic and have no major problems with semen
parameters, a thorough history should be obtained, as well as
psychiatric evaluation to question sex drive and presence of ED.
In this study, the lack of data regarding whether the patients who
presented during the pandemic had a history of COVID-19 infection may be
seen as a limitation. However, the main objective of this study was not
to evaluate the effect of COVID-19 infection specifically, but
demonstrate the overall impact of the pandemic. Therefore, this study
did not examine history of COVID-19 infection in the patients who
presented during the pandemic year.