Investigation of motivations for depositing sperm during the COVID-19 pandemic

Abstract

People are becoming parents later in life and with increased parental age adverse reproductive outcomes are increased. Cryopreservation of gametes enables men and women to protect, prolong and seemingly preserve their fertility. Social freezing is an increasingly popular way of cryopreservation. During the COVID-19 pandemic, the gamete bank Cryos International experienced an increased influx of men wanting to deposit their sperm. A questionnaire-based study was initiated to investigate their motivations for doing so. The results showed that the men chose to deposit mainly due to medical indications (e.g. cancer and sex change), and that the COVID-19 pandemic had no significant influence on the reason for banking their sperm. Investigations into the altruistic reasons for depositing sperm (i.e. caring for reproductive masculinity) could shed new light onto the sparsely studied topic of male reproductive journeys.

Keywords:

• Motivation
• social freezing
• depositor
• sperm
• COVID-19

Introduction

Historically, men have been able to cryopreserve their sperm since the late 1960s (Sherman, 1973), but it has primarily been for medical reasons, such as cancer treatment, military service, transwomen during transition, vasectomy, HIV-positive patients, etc. (Gonen, 2021; Mattawanon et al., 2018; Mitu, 2016). In recent times, it has become increasingly popular for men to cryopreserve their sperm for future use to prolong and protect their fertility for non-medical reasons – social freezing (Gromoll et al., 2016; Law, 2020). The motivation behind social freezing in men is a complex issue as anticipations, knowledge and experiences for men’s reproductive journeys have been studied sparsely. Gonen (2021) looked at factors influencing men’s willingness to pay for cryopreservation and found that important factors are price, personal income and risk of infertility.

Men’s relationship to human reproduction has been conceptualized by Daniels (2008) as a set of assumptions, stating that men are assumed to be virile, less vulnerable to reproductive harm than women, relatively distant from health problems of their offspring. Furthermore, Moore (2007) has argued that masculinity and fertility are intimately connected, and some men experience the quantification and manipulation of sperm as a threat to their masculinity. These notions have been supported by Law (2020), who added that men showed resistance to sperm freezing and hypothesized that it was due to loss of reproductive control. However, these studies are small and men’s own notions about male fertility remains a relatively poorly studied topic as research has mainly focussed on women due to the cultural and social norms surrounding reproduction (Jamieson et al., 2010). Despite an increase of attention in male fertility, men’s knowledge of own fertility is limited (Daumler et al., 2016).

The importance of biological parenthood (i.e. having children with genetic relatedness to oneself), has deep cultural and biological roots, even so that it overrides other potential ways of becoming parents (Dondorp & de Wert, 2009; Faircloth & Gurtin, 2017; Faircloth & Gürtin, 2018; NeJaime, 2017). Parents typically want an easy conception and problem-free pregnancy. However, couples worldwide are delaying childbearing compared to previous decades (Kuhnert & Nieschlag, 2004; Law, 2020; Martin et al., 2017; World Health Organization, 2015). This delay results in increased maternal and paternal age. Paternal age has increased because of increased life expectancies, increased rate of divorce/remarriage, and increased access to assisted reproductive technology (ART) (Brandt et al., 2019). In general, advanced-aged parenthood carries with it a wide range of potential risks and adverse effects for the offspring and mothers, while chances of successful pregnancy also diminish (de Kat & Broekmans, 2018). Advanced maternal age has long been associated with increased risk of adverse reproductive outcomes (Khalil et al., 2013). Likewise, an increasing body of knowledge documents that advanced paternal age (APA) is associated with a decrease in sperm quality, natural fertility, and success rates for ART (Brandt et al., 2019; Levine et al., 2017). APA is still not clearly defined, but consensus details 45 years of age at the time of conception so this will be the metric of this study too (Toriello & Meck, 2008). APA is associated with a host of issues for prospective fathers as well as mothers. For a start, APA is associated with a decline in semen parameters (Johnson et al., 2015; Mazur & Lipshultz, 2018). Female partners have an increased rate of miscarriage (Belloc et al., 2008) with APA partners. The offspring of APA are also at increased risk for a host of adverse effects. APA also increases rate of de novo mutations in offspring. Every additional year of paternal age corresponds to an increase of approximately two new mutations in offspring (Kondrashov, 2012; Kong et al., 2012). The addition of new mutations inherently increases the risk of DNA fragmentations and deleterious point mutations (Humm & Sakkas, 2013). Children of APA have increased risk of mental disorders (e.g. schizophrenia (Lee et al., 2011), autism (Malaspina et al., 2005) and bipolar disorder (Frans et al., 2008)). Additionally, several types of childhood cancers (e.g. non-Hodgkin’s lymphoma (Hemminki et al., 1999; Lu et al., 2010), breast cancer (Hemminki et al., 1999; Lu et al., 2010), and leukaemia (Murray et al., 2002; Teras et al., 2015)) are associated with APA.

Male fertility is also affected by many external parameters (e.g. chemicals (Sharma et al., 2020), diet (Skoracka et al., 2020) and viral infections. Viral infection in males is accepted as a possible cause of infertility. This is in part due to fever associated with a viral infection (Evenson et al., 2000; Sergerie et al., 2007), but also the damage the virus imposes on infected tissues (e.g. mumps (Wu et al., 2021)), herpes simplex, human papillomavirus, hepatitis B and C and HIV (Batiha et al., 2020). Lately, several studies have investigated the effects of SARS-COV-2 and COVID-19 on male fertility because of the increased incidence of the infection compared to females, but also are more likely to suffer or die from complication (Guan et al., 2020; Livingston & Bucher, 2020; Rozenberg et al., 2020). The SARS-COV-2 virus infects through the ACE2 receptor (Tian et al., 2020). Several organs other than the lungs express ACE2 receptors (e.g. kidneys and the bladder), but the highest expression of ACE2 receptors is in the testes (Fan et al., 2020). This has raised concerns about the virus entering and possibly affecting the spermatogenesis process. However, ACE2 expression was found to be mainly expressed in the spermatogonia, Leydig, and Sertoli cells, while spermatocytes and spermatids had low expression (Wang & Xu, 2020), and no virus has been found in semen (Burke et al., 2021; Song et al., 2020).

Concurrently with the SARS-COV-2 pandemic of 2020, the gamete bank Cryos International experienced an increase in men requesting to deposit sperm for future use by 34% (from 127 in 2019 to 170 in 2020). Considering the increased attention to male fertility during the 2020 pandemic, timing of the requests and the topics mentioned above, it sparked questions whether the pandemic had an impact on the men’s motivation for depositing their sperm. Therefore, this study aimed to investigate the motivation of the men depositing sperm during the 2020 pandemic.

Materials and methods

To investigate if the COVID-19 pandemic had any influence on these men’s decision to deposit sperm, surveys were sent to the depositors with demographic questions and questions on their reasons for depositing sperm. The survey was sent to 164 depositors at Cryos International in Denmark in 2020 (6 of the 170 depositors had declined to be contacted). Data collection was carried out between 3 February 2021 and 8 March 2021, and depositors were reminded via email a week before the end of the data collection period. There were seven questions in the questionnaire which consisted of demographic, psychosocial and motivational questions for depositing their sperm. Depositors were allowed to select multiple categories regarding their motivation for depositing their sperm, including a free text field called ‘other’. Questionnaires were created and distributed using the Microsoft Customer Voice application. Data was analysed in Microsoft Excel, Chi-square test of independence was used to determine the significance between variables and a p < 0.05 was considered statistically significant.

Results

A total of 41 depositors participated in the study (25% participation). The mean age of the responders was 32.8 ± 10.3 (mean ± SD) years, whereas the mean age of the entire cohort was 32.9 ± 10.9. The average depositor was typically a single, heterosexual man with no children of his own, but wished to have biologically related children (Table 1). Highest level of education was a high school degree.

Table 1. Demographic characteristics.

	Total (n)	Total (%)
Mean age (years)	32.82
Relationship status
Single	20	49
In a committed relationship (living together)	6	15
In a committed relationship (not living together)	5	12
Married	8	20
Divorced/separated	2	5
Children of their own
Yes	14	34
No	27	66
Sexual orientation
Bisexual	5	12
Heterosexual	26	63
Homosexual	4	10
Mostly heterosexual	3	7
Mostly homosexual	3	7
Education
Elementary school	2	5
High school	12	32
University (bachelor)	9	24
University (master)	11	29
University (postgraduate)	4	11
Wish to have biologically related children
Maybe	10	24
No	1	2
Yes	16	39
Did not answer	14	34
Do you wish to have more biologically related children in the future?
Maybe	7	17
Yes	3	7
No	4	10
Did not answer	27	66

Looking at the association between the influence of COVID-19 to become a depositor and the other categories in Table 2, no associations could not found. Testing for demographic influences showed no association could be found for: (i) relationship status (p = 0.80); (ii) whether or not they had children of their own (p = 0.63); (iii) sexual orientation (p = 0.88); (iv) their own wish to have children (p = 0.66); (v) their education (p = 0.75); or (vi) affected by age (p = 0.69). The free text field ‘other’ was used to elaborate or provide context to their categorical answer (e.g. stating that the medical indication was testicular cancer). One of the two men that stated that their decision to deposit their sperm was affected by COVID-19 added that it was due to pending fertility treatment in another country and that it would be easier to store sperm and ship it rather than travelling themselves due to the travel restrictions at that time.

Table 2. Reasons for depositing sperm.

	n	%
Pending vasectomy	7	11
Medical indication (illness)	15	23
Because I am not in a committed relationship	4	6
Because I am worried about age-related infertility	4	6
Being stationed abroad	0	0
Due to work that might affect my fertility	0	0
Sex change	12	18
Due to the closure of fertility clinics	1	2
To leave something for someone else	3	5
As a back-up option	11	17
Pending surgery	1	2
Other	8	12
Influence of COVID-19 to become depositor
Yes	2	5%
No	39	95

Discussion

This study set out to investigate the motivation behind depositing sperm during the COVID-19 pandemic. The main reason for men depositing their sperm in this study was related to medical indications. There was no influence of COVID-19, meaning that men’s motivation was not affected by the pandemic. Most answers on what medical indication was motivating the deposition was cancer (supplied in ‘Other’) and the deposit would act to secure their fecundity. The results indicate that men are motivated to deposit sperm as a backup before medical procedures (e.g. cancer, sex change and vasectomy). This is in line with previous studies (Gonen, 2021; Law, 2020). Other common reasons for depositing sperm (e.g. before being asked to work abroad or work that might affect fertility) were not found in this study to be of any importance as no depositor cited these as reasons for depositing their sperm. Additionally, 5% (n = 3) of depositors were motivated to store sperm in order to leave their deposit for someone else and only 6% (n = 4) were concerned about age-related infertility indicating a strong belief in their own fertility. The lack of concern regarding age-related infertility is in line with the work conceptualized by Daniels (2008) that men are assumed to be relatively distant from health problems of their offspring. Other studies have found similar results, leading to men having a lack of concern regarding their reproductive future (Hashiloni-Dolev et al., 2020). This is in sharp contrast to the current scholarly evidence, which points to a decline in male fertility with age (e.g. sperm mutation rate doubles every 16.5 years (Gromoll et al., 2016)). It seems that despite increased attention to the topic of male fertility, the general male public is still catching up compared to attention to women fertility (O’Brien et al., 2017).

The men of this study chose to deposit their sperm mainly for internal considerations (e.g. sex change or due to medical illness) and not really because of external considerations (e.g. their partner or the future child). These findings contrast with women’s motivation for preserving their eggs (Baldwin, 2019; Gürtin et al., 2019; Hammarberg et al., 2017; Inhorn et al., 2022). The motivation behind social freezing for women is strongly related to the health of their future offspring, and the desire for a romantic relationship and a nuclear family (Daniluk & Koert, 2016; Inhorn, Birenbaum-Carmeli, Birger, et al., 2018; Inhorn, Birenbaum-Carmeli, Westphal, et al., 2018; Inhorn et al., 2022).

In this study, the average profile of men was slightly different compared to women seeking oocyte cryopreservation. Compared to one exploratory and qualitative study on women cryopreserving their eggs by Baldwin et al. (2015), the women were on average older (36.7 years), more educated than the men in this study and all were heterosexual and almost all single at the time of cryopreservation (87%) (Baldwin et al., 2015). It is interesting to note that almost half of the men seeking to cryopreserve their sperm in this study were in a relationship, while all the women of the other study, seeking the same type of treatment, were single. This could indicate that men to a larger degree than women seek to ensure that their partner can have a child with their sperm, however other reasons cannot be excluded (e.g. securing sperm for future relationships, sex change, etc.). Based on the results of this study, it cannot be determined if sperm depositors display altruistic motivations behind depositing (i.e. a caring reproductive masculinity in which the current female partner’s needs are considered). Neither can it be concluded whether sperm depositing enables men to exercise reproductive autonomy and control. This has to the knowledge of the authors not been investigated in depth, so more qualitative studies need to explore men’s diverse motivations. A follow-up study with qualitative interviews could shed more light on the underlying reasons for depositing sperm. The average profile of the depositors and their motivation for cryopreserving their sperm paints a picture of men at a point where men in the general population have started becoming parents (average paternal age in Denmark in 2021 was 31.5 years (Danmarks Statistik, 2022)). Coupled with medical indications for depositing, the men may feel out of reproductive control and preserve their sperm to get back in control.

Results showed that the pandemic did not affect the responding men’s motivation for depositing their sperm. The men’s motivations were mainly medical in nature and a deposit was seen as a backup for their partner or themselves. This is in line with previous cohorts. The study acknowledges its limitation in making general conclusions about men’s motives for depositing sperm due to a small sample size and lack of comparative data. The study of men’s reproductive journey is sparsely studied, and more research is needed to elucidate whether men that deposited due to medical reasons did it for the sake of themselves, their partner, other family members, or their future child.

Limitations of study

The relatively small sample size may make it difficult to determine true findings as power is reduced and margin of error is increased.

Ethical approval

This study was conducted with all relevant consents signed by all participants and collaborators. Ethical approval was not required according to Komitélovens §14 stk 2 (Komitéloven, n.d.) due to the study being survey based and not involving human biological material.

Acknowledgements

The authors wish to acknowledge the respondents to the questionnaire and Tobias Riisager Dahl for providing overview of the depositor influx.

Disclosure statement

No potential conflict of interest was reported by the author(s). However, it should be noted that all authors except for Charlotte Kroløkke are employees of Cryos International.