Preconception care for males

The GP’s role

Overview

Preconception care is aimed at identifying and mitigating any biomedical, behavioural and social conditions that may compromise a pregnancy and its short- or long-term outcomes. It involves complementing usual best practice with reproductive health care, and helps prepare people for conception, pregnancy and parenthood.

Despite men’s obvious influence over couples’ reproductive decisions, responsibility for reproduction is borne largely by women. Healthcare related to childbearing is primarily focused on women, with men feeling excluded or marginalised as a result.

Preconception care for men may improve participation of men in managing fertility and planning for parenthood, with potential benefits to a man’s health and that of his family.

The existing evidence base is sufficient to inform preconception care for males, even though this aspect of preventive care has been traditionally overlooked. Our knowledge that male health prior to conception influences fertility and pregnancy outcomes obligates action to improve male preconception health. Future high-quality studies of preconception care for males will further inform care.

There are common-sense reasons for providing preconception care for males:

1. Benefit to reproductive outcomes and coincident benefit to male health in general
2. Benefit to the health of partners and children
3. Enhancement of men’s capacity as fathers
4. There is low risk of harm

Most people of reproductive age are accepting of routine discussions with general practitioners about their reproductive intentions.

Paternal factors associated with fertility, and perinatal or offspring health

Paternal factor	Outcome
Advanced age	Reduced fertility Increased risk of preterm birth, miscarriage, stillbirth, offspring congenital abnormalities, trisomy 21 and psychiatric disorders
Alcohol	Adverse effects on offspring health
Cryptorchidism	Infertility
Depression	Parental stress and disengagement with child; child neglect; impaired language, reading, social and behavioural development and mental illness in offspring
Diabetes	Infertility
Metabolic syndrome	Increased risk of pregnancy loss
Obesity	Reduced fertility, preterm birth Adverse effects on offspring health (mostly animal studies)
Occupational and environmental radiation and chemical exposure	Infertility
Physical inactivity	Reduced fertility
Poor diet	Lower sperm quality Adverse effects on offspring health
Sexually transmitted diseases	Infertility, congenital infection of offspring
Smoking	Reduced fertility, congenital abnormalities, small for gestation age offspring Adverse effects on offspring health
Unhealthy behaviours shared with partner	Infertility, adverse pregnancy outcomes, poor parental and child wellbeing

Preconception healthcare for males of reproductive age

Investigations and interventions	Components
Reproductive life plan	Asking about male’s future reproductive intentions, and helping to institute a suitable plan, provides opportunity for timely delivery of information and can provide context for preventive health practices Provide education about the effects on reproduction of paternal aging
Medical history	Previous and existing medical conditions Surgical history Mental health history Family history Social history Occupational history (radiation, chemical exposures) Abuse (physical, emotional, sexual) Alcohol and other drug use Smoking Physical activity Diet Immunisations Medication review
Sexual and reproductive history	Existing children Previous conceptions/pregnancies Trouble conceiving Puberty Sexuality Sexual behaviour Previous and existing relationships Contraception Sexual function
Physical examination	Sexual maturity Gynecomastia Genital exam (including testicular palpation and volume measurement, instruction for self-examination) Height, weight, abdominal circumference/BMI Blood pressure
Laboratory tests	As indicated by history and examination (e.g. infertility; diabetes; adrenal, thyroid, testicular function; chlamydia, gonorrhea, syphilis, HIV) Genetic carrier screening (spinal muscular atrophy, cystic fibrosis, fragile X)
Mental health assessment	There are several mental health assessment tools useful for the assessment of paternal perinatal healt

Barriers and facilitators to provision of male preconception care*

PCC = preconception care, HP = healthcare professional

Provider factors

Barriers

Facilitators

Lack of knowledge of fertility and preconception health or benefits of preconception care; lack of training; lack of knowledge of guidelines Negative attitude towards or not convinced of benefits or efficacy of preconception care interventions Sensitivity of topic, perceived female focus Not working in obstetrics and gynaecology Lack of clarity on whose responsibility it is to deliver PCC (e.g. GP, nurse, other health professional) Competing medical or preventive priorities No opportunity to deliver PCC Discussion of various aspects of PCC dependant on speciality of HP

Having good knowledge about factors that affect fertility Having designated responsibility for providing PCC Having confidence in delivering PCC Having more experience in delivering PCC Seeing more patients from higher risk groups, as they are perceived to be more in need

Patient-related factors

Barriers	Facilitators
Patients not coming in at preconception stage Perception that patient is not thinking about having children Perceived negative attitude of patient to PCC Patient lacking awareness of PCC and its importance Perception that it might raise anxiety in the patient	Request from patient for PCC Mentioning desire to become pregnant Having a health condition perceived to be relevant to PCC (e.g. obesity)

Organisation/system factors

Barriers	Facilitators
Lack of guidelines and tools Lack of time to dedicate to PCC Lack of reimbursement for PCC service/no costing structure No clear division of responsibility	Availability of PCC resources (e.g. checklists, pamphlets, patient education) Access to trained/qualified health professionals