06 July 2015
Professor of Andrology, University of SheffieldAppeared in BioNews 809
When I was first telephoned by a journalist to ask what I thought about the proposal that the NHS should pay for the sperm banking of every 18-year-old male in order to guard against reproductive ageing, I said just one word: 'Crackers!' At least that's the gist of what I said. And so for 24 hours the UK media reported the somewhat polarised debate of why this was, or from my perspective was not, a good suggestion.
The idea that we should be so worried about male reproductive ageing to even consider introducing mass NHS funded sperm banking came from Dr Kevin Smith, a bioethicist from Abertay University in Dundee. The detail was in a paper of his that was published online by the Journal of Medical Ethics at the beginning of June (although, oddly, only picked up by the press just some three weeks later).
Underpinning Dr Smith's radical proposal was the observation from a number of different studies showing that, as men age, their sperm are increasingly likely to contain mutations that increase the risk of neuropsychiatric disorders such as autism and schizophrenia. This is supported to some extent by epidemiological studies reporting that children born to older men are indeed more likely to develop these conditions, although the increased risk is quite small.
This should come as no surprise to the readers of BioNews as over the years it has reported on how the risk of Apert syndome (2003), various congenital problems (2005), early death (2008), lower IQ scores (2009), autism (2012) and bipolar disorder (2014) all increase in the children of older fathers to a greater or lesser extent. It was for this reason that in 2008 – when I chaired the joint societies working party to review the professional guidelines for the medical and laboratory screening of sperm donors – we recommended that, where possible, sperm donors should be under the age of 40.
However, what made Dr Smith's proposals particularly radical was his suggestion that because the average age of paternity in the UK (and in most of the developed world) has been slowly increasing in recent years, that this will inevitably lead to an increased burden of genetic disease in future generations. Furthermore, he suggested that a plausible way to deal with this theoretical problem was for the NHS to fund the sperm banking of 18 years olds so that men had their younger sperm to fall back on if they decided to become a father later in life.
Even if we were to conclude that mass sperm banking was a remotely practical solution for such a theoretical problem, Smith's paper suggests a naïve understanding of what is involved. For a start, according to the Office for National Statistics there are approaching 400,000 males each year who turn 18 years old. Even if only 50 percent of them chose to bank their sperm (an assumption on my part, I agree, but based on the fact that only about 50 percent of men faced with a cancer diagnosis will elect to bank sperm) that means about 200,000 men queuing up outside our clinics.
This will mean an extra 200,000 extra tests for HIV, Hepatitis B and C (an aspect not mentioned by Smith) given that current HFEA regulations (and EU law) require all men banking sperm to be screened for blood-borne viruses. This will certainly add to the approximately £200-per-year cost of keeping sperm frozen cited in many press reports. As would the provision of support and the medical investigation for the 2000 men (about 1 percent of the total) who discover at an early age that they don't have any sperm to bank because they are azoospermic. All in all, I estimate the bill of undertaking such an exercise will come to about £79 million per year, which within 10 years would double the size of the current NHS debt (without taking into account any inflationary pressures).
However, the complexity and cost does not end there. What Smith failed to mention in his article was a realistic appraisal of how banked sperm might be used to achieve fatherhood if and when men return to use it at an older age. We know from our sperm-donor programmes that the sperm from many men does not freeze well (which is a reason why around 60 percent of men are not accepted as donors). This inevitably means that many older men may be sorely disappointed when they return to use their sperm, only to find it cannot be used when it is thawed. Or there may not be enough sperm for artificial insemination, and they might be told that they'll need to use it in one or more cycles of IVF with their partner to stand the best chance of pregnancy.
Even if we ignore the apparent moral dilemma of suggesting men's partners undergo a cycle or two of IVF with his frozen sperm to guard against the theoretical risks that Smith proposes, I assume that he is indirectly calling for NHS-funded IVF for the partners of all older men (however that is defined). And that was the irony of this story.
Whilst I am the first person to argue for full NHS funding for IVF according to NICE recommendations, I suddenly found myself arguing against using NHS funding for mass sperm banking and everything associated with it. What message did this give to the public?
Surely, if we have a spare £79 million of NHS funds sloshing around, wouldn't it be more appropriate to spend it on providing adequate funding of IVF for those who actually need it? Alongside this, we might also develop a comprehensive educational programme in schools and colleges to inform young people about fertility issues and the dangers of leaving it too late, so all but a very few would need to bank anything at all.