A review of guidelines, recommendations, and framework of men’s preconception care : Reproductive and Developmental Medicine

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Review Article

A review of guidelines, recommendations, and framework of men’s preconception care

Rabiei, Zeinab1; Shariati, Mohammad2; Mogharabian, Naser3; Tahmasebi, Rahim4; Ghiasi, Ashraf5; Motaghi, Zahra6,*

Author Information
Reproductive and Developmental Medicine 6(4):p 254-259, December 2022. | DOI: 10.1097/RD9.0000000000000030
  • Open

Abstract

Introduction

Improved pregnancy outcomes are linked to improved preconception health and planned pregnancies[1]. A new method to attract males’ attention to preconception and general health is to focus on men’s health in the context of preconception health and primary care[2]. Preconception care for men is defined as a collection of preventative measures used before conception to enhance pregnancy and newborn outcomes[1]. Preconception care for men is critical for maximizing family planning and pregnancy outcomes, preparing men for parenthood, and enhancing the productive health and behaviors of both men and women[3]. Men’s health during conception has been shown to affect pregnancy and neonatal outcomes via direct and inherited implications on spermatozoa quality[4,5]. Men’s health (eg, diabetes, obesity) and risk behaviors (eg, drug abuse, alcohol, and smoking) have an influence not just on their overall health, but also on their reproductive health[6]. Furthermore, fertility normally declines with age, beginning at 35 years old. The quality and count of sperm, as well as their ability to enter the zona pellucida, are affected[7]. Pregnancy outcomes tend to decline with increasing paternal age, particularly beyond 50 years old. Autism, schizophrenia, and autosomal dominant illnesses, including Marfan syndrome and Down syndrome, are associated with a father’s older age[8]. However, few studies have concentrated on men’s preconception health. Men have critical sexual and reproductive health requirements throughout their lives. For example, nearly four out of 10 american males claimed that their most recent live delivery of a baby was an unwanted pregnancy[9]. Additionally, men have a higher risk of sexually transmitted infections than women[10]. The absence of guidelines for sexual and reproductive health care is a key barrier for clinicians treating men in reproductive care[11]. Medical history, medication use, family history and genetic risks, social history, mental health, nutritional practices, physical examination (including sexually transmitted infections and testicular cancer screening), immunization status, occupational hazards, and health promotion were all covered in Frey’s preconception visit[6]. According to Warner et al., healthcare providers who examine and advise men about their overall reproductive health need a holistic approach[12]. The goal of this review is to offer health care clinicians a framework for men’s preconception care.

Materials and methods

Search strategy

Two independent authors (Z.R. and A.G.H.) searched for published research from 2000 to October 2021 applying following the key terms within the electronic databases: (“reproductive health” AND men* AND recommendation), (male AND program* AND “preconception care”) OR (men’s preconception AND preventative strategies), (male AND preparing for pregnancy AND recommendation), (preconception care AND male AND guideline), (“preconception care” AND male AND package), (preconception AND intervention AND men) OR (male) OR (father), (pre-pregnancy* AND medical checkup AND male), (getting pregnant AND male AND prepare AND framework), (“preconception care” AND protocol AND male), (“preconception care” AND services AND male), (preconception AND risk assessment AND men AND policy), and (preconception care AND clinical content AND men). The electronic databases included Web of Science, PubMed, Scopus, Sciencedirect, ProQuest, Cochrane, SAGE, Springer, UpToDate, and Google Scholar.

Inclusion and exclusion criteria

The articles were preconception guidelines, recommendations, position statements, or clinical review studies that published full-text publications and offered a framework for the preconception treatment of men. The following papers were excluded: abstracts with incomplete conclusions, no full-text accessible, website suggestions, and prospective studies.

Data extraction and quality assessment

Two independent authors (Z.R. and A.G.H.) retrieved many features from the included articles, including the author’s name, year of publication, type of research, nation in which study was conducted, study goal, and key findings. Any discrepancies between the two reviewers were addressed in consultation with the senior author (Z.M.). Two separate writers assessed the research quality using techniques suited for this type of study. The scientific quality of clinical review articles was determined using Oxman and Guyatt’s criteria[13], and the methodological quality of the included practice recommendations was determined using the AGREE-II instrument[14].

Results

As shown in Fig. 1, 835 studies were retrieved using the PRISMA flowchart. After eliminating 115 duplicate studies, 720 articles were evaluated based on their titles and abstracts. After excluding 704 publications based on their titles and abstracts, 16 studies remained for the full-text examination. Finally, 14 studies that matched the inclusion criteria for the present systematic review were included. Twelve articles were clinical reviews, one was a practice guideline, and one was the CDC and US Office of Population Affairs recommendations. Twelve studies were conducted in the United States and two in South Korea. The following section summarizes the features of the study, of which details are provided in Table 1. Individual responsibility across the life span (evaluation of reproductive life plan, acquiring information about contraception), risk assessment (age, medical and surgical history, medications, family history and genetic risks, social history, sexual health assessment, physical examination, laboratory testing, mental health, and intimate partner violence) are the two main topics of preconception care in men, according to the review of studies. The following diagram depicts the key components and subcategories of preconception care for males (Table 2).

Table 1. - Main characteristics of the included studies.
Author, year Purpose of the study Type of study Country
Warner and Grey, 2013[12] The purpose is to provide a holistic framework for health care providers to evaluate and counsel men regarding their overall reproductive health needs Clinical review Scottsdale, AZ
Frey et al., 2008[6] Provide a model framework for preconception care for men that can be used in clinical practice Clinical review Scottsdale, AZ
Frey, 2010[3] Develop a model of men’s preconception care Clinical review Scottsdale, AZ
Marcell et al., 2015[11] This article describes the process of developing recommendations for providing reproductive health services to men synthesis paper US
Hurst and Linton, 2015[32] Describe the key points of preconception care for men Clinical review US
Wilkes, 2016[17] Provide recommendations based on evidence that address reproductive health care Practice Guidelines (position paper) US
Gavin et al., 2017[16] Provide quality family planning services Recommendations US
Choe and Han, 2016[21] To describes risk assessment as an essential element of comprehensive preconception care for men Review Korea
Hoh and Park, 2011[18] The article summarizes key aspects of optimizing the health status of men as fathers before conception Review Korea
Mfuru, 2020[29] This study examined the current state of preconception care provided by primary care providers to men and aspects that could be improved Review Florida
Malnory and Johnson, 2010[15] Discussion of the importance of implementing a life course perspective model, including a reproductive life plan, to improve health outcomes Review US
Solomon et al., 2008[24] Evidence-based genetics and genomics screening for preconception Review US
Coonrod,2008[26] The article discusses the infectious diseases that should be considered during preconception care Review US
Barron, 2013[7] To provide a concise guide of current information and recommendations on reproductive health for the primary care nurse practitioner Review US

Table 2. - Main components and subsets of preconception care for men.
Components of preconception care for Men References
Individual responsibility across the life span
Evaluation reproduction life plan [3,6,11,12,15–17,21,32]
Get information about contraception (When a partner’s pregnancy is not desired, discuss effective contraceptive methods) [17,32]
Risk assessment
Age [12,18]
Medical and surgical history [3,6,11,12,16,21,29,32]
Medications [3,6,12,21]
Family history and genetic risks [3,6,12,17,21,24]
Social history [3,6,11,12,16,17,29,32]
 -Alcohol and other drug use
 -Tobacco use
 -Unsafe sex
 -Working environment with high temperature, lead, and other chemicals
Sexual health assessment [11,12,16]
Sexually transmitted infections: Assess STI risk, provide counseling and immunizations as indicated to prevent acquisition of STIs [11,17,26]
Physical examination [3,6,12,16,21]
 -BMI
 -Blood pressure
 -General examination
 -Genital examination
Laboratory Testing: such as [3,6,12,17,18,21]
Blood tests, urine tests, syphilis serum and AIDS tests, hepatitis and liver function tests, and chest X-ray (tuberculosis test) are essential tests
Laboratory testing should be guided by clinical history
Mental health [3,6,11,12]
Intimate partner violence [17,29]
Health promotion
Vaccinations [6,12,18,21]
Nutrition [6,12,18,21]
Healthy weight [6,12,18]
Stress reduction [6,12,18]
Avoidance of harmful exposures [6,12,18,21]
Medical and psychosocial interventions for identified risks [6,11,12,21]

F1
Fig. 1.:
PRISMA flow diagram of the study.

Individual responsibility across the life span

Evaluation of reproductive life plan

A reproductive life plan is a collection of personal objectives for having children, based on one’s own beliefs and resources, as well as a strategy for achieving these goals[6,15]. According to AAFP and CDC, all couples of childbearing age should have a reproductive life plan in place as a method for reducing adverse birth outcomes. Thus, to provide male preconception care, it is vital to first inquire about the desire to have children. If they aim to have children in less than a year’s time, they should undergo a comprehensive assessment, as indicated below[3,6,12,16,17].

Acquire information about contraception

Men who do not wish to have children should use contraception. Therefore, it is necessary to provide them with contraception information and discuss viable contraceptive techniques[6,12,16,17].

Risk assessment

Age

To date, only the woman’s age has been considered when considering pregnancy. Men’s age, on the other hand, is also a significant determinant. Consequently, male fertility declines with age[18]. After the age of 35, male sperm parameters begin to fall, although male fertility does not appear to be reduced until approximately 50 years of age[19]. Furthermore, the fathers’ age might have a detrimental impact on pregnancy outcomes and child health. Stillbirths, preterm births, infant mortality, Downs syndrome, autism, and schizophrenia are all associated with older men (over 50 years)[20]. Many fathers are unaware of the growing amount of research linking paternal age to childhood schizophrenia and additional other harmful effects[6]. Regarding the unfavorable consequences of older men’s age on newborn outcomes, older men (over 50 years old) should be provided with the relevant information to assist them in making informed choices regarding childbearing.

Medical and surgical history

Surveying a man’s preconception health requires complete medical and surgical history to be considered. Fertility is also affected by several disorders, such as obesity, diabetes, varicocele, and sexually transmitted diseases, among others[3,6,12,21]. Increased adipose tissue in obese males, for example, hinders the production of the sex hormone metabolism, resulting in the transformation of testosterone into female hormones and decreased sperm production. In addition, an imbalance in the production of insulin, SHBG, leptin, and inhibin B leads to lower testosterone levels and interference with spermatogenesis. Obesity is associated with changes in sperm RNA, DNA methylation, and sperm chromatin condensation[22]. Varicocele is another medical condition in men that requires treatment prior to conception. Testicular varicose is one of the most common causes of male infertility, and is responsible for 30%–40% of male infertility cases, with 80% of individuals with this illness producing defective sperm. However, many instances are only detected after infertility because there are few indicative signs[23]. As a result, before attempting conception, men with a known or unknown disorder affecting fertility must take the appropriate steps to manage and cure the problem to the extent possible.

Medications

Numerous drugs have been shown to affect erectile function, libido, sperm count, and sperm quality. Exogenous testosterone, androgen supplements, 5-reductase inhibitors, and calcium channel blockers, among others, may have detrimental effects on male fertility and pregnancy. As a result, physicians must assess men’s medication history, both previous and present[3,6,12,21].

Family history and genetic risks

A thorough three-generation family medical history should be conducted to ascertain known genetic illnesses, congenital abnormalities, developmental delay/mental retardation, and ethnic origins. If this screening history suggests a genetic condition, relevant guidance, including referral to a genetic counselor or a clinical geneticist, should be offered[24].

Social history

Men’s social history should be investigated, including cigarette usage, alcohol and other drug use, hazardous sex, and workplace conditions that involve high temperatures, lead, and other chemicals[3,6,12,18,21]. Such employment types involve chemical employees, electrical workers, electronics workers, metalworkers, dye workers, textile mill workers, laundry workers, furniture makers, nuclear power plant workers, and medical workers[21]. Because many men in these professions are seeing a drop in sperm quality and quantity, it is vital to speak with an expert about how the office environment impacts natural pregnancy before attempting to conceive[18].

Semen quality has been linked to smoking in a dose-dependent manner, although there was no evidence of a relationship between smoking and male fertility. Furthermore, high alcohol use by male partners is linked to aberrant gonadal function, including lower testosterone levels, impotence, and sperm production[25]. Regarding the many severe health consequences of smoking and drinking, men who are planning on having children should be urged to stop.

Sexual health assessment

To assist a couple with a successful pregnancy, a sexual health examination that examines the man’s sexual function, forms of sexual activity (eg, vaginal, anal, or oral sex), and frequency of intercourse is advised in preconception care[16].

The highest pregnancy rate is seen in couples who have intercourse every one to two days. Furthermore, after 2 to 3 days of abstinence in ejaculatory function, semen quality may be at its highest, although prolonged intervals can contribute to decreased pregnancy rates[25]. As a result, health care experts should counsel couples on how to have good sexual relations with the purpose of conceiving.

Sexually transmitted infections

As sexually transmitted illnesses may induce infertility in the female partner and substantial morbidity in the fetus, they should additionally be regarded as a preconception health problem for men. Before becoming pregnant, men should be advised of their STI status and instructed on safe sexual practices[11,17,26].

During preconception care visits, healthcare practitioners should obtain sexual history from men. When making STI screening recommendations, healthcare practitioners should consider each male’s risk behaviors and the social context[17].

Physical examination

A full physical examination should be performed as a part of the preconception assessment. To detect hypertension and obesity, blood pressure, and body mass index (BMI) should be monitored[11,12]. An examination of the chest (gynecomastia, nipple discharge), an abdominal examination to identify any surgical scars, particularly in the lower abdomen or inguinal region, an examination of local neurological symptoms (loss of smell, vision field loss), and last of the genital area should be conducted. The urethra’s position, position and size of the testicles, presence or absence of varicose veins, and, if required, the prostate gland test should all be examined[21].

Laboratory testing

Clinical history should be used to guide the laboratory work. Blood tests, urine tests, syphilis serum, AIDS testing, hepatitis and liver function tests, and chest X-rays (tuberculosis test) are all critical tests for men, just as they are for women. A herpes test and gonococcal test should also be also performed if the male has a history of urethritis[18].

Mental Health

Men’s mental health must be assessed[3,6,12,21]. Premature birth is linked to paternal depression. Approximately 10% of men have postpartum depression, which may interfere with father-infant attachment. Furthermore, there is evidence that a child with a depressed father may have behavioral and emotional developmental issues[20].

Intimate partner violence

Any physical, sexual, verbal, or emotional abuse performed by a current or past partner, such as a spouse, intimate partner, or continuing sexual partner, is defined as intimate partner violence[27]. One of the most serious health concerns for women is violence within an intimate relationship. Men may also be victims of domestic abuse. Children who see violence against their parents need extra help with a number of behavioral and emotional issues[28]. As a result, before trying to conceive, males should be screened for intimate partner abuse to identify victims and send them to an appropriate expert[17,29].

Health promotion

Vaccinations

Before becoming pregnant, men should take steps to reduce the risk of passing illnesses on to their wives and ensure that they are immune to various infectious diseases. As a result, a preconception examination should include a check on a man’s immunization status[6,18].

Men should have mumps, measles-mumps-Rubella, chickenpox, Td for adults, and hepatitis B and hepatitis A vaccinations before becoming pregnant[18].

Nutrition

Nutritional control during the preconception period is not just important for women. The nutritional health of men has a direct impact on their sperm. The sperm count of a guy is lower if he or she does not eat a well-balanced diet. Therefore, both men and women must carefully manage their diets 3–6 months before conception. Carbohydrates, proteins (carnitine and arginine), unsaturated fatty acids (omega-9 and omega-3), vitamins (folic acid, B6, B12, C, E, coenzyme Q10, and lycopene), and minerals (calcium, zinc, selenium, magnesium, and chromium) are all critical nutrients for males before pregnancy[18].

Healthy weight

In the context of health promotion, achieving and maintaining healthy weight is critical. Before pregnancy, a BMI of 20–22 is ideal. Low testosterone levels, poor sperm quality, and impaired fertility are associated with obesity[11]. Obese males are also at risk of diabetes, hypertension, hyperlipidemia, and adult illnesses such as angina. Accordingly, the sperm count is lower in men with these disorders than in healthy men, and numerous sexual dysfunctions are more prevalent[18].

Stress reduction

Stress reduction is a critical aspect in the context of men’s preconceptions. Regular exercise, proper sleep habits, and a nutritious diet are examples of strategies that can minimize stress[6,12].

Regular physical activity boosts the generation of healthy sperm. However, if men continue to exercise hard until they are exhausted, their sperm count and testosterone levels decrease, resulting in an overall decreased fertility. As a result, men should avoid excessive exercise and limit their physical activity to a level appropriate for their physical strength. Cycling, other workouts that raise testicular temperature, and the use of anabolic steroids are also not recommended during the preconception period[6].

Avoidance of harmful exposures

Men should be encouraged to abstain from cigarettes, alcohol, and illegal drugs, and those with dangerous exposure at work should take precautions[6,12,18].

Medical and psychosocial interventions for identified risks

When a man’s risk assessment identifies an abnormality, appropriate action is carried out based on the clinical history to start conception with the best possible health. For example, men who show evidence of hormonal or testicular problems during a physical examination should be sent to an infertility expert[6,11,12,21].

Discussion

This study aimed to offer healthcare practitioners a complete framework for preconception care in men. Although no countries have special preconception care guidelines for males, the american Academy of Family Physicians has produced practice guidelines including preconception suggestions and treatments for both men and women[17]. In certain European nations, drinking and smoking advice for men is combined with preconception care guidelines for women[30]. Furthermore, although there are no special standards or programs for men’s preconception health in Iran, the Infertility Prevention Program includes suggestions for male reproductive health as well as providing women’s information[31]. Based on a review of the research, we have discovered that the majority of them have focused on analyzing the reproductive life plan and risk assessment in males prior to conception. Establishing a plan with precise fertility targets throughout a couple’s reproductive life is critical. The major goal of preconception risk assessment is to detect health issues and high-risk behaviors that affect fertility and fetal health in order to avoid male infertility and unfavorable fetal outcomes, by correctly treating these risks before pregnancy. Different subgroups mentioned in the literature are included in the risk assessment. Male age[12,18] and intimate partner violence[17,29] in the context of preconception risk assessment have only been evaluated in two studies among these populations. While advanced age has a detrimental impact on fertility and newborn outcomes, more studies are required in this area, as well as the necessity of men’s counseling on advanced age. Few studies have examined preconception health promotion, an important element of men’s preconception care. As the father is responsible for half of the fetal production, it seems that men’s health should be promoted more via education and guidance prior to conception. Few studies have focused on men’s preconception of the healthcare framework, which was a limitation of this study. This issue was addressed through research entailing some aspects of men’s preconception care.

Conclusion

Our findings clearly demonstrated the critical components of a comprehensive preconception care approach for men. Preconception health has a number of direct and indirect effects on pregnancy outcomes and men’s health. Therefore, all men who desire to have children should be screened using the preconception framework of primary healthcare professionals. However, preconception care for men remains a developing idea. Further research is required to develop standards for evaluating males during the preconception period.

Acknowledgments

The present study was part of the results of the PhD thesis approved by Shahroud University of Medical Sciences (code: 907). We sincerely want to thank our colleagues who provided advice and knowledge that helped us significantly in writing the paper.

Author contributions

Z.R. and A.G. performed the data search and extraction; M.S. and R.T. participated in data analysis and interpretation; N.M., Z.M. and Z.R. discussed the manuscript revision; Z.R. designed and drafted the manuscript. All authors contributed to the final manuscript and approved the submitted version.

Funding(s)

None.

Conflicts of interest

All authors declare no conflict of interest.

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Keywords:

Guidelines; Men; Preconception Care; Recommendations

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