The Forgotten Father: A Urologist's Perspective on the Male Role in Miscarriage

By Mr Stephen Gordon, Consultant Urologist 

When a couple comes to see a professional after a miscarriage, the man is almost always in the same position. He sits quietly, often at the edge of the consultation, supporting his partner — and silently asking himself whether there was something wrong with him. Something he caused. Something he should have known.

He rarely asks that question out loud.

Miscarriage has, for decades, been framed as a woman's medical problem. The investigations, the referrals, the follow-up — all directed at her. The man leaves the room with no answers, no tests, and no plan. Just the instruction to try again.

As a Consultant Urologist with a special interest in male reproductive health, I believe that needs to change. And the science now strongly supports the case.

Why the male factor has been overlooked

The traditional assumption has been simple: if a man's sperm achieved fertilisation, his contribution was complete. Any problem with the pregnancy must therefore lie with the woman — her hormones, her immune system, her uterine environment.

This reasoning has one major flaw. It treats fertilisation as the end of the sperm's role. It isn't.

Sperm contributes half of the embryo's genome. As the embryo develops, the paternal genome is progressively activated, becoming increasingly important to the viability of the pregnancy. Damaged sperm DNA may allow conception to occur — but if the genetic material carried within those sperm is sufficiently disrupted, the embryo may not survive to term.

Conventional semen analysis — which measures sperm count, motility, and morphology — tells us nothing about the integrity of the DNA inside those sperm. A man can have a perfectly normal semen analysis and carry a significant level of sperm DNA damage. This is why so many couples with "unexplained" miscarriage or fertility remain unexplained: the right question simply hasn't been asked.

What the research tells us

I had the privilege of contributing to a study, published in Reproductive BioMedicine Online in 2021, that set out to answer this question directly.

Haddock L, Gordon S, Lewis SEM, Larsen P, Shehata A, Shehata H. Sperm DNA fragmentation is a novel biomarker for early pregnancy loss. Reprod Biomed Online. 2021 Jan;42(1):175–184.

Working with Professor Hassan Shehata and colleagues at the CRP Clinic in Epsom, we measured sperm DNA fragmentation in 217 men whose partners had experienced miscarriage, comparing them to 76 fertile donors.

The findings were striking. Men whose partners had miscarried had an average sperm DNA damage score of 33% — compared to just 15% in fertile men. That is more than double. And this difference was consistent whether the couple had experienced a single miscarriage or recurrent losses, and whether conception had occurred naturally or through IVF or ICSI.

The DNA fragmentation test was able to distinguish between these two groups with an accuracy (AUC) of 0.965 — making it one of the most robust biomarkers yet identified for pregnancy loss.

Put plainly: sperm DNA quality is not a peripheral factor in miscarriage. It is a central one.

Since then we have now accumulated similar data from over 1000 couples in a similar position with pregnancy loss, failed IVF and those struggling to conceive. We are continuing the research in this area to learn and understand how to best optimise men's health and fertility for the benefit of him now and in the future but also as a couple and the future health of their children.

What I look for as a urologist

When a man is referred to me through the CRP Clinic following miscarriage, I approach him as a patient with his own clinical story — not simply an appendage to his partner's fertility journey.

My assessment covers:

Medical and reproductive history — previous pregnancies, fertility investigations, surgical history, current medications, supplements, and exposure to recreational or performance-enhancing drugs.

Lifestyle factors — smoking, alcohol, diet, exercise, heat exposure (laptops, hot baths, cycling), and body weight. These factors directly influence sperm DNA quality through oxidative stress and can often be meaningfully addressed.

Infection — seminal and genitourinary infections, including those without obvious symptoms, can elevate sperm DNA fragmentation significantly. Appropriate PCR testing and antibiotic treatment, where indicated, can lead to meaningful improvement. Risk of HPV and the impact for men and women is considered.

Varicocele — enlarged veins in the scrotum are present in up to 48% of men with fertility problems. A varicocele raises scrotal temperature and generates oxidative stress, both of which damage sperm DNA. It is often silent. It is often missed. And it is treatable — a straightforward but technical outpatient procedure can reduce DNA fragmentation and, in some studies, has been associated with reduced miscarriage rates. I examine every man for this. An ultrasound can also objectively assess testicular size and for the presence of a varicocele but is also the best method to assess physical testicular abnormalities such as testicular tumours.

Hormonal assessment — testosterone and related hormone levels can affect sperm production and DNA quality. Where deficiency is identified, this can be addressed through appropriate management.

Age and genetics — while our 2021 study did not find a significant correlation between age and DNA damage in the cohort studied (possibly due to relatively small numbers of older men), paternal age remains a relevant factor in some cases, and I take a full picture of both partners' ages into account.

What can be done

This is the question that matters most to couples sitting in front of me — and I am glad to be able to say that the answer is often more encouraging than they expect.

For many men, targeted lifestyle changes — reducing alcohol, stopping smoking, improving diet, losing weight, reducing heat exposure — can produce meaningful improvements in sperm DNA quality within three to six months and often much sooner. I am always asked, "Can we try again soon?". These changes are not passive; they are active treatment.

Where infection is identified, antibiotic therapy is often highly effective. Where varicocele is confirmed and clinically significant, surgical treatment can reduce DNA damage and improve fertility outcomes.

For couples proceeding with IUI, the CRP Clinic offers Zymot microfluidic sperm selection — a device that isolates the sperm with the least DNA damage, improving the quality of what is used for treatment. For IVF and ICSI cycles, knowledge of sperm DNA status informs decisions about fertilisation technique and embryo handling. In some cases, surgical sperm retrieval — which bypasses the transport pathway where much of the damage occurs — is the most appropriate route.

Following any treatment, the CRP Clinic offers a complimentary repeat DNA integrity test at three to six months to assess progress and guide the next decision but also inform ongoing research.

The combined live birth rate for couples receiving joint male and female treatment through the CRP Clinic programme is over 80%. That figure is the result of looking at the full picture — both partners, comprehensively assessed, with a coordinated plan.

For those men who repeated the test after seeing me 2 out of 3 had a significant improvement in their sperm quality. Many others did not need to repeat the test due to a successful pregnancy and the remaining but far fewer couples were able to consider further specialised or experimental tests and options along with assisted conception techniques. 

Working with Professor Shehata and the CRP Clinic

I work alongside Professor Hassan Shehata at the CRP Clinic in Epsom, both in person and by remote consultation. Professor Shehata leads one of the UK's most experienced services for recurrent pregnancy loss, with a particular focus on reproductive immunology and the complex interplay of factors that contribute to miscarriage.

Our collaboration reflects a simple conviction: miscarriage is not one person's problem, and it should not receive one person's investigation. When we look at both partners thoroughly, we find more answers — and we can offer more targeted, evidence-based treatment.

If you have experienced miscarriage — one or more — and the male partner has not been assessed, I would encourage you to consider whether that investigation is overdue.

A note to the man reading this

If you are the partner — reading this quietly, wondering whether any of it applies to you — I want to say something directly.

You are not blameless because we don't investigate you. You are not to blame because we do. This is medicine: looking for answers, not assigning fault.

You may be the missing piece. And if you are, there is something we can do about it. 

Next steps

To discuss sperm DNA testing or a male reproductive assessment, you can contact the CRP Clinic directly or reach me through my website or register here. https://mr-stephen-gordon-consultant-urologist.carebit.co/patients

• CRP Clinic, Epsom: crpclinic.co.uk/news 137/139 High Street, Epsom, KT19 8EH Led by Professor Hassan Shehata FRCOG FRCPI

• Mr Stephen Gordon, Consultant Urologist: urology.me.uk 

Haddock L, Gordon S, Lewis SEM, Larsen P, Shehata A, Shehata H. Sperm DNA fragmentation is a novel biomarker for early pregnancy loss. Reprod Biomed Online. 2021 Jan;42(1):175–184. doi: 10.1016/j.rbmo.2020.09.016