Abstract
Assisted reproductive technologies (ARTs) are increasingly utilized in Ghana, as treatment options for couples with infertility, including male factor infertility. While extensive research has focused on female determinants of ART success, comparatively fewer studies have systematically examined the contribution of male partner characteristics beyond routine semen analysis to clinical pregnancy outcomes following ART. The paucity in research is more pronounced in Ghana. This was a cross-sectional study, conducted at the Chosen Hospital and Fertility Centre between January 2024 and March 2025. The study population comprised 198 male partners of women seeking ART services at the hospital, aged between 30 and 61 years. Baseline data were collected from the male partners before initiation of the ART procedure. The sociodemographic, anthropometric, and clinical data of the men were collected using a semi-structured questionnaire and medical records. Venous blood samples were then collected before ART and analyzed for fasting lipids, glucose, complete blood count, liver, and renal function tests. Semen samples were also collected after 3 to 7 days of abstinence and analyzed. Following the ART procedure, 126 (63.6%) of the women tested positive for pregnancy. The sociodemographic, anthropometric, hematological, biochemical, and seminal variables were compared between ART outcomes. The mean ± standard deviation of serum chloride level in mmol/L was higher in males whose partners tested negative for post-ART pregnancy compared to those who tested positive (101.3±3.5 vs 99.9±2.6, P=0.026). No significant disparities in the other variables were observed between the groups. The findings suggest that, although chloride is essential for normal spermatogenesis, high levels of serum chloride could be detrimental to sperm quality. Routine electrolyte measurements of male partners of infertile couples should be performed before ART procedure.
Introduction
Infertility remains a major psychosocial and public health concern globally, affecting approximately 10% to 15% of couples of reproductive age (Hawkey, 2023; Liang et al., 2025). In Ghana, just like other sub-Saharan African countries, the burden of infertility is particularly dire due to the strong sociocultural importance placed on lineage continuation, childbearing, and marital stability (Fledderjohann, 2012; Geelhoed et al., 2002). In many African societies, infertility is commonly perceived as a female problem, despite substantial evidence that male factors contribute to approximately 40% to 50% of infertility cases, either alone or in combination with female factors (Chimbatata & Malimba, 2016; Roomaney et al., 2024). This misperception often leads to delayed evaluation of male partners and under-recognition of their role in reproductive outcomes, including assisted reproductive technology (ART).
ARTs, including intra-uterine injection, in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), are increasingly utilized in sub-Saharan African countries, such as Ghana, as treatment options for couples with infertility, including male factor infertility (Gerrits, 2016; Tenchov & Zhou, 2025). Although ART has improved pregnancy outcomes for many couples in Ghana, success rates remain variable due to clinical, biological, and lifestyle-related factors involving both partners (Damalie et al., 2025). While extensive research has focused on female determinants of ART success, comparatively fewer studies have systematically examined the contribution of male partner characteristics beyond routine semen analysis to clinical pregnancy outcomes following ART (Jewett et al., 2022; Mazzilli et al., 2023). The paucity in research is more pronounced in Ghana and other sub-Saharan African countries.
Male reproductive potential is influenced by several factors, including sociodemographic factors, nutritional and anthropometric status, medical conditions, hematological, biochemical health, and seminal quality (Amoah et al., 2025; Rotimi & Singh, 2024; Tesarik, 2025). Emerging evidence suggests that systemic conditions such as hepatic and renal dysfunction, metabolic abnormalities, oxidative stress, and subclinical inflammation may affect sperm function and fertilization capacity, even when conventional semen parameters appear normal (Fallara et al., 2023; Smith et al., 2025). Most of the emerging evidence originates from high-income settings, and its applicability to African populations is uncertain due to genetic and environmental variabilities.
Data on male reproductive health regarding ART remain limited in Ghana, and few studies have comprehensively evaluated baseline male partner characteristics in relation to ART success. Understanding whether routinely assessed male sociodemographic, biochemical, clinical, hematological, and seminal factors are associated with pregnancy after ART procedure is essential for patient evaluation, counseling couples, and optimizing resource utilization in fertility centers. This is particularly important in low- and middle-income settings where ART is often costly and largely self-funded (Njagi et al., 2023; Whittaker et al., 2024). This cross-sectional study aimed to determine the baseline male factors associated with pregnancy success of their female partners following the ART procedure.
Materials and Methods
Study Design and Setting
This was a cross-sectional study that was conducted at the Chosen Hospital and Fertility Centre, a specialist ART facility located in Accra, Ghana, between January 2024 and March 2025. The study formed part of the baseline assessment of couples undergoing ART procedures. The Chosen Hospital and Fertility Centre has several specialized departments, including a fertility clinic where specialized professionals carry out ART procedures. The hospital also has a well-equipped medical laboratory where baseline and follow-up laboratory assessments are undertaken following standardized protocols and observing laboratory quality management systems.
Study Population
The study population comprised 198 male partners of women seeking ART services at the hospital, aged between 30 and 61 years. The eligible participants included male partners of infertile women who were scheduled to undergo an ART procedure during the study period. Male partners were included if they were aged 18 years or older, were the biological partners of women undergoing ART, and provided informed consent to participate. Male partners with incomplete baseline laboratory or clinical data were excluded from the analysis.
Sample Size Determination
The minimum sample size was determined using the Cochrane formula for cross-sectional studies, using a prevalence of female infertility of 11.8% from a previous study in Ghana (Geelhoed et al., 2002). The study assumed a 95% confidence interval and an alpha value of 5%. The minimum sample size was estimated to be 139.
Data Collection and Laboratory Analyses
Baseline data were collected from both the women and their male partners before initiation of the ART procedure. Data collection was carried out using semi-structured questionnaires, physical measurements, and laboratory investigations conducted according to standard clinical protocols at the fertility center. A fasting venous blood sample was collected from each male and then dispensed into ethylenediaminetetraacetic acid (EDTA) anticoagulant, anti-glycolytic, and gel-separator vacutainer tubes. The blood samples were placed in a cold box with an ice pack and transported to the laboratory for processing and analysis. The EDTA anticoagulated blood samples were analyzed for complete blood count using an automated hematology analyzer within 2 hr after collection. The blood samples in the anti-glycolytic and gel-separator tubes were centrifuged at 3000 rpm for 10 min to obtain plasma or serum. The serum or plasma samples were aliquoted into Eppendorf tubes in duplicates and then stored at −20°C. The plasma or serum samples were later analyzed for fasting blood glucose, lipids, liver, and renal function tests using an automated biochemistry analyzer and following standard protocols and accepted laboratory quality guidelines. Other laboratory tests were performed, including sickling test, G6PD deficiency, hemoglobin electrophoresis, ABO and Rhesus blood groups, and hepatitis B surface antigen tests. Semen samples were collected from male partners following an abstinence period (3–7 days) and analyzed in accordance with standard laboratory guidelines. Analyses were conducted by trained laboratory personnel using established semen analysis protocols routinely applied at the fertility center. Following the ART procedure, women were assessed for clinical pregnancy using standard pregnancy testing protocols and imaging techniques employed by the facility. Based on the pregnancy test results, participants were categorized into male partners of women who tested positive (126 [63.6%]) and those who tested negative for pregnancy following the ART procedure.
Variables
The primary outcome of the study was the clinical pregnancy status of the female partner following the ART procedure, categorized as positive or negative. The independent variables were the sociodemographic information collected from male partners, including age and other relevant background characteristics. Clinical variables assessed included blood pressure measurements and medical screening results such as hepatitis B status, sickling test, hemoglobin phenotype, blood group, and glucose-6-phosphate dehydrogenase (G6PD) deficiency status. Anthropometric measurements included measurement of body weight and height, from which body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m²). Biochemical variables included fasting blood glucose, renal function tests (serum urea, creatinine, sodium, potassium, and chloride), liver function tests (liver enzymes, proteins, and bilirubin), and fasting lipid profile (cholesterol and triglycerides). The hematological variables included red blood cell, white blood cell, and platelet count and their indices. Semen analysis included semen volume, sperm count, sperm concentration, motility, and morphology.
Statistical Analysis
Data were collected into an MS Excel Spreadsheet and then analyzed using SPSS version 27.0. Continuous variables were assessed for normality using the Kolmogorov–Smirnov test before being summarized as either mean ± standard deviations or medians and interquartile ranges, as appropriate. Categorical variables were summarized using frequencies and percentages. Bivariate comparisons of male partner variables between the pregnancy-positive and pregnancy-negative groups were performed using Student t-test, for parametric data and the Mann–Whitney U test for nonparametric variables. Association tests were performed using the chi-square or Fisher’s exact test as appropriate. All statistical analyses were two-tailed, and significance was set at a p value <.050.
Ethical Approval
The study was approved by the institutional review board of the University for Development Studies (ref# UDS/RB/0019/25). The study followed the guidelines recommended by the 1964 Declaration of Helsinki, its later amendments for human subject studies, and national and local guidelines. The data were de-identified or anonymized to ensure confidentiality.
Results
Participants
There were 206 male partners of infertile women who were potentially eligible for the study. However, 203 were examined for eligibility, and 200 were confirmed eligible. A total of 198 men were finally included in this study because two men declined participation. There was no follow-up in this study, and all 198 were included in the final analysis.
Sociodemographic, Anthropometric, and Clinical Variables
The sociodemographic, anthropometric, and clinical variables were compared between male partners of infertile women who tested positive or negative following the ART procedure (Table 1). The results showed that there were no significant differences between the groups in sociodemographic, anthropometric, and clinical attributes.
Sociodemographic, Anthropometric, and Clinical Attributes of the Study Population.
Note. Continuous variables are summarized as mean ± standard deviation, whereas the categorical variables are summarized as frequency (%).
Differences in Male Partner Biochemical Variables
The fasting lipids, liver, and renal function variables, as well as the fasting blood glucose of male partners of infertile women with or without success following ART, were compared (Table 2). Although there were disparities in hepatic, renal, fasting lipids, and fasting blood glucose levels between the groups, none achieved statistical significance, except serum chloride level which was higher in the post-ART negative pregnancy group than the positive group (P=0.026).
Differences in Male Partner Biochemical Variables Stratified by ART Success.
Note. Results are summarized as mean ± standard deviation.
Differences in Male Partner Hematological Variables
The red blood cell, white blood cell, platelet counts, and their indices were compared between male partners of infertile women’s ART outcome (Table 3). Despite observed disparities between the groups, the differences did not achieve statistical significance.
Differences in Male Partner Hematological Variables Stratified by ART Success.
Note. Results are summarized as mean ± standard deviation.
Differences in Male Partner Seminal Variables
Seminal variables were compared between ART outcome groups (Table 4). Although there were disparities in appearance, viscosity, volume, concentration, count, motility, and morphology, the differences did not attain statistical significance.
Differences in Male Partner Seminal Variables Stratified by ART Success.
Note. Results are summarized as frequency (%) for categorical and median (IQR) for continuous variables.
Discussion
This cross-sectional study aimed to investigate male partner-related factors associated with success following ART procedures among infertile couples attending a fertility center. The findings showed no statistically significant differences in sociodemographic, anthropometric, clinical, hematological, or seminal parameters between male partners of women who achieved pregnancy and those who did not following ART. However, the serum chloride level was significantly higher in males whose partners tested negative for post-ART pregnancy.
The absence of an association between male age and BMI and ART outcomes is contrary to previous findings. Studies showed that advanced paternal age has been linked to reduced sperm quality, increased DNA fragmentation, and adverse reproductive outcomes (Donatti et al., 2023; Kadoch et al., 2024). The observed lack of association in this study may be due to the relatively narrow age distribution in this study and the use of ART techniques that may mitigate age-related sperm dysfunction (Tenchov & Zhou, 2025). Careful selection of quality sperm is undertaken in ART procedures such as IVF, ICSI, and intrauterine insemination (IUI), unlike the traditional method for conception. Similarly, obesity has been associated with hormonal disturbances and impaired spermatogenesis (Leisegang et al., 2021; Palmer et al., 2012). The findings of this study suggest that BMI alone may not significantly influence ART success once couples are selected and managed within specialized fertility programs.
The study showed that clinical variables, including hepatitis B status, hemoglobin phenotype, blood pressure, blood group, sickling status, and G6PD deficiency, were not associated with pregnancy outcomes. This is particularly relevant in Ghana and many African populations, where hemoglobinopathies, hepatitis B infection, and G6PD deficiency are relatively prevalent (Hemoglobinopathies et al., 2025; Sticher et al., 2025). While these conditions are important for general health and reproductive counseling, the present findings suggest that, when clinically stable and appropriately managed, they may not independently compromise ART success. This aligns with emerging evidence that systemic health conditions may have a limited direct effect on fertilization and implantation once ART bypasses several natural reproductive barriers (Tenchov & Zhou, 2025).
Chloride is an essential electrolyte that helps maintain cellular homeostasis and osmotic balance. However, high chloride levels may hurt male reproductive function. Excess chloride can disrupt the ionic microenvironment of the seminiferous tubules, impairing the function of Sertoli cells and the maturation of germ cells necessary for normal spermatogenesis (Raut et al., 2024). Increased chloride concentrations may also promote oxidative stress within testicular tissue, leading to DNA damage, lipid peroxidation and apoptosis of developing sperm cells (Aitken & Roman, 2008). In addition, electrolyte imbalance associated with hyperchloremia may indirectly affect the hypothalamic-pituitary-gonadal axis, potentially altering testosterone production and further compromising spermatogenic activity (Rohrbasser et al., 2016). Collectively, these mechanisms may contribute to reduced sperm quality and impaired male fertility.
Hematological indices, including hemoglobin concentration, white blood cell count, and platelet count, did not differ between groups. Although systemic inflammation and anemia have been hypothesized to affect male fertility through oxidative stress and impaired oxygen delivery to the testes, these effects may be subtle and not adequately captured by routine full blood count parameters (Naelitz et al., 2024; Potiris et al., 2025). Moreover, the clinical relevance of mild hematological variations for ART outcomes remains uncertain, particularly in populations where physiological ranges may differ from Western reference standards.
Conventional semen parameters, including sperm count, concentration, motility, morphology, and volume, were not associated with clinical pregnancy following ART. This finding is consistent with growing evidence that standard semen analysis has limited predictive value for ART success, especially in the era of ART (Tomlinson, 2016; Wang & Swerdloff, 2014). While semen analysis remains central to the diagnosis of male factor infertility, it may not adequately reflect functional sperm competence, including DNA integrity, chromatin packaging, and epigenetic quality (Tomlinson, 2016). These advanced sperm characteristics, which were not assessed in this study, may be more relevant determinants of fertilization, embryo development, and implantation.
This study contributes valuable data from a Ghanaian fertility center, addressing a critical gap in African reproductive health research. Assessing ART in sub-Saharan Africa, including Ghana, is challenged by weak data systems, including the absence of national ART registries and standardized reporting, which limits reliable estimation of service use and outcomes (Archary et al., 2023). ART access is largely restricted by lack of public insurance coverage, high costs and urban concentration of services, resulting in selection bias and poor representation of rural and lower-income populations in research (Damalie et al., 2025). Variability in laboratory standards, clinical infrastructure, and the availability of trained personnel further affect the quality and comparability of data. Sociocultural stigma surrounding infertility, especially for women, reduces care-seeking and study participation, while inconsistent ethical and regulatory frameworks complicate multicenter assessments. These bottlenecks, combined with limited research capacity and funding, contribute to a sparse and fragmented evidence base on ART effectiveness, safety, and equity in the region (Whittaker et al., 2024). The study is a cross-sectional design. A key limitation of the cross-sectional study design is its inability to establish temporal or causal relationships, as exposure and outcome are measured simultaneously, making it unclear whether the exposure preceded the outcome (Savitz & Wellenius, 2023). Such studies are also prone to prevalence-incidence or survivor bias, since they capture only existing cases and may underrepresent short-duration or severe outcomes. Confounding is difficult to control, particularly for unmeasured or unknown variables, which can distort observed associations. Cross-sectional designs are sensitive to measurement and recall bias, especially when relying on self-reported data, and they provide only a snapshot in time, limiting their usefulness for assessing changes, trends, or long-term effects (Wang & Cheng, 2020). Some semen samples were collected using coitus interruptus. Obtaining semen samples for analysis via coitus interruptus is not the best because it introduces several sources of systematic error and bias that compromise the validity of semen analysis (Organization, 2021). Some limitations of coitus interruptus include the loss of the first ejaculatory fraction, which is the most sperm-rich, containing the highest sperm concentration and motility, contamination with vaginal secretions, which can alter semen pH, viscosity, and volume; interfere with sperm motility; and introduce cells or microorganisms that confound microscopic and biochemical assessments. Collecting semen samples by coitus interruptus may lead to inaccurate semen volume measurement due to loss of semen, thereby affecting semen parameters such as total sperm number. Increased risk of sample variability may also arise because the timing and completeness of ejaculation are difficult to control, increasing intra-individual variability and reducing reproducibility. Anxiety or interruption may affect ejaculation quality, potentially altering sperm motility and liquefaction characteristics (Björndahl & Brown, 2022).
Conclusion
The findings suggest that, although chloride is essential for normal spermatogenesis, high levels of serum chloride could be detrimental to sperm quality. Routine electrolyte measurements of male partners of infertile couples should be performed before ART procedure.
Footnotes
Acknowledgements
The staff of The God Chosen Hospital and Fertility Centre are acknowledged for their support during participant recruitment and data collection for the study
Consent to Participate
All participants offered written informed consent before enrollment in the study. The study was voluntary, and a participant could withdraw at any stage.
Consent for Publication
Participants gave their consent for the publication of the study findings
Author Contributions
I.K.A., M.B., N.A.—conceptualization and methodology. N.A., M.B.—supervision, administration, and validation. I.K.A., V.B.O., E.K.A., G.N.A.A., E.K.A., I.Z.A.—experimentation, data collection, data curation, statistical analysis, and writing draft. All the authors reviewed the draft manuscript and approved its content.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data supporting the findings of this study are available through a responsible request from the corresponding author
Code Availability
Not applicable
Declaration of AI and AI-Assisted Technologies in the Writing Process
AI-assisted technologies such as ChatGPT and Grammarly were used for the English language and searching for relevant literature.