Impact of Socioeconomic Status on Male Reproductive Health: A Mini Review

Abstract

The recent trends in decreasing population all over the world are cause of concern, especially in developed countries. Socioeconomic factors as well as age, physiological, and environmental issues are the main contributors in limiting the number of children in modern families. In this regard, male reproductive health has recently attracted significant attention not only in the research community but also in our social platform. Key issues such as infertility and sexual dysfunction contribute to the decline in male reproduction. Socioeconomic status (SES) is the least understood factor that plays a critical role in influencing male reproductive health. The SES of an individual can be a key determinant of the type of infertility care they receive and may also predict fertility outcomes for couples undergoing assisted reproductive technology procedures. This mini review seeks to deepen our understanding of reproductive health equity by exploring the impact of socioeconomic and social factors on men’s sexual health and fertility outcomes. Our attempt is to reveal the complex interconnections between SES and male reproductive well-being.

1. Introduction

There has been a recent decline in birth rates in several countries. Many factors contribute to this decline beyond aging and increasing infertility issues. Studies reveal an alarming surge in infertility rates on a global scale [1], affecting 9% of couples, with male factors responsible for half of all cases [2,3]. In fact, socio-economic factors, cost of raising children, urbanization, and higher living standards are influencing such decisions about family size. Male infertility and sexual dysfunction significantly impact men’s reproductive and overall health. The origins of both infertility and sexual dysfunction are diverse, ranging from medical conditions, hormonal imbalances, psychological, and many other factors [4]. Socioeconomic status (SES) is conventionally defined as a combined economic and social measure of a person’s position in relation to others, based on three core components: education, income (or wealth), and occupation [5]. SES can indeed influence male fertility through various pathways. Lower SES has been found to be associated with higher levels of childbearing stress [6], reduced access to healthcare [7], and increased exposure to environmental issues [8], all of which can impact reproductive health. Additionally, socioeconomic factors can influence lifestyle choices such as diet and exercise [9], which also play an important role in maintaining good health and access to fertility care.

The SES of an individual often serves as an indicator of their overall health status. Among men, SES varies significantly across different regions and societies, influenced by a wide range of factors. Economic disparities also contribute to increased stress and affect mental health, which are directly connected to sexual dysfunction and infertility [10]. The relationship between SES and men’s sexual health is complex and involves multiple factors. In general, individuals with higher SES have better access to education, healthcare, and lifestyle resources, with greater awareness of sexual and reproductive health [11,12]. In contrast, men with lower SES may face barriers to seeking timely medical interventions for their health issues, potentially resulting in untreated conditions impacting fertility and reproductive health [13,14]. This mini review is an attempt to understand the biological, clinical, and environment-mediated mechanisms linking SES to male reproductive health, including semen parameters, hormonal profiles, access to diagnostic services, and exposure to occupational and environmental risks. Further, broader sociocultural determinants such as marriage patterns, partner availability, social infertility, generational fertility preferences, and value-driven reproductive decision making are acknowledged as integral components of reproductive health.

2. Key Socioeconomic Demographic Factors and Male Reproductive Health

The demographic landscape of reproductive health reveals significant variations across various age groups, racial and ethnic populations, geographic regions, individual health status and socioeconomic strata. Understanding the complex interplay of socioeconomic demographic variables have rarely been evaluated before. It is essential for recognizing how these factors significantly influence reproductive health outcomes. Age and SES are key determinants of male and female infertility and are mainly responsible for delaying pregnancy and assisted reproductive technology (ART) decision making. In the male, not only semen volume, sperm concentration, total sperm count and motility, and normal morphology diminish with age [15], but sperm DNA fragmentation and seminal oxidative stress also increase with advancing paternal age. In addition, levels of primary male sex hormones testosterone and dihydrotestosterone (DHT) undergo a significant decrease with age, resulting in hypogonadism—a condition often referred to as “Andropause.” This is the key factor affecting libido and sexual function. An annual decline of 1–2% serum testosterone after the age of 30 is observed in healthy men [16]. Chronic stress associated with socioeconomic disadvantage inhibits the hypothalamic–pituitary–gonadal (HPG) axis that can impair both testosterone production and secretion [17]. SES may also modulate testosterone via downstream health behaviors and metabolic pathways. Lower SES is frequently correlated with higher adiposity and metabolic dysfunction that have been linked to decreased circulating testosterone, independent of age [18].

Ethnicity plays a crucial role in shaping the socioeconomic landscape and, consequently, male reproductive health. Epidemiological studies reveal disparities in semen quality, reproductive hormone levels, infertility prevalence, and access to reproductive healthcare among different ethnic groups. A recent study, though controversial, has shown that white men in the United States often presented with higher sperm count (+128.35 million) and concentration (+26.43 million/mL) compared to black men [19]. Also, Hispanic men’s sperm concentration (+5.12 million/mL) and total motility (+5.28%) were higher than non-Hispanic men [19]. These observed differences are not purely biological. They largely reflect structural socioeconomic inequities such as disparities in income, education, occupational exposures, environmental risks, healthcare access, and chronic stress. Further, genetic variations such as Y-chromosome microdeletions and polymorphisms that result in azoospermia and infertility are linked to ethnicity and influence male reproductive outcomes [20,21]. Research confirms that ethnic minorities, especially those with lower SES, experience barriers to accessing and utilizing male fertility care [22]. Black men received less access to fertility services, including basic semen analysis and ART procedures such as intrauterine insemination (IUI) and in vitro fertilization (IVF), compared to White men [23].

Education and income are two other socioeconomic demographic factors that also influence the reproductive health of an individual. Higher levels of education are linked with better access to job opportunities, higher income levels, and increased awareness of contraception [24,25]. Consequently, working individuals with higher education tend to plan for delayed pregnancies and smaller families, while those with limited access to educational opportunities may face challenges in family planning and accessing contraceptive methods. The connection between income and fertility rates is complex. Families with higher incomes often have fewer children, as they tend to prioritize education and career development. In contrast, lower-income individuals may encounter obstacles in accessing reproductive healthcare and family planning services, which can result in higher fertility rates. Overall, both socioeconomic and demographic factors have a significant impact on men’s reproductive health. Examining factors such as age, ethnicity, education level, and income provides a comprehensive understanding of the complex interactions that influence reproductive well-being among different classes of men (Figure 1).

3. SES and Male Reproductive Health: Perspectives from Developed and Developing Countries

SES influences male reproductive outcomes through two concurrent pathways: (1) restricted access to contraception and family-planning services is associated with increased rates of unintended pregnancies, while (2) chronic exposures associated with socioeconomic problems such as psychosocial stress, nutritional insecurity, and environmental or occupational toxins that contribute to lower biological fertility, poorer semen quality, and higher rates of childlessness. In developed countries, easy access to regular medical check-ups, advanced healthcare services, and higher living standards contribute to improved overall health. However, the use of modern technologies poses risks to reproductive health. For example, excessive use of laptops and smartphones, though still debated, negatively affects sperm production and motility, possibly due to elevated scrotal temperatures [26]. Sedentary lifestyles, mental stress, and exposure to environmental pollutants can negatively impact men’s fertility. Lifestyle modifications such as prolonged sitting, often associated with desk-bound jobs, may lead to reduced sperm quality. Additionally, higher stress levels can cause hormonal imbalances that affect the male gonads, reproductive function, and overall health [27]. In developed nations, higher education levels often lead to improved job prospects and increased awareness about reproductive health, resulting in healthier lifestyle options and family-planning decisions. Fertility rates have declined in some developed nations, largely due to delayed parenthood and smaller family sizes, which in turn may contribute to increased aging populations and reduced birth rates.

Socioeconomic factors greatly influence the management of reproductive health of individuals in developing countries. Limited resources, such as lack of access to advanced medical facilities and modern treatments as well as inadequate healthcare provisions in developing countries, have a negative impact on individual health. Limited educational opportunities and lack of awareness about reproductive health often result in insufficient family planning and contraceptive use, leading to higher birth rates. At the same time, economic instability and unemployment can increase stress levels, which may disrupt hormonal balance and impair reproductive function and decreased fertility. In addition, absence of comprehensive sex education and awareness intensifies existing challenges, leading to higher rates of sexually transmitted infections and unintended pregnancies, which negatively affect overall reproductive health outcomes [28].

Beyond the general differences between developed and developing nations, emerging evidence from low- and middle-income countries (LMICs) reveals additional socioeconomic barriers to male reproductive health. Environmental and geographical factors also interact significantly with SES in determining male reproductive outcomes [29]. In several African, South Asian, and Latin American regions, factors such as widespread occupational exposures, environmental toxins, undernutrition, micronutrient deficiencies, and limited access to quality healthcare collectively exacerbate infertility risks among men with low SES [30,31]. Men engaged in agricultural or industrial work in regions with limited resources, who are constantly exposed to pesticides, heavy metals, and heat stress, are linked to impaired semen quality, hormonal disruption, and increased oxidative stress, further widening SES-related reproductive disparities [30,32]. Further, limited reproductive health literacy, cultural stigma surrounding male infertility, and gendered perceptions that attribute infertility primarily to women restrict healthcare-seeking behaviors among men [14,33]. These compounding issues that underscore SES disparities in LMICs are not only economic but also sociocultural and infrastructural, amplifying the overall burden of male infertility. Expanding research efforts in these areas is critical to developing targeted interventions that address the unique SES-linked determinants of reproductive health in LMICs.

Men’s SES has a significant and multifaceted effect on birth rates across both developed and developing countries. Research consistently shows that higher SES among men is linked to an increased likelihood of higher fertility rates, successful fatherhood, and more stable family formation, while lower SES is associated with elevated rates of childlessness and fewer reproductive outcomes [34]. Historical and evolutionary perspectives, such as the Trivers-Willard hypothesis, suggest that high-status parents are more likely to have male offspring, further linking SES to reproductive patterns [35]. Biologically, men from lower SES backgrounds experience worse fertility outcomes, including lower rates of live births following fertility treatments and higher risks of adverse birth outcomes, such as early preterm births, regardless of maternal SES [36,37]. Additionally, while low-SES men may become fathers earlier, higher-SES men tend to delay parenthood and surpass in lifetime fertility by their late 30s [38]. Economic insecurity and male unemployment in developing countries further delay family formation and reduce fertility, while changing gender roles increase selectivity in partner choice, exacerbating singlehood among low-SES men. Thus, men’s SES profoundly determines birth rates and reproductive trajectories worldwide. Men with high-SES consistently experience more stable and higher fertility, even though their total lifetime fertility may not be higher than that of lower-SES groups. Meanwhile men with low-SES face greater risks of delayed or absent fatherhood, which are driven by different mechanisms contributing to broader demographic declines and social inequalities. SES-linked issues such as educational demands, housing affordability, and work-related time constraints also exist in U.S. populations and contribute to delayed family formation.

4. SES Determining Men’s Access to Infertility Treatment and ART

SES is a potent determinant of health and has a profound impact on men’s access to infertility care, including ART, as well as on their reproductive outcomes. Despite advances in medical science, significant disparities persist, determined by a web of financial, geographic, informational, cultural, biological, and psychosocial factors. Men from lower SES backgrounds are markedly less likely to afford and gain access to fertility services compared to their higher SES peers. U.S. data from the National Survey of Family Growth (2011–2017) show that infertile or subfertile men who have not received an evaluation are more likely to be younger, unmarried, less educated, lower-income, uninsured, and with poorer access to regular healthcare [39]. Research in Utah found that men in deprived areas were less likely to access IUI or IVF and, when they did, they completed fewer cycles and experienced live birth rates 13% lower than those from affluent areas [37]. These patterns are echoed worldwide, illustrating that SES-related disparities in male infertility care are a global concern [40,41]. Financial barriers are among the most significant obstacles. The cost of IVF can range from $12,000 to $17,000 per cycle, with IUI costing $500 to $4000 per cycle. These expenses are often not covered by insurance, particularly in case of male-factor infertility [42]. Many insurance policies focus on female infertility or exclude ART altogether, forcing men to pay out-of-pocket expenses. In countries or states without coverage mandates or public subsidies, this financial burden is particularly acute not only for low-income individuals but also for middle class men, thus leading many to forgo or discontinue any such ART treatment [43,44].

Geographical disparities exacerbate these inequities. Fertility clinics and male reproductive specialists are densely concentrated in high-income urban regions and states with mandated IVF coverage. Rural and deprived urban areas are frequently underserved, requiring men to travel long distances, take time off from work, and shoulder additional costs and barriers that disproportionately affect those with limited financial means [45,46]. Even in countries with universal health systems, such as Denmark, high-income men are ten times more likely to initiate ART, highlighting that the SES disparity persists beyond direct treatment costs [43,47]. Furthermore, awareness and knowledge of male infertility and the availability of various ART treatments are also strongly influenced by SES. Higher-SES men are more likely to be aware of male infertility and its treatment options, directly affecting their likelihood of seeking care [48]. In contrast, lower-SES men may remain unaware of diagnostic or therapeutic avenues, resulting in underdiagnosis and undertreatment. Cultural and gender norms add another layer of complexity where infertility is often viewed as a “women’s issue,” deterring men, especially those from minority or low-SES backgrounds, from engaging in reproductive health or seeking help. Stigma surrounding male infertility, which is sometimes perceived as a threat to masculinity, can lead to silence, shame, and avoidance of a medical evaluation [49,50].

One key question pertains to any correlation between biological variation among various SES groups. It is interesting to observe that SES not only limits access to ART but also correlates with a biological disadvantage. Research indicates that men from socioeconomically deprived areas often exhibit poorer semen quality, including lower sperm concentration, motility, and total sperm count [51]. These disparities are attributed to a combination of chronic health conditions, obesity, environmental exposures, stress, and limited access to healthcare. As a result, low-SES men are more likely to need fertility interventions but are less likely to receive them. The psychosocial impact of infertility can be severe, with stress, depression, and diminished self-worth further influencing decisions regarding fertility treatment and potentially exacerbating infertility itself [52,53]. Men in higher SES groups also experience distinct forms of psychosocial stress that may influence reproductive health. Career prioritization and delayed family formation, which are more common among educated and affluent men, contribute to later paternal age, a factor linked with increased risks of sperm DNA fragmentation and de novo mutations [54]. Racial and ethnic minority men, specifically African American, Hispanic, Asian, and Muslim men, face additional hurdles, including language and cultural barriers, previous negative experiences with healthcare, and a lack of culturally competent providers [46,55,56]. These challenges interact with SES to deepen disparities in both treatment utilization and outcomes.

The cumulative effect of these barriers is substantial, and even when low-SES men access fertility treatment, they undergo fewer cycles and achieve lower live birth rates than their higher-SES peers [37]. This suggests that improved access alone will not close the fertility gap; deeper structural inequities related to health literacy, chronic disease burden, environmental exposures, and stress also contribute to poorer outcomes. To address these entrenched disparities, multipronged reforms are required. Expanding insurance coverage to include male-factor infertility diagnostics and treatments can alleviate financial barriers. Increasing the geographic distribution of fertility clinics and specialists, particularly in underserved areas, would improve access. Public education campaigns to raise awareness and destigmatize male infertility, combined with provider training, can help change norms and reduce informational and cultural barriers. Integrating infertility screening into primary care, especially for at-risk and underserved men with low SES, could enable earlier identification and intervention.

5. Limitations

A key limitation of the current literature is its disproportionate focus on data from high-income nations, with limited empirical research from LMICs. This imbalance restricts a complete understanding of how SES interacts with cultural, occupational, and environmental factors to determine male reproductive outcomes globally. Future research should prioritize large-scale, region-specific studies in LMICs to uncover the full spectrum of SES-related reproductive health disparities and equitable health policy worldwide.

Another important limitation of the current literature is the predominance of cross-sectional evidence, which constrains causal interpretations of how SES influences male reproductive outcomes. Policy-based studies have systematically examined interventions such as healthcare reform, improved access to education, or social protection programs that modify reproductive trajectories over time [57,58]. Emerging evidence from public health research suggests that structural interventions addressing social inequality can have indirect but measurable effects on men’s reproductive and sexual health by improving healthcare access, reducing stress, and enhancing health literacy [59,60]. However, robust longitudinal designs and cross-sectoral evaluations are needed to clarify these pathways, particularly in resource-limited settings. Future studies should incorporate time-based analyses to assess how SES-targeted policies influence biological, behavioral, and social determinants of male fertility across the life course.

6. Conclusions

Men’s SES plays a crucial role in determining their access to infertility care and ART, with cascading effects on individual, familial, and public health. Men with lower SES face greater exposure to stress, environmental toxins, inadequate healthcare, and limited health literacy, all of which negatively impact reproductive outcomes. In contrast, men with higher SES typically have better access to healthcare, education, and awareness, supporting healthier family planning and reproductive outcomes. Although medical advances have improved the success of ART for those who receive treatment, systemic inequalities still prevent many men from accessing these services. Closing this gap will require coordinated policy reforms and targeted interventions to remove financial, geographic, informational, and cultural barriers, ensuring that all men, regardless of their SES, have equitable access to infertility diagnosis and treatment.

We acknowledge that addressing socioeconomic inequalities in male reproductive health requires comprehensive policy reforms that extend beyond healthcare system changes. Fundamental social determinants such as education, employment, and income redistribution play pivotal roles in shaping SES and, consequently, reproductive outcomes. Enhancing education improves health literacy and empowers individuals to make informed reproductive decisions. Stable employment and income distribution alleviate economic stress, facilitating better access to nutritious food, healthier lifestyles, and healthcare services. Therefore, political reforms targeting these broader structural factors are essential for sustainably reducing health disparities. Without simultaneous social and economic policy interventions, medical and healthcare reforms alone will be insufficient to close the gaps in reproductive health outcomes linked to SES.