A Folkloric Approach to Infertility : Tight Underwear Could Be a Factor

It had been several months since Dan, 32, and his wife began attempts to have their first child and, as Dan recalls it now, “nothing was happening.”

As far as both of them knew, there was no biological reason why conception had not occurred, so Dan did what a significant--though totally unquantified--number of American men are apparently doing today. He got rid of his Jockey shorts and started wearing boxers.

This was not on the advice of any doctor. Instead, Dan recalls, “it was something that we had heard around. It was kind of one of those old wives’ tales.”

What Dan and his wife had heard was a folk wisdom so pervasive that 60% to 70% of the men seeking help at the offices of some specialists in male infertility have already shed their form-fitting undershorts and bikini briefs by the time they first see the doctor--90% or more in favor of boxers and the rest going au naturel .

The folklore belief--disseminated by word of mouth, magazine articles and syndicated advice columnists--holds that, since there is strong scientific evidence that testicles exposed to abnormally high heat are severely compromised in terms of sperm production, switching from tight underwear to loose or none will reduce the heat and improve a man’s fertility.

Within months, Dan’s wife was pregnant. The couple’s baby girl, now 9 months, is healthy and Dan is still wearing boxers. “I’m not convinced it was the factor,” he said a few days ago. “But it certainly didn’t hurt anything.”

Dan--as well as a dozen or so other men polled informally by The Times--agreed to talk about their underwear preferences only on the condition they would not be named--and only then with reluctance. And it is that socialized male macho reticence to even discuss such matters that doctors say is one of the reasons that a men’s fertility information underground remains so strong and influential.

Fertility specialists generally--but not unanimously--agree that while the scientific principle of heat reduction on which the Underwear Decision is based is sound, evidence that the heat-sperm relationship depends on underwear style is sparse.

“I see many patients who come here on the advice of their wife’s gynecologist or their friends who tell them that they should wear boxers instead of Jockey shorts,” said Dr. Jacob Rajfer, a UCLA fertility specialist. “In urology, you see a lot of strange things.”

Generally, Rajfer will explain that, while there is a clear relationship between sperm count and exposure to some types of heat--men concerned with fertility are advised not to spend very much time in hot tubs, Jacuzzis or saunas, for instance--the underwear connection remains little more than something that sounds logical but has not been established scientifically. In short, he tells them they can safely put their briefs back on.

Still other urologists and fertility specialists, however, react like Dr. Ira Sharlit or Dr. R. Dale McClure, both of San Francisco. McClure counsels patients not to wear sweat-retaining nylon bikini briefs--though cotton Jockey shorts are acceptable--and Sharlit said he goes along with a drastic shift in underwear preference not because he is convinced it will accomplish anything but because the testicular heat-underwear relationship is based on a logical concept that may eventually prove valid.

“Theoretically, it makes sense,” Sharlit said, “But practically, I don’t know if it makes any difference.”

Like most physicians in the field, Dr. Fredrick Wolk, a Torrance fertility specialist, says he gets “asked about the underwear question all the time.” He tells patients that as long as treating male infertility “is the art of eliminating all the variables that may be associated, the cooler you keep the testicles, the better. Certainly boxer shorts (or no underwear) keep the testicles cooler than briefs and bikinis.”

The belief that there is such a direct connection between testicle temperature and fertility has even spawned the appearance on the market of a $795 “testicular hypothermia device.” It consists of what appear to be very skimpy briefs into which tubes are sewn that connect to a small pump worn around the waist on a belt. The pump circulates cooling fluid through the briefs and the manufacturer claims the system can achieve a drop of two to six degrees in testicular temperature--a margin, according to Repro-Med Systems Inc., of Middletown, N.Y., significant enough to enable production of viable sperm in some infertile men.

In the 1960s and 1970s, this vagary of underwear design began to attract the attention of urologists. According to a review of studies published in medical journals over a 20-year period and interviews with several physicians who have followed the research, three questions seemed pertinent:

- Could tighter underwear and even the tight jeans that were coming into style during the period compromise fertility? Indeed, a letter to the editor in the Medical Journal of Australia even warned in 1979 that the combination of tight underwear and form-fitting jeans “may eventually lead to permanent infertility.”

- Conversely, could tight underwear have a contraceptive effect?

- Furthermore, was it possible that the constant exposure of testicles to abnormally high levels of natural body heat increases the chance that a man could contract testicle cancer--a disorder thought to have at least an indirect relationship to temperature?

Today, the fertility and cancer questions still await answers. The contraception question has faded from significance. Though research on all three lines of inquiry is not complete, it is now clear that, even if Jockey shorts, bikini briefs or tight jeans lower sperm counts, they don’t do so enough or with sufficient consistency to be reliable as a means of contraception.

The contraception belief was “part of a folklore that even extended to Australian aborigines who were said to soak their testicles in hot water to avoid getting women pregnant,” said Dr. Richard Paulson, a USC expert. “But you absolutely cannot be safe with that.”

The cancer issue, while not finally resolved, also appears unconnected to underwear preference, said Dr. Brian Henderson, a prominent USC cancer epidemiologist. Some studies have been published in major journals, including a brief one in the New England Journal of Medicine in 1980 in which three Harvard investigators reported preliminary results of a study of various risk factors for testicle cancer, concluding that “we observed a positive association between the disease and use of Jockey undershorts.”

But that study was not pursued and, today, while “there have been many attempts to prove this over the years, they have been unsuccessful,” Henderson said; “I don’t think there is support for it. It is not a very good hypothesis anymore.”

That has left the fertility issue as the most germane. Dr. Larry Lipshultz, a professor of urology at Baylor University Medical School in Houston, like many fertility experts, noted that, while higher than normal scrotal temperatures are clearly associated with infertility, it remains unproven that simply lowering the temperature will bring about a cure. Other factors may be involved.

Among these is the presence of varicose veins in the scrotum, called varicoceles. Four times more common in infertile men than in fertile ones, vericoceles can often by surgically corrected. When they are, semen quality frequently improves.

It is this doubt about the therapeutic benefit of simply lowering testicle temperature that makes most physicians unsure of the folklore about underwear and skeptical of the newly introduced Repro-Med device. The company has recently been promoting its product, sponsoring a media tour by the previously infertile engineer, Andrew Sealfon, who developed it and became a father.

Sealfon, now 41, said he started on the design work that led up to the Repro-Med device after four years of unsuccessful attempts at pregnancy with his wife that led to discovery, in 1975, that he was infertile. He discarded his Jockey shorts and took to wearing nothing, but to no avail. He said he subsequently learned that infertile men experience testicular temperature elevations too extreme--six degrees or so--to be overcome by switching or eliminating underwear, which does not sufficiently compensate.

Though Sealfon says Repro-Med has sold 500 or 600 of its temperature-reduction devices, doctors remain generally skeptical, noting that the direct relationship between Repro-Med’s product and restoring fertility remains unestablished in soundly designed, long-term studies.

Nor does it appear that American men are stampeding away from tight underwear. In fact, just the opposite is apparently occurring. According to marketing officials of Jockey International, maker of Jockey brand underwear products, briefs have taken an overwhelming lead over boxers, with boxers’ market share falling continuously every year for the last two or three decades.

Bikini briefs are cornering an ever-growing share of the market, according to Jockey and other manufacturers. At the moment, the market at large includes 13% or so for bikinis, 17% boxers and the rest the conventional-style briefs.