After working as a doctor for more than a decade, Joseph Kunto* thought he had life figured out. Four years ago his happiness was complete when he married the woman of his dreams and eagerly made plans to start a family.
But a year later the 37-year-old's life fell apart when be was diagnosed with azoospermia - a complete absence of sperm.
As bad as the prospect of not having children was, Kunto said, the stigma of infertility was even more shattering.
"I became downcast and somehow depressed. I was not well co-ordinated and my concentration was in disarray," he told the Sunday Times.
The fiercest sting came when his wife, a midwife, left him, blaming his infertility for their break-up.
Kunto's experience is far from unusual in a country that has one of the highest male infertility rates in the world, and where the condition is associated with deep shame.
According to Stellenbosch University researchers and urologists Amir Zarrabi and Theunis Kruger, infertile men in Africa are often shunned to the point that they become suicidal.
Writing in the journal Nature Urology, the doctors said the shame and stigma attached to male infertility were so overwhelming that obtaining data about it was "notoriously difficult"; those affected seldom saw medical specialists.
One of the few studies on male infertility in SA, which sampled healthy men of reproductive age, found a sub-fertility (reduced fertility) level of 34.2%, with 12% of men suffering total azoospermia.
Zarrabi and Kruger said the stigma of infertility affected the training of clinicians because so few affected men sought medical help.
"Books have the information on how to treat infertility but doctors learn best when they treat the actual patient. The more patients they treat, the more exposure and insight they get, and that helps them to become better specialists," said Zarrabi.
Traditional healers said cultural beliefs linking fertility to success and wealth contributed to the stigma.
Thobeka Kentane, deputy general secretary of the National Unitary Professional Association for Traditional Health Practitioners of SA, said it was often women who sought treatment for infertility even though the problem lay with their partner.
"Men are still very reluctant to seek help," Kentane said. "Often healers have to be clever about it and play reverse psychology and treat both the woman and the man, just to protect the man's ego. Some of these men are in denial and often come across as egotistic . making treatment difficult."
Kunto said he found it difficult to talk about his condition with family and friends for fear of being judged. "Male infertility is often not mentioned in this part of the world because of cultural and traditional norms that blame everything on women," he said.
"As a man who is not fertile you are treated as an outcast and looked down upon by family members, friends and colleagues. I personally am not too open to discuss it, but I confided in a few family and close relatives, including my medical associates."
He found out about his infertility after his wife failed to conceive. "She came from a family with rich history of early conception. All her siblings got pregnant less than a year after marriage," he said.
He and his wife had other marital issues, he said, but the infertility was a major factor in the breakdown of their relationship. "In African culture, a marriage where there are kids usually lasts no matter the challenges because of the premium placed on children."
Kentane said the way "perfectionism and superiority over women" was emphasised in the upbringing of African men made it difficult for them to accept infertility.
"They see infertility as failure on their part and that is why they would rather not seek treatment at all. The feeling of shame . is so deep that some even find it difficult to seek treatment from female traditional healers," she said.
Zarrabi said a lack of financial resources in the public sector compounded the problem as life-threatening illnesses took priority. This resulted in many young urologists lacking the specialist training they required.
"Infertility is not considered a priority when health-care budgets, government medical services and urology training programmes are determined. It's hard to justify spending several hours doing a microsurgical operation for an infertile man when patients with cancer need life-saving surgery," he said.
Mark van der Heever, spokesperson for the Western Cape health department, said no specific budget was allocated to infertility. All infertility patients earning more than R70,000 a year had to make a financial contribution to their treatment.
*Not his real name..