Male Infertility: A Step-Wise Approach

Cyto-Matrix MemberGeneral, Scientific Research / Clinical Pearls

By: Dr. Colin O’Brien ND, Medical Director, Cyto-Matrix

Up to 50% of male infertility cases have no clear cause and sperm counts continue to dwindle.[1] Yet, countless research studies have uncovered environment factors that may contribute to male infertility through their negative impact on sperm parameters. This means that there are also countless treatment avenues to explore with our male fertility patients.

If physical and anatomical obstructions are ruled out as causes of infertility, consider this step-wise approach for male patients either struggling with fertility due to poor sperm health (i.e. documented low sperm counts and/or poor motility and morphology) or looking to optimize their fertility through proactive means:

 

Step 1: Address diet

It’s no surprise that diet must be the foundational treatment for improving male fertility. Although many of these changes may seem common sense, they are important to reinforce with your patients before exploring more targeted treatments:

  • Remove or reduce alcohol, marijuana, caffeine and cigarette smoke: Collectively, an increased exposure to these substances has shown a dose-dependent increase in free radical production, reduction in semen amounts, and worse sperm motility and morphology.[2] [3] [4] 
  • Add healthy fats: Research has shown that just 75 grams per day of walnuts, a whole food source of polyunsaturated fatty acids, added to a typical Western diet can improve sperm counts, morphology and motility.[5] This study confirms other research showing that there are lower levels of Omega-3 fatty acids in infertile men when compared to fertile males,[6] and that EPA and DHA supplementation can improve sperm counts and concentrations.[7] Finally, excess saturated fat intake is associated with reduced semen volume.[8]
  • Remove refined sugars: As if we needed another reason to advise patients to avoid refined sugars, research has shown that even just an increased consumption of sugar-sweetened beverages (greater than 1.3 per day) can significantly reduce sperm motility.[9]
  • Consider organic: Reduced pesticide exposure through organic food choices may make a powerful impact on the sperm quality of your male population. A 2008 review found that increased pesticide exposure can affect spermatogenesis and may prolong time-to-pregnancy.[10]

It should be noted that both obesity and being underweight have been associated with lowered testosterone and poor sperm count, respectively.[11] When appropriate, a focus on healthy weight management should be encouraged.

 

Step 2: Review personal care products

Education surrounding environmental toxin exposure is key when discussing male fertility concerns.

In addition to other ‘clean-living’ options such as choosing Bisphenol A (BPA)-free options in plastics and cans, consider the impact of these important endocrine disruptors:

  • Triclosan: This anti-microbial agent commonly found in toothpaste, deodorants, shampoos and other household products, has been demonstrated to be negatively associated with normal sperm morphology, concentration and count.[12]  
  • Parabens: Commonly discussed in the context of xenoestrogen activity and female fertility concerns, these preservatives appear to damage mitochondrial function in sperm. [13] A 2017 study showed that urinary paraben levels were significantly associated with abnormal morphology, decreased sperm motility and decreased testosterone levels.[14]
  • Phthalates: The compounds commonly found in plastics and, unfortunately, also beauty products, have also been shown to negatively impact sperm parameters. For example, one study found urinary mono-methyl-phthalate (MMP) concentrations to strongly correlate with sperm concentration, length and maturity.[15] 

 

Step 3: Add in antioxidant support

Now that you have done some removal, it’s time to add more of the good stuff! Antioxidants help to quench the reactive oxygen species that are generated often in response to environmental exposures and, ultimately, reduce the damage done to sperm mitochondria.

A number of reviews and meta-analyses have definitively demonstrated the ability for antioxidants to not only improve sperm parameters[16], but also increase live birth rates and pregnancy rates in subfertile couples.[17]

Consider a combination of the following antioxidants:

  • Vitamin C: A dose-dependent improvement in sperm motility has been found with vitamin C supplementation in smokers.[18] [19] Many studies have used ascorbic acid in combination with vitamin E and zinc for improved sperm parameters. 
  • Vitamin E: Tocopherols are a well-known group of antioxidants that are widely deficient in the modern-day diet. Vitamin E has been shown to improve sperm parameters on its own[20], but particular improvements have been noted when it is combined with selenium[21], and vitamin C.[22] 
  • Selenium: Not only is selenium beneficial for sperm parameters when combined with Vitamin E or N-acetylcysteine, but solo supplementation also shows benefit for sperm counts and motility (100 mcg over 3 months).[23] This makes sense given that selenium is necessary for proper spermatogenesis.[24]
  • Zinc: Zinc’s function in various aspects of male health, including testosterone production, has long been studied and its impact on fertility and spermatogenesis is no different. A recent meta-analysis of 20 studies found that zinc concentrations in seminal plasma were significantly lower in infertile males and that supplementation is capable of increasing semen volume, while also improving sperm motility and morphology.[25] Zinc in combination with folate has also shown benefit for sperm count[26]
  • L-Carnitine and Acetyl-L-Carnitine: Carnitine provides energy to the sperm by transporting fatty acids into the mitochondria, thereby improving sperm motility. Over a dozen human clinical trials have confirmed the use of either L-carnitine, Acetyl-L-carnitine (the form capable of entering the central nervous system) or a combination of both for improved sperm motility, while a number of these same studies have shown improved pregnancy rates.[27]
  • N-acetylcysteine: most well-known for its ability to increase glutathione levels, at only 600mg/day this amino acid can improve sperm motility and volume.[28] The addition of 200mcg/day of selenium has found even better results in these areas, also with improved sperm morphology.[29]

There are many other antioxidants that have shown benefits for improving sperm markers. The key is to individualize your treatments to target patient-specific dietary and environmental factors. Also consider coenzyme-Q10, arginine, astaxanthin, lycopene, folate and melatonin.

 

Step 4: Address stress and consider botanicals and acupuncture

Although diet, lifestyle and nutritional support have a profound ability to improve male fertility outcomes, stress management needs to be considered as elevated stress can alter testosterone levels and, thereby, sperm numbers and functionality.[30]

Many stress reduction techniques may be indicated (i.e. deep breathing) but herbal extracts can act through multiple mechanisms. For example, adaptogens with the ability to positively impact the HPA-axis can also provide powerful antioxidant support.

Two herbs to consider include:

  • Mucuna pruriens: Also known as velvet bean, this herb contains a high concentration of dopamine, can improve psychological stress scores and also improve sperm parameters.[31] 
  • Withania somnifera: More commonly known as ashwagandha, this adaptogenic herb is best known for its ability to reduce stress and anxiety, but it is also a traditional aphrodisiac capable of treating male sexual dysfunction and infertility. A 2013 placebo-controlled study confirmed this ancient wisdom by showing significant improvements in sperm parameters after 3 months of treatment intervention with 225mg, three times per day.[32] A 167% increase in sperm count was seen, with a 53% increase in sperm volume, a 57% increase in sperm motility and a 17% increase in testosterone levels.

Other herbs to consider with positive research for male fertility outcomes include Eurycoma longifolia, Mucuna pruriens and Panax Ginseng.[33]

Finally, acupuncture may be an appropriate intervention capable of not only reducing stress, but also improving blood flow to the testicles and, thereby, offering multiple mechanisms for improved fertility outcomes.

Various studies have shown acupuncture may be beneficial for male infertility through scrotal temperature control, increased testosterone and improved sperm parameters.[34] [35]

 

 

References: 

[1] Levine H et al. Temporal trends in sperm count: a systematic review and meta-regression analysis. Hum Reprod Update. 2017 July 25:1-14.

[2] Wogatzky J et al. The combination matters – distinct impact of lifestyle factors on sperm quality: a study on semen analysis of 1683 patients according to MSOME criteria. Reprod Biol Endocrinol. 2012; 10: 115.

[3] Fronczak CM, Kim ED, Barqawi AB. The insults of illicit drug use on male fertility. J Androl. 2012:33(4):515-528.

[4] Elena Ricci et al. Coffee and caffeine intake and male infertility: a systematic review. Nutr J. 2017; 16: 37.

[5] Robbins WA et al. Walnuts improve semen quality in men consuming a Western-style diet: randomized control dietary intervention trial. Biol Reprod. 2012; 87(4): 101.

[6] Safarinejad MR et al. Relationship of omega-3 and omega-6 fatty acids with semen characteristics, and anti-oxidant status of seminal plasma: a comparison between fertile and infertile men. Clin Nutr. 2010;29(1):100-105.

[7] Safarinejad MR. Effect of omega-3 polyunsaturated fatty acid supplementation on semen profile and enzymatic anti-oxidant capacity of seminal plasma in infertile men with idiopathic oligoasthenoteratospermia: a double-blind, placebo-controlled, randomized study. Andrologia. 2011; 43(1): 38-47.

[8] Hajar Dadkhah et al. The Relationship between the Amount of Saturated Fat Intake and Semen Quality in Men. Iran J Nurs Midwifery Res 2017 Jan-Feb; 22(1): 46–50.

[9] Y.H. Chiu et al. Sugar-sweetened beverage intake in relation to semen quality and reproductive hormone levels in young men. Hum Reprod. 2014 Jul; 29(7): 1575–1584.

[10] Roeleveld N and Bretveld R. The impact of pesticides on male fertility. Curr Opin Obstet Gynecol. 2008 Jun; 20(3): 229-33.

[11] Wogatzky J et al. The combination matters – distinct impact of lifestyle factors on sperm quality: a study on semen analysis of 1683 patients according to MSOME criteria. Reprod Biol Endocrinol. 2012; 10: 115.

[12] Zhu W et al. Environmental Exposure to Triclosan and Semen Quality. Int J Environ Res Public Health. 2016; 13(2): 224.

[13] Tavares RS, Martins FC, Oliveira PJ, et al. Parabens in male infertility—Is there a mitochondrial connection? Reprod Toxicol. 2009; 27(1):1-7.

[14] Jurewicz J. Human Semen Quality, Sperm DNA Damage, and the Level of Reproductive Hormones in Relation to Urinary Concentrations of Parabens. J Occup Environ Med. 2017; 59(11): 1034-1040.

[15] Bloom MS et al. Associations between urinary phthalate concentrations and semen quality parameters in a general population. Hum Reprod. 2015; 30(11): 2645-2657.

[16] Ross C et al. A systematic review of the effect of oral antioxidants on male infertility. Reprod Biomed Online. 2010 Jun; 20(6):711-23.

[17] Showell MG et al. Antioxidants for male subfertility. Cochrane Database Syst Rev. 2011 Jan 19; (1):CD007411.

[18] Dawson EB, Harris WA, Powell LC. Relationship between ascorbic acid and male fertility. World Rev Nutr Diet. 1990; 62: 1–26.

[19] Agarwal A, Sekhon LH. The role of antioxidant therapy in the treatment of male infertility. Hum Fertil. 2010;13(4):217-225.

[20] Kessopoulou E et al. A double-blind randomized placebo cross-over controlled trial using the antioxidant vitamin E to treat reactive oxygen species associated male infertility. Fertil Steril. 1995 Oct;64(4):825-31.

[21] Keskes-Ammar L et al. Sperm oxidative stress and the effect of an oral vitamin E and selenium supplement on semen quality in infertile men. Arch Androl. 2003 Mar-Apr; 49(2): 83-94.

[22] Baker HW et al. Protective effect of antioxidants on the impairment of sperm motility by activated polymorphonuclear leukocytes. Fertil Steril. 1996 Feb; 65(2): 411-9.

[23] Scott R et al. The effect of oral selenium supplementation on human sperm motility. Br J Urol. 1998;82(1):76-80.

[24] Boitani C and Puglisi R. Selenium, a key element in spermatogenesis and male fertility. Adv Exp Med Biol. 2008; 636: 65-73.

[25] Zhao J et al. Zinc levels in seminal plasma and their correlation with male infertility: A systematic review and meta-analysis. Scientific Reports. 2016; 6: 22386.

[26] Wong WY et al. Effects of folic acid and zinc sulphate on male factor subfertility: a double-blind, randomized, placebo-controlled trial. Fertil Steril. 2002;77(3):491-498.

[27] Mongioi L et al. The role of carnitine in male infertility. Andrology. 2016 Sep;4(5):800-7.

[28] Ciftci H et al. Effects of N-acetylcysteine on semen parameters and oxidative/antioxidant status. Urology. 2009 Jul;74(1):73-6.

[29] Safarinejad MR and Safarinejad S. Efficacy of selenium and/or N-acetyl-cysteine for improving semen parameters in infertile men: a double-blind, placebo-controlled, randomized study. J Urol. 2009; 181(2): 741-751.

[30] Nargund VH. Effects of psychological stress on male infertility. Nat Rev Urol. 2015 Jul; 12(7): 373-82.

[31] Shukla KK et al. Mucuna pruriens Reduces Stress and Improves the Quality of Semen in Infertile Men. Evid Based Complement Alternat Med. 2010; 7(1): 137-144.

[32] Ambiye VR et al. Clinical Evaluation of the Spermatogenic Activity of the Root Extract of Ashwagandha (Withania somnifera) in Oligospermic Males: A Pilot Study. Evid Based Complement Alternat Med. 2013; 2013: 571420.

[33] Salvati G et al. Effects of Panax Ginseng C.A. Meyer saponins on male fertility. Panminerva Med. 1996; 38(4): 249-254.

[34] Siterman S et al. Success of acupuncture treatment in patients with initially low sperm output is associated with a decrease in scrotal skin temperature. Asian J Androl. 2009;11(2):200-208.

[35] Pei J et al. Quantitative evaluation of spermatozoa ultrastructure after acupuncture treatment for idiopathic male infertility. Fertil Steril. 2005; 84(1): 141-147.