How Sexually Transmitted Infections Affect Sperm Health

A healthy male produces millions of sperm?each day, although?only a few of these sperm will ever go on to fertilise an egg and create an embryo. Despite the vast quantity of sperm produced by a healthy man, the number of sperm which actually fulfil their fertilising potential is therefore extremely small. Even when a man is producing sperm at a healthy capacity and his partner is fertile, it is not uncommon for couples to take up to a year to conceive.

Some men produce sperm which is suboptimal, either in quantity or quality. These men will typically take longer to conceive and are more likely to require the assistance of artificial reproduction techniques to do so. Some men may experience suboptimal sperm production because of a genetic or birth trait (e.g. deletions on the Y chromosome or history of cryptorchidism). In many cases, sperm production declines over time as a result of exposure to a range of risk factors.

Sexually Transmitted Infection (STIs) have a range of negative health affects. In males, one effect of STIs is reduced fertility. Avoiding STIs is therefore an important measure men can take to maintain optimal sperm production and maximise their chances of conception.

The extent to which sexually transmitted infections impact on male fertility depends on the prevalence of these infections in the population. In developed countries, STIs play only a minor role in impairing male fertility.

For the most part, STIs affect sperm transport (e.g. by causing infection and subsequent damage to the testicular tubes through which sperm travel) rather than spermatogenesis (the production of sperm in the testes). There is however evidence that the STIs Ureaplasma urealyticum, Trichomonas vaginalis and Chlamydia Trachomanis all impair sperm production. As these STis are often asymptomatic and can be difficult to diagnose, it is likely that their contribution to male infertility is underestimated.

The ways in which impaired sperm production related to STIs is an area that requires further research. However, a number of hypotheses have been put forward. Laboratory studies have shown that some bacteria impair sperm motility and viability, and it is possible that the bacteria which cause STIs also impair sperm in these ways. Chronic inflammatory conditions (untreated STIs are considered chronic inflammatory conditions) are associated with sub optimal sperm function. Infections of the genital tract may cause damage to the testes. There is also some evidence that the production of anti-sperm antibodies in the genital tract increase in response to infection, and increased anti-sperm antibodies are associated with decreased semen parameters.

Human Immunodeficiency Virus (HIV) also impacts on sperm production and semen parameters deteriorate as immunodeficiency progresses. For example, one recent study reported decreased concentrations of motile sperm in HIV+ compared to HIV- men. The ways in which HIV is related to male sub-fertility is also unclear. It may be associated with decreased immune function, the effects of anti retroviral therapy medication, or co-existing genito-urinary tract infection.

STIs, as the name suggests are spread through sexual contact. The two main ways individuals can avoid STIs are by avoiding sexual activity, or using a male or female condom to prevent the mixing of sexual fluids which transmit STIs, during intercourse. Individuals who do not use condoms consistently should be tested for STIs such as Chlamydia, which are typically asymptomatic and may therefore only be diagnosed if laboratory tests are conducted.

Individuals who do not manage to avoid STIs should seek prompt treatment. Many STIs can be treated quickly and easily using antibiotics. Prompt treatment can limit damage to the male reproductive system and its negative effects on sperm production and transport.

For?more information on sperm health and male fertility, see Sperm Health

Royal College of Obstetricians and Gynaecologists. Fertility: Assessment and treatment for people with fertility problems - Clinical Guideline [online]. Royal College of Obstetricians and Gynaecologists. 2004 [cited 30 October 2008]. Available from URL: http://www.rcog.org.uk/index.asp?PageID=696Ochsendorf, F.R. Sexually Transmitted Infections: impact on male fertility. Andrologia. 2008;40(2):72-5.Cunningham, K.A. Beagley, K.W. Male genital tract chlamydial infection: implications for pathology and infertility. Biol Reprod. 2008;79(2):180-9.Coates, T.J. Richter, L. Caceros, C. Behavioural Strategies to reduce HIV transmission: how to make them work better. The Lancet. 2008;372:669-84.McLachlan, R.I. de Krester, D.M. Male Infertility: The Case for Continued Research. MJA, 2001;174:116-7.Cengiz, T. AydoganliL. Baykam, M. et al. Chlamydial infections and male infertility. Int Urol Nephrol. 1997.;29(6):687-93.Bunjan, L. Serserie, M. Moinard, N. et al. Decreased semen volume and spermatozoa motility in HIV-1 infected patients under antiretroviral treatment. J Androl. 2007;28(3):444-52.

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Effect of Environmental Factors on Sperm Health

Humans are constantly exposed to a range of chemicals and toxins in their environment which can affect their health, including their reproductive health. For men, a range of environmental exposures are associated with reduced sperm concentration and quality. Men whose sperm is sub-optimal in either quantity or quality are less likely to conceive, and will, on average, take longer to do so, should they manage to successfully conceive.

While environmental chemicals and toxins are found in many environments, they are most commonly found at dangerous concentrations in occupational environments, such as chemicals used in agricultural and manufacturing sector workplaces. There are also many more environmental exposures which potentially increase the risk of male infertility but have not yet been studied (e.g. hundreds of chemicals are now used in manufacturing and other industries, and all are likely to have different health effects, but the effects on male infertility have been studied for only a few). The environmental factors which have evidence of an association with male infertility, include heat, radiation, chemicals and trauma.

Sperm production in humans and other mammals is dependent on the temperature of the testicles. Sperm is optimally produced when the testicles are 2-4oC below body temperature. The temperature of the testes is regulated by the scrotum (which expands and contracts to facilitate heat transfer) and heat exchange between blood flowing into the testes via the arteries in the spermatic cord, and that flowing out of the testes via the veins in the spermatic cord. This results in the pre-cooling of blood entering the testes, although the pre-cooling mechanism can only regulate testicular temperature to an extent.

In situations of extreme heat, the scrotum's natural cooling mechanisms may be insufficient to prevent a rise in testicular temperature. The increased testicular temperature may affect both the quality and quantity of sperm produced.

Some men expose themselves to extremely high temperatures in their day to day life, for example by taking hot baths. However, the majority of unsafe heat exposure occurs in occupational situations. A number of studies have demonstrated an association between sperm quality and heat exposure. A large case control study found that men exposed to heat because of their occupation were 1.8 times more likely to have morphologically abnormal sperm. They were also 1.8 times more likely to have been trying unsuccessfully to conceive for more than one year, than men who had not been occupationally exposed to heat.

Studies have also demonstrated that the following occupational groups have a higher risk of infertility, which is thought to be related (at least in part) to testicular heat exposure.

Occupational drivers

One study at an infertility clinic found that occupational drivers accounted for 9.4% of patients but only 3.8% of the general population. Drivers are thought to be at greater risk of infertility because long periods of sitting can increase testicular heat, as the testicles are insulated by the thighs whilst a man is seated.

Ceramic oven operators

One study comparing oven operators to other, non-heat exposed workers in a ceramic factory reported that significantly greater proportions of oven operators were childless (7.6% of oven operators compared to 1.1% who don't work in that industry) and reported difficulty conceiving (23% of oven operators compared to 12% of men not in that industry). The semen of the oven operators contained significantly less motile sperm (7% motile) than that of the other workers in the ceramic factory (who had 28% motile sperm).

Bakers

One study reported that a significantly lower proportion of men in the baking profession conceived within three (14%) or six months (29%) than men working in non-heat exposed professions (55% at three months, 74% at six months).

Radiation and other toxic substances found in war environments negatively affect sperm quality. Compared to other body organs the testes are very sensitive to radiation. Radiation exposure affects spermatogenesis (the production of sperm).

A French study found that men who had worked on a nuclear submarine were 2.9 times more likely to be infertile than men who had not. It is most likely that this decreased fertility was related to suboptimal sperm production. Other studies have demonstrated that radiation exposure affects testicular function and spermatogenesis (as opposed to other male infertility factors like sperm transport and sexual function).

Another study of gulf war veterans reported that returned servicemen who participated in the 1990-1991 Gulf war were 41% more likely to be infertile than servicemen who were not deployed to the Gulf region during that war. Similarly Gulf war veterans were 18% more likely than non-deployed servicemen to take more than one year to conceive. The authors of this study believed that sub-fertility in Gulf War veterans was caused by impaired spermatogenesis, caused by toxic exposure during the war.

Exposure to radiation during radiotherapy for cancer treatment is also a known risk factor for testicular failure in men. Impairment of sperm production is dose dependent. This means that the higher the dose or longer the direction of radiotherapy, the more likely sperm production is to be impaired. Recovery of testicular function following radiotherapy typically takes more than five years.

Men who are regularly exposed to some chemical substances are more likely to be infertile than men who are not. For example, a longitudinal study, which compared the semen samples of men with varying exposures to organophosphorous pesticides found that men with the highest exposure to these pesticides had the poorest sperm quality.

Another study of men attending an Argentinean infertility clinic found a link between pesticide exposure and sperm concentration, output and motility less than would be expected. The greater an individual's exposure to pesticides, the more likely their sperm concentration, output, motility and proportion of morphologically normal sperm would be reduced. Exposure to glycol ether has also been shown to increase the risk of suboptimal sperm production. There are numerous pesticides which have not been studied in relation to male fertility and further research regarding these is necessary.

Chemotherapy medications used to treat cancer often cause infertility and the extent to which a man's fertility is affected by chemotherapy depends on the type of chemotherapy drug used, the dose, duration of treatment and the man's age when he is treated. Typically patients who are younger and taking lower medication doses are less likely to experience impaired fertility than older patients and those taking higher medication doses, however some chemotherapy medications are more likely to result in infertility than others.

Male subfertility or infertility following chemotherapy most commonly occurs as a result of damage to the germinal epithelium lining the tubules of the testis. This is the section of the testis where the germ cells from which sperm are produced reside.

A patient's libido is often also affected by chemotherapy. This can be as a direct result of the medications or their side effects or because of the psychosocial effects of the treatment which may negatively affect a men's ability to conceive.

The likelihood of a man developing impaired spermatogenesis also depends on the type of cancer. Amongst men with acute leukaemias, it is estimated that at least 21% experience some degree of subfertility following treatment. For other cancers such as tumours of Hodgkin's disease and testicular cancers, the proportion of men experiencing impaired fertility is much higher (65-75%). In cases of testicular carcinoma or Hodgkin's disease fertility is partially impaired as a result of the disease itself (i.e. impaired fertility is common even prior to chemotherapy). Fertility often recovers following chemotherapy, however typically not for many years.

Testicular trauma can negatively affect spermatogenesis, however scientists do not yet fully understand why.

Men who wish to protect the health of their sperm can do so by avoiding a range of environmental exposures. They should:

Avoid occupations which involve exposure to extreme heat (e.g. baking, ceramics) or extreme testicular heat (e.g. driving, which requires long periods of sitting in a position in which the testicles are insulated);Avoid hot baths;Wear boxer shorts instead of tight underwear;Avoid occupations which involve high levels of exposure to radiation (e.g. military), and toxic chemicals (e.g. agriculture);Cryopreserve sperm for future use in assisted reproduction cycles if they are to undergo radiation therapy or chemotherapy.Evidence from laboratory studies of rats suggests that hormone treatment prior to chemotherapy help protect fertility, however further studies on humans are necessary to confirm this result;Evidence suggests that following testicular trauma, testicular repair is more effective than removal of the injured testicle in protecting fertility.

For?more information on sperm health and male fertility, see Sperm Heal

For more information on workplace health including office ergonomics series, useful tips on avoiding injuries in the workplace and costs on the workforce, see Workplace Health.

Oliva, A. Spira, A. Multigner, L. Contribution of environmental factors to the risk of male infertility. Human Reprod. 2001;16(8):1768-76.Royal College of Obstetricians and Gynaecologists. Fertility: Assessment and treatment for people with fertility problems - Clinical Guideline [online]. Royal College of Obstetricians and Gynaecologists. 2004 [cited 30 October 2008]. Available from URL: http://www.rcog.org.uk/index.asp?PageID=696McLachlan, R.I. de Krester, D.M. Male Infertility: The Case for Continued Research. MJA. 2001;174:116-7.Thonneua, P. Bujan, L. Multigner, L. Mieusett, R. Occupational Heat Exposure and Male Fertility: A Review. Human Reprod, 1998;13(8):2122-5.de la Calle, F.P. Rachou, E. le Martelot, M, et al Male Infertility Risk Factors in a French military population. Human Reprod, 2001;16(3):481-6.Alvarez, J.G. Nurture vs Nature: how can we optimise sperm quality. J Andrology, 2003;24(5):640-8.Maconochie, N. Doyle, P. Carson, C. Infertility among male UK veterans of the 1990-01 Gulf war: reproductive cohort study. BMJ, 2004;329(7459):323.Juhler, R.K. Larsen, S.B. Meyer, O. Human semen quality in relation to dietary pesticide exposure and organic diet Arch Environ Contam Toxicol, 1999;37(3):415-23.Cherry, N. Moore, H. McNamee, R. et al. Occupation and male infertility: glycol ethers and other exposures. Occup Environ Med. 2008;65:708-14.Lenz, K.I. Valley, A.W. Review: Infertility after chemotherapy: a review of the risks and strategies for prevention. J Oncol Pharm Pract. 1996;2:75-100.Shaul, D. Xie, H. Diaz, J. et al. Surgical treatment of testicular trauma: effects on fertility and testicular histology. J Pediat Surg. 1997;32(1):84-7.Hirsch, A. Male Subfertility [Clinical Review]. BMJ. 2003;327:669-72.Meistrich, M.L. Wilson, G. Ye, W.S. et al. Relationship among hormonal treatments, suppression of spermatogenesis, and testicular protection from chemotherapy-induced damage. J Clin Oncol. 1997;15:3488-95.Delic, J.I. Protection of spermatogenesis during cancer chemotherapy. Sys Biol Reprod Med. 1987;18(3):211-3.Lin, W. Kim, E. Quesada, L. et al. Unilateral testicular injury from external trauma: evaluation of semen quality and endocrine parameters. J Urol. 1998;159(3):841-3.

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Effect of Diet on Sperm

A healthy male produces millions of sperm each day although only a few of these sperm will ever go on to fertilise a human egg and create an embryo. Despite the vast quantity of sperm produced by a healthy man, the number of sperm which actually fulfil their fertilising potential is therefore extremely small. Even when a man is producing sperm at a healthy capacity and his partner is fertile, it is not uncommon for couples to take up to a year to conceive.

Some men produce sperm which is sub-optimal, either in quantity or quality. These men will typically take longer to conceive and are more likely to require the assistance of artificial reproduction techniques to do so. While some men may experience sub-optimal sperm production because of a genetic or birth trait, for example deletions on the Y chromosome or history of cryptorchidism, in many cases sperm production declines over time as a result of exposure to a range of risk factors.

The types and quantity of food a man eats affects his sperm production. Unhealthy eating patterns, including excessive total calorie intake and excessive fat and sugar intake, are associated with sub-optimal sperm production and/or infertility in men.

Fertility gradually declines as weight increases above normal levels (i.e. Body Mass Index (BMI) >25kg/m2 ). BMI increases if an individual consumes more energy than they expend each day (in terms of total calorie intake), and is particularly likely to increase when individuals consume large amounts of fat and sugar.?Thus obesity related infertility is primarily related to poor dietary habits. While further research is needed to examine the exact ways in which obesity impairs fertility in men, there is considerable evidence that the association exists, and that the more a man's weight increases, the more his sperm production and fertility declines.

This information will be collected for educational purposes, however it will remain anonymous.

Evidence shows that obese men have lower concentrations of testosterone and sex-hormone binding globulin, both important hormones in the sperm production cycle. Studies have also demonstrated that obesity negatively affects semen quality. For example, one study showed that overweight (BMI >25kg/m2) and obese (BMI >30kg/m2) men had significantly lower concentrations of morphologically normal and motile sperm than normal weight (BMI <25kg/m2) men. It also found that men with a BMI >25kg/m2 had significantly higher concentrations of sperm with chromatin defragmentation (i.e. abnormalities in the genetic information contained in chromosomes). Another study found that poor semen quality was associated with sedentary occupation and that semen quality worsened as BMI increased.

Several ways that obesity might impair fertility in men have been identified. Obesity in men is associated with a changed hormonal environment characterised by elevated oestrogen and reduced testosterone levels. As sperm production is highly dependent on testosterone, low levels of this hormone are likely to impair sperm production.

Obesity is also associated with increased oxidative stress in the testicles. Oxidative stress is stress induced by increased numbers of molecules containing free oxygen. These molecules are highly reactive and can easily catalyse chemical reactions with other, usually stable molecules. While oxidative stress does not impair sperm production, reactions catalysed by free radical molecules (i.e. those containing unstable oxygen species) can damage healthy sperm following production.

Excessive fat in the thigh and pubic region resulting from obesity, may have an insulating effect on the testicles. This causes the temperature of the scrotum and testicles to increase. Increased scrotal temperature is also thought to negatively influence sperm production.

A number of studies have revealed associations between individual metabolic disturbances and various indicators of reduced male fertility and/or poor semen parameters. Metabolic syndrome (a pre-diabetes condition characterised by several metabolic abnormalities occurring simultaneously) and/or type 2 diabetes mellitus are also associated with impaired fertility in men. These metabolic conditions are all associated with poor dietary habits. Obesity also typically occurs with metabolic syndrome and type 2 diabetes (see above for effect of obesity on sperm).

Non-insulin dependent diabetes mellitus

Non-insulin dependent (type 2) diabetes mellitus, is a condition typically induced by poor dietary habits. It is associated with hypogonadism, a rare but important cause of male infertility characterised by an imbalanced hormonal environment and breakdown in the pathway which transmits signals between the brain's hypothalamus and the man's reproductive system. While hypogonadism typically comes after type 2 diabetes (and therefore cannot be caused by it), scientists believe that both conditions may be caused by insulin resistance. Insulin resistance results from type 2 diabetes and is one of the metabolic imbalances which characterises metabolic syndrome.

Dyslipidaemia

Dyslipidaemia (increased concentrations of lipids, including cholestrerol in the blood) is another metabolic imbalance characteristic of metabolic syndrome. Evidence of the associations between dyslipidemia and male fertility to date suggests that high cholesterol is associated subfertility in men. One study reported a very high prevalence of dyslipidaemia (65%) amongst infertile men. In addition, a laboratory study in which rats were fed either a high or anti-cholesterol diet showed a reduction in the fertilising capacity of male rats following the high cholesterol diet.

Hypertension

Available evidence suggests that high blood pressure (hypertension) is associated with reduced testosterone, which is likely to affect sperm production.

It has been hypothesised that increased intake of antioxidant nutrients may increase male fertility. This is because sperm quality is negatively affected by increasing concentrations of reactive oxygen species in the semen, and antioxidants reduce the concentrations of these molecules.

The results of one laboratory study in which rats were fed anti-oxidant supplements, support this hypothesis. Rats receiving the antioxidant supplements were more likely to mate and experienced increased testicular size and concentrations of morphologically normal sperm, compared to those which did not received antioxidant supplements. However, there remains insufficient evidence of the effect of antioxidants on the fertility of human males, to recommend antioxidant supplementation as a therapeutic intervention.

There are many measures related to diet, alcohol and other drugs which an individual can undertake to protect the health of their sperm. Essentially men need to maintain a healthy weight and eat a healthy, balanced diet.

Maintaining a healthy weight

Maintaining a healthy weight (i.e. BMI between 20-25kg/m2) is an important step in ensuring optimal sperm production, as obesity is associated with reduced sperm production. To maintain a healthy weight, men should ensure that their total calorie intake matches energy expenditure by:

Reducing total calorie intake: for example by limiting fat and sugar, reducing fast food consumption, eating freshly prepared meals and snacking on fruit or nuts instead of chips and biscuits. Individuals may find it helpful to monitor their calorie intake using a calorie counter; Increase daily exercise: to at least 30 minutes per day, for example by integrating exercise into day to day activities like walking to work or bike riding with children;

Eat a healthy well balanced diet

A well balanced diet is one: which is high in fibre, fruits and vegetables and low in fats and sugars. Studies have shown that diet composition affects the metabolism independently of total calorie intake. Eating a range of healthy foods has a protective effect in relation to metabolic syndrome, even amongst obese individuals.

For more tips on losing or maintaining weight, see weight loss.

?For more information on nutrition, including information on?types and composition of food, nutrition and people, conditions related to nutrition, and diets and recipes, as well as some useful videos and tools, see Nutrition.?

For?more information on sperm health and male fertility, see Sperm Health

Royal College of Obstetricians and Gynaecologists. Fertility: Assessment and treatment for people with fertility problems - Clinical Guideline [online]. Royal College of Obstetricians and Gynaecologists, 2004 [cited 30 October 2008]. Available from URL: http://www.rcog.org.uk/index.asp?PageID=696McLachlan, R.I. de Krester, D.M. Male Infertility: The Case for Continued Research. MJA, 2001;174:116-7.NHMRC. Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults; 2003. [cited 2009, May 26] Available from http://www.health.gov.au/internet/main/publishing.nsf/Content/obesityguidelines-guidelines-adults.htmOsuna, J.A. Gomex-Perez, R. Arata-Bellabarba, G. Villaroel, V. Relationship between BMI, total testosterone, sex-hormone binding globulin, leptin, insulin and insulin resistance in obese men. Arch Androl, 2005;52(5):355-61.Kort, H.I. Massey, J.B. Elsner, C.W. et al Impact of Body Mass Index values on sperm quantity and quality. J Andrology, 2005;7(3): DOI: 10.2164/jandrol.05124 [Cited 2009, May 26] Available from: http://www.andrologyjournal.org/cgi/content/full/27/3/450 Magnusdottir, E.V. Thorsteinsson, T. Thorsteindottir, S. et al. Persistent organochlorines, sedentary occupation, obesity and human male subfertility. Human Reprod. 2005;20(1):208-15.Kasturi, S.S. Tannir, J. Brannigan, R. "The Metabolic Syndrome and Male Infertility" in J Andrology. 2008;29(3):251-60.NSW Health. Thirty ways to go for 2&5. 2009. [cited 2009, May 1] Available from: http://www.gofor2and5.com.au/DataStore/files/pdf/NSW/NSW_Thrifty_FS_09.pdf Queensland Government. Find your 30. 2008.[cited 2009, May 1] Available from: http://www.your30.qld.gov.au/Your30/tabid/54/Default.aspxShai, I. Schwarzfuchs, D. Henkin, Y. Weight Loss with a Low-Carbohydrate, Mediterranean, or Low Fat Diet. NEJM. 2008;359(3):229-41.

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How Tobacco, Alcohol and Drugs Affect Sperm

A healthy male produces millions of sperm?each day, althoughonly a few of these sperm will ever go on to fertilise an egg and create an embryo. Despite the vast quantity of sperm produced by a healthy man, the number of sperm which actually fulfil their fertilising potential is therefore extremely small. Even when a man is producing sperm at a healthy capacity and his partner is fertile, it is not uncommon for couples to take up to a year to conceive.

Some men produce sperm which is suboptimal, either in quantity or quality. These men will typically take longer to conceive and are more likely to require the assistance of artificial reproduction techniques to do so. Some men may experience suboptimal sperm production because of a genetic or birth trait (e.g. deletions on the Y chromosome or history of cryptorchidism). In many cases, sperm production declines over time as a result of exposure to a range of risk factors.

Drugs, tobacco and alcohol allhave a range of short and long term health effects, including effects detrimental tothe production of sperm. These effects include reduced concentrations of sperm in the semen and reduced concentrations of sperm which have a normal shape and are able to move or swim. Men who are trying unsuccessfully to conceive, and those who wish to protect the health of their sperm for the future, should therefore avoid a range of drugs, including alcohol and tobacco.

A number of studies have reported an association between tobacco smoking and male infertility and/or suboptimal sperm production.A review of observational studies on smoking and semen parameters found that 20 of the 25 studies reported an increased risk of lower sperm concentration in smokers compared to non-smokers. On average, sperm concentration was 13% lower in smokers compared tonon-smokers. Smoking men also had a lower average proportion of sperm that were motile (moving or swimming) and morphologically normal (sperm with a correct body shape), compared to non-smoking men.

For more information on smoking and its health effects, and some useful tools, videos and animations, see Smoking.

A number of performance enhancing and recreational drugs affect male fertility. Performance enhancing drugs (e.g.anabolic steroids) are associated with subfertility in men. They cause men to become subfertile by changing the concentrations of various hormones that influence the sperm production process.

The hormone-altering effect caused by consuming performance enhancing drugs is reversible.Normal hormone levels should return 612 months aftera man has stopped taking these drugs.

Recreational drugs(also called lifestyle drugs) include marijuana, alcohol, heroin and cocaine. These drugs can impair sperm production and/or quality.

Long term overconsumption of alcohol is associated with decreased semen parameters (decreases in one or more of the measures of semen quality) as determined by semen analysis testing, and detrimental changes in hormonal levels.

Use AUDIT to assess your drinking patterns

For more information on drinking alcohol, including drinking disorders and alcohol's effect on the body, as well as some useful tools, see Alcohol.

Drugs used in medical treatment can also affect male fertility. Those used in chemotherapy are particularly well known for their irreversible affect on sperm production. It is not uncommon for men who have undergone chemotherapy to be left sterile by the treatment.

Medications that change the body's hormonal environment (e.g. testosterone injection,anti-androgenic drugs) can also impair sperm production. This is because hormones regulate the sperm production process, and changes to hormone levels therefore affect sperm production.

Many of the drugs that affect sperm health are lifestyle drugs, that is, drugs taken for recreation rather than medical purposes. As such, there are a range of lifestyle modifications individuals can make in the interests of maintaining sperm health, including:

Stopping smoking;Minimising alcohol consumption;Avoiding anabolic steroids and other performance enhancing drugs; andAvoiding marijuana, cocaine and other recreational drugs.

Some of the drugs that affect male fertility are used for medical purposes, and in some cases for life-saving medical treatment, so avoidance may not always be possible. In these cases, individuals should investigate the possibility of cryopreserving spermbefore undertakingfertility-threatening treatments such as chemotherapy. Cryopreserved sperm can then be used in assisted reproductive technologies such as in vitro fertilisation (IVF).

Formore information on sperm health and male fertility, see Sperm Health

Royal College of Obstetricians and Gynaecologists. Clinical Guideline: Fertility: Assessment and treatment for people with fertility problems [online]. Royal College of Obstetricians and Gynaecologists. 23 February 2004 [cited 30 October 2008]. Available from URL: http://www.rcog.org.uk/ files/ rcog-corp/ uploaded-files/ NEBFertilityFull.pdf Hirsh A. Male subfertility. BMJ. 2003; 327: 669-72.McLachlan R. Fact sheet: Male infertility [online]. Andrology Australia. 31 August 2007 [cited 15 April 2009]. Available from URL: http://www.andrologyaustralia.org/ pageContent.asp? pageCode= MaleInfertility Mathusami KR, Chinnaswamy P. Effects of chronic alcoholism on male fertility hormones and semen quality. Fertil Steril. 2005; 84(4): 919-24.Vine MF. Smoking and male reproduction: A review. Int J Androl. 1996; 19(6): 323-37.Balen AH, Rutherford AJ. Management of infertility. BMJ. 2007; 335: 608-11.McLachlan, R.I. de Krester, D.M. Male Infertility: The Case for Continued Research. MJA, 2001;174:116-7.

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Supplements For Healthy Sperm

Healthy males produce millions of sperm each day and only a few of these ever go on to fertilise an egg. Despite the abundance of sperm, conception can take up to a year for many couples with healthy gametes (sex cells - sperm in males and eggs in females). When sperm quality is reduced, for example sperm are immotile (cannot move properly) or abnormally shaped (which may impair their ability to penetrate the shell of an egg) conception may take considerably longer or only be achieved with assisted reproduction technologies.

Many factors, including an individual’s genetic make up, sexual and reproductive health conditions such as sexually transmitted diseases and lifestyle factors such as smoking, affect the health of sperm. Nutritional intake, including intake of particular vitamins and micronutrients, has also been shown to affect the quality and quantity of the sperm a man produces. As a result there has been increasing interest in the role of nutrition in protecting and/or improving sperm health. Scientists have also devoted attention to studying whether or not taking nutritional supplements protects the health of sperm and if it could be an effective treatment for male factor infertility (infertility due to problems with the male).

Sperm production is highly dependent on DNA synthesis as each time a cell divides and replicates new DNA is required. DNA requires nutrients to grow and, as most of the nutrients required for DNA synthesis are derived from the diet, a man’s nutritional intake affects the production and health of the stem cells from which his sperm are produced. The processes which are essential for sperm production (mitosis, meiosis and spermatogenesis) each involve the division of cells and each process is thus dependent upon the production of new DNA. Nutritional intake can therefore affect sperm health by affecting the health and availability of DNA on which the cell replication and duplication process depend.

In addition to regulating DNA synthesis, dietary vitamins and micronutrients fulfil important functions in DNA repair and transcription. A number of the processes which regulate sperm production also depend on vitamins and minerals including zinc and B group vitamins to fulfil their functions. Nutrients which are antioxidants (e.g. vitamin E) also affect the development, growth and survival of new sperm cells, because antioxidants protect developing and mature sperm cells from oxidative damage. In the absence of antioxidant protection, oxidative damage might otherwise cause the cells to die (called apoptosis).

The ways in which various nutritional components (e.g. vitamins, micronutrients) affect sperm production is complex and has not yet been adequately investigated by scientific studies. However, scientific evidence so far indicates that several vitamins and micronutrients play an important role in facilitating the production and growth of sperm cells.

B group vitamins

B group vitamins, including niacin and cobalamin (vitamin B12) contribute to DNA synthesis, repair and apoptosis. They protect the DNA of dividing and replicating cells from damage and also help to maintain the genetic integrity of DNA, so that each of the cells created through division and replication is an exact replica of the cell which divided (if the genetic integrity of the DNA is disrupted, this may result in cells which are slightly different being produced and these cells may include irregularities which can cause genetic health conditions or cancer).

B group vitamins also play an important role in facilitating the production of an antioxidant called homocysteine. Homocysteine is known as an endogenous antioxidant, meaning that it is produced in the human body (unlike dietary antioxidants which enter the body when an individual eats food containing antioxidants). Homocysteine plays an important role in protecting cells from oxidative damage throughout sperm production, and as its production in the human body is dependent on the availability of B group vitamins, these vitamins play a role in protecting the health of sperm.

Folate

Folate is also a B group vitamin. Following consumption, dietary folate must be converted into its biologically active form, that is, the form in which it can be used by the body’s cells. In order to be converted to its biologically active form, folate undergoes reactions with other compounds in the body, including the B group vitamin cobalamin (Vitamin B12) and zinc. As such, the amount of biologically available folate depends not only on dietary consumption, but also on the availability of other nutrients.

Once converted to its biologically active from, folate plays an important role in DNA synthesis. Folate regulates the function of two amino acids (called cysteine and methionine) which help facilitate the DNA synthesis process. As DNA is essential for the production of sperm stem cells (cells which produce male sperm), folate is important for sperm production. In addition, folic acid (a synthetic form of folate which is used in folate supplements) has antioxidant properties (discussed further below) which may also enhance sperm health.

Zinc

Zinc is found in relatively high concentrations in the prostate gland, testes and semen (seminal fluids). It is thought to play a role in testicular development and testosterone metabolism, both of which are important for the development of healthy sperm. There is also some evidence that zinc plays a role in:

Regulating the oxygen consumption of sperm; Regulating the sperm’s acrosome reaction (the reaction of the head of the sperm, which is particularly important in the fertilisation process as it is the head of the sperm which penetrates the shell of the female egg); and Maintaining the stability of the nuclei of cells, which contains the cell’s DNA.

Zinc also appears to have an anti-apoptotic effect (protects cells against self-programmed death) in low concentrations, although, on the contrary high zinc concentrations may induce apoptosis. The mechanisms by which zinc exerts these apoptotic and anti-apoptotic effects is not well understood.

Like folate, zinc also fulfils important functions in the process of cell division. More than 80 different enzymes plus zinc are involved in preparing the DNA of a cell for the division and replication. Zinc thus affects sperm health, by regulating the actions of these enzymes and the stem cell’s replication and division process.

Zinc also has antioxidant properties and antioxidants play an important role in protecting DNA and other cell components from oxidative damage (discussed further below). However, evidence from animal studies also suggests that in high concentrations, zinc may catalyse some oxidative reactions. Thus very high concentrations of zinc may actually increase, rather than reduce oxidative damage.

Vitamins and micronutrients with antioxidant properties

Dietary antioxidants include vitamins A, C and E, as well as micronutrients with antioxidant properties such as folate, zinc and selenium. There are also many endogenous antioxidants (antioxidants produced by the body) including glutathione, bilirubin acid and uric acid. Antioxidants protect DNA and other cell components from oxidative damage (damage caused by reactions with unstable oxygen atoms) which may otherwise cause apoptosis (cell death). As healthy DNA is vital to the development of healthy sperm cells, antioxidants enhance sperm health indirectly by improving the quality of the DNA and other cell components from which they form.

As well as affecting developing sperm, antioxidants also influence the fertilising capacity of mature sperm because they scavenge reactive oxygen species (species attached to unstable oxygen atoms) which may otherwise cause oxidative damage to the mature sperm cells. Mature sperm cells are coated with very thin membranes consisting mainly of fatty acids. These thin membranes enable the cells to be highly fluid (and thus to “swim” up the vaginal tract in search of an egg following ejaculation during intercourse). However, because the membrane is very thin it is also highly susceptible to oxidative damage which can affect sperm maturation, the motility of mature sperm (ability to move) and also sperm’s acrosome reaction (the reaction of the head of the sperm when it comes into contact with an egg).

Elevated concentrations of reactive oxygen species in seminal fluid is an indicator of male infertility, even if the seminal fluid contains sufficient concentration of sperm and all other semen parameters are normal. Antioxidants therefore play an important role in maintaining sperm health by preventing oxidative stress (an imbalance between oxidant and antioxidant concentrations), which is thought to be the underlying cause in about half of all cases of male factor infertility.

Numerous studies have now been conducted examining the influence of nutritional supplements on various semen parameters which are indicators of how healthy a man’s sperm is. However, evidence regarding the impact of nutritional supplements on measures of fertility (the man’s capacity to fertilise a woman’s egg) is more limited.

Antioxidants

There is some evidence that antioxidant intake or supplements influences semen parameters. Several studies have reported associations between antioxidant intake or oxidative stress (excessive quantities of reactive oxygen species which can cause oxidative damage) in seminal fluid and other semen parameters. For example, one study reported that very high total intake (above the recommended daily intake) of the antioxidants vitamin C, E and β-carotene was significantly associated with greater concentration and quantity of sperm in seminal fluid and also improved sperm motility (movement). However, the study found that these improvements only occurred in men with very high antioxidant intake and men with normal antioxidant intake did not have improved semen quality compared to men with low antioxidant intake.

Numerous studies have also reported associations between the concentration of reactive oxygen species in seminal fluid and sperm motility and/or normal morphology (shape). These studies indicate that as the number of reactive oxygen species increases, the motility of sperm and the proportion of sperm which have a normal shape, decreases.

Some small studies have also shown improvements to men’s semen quality after taking nutritional supplements containing various antioxidants, including vitamin E, coenzyme Q10 (an antioxidant involved in regulating the mitochondrion, an energy producing component of cells) and glutathione (and endogenous anti-oxidant). Further studies, involving large numbers of men are still needed to confirm these associations.

Selenium and N-acetyle-cysteine

Two studies in which have compared the semen quality of men who had taken selenium (or selenium and N-acetyle-cysteine) supplements with men who had not taken supplements, have reported improved semen parameters (e.g. improved sperm motility) in the men who took selenium.

B Vitamins

Folate

Numerous studies have reported associations between men’s dietary folate intake or folate concentration in seminal fluid and semen parameters. These studies have generally shown that increasing folate intake or concentrations in sperm are associated with improved semen quality, including sperm count and concentration. There is also evidence that folate affects the health of sperm DNA and higher folate intake reduces the risk of sperm aneuploidies (abnormalities of the number of chromosomes in the sperm cells which will can cause genetic conditions such as Down syndrome). There is also evidence that folate supplements might be most effective when administered in combination with zinc supplements.

Vitamin B12 (cobalamin) and pyridoxine

Two studies have examined the role of cobalamin and pyridoxine on semen parameters and these indicate that increased concentrations of these B group vitamins in seminal fluid improves semen quality, including sperm count and ejaculate volume.

Zinc

Studies to date have produced conflicting evidence about the influence of zinc on semen parameters. Some studies have indicated that increased zinc intake improves semen quality, and others have indicated that increased zinc intake does not improve semen quality. Further studies are therefore needed to better understand how zinc intake and concentrations affect semen quality.

While there is increasing evidence that nutritional supplements improve particular semen parameters in particular groups of men, the evidence is derived mostly from small trials. Typically evidence from large trials, involving for example hundreds or thousands of participants, is needed before particular interventions (in this case, provision of nutritional supplements) can be recommended as treatment for health conditions (such as male factor infertility). Therefore, more research, involving greater numbers of men is needed to determine whether or not nutritional supplements improve semen quality before they can be recommended as a treatment for male factor infertility.

It is also important to note that most evidence to date details associations between increased micronutrient intake and improved semen parameters, but not improved fertility (for example, the time it takes for a couple to conceive or the risk of miscarriage after conception). While improved semen quality should theoretically improve male fertility, there is to date no direct evidence that the semen quality improvements associated with increased micronutrient intake also improve fertility. Studies which investigate whether or not nutritional supplements improve time to pregnancy and other indicators of fertility are also needed. Currently there remains insufficient evidence on the effect of nutritional supplements on the fertility of human males to recommend them as therapy for male factor infertility.

However, we do know from strong clinical evidence that a healthy diet (e.g. low in fat and containing plenty of fruit and vegetables) and lifestyle (with plenty of exercise), which protects against the development of obesity, diabetes and other chronic health conditions protects sperm health. Men who are concerned whether their nutritional intake is affecting their sperm health should therefore focus on improving their diet and getting regular exercise, rather than taking nutritional supplements.

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