Male infertility

In the vast majority of cases of infertility, the female partner is most likely to seek help, and very often the woman alone is offered conventional treatment (1). However, the fact is that male factor infertility accounts for up to 50% of cases of difficulty conceiving (2,3). There is a myth that age does not affect fertility in men.

However, while some men are able to conceive into their seventies, age can in fact have a significant impact on male fertility, and most men will have reduced sperm motility and less genetic integrity from their late forties (4). Even in younger men, fertility rates have declined dramatically over the last four decades (5). Environmental concerns such as exposure to radiation and plastics, together with lifestyle factors, are increasingly implicated in male infertility (6).

Male infertility is divided into three categories:

1. Pre-testicular causes (such as reduced pituitary function, exposure to oestrogens, and thyroid problems)
2. Testicular causes (such as infection, trauma or varicocele)
3. Post-testicular causes (such as erectile dysfunction, retrograde ejaculation or structural abnormalities)

This article will focus on pre-testicular causes of infertility in men and on helping to improve sperm abnormalities with herbal medicine and nutrition.

Pituitary problems

Reduced production of pituitary gland hormones, resulting in low levels of testosterone and other male hormones, may be caused by a pituitary tumour, head injury, obesity, nutritional deficiency, stress, inflammatory disease, ageing, and certain medications. 

Exposure to oestrogens

Exposure to oestrogen may inhibit sperm production in males (7). Synthetic oestrogens are widely used in livestock, poultry, and dairy industries. Many commonly used pesticides also have oestrogenic effects within the body, and chemicals such as dioxin, dichlorodiphenyltrichloroethane (DDT), and polychlorinated biphenyls (PCBs) are known to interfere with sperm production. Excessive body fat and high insulin levels (both associated with obesity) are associated with increased production of oestrogen (8). Liver problems may cause reduced oestrogen metabolism and are therefore associated with increased oestrogen in men (2). 

Sex hormone-binding globulin (SHBG) 

Sex hormone-binding globulin (SHBG) is a glycoprotein that binds to reproductive hormones such as testosterone and transports them in the blood as biologically inactive forms. A high SHBG level in males means that less testosterone is available to the body’s tissues.

SHBG is increased by high levels of oestrogen, decreased testosterone (due to stress, advancing age or pituitary problems in men), or by deficiencies of vitamin D, magnesium and zinc; or a diet low in carbohydrates, protein, fat, or omega-3 oils.

Thyroid abnormalities

Thyroid function is regulated by the hypothalamic-pituitary axis and therefore changes in thyroid function can impact greatly on reproductive hormone function (9). There is also increasing evidence for the role of thyroid autoantibodies in male subfertility, which may be linked to inflammatory changes in the reproductive tissues (9).

Conversely, an overactive thyroid increases conversion of testosterone to oestrogen (10), which inhibits testicular function and sperm production in males as previously discussed (7). 

Low sperm count, abnormal morphology and low sperm motility

Low sperm count, abnormal morphology and low sperm motility may be caused by various factors including genetic abnormalities, obesity, hormone imbalances, nutritional deficiencies, and various environmental factors, such as exposure to toxins, heavy metals, radiation, alcohol, and excessive heat (8,11). A  history of genitourinary infections can affect sperm quantity and quality, and even having a high fever can impact sperm production for up to six months (12). 

Cigarette smoking and cannabis smoking have both been associated with decreased sperm count, alterations in motility, and an overall increase in the number of abnormal sperm (13,14). Smoking also reduces blood flow to the genitals (15). Alcohol consumption also increases the number of abnormal sperm (16). Drugs, such as amphetamines, cocaine, and ecstasy can cause aspermia (absence of semen after orgasm) (12). While anabolic steroids cause reduced or absent sperm (17).

A number of orthodox drugs, such as immunosuppressants, anti-androgens, antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs), may cause reduced testosterone levels and/or decreased sperm count, reduced motility, and abnormal sperm morphology. Alpha blockers (used to treat the symptoms of benign prostatic hyperplasia) may lead to decreased sperm count and motility, and reduced ejaculate volume, while antidepressant drugs, which are regularly used by a significant number of men, have been shown to increase sperm DNA fragmentation (17).

Ejaculation that occurs daily or more frequently (due to frequent intercourse or masturbation) can also reduce sperm count (12) Conversely, low sperm motility may be caused by long periods of abstinence. Therefore, intercourse every thirty-six hours or so around the time of ovulation is optimal for conception (12).

Symptoms of low levels of testosterone may include reduced muscle mass, fatigue, reduced libido and erectile dysfunction, Symptoms of excess oestrogen in men may include gynecomastia (breast development) (18).

Symptoms of low thyroid function may include fatigue, weight gain, intolerance of cold, dry skin and hair, slow heart rate, depression, constipation, and hoarse voice. Conversely, hyperthyroidism is associated with increased appetite, weight loss, heat intolerance, sweating, increased heart rate, diarrhoea, restlessness, and tremor.

Improving testosterone levels, sperm count, morphology and motility

Astragalus (Astragalus membranaceus) also significantly increases sperm motility (29). Andrographis (Andrographis paniculata) increases testosterone levels and both herbs may improve immune response in men with Ashwagandhaanti-sperm antibodies (18). 

Ashwagandha (Withania somnifera) is traditionally used in Ayurvedic medicine for the treatment of male sexual dysfunction and infertility. It is particularly suited to men suffering from stress and anxiety (2). It improves testosterone production, reduces oxidative stress, and improves semen quality, increasing semen volume, sperm count, and motility (2,26). 

Maca (Lepidium meyenii) also improves sperm count and motility. It may act by increasing the bioavailability of testosterone, or augmenting testosterone receptor binding (27). Ginseng (Panax ginseng) is another useful herb for improving testosterone levels and sperm count (18). 

African prune tree bark (Pygeum africanum) increases total prostatic secretions and helps to maintain the appropriate pH of seminal fluid. Sperm motility is partly determined by the pH of the prostatic fluid. Therefore, Pygeum africanum (100–200mg extract per day) may help to promote optimal sperm motility and improve fertility (28).

Reducing excess oestrogen

Measures to reduce obesity may help to reduce excess oestrogen levels and improve fertility. In addition, linseed and saw palmetto (Serenoa serrulata) help to reduce the conversion of testosterone to oestrogen (18). Various other foods and herbs have also been shown to inhibit the conversion of testosterone to oestrogen, including

• Green tea (Camellia sinensis)
• Turmeric (Curcuma longa)
• Dandelion (Taraxacum officinale)
• vegetables (such as asparagus, bell peppers, cruciferous vegetables, celery)
• Mushrooms
• Citrus fruits (such as oranges)
• Strawberries (30)

It is advisable to avoid hormone-containing meat and dairy products and opt for organic foods wherever possible (7). 

Bitter herbs — such as dandelion, gentian (Gentiana lutea) and artichoke (Cynara scolymus), which increase liver function — may help to reduce oestrogen excess. Foods high in methionine (such as beans, pulses, onions, and garlic) also assist with metabolism of oestrogen in the liver (31). In addition, cruciferous vegetables (such as cabbage, broccoli, and kale) have been shown to increase metabolism and elimination of oestrogen (32).

Supporting the thyroid 

Consuming iodine rich foods including seaweeds, ensuring adequate selenium intake (from Brazil nuts), and exercising for at least 20–30 minutes a day can help to improve thyroid function in people with clinical or subclinical hypothyroidism (10). Other important nutrients for thyroid hormone synthesis include L-tyrosine, and vitamin B complex. Herbal medicines such as bladderwrack (Fucus vesiculosis) can also increase thyroid function (33). Maca (Lepidium meyenii) improves the bioavailability of testosterone as well as increasing thyroid hormone levels (34). Withania somnifera can help to reduce autoimmunity in addition to supporting thyroid function.

For patients with an overactive thyroid, herbs such as lemon balm (Melissa officinalis) and Lycopus virginicus (gypsywort) reduce thyroid overactivity (35). Reishi (Ganoderma lucidum) and sariva (Hemidesmus indicus) reduce autoimmunity (18). Motherwort (Leonurus cardiaca) is useful for reducing cardiovascular symptoms in patients with overactive thyroid. However, anyone taking medication for a thyroid abnormality should consult with a qualified medical herbalist before taking herbal medicines that affect thyroid function.

Improving testosterone levels, sperm count, morphology and motility

Pituitary function, (and therefore testicular function) may be improved by increasing exercise and improving nutrition. Supplementing essential nutrients can double the sperm count, improve sperm motility by about a quarter, and increase ejaculate volume by about a third (19).

SHBG, which reduces the amount of testosterone available to the body’s tissues, may be reduced by supplemental omega-3 oils, magnesium, zinc, vitamin D; and including healthy sources of carbohydrate, protein, and fat in the diet.

Zinc deficiency is associated with both decreased testosterone levels and sperm count, and several studies have found supplemental zinc may prove helpful in treating male infertility (20). Zinc is found in many foods, including red meat, poultry, seafood, beans, nuts, dairy products, and breakfast cereals (21).

Carnitine is essential in sperm energy production. It contributes directly to sperm motility and may be involved in the successful maturation of sperm (7). Arginine is also essential for sperm motility (22).

The sperm cell membrane and sperm DNA is highly susceptible to oxidative damage (due to stress, smoking, and exposure to other toxic substances), and antioxidant nutrients including vitamins C and E, selenium, and glutathione have been shown to significantly improve sperm concentration and motility and increase the chance of impregnation (7).

Co-enzyme Q10 is involved in energy production in sperm and also acts as an antioxidant (23). Sperm concentration, motility, and morphology have all been shown to significantly improve after twelve months of co-enzyme Q10 therapy, resulting in a beneficial effect on rate of conception (24).

Vitamin B12 is important in cellular replication, and deficiency is associated with decreased sperm count and motility (7,25).  It may be more convenient for most patients to take a male fertility supplement which combines these nutrients.Scrotal temperature is highly regulated by the body, and sperm production is significantly reduced at temperatures above 35 degrees Celsius. Therefore men attempting to improve their fertility should avoid wearing tight fitting underwear or trousers, and should avoid taking hot baths or saunas, or using hot tubs (7).

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