1. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
Advanced ART Course for Clinicians (NUHS, Singapore)
MSc, Sexual & Reproductive Medicine (South Wales, UK)
Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata
Managing Committee Member, Bengal Obstetric & Gynaecological Society
Secretary, Subfertility and Reproductive Endocrinology Committee, BOGS
Clinical Examiner, MRCOG (Part 3) Examination
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019
Role of Multivitamins & Antioxidants in
Managing Male Infertility
3. 1. Men’s fertility potential
depends on female factors
• Assessment of tests and treatments for the male is
challenging due to inconsistent endpoints and the
observation that many of these endpoints are
dependent upon and measured from the female
• Ideally, the endpoint for fertility trials should be
"live birth or cumulative live birth (WHO, 2021)
6. Limitations of WHO Guideline
• Based on parameters in a large group of fertile men
along with defined confidence intervals from recent
fathers with known time-to-pregnancy (TTP).
• The WHO does not consider the values set as true
reference values but recommends or suggests
• Day to day variation
• Functional ability of the sperms?
7. Collection Method Masturbation
Abstinence 4 days
Volume 1.5 ml
Liquefaction Time 45 minutes
Sperm Concentration 1.2 million/ ml
Total Motility 30%
Progressive Motility 16%
Non progressive Motility 14%
Motile Sperm Count 0.54 million
Normal Morphology 1%
Round cells Nil
16. 6. Semen collection- may NOT
be so easy
• Washing facility
• Ask- Why Difficulty
• Erection issue
• Coitus interruptus
• Nontoxic condom
• Home Collection
• Urine (In RE)
• Prostatic Massage
17. Collection Method Masturbation Abstinence 4 days
Collection Complete Volume 2 ml
Colour Whitish Viscosity Normal
Liquefaction Time 45 minutes pH 7.6
Sperm Concentration 36 million/ ml
Total Motility 46% Progressive Motility 33%
Non progressive Motility 13% Immotile 54%
Motile Sperm Count 16.56 million/ ml TMSC 33.12 million
Normal Morphology 5% Abnormal Morphology 95%
Vitality 32% Round cells Nil
• Treated for “male factor” with antioxidants
• Unexplained subfertility
• Conceived with OI with hMG first cycle, delivered
7. Can we interpret properly?
19. MAGI (Male Accessory Gland Infection)
• The clinical significance of an increased
concentration of leukocytes in the ejaculate is
• Special Tests- Round cells vs Pus cells
• Method of collection
• Hand washing before collection
• Culture of semen
• Antibiotics- only when documented infections
• Consider urethral swab/ prostatic fluid culture
EUA, 2018; ASRM, 2020; Vignera et al., J Med Microbiology, 2014
21. A story of “Pus cells”
• Persistent Pus cells
• Culture negative
• Pain during
• No pus cells after
• Conceived after OI,
26. Pathological effect of ROS on
High concentrations and prolonged
exposure to ROS causes extensive
damage to various integral cellular
biomolecules, including proteins,
lipids and nucleic acids, which
hampers multiple cellular functions
Oxidative stress in Male
Hypertension and the development of
oxidative stress. There is proliferation
of the vascular smooth muscles and
the narrowing of vascular lumen. The
narrowing of the vascular lumen
leads to increase in the generation of
ROS, thus causing oxidative stress.
Diabetes and impaired
increase the production of
advanced glycation end
products, causing imbalance
in the ratio of ROS
generation and elimination
by antioxidants, thereby
resulting in the development
of oxidative stress
stress in Male infertility
Front. Reprod. Health 4:822257., February
2022, volume 4, 1-15
27. Reproductive Consequences of
ROS and Oxidative Stress
In-Vitro Fertilization (IVF) / Intracytoplasmic
Sperm Injection (ICSI) Outcomes:
• ICSI is also affected for an excessive presence
of ROS molecules in seminal plasma and
• The damaged cell development generated by
oxidative stress, causing apoptosis and
Astaxanthin several-fold stronger antioxidant activity than vitamin E and b-carotene.
potent antiperoxidation activity.
Coenzyme Q10 Protects the cell membrane from lipid peroxidation.
improves Total Antioxidant Capacity (TAC) concentrations and decreased
Malondialdehyde (MDA) levels.
L-Carnitine increases fatty acid transport into sperm mitochondria which are needed for sperm
Lycopene antiproliferative, immunomodulatory, and anti-inflammatory effects that promote cell
Vitamin B9 (Folic
Protects against mutations and DNA strand breaks.
Regulates DNA methylation and gene expression
prevents abnormal chromosomal replication and mitochondrial DNA deletions.
Zinc role in signaling, enzymatic activities, sexual maturation and managing mitochondrial
improves chromatin integrity
Selenium Suppresses testicular toxicity and modulate DNA repair.
29. Combined conventional/antioxidant "Astaxanthin"
treatment for male infertility: a double blind,
• To evaluate the treatment of male infertility with a strong natural antioxidant.
• 30 men with infertility of ≥12 months and female partners with no cause of
• Astaxanthin 16 mg/day or placebo for 3 months were given.
• Effects of treatment on,
Reactive oxygen species (ROS)
Zona-free hamster oocyte test
Serum hormones including testosterone, LH, FSH and Inhibin B, and spontaneous or IUI-induced
pregnancies were evaluated
Asian J Androl 2005; 7 (3):
LH: Luteinizing Hormone, FSH: Follicle Stimulating Hormone, IUI:
• ROS and Inhibin B decreased
• Sperm linear velocity increased in
the Astaxanthin group.
• The results of the zona-free
hamster oocyte test* tended to
improve in the Astaxanthin group.
• A total pregnancy rate of 54.5 % in
the Astaxanthin group.
• The conception per month was 23.1
% in the Astaxanthin group.
*The hamster zona-free ovum test (HZFO test), or hamster test is a method for
diagnosing male infertility due to the inability of the sperm to penetrate the ova.
Semen characteristics and hormone results at
baseline and after 3 months of treatment.
The present study suggests a positive effect of Astaxanthin on sperm parameters and fertility.
Asian J Androl 2005; 7 (3):
31. Coenzyme Q10 supplementation in infertile men with low-
grade varicocele: an open, uncontrolled pilot study
• To evaluate the antioxidant capacity of seminal plasma of infertile
men with varicocele.
• 38 patients were recruited.
• Patients underwent an oral supplementation with CoQ10 at a dosage
of 50 mg twice a day for 12 weeks.
• A semen analysis was performed at baseline and 3 months.
• Coenzyme Q10 therapy improved semen parameters and
Andrologia. 2014 Sep;46(7):805-7
32. The effect of L-Arginine of treatment for infertile men on
• The study is to determine the effect of oral supplement of L-Arginine on semen
parameters as a treatment for infertile men.
• Study conducted on 15 infertile men.
• L-arginine was given orally at a dose 1000 mg one capsule per day morning.
• All semen parameters were measured, such as semen volume, sperm count,
motility, pH, Vitality and normal morphology and abnormal shape.
• Biochemical tests like, GSH, MDA, IL-6, and CRP, were analyzed according
Tikrit Journal of Pure Science Vol. 24 (5) 2019, 1-4. Glutathione (GSH), Malondialdehyde (MDA), Interleukin 6 (IL-6), and C- Reactive protein (CRP).
33. The mean & standard deviation of semen
parameters of infertile men before &
after treatment with L- Arginine
Significant reduction in Sluggish, abnormal
sperm shape and non-motile sperm count
after treatment with L-Arginine.
L-arginine which provides protection against oxidative stress.
It protects spermatozoa against lipid peroxidation by increased the release of nitric oxide gas.
Supplement of arginine per day to infertile men markedly increased sperm count and motility.
Significant elevation in the concentration of Glutathione (GSH). A significant reductions in
the concentration of Malondialdehyde (MDA), Interleukin 6 (IL-6), and C- Reactive protein
Tikrit Journal of Pure Science Vol. 24 (5) 2019, 1-4
34. • 60 patients were included with 30 patients in
case and 30 patients in control groups.
• Homocysteine lowering agents were given (folic
acid 5mg, vitamin B12 500 microgram, vitamin
B6 5 mg )
• Homocysteine lowering agents were given for 6
• Re-assessed homocysteine levels after 6 weeks.
Conceptions over a period of one year were
homocysteine levels was 10.4 µmol/l
Int J Reprod Contracept Obstet Gynecol. 2013 Jun;2(2):165-171
To study the role of hyperhomocysteinemia in
Homocysteine lowering agents
have a favourable impact on the
Their use is suggested in cases of
infertility associated with
• An anti-estrogen drug that stimulate spermatogenesis.
• It is useful in idiopathic cases of male infertility.
• It can increase male fertility hormones (FSH and LH) and stimulate sperm
• It is also useful in some hypogonadal, infertile men with low testosterone levels.
• The recommended dose for infertile men is 25 mg or 50 mg three times per week.
• Possible side effects include headache, nausea, vomiting, diarrhea, flushing and visual
disturbances such as blurred vision.
Empirical Therapies: Antiestrogen, Aromatase
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available
• It is an estrogen receptor blocker that improve semen parameters,
when used together with clomiphene.
• It can improve sperm counts and other semen parameters in
• The usual dose is 10 mg twice a day.
• Possible side effects includes weight gain, edema, leg swelling,
nausea, skin rash and erectile dysfunction.
37. Aromatase Inhibitors (Anastrozole and Letrozole):
• Aromatase inhibitors are medications that block the conversion of
testosterone to estrogen.
• They are considered the treatment of choice for infertile males.
• They improve abnormal semen and hormonal parameters.
• The recommended dose of anastrozole is 1 mg three times a week,
while the dose of letrozole is 2.5 mg three times a week.
• The most common side effect reported with these medications is joint
pain and stiffness.
38. 10. Severe Male Factor is NOT ONLY a
• Cardiovascular diseases
• Lymphoma, extragonadal
germ cell tumours, peritoneal
• Repeated hospitalization
• Increased mortality
• Testicular Cancer
Choy and Eisenberg, 2020; Bungum et al., 2018; Eisenberg et
al., 2013; Jungwirth et al., 2018; Hotaling and Walsh,
•H/O undescended testicles
(post-mumps or others)
39. Sperm abnormality may be the
first symptom of testicular cancer
• 31 yrs
• Came for IUI (D)
• Malignant teratoma-
treated by orchidectomy
40. 11. Severe Male Factor- if not
left untreated ???
• Progressive decline in semen parameters
41. • Overall, 16 (24.6%) of 65 patients with severe
oligozoospermia developed azoospermia.
• Two (3.1%)patients with moderate
oligozoospermia developed azoospermia
• None of the patients with mild
oligozoospermia developed azoospermia.
42. Revisiting History
• Duration of subfertility
• Occupation- Driving, IT, chemical industry (heavy
• Medical history- Diabetes, Mumps, Cancer
• Surgical history- Hernia, Orchidopexy, Pituitary
Surgery, Bladder neck surgery
• Drug history- Sulphasalazine, Finesteride,
cytotoxic drugs, steroids
• Sexual history- Low libido, ED
43. If previously fathered a baby?
• Secondary subfertility of 6 yrs
• Previous- one male baby, 10
yrs, natural conception
• Only female was evaluated
• Male- azoospermia on
• Diabetic for 7 yrs,
• Endocrine, imaging all normal
• Lost to F/U
• Secondary subfertility of 10 yrs
• Previous- one male baby, 12
yrs, natural conception;
followed by 2 TOP
• Only female was evaluated
initially- multiple cycles of OI
with CC, letrozole, hMG
• Varicocele surgery 10 yr ago
• Male- Severe OAT on several
• Endocrine, imaging all normal
• Planning for ICSI
44. Darren et al. Male infertility – The other side of the equation . 2017
46. Varicocele- always CLINICAL Diagnosis
• Subclinical: not palpable or
visible, but can be shown by
special tests (Doppler
• Grade 1: palpable during
Valsava manoeuvre, but not
• Grade 2: palpable at rest, but
• Grade 3: visible at rest.
47. Surgery for Varicocele (EUA, 2018)
• Grade 3 varicocele
• Ipsilateral testicular atrophy
• Abnormal semen parameters
• No other fertility factors in the couple
48. In couples seeking fertility with ART, varicocele repair
• may offer improvement in semen parameters
• may decrease level of ART needed
49. Varicocelectomy- How, when?
• Scrotal operation
• Inguinal operation
• Laparoscopic approach
• High ligation
effective method with
minimum risks of
complications and lower
recurrence rates (EUA, 2018)
Positive Predictive Factors
1. Grade 3 varicocele
2. TMSC ≥5 million
3. High SDF
Samplaski and Jarvi, 2016
54. CBAVD is NOT uncommon
• 40 yr, CBAVD
• TRUS- Rt SV absent,
Lt SV very small
• FSH 3.8, Testo 353
• TESA- Motile sperms
• CFTR negative
• ICSI done, no
• 35 yr, CBAVD
• TRUS- B/L SV
• IUI (D) twice,
Lost to F/U
• 33 yr, CBAVD diagnosed
during hydrocele Sx
• TRUS- Rt SV absent, Lt
SV very small
• FSH 2.62, LH 8.79, Testo
• Did IUI (D), conceived
55. Cryptorchidism in adults (EUA, 2018)
• In adulthood, a palpable undescended
testis should NOT be removed because
it still produces testosterone.
• Correction of B/L cryptorchidism,
even in adulthood, can lead to sperm
production in previously azoospermic
• Perform testicular biopsy at the time of
orchidopexy in adult- to detect germ
cell neoplasia in situ
56. Cryptorchidism- Multidisciplinary
• 28 years
• Nonobstructive azoospermia
• Testo 74.47, LH 17.25, FSH 29.91
• H/O Laparotomy for GI perforation , 17
• MRI advised by Urologist
• Endocrinologist started TRT
• 3 cycles IUI (D) failed
• Conceived after first cycle of IVF with
donor sperms- twin pregnancy,
spontaneous reduction to single tone
59. Importance of history and examination
Rt sided orchidopexy during appendicectomy at 18 yr
Subsequently Rt testis atrophied
Lt side operated after 6 months, could not be brought to scrotum,
biopsied, seen by MRI (not seen in USG)
1. Clinically abnormal findings-
2. Tight scrotum (Cremasteric
3. Obese patient
• NOT for Varicocele detection
• NOT the replacement for
clinical examination (EUA,
2018; ASRM, 2020)
Transrectal ultrasound (TRUS)
1. Low volume and pH of
2. Ejaculatory disorders (EUA,
2018; ASRM, 2020)
62. Testicular microlithiasis
• FSH 17.77, LH 5.67, Testo 7.24
nmol/l, E2 13.32
• Trial TESE- B/L Maturation Arrest
• Finally decided for IUI (D)
•Mumps orchitis 20 yr age
•FSH 29.7 LH 6.49, Testo 219, E2 37, Ratio
•Letrozole for 4 months → Azoospermia
•Trial TESE- No sperms found-
•H/P- SCO (Sertoli cell Only)
•3 cycles IUI (D) failed, opts for IVF with
63. Sperm concentration <10 million/ml
Clinically suspected endocrinopathy
FSH, LH, Testosterone, HbA1C
FSH/ LH low
Prolactin, TSH if
64. Testosterone Supplementation?
• Should only be done in men with primary
hypogonadism, NOT interested in fertility (EUA, 2018;
EUA, 2016; AUA, 2018; CUA, 2015)
• They provide feedback inhibition on pituitary
gonadotrophins (FSH and LH) leading to
secondary hypogonadism (de Souza and Hallak, 2011; McBride and
Coward, 2016; WHO, 2010)
• If T:E2 ratio <10 (T- ng/dl, E2- pg/ml),
consider Aromatase Inhibitors (Letrozole,
Anastrozole) (EUA, 2018; AUA, 2018)
66. Hypogonadotrophic Hypogonadism
• hCG 2000-5000 IU 3 times a week
• Serum testosterone should be checked every 1–2 months
• The sperm count should be monitored monthly
• Sperm parameters become normal within 6 months but
sometimes it can take 24 months of time
• If hCG alone cannot restore spermatogenesis, FSH is
added in the dose of 75-150 IU 3 times a week
67. Stories of Hypo/Hypo
• 32, yr, H/O delayed puberty
• Was on TRT (17-23 yr age)
• Gynaecomastia surgery, 22 yr
• LH 0.06, FSH 0.02, Testo 0.63, PRL
1.18, TSH 2.48
• Low libido, ED
• Anosmia, MRI- B/L olfactory bulb
• Genetic tests advised, Lost to F/U.
•36 yr, Azoospermia
•sudden loss of body hair, low libido→
nonfunctioning Pituitary macroadenoma →
Endoscopic surgery H/P Lymphocytic
•Sexual function and sec sex characters
improved after Sx
•On cortisol, L-thyroxine supplementation
•Started hCG f/b hMG by endocrinologist
•Sperm conc 1-2/ hpf
•Advised to continue hMG
70. Smits RM, Mackenzie-Proctor R, Yazdani A, Stankiewicz MT, Jordan V, Showell MG. Antioxidants for
male subfertility. Cochrane Database Syst Rev. 2019;3(3):CD007411. Published 2019 Mar 14.
• may improve live birth rates
• clinical pregnancy rates may also increase.
• Overall, there is no evidence of increased risk
of miscarriage, however antioxidants may give
more mild gastrointestinal upsets
• Subfertilte couples should be advised that
overall, the current evidence is inconclusive.
71. TMSC PR/CYCLE
10–20 million 18.29%
5–10 million 5.63%
Guven et al, 2008;Abdelkader & Yeh, 2009
Hamilton etral., 2015
Criteria TMSC Treatment
Pre wash TMSC > 5 million IUI
Pre wash TMSC 1 - 5 million IVF
Pre wash TMSC <1 million ICSI
IUI, IVF or ICSI?
72. TMSC <5 mil/ml and IUI
• Counsel before IUI
1. Double Ejaculate Kucuc et al., 2004; Oritz et al., 2016
2. “Trial IUI”- Post wash- IMSC Ombelet et al., 2014
3. IMSC >1 mil/ml → Further IUI
4. IMSC <1 mil/ml → ICSI
5. No role of double insemination or any
special washing technique ESHRE., 2018
75. Strategies in Severe OAT
• Donor sperm is NOT the solution
• Investigate the cause
• Consider freezing of the sperms
• Short “trial” of medical therapy
• Trial IUI- Double ejaculate, IMSC
• ICSI is the standard treatment
79. Investigation depends on the plan
• B/L testes- 6 cc
• FNAC- B/L
• FSH 37.2, LH 24.4,
Testo 245.53, E2
37, ratio <10
• Not keen for IVF-
80. FNAC- role?
• Isolated foci of spermatogenesis
• “Trial TESA/TESE”
• If obtained, cryopreserve the sperms
• FSH >7.6 AND testicular long axis <4.6 cm- 89% chance
• FSH <7.6 AND testicular long axis >4.6 cm- 96% chance
• Consider TESA in indeterminate cases- NOT
98. Meticulous semen analysis in a standard laboratory
Physical examination and rational investigations
Avoid non-evidence based drugs for long time
Antioxidants- Useful in mild problem
Antioxidants- Not reliable in severe problem
Donor sperm is NOT the only solution
IUI or ICSI- depends on the overall assessment
Take Home Messages