ANTIOXIDANTS AND MALE INFERTILITY

DR. ABHISHEK SINGH PARIHAR

M.S.( OBS & GYNAE), FELLOW REPRODUCTIVE MEDICINE.

CONSULTANT : LIFECARE I.V.F

E), FELLOW REPRODUCTIVE MEDICINE

Consultant – Life care IVF

In 40- 60% Of Infertile Couples A Male Related Problem Is A Cause Of Infertility .

Sperm production cycle occurs in a mean 64 ± 8 days (range: 42–76 days)—(by stable isotope and gas spectrometric analysis)

Several reports describe reduction in male fertility over recent decades.

Estimates that sperms counts in U.S males decreasing by 1.5% each year

50%

30%-80% of infertile men have elevated markers of OS Agarwal et al., Urology 2006

Reactive Oxygen Species (ROS)(Log ROS + 1; cpm)

OXIDATIVE STRESS

An emergingexplanationfor several

cases of maleinfertility

2,5

2

1,5

1

0,5

0

REACTIVE OXYGEN SPECIES (ROS)

Chemical species with unpaired electron capable to oxidize lipids, proteins and nucleic acids:

Superoxide anion (•O-2) Hydroxyl radical (•OH) Hydrogen peroxide (H2O2) Peroxyl radical (ROO•) Hypochlorite ion (OCl-) Generated from aerobic metabolism in mitochondria. Sources: Leukocytes (extrinsic) Spermatozoa (intrinsic) Sperm and Seminal Plasma Antioxidants: Enzymatic (SOD, catalase, GPX): inactivate ROS

(conversion into other substances) Non-enzymatic (ascorbic acid, alpha-tocopherol,

carnitine, etc.): neutralize ROS Lampiao et al., Oxidative stress. In: Male Infertility. Parekattil & Agarwal (eds) 2012, pp.225-35

REACTIVE OXYGEN SPECIES

THE NEGATIVE EFFECTS OF ROS ON SPERM QUALITY HAVE GAINED LOT OF ATTENTION

OXYGEN & ROS PARADOX

ORIGIN OF OXIDATIVE STRESS

SPERM DNA FRAGMENTATION AND ASSISTED CONCEPTION

Live Birth Rates byIntrauterine Insemination

OR = 0.07 [95% CI: 0.01-0.48]

Normal Elevated

Pregnancy by Method in Casesof Elevated Sperm DNA

Fragmentation

42%

26%

P <0.05

Adapted from Bungum et al., Hum Reprod 2007

ICSI

1.5%

IVF

19%19%

19%

SPERM DNA FRAGMENTATION AND MISCARRIAGEPopulation: Meta-analysis of 16 cohort studies (2,969 couples), 14 prospective.Techniques for DNA integrity:Acridine orange-based assays, TUNEL and COMET. Findings: Significant increase in miscarriage rates in patients undergoing IVF/ICSI with high sperm DNA damage compared with those with low DNA damage. Risk ratio (RR) = 2.16 (1.54, 3.03), P < 0.00001).

Miscarriage rates are positively correlated with sperm DNA damage levels

I Robinnson L et al. Hum Reprod. 2012; 27(10): 2908-17 Rob

SIGNS OF OXIDATIVE STRESS IN SEMEN ANALYSIS Reduction of sperm parameters

( Asthenozoospermia is the best surrogate marker of OS ( Kesks et al. , Ammar et al. )

DNA fragmentation ( Kao et al. 2007)

Hyperviscosity– (ureaplasma infection ? ) Semen leukocytes ( round cells ) count using

peroxidase or seminal elastase test ( Kopa et al. 2003)

Testing Malondialdehyde level in sperm/seminal

plasmaOr

Chemoluminescence assays using luminol/lucigenin are expensive, complicated and highly sensitive.

MANAGEMENT OF OS –RELATED INFERTILITY

In >80% of males medical treatment is ineffective .General measures1 –Lifestyle modification ( smoking , poor diet ,

alcohol ,obesity, stress)

2–Avoid activities heating the scrotum

3–Proper ventilation /use of personal protective equipment to reduce exposure to chemicals /metals linked with OS

4–Treatment of infections / variecocele5–ANTIOXIDANTS ,VITAMINS AND FOOD

SUPPLEMENTATION.

ROLE OF MICRONUTRIENTS IN FERTILITY

Nutrition plays vital role in maintaining

male fertility:

Involved in the successful maturation

of sperm

Provides nutrition for motility of sperm

Improvement in sperm count and

motility

Helps in production of sex hormones

Prevents sperm damage

NUTRITIONAL CONSIDERATIONS

Various micronutrients are

associated with male

fertility.

Deficiency of these

Micronutrients &

ANTIOXIDANTS may result

in infertility.

Nutritional Factors

Free radical scavengers L-Carnitine Lycopene Coenzyme Q10 Vitamin C Zinc Vitamin E Arginine Glutathione Vitamin B12 Selenium

IDEAL NUTRACEUTICAL FOR MALE INFERTILITY

Coenzyme Q10

Improves sperm motility by providing energy through ATP generation in mitochondrion

L-carnitine

Improves sperm motility by providing energy to the sperm cell through fatty acid metabolism

Lycopene

Increases sperm count and improves morphology by reducing oxidative damage to sperm DNA and lipids

Zinc

Promotes sperm production & maturation testosterone synthesis & improves sperm morphology

VITAMINS , MINERALS AND HERBS USED FOR INFERTILITY TREATMENT

Vitamins B complex combat the effect of oxidative stress. B5 –for hormone production Folic acid – Arole in RNA and DNA synthesis during

spermatogenesis and has antioxidative properties.

Vitamin C: Helps carry oxygen to sex organs Necessary for balanced hormone / sperm

production

Selenium is related to significantly a higher concentration of sperm per ejaculate .

Herbs: Red clover / rich in every trace element, vitamins and

proteins . Red raspberry – high in essential minerals . Damiana–potent aphrodisiac

ORAL ANTIOXIDANT THERAPY

Methodological weakness of antioxidants trials make it difficult to determine “who”,“how” and “for how long??

Patient selection and controls

Associated pathology

Single or combination antioxidants

Dosage & formulation

Outcome measures

Varying duration of treatment

Lack of diagnostic markers for oxidative stress

Presence of molecular and genetic differences

Controversies

ORAL ANTIOXIDANTSIN MALE INFERTILITY

BeneficialKodama 1997Dawson, 1992

Kessopoulou, 1995Vezina, 1996

Vicari, 2001; 2002Lenzi, 2003; 2004

Cavallini, 2004Comhaire, 2005

Grecco 2005Menezo 2007

Tremellen 2007Piomboni 2008Gil Villa 2009

No effectGiovenco, 1987Moilanen, 1993Iwanier, 1995

Rolf, 1999Sigman, 2006

Detrimentallong-term use andhigh doses;increased mortality

incancer population-based studies.

No Consensus Yet.

Short-term useappear to be safe.

Caution againstindiscriminate useof high dosages forlong periods.

Who are the candidates for OralAntioxidant Therapy?

Infertile men with OS Diagnosis

HOW TO USE ANTIOXIDANT THERAPYTREATMENT STRATEGY

Once OS is diagnosed,focus on identifying and

controlling source of increased ROS

Varicocele Genital Infection

Smoking

Medication

Drug abuse Systemic disease

Pollution Radiation

Differentiate betweensperm and leukocytesource of ROS

Testing forLeukocytes in Semen

Select antioxidantformulation and dosage

Ascorbic acid (Vit. C)

- tocopherol (Vit. E)

Glutathione

N-acetyl-cysteine

Carnitine

Coenzyme Q10

Lycopene

Picnogenol

Pentoxifylline

Selenium

Shao-Fu-Zhu-Yu-Tang

Astaxanthin

Lepidium meyenii

-linolenic acid and lignans

Folic acid

Zinc

ORAL ANTIOXIDANTS IN MALE INFERTILITY

OUR FORMULA MAXOLA -L Co Enzyme Q 10-20mcg Vitamin B12 2.5 mcg

Folic acid 500 mcg Zinc Sulfate 10mg

Selenium 50 mcg Lycopene 2500mcg

Fructose 1g L-Carnitine fumarate -1g

Acetyl-L-Carnitine 0.5g Citric Acid 50mcg

PLAIN MAXOLA does not contain LYCOPENE.

How long: minimum 2 months

From initiation of sperm production to ejaculation

Old concept ~80 days

New concept 60 days

Oral AntioxidantsCochrane Review 2011

Outcome

Live birth

Pregnancy rate

DNA fragmentation

Miscarriage, spermcount, sperm motility

Adverse effects

Nstudies

3

15

1

6-16

6

participants

214

964

64

242-700

426

Effect size(OR; 95% CI)

4.85 [1.92, 12.24]

4.18 [2.65, 6.59]

-13.80 [-17.50, -10.10]

No effect

No effectImprove the outcomes of live birth and pregnancy rate for

subfertile couples undergoing ART cycles

ALTERNATIVE TREATMENT

Testicular (not epididymal) sperm extraction in men with poor sperm DNA quality if conservative treatment ( AO and lifestyle modification) have failed. ( Greco2005, O΄Connell 2002 ).

Reduce centrifugation time prior to IUI /IVF

Use of non–centrifuge separation techniques (swim–up etc…)

Limit the sperm culture time in media away from seminal plasma

ALTERNATIVE TREATMENT

Culturing sperm under low oxygen tension ( 5% O2) reduces seminal leukocyte ROS.

Avoid using frozen sperm (if possible ) since ROS are produced during freezing /thawing ( Watson 2000)

Supplement sperm separation media with a variety of AO ( catalase—Rossi et al 2001,vit.C — Zheng and Zhang, EDTA, glutathione/hypotaurine , albumin, N– acetyl–cysteine.

SUMMARY Oxidative stress impairs sperm function and is a risk factor for male infertility and miscarriage .

current evidence suggest that OA supplementation for subfertile males improve the chances for pregnancy and live birth for couples undergoing ART.

Well-designed studies are needed to determine the best candidate for AO therapy and which formulation and dosages yield better results.

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Thank you