Dr. Eeson Sinthamoney
Consultant Obstetrician and Gynaecologist
Hospital Kuala Lumpur

• In women: raised BMI associated with difficulty in conceiving
• Overweight and obese women undergoing fertility treatment had significantly lower pregnancy rates and higher miscarriage rates
• Underweight women had less embryos available

• In men, relationship less clear
• Many studies indicate high or low BMI associated with significantly reduced sperm quality
• However some evidence also suggests otherwise
• Body weight loss may be reasonable in male infertility

• Many studies demonstrate the positive effects of OTC supplementation on female fertility, semen parameters and pregnancy outcomes
• Conversely, also many studies that demonstrate lack of improvement
• Gold standard of evidence?

Why is good evidence difficult to find?
1. Infertility often multifactorial
2. Baseline dietary intake
3. Single agent versus multiple supplements
4. Dosages?

• Several small studies suggest that some nutrients may be essential in female reproduction
• Current interest focused on vitamin D and anti-oxidants

Cell respiration l
Production
Alcohol / tobacco smoke
/ environmental pollutants
Reactive oxygen species
Anti-oxidant co-factors
Example: selenium, zinc and copper
Scavenging, disposing or suppresing
Anti-oxidants
(example Vitamin C and E)

• Main nutrients: vitamin C, vitamin E, selenium, and the carotenoids (vitamin A precursor)
• A multitude of other nutrients, including minerals such as copper, manganese, zinc, flavonoids (such as grape seed extract and phenols found in green tea)
• Co-enzyme Q10, also possess antioxidant properties

• Evidence exists supporting the role of oxidative stress in male fertility
• However, in women, while there is suggestion of the same, relationship not well addressed

Nutrients
Smoking and alcohol
Caffeine
Implications in implantation
Effect on embryo quality
Effect on oocyte quality and maturation
Increase in menstrual regularity
Higher rates of conception
Active and passive smokers have reduced fertility
Reduced implantation rates in IVF reduced pregnancy rates

2 alcoholic drinks a day impairs fertility
High levels (>500mg/day = >5 cups/day) delays conception

• Involved in female reproduction and improves fertility treatment outcome
• Some studies show that women with higher serum and FF vitamin D levels have higher pregnancy rates after IVF
Replete vitamin D stores predict reproductive success following in vitro fertilization. Ozkan S et al. Fertil Steril. 2010 Sep;94(4):1314-9.
Vitamin D and fertility-a systematic review. Lerchbaum E, Obermayer-Pietsch BR. Eur J
Endocrinol. 2012 Jan 24.

• Some strong but indirect evidence that oxidative stress affects fertility
• Best available evidence suggests a varied diet with regular use of multivitamins, limited caffeine and alcohol and a healthy body weight promotes fertility

• Up to 50% of fertility problems involve a male factor
• More information available concerning nutrients and sperm characteristics

• Assist sperm metabolism as an energy source for spermatozoa and effect motility and sperm maturation
• Also an anti-oxidant
• Multiple RCT studies demonstrate improvements in concentration, motility, morphology also the converse also shown
• Primarily meat products
• Dosage?  Up to 3g/day safe

• Studies in infertile men demonstrate positive co-relation between higher seminal fluid
CoQ10 concentrations and sperm motility and fertilization potential in couples undergoing
IVF  pregnancy rates?
• Source: oily fish (sardines), organ meat, whole grain, vegetables
• Dosage: 200-300mg/day up to 12mg/kg/day

• Important role in DNA synthesis and proper cell function
• Critical role in spermatogenesis
• Mixed reports on effect of folate on male fertility
• Sources: dark green leafy veg, beans, eggs, meats
• Unsure if additional folate above RDA will improve fertility

• One of the most abundant anti-oxidant produced in the body
• Important role in maintaining exogenous antioxidants (Vitamin C, E) in its active form
• Shown to improve sperm motility, improved sperm concentration and decreased sperm DNA fragmentation
• Source: fresh meat, fruits & veg
• Up to 3g/day tolerated
• Poor oral availability  IM administration

• B-carotene is pre-cursor or vitamin A
• Anti-oxidant properties
• Specific benefits on sperm production and function difficult to clearly demonstrate
• Up to <10000iu/day tolerated
• However, readily stored and may reach toxic levels

• Associated with various improvements in semen quality
• Supplementation up to 1000mg/day improves count, motility, viability and morphology
• Protects sperm DNA against oxidative damage
• May work synergistically with other vitamins and anti-oxidants
• RDA: 90mg/day; dosage: 500mg/day

• Potent anti-oxidant
• Substantial support for improvement in many sperm parameters
• Sources: veg oil, meat, poultry
• Recommended dose: 200-400iu/day
• Upper daily intake: 1600iu/day
• May be increased risk of complications (CVS) if
>400iu/day and bleeding risk >800iu/day

• Role in maintaining normal testicular development, spermatogenesis and sperm function
• Studies support use of selenium to improve sperm motility, concentration and morphology especially I combination with vitamin E
• Optimal dosing: 100-210mcg/day
• Sources: meat, seafood, eggs; veg is poor source

• Vital role in testicular steroidogenesis, testicular development, sperm O2 consumption and other functions
• Chronic mild zinc deficiency assoc with oligospermia, decreased serum T2
• Zn therapy associated with improvement in sperm motility, reduced sperm DNA fragmentation and other improvements
• Upper limit: 40mg/day

Not new!
1. mother-in-law’s advice
2. Nutrients?
3. Sperm sorting mechanisms – varied options, evolving over time post sort purity average 87.9%
4. PGD
Flow cytometric sorting of human sperm: MicroSort clinical trial update. Karabinus DS.
Theriogenology. 2009 Jan 1;71(1):74-79

• Lack of good quality evidence
• However: information available suggests that selective use of certain supplements beneficial but dosage information lacks clarity
• Certainly- anti-oxidant use may improve live birth and pregnancy rate outcomes for subfertile couples undergoing ART
• However: avoid doses beyond RDA to avoid complications
• Blood level assessment?