Page 151 - Remedial Andrology

10.5 Non-Invasive Male Infertility Management
10.5.1 Idiopathic male infertility and oligo-astheno-terato-zoospermia
Oligo-astheno-teratozoospermia (OAT) is a clinical condition with a reduced number of spermatozoa in the
ejaculate, which is also characterised by reduced sperm motility and morphology; often referred to as OAT
syndrome (OATS). Several conditions can cause OATS, although the aetiology may be unknown in a significant
number of cases [78, 1605].

10.5.2 Empirical treatments
10.5.2.1 Life-style
Studies suggest that environmental and lifestyle factors may contribute to idiopathic infertility acting additively
on a susceptible genetic background [78, 1605]. Hence, lifestyle improvement can have a positive effect on
sperm parameters (see below).

10.5.2.1.1 Weight loss
Few authors have investigated the role of weight loss on male fertility outcomes. Non-controlled studies have
suggested that weight loss can result in improved sperm parameters [78, 1781, 1782]. However, data derived
from RCTs are more conflicting. A meta-analysis of 28 cohort studies and 1,022 patients, documented that
bariatric surgery did not improve sperm quality and function in morbidly obese men [1783]. Data on ART
outcomes are lacking. However, it is important to recognise that weight loss can improve obesity-related
secondary hypogonadism, which may result in better outcomes in couples seeking medical care for infertility,
and is important for the general health of the male partner [1781, 1783].

10.5.2.1.2 Physical activity
Regular physical activity is recommended by the WHO in order to prevent and reduced the risk of several
long-term chronic diseases [1784]. A recent meta-analysis has documented that moderate-intensity (20–40
metabolic equivalents (METs)/week) or even high-intensity (40–80 METs-h/week) recreational physical activity
can result in better semen parameters [1785]. In addition, similar to what is observed from weight loss,
improvements in hormonal profile have also been reported [1781].

10.5.2.1.3 Smoking
Epidemiological data indicates that about one in three men of reproductive age smokes, with the highest
prevalence observed in Europe among all the WHO regions [1786]. Data derived from a large meta-analysis of
20 studies with 5,865 participants clearly show a negative association between smoking and sperm parameters
[1786]. Experimental studies performed in rats have shown that nicotine has a dose-dependent deleterious
effect on sperm, which can be improved by nicotine cessation [1787]. Data in men are lacking and only
one case report has indicated an improvement of sperm parameters after 3 months of a smoking cessation
programme [1788]. Similar data have been reported in a recent non-controlled study, which showed a possible
benefit on ART after the male partner stopped smoking [1789].

10.5.2.1.4 Alcohol consumption
Data derived from a recent meta-analysis including 15 cross-sectional studies and 16,395 men suggested
that moderate alcohol does not adversely affect semen parameters, whereas high alcohol intake can have a
detrimental effect on male fertility [1790]. Similar to what has been reported for weight loss, however, heavy
chronic ethanol consumption (defined as > 2 drinks/day [1791]) can reduce testosterone levels, which can be
restored by alcohol cessation [1792].

10.5.2.2 Antioxidant treatment
Inflammation is a positive reaction of the human body to overcome potential noxious stimuli. However,
chronic inflammation can induce several negative biochemical and metabolic effects that contribute to the
development of several medical conditions. Oxidative stress is considered to be of the most important
contributing factors in the pathogenesis of idiopathic infertility. ROS, the final products of OS, can impair
sperm function acting at several levels, including plasma membrane lipid peroxidation, which can affect sperm
motility, the acrosome reaction and chromatin maturation leading to increased DNA fragmentation [1793].
Accordingly, seminal levels of ROS have been negatively associated with ART outcomes [1794]. Despite
this, evidence for the role of antioxidant therapy in male infertility is still conflicting. A Cochrane systematic
review and meta-analysis including 34 RCTs and 2,876 couples using various antioxidant compounds, it was
concluded that antioxidant therapy had a positive impact on live-birth and pregnancy rates in sub-fertile
couples undergoing ART cycles [1795]. Similar results were also reported in the most recent meta-analysis
including 61 studies with 6,264 infertile men, aged 18-65 years [1796]. More recently, the Males, Antioxidants,
and Infertility (MOXI) trial found that antioxidants did not improve semen parameters or DNA integrity compared

150 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021