1. Dr. Ajit Saxena APOLLO HOSPITALS NEW DELHI Ian

2. Causes for male Infertility Hum Reprod Update 1999; 5(2): 120 Percent (%) 2

3. Idiopathic male Subfertility  40-75% of cases.  Most common pathological cause of Idiopathic Subfertility is – free radical induced damage to the sperm. Free radical is defined as oxygen molecule containing one or more unpaired electrons in atomic or molecular orbitals. 3

4. Biology of ROS Pathology stems from imbalance between production and scavenging Production Degradation 4

5. Oxidative stress balance 5 Idiopathic Iatrogenic Lifestyle Infection Environmental Autoimmune Testicular Chronic Disease Damage to DNA Damage to membrane

6. Focus Role of various micronutrients in treatment of male infertility.  Coenzyme Q10  L-Carnitine  Lycopene  Zinc 6

7. CoQ10 is a naturally-occuring lipid soluble compound found in every cell in the body. Coenzyme Q10 (CoQ10) is concentrated in the mitochondrial mid-piece Coenzyme Q10 (CoQ10) acts as an electron carrier in the mitochondrial respiratory chain.* It helps in transfer of electrons in respiratory chain & prevents lipid per oxidation & generation of ROS. Thus it stabilizes cell membrane, maintains & promotes sperm motility *CLIN. CHEM. 41/2, 217-219 (1995) **Chem Scripta 1987;27:145-58 Co enzyme Q10 7

8. Free Radical Scavenger Energizer CLIN. CHEM. 41/2, 217-219 (1995) Co enzyme Q10 - Mechanism 8

9. In sperm cells, coenzyme Q10 (CoQ10) is concentrated in the mitochondria. Coenzyme Q10 is responsible for energy for movement and all other energy-dependent processes in the sperm cell. Reduction in levels of CoQ10 is observed in sperm cells and seminal plasma of idiopathic (IDA) and varicocele-associated (VARA) asthenozoospermic patients.* It is observed that sperm cells, characterized by low motility and abnormal morphology, have low levels of CoQ10. *Andrologia 34 (2002), 107–111. Co enzyme Q10 - Mechanism 9

10. EFFECT OF CoQ 10 ON SPERM MOTILITY In study of 38 patients (16 -normal motility & 22 –Asthenozoo-spermia) semen samples were washed in Ham’s F-10 media, incubated with increasing concentration of CoQ for 24 hrs. Results : Normal patients- No significant change in motility rates Asthenozoospermia - Significant increase in motility in 50 µM CoQ10, No significant increase in 5 µM CoQ10 Dept. OBGY, Hadassah-Hebrew University Medical School, Jerusalem, Israel, 97. 10

11. Administration of CoQ10 increased the pregnancy rate by 36% and with improvement of sperm count and functional sperm concentration in 70% and 60% individuals, respectively. Sperm motility and sperm motility index improved in 54% and 46 % while 38 % showed improvement in sperm morphology. Folia Med (Plovdiv).2005;47(1):26–30. Coenzyme Q10: Clinical Trials Improvement in sperm motility, motility Index and sperm morphology Sperm Morphology Motility index Sperm Motility 11

12. Patients – 22 infertile men with idiopathic asthenozoospermia. Coenzyme Q10 - 100 mg for 6 months A significant increase was also found in sperm cell motility Conclusion: The exogenous administration of CoQ(10) may play a positive role in the treatment of asthenozoospermia. This is probably the result of its role in mitochondrial bioenergetics and its antioxidant properties. Fertil Steril. 2004 Jan;81(1):93-8. Coenzyme Q10: Clinical Trials 12

13. Lewin et al. showed that Coenzyme Q10 results in improvement in sperm functions in asthenospermic men Mol Aspects Med 1997;18 S213-S219. 13

14. Carnitine Trimethylated aminoacid -ester Synthesized in liver, brain, and kidney from dietary amino acids-methylationof lysine Most derived from diet: red meat, fish and dairy products 14

15. L- Carnitine The main function of L-Carnitine in the epididymis is to provide an energetic substrate for spermatozoa. May be involved in the successful maturation of sperm. L-Carnitine is necessary for transport of fatty acids into the mitochondria to produce energy. Low levels of L-Carnitine reduces fatty acid concentrations within the mitochondria, leading to decreased sperm motility Drugs 1987;34:1-24. Arch Ital Urol Nefrol Androl 1992;64:187-196. 15

16. L-Carnitine Significantly high levels of free L-Carnitine is observed in the seminal plasma of the fertile men compared to the infertile men. The level of free L-Carnitine in the semen has positive correlation with sperm concentration, sperm motility and vitality of sperm cells L-Carnitine provides readily available energy for use by spermatozoa, which positively affects sperm motility, maturation and the spermatogenesis process. Folia Med (Plovdiv). 2005;47(1):26–30.. Zhonghua Nan Ke Xue. 2007;13(2):143–146. 16

17. L-Carnitine: Clinical Trials According to a study conducted by Costa et al. L-carnitine increased the sperm parameters drastically Andrologia.1994;26:155-159 17

18. L- Carnitine for asthenospermia with varicocele Carnitine Placebo Zhonghua Nan Ke Xue. 2004;10(9):671–672. There was significant improvement in sperm count,motility and pregnancy rates in Subfertility due to varicocele. 18

19. Use of Carnitine therapy in selected cases of male factor Subfertility: A double-blind crossover trial Patient(s): One hundred infertile patients (ages 20–40 years) with the following baseline sperm selection criteria: concentration, 10–20 X 10 6 /mL; total motility, 10%–30%; forward motility, <15%; atypical forms, <70%; velocity, 10– 30 µ/s; Interventions : L-Carnitine therapy or placebo; Duration : 4 months FERTILITY AND STERILITY VOL. 79, NO. 2, FEBRUARY 2003 19

20. Total motile sperm/mL Carnitine Placebo FERTILITY AND STERILITY VOL. 79, NO. 2, FEBRUARY 2003 20

21. L- Carnitine in idiopathic asthenozoospermia: a multicenter study. Italian Study Group on Carnitine and Male Subfertility. Andrologia 1994;26:155-159  N = 100 patients  L-carnitine  Duration - 4 months.  Percentage of motile spermatozoa increased from 26.9 ± 1.1 to 37.7 ± 1.1 %.  Total number of spermatozoa per ejaculate also increased Conclusion - Oral administration of L-Carnitine may improve sperm quality 21

22.  Lycopene is a bright red pigment and phytochemical found in tomatoes and other red fruits, water melon & guava.  Belongs to a class referred to as carotenoids which are yellow, orange, and red pigments synthesized by plants Lycopene 22

23.  Lycopene possesses superior abilities in comparison to other carotenoids.  It has the ability to quench singlet oxygen and prevent oxidative damage to other molecules.  This is because of its unique structure of: 11 conjugated double bonds and no cyclic groups Lycopene 23

24. The general mechanism by which Lycopene works is by preventing oxidative damage to sperms, which includes Damage to the cell membrane DNA molecules Lipids Proteins Lycopene has been demonstrated to be the most potent antioxidant with the ranking: lycopene > α- tocopherol > α -carotene > β- carotene > lutein. Lycopene – Biological activity 24

25. Lycopene: Clinical Trials Int Urol Nephrol. 2002;34:369–372.  A Study evaluated the effect of oral lycopene therapy in men with idiopathic Subfertility.  Lycopene - 2000 mcg, twice a day for three months  N - 30 Patients 25

26. Improvement in sperm concentration 26

27. Results Improvement in sperm concentration - 20 patients (66%) Improved motility – 16 patients (53%) Improvement in sperm morphology - 14 patients (46%) Associated with significant improvement and resulted in six pregnancies in 26 patients (23%) Conclusion - Lycopene therapy seems to have a role in the management of idiopathic male Subfertility 27

28.  Zinc is a micronutrient abundantly present in meat and seafood and serves as a cofactor for more than 80 enzymes involved in DNA multiplication and protein synthesis  Zinc deficiency is associated with decreased testosterone levels & sperm count.  Zinc levels are generally lower in infertile men with diminished sperm count  Furthermore, zinc finger proteins are implicated in the genetic expression of steroid hormone receptors*, and zinc also has anti- apoptotic ** and antioxidant properties.*** *Endocr Rev 1992 :13,129–145. **Curr Drug Targets 2003:4,323–338. ***Free Radic Biol Med 31,266–274. Zinc Rev Prat. 1993;43:146-151. Ann Nutr Metab. 1986;30:213-218. 28

29. Zinc – Clinical Trials  N - 100 men with asthenozoospermia  Two groups--250 mg twice daily zinc therapy for 3 months and no therapy.  Duration – 6 months  There was significant improvement in the sperm quality; sperm count, progressive motility, fertilizing capacity Conclusion: Zinc therapy has a role in improving sperm parameters in men with asthenozoospermia Eur J Obstet Gynecol Reprod Biol. 1998 Aug;79(2):179-84.

30. Netter et al. studied the effect of zinc supplementation on testosterone, dihydrotestosterone and sperm count. The results of the study were dramatic Zinc – Clinical Trials 37 patients were studied Testosterone and dihydrotestosterone levels increased significantly Nine wives became pregnant, six within 3 months and three within 2 months 30

31. Zinc: Clinical Trials According to study conducted by Tikkiwal et al. zinc resulted in Significant improvement in sperm count, Number of progressively motile and normal spermatozoa Normal acid phosphates activity. Indian J Physiol Pharmacol. 1987;31(1):30-34. 31

32. Clinical Trial : Analysis & Interpretation of Results First Indian randomized, double blind, placebo- controlled clinical trial of Nutraceuticals for male subfertility

34. Micronutrient Lycopene – 2.5 mg Co-Q10 – 50 mg L-Carnitine – 500 mg Zinc – 12.5 mg 34

35. Improvement in Sperm count (Million/mL) in each arm from baseline

36. Improvement in Sperm Count from Baseline

37. Improvement in Motile Sperm (%)in each arm from baseline

38. Improvement in Motile Sperms from Baseline

39. Improvement in Sperm with rapid progression: WHO A (%)

40. Change in Sperm with WHO Grade A motility

41. Improvement in Sperm with Normal Morphology

42. Reduction of Sperm with Abnormal Morphology

43. Change in Sperm with normal Morphology

44. Change in sperm with Abnormal Morphology

45. History taking

46. PDE5 inhibitors Drugs 2004; 64 (23)

47. Non-Responders to PDE5 Inhibitors Comorbidities (Diabetes, Nuropathy) Comorbidities (Diabetes, Nuropathy) Inappropriate use Inappropriate use Misdiagnosis (Pt. Having HSDD) Misdiagnosis (Pt. Having HSDD) Psychological and partner issues Psychological and partner issues World J Mens Health 2013 April 31(1): 31-35

48. Mode of action of L Arginine: REVERSAL OF ENDOTHELIAL AND ERECTILE DYSFUNCTION

49. Role of Nitric Oxide in ED Sexual Stimulation nNOS eNOS L -Arginine Nitric Oxide Guanylate Cyclase GTP GMP cGMP PDE-5 Erection GTP, guanosine triphosphate; GMP, guanosine monophosphate; cGMP, cyclic GMP; nNOS, neuronal nitric oxide synthase; eNOS endothelial nitric oxide synthase. Burnett AL. Int J Impot Res. 2004;16:S15-S19.

50. Andrology. 2013 Mar;1(2):223-8.

54. Conclusion Very few medical fields have changed as dramatically over the past decade as reproductive medicine, particularly in terms of the diagnostic and treatment strategies for male infertility. These advances include oxidative stress and male infertility. The nutraceutical theory remain the safest and most cost- effective ways of treating infertile men, and, perhaps more importantly for the couples involved, many of these techniques enable couples to conceive naturally.