The value of multi-vitamins and anti-oxidants in the treatment of male factor infertility is a grey area.

In this study Prof Minhas and an expert team from Europe have highlighted that there is some evidence that medical and nutritional supplements eg multi-vitamins may improve semen parameters, although the evidence that anti-oxidant therapy leads to an increase live birth rates, spontaneous pregnancy, or pregnancy following assisted-reproductive techniques is limited. There seem to be several medical and nutritional treatments, such as pentoxyfylline, coenzyme Q10, L-carnitine, follicle-stimulating hormone, tamoxifen and kallikrein, that appear to improve semen parameters, but the studies have a risk of moderate or high bias. 

Opinion: The potential benefits of nutritional supplements or anti-oxidants seems to outweigh any harmful effects and therefore it would be reasonable to consider starting supplements if you have fertility problems.

Professor Minhas is Co-chair of the European Association of Urology Guidelines on male sexual and reproductive health. Working with colleagues from around the world, the group has extensively analysed studies from the scientific literature on male infertility and other Men's health problems and can be found here.

A summary of the section on male fertility has provided specific recommendations on male infertility and can be summarised as follows:

1. When to perform sperm DNA fragmentation testing and its applications and limitations.

2. Highlighted the importance of taking a history, examining and investigating all men with infertility. Tests may include performing Ultrasound scanning of the testicles, evaluation for infections, hormone blood tests and genetic testing. 

3. Highlighted that varicoceles are an important cause of male infertility and treatment can also be considered in men with raised sperm DNA fragmentation.

4. Highlighted that the optimum sperm retrieval technique in men with non obstructive azoospermia (no sperm) should be either a conventional TESE or microdissection testicular sperm extraction. 

5. When evaluating the couple for male factor infertility and deciding on treatment, it is important to take into account the female partners age at all times and their ovarian reserve.

In this paper, we give an update on the management of men with no sperm in the ejaculate or non obstructive azoospermia.

Prof Minhas and his colleagues highlight the types of surgery available and potential future treatments that are emerging. We also discuss the limitations of optimising treatment prior to micro dissection testicular sperm extraction including varicocele treatment and hormonal stimulation including hCG and SERM before surgery.

Prof Minhas prefers to perform microdissection testicular sperm extraction in men with non obstructive azoospermia (NOA). He has almost 20 years experience of this technique and is one of the only surgeons in the UK who has published his outcomes of sperm retrieval rates and live rates after surgery. In a series of papers, he and his team confirm sperm retrieval rates of between 45-55% in men with NOA. In this paper, his team also provide data on ICSI outcomes, which very few clinics do. 

His previous research has also verified that using frozen sperm in men with NOA is just as good in terms of live birth rates compared to fresh sperm.

In this research paper, Prof Minhas and his team at Imperial highlight the importance of the bacteria in the seminal fluid or the so called semen microbiome. In men this is very varied in both fertile and infertile men. In this study Prof Minhas and his team show that bacteria in the seminal fluid appears to negatively impact on sperm concentration, progressive motility, and DNA fragmentation index.

In particular an organism called Ureaplasma urealyticum negatively impacts on sperm concentration and morphology, Enterococcus faecalis negatively impacts on total motility, and Mycoplasma hominis negatively affects concentration, progressive motility and morphology. This study highlights the importance the male seminal fluid and bacteria within it, on male fertility and the value of screening.

About 10-30% of men with non obstructive azoospermia will have low testosterone. This can be associated with either raised FSH (the hormone that stimulates sperm production from the testis) or normal FSH. If the FSH is raised this is termed hypergonadotrophic hypogonadism and simply means that the pituitary gland where FSH is produced is having to work the testis harder. If the FSH is normal then this is termed normogonadtrophic hypogonadism. Sometimes the FSH can be low and the testosterone low, a specific condition called hypogonadotrophic hypogonadism. 

In men who have NOA, many Urologists will use drugs such as Clomid or hCG to increase testosterone prior to testicular sperm extraction or TESE. The hope is that a 3-6 month treatment may increase the chances of finding sperm at the time of TESE.

However, in this recent research or meta-analysis, Prof Minhas and his international colleagues have demonstrated no beneficial effects of taking hormone therapy before sperm extraction in men with raised testosterone and high FSH. Although, they do stress that more studies are needed to confirm these results.