Khivan Oberoi, ND
Exploring the clinical complexities of male infertility and the impact of lifestyle, environmental, and naturopathic interventions on reproductive outcomes — with real-world case examples that demonstrate how integrative care can optimize fertility before advanced reproductive technologies are required.
Abstract
This article by Khivan Oberoi, ND examines the multifactorial nature of male factor infertility, highlighting often-overlooked contributors such as oxidative stress, DNA fragmentation, and lifestyle factors. Through two detailed case studies, Dr. Oberoi illustrates how naturopathic interventions — including dietary optimization, antioxidant support, and substance cessation — can significantly improve sperm parameters and reduce the need for invasive reproductive procedures.
Male factor infertility is a significant contributor to reproductive challenges, accounting for nearly 40% of all infertility cases, either as a sole factor or in combination with female factors [1]. As advancements in diagnostic and therapeutic approaches continue to evolve, understanding the nuances of male reproductive health has become essential for medical professionals managing couples facing infertility. The pathophysiology of common male factor infertility diagnoses encompasses a broad spectrum, including endocrine disruptions, genetic abnormalities, and anatomical abnormalities each impacting spermatogenesis, sperm quality, and overall reproductive outcomes.
In clinical practice, the complexity of male infertility is often underappreciated, with conventional evaluations frequently overlooking subtle but impactful factors such as oxidative stress, DNA fragmentation, and immunological responses. For general practice and primary care providers, the reflexive response to any male factor infertility concerns is to refer immediately to urology and while that is a valuable referral, much can be offered to these patients as they wait to be seen by specialists.
The aim of this article is to share a case series of complicated male factor fertility situations and share Naturopathic considerations with the goal of patients looking to grow their families and conceiving biological children with minimal use of Advanced Reproductive Technology.
Case 1:
A 36 yo AFAB (assigned female at birth) and 37 yo AMAB (assigned male at birth) presenting after In Vitro Fertilization cycle that resulted in 26 eggs, 13 of which fertilized and 5 embryos that developed to Day 5 blastocyst. All blastocysts were sent for preimplantation genetic testing and one embryo was determined to be genetically compatible with life. A frozen embryo transfer of that genetically healthy embryo failed and the couple was evaluating the next steps that would help improve future fertility outcomes.
While the female presenting partner had a diagnosis of Polycystic Ovarian Syndrome, given that both partners had normal genetic karyotype screenings, male factor infertility and abnormalities of the sperm became my predominant concern given the dramatic attrition from the number of fertilized eggs to the final, single, genetically healthy embryo.
Upon discussion, I came to learn that the male partner’s initial semen analysis at the reproductive endocrinology facility had been abnormal with a sperm count of progressive motile sperm to be <0.2ml. The provider there determined that proceeding with the egg retrieval via TESE (Testicular Sperm Extraction) would be done the day of retrieval unless the sperm count had improved sufficiently, after the female partner had completed approximately 10 days of injectable hormonal stimulation. During the time between the initial and repeat semen analysis, both patients adjusted their diet and the male patient reportedly lost 20 lbs. The patients reported the semen analysis on the day of egg retrieval was sufficiently improved so TESE was not required, and they proceeded with the egg retrieval and completed fertilization with that sample.
After the failed transfer, the male patient was referred to urology for testing. The testicular ultrasound found bilateral dilated seminal vesicles but a follow up pelvic MRI was essentially normal indicating possible mild BPH, all hormonal testing was WNL Estradiol 22.9, Total Testosterone 309, FSH 6.4, LH 3.7. The patient was then discharged from urology care.
In my visit with the male patient, he shared his history of alcohol, marijuana use for many years and more recent cocaine use in the year prior to starting IVF. During the time between the first and second semen analyses, he reported that he had stopped using cocaine but was and has continued to drink 3-4x/week, having 5-6 beers or 2-3 cocktails a week and smokes marijuana nightly. In reviewing records from urology and reproductive endocrinology, I saw no documentation of substance use. The patient also traveled frequently for work and his diet consisted of primarily fast food with rare intake of fruits and vegetables, and coffee, Gatorade and diet soda as his primary beverages.
Given his extensive physical examination and imaging and generally normal hormonal evaluation, I determined the abnormalities in his semen analyses were likely due to substance use and dietary insufficiency of antioxidants, vitamins, and minerals. We had a prolonged discussion about the possibilities of him changing these lifestyle habits, ideally having no alcohol or marijuana for at minimum 3 months prior to pursuing conception to allow for gamete development and then doing a repeat semen analysis to assess the impact of such changes. The patient reported he was willing and able to make such changes.
The patient’s repeat semen analysis was unsuccessful due to spillage, but the microscopy comments included “71 immotile sperm observed in microcell, 1 rapid, 2 slow and 9 non-progressive”. While incomplete, this sample likely reflects persistent abnormalities in the genetic health of the developing gametes. The patient did not respond to requests to schedule follow up testing and visits so I cannot make direct conclusions regarding any changes he did or did not make in his lifestyle behaviors.
My main takeaway from this case was the profound negative impact that environmental factors can have on gamete development, even in the absence of genetic, anatomical, or physiological issues. Advising couples who are planning to conceive to avoid substance use goes beyond simply ‘optimizing fertility.’ It plays a crucial role in preventing miscarriage, reducing IVF failures, and averting significant emotional trauma.
Case 2:
35 yo AMAB and 27 yo AFAB presenting after two failed Intrauterine Insemination (IUI) trials to discuss optimizing baseline health to improve future trials of IUI. This couple required the use of assisted reproductive technology to conceive a biological child due the male partner’s history of a spinal cord injury that prevented erectile and ejaculatory function. They had worked with a fertility clinic that recommended the use of penile vibratory stimulation (PVS) and/or electroejaculation (EEJ) to acquire semen samples that would then be used for IUI.
Fortunately, the male partner’s semen analysis was within normal limits. It is common amongst males with spinal cord injuries for sperm counts to be normal while sperm motility and viability are often abnormal [2]. However, given the lack of success with prior IUIs, the couple was considering whether to pursue another round of PVS/EEJ, or proceed with a surgical technique for sperm extraction. Both Microsurgical Epididymis Sperm Aspiration (MESA) and Testicular Sperm Extraction (TESE) are used as alternative options for accessing sperm either from the epididymis or the testicles directly [2,3]. Both are minor surgical techniques done with local anesthesia and can be used in a variety of male infertility cases, usually in combination with ICSI (intracytoplasmic sperm injection) where very small numbers of sperm can be used for successful fertilization. Given the patient had a normal semen analysis, his fertility team theorized they would be able to access a sufficient semen sample for IUI.
This couple had been optimistic in their chances for conceiving via IUI and now found themselves considering more invasive procedures and potentially even proceeding to IVF, indicating fertility treatment for the female partner. This was a challenging situation both morally and financially for this couple.
After their initial visit and reviewing the previous semen sample, I suggested three months of fertility optimization for both partners, especially given the female partner’s recently diagnosed subclinical hypothyroidism. I recommended dietary modifications to increase micronutrient dense food intake, eliminating alcohol use and adding zinc, L-carnitine and CoQ 10 as supplements for the male partner.
In comparing the semen analysis from the initial IUI to the semen analysis 3 months later, we observed improvements in a variety of parameters: Total sperm count increased from 16.1 million to 54.5 million, post-wash sperm counts increased from 33 million to 119 million and motility increased from 7% to 19.1%. Given these outcomes and the reality of having sufficient samples to allow for multiple IUIs (and the normalization of the female partner’s TSH level with medication), they opted to proceed with 2-3 more rounds of IUI before reconsidering proceeding with further assisted reproductive technology intervention.
Conclusion
In conclusion, addressing male factor infertility requires a comprehensive and individualized approach that considers lifestyle, environmental factors, and medical interventions. As demonstrated in these cases, the role of lifestyle changes—such as reducing or eliminating substance use and enhancing dietary habits—can be crucial in improving sperm quality and overall reproductive outcomes. These adjustments not only provide immediate support to patients navigating infertility but also contribute to long-term enhancements of overall health. For many patients, even subtle changes can have significant impacts on gamete quality, thus increasing the chances of achieving conception with minimal reliance on invasive reproductive technologies.
The cases also highlight the need for a collaborative approach that includes both conventional and integrative perspectives. By emphasizing lifestyle optimization and working closely with each patient’s unique needs, practitioners can create a pathway toward achieving conception that is less reliant on advanced reproductive interventions and more focused on sustainable health practices that support both partners.
Khivan Oberoi, ND, knew from childhood that she wanted to practice naturopathic medicine, empowering people to care for their bodies and heal as naturally as possible. Her own eight year fertility journey, culminating in the birth of her daughter with the support of a dedicated care team, deepened her commitment to whole person, family centered care. Dr. Oberoi’s purpose is to ensure patients feel heard, respected, and supported as they navigate their own paths to growing their families. A longtime Oregon resident, she balances her clinical work with a love of travel and time outdoors, and can just as often be found hiking Pacific Northwest trails as reading a good book on a rainy afternoon.
References:
- Leslie SW, Soon-Sutton TL, Khan MAB. Male Infertility. [Updated 2024 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562258/
- Patki, Prasad, et al. “Effects of Spinal Cord Injury on Semen Parameters.” The Journal of Spinal Cord Medicine, vol. 31, no. 1, 2008, p. 27. pmc.ncbi.nlm.nih.gov, https://doi.org/10.1080/10790268.2008.11753977.
- Anderson, Ross, et al. “Spinal Cord Injury and Male Infertility—a Review of Current Literature, Knowledge Gaps, and Future Research.” Translational Andrology and Urology, vol. 7, no. Suppl 3, July 2018, p. S373. pmc.ncbi.nlm.nih.gov, https://doi.org/10.21037/tau.2018.04.12.
- Buhling, Kai, et al. “Influence of Oral Vitamin and Mineral Supplementation on Male Infertility: A Meta-Analysis and Systematic Review.” Reproductive Biomedicine Online, vol. 39, no. 2, Aug. 2019, pp. 269–79. PubMed, https://doi.org/10.1016/j.rbmo.2019.03.099.