Improving Fertility: Evidence-Based Treatments and Lifestyle Modifications
For Male Factor Infertility
Men with infertility should prioritize weight loss if overweight/obese, smoking cessation, and discontinuation of anabolic steroids, as these have the strongest evidence for improving fertility outcomes. 1, 2
Lifestyle Modifications with Strong Evidence
- Weight loss is strongly recommended for overweight or obese men, as it can enhance sperm parameters and overall reproductive health 2
- Smoking cessation should be encouraged, though the evidence shows only a small impact on sperm concentration, motility, and morphology 1, 2
- Regular physical exercise is recommended as it can improve sperm parameters and overall health 2
- Anabolic steroid use must be discontinued immediately, as ongoing use suppresses spermatogenesis and directly interferes with fertility 1
Dietary Recommendations
- A diet lower in fats and meats with more fruits and vegetables is preferable to a higher-fat diet, though the evidence quality is low 1, 3
- Current data on specific dietary supplements (including trace minerals like boron) remain limited, and the focus should remain on proven risk factors 3
Supplement Considerations
- Antioxidant therapy may improve sperm parameters in men with idiopathic infertility, though evidence for improving live birth rates remains conflicting and of low quality 2
- Prebiotic/probiotic supplementation showed significant improvements in sperm concentration, motility, normal morphology, and DNA integrity in one RCT of 56 men with idiopathic infertility 2
- Any intervention requires at least 74 days (approximately 2.5 months) to show full effects, as this is the duration of spermatogenesis 2
Critical Hormonal Considerations
- Testosterone therapy is absolutely contraindicated in men seeking fertility, as it suppresses spermatogenesis 2
- For men with secondary hypogonadism seeking fertility, gonadotropin therapy (hCG with or without FSH) is recommended rather than testosterone replacement 2
- Hormonal evaluation including FSH and testosterone should be obtained for infertile men with impaired libido, erectile dysfunction, or oligozoospermia 1
When to Pursue Advanced Treatment
- For men with severe oligoasthenoteratozoospermia (OAT) syndrome, assisted reproductive technology may be more effective than supplements alone 2
- Underlying conditions such as varicocele, accessory gland infections, and hormonal imbalances should be treated, as they may impact fertility outcomes 2
For Female Factor Infertility
Ovulatory Dysfunction Treatment
For women with ovulatory dysfunction desiring pregnancy, clomiphene citrate is the FDA-approved first-line treatment, starting at 50 mg daily for 5 days. 4
- Treatment should begin on or about the 5th day of the cycle, with coitus timed to coincide with expected ovulation 5-10 days after completing the course 4
- If ovulation does not occur after the first course, increase to 100 mg daily for 5 days 4
- If three ovulatory responses occur without pregnancy, or if ovulation does not occur after three courses, further clomiphene treatment is not recommended 4
- Long-term cyclic therapy should not exceed approximately six cycles total (including three ovulatory cycles) 4
Lifestyle Modifications for Women with PCOS
- Behavioral interventions combined with diet and exercise show efficacy for weight loss in women with PCOS, with significant reductions in weight (MD -7.00%) 1
- A multidisciplinary model of care with a dietitian, health psychologist, gynecologist, and endocrinologist enhanced weight loss when combined with dietary consultation 1
- Weight loss interventions showed improvements in anthropometric measures, though fertility outcomes such as pregnancy, live birth, and miscarriage were not consistently reported in studies 1
Dietary Considerations for Women
- Higher intake of monounsaturated fatty acids, fruits, vegetables, plant-based proteins, nonheme iron, and high-fat dairy is recommended to improve fertility 5
- Reduce intake of trans fatty acids and high glycemic index carbohydrates 5
- Multivitamin supplementation containing folic acid and iron is advised 5
For Unexplained Infertility (Couples)
For couples with unexplained infertility and men with total motile sperm count >10 million, at least three cycles of intrauterine insemination with ovarian stimulation (IUI-OS) is the most effective first-line option. 1
- The gradient technique for semen preparation showed significantly higher ongoing pregnancy rates (23.4% vs 10.7%) compared to swim-up technique in couples with unexplained infertility 1
- Both partners should be evaluated simultaneously, as 50% of infertility cases involve male factors, often combined with female factors 6
Common Pitfalls to Avoid
- Never base clinical decisions on a single abnormal semen analysis; at least two abnormal tests are required before proceeding with further andrological investigation 6
- Do not prescribe testosterone to men seeking fertility, as this is the most common and devastating error in male fertility management 2
- Ensure adequate diagnostic evaluation before starting treatment, including exclusion of pregnancy, ovarian cysts, and abnormal vaginal bleeding in women 4
- Recognize that evidence quality for most supplements and dietary interventions is low, with many studies having methodological limitations 2, 7
- Address psychological stress, as the diagnosis of infertility and subsequent treatments are stressful for both partners; methods such as yoga and cognitive behavioral therapy may be beneficial 7, 8