What nutritional therapy is recommended for a patient with Teratozoospermia (abnormal sperm morphology) and Leukospermia (presence of white blood cells in semen)?

Nutritional Therapy for Teratozoospermia with Leukospermia

Based on current evidence, antioxidant supplementation with vitamin C (80 mg/day), vitamin E (40 mg/day), and coenzyme Q10 (120 mg/day) may be offered to patients with teratozoospermia and leukospermia, though guidelines emphasize that the clinical utility of such supplements remains questionable and evidence is insufficient to make a strong recommendation. 1, 2

Evidence-Based Approach

Guideline Recommendations on Nutritional Supplementation

The most recent guidelines provide limited support for nutritional interventions:

• The 2025 EAU guidelines and 2024 AUA/ASRM guidelines state there are insufficient data to recommend supplemental antioxidant therapies for men with abnormal semen parameters. 1, 2

• The WHO analysis (2017) concluded with low-quality evidence that supplementary oral antioxidants do not have proven efficacy for treating male infertility. 1

• Current medical guidelines do not identify specific micronutrients as recommended supplements for improving male fertility outcomes. 2

Rationale for Antioxidant Therapy Despite Limited Guidelines

The combination of teratozoospermia (abnormal sperm morphology) and leukospermia (white blood cells in semen) creates a specific clinical scenario where oxidative stress is particularly relevant:

• Leukospermia generates reactive oxygen species (ROS) that damage sperm DNA, lipids, and proteins, contributing to both morphological abnormalities and reduced fertility potential. 3

• Men with isolated teratozoospermia demonstrate significantly increased sperm DNA breaks, higher rates of apoptotic markers, and decreased seminal antioxidant capacity (reduced glutathione, glutathione S-transferase, and protein sulfhydryl groups). 3

• The presence of white blood cells amplifies oxidative stress beyond what occurs in isolated teratozoospermia alone, providing theoretical justification for antioxidant intervention. 3

Specific Antioxidant Regimen with Supporting Data

If choosing to offer antioxidant therapy, the following regimen showed clinical outcomes in research:

• Vitamin C: 80 mg/day 4
• Vitamin E: 40 mg/day 4
• Coenzyme Q10: 120 mg/day 4

This combination demonstrated significant improvements in sperm concentration and motility after 3-6 months of treatment, with 28.4% partner pregnancy rate (9.5% spontaneous). 4

Critical Caveats and Limitations

Important considerations when counseling patients:

• The pregnancy outcomes from antioxidant studies lack robust placebo-controlled design and may reflect natural variation rather than treatment effect. 1, 2

• Heterogeneity of supplement studies and lack of standardized protocols make it difficult to draw definitive conclusions about efficacy. 2

• Well-designed randomized controlled trials with primary outcomes of time to pregnancy and live births are urgently needed but currently lacking. 2

Priority Interventions Before Nutritional Supplementation

Guidelines emphasize addressing modifiable lifestyle factors first, as these have proven benefits:

• Smoking cessation 1
• Weight loss if obese (BMI >30 or morbid obesity) 1
• Physical exercise 1
• Avoidance of excessive alcohol consumption 2
• Review and modification of medications that may impair fertility 2

Monitoring and Follow-Up

If initiating antioxidant therapy:

• Repeat semen analysis at 3 months and 6 months to assess response 4
• If no improvement in semen parameters or conception after 6 months, consider discontinuation and referral for assisted reproductive technology 4
• Investigate and treat underlying causes of leukospermia (infection, inflammation) concurrently 1

When to Refer for Assisted Reproductive Technology

Patients should be counseled that:

• If conception has not occurred after 12 months of regular unprotected intercourse despite nutritional interventions, both partners require comprehensive fertility evaluation 1, 5
• Intracytoplasmic sperm injection (ICSI) may be necessary depending on severity of teratozoospermia and female partner factors 1
• Genetic testing (karyotype and Y chromosome microdeletion) should be performed if severe oligozoospermia (<5×10⁶/ml) is present 1