What interventions and lifestyle modifications are recommended to increase sperm count and quality in a male patient of reproductive age prior to sperm analysis?

Optimizing Sperm Count and Quality Prior to Analysis

Men should implement lifestyle modifications including weight loss, smoking cessation, regular exercise, and adoption of a Mediterranean-style diet rich in fruits, vegetables, whole grains, seafood, and nuts while avoiding processed meats, sweets, and sugar-sweetened beverages for at least 3 months before sperm analysis. 1

Lifestyle Modifications (Highest Priority)

Weight Management and Exercise

• Achieve and maintain a BMI between 18.5-25 kg/m², as obesity impairs spermatogenesis through disruption of the hypothalamic-pituitary-gonadal axis 1, 2
• Engage in regular physical exercise, which has been shown to enhance sperm parameters independently of weight loss 1
• Weight loss in overweight/obese men improves sperm concentration, motility, and morphology 1

Smoking and Substance Cessation

• Complete smoking cessation is essential, as tobacco use significantly impairs sperm parameters and DNA integrity 1
• Avoid all recreational drugs including marijuana and electronic cigarettes, which are detrimental to male reproductive health 3
• Eliminate anabolic steroid use completely, as these suppress spermatogenesis through negative feedback and can cause azoospermia requiring months to years for recovery 2, 4

Thermal Exposure

• Avoid hot tubs, saunas, and prolonged heat exposure to the genital area, as elevated scrotal temperature damages spermatogenesis 2, 4
• Minimize laptop use on the lap and avoid tight-fitting underwear 4

Dietary Interventions

Mediterranean Diet Pattern (Strongest Evidence)

• Adopt a Mediterranean-style diet emphasizing fruits, vegetables, whole grains, nuts, low-fat dairy, fish, and seafood 1, 3, 5, 6
• This dietary pattern shows the strongest correlation with improved sperm concentration, motility, morphology, and reduced DNA fragmentation 6
• Higher Mediterranean Diet adherence scores are positively correlated with semen parameters and negatively correlated with FSH and LH levels 6

Foods to Emphasize

• Fish, shellfish, and seafood (rich in omega-3 fatty acids) 7, 5, 8
• Poultry as the primary protein source 5, 8
• Vegetables and fruits (high in antioxidants including vitamin C, vitamin E, β-carotene, lycopene, and cryptoxanthin) 7, 5
• Nuts and seeds (sources of selenium, zinc, and vitamin E) 3, 7
• Whole-grain cereals 5, 8
• Low-fat dairy and skimmed milk 5, 8

Foods to Avoid or Minimize

• Eliminate ultra-processed foods (UPFs), which are strongly correlated with poor sperm parameters including reduced viability and abnormal morphology 6
• Avoid processed meats and limit red meat consumption 3, 5
• Minimize sugar-sweetened beverages and sweets 3, 5
• Reduce full-fat dairy and cheese intake 5
• Limit soy food consumption 5

Alcohol and Caffeine

• Limit alcohol to low-to-moderate intake ranges, as excessive consumption negatively affects fecundability 1, 3, 5
• Restrict caffeine to less than 5 cups per day (approximately 500mg), though moderate intake does not appear detrimental to semen quality 2, 3

Nutritional Supplementation

Antioxidant Therapy (Conditional Recommendation)

• Consider antioxidant supplementation, though evidence remains conflicting and quality is low 1
• When high-risk-of-bias studies are removed from meta-analyses, the benefit on live birth rates becomes uncertain 1
• Specific antioxidants with some supporting evidence include vitamin E, vitamin C, selenium, zinc, coenzyme Q10, and carnitine 7, 5

Prebiotic/Probiotic Supplementation

• May consider prebiotic/probiotic compounds, as one RCT showed significant improvements in sperm concentration, motility, morphology, and DNA integrity 1
• Further high-powered RCTs are needed before definitive recommendations can be made 1

Folic Acid

• Men should consume folate-rich foods as part of a balanced diet 1

Critical Medications to Avoid

Testosterone and Hormonal Agents

• Never use exogenous testosterone or testosterone replacement therapy if fertility is desired, as it completely suppresses spermatogenesis through negative feedback on the hypothalamus and pituitary, potentially causing azoospermia 2, 4, 9
• Recovery from testosterone-induced azoospermia can take months to years 2, 4

Hormonal Treatments (Limited Evidence)

• Selective estrogen receptor modulators (SERMs) and aromatase inhibitors have been studied for idiopathic infertility but evidence quality is low and most studies lack placebo controls 1
• These agents are not FDA-approved for male infertility and benefits are limited 2, 9

Timeline for Optimization

• Implement all lifestyle and dietary modifications for a minimum of 3 months before sperm analysis, as the spermatogenic cycle requires approximately 74 days 4
• Repeat semen analysis at least 1 month after initial testing to account for biological variability 4

Screening for Underlying Health Conditions

Cardiovascular and Metabolic Assessment

• Screen for modifiable cardiovascular risk factors including hypertension, diabetes, and dyslipidemia, as infertile men have higher rates of cardiometabolic disorders and increased mortality compared to fertile controls 1
• This urological assessment represents an opportunity to target occult early-stage disease and potentially improve life expectancy 1

Contraception and Sexual Health

• Men should be counseled on contraception when pregnancy is not desired and on overcoming fertility issues when conception is planned 1
• Partners of men with suspected sexually transmitted infections should be referred for evaluation and treatment 1

Common Pitfalls to Avoid

• Do not assume a single semen analysis is sufficient—biological variability requires at least two analyses separated by 2-3 months 4, 9
• Do not initiate empiric antioxidant therapy without discussing that evidence for live birth improvement is weak and inconsistent 1
• Do not recommend nutritional supplements as a substitute for comprehensive dietary pattern changes, which have stronger evidence 3, 6
• Avoid recommending isolated nutrient supplementation when the patient's overall dietary pattern remains poor 6