SEXUAL DYSFUNCTION AND INFERTILITY Comparing the Effectiveness of Dietary Vitamin C and Exercise Interven- tions on Fertility Parameters in Normal Obese Men Bahare Rafiee,1,2 Mohammad Hossein Morowvat,1* Nasrin Rahimi-Ghalati3 Purpose: Comparing the effectiveness of dietary vitamin C and weight loss exercises interventions for weight loss on semen characteristics in normal obese man. Materials and Methods: A total number of 200 men were randomly allocated into two groups based on body mass index, exercise and vitamin C groups. Also, 50 men with normal spermogram were placed in a control group. In exercise group, a 6 months intensive exercise program was designed under a coach’s supervision to reduce the body weight. In vitamin C group, 1,000 mg of vitamin C were given every other day as supplement. Results: Weight loss increased the volume of semen in participants with 25-30 (P = .02) and more than 30 body mass index (P = .001). The increased concentration of sperm per mL of semen in body mass index (BMI) 25-30 group (P = .01) and more than 30 (P = .003) BMI was significant. Improving sperm motility after two hours in participants with more than 30 (P = .01) BMI was significant. In vitamin C group, the improvement of sperm concentration in participants who had less than 25 (P = .01), between 25 and 30 (P = .01), more than 30 (P = .02) BMI was significant. Sperm motility improved in all three groups (P = .001, P = .02 and P = .003, respectively). Conclusion: Weight loss can significantly increase semen volume, its concentration, its mobility and percentage of normal morphology. Consuming vitamin C significantly improves sperm concentration and mobility, but the semen volume and the percentage of normal morphology will not change significantly. Keywords: ascorbic acid; administration; fertility; physiology; humans; nutritional requirements; population con- trol; fertility; drug effects; infertility; male. INTRODUCTION International Committee for Monitoring Assisted Re-productive Technology (ICMART) and the World Health Organization (WHO) guidelines, have defined the infertility as not becoming pregnant after one year sexual intercourse without protection due to the repro- ductive systems disease.(1) The regular rate of fecundi- ty is 85-80% after 12 months.(2) About 15% of couples suffer infertility of which 25-50% is contributed to male factor.(3) Pathology of male factors can be categorized into three groups. First are the pre-testicular factors. They include hypogonadism; hypothyroidism; follicle-stimulating hormone reducing drugs including spironolactone and cimetidine, and nitrofurantoin that decreases sperm motility; aberrant life style (cigarette smoking, chron- ic alcoholism, marijuana); and vigorous activities like energetic bicycle riding.(4,5) Second are testicular fac- tors. They include age, neoplasm e.g. seminoma, cryp- torchidism, varicocele which account for 14%, mumps viral infection, Klinefelter syndrome and idiopathic fac- tors which account for 30 % of male infertility.(6,7) Third are the post-testicular factors, including: impotence, vas deferens obstruction, lack of vas deferens, infection such as prostatitis, ejaculatory duct obstruction and hy- pospadias.(8) WHO has depicted the normal semen analysis chart, ac- cording to which the semen volume is the total amount of fluid ejaculated that should be ≥1.5 mL. Sperm concentration (commonly known as ‘sperm count’) is regarded as the total number of sperm in a measured volume of an ejaculation. The sperm concentration is reported as the number of sperm per mL of semen that should be ≥15 million per mL. Total sperm num- ber (also known as ‘total sperm count’) is described as the total number of sperm in the ejaculate, calculated by multiplying the semen volume by the sperm that should be ≥ 39 million. Sperm motility (i.e. swimming 1 Pharmaceutical Sciences Research Center, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran. 2 Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran. 3 Bagherian Industrial School, Ministry of Education and Training, Shiraz, Iran. Correspondence: Pharmaceutical Sciences Research Center, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran. Tel: +98 71 32426729. E-mail: mhmorowvat@sums.ac.ir. Received November 2015 & Accepted February 2016 Sexual Dysfunction and Infertility 2635 Vol 13 No 02 March-April 2016 2636 or movability of sperm) or the number of motile (mov- ing) sperm is compared with the number of non-motile sperm and is expressed as the percentage of the total number of sperm that should be ≥ 40% motile within 60 minutes of ejaculation. Sperm vitality (‘live’ sperm) that is the number of sperms in the sample which are ‘alive’ is a percentage of the total number of sperms that should be ≥ 58%. Sperm morphology (the shape of the sperm) that is de- fined as the number of ideally formed sperms (defined as ‘normal’) is compared to the number of incorrect- ly shaped sperms (normally defined as ‘abnormal’). It is described as the percentage of the total number of sperms that should be ≥ 4%. White blood cell count rou- tinely occurs in semen. Huge amounts of white blood cells in the ejaculate can be defined as an infection of the reproductive tract. However, in some men it hap- pens for no known reason. This factor should be < 1 million per mL. Semen pH is measured to test if the ejaculate is alkaline or acidic. Semen should be slightly alkaline. More acidic semen, along with a low amount of semen, can be a sign of possible blockage in the flow of semen. Its pH should be ≥ 7.2.(2) Male germ cells are prone to produce ROS (reactive ox- ygen species) in different levels of development such as the acrosomal reaction and fusion of sperm and oocyte. Reactive oxygen species will be deactivated by exist- ing antioxidants (vitamins C and E) in semen.(9) Oxi- dative stress happens when either the level of reactive oxygen species is high or antioxidants defects occur.(10) Increased levels of ROS will reduce the sperm motili- ty.(11,12) Nowadays different techniques are designed to determine the level of spermatozoal DNA destruction caused by oxidative stress. A reliable one is measuring of 8-hydroxy-dioxy guanosine biomarker.(13) Obesity could intensify the risk of infertility in men. El- evated body mass index (BMI) reduces the total amount of sperm and increases the DNA damage in sperms.(14) Calorie limiting diet would improve testicular gene ex- pression in immature rhesus.(15) The reduction of body fat mass causes hypothalamic-pituitary-testicular fit- ness and increases in the production of testosterone in infertile men.(16) In humans, reducing calorie intake im- proves gene expression in epididymis (post testicular) and sperm maturation instead.(17) This study compared the effectiveness of exercise inter- ventions for reducing BMI and vitamin C on male fer- tility parameters (semen volume, sperm concentration, motility and normal morphology). MATERIALS AND METHODS This interventional study was conducted on 200 men who were referred to private clinics. They were 20 to 60 years old, did not have varicocele and chronic dis- eases history and used certain medications prescribed by the private clinics. Their medical history including age, blood group, familial, medical, and sexual histo- ry, lifestyle, personal consent, intercourse frequency per month, drinking alcohol, using certain medications, smoking habits, chronic diseases and personal sexual satisfaction was documented. Men with diabetes, hy- pertension, mumps history, sexually transmitted diseas- es and varicoceles were excluded from the study. The participants were randomly allocated into two groups based on BMI and also, 50 men of both groups with normal spermogram were placed in the control group. In both groups, men with a BMI of 30 to 35 were placed in group 1st group, those with a BMI of 25 to 30 in the 2nd group and those with a BMI less than 25 in 3rd group. In the exercise group, a six-month daily inten- sive exercise program was designed under a couch’s supervision to reduce weight. In the vitamin C group, 1,000 mg of vitamin C were given every other day as supplement. Semen Sampling Method Semen samples were collected once, at the beginning of study and at the end of the intervention. Sperm samples were taken by masturbation after 3-5 days of sexual ab- stinence and kept in a plastic container. Then it was in- cubated at 37°C for 30 minutes and was analyzed after one hour. The sperms were counted by light microscope with a magnification of 400. Different characteristics of semen including the appearance, size; pH, color, viscosity, liq- uefaction time, concentration and sperm motility were Table 1. Semen parameters based on the body mass index before the 6-month exercise intervention. BMI, kg/m2 Volume, mL Concentration (million/mL) Motility, % Morphology, % Control 3.54 ± 3.45 63.2 ± 1.24 67 55 < 25 3.12 ± 2.21 62.5 ± 2.2 62.2 51.2 25-30 2.64 ± 3.15 48.5 ± 1.95 51 40.2 31-35 1.8 ± 2.95 35.3 ± 2.11 45 28.2 Abbreviation: BMI, Body Mass Index. Dietary vitamin C and Exercise on Fertility Parameters-Rafiee et al. investigated. Statistical analysis was done by Statisti- cal Package for the Social Science (SPSS Inc, Chicago, Illinois, USA) version 16.0. P value significance was less than .05 and confidence interval was at 95%. Paired t-test was used to compare the results before and after interventions. RESULTS The participants’ mean age was 35.2 years old. In exer- cise intervention group, the average of weight loss was 3.2 kg in the control group, 4 kg in men with a BMI less than 25, 6.1 kg in people with a BMI of 25 to 30 and 8.5 kg in those with BMI more than 30. The increase in semen volume of those with 25-30 (P = .02) and more than 30 BMI (P = .001) was significant (Table 1). The increased concentration of sperm per mL of semen in those with 25-30 (P = .01) and more than 30 (P = .003) BMI was also significant. Improving sperm motility af- ter two hours in men with more than 30 BMI (P = .01) was significant. The increase in normal sperm morphol- ogies in men with less than 25 (P = .02), 25 to 30 (P = .001) and more than 30 (P = .01) BMI were significant (Table 2). In vitamin C group, the average semen volume did not change significantly (Table 3). However, the improve- ment of sperm concentration in men less than 25 (P = .01), 25 to 30 (P = .01), more than 30 (P = .02) BMI was were significant. Sperm motility increased in all three groups (P = .001), (P = .02) and (P = .003). The percentage of sperm with normal morphology was not significant (Table 4). DISCUSSION According to the results of this study, decreasing the body mass index can improve volume, concentration, motility and normal morphology of the sperm. Con- sumption of vitamin C can also improve of sperm con- centration and motility. These findings are similar to findings of Dawson and colleagues which was done on infertile smokers. Their patients were given 1 gram per day of vitamin C and a high dosage regimen. They showed that diet improves fertility parameters.(18) In another study on 97 fertile men, Eskenazi and col- leagues found out that consuming vitamin C can in- crease sperm concentration and motility.(19) However, a study that was done by Kessopoulou and colleagues showed that antioxidants, particularly vitamin E cannot affect sperm quality for eight weeks.(20) They stated that in this study the time for improvement of fertility pa- rameters was too short in their study. Regarding physiological aspect, antioxidants may pro- tect germ cells from oxidative damage.(21) Oxidative damage is associated with reduction of sperm mobility and capacity of oocytes-sperms fusion.(22) After facing with reactive oxygen species, sperm membrane will be rigid and cause fracture and damage in cell membrane. Treatment with antioxidants can prevent the sperm membrane from lipoproxidation damages.(23) Treatment with antioxidants also prevents the sperm DNA damage and mutation.(24) Obesity is a health problem that is related to male in- fertility and abnormal fertility parameters.(25) Jensen and colleagues reported the semen analysis is abnor- mal in obese men and, the prevalence of oligospermia Table 2. Semen parameters in men according to body mass index after six months of exercise interventions. BMI, kg/m2 Volume Concentration (million/mL) Motility, % Morphology, % P Valuea P Valueb P Valuec P Valued Control 3.6 ± 3.11 65.5 ± 2.21 65 65 .1 .2 NS NS < 25 3.10 ± 2.25 63.3 ± 3.11 63.1 61 .5 .3 NS .02 25-30 3.52 ± 3.51 55.8 ± 2.13 55.8 58.1 .02 .01 NS .001 31-35 2.85 ± 3.1 48.9 ± 3.11 54.1 35 .001 .003 .01 .01 Abbreviations: BMI, Body Mass Index; NS, not significant. a P value for semen volume, b P value for sperm concentration, c P value for sperm motility, d P value for sperm morphology. BMI, kg/m2 Volume Concentration (million/mL) Motility, % Morphology, % Control 3.82 ± 3.26 64.5 ± 1.75 61.1 58 < 25 3.51 ± 4.12 61 ± 2.32 65.12 52.8 25-30 2.15 ± 3.62 45.2 ± 1.3 48.32 40.5 31-35 2.5 ± 3.16 40.1 ± 2.12 38.3 35.1 Abbreviation: BMI, Body Mass Index. Table 3. Semen parameters in men according to body mass index before taking vitamin C. Dietary vitamin C and Exercise on Fertility Parameters-Rafiee et al. Sexual Dysfunction and Infertility 2637 Vol 13 No 02 March-April 2016 2638 is more, compared to men with normal BMI.(16) Kort and colleagues noted that increase in BMI is negatively linked with number of normal sperm, sperm concen- tration, motility and serum testosterone levels. This is consistent with the results of our study.(14) Studies show that weight loss can improve the quality of semen pa- rameters leading to more fertility.(26) Although obesity is associated with a reduced number of intercourse as well as erection dysfunction(27) it seems that a hormone deficiency is at the beginning of this vicious cycle that causes the disorder in semen parameters.(28) This would be interesting topic to evaluate the pathologic effects of obesity on sexual desire and erection dysfunction. Moreover, other food regimen or supplements as major nutritional factor, could be examined for enhancing the sperm motility. CONCLUSIONS The study was designed to assess of the relationship be- tween weight loss interventions and semen parameters. It also investigated the influence of oral vitamin C, as an antioxidant on semen quality. Weight loss can cause a significant increase in semen volume, sperm concen- tration, mobility and percentage of normal morphology. Consumption of vitamin C can significantly improve sperm concentration and mobility. But the volume of semen and the percentage of normal morphology does not change significantly. ACKNOWLEDGEMENTS This work was supported by Research Deputy of Shi- raz University of Medical Sciences, Shiraz, Iran (Grant no. 94-01-36-10593). The authors would like to thank Seyed Muhammad Hussein Mousavinasab for his sin- cere cooperation in editing this manuscript. CONFLICT OF INTEREST None declared REFERENES 1. Zegers-Hochschild F, Adamson GD, de Mouzon J, et al. 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