SEXUAL DYSFUNCTION AND ANDROLOGY
Impact of Spirulina Supplementation on Semen Parameters in Patients with Idiopathic Male Infertility: A
Pilot Randomized Trial
Roya Modarresi,1 Alireza Aminsharifi,2 Farzaneh Foroughinia,3, 4*
Purpose: To evaluate the efficacy of therapy with spirulina supplement on semen parameters in patients with
idiopathic male infertility.
Materials and Methods: A total of 40 men with idiopathic infertility were randomly assigned into two groups.
Group A received 2 g spirulina supplement as well as conventional regimen for the treatment of infertility selected
by their physician (220 mg/day zinc sulfate, 500mg/day L-carnitine, and 50 mg/day clomiphene) during 12 weeks
of the study, while group B received placebo plus conventional therapy during the study period. Semen parameters
were analyzed at baseline and at the end of the study as a primary endpoint. The secondary endpoint was the rate
of pregnancy occurring in the patients. wives.
Result: No significant differences in semen parameters were observed between the spirulina and control groups
[count (16.43 vs. 46.00, P = .164), motility (51.00 vs. 48.7, P = .008), and morphology (47.50 vs. 15.00, P = NA)].
Our results showed a pregnancy rate of 5% in the spirulina group versus 0% in the control group.
Conclusion: This pilot randomized trial provides initial evidence on the possible beneficial effects of spirulina
mainly in patients with impaired sperm motility or morphology. Due to the limited sample size, further larger
randomized trials not only at the level of semen parameters but at the scope of paternity are required to confirm
these potential benefits.
Keywords: idiopathic male infertility; pregnancy; semen parameters; spirulina supplement.
INTRODUCTION
Idiopathic infertility is one of the most common re-productive disorders in men worldwide. Approxi-
mately one out of ten couple is infertile and infertility
in about half of them is the result of male factors. The
pathogenesis and etiology of infertility are not com-
pletely understood in most cases; therefore, it is named
idiopathic infertility. This disorder results from inter-
action between genetic and environmental factors and
can be easily manipulated.(1,2) Because of the society’s
shift toward industrialism during the last decades, con-
cerns have arisen about the effect of higher exposure
to chemicals and radiations in everyday life and work-
place that could also lead to infertility.(3,4)
Although some progression has been reported in the
treatment of infertility in the literature, there is still
no standard treatment with acceptable efficacy for this
problem. Vitamins and minerals as efficient anti-oxi-
dants help to protect the body from oxidative damage.
Therefore, these supplements have been studied for
the management of fertility problems in both men (oli-
gospermia) and women (anovulation).(5,6)
Spirulina is a cyanobacterium blue-green micro-alga. It
1Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
2Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran.
3Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
4Clinical Pharmacy Department, Shiraz University of Medical Sciences, Shiraz, Iran.
*Correspondence: Clinical Neurology Research Center, Department of Clinical Pharmacy, Shiraz University of Medical Sciences,
Shiraz, Iran.
Tel: +989177136095, E-mail: farzanehforoughinia@yahoo.com.
Received August 2017 & Accepted February 2018
has protein content of 50-70% of total dry weight and
also it is full of vitamins such as A, E, D, K, B1, B2,
B3, B6, B12, panthotenic acid, folate and minerals such
as mg, Zn, Fe, Cu, and selenium.(7,8) It has been men-
tioned as a safe edible alga. Various studies on mice
have shown no adverse effects on non-pregnant and
pregnant mice that were given spirulina in their daily
routines.(9,10)
To our best of knowledge, no clinical trial has been
done to address the effect of spirulina on idiopathic
male fertility. Therefore, in this pilot trial, we investi-
gated the effect of sprirulina as a rich supplement for
the management of male patients with infertility for the
first time.
MATERIALS AND METHODS
Study design
This is a pilot randomized clinical trial with dou-
ble-blind study design that was conducted in two in-
fertility clinic, Shahid Motahari and Shahid Faghihi,
affiliated to Shiraz University of Medical Sciences
(SUMS), Shiraz, Iran. The study was approved by the
ethical committee of SUMS. The identifier code of
Sexual Dysfunction and Andrology 78
Vol 16 No 01 January-February 2019 79
(IRCT) is IRCT2016081320441N5. As to the ethics, all
participants were counseled about the possible effica-
cy and side effects of spirulina and their consents were
obtained.
Study population
This trial was performed from June 2015 to June 2016.
All patients with male factor-infertility and poor semen
parameters were considered.
Male infertility was diagnosed if one or more stand-
ard semen parameters were below the cutoff levels
accepted by WHO (1999) (sperm density less than 20
*106/mL, sperm motility less than 50%, and normal
morphology less than 30%)(11). To eliminate possible
adverse effects of various factors on spermatogenesis,
all the participants had at least two semen analysis per-
formed 3 months apart.
Inclusion and exclusion criteria
Inclusion criteria were the ages between 20-40 years
old of participants and their wives, abnormal semen pa-
rameters, and documentation of fertile female partner.
exclusion criteria were as follows: known medical (var-
icocele or cryptorchidism) or surgical condition which
can result in infertility, a history of cancer chemother-
apy, body mass index 30kg/m2 or greater, a history of
alcohol, drug, or other substance abuse, administration
of androgens, anti-androgens, and immunosuppressant,
severe kidney (serum creatinine greater than 2.0 mg/
dL) and liver insufficiency (serum bilirubin greater than
2.0 mg/dL), Azoospermia, and endocrinopathy.
Procedures
A total of 40 patients with idiopathic male infertility
were enrolled in the study. Patients were randomized
into group A (spirulina group, n=20) and group B (con-
trol group, n=20) by simple randomization. All partici-
pants were asked to complete occupational and lifestyle
questionnaire face to face. Presence of varicocele was
determined by doppler ultra-sonography of the scro-
tum with the valsalva maneuver. Patients in Group A
received 2 g spirulina supplement (Far East microalgae
Ind. co., Ltd, Taiwan) as well as conventional regimen
for the treatment of infertility selected by their physi-
cian (220mg/day zinc sulfate,(12) 500mg/day L-carni-
tine,(13) and 50mg/day clomiphene(14) during 12 weeks
of the study, while group B received placebo plus con-
ventional therapy during the study period. Patient’s
compliance was assessed by comparing the number
of pills ingested and the number of days between dis-
pensing visits. The follow up visits were in weeks 4, 8,
and 12 after treatment administration, during which the
patient’s compliance were evaluated. The investigator,
responsible to provide drugs for patients and follow-up
them, was blinded.
Evaluations
Two standardized semen samples were collected from
all patients at baseline and after 12 weeks of treatment.
The samples were obtained at home by masturbation
into polypropylene containers after 3 to 5 days of ab-
stinence and delivered to laboratory within 1 hour after
production. Semen parameters were analyzed blinded
by two laboratory technicians at baseline and at the
end of the study as a primary endpoint. The secondary
endpoint was the rate of pregnancy occurring in the pa-
tientsˈ wives confirmed by a positive blood pregnancy
Spirulina supplementation on semen parameters-Modarresi et al.
Table 1. Semen parameters analysis at baseline and after 12 weeks of treatment in two study groups.
Baseline 12 weeks P value
Groups Control (N = 20) Spirulina (N = 20) Control (N = 20) Spirulina (N = 20)
Mean ± SD N (%) Mean ± SD N (%) Mean ± SD N (%) Mean ± SD N (%) Baseline Baseline 12 weeks Baseline
control- control-12 control- Spirulina-12
baseline weeks 12 weeks weeks
Spirulina control Spirulina Spirulina
Oligospermia 16.23 ± 3.69 3 5.42 ± 2.25 3 46.00 ± 29.13 3 16.43 ± 7.72 3 .0123 .153 .164 .076
(Sperm count) (15) (15) (15) (15)
(106/mL)
Asthenosperima 33.04 ± 9.72 10 37.3 ± 10.97 8 48.7 ± 13.82 10 51.00 ± 7.12 8 .39 .008 .675 .01
(Sperm motility) (50) (40) (50) (40)
(% motile)
Teratospermia 19.0 ± 0.00 1 5.5 ± 0.5 2 15 ± 0.00 1 47.5 ± 10.5 2 NA NA NA .02
(Sperm morphology) (5) (10) (5) (10)
(% normal)
Oligospermia 10.3 ± 4.59 4 14.90 ± 3.1 2 17.75 ± 13.2 4 6.88 ± 1.28 2 .28 .327 .334 .077
+ + (20) + (10) + (20) + (10)
Asthenospermia 21.42 ± 15.94 31.34 ± 3.66 38.25 ± 8.31 35.50 ± 6.50 .46 .110 .703 .512
Asthenospermia 40 ± 0.00 1 30.00 ± 0.00 1 55 ± 0.00 1 40.00 ± 0.00 1 NA NA NA NA
+ + (5) + (5) + (5) + (5)
Teratospermia 15 ± 0.00 15.00 ± 0.00 65 ± 0.00 65.00 ± 0.00q NA NA NA NA
Oligospermia 17 ± 0.00 1 8.03 ± 5.30 4 28 ± 0.00 1 10.9 ± 7.85 4 NA NA NA .566
+ + (5) + (20) + (5) + (20)
Asthenospermia 29 ± 0.00 18.00 ± 11.8 20 ± 0.00 21.75 ± 14.21 NA NA NA .698
+ + + + +
Teratospermia 5 ± 0.00 13.00 ± 3.31 25 ± 0.00 35.00 ± 15.00 NA NA NA .028
Abbreviations: NA, Not Assigned
test.
Statistical Analysis
Statistical analysis was performed using Statistical
Package for Social Sciences software, version 22 (SPSS
Inc, Chicago, USA). Variables were tested for normal-
ity by Kolmogorov-Smirnov test. Categorical variables
were described with absolute and relative (percentage)
frequencies. Continuous variables were expressed as
mean ± standard deviation (SD). Student t-test and
paired t-test were applied for statistical analysis of con-
tinuous variables. Differences in proportions were test-
ed by Pearson chi-square when assumptions were met;
if not, the Fisher’s exact test was used. P-value< 0.05
was considered as the significance level.
RESULTS
The CONSORT diagram of the clinical trial is reported
in Figure 1. During the follow up period, 5 patients in
each group were excluded from the analysis due to the
loss of follow up and withdrawal of consent.
Evaluation of patients before/after treatment in the con-
trol group revealed that the average sperm motility in
patients with one disordered factor was the only meas-
ure that was significantly increased after the treatment
with conventional regimen (33.04 ± 9.72 vs. 48.70 ±
13.82, P = .008) (Table 1).
Assessment of participants before/after treatment in the
experimental arm showed that both the average sperm
motility in isolated motility disorder (37.30 ± 10.97 vs
51.00 ± 7.12, P = .01) and the average sperm morpholo-
gy in isolated morphology problem (5.5 ± 0.50 vs 47.50
± 10.5, P = .02) were recovered completely after treat-
ment and these differences were statistically significant.
However, in participants with all three disordered fac-
tors of the sperm count, sperm morphology, and sperm
motility, the only factor that was statistically improved
after the treatment was sperm morphology (P = .02)
(Table 1). In groups in which there was only a single
outlier participant with a specific disorder, their given
statistics were not calculated.
According to our results, the average sperm count, mor-
phology, and motility were not significantly different
between the study groups at the end of the study period
(Table 1).
Our results showed a pregnancy rate of 5% in the part-
ner of patients in the spirulina group versus 0% in the
control group.
DISCUSSION
We found no significant differences with regards to se-
men parameters between the study groups. On the other
hand, significant improvement in the sperm morphol-
ogy and motility was reported after the treatment with
spirulina (compared to pre-treatment specimen); while
motility was the only variable that was improved in the
control group (compared to pre-treatment specimen).
Although the exact etiology of male infertility is un-
known, it is attributed to several environmental factors
such as exposure to certain chemicals, heavy metals,
pesticides, electromagnetic radiation, smoking, alcohol
abuse, chronic stress, and inflammation in the male re-
productive system.(15-18) Most of these factors ultimate-
ly cause oxidative stress. The resulting excessive free
radicals cause a pathological response that can lead to
reduced sperm count, decreased sperm motility, and de-
velopment of abnormal sperm morphology.(19)
The semen protective antioxidant system consists of
enzymetic and non-enzymatic factors. Vitamin A, E, C,
and B complex, glutathione, pantothenic acid, carote-
noids, coenzyme Q10, carnitine, and minerals such as
zinc, selenium, and copper are efficient anti-oxidants
that help to protect the body from oxidative damage.
(19) As a result, various clinical trials have been per-
Figure1. Flow diagram of the trial
Spirulina supplementation on semen parameters-Modarresi et al.
Sexual Dysfunction and Andrology 80
Vol 16 No 01 January-February 2019 81
formed to evaluate the possible beneficial effects of
these agents on improvement of the sperm parameters
in males as well as pregnancy rates in their partners in
patients with idiopathic male infertility.(20-21)
In a study, the effects of selenium supplementation in
males with infertility were considered. Results showed
that a low dosage of selenium could improve the sperm
motility and increase the chance of successful concep-
tion. However, not all participants responded to treat-
ment in this study and only 56% of them showed a
positive response to this treatment.(5) Our results also
showed that treatment with spirulina could significantly
increase the sperm motility based to baseline-12 weeks
of treatment sub-analysis in spirulina-treated patients.
In another study, the efficacy of folic acid and zinc
sulfate on semen parameters was evaluated in infertile
and subfertile men. Results revealed that treatment with
these supplements could significantly increase the total
sperm count (74%) and also lead to minor increase in
abnormal spermatozoa (4%) in both subfertile and fer-
tile men. However, pre-intervention concentrations of
folate and zinc in the blood and seminal fluid did not
significantly differ between fertile and subfertile men.
(12) The improving effects of zinc sulfate on the semen
parameters have been studied in another trial in infertile
men. This study reported strong linear associations be-
tween the sperm count and normal sperm morphology
with seminal zinc concentrations.(20) In our study, there
was a trend toward an increase in the level of sperm
count after 12-week treatment period in spirulina-treat-
ed patients (5.42 vs. 16.43, P = .076). Though, this im-
provement was not statistically significant which may
be due to a significant lower baseline sperm count in
this group compared to controls and a limited sample
size in both groups, therefore; it deserves further evalu-
ation in the clinical setting.
A trial analyzing the efficacy of coenzyme Q10 sup-
plementation on semen parameters showed a signifi-
cant improvement in the semen morphology, density,
and motility in infertile men. This study mentioned a
positive correlation between treatment duration with
coenzyme Q10 and improvement in semen parameters.
Coenzyme Q10 also significantly decreased the serum
follicle stimulating hormone and luteinizing hormone at
the 26-week treatment phase.(21) Another trial was per-
formed on 228 men randomly distributed in two groups
of placebo and coenzyme Q10 treatment (200mg/day
for 26 weeks). At the end of the trial, the sperm density,
motility, and morphology increased significantly in the
men treated with coenzyme Q10.(22)
With regard to the protective effects of vitamins and
minerals in the improvement of spermatogenesis in men
with idiopathic infertility and the fact that spirulina is
full of minerals, vitamins and caretinoids, in this study,
we evaluated the hypothesis that this supplement may
have beneficial effect on the semen parameters in infer-
tile men.(7) The efficacy of spirulina on animal fertility
has been extensively studied. Its beneficial effects on
improving the reproductive performance and reducing
teratogenicity in albino mice were addressed previous-
ly. An increase in fertility rate from 77.5% to 82.5%
and a 33.7% decrease in stillbirth rate were shown. This
agent also improved the survival rate of off-springs
in diabetic mice from 83.61% to 88.9%.(23) In another
study, spirulina was shown to be safe as a supplement
used in laying hens’ diets with a significant improve-
ment on reproductive and productive performances.
(24) In a pilot study carried out on 6 boars, it was re-
vealed that the addition of spirulina to the main diet for
40 days could increase the volume of ejaculation (30
mL) as well as the spermatozoa concentration (27mln/
mL). The sperm motility also had a 30% increase in this
study.(25)
Despite these promising experimental studies, we did
not find any clinical study in the literature to assess
the efficacy of spirulina on human reproductive func-
tion. Therefore, we designed this pilot study with rand-
omized trial design to analyze the value of this natural
product on the semen parameters in comparison with
conventional treatment in men with infertility and ab-
normal semen analysis.
According to the WHO definition, abnormality in any
of the sperm count or motility or morphology can lead
to infertility. This study showed that the addition of 2
g spirulina per day to the conventional treatment did
not significantly improve the semen parameters and
sperm function in all subgroups. In addition to routine
analysis mentioned in previous studies, to better assess
the results, we evaluated the efficacy of treatments in
different subgroups (i.e. patients with isolated versus
multiple abnormalities in their semen analysis). In the
spirulina-treated group there were significant differenc-
es between baseline and post-treatment sperm motil-
ity and morphology in patients with isolated motility
or morphology disorders. Interestingly, the positive
effect of spirulina on improvement of the sperm mor-
phology was also observed in patients with combined
oligospermia, asthenospermia, and teratospermia dis-
orders. Therefore, with attention to one case of con-
firmed pregnancy in the spirulina arm, it sounds that it
exerts its benefit on fertility mainly by improving the
morphology of sperm.
Study limitations
We admit that the small sample size of this pilot study
in the subgroups can be a limitation for a thorough sta-
tistical analysis. Improved semen quality and quantity
does not certainly translate into an improved pregnancy
rate. Although we followed all the patients for assess-
ing pregnancy occurrence during the study period, there
were 7 single males in the control group and 4 in the
spirulina group that made this assessment impossible
for all participants.
CONCLUSIONS
This pilot randomized trial provides initial evidence
on the possible beneficial effects of spirulina mainly
in patients with impaired sperm motility or morpholo-
gy. Due to the limited sample size, further larger rand-
omized trials not only at the level of semen parameters
but at the scope of paternity are required to confirm
these potential benefits.
ACKNOWLEDGMENTS
This research, extracted from a thesis written by Roya
Modarresi, was financially supported by Pharmaceu-
tical Sciences Research Center, Shiraz University of
Medical Sciences, Shiraz, Iran (grant number: 8346).
The authors would like to express their gratitude to
Center for Development of Clinical Research of Nema-
zee Hospital for statistical analysis, Dr Shokrpour for
editorial assistance, and the assistance of the staff of
Spirulina supplementation on semen parameters-Modarresi et al.
Shahid Motahari and Shahid Faghihi clinics.
CONFLICT OF INTEREST
The Authors declare that there is no conflict of interest.
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Sexual Dysfunction and Andrology 82