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REPLAY: Male Infertility and Modern-Day Challenges to Sperm Health with Emma Sutherland and Belinda Kirkpatrick

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REPLAY: Male Infertility & Challenges to Sperm Health with Emma Sutherland and Belinda Kirkpatrick

With one in six couples experiencing fertility difficulties, and with one-third of infertility cases being related to male reproductive issues, it is crucial for us as practitioners to be optimising sperm health in our male patients.

Today Emma Sutherland speaks with naturopath, nutritionist and fertility specialist Belinda Kirkpatrick about diet and lifestyle issues that contribute to male infertility, focusing in particular on sperm health. They discuss the dos and don’ts of sperm testing, strategies and nutrients that improve DNA fragmentation, and how to foster relationships with doctors and specialists for the best outcome for our patients.

Covered in this episode

[00:09] Welcoming Belinda Kirkpatrick
[01:37] Surprising fertility statistics
[04:30] Contributing factors to declining sperm counts 
[09:44] Dos and don’ts of sperm testing
[15:44] DNA fragmentation testing and how to use this information in clinical practice
[22:37] Strategies and nutrients that improve DNA fragmentation
[25:16] The importance of therapeutic dosing in fertility
[31:32] Diet and lifestyle factors that affect sperm 
[35:38] Men respond to data
[39:47] Creating collaborative care with doctors and specialists
[42:14] Melatonin and male infertility 
[44:37] Building a financially viable clinical practice
[47:14] Thanking Belinda and final remarks

Key takeaways

  • Sperm cells are extremely vulnerable to oxidative stress and environmental toxins. Advanced paternal age, poor diet, and nutritional deficiencies can contribute to poor sperm health. Chemical exposure such as xenoestrogens, pollutants, pesticides, and herbicides, as well as drugs, smoking, alcohol, and vaping play a major role in sperm health as well.  
  • Sperm tests are invaluable in clinical practice, and can help determine supplemental, diet, and lifestyle recommendations. The ‘do’s and don’ts’ of sperm testing: 
    • Get one done, and ensure you have a copy of the results. Many times the patients will be told it is ‘fine’ or ‘normal,’ if the results are within reference ranges, but this does not mean sperm health is not optimal.  
    • Do not do the test at home, then bring the specimen to the lab. Get the test done in the lab of a fertility clinic.  
    • Ensure three days of abstinence before the test to get a proper baseline.  
    • Do not perform the test if unwell, including if the client has a fever, any kind of bacterial infection or needed antibiotics.  
    • Get a DNA fragmentation done at the same time as the semen analysis. 
  • Sperm DNA fragmentation refers to abnormal genetic material within the sperm - a physical break in one or both of the DNA strands of the chromosomes. Healthy sperm DNA is crucial for successful fertilization and normal embryo development, and research has shown fragmentation can lead to male subfertility, IVF failure, miscarriage, and poor embryo progression. 
  • Nutrients to consider to improve sperm quality: 
    • Vitamin E 
    • Vitamin C 
    • CoQ10 
    • N-acetylcysteine,  
    • Acetyl carnitine 
    • Vitamin D 
  • Men produce testosterone, which is a prominent hormone in sperm production, while they sleep, making proper sleep essential for conception. Research shows men who sleep for 6 hours a night are less likely to get their partners pregnant than those who get between 7 and 8 hours. 
  • Diet plays a major role in sperm health including: 
    • Soy food intake is negatively associated with sperm concentration.  
    •  Saturated and trans-fatty acid intake is negatively associated with sperm concentration.  
    • Fish and omega-3s fatty acids are associated with an increase in sperm morphology. 
    • Pesticides in fruit and vegetables lower sperm quality and morphology.  

Resources discussed and additional reading

Website: Belinda Kirkpatrick
Article: Male Fertility (Fertility Society of Australia and New Zealand
Website: Fertility Society of Australia and New Zealand
Research: 'A projection of Australia’s future fertility rates, September 2020' (Centre for Population, 2020)
Research: Temporal trends in sperm count: a systematic review and meta-regression analysis (Hum Reprod Update, 2017)
Research: Substance Abuse and Male Hypogonadism (J Clin Med., 2019)
Research: The effect of sperm DNA fragmentation on miscarriage rates: a systematic review and meta-analysis (Human Reproduction, 2012)
Research: The effect of antioxidants on male factor infertility: the Males, Antioxidants, and Infertility (MOXI) randomized clinical trial (Fertil Steril., 2020)
Research: The Environment And Reproductive Health (EARTH) Study (Harvard T. H. Chan School of Public Health)
FX Medicine Infographic: Male Reproductive Health: Optimising Fertility
FX Medicine Article: Impact of Artificial Sweeteners on Fertility, Reproductive, Pregnancy and Offspring Health Outcomes 

Emma: Hi and welcome to FX Medicine where we bring you the latest in evidence-based integrative functional and complementary medicine. I'm Emma Sutherland, a Sydney-based naturopath, and joining us on the line is Belinda Kirkpatrick, clinical nutritionist and naturopath, and founder of BK Naturopathy & Nutrition

She's helped hundreds of patients overcome their fertility challenges, and that is what she's here to discuss with us, how to help your patients experiencing infertility. But today we are going to focus on the men. 

Welcome to FX Medicine, Belinda.

Belinda: Thanks, Emma. Thank you for having me.

Emma: My pleasure. Now, tell us a little a bit about yourself, your qualifications, your experience. Who is Belinda Kirkpatrick?

Belinda: Good question. So I'm a naturopath and nutritionist like you mentioned. I've been in clinical practice for over 17 years now. I've got a Masters in Reproductive Medicine in addition to my Bachelor of Health Science in Naturopathy. And, yeah, I'm in clinical practice five days a week and absolutely love it. 

So the majority of my patients are fertility patients, and I am really passionate about the male side as well as the female side because it does often get overlooked.

Emma: Yeah, I couldn't agree more. I mean, we've had many conversations over the years about this topic, and it's just great to be able to deep dive into it with you on FX. 

So let's just look at some statistics. Let's just set the scene. So according to the Fertility Society of Australia and New Zealand, one in six couples have difficulties falling pregnant. And overall about one-third of infertility cases are caused by female issues, and one-third by male, and the last third by both male and female.

And there's the 2020 projection of Australia's Future Fertility Rates Report, and this I found really fascinating. It said that, in 1961, the average number of babies per woman was 3.55. And as of 2018, it had dropped to 1.74. And the predictions are that in 2030, it's going to be 1.7 babies per woman. 

So does this have anything to do with male fertility? This is what we're here to talk about today. So what's your overview on those stats?

Belinda: Oh, I guess, in one way, they're such scary stats, aren't they? Because if it is because of a fertility decline and people are trying to have that many babies, then it's a massive issue. I think we know that sperm counts have declined, which we're obviously going to get into more in the next little while together. 

I think there's probably two arms with the statistics that you mentioned there. I don't know how many women, certainly women I know and in my clinic, want to have three and a half or four babies. So some of it might be that we are leaving it a little bit longer. Obviously, housing prices are expensive. Schools are expensive. Life's expensive. So some of that may actually be that they don't want to have as many babies as before, better contraception, and things like that. 

But certainly, as you and I know as practitioners, people are really struggling to fall pregnant, and I feel like even in... I feel like maybe we've been practising for the same amount of time actually, but in that 17 years, I would say that over the last even 5 and 10, I feel like I've noticed an even bigger jump, again, of people having difficulties. Particularly people in their early 30s as well, not just in their late 30s and early 40s.

Emma: Yeah, yeah, agreed. I mean, let's just look at the sperm count. So a 2017 systematic review found that sperm counts have declined by as much as 50% since 1973. Now, I find that quite alarming, to be honest.

Belinda: Oh, it's so shocking. I actually had a conversation about this at a dinner party a few months ago. And everybody was saying, "No way!" Then I second-guessed myself because I was like, "Well, maybe it wasn't 50%. That sounds massive," and I pulled it up and everybody was like, "What?" It's absolutely shocking.

Emma: Yeah. Why do you think that there has been such a decline in sperm counts?

Belinda: I mean, there are so many kinds of reasons, and sperm is one of the smallest cells in the body and is just so vulnerable. So I think we've absolutely got advanced paternal age as being an issue, poor diet, nutritional deficiencies. Chemical exposure is massive. I think there's lots of research looking at these environmental causes, xenoestrogens in plastics and pollutants, pesticides, herbicides. Those things that are in our environment are huge. 

Things like drugs, smoking, alcohol, vaping, which is massive at the moment and quite scary as well. And I think there's also a lot of evidence and research coming through on electromagnetic radiation, so things from mobile phones, and laptops, and things like that.

Emma: Yeah, and I mean, I was reading over the last week a lot of research on male fertility. And I came across a 2019 paper on substance abuse and hypogonadism, and those two approaches. There were the factors like environmental causes and alcohol that actually reduced testosterone. While other factors like nicotine and amphetamines, they're causing damage through oxidative stress. So there's these different mechanisms at play that's really causing problems with sperm.

Belinda: Absolutely. It's just so multifactorial, and sperm is just so vulnerable to damage. And I think also, too, when you look at, I guess, the age of people and particularly men having children now, they also have been just by life exposed to more. They drank more alcohol. They may have used drugs occasionally. Just what they've been exposed to, mobile phones, laptops, heating, all those sorts of things. Lack of sleep, that's a big one. 

Emma: Yeah.

Belinda: Anabolic steroids. I know certainly where I practice, I feel like so many people's partners have had a history of steroid use.

Emma: Well, can I just tell you this brief... I had a case just in the last couple of months. Anyway, they had one child already. She's trying to get pregnant again but cannot get pregnant. She's done the HyCoSy, the ultrasounds, the bloods. You name it, she's done it. They finally organised a sperm count. He has zero sperm count because he's been taking anabolic steroids.

Belinda: Yeah, yeah.

Emma: I mean, I was actually quite blown away. To see that on a report really blew my mind. These are powerful drugs.

Belinda: Absolutely. And they do...I mean, they're obviously worse while you're using them, but I've got patients who used them 5, 10, 15 years ago, which I'm still seeing really poor sperm parameters or semen parameters, which likely is based on that history of use as well.

Emma: Yeah, exactly. That's right. I mean, sperm can turn around. I mean, we get good changes in DNA fragmentation when we do our amazing work. But some things, that damage is just going to be there for a long time.

Belinda: Absolutely. And that's the exciting thing about sperm though, right, is that it is made every three or four months. There is so much that we can do and I often think it's... I almost hope that the issue is with the sperm as I'm working out my fertility patients and really trying to kind of investigate what's going on, but I know that a lot of the time—obviously, not if it's some sort of genetic condition or something else that's happened along the way —but a lot of the time it is an area where we really can just make a huge difference. And men in particular—this is possibly slightly sexist, I know, so sorry about that—often are really much more numbers-based than women, I find, in my clinic.

Emma: Yeah, of course.

Belinda: Women will be like, "Oh, these things are good for my egg quality. Absolutely, I'm really into that. This is what I'm going to do with my diet." And a lot of men, and forgive me for generalizing, will be, "Look, here's your...this is your semen analysis. This is what we want it to be. Let's test it again in four months' time, if you haven't already conceived, and let's see if what we're doing is making an impact." And I think that's the really exciting thing about sperm is that we can measure it so nicely in many ways. And so that helps to keep that person on track. I mean, hopefully your guy with the steroid use would have been hopefully quite motivated by seeing that result.

Emma: He was a little bit shocked but also shamed and reluctant, but he's on medical treatment now. So, we just have to work alongside that. 

Now I wanted to talk about sperm testing because you and I both know that there's better ways to do it and there's terrible ways to do it. So it's...

Belinda: There's sperm testing and there's sperm testing.

Emma: Yeah, that's right. And I would agree with you. It is absolutely invaluable in clinical practice, and it really helps me, as a practitioner, to determine what I'm going to recommend in the way of supplements, and diet, and lifestyle, but what are the dos and don'ts? Talk us through the dos and don'ts of an accurate sperm test, one that you can confidently use the information from and make recommendations.

Belinda: Yeah. So first of all, the first “do” is get one done. So even if you're not seeing that male partner, so I know most of my patients will come in with both, but a big proportion also come in with just the female. It feels like it's all just a female kind of issue. So even if I'm not seeing them, I'm like, "I need them to do one." 

So we also need to make sure that there is one that has been completed and that your eyes have seen it if, it has been done. So, "Oh, the doctor said it was fine," and then you write down, "Sperm fine," and then leave it, that's the “don't.” So that's not even...we haven't even got to our actual testing. Make sure that you have tested and make sure that you don't just rely on somebody else saying it's fine.

Emma: Oh, look, that drives me completely bonkers in clinical practice because the men have been told it's fine. And then you look at it yourself and you're like, "It's not fine. It's so far from optimal," I guess is the point. I'm always saying to patients, "Normal is not always optimal. It's just average. You don't want to be average."

Belinda: And even if it's fine and it's actually... even if they've been told that it's fine and it's actually not fine. I had a patient, they're trying to conceive their second child. The first child is five, so they're trying to conceive the second child for three years. They're both in their very early 30s, and they pushed the doctor to have a semen analysis a year ago and were told that it was fine. And so anyways, she started seeing me, not him. I eventually, after asking several times, got a hold of the analysis. The motility was 10%. That sperm was not even getting... And I said, "This is actually...you're so unlikely to conceive naturally if this is still the case at the moment, and we're getting it done again." And now we're really disappointed because they were like, "Why weren't we referred on at that time?" And I think sometimes when the patient has actually pushed to get the analysis done, sometimes when the result comes back, the GP may or may not have the experience to know when to refer them on, particularly if they're young and they've already got a child. Generally it doesn't feel like they need to see a fertility specialist if you're 31 and you've already got a child but, as we know, you do.

So if you are getting an analysis, which as we've said is incredibly important you can get it done either at a fertility clinic. So that doesn't mean that they've got to go and see a doctor there. We can still use the lab of a fertility clinic, which is the important thing. So what we don't want to do is to do a test at home, take it with you, drop it off at your local pathology centre. Who knows how they keep it and how it's tested? So that's really just a... When people come in with a result that they've done like that from just general pathology, just look at that as in, "Okay, it's not hideous, but we're going to need to do it again if the picture calls for it." If they've been trying for a while and it hasn't been happening, you want to get it done at the clinic yourself.

Emma: Yeah.

Belinda: So it needs to be that they've had the right amount of days abstinence. It's usually three days of abstinence so we can get a baseline of when that gets tested again, it's the same the next time as well. So really in the fertility clinics, they'll have a much more in-depth look at it. So you might actually get a worse result at a fertility clinic compared to what you got in a past result at the pathology clinic, and they just need to be aware that you can't actually compare them because the fertility clinic, the testing is just so much more vigorous.

Emma: Yeah. I would have to agree. And as far as usually, their updated semen analysis at an IVF lab does come back worse, and you almost have to mentally prepare them for that kind of result because unfortunately, it's part of the process but that's the realistic picture that you're looking at. 

What about if a man is not well? If he's got a cold or something, should he hold off doing the analysis? Would that make a difference?

Belinda: Yeah, absolutely. If he's just got a little tiny head cold, you probably—I mean, nowadays you can't go anywhere if you've got a head cold—but if you've just got a little bit of a head cold, that should be kind of okay if it's just kind of mild, a bit of a sniffly nose. But certainly, if you've been unwell, you've had a fever, you've had any kind of bacterial infection or needed antibiotics because of some kind of infection, I would generally wait at least a couple more weeks of being well to get it done. 

And they're expensive to do. I mean, look, the general semen analysis for Australia, they're around about $100 and you get $80 or $90 back on Medicare. It's that second part of the analysis called the DNA fragmentation, which is $300 to $400 so we don't want to be sending men back there every 5 minutes. They're not usually jumping up and down, waiting to go again. 

Emma: No.

Belinda: So we want to make sure that the result that we're capturing is actually an accurate representation of what has been going on for the last two months.

Emma: Yeah, some really great points there. So first of all, get one done. Second of all, make sure if they've had it done, you sight that analysis yourself. And then if they need to be referred, send them to an IVF lab, remind them of the three days of abstinence, and then don't do it if you're sick.

Belinda: Absolutely, yeah. I pretty much always get a DNA fragmentation done at the same time. So that's kind of, whenever you get a DNA fragmentation test done with a semen analysis, it's always an add-on to the semen analysis. You can't go back and just do that part. 

So it is that extra money, which is expensive, but otherwise, if you're just looking at the analysis, the general analysis will have the concentration, the count, the morphology, what they look like, the motility, how they're moving and how they swim, all those things are really important information. But if a DNA inside that sperm is fragmented or broken down, so meaning the integrity of the genetic material in the sperm isn't okay, then that sperm can look good, but inside it may not actually have what it needs to fertilise.

Emma: Yeah, yeah. It's a really good point. I mean, what does the literature say about DNA fragmentation? I know it's a bit of a passion of yours, but talk us through its use in clinical practice?

Belinda: So I guess that the sperm DNA fragmentation basically is referring to abnormal genetic material within the sperm. And research has shown that that can lead to male subfertility, IVF failure, miscarriage, maybe poor embryo progression, not going all the way to Day 5, particularly a drop-off between Day 3 and Day 5 in an IVF cycle. And it's basically just the DNA inside that sperm is fragmenting or breaking down. So there's an actual physical break in one or both of the DNA strands of the chromosomes that are actually contained in the sperm. And so that genetic material is really crucial for successful fertilization and normal embryo development as well.

I'd often say to people it's like seeing a gorgeous guy, person, or whatever, standing over there, and you're like, "Oh, my gosh, that's my next husband. That should have been my husband over there. I'm going to go and talk to him." And you go over and you just can't get a conversation going, right? Everybody's been there, right? So everything can look good. It can move well. Everything can be perfect, but it's what's inside that also matters. It probably should matter more in a relationship sense. But with sperm, we want the outside to also be good, a little bit superficial, but the inside is really important. And I often actually use that analogy and patients then understand it because some of it's difficult for them to understand why the semen analysis can actually be okay, but then when we get it done again, I'm wanting to add that DNA fragmentation.

Now, I always add that if there's any sort of toxic exposure, so maybe your patient is a house painter. Maybe they're a diesel mechanic. Maybe they're exposed to...maybe they're a landscape gardener where you're like, "Okay, you're probably..." I mean, a hairdresser, you're probably being exposed to lots in your occupation. And then where there is advanced paternal age as well. Now, what is advanced paternal age? Nobody knows. Certainly above 40 for me, but I would test the DNA if I get anybody over 35.

Emma: Okay. So over 35, you think it's worthwhile getting done, and the cost is justified and relevant for them.

Belinda: It just means, I guess, that if in another four or five, six months, they still haven't conceived, you're not like, "Oh, maybe we should have checked that DNA frag. Let's go back and do it again. Do you mind booking another semen analysis?" At least then we kind of know. We're not getting semen analyses for people who've been trying for two months to conceive, right? So these are people who have some degree of subfertility, and I do believe that it is in their best interest to get an accurate workup from the beginning.

Emma: And, I mean, clinically does this mean that it's a couple that don't seem to have any other fertility impediments that are obvious and they're not conceiving at all, or if she's doing her basal body temperatures, will you see that fertilization is occurring but implantation fails? What do you actually see clinically with this issue?

Belinda: Yeah, look, it can be any or all of the above. So we've got current research that's kind of suggesting the presence of DNA damage in sperm can more than double your risk of miscarriage and loss. So for people who are having recurrent miscarriage, obviously we're working up everything else in the female, but that part is also really important as well. I'm often seeing poor embryo progression in an IVF cycle, like I mentioned. But to be honest, because there really are so few comparatively things that we're working up with male fertility compared to the poor woman who's just being turned inside out with investigations, all of those things that you mentioned—not conceiving, having losses, any type of fertility issue, poor fertilization, all that sort of stuff—we just want to make sure that that sperm is actually doing what it's meant to be doing.

And DNA frag is like, again... Obviously, I'm a nerd, so I was about to say it's really exciting because most of the time we can get it so much better. I've seen some DNA damage halve in three to four months of treatments. 

Emma: Yeah.

Belinda: So unless they've had some sort of chemotherapy or something like that, which can maybe make a little more longer lasting damage, then along the time, it's really well improved with diet, lifestyle, and supplementation.

Emma: Yeah, I have to say. One case comes to mind for me, and he had a high level of DNA fragmentation, and he wasn't really willing to take much, right? He just wasn't willing, but he was prepared to stop smoking and start walking. And that was literally all we did, and his DNA fragmentation really improved just with those two interventions. And I was actually quite shocked at how much it improved. I really was, but it made me realise male fertility is so malleable to change because of the short timeframe involved in spermatogenesis.

Belinda: It's fantastic. And I think the smoking thing cannot be underrated. There is research paper upon research paper on the negative effects of smoking. And like I mentioned earlier in the conversation, vaping. I can't believe how many people like normal adults, not just teenagers, and teenagers are vaping. And so I think we're going to see huge issues with that as well, but even a small amount of cigarettes. There's also those...oh, no, I can't remember the name of them, but they're traditional. I'm pretty sure they're Lebanese.

Emma: Oh, the hookah.

Belinda: It's like a hookah, but there's another name for it, so I didn't know whether hookah was the real name. But, yeah, but often there is...even the fruity ones, they've often got really, really high doses of nicotine in there as well. I've certainly got quite a lot of patients that I've had to tell them the equivalent of that compared to cigarettes and make them really realise that they also have that same kind of effect on sperm.

Emma: Yeah. What are some other strategies, what are some other nutrients that improves DNA fragmentation specifically? What are you seeing really good clinical results with?

Belinda: Yeah. First of all, regular ejaculation, right? So coming back to those real, basic naturopathic principles of really getting that diet and lifestyle sorted first. So, regular ejaculation. 
Now, a lot of people as you and I will know, when they have been trying to conceive for a while, unfortunately, sometimes...or not unfortunately. Some of them are having lots of sex, and sometimes they're really not having much at all. So they might be doing every second day for a week in the middle of a cycle...

Emma: That's the pattern.

Belinda: ...and then that's it.

Emma: Yeah, that's the pattern that you see most commonly.

Belinda: Absolutely, or they're doing IVF and they've had so much stress. And so many times of having to try, that they've just dropped off actually having sex for fun. And so regular ejaculation we know can really improve DNA fragmentation. So a good every couple of days, two or three times a week, if the DNA fragmentation is low. I mean, if you're already having regular ejaculation or sex, they don't need to do more. But people who really are maybe, "Oh, once every week or two," or something like that, that is really important.

Emma: What do you think the mechanism is there, that improves the DNA fragmentation though?

Belinda: Yeah, I think it's just turning it over. So the sperm just isn't there in the testes, and the DNA is fragmenting and breaking down. So you're just getting much faster turnover, so it's being produced and it's not really being allowed to age as much.

Emma: Yeah, I think the ability of sperm to suffer oxidative damage is so high, that it just obviously shortens the timeframe for all that window of oxidative damage to occur.

Belinda: And especially then as we get older too, when we've already got that potentially a bit high level of oxidative stress and then we add a little bit more onto that, that can be disastrous for sperm.

Emma: Yeah, agreed. And how about some nutrients? What would be a couple of your favourite nutrients from a DNA fragmentation or male fertility perspective, either one?

Belinda: Yeah. I think the DNA frag certainly vitamin E and vitamin C work really beautifully in terms of protecting the sperm membrane from oxidative damage and really improving that DNA fragmentation as well. I'm often doing CoQ10 or potentially Ubiquinol as well. All of your antioxidants, whether it's N-acetylcysteine, acetylcarnitine, vitamin E, vitamin C, vitamin D. Don't forget about vitamin D. And then making sure their diets are really full of antioxidants as well.

Emma: Yeah, I also think dosing, the actual dose makes so much difference. So looking at a paper that came out in 2019, the MOXI study, which was male antioxidants and infertility. And it was men taking three months of an antioxidant formula, and it really didn't show much improvement. And I was like, "Why is that so?" because that's not what I see clinically. But then when I looked at the actual doses of what was in that antioxidant formula... 

For example, they had 500 milligrams of vitamin C. Now, that's much lower than I would prescribe clinically. And I think that theoretically we think, "Oh, yes, antioxidants, that makes sense with sperm," but give us some more information around dosing, because I think that's where the magic happens. When you get the dose right, that actually affects a change. And we may see this...people have come in to see your clinic and they're like, "Oh, I've seen a naturopath before, and, oh, I took this and it didn't really work." But then when you question them carefully, you can just see that the failure has not been in prescribing the wrong thing but prescribing the correct dose.

Belinda: Yes. And the correct combination and the right amount of time and even the quality as well. If you get a poor quality vitamin E that's a low dose and is potentially already oxidized, I mean, potentially it's becoming actually pro-inflammatory instead of anti-inflammatory or pro-oxidation. So it's really important in terms of not just sort of going, "Oh, yeah, you pick this up off the shelf, great." I'll often try to get them to use those things up and then give them another alternative.

But certainly the doses from that MOXI study, I mean, like that 500 milligrams of vitamin C, I mean, that's barely what we'd even call a supplemental dose. And I think the really important thing is that we actually are using therapeutic doses, not just supplemental doses. So making sure that with vitamin C, we know that it's better little and often. So you might be doing 1,000 milligrams, but you might be doing 2 or 3 times a day. It works beautifully we know with vitamin E. 

Vitamin D, making sure that you're dosing according to the test results, this can really improve motility and concentration. but we need to be getting the right dose. So not just, "Oh, I've been low in vitamin D, so I've been taking this particular over the counter 1,000 IU brand the last year," you could easily think, "Oh, yeah, that should be fine." But those ones you've got to remember they're just designed to keep you where you're at, right?

Emma: Correct.

Belinda: Not actually ever increase those levels. So some of these things we can test like vitamin D, but most of them vitamin C, vitamin E, and things like that aren't testable. We've just got to be using them.

Emma: Yeah, but I think as well, it's also thinking about, well, how is that nutrient actually absorbed? Are there any barriers to how that's being absorbed? Vitamin D is fat soluble. Do they have good levels of digestive enzyme? Are they actually absorbing what you're giving them as well?

It’s so critical because I think another clinical presentation I see is that when fertility patients come in and they bring with them a bag or a box of supplements, and I look at them, and I'm like, "Well, I actually don't know how much you're absorbing out of all of that, and I don't know how much you're excreting. But from your symptoms, I don't think you're absorbing what you need to be to get this therapeutic shift." So how do you work with that absorption factor?

Belinda: Yeah, I think when they come with that big bag of vitamins and, gosh, we've all had that, some of it, yes, absolutely might be an absorption issue, but a lot of the time they're buying over-the-counter vitamins, they buying them from overseas on websites. I mean, does it really have 25 milligrams of zinc in it or doesn't it? So is it an absorption issue or is it just a poor quality vitamin that really only had 5 milligrams of zinc oxide that you don't absorb particularly well anyway. I mean, who even knows in that sense? 

But certainly I think one of the most important things is, and particularly when people do come in with all the bits and pieces, is really popping them...giving them a dose sheet, so giving them a spread sheet that tells them exactly what to take and when.

So like you mentioned, if you've got vitamin D or you've got fish oils or, say, vitamin E that need to be absorbed with fat in a meal, obviously naturopathically we're going to be working on their digestion and making sure that their digestive system is working well anyway but making sure that they really know when to be taking those vitamins because I'll often ask them when they come in with their bag, "Oh, when do you take these?" "Oh, I take this one and this one before bed. I take this one whatever." And it’s like, "Oh, you're taking iron and zinc at the same time. You're taking vitamin D before bed on an empty stomach." So I think that we can really help them as well. 

And I think that's what a lot of patients want is that they often will get started on their own but then they do actually want that level of support. And often it is buying those things, they've read a book, or they've heard something and they've done some research online, and they usually are quite happy to be then transitioned over into a better quality usually practitioner-only vitamin when they've finished all those as well.
And like we said with sperm, we can test it again. So often I'll say, "How long have you been on these for?" and they might say, "Six months." "Is that when you've done two semen analyses in that time and they both were poor?" So let's not just keep taking something that's meant to work. And even with my stuff, too, I say, "Look, let's work on this morphology for four months and retest, if you haven't already fallen pregnant by then. If what we're doing is not working, let's not waste your money in time because it should be."

Emma: Yeah, agreed.

Belinda: Let's look at why or what else, or change it up or see what else might be going on.

Emma: Yeah, agreed. And these patients are very vulnerable patients. Fertility is epically a rollercoaster, and I think, as practitioners, it is our duty of care to put a line in the sand sometimes and say, "We can see that this isn't giving us the results we need, and we need to think outside the square." 

What else do you think affects sperm health? So I always think I want the men coming to see me to have like super, super healthy sperm. What else do you think gets in the way of that?

Belinda: Look, I certainly think diet is a big one. Sleep quality is a big one. I think, for men, so much of it is actually just diet and lifestyle based, isn't it?

Emma: Yeah.

Belinda: How much alcohol are they drinking? How much coffee are they having? What are their stress levels like? Are they getting enough sleep? And we know that there's been research saying that men who sleep for 6 hours a night are 31% less likely to get pregnant—well, get their partners pregnant—than those who get between 7 and 8 hours because of that kind of production in testosterone. If you don't sleep enough, that reduces the release of testosterone. So even just simple things like that, I mean, how many men do we know that get less than 6 hours of sleep at night?

Emma: Yeah, plenty.

Belinda: Lots.

Emma: Yeah. Absolutely plenty. Yeah. And, look, I was reading a 2018 review, and it discussed the benefits of omega-3 fatty acids alongside a Mediterranean diet, which I think is the most researched diet in the world and one that most naturopaths and practitioners would feel very comfortable with. But interestingly, it also mentioned, in the same paper, the harmful effects of xenoestrogens found in the conventional dairy and beef. 

So what are your top three dietary strategies to help produce sperm with a high fertility potential?

Belinda: Yeah. Well, I mean, I think... And I'm going to come to my top three in a second. If you guys ever looked at that EARTH Study, so that the Environment and Reproductive Health Study, which is like an ongoing preconception cohort, which is looking at the impact of nutritional, lifestyle, environmental factors in men and women on fertility and pregnancy. So that study's been looking at male factor on IVF outcomes, and they were saying that soy food intake is negatively associated with sperm concentration. 

Emma: Right.

Belinda: Saturated and trans-fatty acid intake negatively associated with sperm concentration. Whereas your fish and omega-3s, like you mentioned, associated with an increase in sperm morphology and that the pesticides in fruit and vegetables lower sperm quality, lower sperm morphology. So there's so much research in this area for us to really be able to sink our teeth into.

And so I guess what I would say in terms of my top three strategies is that I've got this kind of what I call my “healthy eating mantra.” So every time that they...well, most times that they eat, I want them to have something on their plate that's a source of good quality protein, some good fats, and something fresh, which is ideally salad or vegetables, or maybe fruit. So that way then, if they're filling up with things they need to be having where basically they're trying to crowd out sugar, excess bread and grains. They can have bread and grains if they feel like it, but it needs to be more the accompaniment to the meal rather than the base of the meals. So I think really getting that nutrient-dense meal is really important.

Emma: Yes.

Belinda: And really looking at where their fats are coming from, because like you mentioned the Mediterranean diet, so there's been a lot of research on fertility between the Mediterranean diet and then just a general healthy, low processed diet, which is what you'd think is nearly the same. But the main difference in it was actually just the use of oils and particularly olive oil in the Mediterranean. And so they're saying that it's actually that use of olive oil and cold pressed oils that actually improves, that actually gives it the edge on fertility

Emma: I love that. I really love that. I use a lot of olive oil in my house.

Belinda: Oh, love the olive oil. And so, again, make sure it's stored properly. Give them a little bit of guidance. I don't mean spend an hour on it, but is it in a dark bottle? Do you keep it in a cupboard? How do you use it rather than, "Yeah, and I get it in a big bowl, and I sit it in the sun, and I love to let things fall in it."

Emma: Yeah, and I think this is where handouts and follow-up information can be so helpful when working in male fertility, because I've got to say nearly every man that I've ever worked with in this space, he just really appreciates data. And so if you can provide them with data, it's kind of speaking their language. Explain to them the research on smoking if they're a smoker. Really get them on board by going through the data. I found that to be such a great, successful way to work clinically rather than, with women we can tend to be a little bit more emotive, and softer, and more storytelling-like in our consults. With men, it's like I really find that they respond so well for the hard data.

Belinda: They not only respond...and obviously we're talking generally. They not only respond really well to hard data, you've got to have them in front of you online, in person, whatever, rather than using the woman as the conduit. That is a terrible way of doing it. They respond really well to direct kind of conversation data with specific on the dose very specific things that I want them to kind of be focused on. And it's really interesting because when I have just a male consult repeat, and I got him going, I'm like, "Oh, so were you able to reduce your alcohol intake?" and they're like, "Yeah, you told me to." "Oh, yeah, yeah. Okay, tick that off. And how many coffees are you doing?" and they're like, "Well, you said to not do more than one."

Emma: Correct.

Belinda: I'm like, "Oh, but are you doing that?" and they're like, "Yeah." So it's actually also like a really fast consult sometimes because often if they're motivated, and it's your responsibility to help them to get motivated with this data, with the look of outcomes, with understanding the roadmap of, "Look, we're doing this for four months and then retesting if you're not already pregnant by then." So it's highly motivating. And I would say that a good 80 plus percent of the time, they then just take on all the things that you tell them to. But you've got to spell them out and you've got to write down exactly what it is that needs to be done. So not overwhelming somebody with information but really giving them the things that need to be done. And do you find that in clinic? They're all sort of like, "Yep, did that...?"

Emma: Absolutely.

Belinda: Oh, wow. Yeah, they're just like...

Emma: Yeah, they're really compliant. And I think it's when you get granular with them and give them very specific things to do. They're really responsive, and it's really incredibly rewarding when you get that second or that repeat sperm analysis back, and you can be sharing how amazing it is with them and what they've done has resulted in this improved outcome. It's so exciting. That consult is always a really good one.

Belinda: It's really good. I had a patient just a couple of weeks ago, and they're now pregnant with their second child. Actually, the first one's four, and they've been trying for three years. They're quite similar to the other one. And this guy had a really high level of anti-sperm antibodies, and they wanted to treat him with low-dose naltrexone. They wanted to do all these things. They wanted them to do IVF, but this couple were not interested in that because of religious reasons. And they said to me, "Look, we need you to get these down." They were like, "Look, it's going to be really difficult even with IVF and things." And literally four months later and we're about to get them retested, she falls pregnant. Then he gets them retested, and they've gone down by 90%.

Emma: Unbelievable.

Belinda: They're below normal. Even I was like, "Okay, that's amazing. Wow. Did we really just do that?" Unbelievable. Well, believable, that's what we're trying to do obviously but sometimes you're just like, "Wow, that was..." They'd been told that was it. If they weren't going to be open to IVF, they wouldn't be conceiving naturally and "Sorry, this is the end of the road," type of thing. And those are not one-off stories.

Emma: No, I think anyone that works in fertility would have similar stories, and this is why I think it's so exciting, the profound difference that we can make to not only the male fertility but also to that future child's health, is going to be optimised and it's going to be better because of better sperm health. The research is really there. 

Now, I know you work a lot in IVF, but what's a tip that you can share about liaising with the medical profession throughout collaborative care?

Belinda: Yeah. Look, I'm really big on collaborative care, and, I guess, I've gotten to that point by... There's doctors and specialists that I use a lot. They refer to me, I refer to them. The more that you can be working with a group of doctors and specialists, they get to know you and they get to understand how you're working and see the improvement as well. So some of that is just stick with it. Find people that you feel like you can trust or that you respect their work. When you're referring to them, they'll then start to see that the type of clients and what you're doing with patients and start to build some trust with you as well, because a lot of the time it is just about that building trust.

So I always write a letter detailing what we're doing, if we're wanting to doing any tests and things via a GP, there's always a brief history, writing down what's happening and what we're wanting to do. I don't necessarily write why I want to do those tests, but it's sort of like they were wanting to do this kind of comprehensive thing. And I always say, "Thank you for your care and co-management of da da da da da." So it's like, "Okay, we're both working together here." 

And you're not always going to get people that want to work with you, and that's okay. You just know that, once you do start to get those doctors or specialists and things that are referring back to you or even just to start with that you are saying to your patient, "I appreciated Belinda's letter. Yeah, that's great,” or, "Belinda's taking care of the supplements, that's great." Even that just first step of getting that, I guess, respect going each way. But we do need to, I guess, earn respect.

Emma: Absolutely.

Belinda: It doesn't just come. And we don't give respect to people that haven't earned it really either. So it does kind of cut both ways. So just make sure that you are very direct in terms of... Not rude, but succinct is probably the better way of saying that. Don't waste somebody's time.

Emma: No, they're busy. They're very busy.

Belinda: And don't ask for things that you know you're not going to get.

Emma: Yeah, yeah, agreed.

Belinda: So if you're wanting to refer to things that aren't Medicare rebatable tests, I don't add them onto the big list of things that I want to ask them to do, because you're just starting to then go... They're going to get their back up a little bit or they're like, "Oh, I don't really know too much about that test." So if it's not a Medicare rebatable test, just refer for yourself.

Emma: Yeah, and I wanted to talk about... I've been reading around male infertility and melatonin, and the research is interesting. It definitely is showing that melatonin influences LH and FSH and therefore testicular function. And it really can affect the spermatogenesis. Are you using any melatonin clinically? Have you looked at the research? What are your thoughts? Because it is a bit novel, I know. It's a bit new.

Belinda: Yeah. Look, I have had a look at the research, and I do find it really interesting. And I think the naturopath in me, and this is obviously not scienfitically based, try to relate it back to lifestyle, and sleep, and things as well. 

So in Australia, melatonin is a prescription, and I don't really see it being given out for sperm and spermatogenesis and things really at all, to be honest. So people who have been on it have usually bought it from overseas, over the counter. So I'm not exactly sure of the doses and things, but when people are on it, particularly women, I'm like, "Okay, that's actually really useful for egg health as well. So, if you are taking that, then that's certainly not a bad thing."

So I do wonder though, like I mentioned, that study that looked at the sleep quality. And there has been short and long, to be honest, sleep durations and late bedtimes have been associated with impaired sperm health. We know that men produce testosterone, which is a prominent hormone in sperm production while they sleep. So I wonder as to whether we can use some of that research on melatonin as to be able to go, "Look, you can produce your own melatonin by getting enough sleep and sleeping at the right time. Dark rooms and things." But, yeah, I haven't actually been using actual melatonin and seeing the impact on that, but I do think it's really exciting because there's almost no contraindications to using it.

Emma: Yeah. Yeah. And, look, there's always something new and novel in naturopathic medicine, isn't there? So it's just interesting to see what else other practitioners are doing out there.

Belinda: Absolutely, yeah. That's the thing. There's always more you can do. Patients be like, "Oh, what about this? I also take some of this." I don't know, if you want to. So that's often where I sit and say, "Look, there's not really a harm in doing that, but I do feel really confident with the protocol that we've got here so that they're actually able to follow through on the protocol that you've got rather than chopping and changing as soon as they read something new."

Emma: Yeah, it's just not effective. 

Now, I wanted to ask you one of my last questions is, what advice would you give a new graduate or a new praccie on building a successful, but most importantly, a financially viable clinical practice? I mean, you've been in practice for 17 years. You've run your business. You are clearly very successful. What would be some advice to somebody that is less experienced or has just graduated?

Belinda: Yeah, look, it does take a little while to build your client base. So I think the first thing is ahve patience. Don't have an unrealistic expectation on what it is going to be. So you need to be getting new clients, and then repeat clients, and then some of those repeat clients will become inactive, and then they'll reactivate themselves after six months, six years, whatever. So it takes a while to get all those different types of clients happening.

I think in terms of what we give… I’ve had three or four associates working under me now. And the biggest thing that people tend to do is to over-give information. And I know you and I have spoken about this before.

Emma: Yeah, the firehosing. I call it firehosing. It's just too much, too quick, and it blows the patient out. It's just too much. Yes, agreed.

Belinda: And sometimes you've given them a dose sheet that actually has everything they need to do for the next five years, whether they'd be well and healthy again. So what's the point in coming back? 

Emma: Agreed.

Belinda: And you're also not doing them any favors because it's not like you've given them that five-year plan and now they're going to actually enact it. They're going to go, "Oh, my gosh, that was way too much. I've done three things and I've forgotten about it and not going back because I feel like I haven't actually done what she's asked me to do."

So make sure that you're really giving, I guess, patient-centric, the things that they... Tips. Make sure they're very, very clear. Don't over explain. Like when the physio says to me, "Oh, these are the exercises we need to do. This is why..." I'm happy with just hearing that "This is why," in a one sentence kind of nutshell and other things some people want to know more and that's great. You can give them more, but I don't need them to write down for me exactly why we're doing every single exercise and all this sort of stuff. It's like, I just want to know what I'm doing for the next say week or two until I see the physio again. And then when I go back, they can then give me that feedback, because they're not as interested in it as we are.

Emma: No, agreed. And I love those tips. So be patient, don't firehose your patients, take things step by step, and give very clear practical instructions to your patients. Don't over-complicate it. 

Well, Belinda, thank you so much for spending the time with us today, and thanks for all the amazing work you're doing in this area. I mean, infertility is such an emotional experience for our patients who are experiencing it, and you really provide practical and manageable solutions. So, thank you so much.

Belinda: Thank you so much for having me.

Emma: No problem. Well, thanks everyone for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website, fxmedicine.com.au. I'm Emma Sutherland, and thanks for joining us. We'll see you next time.


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