Male infertility refers to a man’s inability to get a female partner pregnant despite engaging in regular unprotected intercourse for at least a year. Globally, around 1 in 6 people of reproductive age — men and women — will experience infertility at some point during their lifetime (1). Approximately 7% of all men are affected by infertility (2). In UK alone, around 10.1% of men report having experienced infertility (3).

Male infertility is predominantly categorised by reproductive history or reproductive history. According to reproductive history classification, there are two types of male infertility:

1. Primary infertility — when a couple has never had children, either together or in previous relationships and struggle with infertility (4).
2. Secondary infertility —when the couple has already had children together or have done so separately in previous relationships, but are are having trouble (4).

When classified by underlying cause, male infertility can be defined as:

1. Pre-testicular — caused by systemic or hormonal conditions
2. Testicular — owing to issues with the testes impacting spermatogenesis
3. Post-testicular — from pathophysiologies affecting sperm transport or ejaculation (2)

While Western medicine looks into sperm count (oligospermia or azoospermia), motility, and morphology as indicators of male infertility. Chinese medicine offers a different insight into male infertility; it views male infertility as a result of deeper imbalances within the body, instead of a single disease. 

Kidneys are of utmost importance when addressing male infertility. Kidneys store jing, which is essentially an essence that a man acquires from his parents. Inherited weak jing can be due to poor parental health at conception, maternal illness during pregnancy, premature birth, or inherited genetic weakness.

Jing plays a very important role in growth, development and fertility. A man’s fertility is strong, when his Kidney jing is strong and Kidney yang is healthy. 

Weak Kidney jing can affect: 

• Production of healthy active sperm 
• Sperm count, motility, and structure
• Erectile dysfunction or premature ejaculation
• Libido 
• Hormonal balance 

Age also plays a factor in jing, levels of jing created by the Kidneys begin to decline with age. If jing becomes insufficient or damaged, sperm count drops, motility weakens, and morphology becomes abnormal. Even DNA integrity within the sperm declines with age (5).

The root cause of male infertility in Chinese medicine often starts with Kidney jing deficiency. Jing is the foundation and the root nutrition that is essential for healthy sperm production and overall male fertility. If jing is deficient or weak it further leads to imbalances in Kidney yang or Kidney yin. 

If Kidney yin and yang are balanced, a man’s sperm production and overall fertility will be healthy and functioning well. Kidney yang deficiency diagnosis occurs when there isn’t enough warmth in the body. Warmth is required to convert jing into active healthy sperm. In the same way, Kidney yin deficiency diagnosis occurs when the body is lacking cooling and nourishing support. Cooling support is required for healthy sperm. 

Along with Kidney, other organs such as Liver, Spleen and Heart also play a part in male infertility. In Chinese Medicine, the Liver is linked to emotion and is in charge of flow of qi. When the mind and body experience emotions such as anger, stress, frustration, Liver qi can stagnate, which affects the flow of qi to the reproductive organs. This was also found in a study in which liver qi stagnation was identified as a common TCM syndrome associated with male infertility (6).  

Spleen turns food into qi and Blood and moves nutrients throughout the body. When there is Spleen deficiency nutrients don’t reach the Kidneys to support sperm production. This was also confirmed by a clinical analysis of 500 infertile men where Spleen deficiency was one of the pattern diagnoses (7).

When Liver qi stagnation or Spleen deficiency are left untreated, they can turn into damp heat (inflammation) affecting sperm quality and motility even further. 

Along with weak jing being inherited from parents, jing can become weak or deficient from a range of different factors such as chronic overwork or long term stress, age, poor nutrition, chronic illness, excessive sexual activity. Therefore, addressing the root case in restoring male reproductive health is vital not just the symptoms. 

Kidney yang deficiency will show symptoms such as: 

• Low sperm motility
• Low libido 
• Erectile dysfunction 
• Frequent urination
• Fatigue

Kidney yin deficiency will show symptoms such as:

• Poor sperm quality
• Low semen volume
• Premature ejaculation 
• Cold hand and feet

As male fertility is closely linked to Kidney jing, Chinese medicine recommends herbs that have the ability to tonify the Kidneys, promote blood circulation, balance yin yang and clear Damp heat also known as inflammation. 

Red sage (dan shen, Salvia miltiorrhiza)

Salvia miltiorrhiza is a herb that is rich in antioxidant and offers anti-inflammatory properties (8). In Chinese medicine, it is used for male infertility with the goal of tonifying the Kidneys, promoting blood circulation, and clearing damp-heat (inflammation) to repair the function of the sperm. 

Goji berry (gou qi zi, Lycium barbarum) 

Goji berries strengthen jing (especially Kidney jing), which is the root foundation and the nutrition that is essential for healthy sperm production and overall male (9). Goji berries are recommended for age-related jing/fertility decline. It also nourishes Kidney yin so it makes a great herb for male infertility arising due to Kidney yin deficiency. 

In a clinical trial in men with varicocele, goji berry improved antioxidant enzyme activity and reduced oxidative stress markers (MDA), and was associated with significant improvements in sperm count, motility, morphology, and testosterone levels compared with placebo (10).

Chinese dodder (tu si zi, Cuscuta chinensis)

Tu si zi has the ability tonify Kidney yang, support jing, improve semen quality, protect sperm from oxidative/inflammatory damage, and overall male reproductive health. This was confirmed by research which found that Cuscuta chinensis flavonoids significantly reduced oxidative stress, increased reproductive hormone levels, improved sperm motility and density, and reduced sperm apoptosis in male mice (11).

Astragalus (huang qi, Astragalus membranaceous)

Astragalus is a popular TCM herb used to enhance Kidney jing indirectly, it also tonifies qi, strengthens the Spleen and Kidney, promotes blood circulation, all of which help with male fertility. Huang qi also has antioxidant and anti-inflammatory properties. Studies have shown that astragalus increased sperm count and motility in mice while affecting genes involved in spermatogenesis, as well as significantly increasing human sperm motility in vitro compared with control. (12,13). 

Weak or deficient jing, along with other deficiencies can be addressed with diet and lifestyle changes along with herbal remedies. Acupuncture is a popular treatment for male infertility. A systematic review found that acupuncture may improve male fertility by enhancing semen quality, including sperm count and motility, potentially through hormonal regulation and reduced inflammation (14). Echoing this, another study in 2022 concluded that acupuncture showed a “significant positive effect” on clinical outcomes in male infertility (15). 

Diet is another major factor. In TCM, food is a daily medicine. Diet for male infertility focuses on rebuilding Kidney jing, Kidney yang, yin as well as Liver qi and Spleen. Here are some foods recommended based on your diagnosis and root cause. 

• Support jing: Eating warm, nutrient-dense foods such as bone broth, eggs, black beans, walnuts, seeds, seafood, and slow-cooked meats helps nourish Jing
• Support Kidney yang: Lamb, beef, shrimp, cinnamon, ginger, leeks, chestnuts
• Support Kidney yin: Black sesame seeds, tofu, duck, eggs, spinach, asparagus
• Support Liver qi: Green leafy vegetables, beetroot, turmeric, peppermint tea, lemon
• Strengthen the Spleen: Rice, oats, millet, sweet potatoes, squash, carrots

1. World Health Organization. Infertility Prevalence Estimates, 1990–2021. World Health Organization; 2023. https://www.who.int/publications/i/item/978920068315   
2. Krausz C. Male infertility: Pathogenesis and clinical diagnosis. Best Practice & Research Clinical Endocrinology & Metabolism. 2011;25(2):271-285. https://doi.org/10.1016/j.beem.2010.08.006  
3. Datta J, Palmer MJ, Tanton C, Gibson LJ, Jones KG, Macdowall W, Glasier A, Sonnenberg P, Field N, Mercer CH, Johnson AM, Wellings K. Prevalence of infertility and help seeking among 15 000 women and men. Hum Reprod. 2016;31(9):2108–2118. https://doi.org/10.1093/humrep/dew123  
4. World Health Organization. Infertility fact sheet. World Health Organization; November 28, 2025. https://www.who.int/news-room/fact-sheets/detail/infertility 
5. Petersen CG, Mauri AL, Vagnini LD, Renzi A, Petersen B, Mattila M, Comar V, Ricci J, Dieamant F, Oliveira JBA, Baruffi RLR, Franco Jr JG. The effects of male age on sperm DNA damage: an evaluation of 2,178 semen samples. JBRA Assist Reprod. 2018;22(4):323‑330. https://doi.org/10.5935/1518‑0557.20180047 
6. Zhang Z, Yang J, Kong T, Wang C, Ning P, Chen X, Li X, Jia Y, Chen X, Liu S, Zhang Y. Traditional Chinese Medicine syndrome elements of male infertility revealed by latent tree model analysis. J Tradit Chin Med. 2018;38(6):926‑935. https://doi.org/10.1016/S0254‑6272(18)30993‑2 
7. Yu X‑J, Yu Q‑X, Chang D‑G, Li J‑J, Li Y, Dong L. Distribution of traditional Chinese medicine syndrome types of male infertility in Chengdu area. Zhonghua Nan Ke Xue. 2019;25(10):909‑913. PMID:32233223.
8. Zhang Y, Li X, Wang Z. Antioxidant activities of leaf extract of Salvia miltiorrhiza Bunge and related phenolic constituents. Food Chem Toxicol. 2010;48(10):2656-62. https://doi.org/10.1016/j.fct.2010.06.036 
9. Ma D, Li D, Du G, Liu S, Wang A, Chang H, Lv H, Wang H, Wang F, Guo J. Therapeutic mechanisms of Lycii Fructus in male infertility: a comprehensive review. Front Pharmacol. 2025;16:1613156. https://doi.org/10.3389/fphar.2025.1613156 
10. Mehdikhanloo M, Raeef AA, Mohammadi N, Mahmoodi M, Nasirzadeh M, Mohammad‑Sadeghipour M, Hajizadeh M. The effects of Lycium barbarum polysaccharide on oxidative stress and sperm health in varicocele patients: a randomized clinical trial. Tissue Cell. 2026;98:103160. https://doi.org/10.1016/j.tice.2025.103160 
11. Li X, Zhang Y, Wang W, et al. Protective effects of Cuscuta chinensis flavonoids on bisphenol A-induced reproductive toxicity in male mice. Reprod Toxicol. 2023;114:91‑101. https://doi.org/10.1016/j.reprotox.2023.04.006 
12. Wonnam Kim, Do Rim Kim, Mun Seog Chang, Seong Kyu Park. Astragalus membranaceus augment sperm parameters in male mice associated with cAMP-responsive element modulator and activator of CREM in testis. J Tradit Complement Med. 2015;6(3):294-298. https://doi.org/10.1016/j.jtcme.2015.10.002 
13. Hong J-S, Lee I-S, Lee S-B, et al. Astragalus membranaceus stimulates human sperm motility in vitro. (Study using sperm migration method). Fertil Steril. 1992;58(4):abstract. PMID:1471613.
14. Feng J, He H, Wang Y, Zhang X, Zhang X, Zhang T, Zhu M, Wu X, Zhang Y. The efficacy and mechanism of acupuncture in the treatment of male infertility: a literature review. Front Endocrinol (Lausanne). 2022;13:1009537. https://doi.org/10.3389/fendo.2022.1009537 
15. Feng J, He H, Wang Y, Zhang X, Zhang X, Zhang T, Zhu M, Wu X, Zhang Y. The efficacy and mechanism of acupuncture in the treatment of male infertility: A literature review. Front Endocrinol (Lausanne). 2022;13:1009537. https://doi.org/10.3389/fendo.2022.1009537 

Erectile dysfunction is the inability to achieve an erection, or to maintain a firm enough erection for sexual activity. Ejaculatory dysfunction on the other hand, refers to the inability to ejaculate, or a problem with the timing of ejaculation. It can include premature ejaculation, retrograde ejaculation, and anorgasmia (inability to reach orgasm).

Emotional and psychological factors

Erectile dysfunction is commonly caused by emotional or psychological factors, such as stress or anxiety, which trigger the release of adrenaline, restricting the blood supply to the genitals. If the person still experiences morning erections, and the ability to maintain an erection and to ejaculate during masturbation, this strongly suggests that erectile and ejaculatory problems may be related to stress or trauma.

The loss of morning erections and inability to maintain an erection or to ejaculate during masturbation is more likely to suggest a physiological problem, such as nervous system or vascular disease, or a side effect of medication (1).

Hypogonadism

Hypogonadism is associated with reduced production of LH and FSH from the pituitary gland and resulting low levels of androgens (male hormones), such as testosterone. It may be caused by obesity, nutritional deficiency, stress, inflammatory disease, ageing, and certain medications. Symptoms of hypogonadism include reduced muscle mass, fatigue, and erectile dysfunction (2).

Other underlying conditions which may cause erectile dysfunction

Erectile and ejaculatory dysfunction may also be associated with nervous system diseases (such as MS), and vascular conditions (such as diabetes) (3).

Medications which may cause erectile dysfunction

Medications which may cause erectile dysfunction and decreased libido include anti-androgens for the treatment of prostate enlargement, opioid analgesics for treatment of pain, selective serotonin reuptake inhibitors (SSRIs) for treatment of depression and anxiety, antipsychotics for treatment of mental health problems, and some diuretics and hypertensives for reducing blood pressure (4).

Premature ejaculation

Premature ejaculation is ejaculation that occurs with minimal stimulation, often before penetration. The cause is unknown, but the incidence tends to decrease with age (5).

Retrograde ejaculation

Retrograde ejaculation occurs when the bladder neck fails to close during ejaculation, and semen travels backwards into the bladder instead of being ejaculated through the penis. The urine may be cloudy after orgasm due to the presence of sperm in the bladder. Retrograde ejaculation is not harmful, but because little or no semen is ejaculated, it usually causes infertility.

Retrograde ejaculation may be caused by a spinal injury; surgery (such as prostate or bladder surgery); or neuropathy (due to diabetes of multiple sclerosis, for example) (5). Some drugs, such as those used to treat depression (e.g., SSRIs), high blood pressure (e.g., beta blockers), or enlarged prostate (e.g., alpha-adrenergic receptor antagonists), may also cause retrograde ejaculation by preventing the bladder neck from closing properly during ejaculation.

Anorgasmia

Anorgasmia, or inability to reach orgasm, may be due to emotional or psychological factors, or may be caused by a spinal injury; surgery (such as prostate or bladder surgery); or neuropathy (due to diabetes of multiple sclerosis, for example) (5).  Some drugs, such as those used to treat depression (e.g., SSRIs), high blood pressure (e.g., beta blockers), antihistamines and antiepileptic drugs may also cause anorgasmia.

Emotional and psychological factors may be improved with counselling, stress management techniques, and herbal adaptogens such as ashwagandha (Withania somnifera) and nervines such as St John’s wort (Hypericum perforatum). Damiana (Turnera diffusa) is traditionally used to treat sexual dysfunction and as a tonic for depression and nervous exhaustion (6,7).

Ginseng (Panax ginseng) root is an adaptogen, which helps to reduce fatigue and improve physical performance and well-being when under stress (8).  It improves androgen levels, (9) and reduces symptoms of erectile dysfunction in men (2).

Maca (Lepidium meyenii) improves FSH and LH production by the pituitary, increasing production of androgens, improving libido, and reducing erectile dysfunction (10). Dried maca contains gamma-aminobutyric acid (GABA), and constituents that inhibit monoamine oxidase (MAO), the enzyme that breaks down neurotransmitters such as serotonin and dopamine. This leads to a reduction in symptoms of both anxiety and depression (11). Maca also improves libido and sexual function in both men and women with sexual dysfunction due to antidepressant medication (12).

Saw palmetto (Serenoa repens) is a warming, astringent herb, which is traditionally considered to be a tonic for the genitourinary system. It is thought to remedy any atony of the testes, (13) and is recommended treating erectile dysfunction in men, particularly where this is the result of nervous exhaustion (14).

Pine (Pinus pinaster) bark extract improves testosterone levels; restores erectile function; and increases levels of nitric oxide, which acts as a vasodilator (15).

Ginkgo (Ginkgo biloba) is a circulatory stimulant which also improves libido, erection, and orgasm in men, including those with antidepressant-induced sexual dysfunction (16).

Yohimbe (Pausinystalia yohimbe) has traditionally been used in Africa as an aphrodisiac and to treat sexual dysfunction, including erectile dysfunction in men (17,18).

Nutmeg (Myristica fragrans) is considered to be rejuvenative to the reproductive tissues and is used to help improve libido and to restore erectile function in Ayurveda. It is also considered to have an astringent action and is used to help prevent premature ejaculation (19).

In Chinese medicine, sour herbs such as schisandra (Schisandra chinensis) are traditionally used for treating premature ejaculation (2).

Relaxing nervines such as skullcap (Scutellaria lateriflora) may also help to reduce the tendency to premature ejaculation (20). Other measures that are useful for improving premature ejaculation include pelvic floor muscle exercises to help regain control of the ejaculatory reflex (21).

Sympathomimetic drugs (such as ephedrine) and anti-cholinergic drugs (such as ipramine) may be used to keep the bladder neck closed during ejaculation. These drugs seem to be more effective when used together, compared to either drug used alone (22). Therefore sympathomimetic herbs such as ephedra (Ephedra sinica), and anticholinergic herbs such as deadly nightshade (Atropa belladonna), may also be helpful for patients with retrograde ejaculation, particularly when used in combination. Both of these herbs are restricted to practitioner-use only, and so may only be prescribed by a qualified medical herbalist following a consultation.

In cases of retrograde ejaculation or anorgasmia due to multiple sclerosis of diabetic neuropathy, treatment of the underlying condition may help to improve ejaculation. 

However, patients with retrograde ejaculation or anorgasmia due to spinal cord damage or surgery are unlikely to respond to medical or herbal treatment and may need to undergo assisted reproduction in order for their partner to conceive. Sperm can be aspirated from the testicles under local anaesthesia and processed before use in intrauterine insemination (IUI). 

Arginine (found in red meat, fish, and poultry, or 5 g a day as a supplement) also improves levels of nitric oxide, which improves symptoms of organic ED (23).  Other useful nutrients include zinc (found in meat, poultry, seafood, eggs, nuts and seeds), which supports testosterone production; and magnesium and B vitamins, which help with hormone balance, nervous system function and reducing stress levels.

1. Campana A, de Agostini A, Bischof P, Tawfik E, Mastrorilli A. Evaluation of infertility. Graduate Foundation for Medical Education and Research (GFMER). https://gfmer.ch/Books/Reproductive_health/infertility_evaluation.html. Accessed June 20, 2020.
2. Bone K, Mills S. Principles and Practice of Phytotherapy: Modern Herbal Medicine. London: Churchill Livingstone; 2013.
3. Dohle GR, Diemer T, Giwercman A, Jungwirth A, Kopa Z, Krausz C. Guidelines on Male Infertility. Arnhem, the Netherlands: European Association of Urology; 2010.
4. Semet M, Paci M, Saïas-Magnan J, Metzler-Guillemain C, Boissier R, Lejeune H, Perrin J. The impact of drugs on male fertility: a review. Andrology. 2017;5(4):640–663. https://doi.org/10.1111/andr.12366 
5. Heffner LJ, Schust DJ. The Reproductive System at a Glance. Oxford: John Wiley & Sons; 2014.
6. Chevallier A. The Encyclopedia of Medicinal Plants. New York: DK; 1996.
7. Bown D. Encyclopedia of Herbs and Their Uses. New York: DK; 1995.
8. Bone K. A Clinical Guide to Blending Liquid Herbs. London: Churchill Livingstone; 2003.
9. Holmes P. The Energetics of Western Herbs: A Materia Medica Integrating Western & Chinese Herbal Therapeutics. Vol 1. 4th ed. Santa Rosa, CA: Snow Lotus; 2007.
10. Holmes P. The Energetics of Western Herbs: A Materia Medica Integrating Western & Chinese Herbal Therapeutics. Vol 2. 4th ed. Santa Rosa, CA: Snow Lotus; 2007.
11. Shin BC, Lee MS, Yang EJ, Lim HS, Ernst E. Maca (Lepidium meyenii) for improving sexual function: a systematic review. BMC Complement Altern Med. 2010;10:44. https://doi.org/10.1186/1472-6882-10-44 
12. Gonzales-Arimborgo C, Yupanqui I, Montero E, et al. Acceptability, safety, and efficacy of oral administration of extracts of black or red maca (Lepidium meyenii) in adult human subjects: a randomized, double-blind, placebo-controlled study. Pharmaceuticals (Basel). 2016;9(3):49. https://doi.org/10.3390/ph9030049 
13. Dording CM, Fisher L, Papakostas G, Farabaugh A, Sonawalla S, Fava M, Mischoulon D. A double-blind, randomized, pilot dose-finding study of maca root (Lepidium meyenii) for the management of SSRI-induced sexual dysfunction. CNS Neurosci Ther. 2008;14(3):182–191. https://doi.org/10.1111/j.1755-5949.2008.00052.x 
14. Grieve M. A Modern Herbal. http://botanical.com. Accessed March 3, 2020.
15. Ellingwood F. The American Materia Medica. http://henriettesherbal.com/eclectic/ellingwood/index.html. Accessed March 3, 2020.
16. Stanislavov R, Niklova V, Rohdewald P. Improvement of erectile function with Prelox: a randomized, double-blind, placebo-controlled, crossover trial. Int J Impot Res. 2008;20(2):173–178. https://doi.org/10.1038/sj.ijir.3901597 
17. Cohen A, Bartlik B. Ginkgo biloba for antidepressant-induced sexual dysfunction. J Sex Marital Ther. 1998;24(2):139–143. https://doi.org/10.1080/00926239808404927 
18. National Center for Complementary and Integrative Health (NCCIH). Yohimbe. https://nccih.nih.gov/health/yohimbe. Accessed July 15, 2015.
19. Guay AT, Spark RF, Jacobson JS, Murray FT, Geisser ME. Yohimbine treatment of organic erectile dysfunction in a dose-escalation trial. Int J Impot Res. 2002;14(1):25–31. https://doi.org/10.1038/sj.ijir.3900803 
20. Pole S. Ayurvedic Medicine: The Principles of Traditional Practice. London: Churchill Livingstone; 2006.
21. Pastore AL, Palleschi G, Fuschi A, Maggioni C, Rago R, Zucchi A, Constantini E, Carbone A. Pelvic floor muscle rehabilitation for patients with lifelong premature ejaculation: a novel therapeutic approach. Ther Adv Urol. 2014;6(3):83–88. https://doi.org/10.1177/1756287214523329 
22. Jeffreys A, Siassakos D, Wardle P. The management of retrograde ejaculation: a systematic review and update. Fertil Steril. 2012;97(2):306–312. https://doi.org/10.1016/j.fertnstert.2011.11.019 
23. Chen J, Wollman Y, Chernichovsky T, Iaina A, Sofer M, Matzkin H. Effect of oral administration of high-dose nitric oxide donor L-arginine in men with organic erectile dysfunction: results of a double-blind, randomized, placebo-controlled study. BJU Int. 1999;83(3):269–273. https://doi.org/10.1046/j.1464-410x.1999.00906.x 

BPH involves hyperplasia of both stromal and epithelial cells within the transition zone of the prostate. This results in compression of the urethra and changes in bladder dynamics (1,4).

Key elements of pathophysiology include:

1. Androgen conversion to dihidrotestosterone (DHT) (1,4): Free testosterone is converted to DHT via the enzyme 5-α-reductase, highly active in prostatic tissue. DHT binds androgen receptors with greater affinity than testosterone, promoting cellular proliferation and inhibiting apoptosis.
2. Oestrogen’s pro-inflammatory role: Elevated levels of oestrogen can be pro-inflammatory. In BPH, oestrogen increases stromal growth, fibrosis, and the secretion of growth factors. Increased enzymatic aromatase activity, stimulated by systemic inflammation, drives excess conversion of testosterone to oestradiol. This increases the oestrogen/testosterone ratio and perpetuates prostate enlargement (5,6).
3. Chronic inflammation and cytokine activity: Inflammatory cytokines, including TNF-α, IL-6, and IL-8, stimulate cell proliferation, angiogenesis, and extracellular matrix deposition. TNF-α also increases the activity of aromatase enzyme, supporting oestrogenic activity and creating a self-reinforcing cycle of inflammation and hyperplasia (7,8).
4. Bladder changes: Long-standing obstruction can lead to detrusor hypertrophy, bladder hypersensitivity, and functional changes such as reduced compliance or impaired contractility. All this contributes to urgency, frequency, and incontinence (1).

This combination of hormonal, inflammatory, mechanical, and neuromuscular factors underpins the clinical manifestations of BPH.

These are risk factors contributing to BPH (9):

• Age over 50, with exponential risk increase with each decade
• Family history of BPH
• Metabolic syndrome, including obesity, hypertension, dyslipidaemia and insulin resistance
• Sedentary lifestyle and poor diet
• Systemic inflammation

The exact cause of BPH remains multifactorial and incompletely understood. However, several interrelated mechanisms have been identified:

Hormonal imbalance

Ageing alters androgen and oestrogen levels. Even though circulating testosterone declines with age, the prostate experiences increased conversion of free testosterone into DHT through 5-α-reductase. DHT is a potent androgen that stimulates prostate cell proliferation (5).

Simultaneously, ageing people with a prostate often exhibit an increased oestrogen-to-testosterone ratio, further exacerbated by aromatase activity. Aromatase converts testosterone into oestradiol-17β, an oestrogen that can upregulate growth factors and inflammatory signalling in the prostate (4).

Chronic inflammation

Persistent low-grade inflammation is increasingly considered both a cause and a result of prostatic enlargement. Inflammatory cytokines, including TNF-α, promote aromatase activity, perpetuating a cycle of hormonal imbalance and cellular proliferation. This chronic inflammatory environment contributes to fibrosis, smooth muscle hyperplasia, and stromal expansion (1,7).

Metabolic factors

Metabolic syndrome, insulin resistance, and obesity are associated with increased risk of BPH and LUTS (10). Hyperinsulinaemia can stimulate sympathetic nervous system activity and increase prostatic smooth muscle tone, while adipose tissue increases aromatase activity, promoting hormonal imbalance.

Genetics

Evidence suggests that familial clustering of BPH may be partly due to variations in androgen metabolism and growth factor expression. Epigenetic mechanisms, including DNA methylation and altered gene expression in prostatic stromal and epithelial cells could also be playing a role (11).

Symptoms of BPH happen as a result of mechanical obstruction from prostate enlargement and dynamic changes in smooth muscle tone around the bladder neck and urethra. Patients may present with classic LUTS, which are divided into voiding (obstructive) and storage (irritative) symptoms.

Common symptoms include (1,12):

• Increased urinary frequency, particularly during the night (nocturia)
• Urgency, sometimes accompanied by urge incontinence
• Hesitancy, a delay before initiating voiding
• Weak or intermittent urinary flow
• Sensation of incomplete bladder emptying
• Post-micturition dribbling

Assessment tools used in clinical practice include the International Prostate Symptom Score (IPSS), which grades severity, and digital rectal examination (DRE), typically revealing a smooth, symmetrically enlarged prostate (13). In some cases, urodynamic studies, urinary flow tests and prostate-specific antigen (PSA) levels may be assessed to rule out malignancy or alternative pathology (14).

Key strategies to improve symptoms of BPH include addressing hormonal balance, inflammation, and urinary function through the use of aromatase-modulating plants, anti-inflammatory herbs and bladder tonic herbs (22).

Aromatase-modulating plants

Phytoestrogens are chemical compounds in plants that act as aromatase inhibitors by decreasing aromatase gene expression, inhibiting the aromatase enzyme itself, or in some cases acting at both levels of regulation (15). Aromatase enzyme converts testosterone into oestrogen.

Testosterone has an anti-inflammatory effect, and oestrogen, although at times anti-inflammatory, generally has a pro-inflammatory effect. Pro-inflammatory cytokines (e.g., TNF-alpha) circulating in the body stimulate aromatase activity, therefore promoting the conversion of testosterone into a pro-inflammatory type of oestrogen. This is why persistent inflammation in the body is going to contribute to the aromatisation of testosterone into oestrogen.

Phytoestrogen containing plants (16):

• Red clover (Trifolium pratense) contains isoflavone biochanin A, an isoflavone that reduces aromatase gene expression (17).
• Hops (Humulus lupulus) contains prenylated flavonoids, which modulate aromatase activity and can influence androgen metabolism (18).
• Soy (Glycine max) contains the isoflavone genistein, a phytoestrogen that exhibits both aromatase inhibition and anti-inflammatory effects (16).
• Lemon (Citrus x limon), bitter orange (Citrus aurantium) and other citrus species have peel rich in naringenin, naringin and quercetin, all of which are aromatase inhibitors (19).

Foods with aromatase-modulating activity include bay leaf, mint (Mentha spp.), garlic (Allium sativum), saffron (Crocus sativus), and Brassica family vegetables, particularly broccoli sprouts (16).

Anti-inflammatory herbs

Given the central role of TNF-α and inflammatory cytokines in BPH pathophysiology, herbs that reduce inflammation are a valuable therapeutic addition.

• Saw palmetto (Serenoa repens) reduces 5-α-reductase activity, improves urinary flow, and has anti-inflammatory actions (20).
• Nettle (Urtica dioica radix) root can modulate sex hormone-binding globulin (SHBG) and reduce prostatic inflammation (21).
• African prune tree (Pygeum africanum) improves LUTS through anti-inflammatory and anti-proliferative actions (21).
• Turmeric (Curcuma longa) inhibits pro-inflammatory cytokines like NF-κB and TNF-α.

Urinary tonics

These herbs support urinary function by strengthening the bladder and can help reduce irritative symptoms (22). Examples include corn silk (Zea mays), which is demulcent and soothing to the urinary tract,  small-flowered willow herb (Epilobium parviflorum), traditionally used for prostatitis and BPH, and varuna (Crataeva nurvala), a well-known Ayurvedic herb traditionally used to support urinary tract health which helps strengthen the tone of the bladder wall and detrusor muscle (22).

Key herbs for treating prostate enlargement

Saw palmetto (Serenoa repens)

Saw palmetto has been traditionally used to manage symptoms of BPH and has been widely studied for this purpose. Its primary active constituents are found in a liposterolic extract, which includes free fatty acids (FFAs) and phytosterols (22). Clinical trials have most commonly used a dosage of 320 mg per day (23,24). Evidence from several studies suggests that saw palmetto exhibits mild 5-alpha-reductase inhibitory activity (23).

In addition, saw palmetto demonstrates anti-inflammatory effects by reducing pro-inflammatory cytokines such as IL-1 and TNF-α. A study reported a statistically significant reduction in BPH symptoms associated with saw palmetto intake (p < 0.006) (24).

However, the evidence regarding its effectiveness remains conflicting. A meta-analysis concluded that saw palmetto was more effective than placebo in reducing nocturia (p < 0.05) (23). In contrast, a Cochrane Review found no significant improvement in BPH symptoms (25). It is important to note that many of the trials included in the Cochrane Review evaluated saw palmetto as a monotherapy and used preparations of varying quality. Standardisation to free fatty acid content appears to be a key factor influencing outcomes.

The available evidence suggests that saw palmetto may be most effective when used synergistically with other medicinal plants, such as nettle root and African prune tree (26). 

Nettle root (Urtica dioica radix)

Nettle root is another medicinal plant traditionally used for treatment of BPH. It contains bioactive compounds such as polyphenols and quercetin, which have a significant anti-inflammatory action (23). Clinical trials have demonstrated good efficacy when nettle root is used in combination with a standardised free fatty acid (FFA) extract of saw palmetto (26). In these studies, participants experienced reduced urinary frequency, improved urinary flow, and decreased levels of sex hormone–binding globulin (SHBG).

Nettle root also appears to inhibit aromatisation, the conversion of free testosterone into pro-inflammatory oestrogen, which may further contribute to its benefits in BPH (27). This action could be attributed partly to lignans in nettle root, which bind to SHBG, decreasing DHT conversion (28). Additionally, clinical data indicate that nettle root is more effective when combined with an extract of Pygeum africanum than when used as a monotherapy (29).

African prune tree (Pygeum africanum)

African prune tree been studied for the treatment of BPH (30). Although its exact mechanism of action is not fully understood, evidence suggests that it has mild 5-alpha-reductase inhibitory activity, anti-inflammatory effects, and the ability to inhibit growth factors involved in prostatic enlargement (30). Clinical studies have shown that Pygeum africanum is particularly effective when used in combination with nettle root, further supporting the importance of synergistic herbal therapies in BPH management (21).

A Mediterranean diet has been associated with improved outcomes BPH. A diet rich in vegetables, fruits, nuts, legumes, whole grains, fish, and olive oil while low in red meat, provides high levels of antioxidants, carotenoids, vitamin C, and polyphenols (31). These nutrients are linked to a lower incidence of BPH and reduced symptom severity.

Reducing caffeine and alcohol intake can also improve urinary urgency and frequency, while increased consumption of cruciferous vegetables like broccoli Brussels sprouts supports oestrogen metabolism and detoxification (31,32).

Improving insulin sensitivity is also important to symptom management (33). Regular physical activity, particularly moderate aerobic exercise, reduces systemic inflammation, sympathetic nervous system activity, and lower urinary tract symptoms.

Chronic stress, which increases sympathetic tone and bladder tension, can worsen voiding symptoms, so relaxation techniques such as breathing exercises, yoga, tai chi, and meditation can support parasympathetic activity and improve urinary function (34).

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16. Balunas MJ, Kinghorn AD. Natural compounds with aromatase inhibitory activity: an update. Planta Med. 2010;76(11):1087–1093. https://doi.org/10.1055/s-0030-1250169 
17. Wang Y, Man Gho W, Chan FL, Chen S, Leung LK. The red clover (Trifolium pratense) isoflavone biochanin A inhibits aromatase activity and expression. Br J Nutr. 2008;99(2):303–310. https://doi.org/10.1017/s0007114507811974 
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20. Habib FK. Serenoa repens: the scientific basis for the treatment of benign prostatic hyperplasia. Eur Urol Suppl. 2009;8(13):887–893.
21. Hartmann RW, Mark M, Soldati F. Inhibition of 5α-reductase and aromatase by PHL-00801 (Prostatonin®), a combination of Pygeum africanum and Urtica dioica extracts. Phytomedicine. 1996;3(2):121–128. https://doi.org/10.1016/s0944-7113(96)80025-0 
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Infertility is defined as the inability to conceive a child within one year of unprotected intercourse (1,2). Overall, 15–20% of couples experience difficulty conceiving (3,4,5); however, in the vast majority of these cases, the woman alone is offered conventional treatment (6).

Reproductive health problems leading to infertility in women can be divided into two broad categories: organic infertility and functional infertility. Organic infertility is that which is clearly related to an underlying medical condition, such as hypothalamic or pituitary problems, primary ovarian insufficiency, polycystic ovarian syndrome (PCOS),  thyroid problems, pelvic inflammatory disease, endometriosis, and cervical or uterine abnormalities (7,8).

Functional infertility on the other hand is due to incorrect functioning of the reproductive system, which is not due to any underlying medical condition. It includes improper functioning of the reproductive hormones for which no underlying cause has been identified, as well as unexplained causes of infertility (9).

Abnormal blood flow

Poor peripheral circulation is a common complaint among women with a history of reproductive problems (10). Women with poor peripheral circulation may also be suffering from poor pelvic circulation, which impairs nourishment of the uterus and ovaries (11).

Painful periods may also suggest reduced uterine circulatory capacity (12). Spasmodic dysmenorrhoea (with cramping pains during menstruation) is a constrictive condition which restricts blood flow. Conversely, congestive dysmenorrhoea, which is signified by a dull, dragging sensation before the onset of menstruation, is due to pelvic blood congestion (13). Thrombophilia is another cause of poor uterine perfusion and may be a factor in subfertility (14). 

Adequate endometrial blood supply is required for implantation to occur, and women with unexplained subfertility demonstrate a significant reduction in endometrial perfusion (15). Furthermore, poor ovarian blood flow is associated with luteal phase defect, which results in low progesterone levels during the mid-luteal phase (16).

Functional hormonal imbalance

Functional imbalance of various reproductive hormones may be contributing factors to subfertility in many cases, even when blood tests show hormones to be within normal ranges.

Oestrogen

Before menopause, oestrogen is produced in the ovaries in response to follicle stimulating hormone (FSH) from the pituitary gland. Both low levels of oestrogen and oestrogen excess can lead to reproductive health problems and reduced fertility.

Symptoms of low oestrogen may include irregular or absent periods, hot flushes and night sweats, mood changes, poor concentration, sleep disturbance, reduced libido, vaginal dryness, dry eye syndrome, and changes in skin and hair (17).

Conversely, women with conditions such as menorrhagia, endometriosis, fibroids, and oestrogen-dependent cancers, are likely to have a relative excess of oestrogen (18). However, not all women with relative oestrogen excess have an identifiable oestrogen-dependent medical condition. Increased oestrogen is also associated with early larger breast size, and abdominal obesity (characterised by an increased waist to hip ratio) (19,20). Therefore women are often diagnosed with oestrogen dominance based on their clinical presentation.

Functional hormone imbalance may also be suggested by symptoms associated with premenstrual syndrome (PMS) (21). Relative oestrogen excess may increase feelings of irritability, aggressiveness, and anxiety (22). Therefore, women with premenstrual mood disturbances who are having difficulty conceiving are likely to have a relative excess of oestrogen.

Progesterone 

Progesterone is predominantly produced by the corpus luteum after ovulation, in response to stimulation by LH from the pituitary gland. Its main function is to prepare the endometrium for fertilisation; and if this occurs, to maintain the endometrium during early pregnancy and inhibit uterine contractions that would otherwise result in pregnancy loss. It also helps to counterbalance the effects of high levels of oestrogen (23). 

Any condition that results in anovulation will lead to low progesterone levels. In women who have no underlying medical condition, and who are ovulating, the corpus luteum may not produce sufficient levels of progesterone, leading to a shortened luteal phase. Symptoms such as dysfunctional uterine bleeding, cyclic breast disorders, and premenstrual mood changes may also suggest progesterone deficiency (24). Progesterone is readily converted to other hormones, including stress hormones. Therefore, stress can significantly reduce progesterone levels (23). 

Cortisol and stress

In stressful situations the adrenal glands produce cortisol in order to help the body to adapt. However, chronic stress can lead to persistent cortisol elevation.

Signs and symptoms of elevated cortisol include cognitive difficulties, mood changes, raised blood pressure, elevated  blood sugar levels, central obesity, and bone loss. High cortisol also leads to decreases in sex hormone-binding globulin (SHBG), which alters the activity of reproductive hormones.

Stress also causes the body to increase production of epinephrine (adrenalin), which causes blood to be drawn away from the uterus, and prevents the uptake of progesterone by progesterone receptors (25,26). When adrenaline is continuously elevated, production of oestrogen is  reduced (23). There is also evidence that stress alters prolactin levels. All of these effects on various reproductive hormones can reduce fertility (27).

Prolactin

Hyperprolactinaemia refers to elevated levels of prolactin, the pituitary hormone responsible for breast development and lactation (28). Hyperprolactinaemia may be caused by head or chest wall trauma, stress, various medications (especially those affecting dopamine levels), hypoglycaemia, autoimmune disease, and low thyroid function (23,29,30).  Prolactin is thought to contribute to some of the symptoms of PMS, particularly breast tenderness, fluid retention and increased anger and aggression (21,31,32). 

Prolactin levels are frequently higher in women with functional infertility, even where they may not necessarily exceed the normal reference range (21). Higher concentrations of prolactin inhibit progesterone and reduce oestrogen levels by inhibiting the activity of aromatase (the enzyme which catalyses the conversion of androgens to oestrogen) (23). 

Prostaglandin imbalance

Prostaglandin E2 (PGE2) causes inflammation, increased uterine muscle spasm, and uterine ischaemia (33,34); and significantly higher concentrations of PGE2 are found in the endometrium and menstrual fluid of women with dysmenorrhoea (35). Abnormal response to prostaglandins may also lead to premenstrual aches and pains (hyperalgesia) and menstrual migraine (34). 

An aberrant uterine response to PGE2 has been demonstrated in women with functional infertility (36). It is likely that the aberrant response to PGE2 may be responsible for failure of implantation due to uterine stimulation. 

Nutritional deficiencies

Infertility can be associated with deficiencies of various nutrients including vitamins A, C, E, B vitamins, folic acid, zinc, iron, and essential fatty acids such as EPA and DHA (37,38). Women who take multivitamins have a lower risk of infertility (39,40). 400 mcg folic acid per day is also recommended for women who are trying to conceive in order to prevent spina bifida (41).

Gluten intolerance 

Consumption of foods containing gluten (wheat, rye, barley, and spelt) may contribute to infertility in patients with gluten intolerance (42,43). It has been suggested that this may be due to resulting malabsorption of folic acid and other nutrients (44). Nutritional deficiencies (such as iron deficiency anaemia, folate or B12 deficiency), which cannot be explained by diet or blood loss, may indicate malabsorption due to possible gluten intolerance. 

Caffeine

The fertility of healthy women attempting to conceive may be halved by consumption of the equivalent of one cup of coffee or more per day (45). The mechanism of action of caffeine on fertility is unknown; however, it may be due to a combination of reduced circulatory capacity and increased production of stress hormones. Caffeine consumption has also been associated with increased risk of miscarriage. 

Alcohol 

Several studies have demonstrated that the likelihood of conception decreases with increasing alcohol intake even among women with an alcohol intake corresponding to five or fewer drinks per week (46). As little as four units of alcohol per week has also been associated with a significantly increased risk of miscarriage (47). 

Smoking 

Cigarette smoking has been linked with reduced fertility in women (48,49). The percentage of women experiencing conception delay for more than twelve months is over 50% higher for smokers than in non-smokers, and the impact of passive cigarette smoke exposure is almost as great as the impact of active smoking (50).

Each stage of reproductive function including folliculogenesis, hormone production, embryo transport, endometrial receptivity, and endometrial angiogenesis, is a target for cigarette smoke (51). Uterine blood flow is also impaired, which may be due to increased levels of adrenalin and noradrenalin, with resulting vascular resistance (52). In addition to cigarette smoking, smoking cannabis causes disturbances in the endocannabinoid system potentially contributing to infertility (53).

Exercise 

Women who exercise tend to have lighter and less frequent periods (54). This may be as a result of increased oestrogen clearance. Women who exercise regularly also have a reduced risk of infertility due to ovulatory disorders (39). However, it is also important to avoid over-exercising, since vigorous exercise for more than one hour per day is associated with infertility (55).

Drug-induced infertility

The effects of various prescription drugs (such as antipsychotics, spironolactone, and chemotherapy drugs) on fertility are well documented. However, the effects of non-steroidal anti-inflammatory drugs (NSAIDs) are less well known. NSAIDs are available over the counter, and are widely used for the treatment of pain, inflammation, and fever. However, they may also interfere with maturation and egg release by interfering with prostaglandin synthesis (56).

Treatment for organic infertility consists of treating the underlying cause  and is therefore beyond the scope of this article, which will focus on treatment of functional infertility, which is not due to any underlying medical condition.

Improving blood flow

Warming herbs such as rosemary (Rosmarinus officinalis) and ginger (Zingiber officinale) may be used to stimulate the peripheral circulation, and may also help to promote healthy circulation to the reproductive organs (57). 

In cases of spasmodic dysmenorrhoea, uterine spasmolytics such as peony (Paeonia lactiflora), cramp bark (Viburnum opulus) may be useful to improve uterine blood flow. Magnesium may also help to decrease uterine cramping (13). It is found in foods such as soya products, whole-grain cereals, seeds, and green leafy vegetables (58).

In cases of pelvic blood congestion, uterine tonics such as raspberry (Rubus idaeus) may be more useful, to encourage more effective uterine contractions (13) Yarrow (Achillea millefolium) also reduces pelvic congestion, possibly due to an anti-thrombotic effect, as well as relaxation of the veins, which allows congestion to move out of the capillaries (59,60).

There are numerous herbs, such as motherwort (Leonurus cardiaca),which seem to possess the apparently contradictory effects of both stimulating uterine activity and relieving spasm. This combination of actions helps to regulate uterine function by encouraging more orderly and effective contractions (13). Dong gui (Angelica sinensis) is another uterine tonic and antispasmodic herb, which is widely used to treat dysmenorrhoea, and is traditionally used to treat blood stasis in TCM (8,61). It is also thought to regulate prostaglandin synthesis, and to act as a circulatory stimulant (8,13). 

Nutrients which help to reduce blood stagnation include: niacin (vitamin B3), found in whole grains and sprouted legumes; vitamin C, found in fresh fruit and vegetables; vitamin E, found in whole grains, nuts, and seeds and leafy green vegetables; and omega-3 fatty acids, found in oily fish and seeds such as chia and flax (59). 

Increasing exercise helps to improve pelvic circulatory capacity, and other approaches such as sitz baths may also be used to increase the pelvic circulation and reduce congestion (1,62).

Improving oestrogen levels

Phytoestrogens are plant based compounds, which include isoflavones (found in soybeans) and lignans (found in flax seed). Phytoestrogens have an affinity for oestrogen receptors, and exert a weak oestrogenic effect in comparison to oestradiol (63). They can help to reduce symptoms associated with lower oestrogen levels, with limited side effects (64). 

Similarly, herbs such as shatavari (Asparagus racemosa), and fenugreek (Trigonella foenum graecum) contain steroidal saponins such as diosgenin, which also bind to oestrogen receptors (65).

Maca (Lepidium meyenii) can also help to improve ovarian function in women with low oestrogen. It improves both pituitary and ovarian function, and thereby increases production of both oestrogen and progesterone, reducing symptoms such as hot flushes, sweating, sleep disturbance, mood changes, joint pains, and heart palpitations (66). 

Adaptogens and adrenal tonics, such as ashwagandha (Withania somnifera) improve adrenal function, and may thereby help to increase adrenal reproductive hormone production (67). Ashwagandhahas also been shown to increase levels of DHEA, which is essential for oestrogen production in the ovary (68).

Reducing relative oestrogen excess

Environmental oestrogen-like chemicals (xenoestrogens), which are found in food contaminants (such as pesticides and plastic residues), may have an oestrogenic effect, and are increasingly implicated in cases of infertility (69). Non-organic meat and dairy products can also contain high levels of xenoestrogens (70). Women who are trying to conceive are advised to avoid eating food that has been stored or heated in plastic packaging, to avoid using pesticides in the garden, to buy organic produce where possible, and to peel or scrub any non-organic fruit and vegetables. It is also advisable to take a vitamin B complex supplement, since vitamin B deficiency seems to increase susceptibility to the effects of excess oestrogen (71).

Excess oestrogen is metabolised by the liver and herbs which improve liver metabolism include turmeric (Curcuma longa), St John’s wort (Hypericum perforatum), rosemary (Rosmarinus officinalis) and schisandra (Schisandra chinensis). 

Foods high in methionine (such as beans, pulses, onions, and garlic), cruciferous vegetables (such as cabbage, broccoli, and kale), resveratrol (from berries, grapes and red wine), linseeds, green tea, and soya also assist with metabolism of oestrogen in the liver (13,72).  

In cases of oestrogen dominance, phytoestrogens, found in soybean products, and to a lesser extent, other beans and pulses, whole-grain cereals, nuts, and seeds, compete with endogenous oestrogens and prevent them from exerting stronger oestrogenic effects (73). In order to be absorbed from the digestive system, isoflavones must first undergo hydrolysis by enzymes, which are produced by bifidobacteria in the intestine (74). Therefore, the efficacy of dietary phytoestrogens varies between different individuals depending on their gut flora. Consuming fermented soya products or taking a probiotic supplement may help to enhance the bioavailability of isoflavones (75).

Improving progesterone function

Agnus castus (Vitex agnus-castus) addresses a wide range of problems, such as premenstrual mood disturbance, fluid retention, and mastalgia due to poor progesterone function and hyperprolactinaemia (76,77,78). It is thought to inhibit prolactin release from the anterior pituitary, which leads to an increase in luteinising hormone (LH), promoting corpus luteum development in the luteal phase, and thereby increasing levels of progesterone (79). Other herbs that are thought to improve progesterone function include yarrow (Achillea millefolium), lady’s mantle (Alchemilla vulgaris), and peony (Paeonia lactiflora) (80). In fact, Paeonia lactiflora is thought to have a regulating effect on a variety of hormones including oestrogen, androgens, progesterone, and prolactin (13). 

Magnesium helps to decrease conversion of progesterone to aldosterone. It is found in soya products, whole-grain cereals, seeds, and leafy green vegetables. Adaptogens and adrenal tonics improve adrenal function, and may thereby help to increase adrenal production of progesterone and its metabolites (67). They include herbs such as siberian ginseng (Eleutherococcus senticosus) and ashwagandha (Withania somnifera).

Treating stress and raised cortisol 

In conjunction with stress management techniques, herbal treatment for excess cortisol includes nervine tonics such as St John’s wort (Hypericum perforatum), and relaxing nervines such, chamomile (Matricaria recutita) to decrease levels of stress. Adrenal adaptogens such as ashwagandha (Withania somnifera) increase the individual’s ability to adapt to various environmental factors, and to avoid the damage they may cause (81).

Reducing prolactin levels

Therapeutic measures that reduce prolactin may also help to improve fertility. For example, agnus castus (Vitex agnus castus) has been shown to increase conception in infertile women with hyperprolactinaemia and luteal phase dysfunction (77,82).  It increases dopamine, which lowers levels of prolactin (13). 

Sage (Salvia officinalis) binds to GABA receptors, increases dopamine, and inhibits prolactin synthesis and release (30,83). Black cohosh (Cimicifuga racemosa) also has a dopaminergic action, which inhibits prolactin release (23).

Deficiencies of vitamin B6, magnesium, and zinc are associated with low dopamine and raised prolactin (23). Therefore, supplementing these nutrients may help to improve dopamine synthesis, and thereby reduce hyperprolactinaemia (18). Since stress affects prolactin levels, stress management and relaxation techniques may be useful for reducing elevated prolactin levels in conjunction with herbal medicine and nutritional supplements (18).

Reducing  PGE2 in favour of  anti-inflammatory prostaglandins

Prostaglandin E2 (PGE2) is synthesised from arachidonic acid found in animal fats (33). Therefore, reducing consumption of animal fats and increasing intake of raw vegetable and seed oils selectively decreases dietary precursors of series 2 prostaglandins, and increases series 1 prostaglandins, which have anti-inflammatory, antithrombotic, and antispasmodic effects.

Essential fatty acid supplements such as evening primrose or starflower oil contain linolenic and gamma linolenic acid, which increase PGE1 (84). Vitamin E can also positively influence prostaglandin ratios; and vitamin B6 and zinc are necessary co-factors in the production of series 1 prostaglandins (13).

Ginger (Zingiber officinale) has been shown to reduce the production of prostaglandin E2, and thereby reduce excessive uterine contractions (85). Dang gui (Angelica sinensis) is also thought to regulate prostaglandin synthesis (13).

Uterine spasmolytics such as peony (Paeonia lactiflora) and cramp bark (Viburnum opulus) may be useful for dysmenorrhoea with intermittent cramping pains. Magnesium may also help to decrease uterine cramping (13). It is found in foods such as soya products, whole-grain cereals, seeds, and green leafy vegetables (13). 

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For some women breastfeeding may come easily and feel satisfying. For others it may be stressful, difficult and uncomfortable. It is a skill that can take significant patience and effort to establish and can easily be abandoned with a switch to formula and bottle feeds.

Breast milk is generally regarded as the ideal food for babies. As well as providing the correct balance of nutrients, it contains antibodies from the mother that can help protect against common infections. Breast-fed babies are less likely to be hospitalised with diarrhoea and vomiting, and reports suggest that it can also lower the likelihood of obesity and cardiovascular disease in later life (1).

There are benefits for the mother, too. Apart from encouraging bonding, it can help speed up the process of shrinking the womb back to its pre-pregnancy size (uterine involution), help the mother regain her pre-pregnancy weight and reduce the risk of ovarian and breast cancer in later life (2).

Starting breastfeeding needs support from healthcare professionals so that the mother knows how to position her baby so that it latches onto her breast easily and successfully, so that the process becomes comfortable and enjoyable for both of them. The La Leche League (3), also offers help, via a network of local groups, as well as online by social media or telephone, to help women with breastfeeding difficulties.

In the first weeks of life, breast-fed newborns need to feed eight to 12 times in every 24 hours. For mothers of premature babies expressing milk will ensure a continuing supply once the baby is home, while regular feeds also encourage further lactation. Hospital staff that claim a woman is producing insufficient milk and insist on formula top-ups can severely damage a new mother’s confidence in her ability to feed her baby successfully once she is home.

It is generally recommended to continue breastfeeding for six months even when supplemented with additional solids.

The ability to produce milk (lactation) starts in mid-pregnancy as the breasts begin to enlarge ready to secrete milk. The hormone prolactin is primarily responsible for milk production (lactation), stimulating the mammary glands to produce milk. Levels of the hormone increase during pregnancy and when, after the birth, levels of the hormone progesterone fall, prolactin and the suckling stimulus trigger actual milk production. Once lactation starts, as long as suckling continues milk will be produced. 

The first secretion produced is called colostrum and contains more minerals, proteins, and vitamins A and K than later milk. It also contains antibodies, which specifically help to protect the mucous membranes lining the baby’s throat, lungs and digestive tract from infections, and also various growth factors that help with physiological development. Within a few days a high-protein milk begins to be produced instead in much larger quantities than the colostrum. This levels off after about day nine with a regular volume maintained by regular feeds.

Often the main problem is actually getting started; finding a comfortable, relaxed position for holding the baby and latching on successfully. An adequate milk supply with the breasts drained of milk at each feed requires the mother to have good nutrition and enough energy to cope with a newborn.

What she eats not only impacts the quantity of milk she can produce, but also its taste. Spicy and pungent foods — such as chili and garlic — do give a flavour to breast milk; this might help the child be more willing to enjoy these tastes in later life. However, if they suddenly object to taking milk they had previously enjoyed, it is always worth checking on any recent food eaten by the mother that they might be objecting to. Other common issues with breastfeeding are covered in the next section.

Insufficient milk

Insufficient milk can be related to inadequate nutrition, lack of rest or stress; although, some women are just naturally short of milk and find breastfeeding a problem in successive pregnancies. Large babies can also prove very demanding and it may be necessary to supplement feeds from an early age. Advice changes but a few years ago it was certainly common for health visitors to recommend solids for larger babies from six weeks. Typical signs of insufficient milk can include a baby that has delayed bowel movements, decreased urination, weight loss and lethargy. Good maternal nutrition is vital — women need an additional 500 calories a-day when breastfeeding.  

Engorgement

Engorgement is commonest in the first five days after the birth. The milk may “come in” suddenly in a rush, and be far in excess of baby’s needs. Breasts that are over-full can feel hard, tight and painful. “Little and often” is generally the solution – increasing the frequency of the baby’s feeds will generally help to keep the problem under control. Help can be needed to ensure that the baby is well-attached — which can be difficult if the nipple is overstretched and painful — midwives or health visitors can offer assistance. A little excess milk can also be expressed by hand. A warm compress will help encourage milk flow when expressing the surplus.

Mastitis

Mastitis is an inflammation of the breast tissue. It can be very painful with lumpy tender breasts, hard or swollen areas, possibly a discharge from the nipple and the risk of feverish symptoms, which may need antibiotic treatment. The cause is often a blocked milk duct. Symptoms generally ease within 12–24 hours but seek medical help if they persist. In some cases an accumulation of milk in the breast can lead to bacterial infection and in severe acute cases an abscess may form which may need surgical incision to drain pus. Herbs that can help are included in the next section.

Blocked ducts

Blocked ducts are associated with insufficient drainage possibly due to excess milk, poor latching by the baby, feeding from one breast more often than the other, long periods between feeds or milk being left in the breast after a short feed. The baby may reject the breast as the milk flow is restricted and the breast becomes engorged or results in mastitis. If the breast is not drained of milk by the end of a feed, expressing any surplus may help prevent a blockage developing.

Sore nipples

Sore nipples are commonplace and generally caused by poor positioning of the baby, although they may also be due to sensitivity to the baby’s sucking. Sore nipples are the commonest reason for giving up breast feeding. 

Cracked nipples

Cracked nipples, often related to candida infection (thrush) can also be a problem — especially if the baby is affected as well (usually signified by a white patches, on gums or the tongue that do not easily wipe off). It can become a persistent problem unless the infection is completely cleared. Typical symptoms include pain in both breasts, which is worse after feeds.

Herbs to encourage milk production

Many herbs have traditionally been used to encourage milk production (known as galactagogues). The list includes

• Aniseed (Pimpinella anisum)
• Basil (Ocimum basilicum)
• Caraway (Carum carvi)
• Centaury (Centaurium erythraea)
• Cumin (Cuminum cyminum)
• Fennel (Foeniculum vulgare)
• Fenugreek (Trigonella foenum-graecum)
• Goat’s rue (Galega officinalis)
• Milk thistle (Silybum marianum)
• Nettle (Urtica dioica)
• Raspberry leaf (Rubus idaeus)
• Vervain (Verbena officinalis)

Several of these are common culinary herbs so using them in cooking is often the easiest way of adding them to your diet. Some, such as fennel, vervain and nettle, are readily available in commercial tea bags. Vervain and basil also have antidepressant qualities, so can be good choices if the stress of breastfeeding is affecting mood.

Alternatively a teaspoon of the dried herb to a cup of boiling water, infused for up to 10 minutes and taken two or three times a day is the usual recommendation. Not all have been extensively studied in clinical trials although one that focussed on fenugreek and milk thistle found that both had a significant impact on milk production (4,5). However, the study also noted that milk thistle can have a laxative effect and in some cases cause an allergic reaction (5).

Some of the hormonal herbs — notably agnus castus (Vitex agnus-castus) — will also help to stimulate milk production; Use tinctures and take 10 drops in water each day. Agnus castus will stimulate production of prolactin.

Herbs for mastitis

Prompt treatment for mastitis is important and the traditional remedy was simply to put a lightly crushed cabbage leaf — or soften the leaf slightly in your hands — between breast and bra and replace every four hours; if it is a large leaf, remove the rib. Cabbage is anti-inflammatory and there is plenty of anecdotal evidence to confirm its efficacy. Cabbage leaves can also help with engorgement.

Other effective external treatments for mastitis include poultices of chamomile (Chamomilla recutita), fresh broad plantain (Plantago major) or powdered marshmallow root (Althaea officinalis) — which can also be macerated in cold water overnight and the liquid used to soak a compress. 

Compresses soaked in chamomile infusion can also help or use a cloth soaked in hot water to which 2–3 drops of lavender, rose geranium or fennel oil have been added. If using essential oil ensure that the breast is wiped clean before feeding.

Treatment of fever

If there is any infection or signs of fever then echinacea (Echinacea purpurea) is valuable, either as tablets or as a tincture (up to 10ml every three or four hours); both are readily available commercially. If there is no relief within 12 hours, seeking professional help is advised. 

Hot compresses of lavender (Lavandula officinalis) or chamomile are usually recommended for engorgement, especially when expressing the surplus milk; although if there is excess heat in the breast, a cold compresses or an ice pack of frozen infusion can be used instead. Excessive milk production can be eased by drinking a cup of sage (Salvia officinalis) infusion once a day. Opt for Greek sage (Salvia fruticosa) rather than the common broad-leaved variety, as it contains much less thujone, which can be toxic in high doses (6). 

Herbs for sore or cracked nipples

At one time it was not unusual for new mothers to be sent home from hospital with a tube of marigold (Calendula officinalis) cream to use on sore nipples and it is still the most popular remedy. A marigold lotion or compress soaked in infusion or well-diluted tincture can ease discomfort during feeds with marigold cream or ointment applied to the nipple and areola (the pigmented area around the nipple) after the feed. This can be wiped away with the cloth soaked in marigold infusion before the next feed. Alternatives are chamomile or marshmallow used in very similar ways. Cracked nipples, often related to candidiasis, will also respond to marigold cream, owing to the herb’s antifungal properties.

Chamomile or marigold infusions used to soak a warm compress can also be helpful for blocked ducts (massage the breast gently towards the nipple).

And as well as drinking sage tea (one teaspoon of dried Greek sage to a cup of boiling water three times daily) to dry the milk at weaning, mothers in many tropical parts of the world where aloes grow have long used fresh aloe vera (Aloe vera) juice applied to the nipple to discourage the toddler from sucking. Cut a leaf from the plant and apply the sap directly.

Although it may seem impossible at times, reducing stress, staying relaxed and sleeping as much as possible are essential components in successful breastfeeding.

Sleep and relaxation

Relaxation is not easy with babies and other small children in the household demanding attention. Catching up on sleep while baby sleeps is one tactic worth trying. Drinking chamomile (Matricatia chamomilla) tea will help calm the mother, but it also affects her milk so the baby is calmed too and, hopefully, taken at night both enjoy some good sleep. 

Tea and coffee are stimulating, and they will stimulate the baby too. So, while coffee may give an energy boost to an exhausted mother, it might have a similar affect on baby. Other herbal teas can help — vervain (Verbena officinalis), lemon balm (Melissa officinalis) and lavender (Lavandula officinalis) are all soothing and relaxing.

Diet

Breastfeeding women need a minimum of 500 extra calories a day in a diet that contains plenty of protein, unrefined carbohydrates, fruit and vegetables. Calcium is especially important; In the past it was not unusual for women on a poor diet to lose teeth during breastfeeding as their own calcium levels were leached in producing milk for their babies. Good sources of calcium include hard cheese, sardines, nuts, pulses, tofu, and hard water The recommended daily amount during breastfeeding is 1,250 mg — so, if the diet is poor, supplement with calcium citrate or amino acid-chelated calcium.

As well as calcium the diet needs to include increased supplies of other minerals — magnesium, phosphorus, zinc, copper and selenium — as well as vitamins and essential fatty acids. Most will come from a nourishing and well-balanced diet, but adding a teaspoon of cold-pressed walnut oil to salads or vegetables will help provide essential fatty acids or take a fish oil supplement — such as cod liver oil. Avoid multi-vitamin supplements that include more than 50 mg of vitamin B6 daily as it can suppress prolactin (the hormone responsible for milk production).

In northern latitudes, especially in winter when there is little sun, most people end up with low vitamin D levels so supplementation is advisable — especially between October and March. The usual recommended daily dose is 400 IU (10 µg) but some specialists suggest significantly more — especially if the baby’s vitamin D levels are low. The Academy of Breastfeeding Medicine recommends that breastfed babies should receive vitamin D supplementation for a year, starting soon after birth at doses of  (400–800 IU per day) (7).Currently the safe upper limit for daily vitamin D is 4,000 IU daily but research shows that high dose maternal vitamin D supplementation (4,000–6,400 IU daily or a single monthly dosage of 150,000 IU) can enrich breastmilk sufficiently to give adequate vitamin D levels in babies (8). 

Exhaustion

Incessant demands, sleepless nights and lack of energy are all too common for breastfeeding mothers.  Invigorating herbal teas can help — especially tulsi (Ocimum tenuiflorum), mint (Mentha piperita), nettle (Urtica dioica) or ginger (Zingiber officinale). Oats are also helpful either in teas or as oatmeal porridge with honey as a breakfast to help combat exhaustion. The addition of a banana counters any potassium deficiency. 

Ginseng (Panax ginseng) is sometimes recommended to provide an energy boost, but its long term use in lactation has not been studied — so it may be used for short periods only. Commercial tablets are readily available.

A relaxed breastfeeding session free of any external stresses and worries can provide a harassed mother with valuable space in a busy day to simply enjoy the experience of bonding with her baby. Whenever possible choose a quiet comfortable location away from noise and distractions focus on the moment.

1. Shanshan et al. (2024) “Breastfeeding in infancy and cardiovascular disease in middle-aged and older adulthood: a prospective study of 0.36 million UK Biobank participants”, The Journal of Nutrition, Health and Aging 28 (10). https://doi.org/10.1016/j.jnha.2024.10034 
2. “Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease”, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)09454-0/abstract; , et al. (2015) “Breastfeeding and cancer”, Cancer Epidemiology, 39 (1). https://doi.org/10.1016/j.canep.2014.12.007 
3. https://laleche.org.uk/
4. Bazzano et al. (2016) “A Review of Herbal and Pharmaceutical Galactagogues for Breast-Feeding”, Ochsner Journal 16:511–524. https://pmc.ncbi.nlm.nih.gov/articles/PMC5158159/
5. Ryan et al. (2023) “Use of Galactagogues to Increase Milk Production Among Breastfeeding Mothers in the United States: A Descriptive Study”. Journal of the Academy of Nutrition and Dietetics, September 2023, Volume 123 Number 9, 1329-1339.
6. Länger R, Mechtler C, Jurenitsch J. Composition of the essential oils of commercial samples of Salvia officinalis L. and S. fruticosa Miller: a comparison of oils obtained by extraction and steam distillation. Phytochem Anal. 1996;7(6):289-293. https://doi.org/10.1002/(SICI)1099-1565(199611)7:6%3C289::AID-PCA318%3E3.0.CO;2-7
7. La Leche League: https://llli.org/breastfeeding-info/vitamin-d
8. Oberhelman et al. (2013) Mayo Clin Proc. December ; 88(12): 1378–1387. https://doi.org/10.1016/j.mayocp.2013.09.012 

In the vast majority of cases of infertility, the female partner is most likely to seek help, and very often the woman alone is offered conventional treatment (1). However, the fact is that male factor infertility accounts for up to 50% of cases of difficulty conceiving (2,3). There is a myth that age does not affect fertility in men.

However, while some men are able to conceive into their seventies, age can in fact have a significant impact on male fertility, and most men will have reduced sperm motility and less genetic integrity from their late forties (4). Even in younger men, fertility rates have declined dramatically over the last four decades (5). Environmental concerns such as exposure to radiation and plastics, together with lifestyle factors, are increasingly implicated in male infertility (6).

Male infertility is divided into three categories:

1. Pre-testicular causes (such as reduced pituitary function, exposure to oestrogens, and thyroid problems)
2. Testicular causes (such as infection, trauma or varicocele)
3. Post-testicular causes (such as erectile dysfunction, retrograde ejaculation or structural abnormalities)

This article will focus on pre-testicular causes of infertility in men and on helping to improve sperm abnormalities with herbal medicine and nutrition.

Pituitary problems

Reduced production of pituitary gland hormones, resulting in low levels of testosterone and other male hormones, may be caused by a pituitary tumour, head injury, obesity, nutritional deficiency, stress, inflammatory disease, ageing, and certain medications. 

Exposure to oestrogens

Exposure to oestrogen may inhibit sperm production in males (7). Synthetic oestrogens are widely used in livestock, poultry, and dairy industries. Many commonly used pesticides also have oestrogenic effects within the body, and chemicals such as dioxin, dichlorodiphenyltrichloroethane (DDT), and polychlorinated biphenyls (PCBs) are known to interfere with sperm production. Excessive body fat and high insulin levels (both associated with obesity) are associated with increased production of oestrogen (8). Liver problems may cause reduced oestrogen metabolism and are therefore associated with increased oestrogen in men (2). 

Sex hormone-binding globulin (SHBG) 

Sex hormone-binding globulin (SHBG) is a glycoprotein that binds to reproductive hormones such as testosterone and transports them in the blood as biologically inactive forms. A high SHBG level in males means that less testosterone is available to the body’s tissues.

SHBG is increased by high levels of oestrogen, decreased testosterone (due to stress, advancing age or pituitary problems in men), or by deficiencies of vitamin D, magnesium and zinc; or a diet low in carbohydrates, protein, fat, or omega-3 oils.

Thyroid abnormalities

Thyroid function is regulated by the hypothalamic-pituitary axis and therefore changes in thyroid function can impact greatly on reproductive hormone function (9). There is also increasing evidence for the role of thyroid autoantibodies in male subfertility, which may be linked to inflammatory changes in the reproductive tissues (9).

Conversely, an overactive thyroid increases conversion of testosterone to oestrogen (10), which inhibits testicular function and sperm production in males as previously discussed (7). 

Low sperm count, abnormal morphology and low sperm motility

Low sperm count, abnormal morphology and low sperm motility may be caused by various factors including genetic abnormalities, obesity, hormone imbalances, nutritional deficiencies, and various environmental factors, such as exposure to toxins, heavy metals, radiation, alcohol, and excessive heat (8,11). A  history of genitourinary infections can affect sperm quantity and quality, and even having a high fever can impact sperm production for up to six months (12). 

Cigarette smoking and cannabis smoking have both been associated with decreased sperm count, alterations in motility, and an overall increase in the number of abnormal sperm (13,14). Smoking also reduces blood flow to the genitals (15). Alcohol consumption also increases the number of abnormal sperm (16). Drugs, such as amphetamines, cocaine, and ecstasy can cause aspermia (absence of semen after orgasm) (12). While anabolic steroids cause reduced or absent sperm (17).

A number of orthodox drugs, such as immunosuppressants, anti-androgens, antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs), may cause reduced testosterone levels and/or decreased sperm count, reduced motility, and abnormal sperm morphology. Alpha blockers (used to treat the symptoms of benign prostatic hyperplasia) may lead to decreased sperm count and motility, and reduced ejaculate volume, while antidepressant drugs, which are regularly used by a significant number of men, have been shown to increase sperm DNA fragmentation (17).

Ejaculation that occurs daily or more frequently (due to frequent intercourse or masturbation) can also reduce sperm count (12) Conversely, low sperm motility may be caused by long periods of abstinence. Therefore, intercourse every thirty-six hours or so around the time of ovulation is optimal for conception (12).

Symptoms of low levels of testosterone may include reduced muscle mass, fatigue, reduced libido and erectile dysfunction, Symptoms of excess oestrogen in men may include gynecomastia (breast development) (18).

Symptoms of low thyroid function may include fatigue, weight gain, intolerance of cold, dry skin and hair, slow heart rate, depression, constipation, and hoarse voice. Conversely, hyperthyroidism is associated with increased appetite, weight loss, heat intolerance, sweating, increased heart rate, diarrhoea, restlessness, and tremor.

Improving testosterone levels, sperm count, morphology and motility

Astragalus (Astragalus membranaceus) also significantly increases sperm motility (29). Andrographis (Andrographis paniculata) increases testosterone levels and both herbs may improve immune response in men with Ashwagandhaanti-sperm antibodies (18). 

Ashwagandha (Withania somnifera) is traditionally used in Ayurvedic medicine for the treatment of male sexual dysfunction and infertility. It is particularly suited to men suffering from stress and anxiety (2). It improves testosterone production, reduces oxidative stress, and improves semen quality, increasing semen volume, sperm count, and motility (2,26). 

Maca (Lepidium meyenii) also improves sperm count and motility. It may act by increasing the bioavailability of testosterone, or augmenting testosterone receptor binding (27). Ginseng (Panax ginseng) is another useful herb for improving testosterone levels and sperm count (18). 

African prune tree bark (Pygeum africanum) increases total prostatic secretions and helps to maintain the appropriate pH of seminal fluid. Sperm motility is partly determined by the pH of the prostatic fluid. Therefore, Pygeum africanum (100–200mg extract per day) may help to promote optimal sperm motility and improve fertility (28).

Reducing excess oestrogen

Measures to reduce obesity may help to reduce excess oestrogen levels and improve fertility. In addition, linseed and saw palmetto (Serenoa serrulata) help to reduce the conversion of testosterone to oestrogen (18). Various other foods and herbs have also been shown to inhibit the conversion of testosterone to oestrogen, including

• Green tea (Camellia sinensis)
• Turmeric (Curcuma longa)
• Dandelion (Taraxacum officinale)
• vegetables (such as asparagus, bell peppers, cruciferous vegetables, celery)
• Mushrooms
• Citrus fruits (such as oranges)
• Strawberries (30)

It is advisable to avoid hormone-containing meat and dairy products and opt for organic foods wherever possible (7). 

Bitter herbs — such as dandelion, gentian (Gentiana lutea) and artichoke (Cynara scolymus), which increase liver function — may help to reduce oestrogen excess. Foods high in methionine (such as beans, pulses, onions, and garlic) also assist with metabolism of oestrogen in the liver (31). In addition, cruciferous vegetables (such as cabbage, broccoli, and kale) have been shown to increase metabolism and elimination of oestrogen (32).

Supporting the thyroid 

Consuming iodine rich foods including seaweeds, ensuring adequate selenium intake (from Brazil nuts), and exercising for at least 20–30 minutes a day can help to improve thyroid function in people with clinical or subclinical hypothyroidism (10). Other important nutrients for thyroid hormone synthesis include L-tyrosine, and vitamin B complex. Herbal medicines such as bladderwrack (Fucus vesiculosis) can also increase thyroid function (33). Maca (Lepidium meyenii) improves the bioavailability of testosterone as well as increasing thyroid hormone levels (34). Withania somnifera can help to reduce autoimmunity in addition to supporting thyroid function.

For patients with an overactive thyroid, herbs such as lemon balm (Melissa officinalis) and Lycopus virginicus (gypsywort) reduce thyroid overactivity (35). Reishi (Ganoderma lucidum) and sariva (Hemidesmus indicus) reduce autoimmunity (18). Motherwort (Leonurus cardiaca) is useful for reducing cardiovascular symptoms in patients with overactive thyroid. However, anyone taking medication for a thyroid abnormality should consult with a qualified medical herbalist before taking herbal medicines that affect thyroid function.

Improving testosterone levels, sperm count, morphology and motility

Pituitary function, (and therefore testicular function) may be improved by increasing exercise and improving nutrition. Supplementing essential nutrients can double the sperm count, improve sperm motility by about a quarter, and increase ejaculate volume by about a third (19).

SHBG, which reduces the amount of testosterone available to the body’s tissues, may be reduced by supplemental omega-3 oils, magnesium, zinc, vitamin D; and including healthy sources of carbohydrate, protein, and fat in the diet.

Zinc deficiency is associated with both decreased testosterone levels and sperm count, and several studies have found supplemental zinc may prove helpful in treating male infertility (20). Zinc is found in many foods, including red meat, poultry, seafood, beans, nuts, dairy products, and breakfast cereals (21).

Carnitine is essential in sperm energy production. It contributes directly to sperm motility and may be involved in the successful maturation of sperm (7). Arginine is also essential for sperm motility (22).

The sperm cell membrane and sperm DNA is highly susceptible to oxidative damage (due to stress, smoking, and exposure to other toxic substances), and antioxidant nutrients including vitamins C and E, selenium, and glutathione have been shown to significantly improve sperm concentration and motility and increase the chance of impregnation (7).

Co-enzyme Q10 is involved in energy production in sperm and also acts as an antioxidant (23). Sperm concentration, motility, and morphology have all been shown to significantly improve after twelve months of co-enzyme Q10 therapy, resulting in a beneficial effect on rate of conception (24).

Vitamin B12 is important in cellular replication, and deficiency is associated with decreased sperm count and motility (7,25).  It may be more convenient for most patients to take a male fertility supplement which combines these nutrients.Scrotal temperature is highly regulated by the body, and sperm production is significantly reduced at temperatures above 35 degrees Celsius. Therefore men attempting to improve their fertility should avoid wearing tight fitting underwear or trousers, and should avoid taking hot baths or saunas, or using hot tubs (7).

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