Medications and Supplements

Medications and Supplements- Male Infertility

Sperm production is a complex process that lasts approximately ten weeks, during which time sperm precursor cells are transformed into fully mature sperm. At any time during this process, sperm production can be influenced by outside factors, including medications or supplements that may be taken.  In general, topical medications (such as creams or ointments) are going to have much less systemic absorption, and typically have little impact on male fertility potential.


Prescription Medications

 

The following categories of medications are known to potentially have a significant negative impact on male fertility:

      1) Antibiotics

      2) Antifungal/antiparasitic medications

      3) Antiseizure medications

      4) Cardiovascular medications

      5) Chemotherapeutic agents

      6) Gastrointestinal medications

      7) Gout medications

      8) Hormonally active agents

      9) Narcotics/opiates

     10) Prostate medications

     11) Psychiatric medications

 

This website does not contain a complete list of all medications that can potentially have a negative impact on sperm quality - studies are constantly being performed to identify additional medications that can affect fertility.  However, we have tried to include as many as possible of the most common agents that are known to impact sperm numbers and quality.

It is important that you have a discussion with your health care provider before making any changes to your medications. This book aims to provide you with information for your own knowledge, and you can share it with your personal physician if you learn something that may be pertinent to your situation. Decisions about which medications are right for you depend heavily upon individual factors, and the potential risks or benefits to stopping or changing any of your medications need to be adequately weighed by a health care professional familiar with your medical history and circumstances.

 

Antibiotics

Many antibiotics are known to have a potentially negative impact on sperm quality. These include:

      1) Tetracycline

      2) Aminoglycosides (such as erythromycin, gentamicin, and neomycin)

      3 )Nitrofurantoin

      4) Minocycline

      5) Sulfamethoxazole (Septra, Bactrim), co-trimoxazole

      6) Penicillin

      7) Ampicillin

 

Antifungals and Antiparasitics

Some antifungal and antiparasitic medications are known to have a potentially negative impact on sperm quality. These include:

      1) Ketoconazole

      2) Chloroquine

      3) Niridazole

 

Antiseizure Medications

Although antiseizure medications such as carbamazepine (Tegretol) are known to be associated with decreased testosterone levels and sperm quality in some men, these medications cannot typically be safely stopped due to the health and safety risks involved with recurrent uncontrolled seizures. Epilepsy itself may also be related to hormonal imbalances in some men.

 

Cardiovascular Medications

There are many types of medications that are used to treat various cardiovascular problems, and some of them may have an effect on fertility in men:

 

      1) Spironolactone: can decrease testosterone levels and negatively impact sperm function

      2) Calcium channel blockers: may interfere with egg/sperm interactions

      3) Digoxin: may affect erections and libido

      4) Clonidine: can increase the chance of erectile dysfunction

      5) Beta-blockers: can increase the chance of erectile dysfunction

      6) Thiazide diuretics: can increase the chance of erectile dysfunction

 

Initial human studies of atorvastatin (Lipitor) showed decreased sperm motility, but no significant impact was seen in larger studies, so it is likely okay to use it to control high cholesterol.

 

Chemotherapeutic Agents

See “Cancer Treatment” in the "Medical Conditions and Male Fertility" section of this website for more information regarding the impact of chemotherapy on male fertility.

 

Gastrointestinal Medications

A number of drugs used to treat gastrointestinal problems may be problematic for men trying to conceive. I’ve listed some potential alternatives.

 

1) Cimetidine (Tagamet)

-Potential alternatives: ranitidine (Zantac), famotidine (Pepcid), omeprazole (Prilosec)

 

2) Metoclopramide (Reglan)

-Potential alternative: prochlorperazine (Compazine)

 

3) Sulfasalazine (Azulfidine)

-Potential alternative: mesalamine (Asacol)

 

One medication that differing opinions exist about is azathioprim (Imuran), which is used for treatment of Crohn’s disease (and also for treatment of rheumatoid arthritis). It may cause a small decrease in sperm motility and a mild increase in sperm DNA fragmentation. It also may have a possible mild mutagenic effect, but animal studies suggest that this is more likely to cause a slight increase in early embryonic death, as opposed to increased birth defects in children who are born.

 

Gout Medications

Colchicine and allopurinol, two medications used to treat gout, may have an impact on male fertility. Potential alternatives for treating this condition include probenecid, NSAIDs, corticosteroids, and dietary modification.

 

Hormonally Active Agents

Medications that impact hormone levels can have a significant negative impact on sperm production and quality. Examples of these medications include:

 

1) Exogenous androgens. These are a very common source of male fertility problems, and are covered in their own section "Exogenous Androgens/Anabolic Steroids" in this website.

2) Treatments for advanced prostate cancer. Drugs such as cyproterone, leuprolide (Lupron), goserelin (Zoladex), and bicalutamide (Casodex) can decrease testosterone production.

 

3) Estrogen therapy. This may decrease sperm function and potentially increase the risk of testicular cancer.

 

Narcotics/Opiates

Long-term narcotic use is known to have a significant negative impact on testosterone levels in most men, which can in turn have a negative impact sperm production and quality. Examples of commonly used pharmaceutical narcotics include:

 

1) Codeine (Tylenol #3, Paramol, Nurofen Plus)

2) Hydrocodone (Vicodin, Norco, Lorcet, Lortab)

3) Oxycodone (OxyContin, Percocet, Roxicodone, Tylox)

4) Morphine (Duramorph, Avinza, Kadian)

5) Fentanyl (Durogesic, Actiq)

6) Methadone

 

Prostate Medications

Possible negative effects may be found with the following:

 

1) Alpha-blockers such as tamsulosin (Flomax), silodosin (Rapaflo): may cause anejaculation or retrograde ejaculation (see those sections later in this chapter)

2) 5-alpha reductase inhibitors such as finasteride (Proscar), dutasteride (Avodart): some studies have found a mild increase in the risk of ejaculatory and erectile dysfunction with these medications, as well as the potential for hormonal imbalances

3) Saw palmetto (herbal supplement): may act like 5-alpha reductase inhibitors (above) and cause similar problems

 

Psychiatric Medications

Some antidepressant medications, especially the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro), can be problematic for men trying to conceive. They may be associated with erectile dysfunction and ejaculatory dysfunction (see the sections on these later in this chapter). They may cause a longer sperm transit time, which can lead to decreased sperm motility, increased sperm DNA fragmentation, and in rare cases azoospermia (which studies show resolved one month after stopping the medication).

Some studies have shown fewer sperm transport issues with a change in antidepressants from SSRIs to medications such as bupropion (Wellbutrin). Of course, the mental well-being of the man needs to be taken into consideration as well, and any changes to antidepressant medications should only be made under the careful monitoring of a primary care physician or psychiatrist.

Antipsychotic medications such as haloperidol, benperidol, and trifluperidol can modestly decrease sperm production and quality in some men. These medications can be difficult and/or unsafe to modify, and changes should be made only under the care of a primary care physician or psychiatrist.

 

Other Medications That Can Affect Sperm Production

A number of other drugs may cause fertility-related problems in men:

 

1) Cyclosporine: used to prevent rejection in organ transplantation, it can decrease sperm quality in some men.

 

2) Danazol: a weak androgen sometimes used to treat angioedema. Its effects on fertility are not clear at this time.

 

3) Isotretinoin (Accutane): an acne drug that can decrease sperm production. Note that while women taking it are at serious risk of having a child with birth defects should they become pregnant while on the drug, men taking it do not run the same risks of birth defects in children they may father while on it.

 

4) Methotrexate: a chemotherapeutic agent used for leukemia, rheumatoid arthritis, and psoriasis. It may have a potential negative impact on sperm quality as well as a potential increase in birth defects. See “Cancer Treatment” later in this chapter.

 

5) PDE-5 inhibitors: used for the treatment of erectile dysfunction. See ”Erectile Dysfunction” later in this chapter.

 

6) Finasteride (Propecia): used in the treatment of male pattern hair loss. This drug can potentially have a negative impact on erections, ejaculation, and the hormonal environment for sperm production. An alternative that could be used is minoxidil (Rogaine).

 

7) Rapamycin and sirolimus: used in treatment of certain cancers and some benign vascular disorders. There is some evidence that these drugs can potentially decrease sperm counts and testosterone levels.


Herbal Medications and Supplements

 

Herbal medications are widely used in the United States; many people believe that these “natural” remedies have a lower risk of adverse side effects. Many men with fertility problems turn to herbal medications. A 2004 study looked at 481 men evaluated in an infertility clinic and found that 31 percent of them were taking alternative medications, and that 17 percent of these supplements had clear hormonal activity that was potentially detrimental to sperm production.

I recommend that men with fertility problems stop taking natural supplements. This is not to say that I believe there are no supplements that may eventually be found to have a beneficial impact on sperm counts and quality. Rather, at this time there are multiple problems with the way that natural supplements are tested, manufactured, and marketed.

You may think what you want about vast federal bureaucracies and their inevitable political squabblings and inefficiencies, but the FDA does provide a very powerful and beneficial service in terms of securing a degree of safety and fraud prevention with the manufacture, marketing, and distribution of prescription medications. The days of snake-oil salesmen peddling ineffective and sometimes dangerous homemade remedies are thankfully behind us, at least when it comes to medications requiring a prescription.

Unfortunately, natural supplements do not fall under the jurisdiction of the FDA, and therefore they do not undergo the same intense level of scrutiny that prescription medications need to pass before being approved for use. The criteria for safety and efficacy testing are much less stringent with natural supplements. When it comes to male fertility, a huge number of alternative treatments, ranging from specific natural supplements to eating more avocados or oysters, have been found by small, uncontrolled studies to potentially be associated with an improvement in semen parameters. In the field of prescription medications, most medications that small, uncontrolled studies have suggested may have some positive effects are later, after being tested in the much larger, more rigorous studies required to attain FDA approval, shown not to have a significant positive outcome. Natural supplements, however, do not have to undergo these larger studies, and therefore claims from these small studies are rarely proven or disproven. These small studies also do not produce the same kind of safety data seen with larger, more rigorous studies.

The other problem with a lack of FDA oversight is that the manufacturing process is much less stringently regulated for nonprescription substances. Therefore, purity and amounts of active ingredient can vary significantly between products from different manufacturers. Another alarming trend is the undisclosed addition of certain pharmaceutical agents into allegedly “natural” supplements. Sildenafil (Viagra) has been found in supposedly natural nonprescription supplements for erectile dysfunction, for example, and testosterone derivatives have been found in supposedly natural bodybuilding supplements.

In addition, many natural substances (such as root and bark extracts) have not been thoroughly studied, and may in fact contain hormonally active chemicals that are actually detrimental to male fertility.

Even if you’re taking supplements for other reasons besides fertility, I strongly recommend that you stop taking them when you are trying to have a child. Some studies have shown that commonly used herbal supplements such as St. John’s wort, echinacea, and ginkgo biloba may have a negative impact on male fertility.

The argument can be made that large scientific studies are expensive, and no company is going to spend the money to conduct these studies on natural supplements for which a patent cannot be obtained. I think that there may be a role for government financial support of such studies for particularly promising supplements. However, until larger controlled studies show measurable and reproducible improvements in fertility, I do not feel that these supplements are worth the money or the risk of potentially negative side effects.