As normal spermatozoa reach maturation, the spermatozoa live in aerobic conditions constantly facing oxygen. While life is dependent on this oxygen, at the same time oxygen metabolites, such as ROS (Reactive Oxygen Species), can modify cell functions and/or endanger cell survival.^{[1,11,18,20,21]}

Neutraceutical is a portmanteau of nutrition and pharmaceutical and refers to food claimed to have medical effect on human health. It may also be narrowly defined as different types of carbohydrates and sugars, called glyconutrients by one company separate from supplements containing vitamins and minerals. Such food are also functional food. It can also refer to individual chemicals present in common foods. Many such neutraceuticals are phytonutrients. More rigorously, nutraceutical implies that the extract or food is demonstrated to have a physiological benefit or provide protection against a chronic disease. Nutraceutical or in combination of Lycopene , Selenium, Folate and Zinc , Coenzyme Q, L-Arginine, Methylcobalamin, Ascorbic acid, Tocoferol can be effective in Male Infertility Management.^[1,2,3,12]

ROS (Reactive Oxygen Species)

ROS are highly reactive oxidizing agents belonging to the class of free radicals, or molecules with unpaired electrons. Thus ROS are oxygen containing free radicals with superoxide anion O₂, hydroxyl radical (OH-), and hypochlorite radical (OHCl-) free radicals that are highly active oxidant and superoxide anion hydrogen peroxide, peroxyl and hydroxyl radicals. ROS can be produced by immature spermatozoa and leucocytes. In normal sperm physiology, low levels of ROS are beneficial and have been shown in to stimulate sperm capitation, enhance zona pellucita binding and promote acrosomes reactions. In contrast high levels of ROS are harmful and lead to lipids peroxdation of a sperm plasma membrane and DNA fragmentation. Increased lipid peroxidation an associated with impaired sperm motility and diminished capacity for sperm–ocyte fusion.

ROS primarily act as the mediators of normal sperm function. ROS also have the potential for a toxic effect at high levels on sperm quality and function.

The pathogenesis of seminal oxidative stress develops due to the imbalance between ROS generating and scavenging activities. Normally there is a production of the Reactive Oxygen Species (ROS) but they are usually diminished due to scavenging activities so the level of production and death is in balance. If there is any imbalance, then the level of ROS becomes very high and cellular damage can occur. When this oxidative stress occurs and there is an excess of ROS at the same time, there is cellular damage due to abnormal ROS generation and a deficiency of ROS scavengers or antioxidants like Superoxide Dismutase (SOD), Catalase, and Glutathione. The source of the excess ROS production in semen is due to abnormal spermatozoa and seminal leukocytes. In this discussion authors wants to highlight the role of antioxidants from the nutraceutical class in the infertility management.^{[5,
8,18,21,28]}

LYCOPENE IN MALE INFERTILITY

Lycopene is one of the 650 carotenoids. It is found in fruits, Vegetables and in microorganisms where its serves as an accessory light gathering pigments and to protect these organisms against the toxic effects of oxygen and light. Tomatoes, especially, are the richest sources. The red color of tomatoes, watermelon, and guavas, is a good indication that they contain lycopene. Lycopene has been recognized as an oral antioxidant. Lycopene has the highest antioxidant activity of all the carotenoids.It has the ability to quench singlet oxygen to trap peroxyl radicals, to inhibit the oxidation of DNA. Excessive generation of reactive oxygen species (ROS) containing free oxygen radicals has been identified as one of the causes of male infertility. The presences of antioxidants in local genital tract secretions of men have been demonstrated. Modulations of their concentrations in immune in fertile man and their correlation with the antisperm antibody titers strongly suggest the involvement in dietary antioxidants in male infertility , especially medicated through immunologic factors. Lycopene is a component of human redox defense mechanism against free radicals . It is found in high concentrations in the testis and in seminal plasma and decreased level have been demonstrated in men suffering from infertility. Reactive oxygen species are detrimental to the health and function of spermatozoa. Semen contains enzymatic and non-enzymatic defense mechanisms to combat such species, and lycopene, a dietary antioxidant, forms part of the non-enzymatic arm. Oral lycopene therapy can improve various seminal variables in idiopathic infertility. Whether this improvement is a direct consequence of increased lycopene levels in semen, resulting in an increased radical scavenging ability, remains unknown. However, a large multi-centric randomized classical controlled trial with laboratory parameters is necessary to establish the definite indication for lycopene therapy in male infertility.^{[1,3,7,17,23]}

SELENIUM

Generally selenium is found in vegetables, mushrooms, nuts, eggs, meat. Selenium is vital for human health .Scientists observed that selenium deficiency lowers the reproduction rates in man as well as in animals. Selenium is needed for production of testosterone. When selenium levels are low, sperm are immobile because the tail is weakened or deformed. In men, selenium is essential for sperm production-almost half of the male body's supply of selenium is concentrated in the testicles and the seminal ducts adjacent to the prostate gland. Selenium is an antioxidant that prevents free-radical damage, works synergistically with vitamin E, and preserves tissue elasticity. In one double-blind trial, low-fertility men who took selenium supplements increased the mobility of their sperm by 100 percent. Several studies have been carried out to find the mechanism of selenium action through identified selenoproteins. The action of selenium is best known as antioxidant which acts through various selenoproteins viz: glutathione peroxidise, thioredoxin reductase and selenoproteins P. Oxidative stress is currently being considered a leading cause of male infertility .Presently the involvement of redox active transcription factor AP1 (Activator protein 1) in testicular function is being studied. AP1 is a redox sensitive and also controls cell proliferation. The effects of selenium might be mediated through it.^[4,6,12,26]

FOLATE, ZINC AND GLUTATHIONE

Folate:

The micronutrient folate is present in a wide variety of foods,such as green-leafy vegetables, liver, bread, yeast and fruits.Folate is important for the synthesis of DNA, transfer RNA andthe amino acids, cysteine and methionine. There are two types of folic acid a methyl form required for producing the amino acid methionine and a non-methyl form which is required for producing one of the components of DNA. DNA synthesisplays an important role in germ cell development and therefore,it is obvious that folate is important for reproduction. Ithas also been reported that folic acid, the synthetic form offolate, effectively scavenges oxidizing free radicals and assuch can be regarded as an antioxidant. Despite its water-soluble character, folic acid inhibits lipidperoxidation (LPO). Therefore, folic acid can protect bio-constituentssuch as cellular membranes or DNA from free radical damage.Folate has role in spermatogenesis. The new study, published in the February issue of Fertility and Sterility, found that low levels of folic acid in men are associated with decreased sperm count and decreased sperm density. In addition, the researchers suspect that low folate levels may correlate with poor synthesis and repair of sperm DNA and thus greater risk of chromosome breaks and subsequent cancer in their offspring and there should be looked not just at mothers and how nutrition affects their progeny, but also at men, the other half of fertility. Normally, DNA is made up of four different nucleic acids: adenine, cytosine, thymine and guanine. The non-methyl folate is responsible for converting a related nucleic acid base, uracil into thymine for incorporation into DNA. If folic acid is in short supply, thymine levels will drop and a large amount of uracil instead of thymine is incorporated into human DNA. This leads to chromosome breaks when DNA is being repaired and subsequent mutations.^{[2,3,9,10,12,17,28,31]}

Zinc

Zinc is a micronutrient abundantly present in meat and seafood. Zinc serves as a cofactor for more than 80 metalloenzymes involved in DNA transcription and protein synthesis. Because DNA transcription is a major part of germ cell development, zinc is likely to be important for reproduction. Zinc concentrations are very high in the male genital organs compared with other tissues and body fluids, particularly in the prostate gland which is largely responsible for the high zinc content in seminal plasma. Spermatozoa themselves also contain zinc, which is derived from the testis. The relationship between zinc concentrations in seminal plasma and semen fertility parameters. It is involved in virtually every aspect of male reproduction, including hormone metabolism, sperm formation, and sperm motility. Zinc found in the seminal fluid, increases sperm count and mobility, and blood testosterone levels. Zinc deficiency is characterized by decreased testosterone levels and sperm counts. Zinc levels are typically much lower in infertile men with low sperm counts. So, zinc has been implicated in testiculated development, sperm maturation and testosterone synthesis.^{[6,7,9,13,14,15,19,25]}

Glutathione:

Glutathione, in purified extracted form, is a white powder that is soluble in water and in alcohol. It is found naturally in many fruits, vegetables, and meats. However, absorption rates of glutathione from food sources in the human gastrointestinal tract are low.It is produced in the human liver and plays a key role in intermediary metabolism, immune response and health, though many of its mechanisms and much of its behavior await further medical understanding. It is also known as gamma-Glutamylcysteineglycine and GHS. It is a small protein composed of three amino acids, cysteine, glutamic acid and glyceine. Glutatione is found in two forms, a monomer that is a single molecule of the protein, and a dimmer that is two of the single molecules joined together. The monomer is sometimes called reduced glutathione, while the dimmer is also called oxidized glutathione. The monomer is the active form of glutathione. Oxidized glutathione is broken down to the single molecule by an enzyme called glutathione reductase. Glutathione is the most abundant antioxidant found in the body.It plays an important role in protecting lipids, proteins,and nucleic acids against oxidative damage. It combines withvitamin E and selenium to form glutathione peroxidase. Studies show that anti-oxidant supplementation – glutathione in particular – can improve sperm quality, and possibly increase chances of conceiving. A decrease in levels of reduced glutathione (GSH) during sperm production is known to disrupt the membrane integrity of spermatozoa due to increased oxidative stress. Intracellular glutathione levels of spermatozoa are known to be decreased in certain populations of infertile men. Compared with a control group, the infertile men in all groups had significantly higher levels of ROS and lower levels of total antioxidants. There is strong clinical evidence to show that men diagnosed with infertility have high levels of oxidative stress that may impair the quality of their sperm. In some groups, higher levels of ROS were associated with lower sperm counts and defective sperm structure, while lower antioxidant levels correlated with reduced sperm movement. Glutathione therapy significantly increasedsperm motility, particularly forward progression. Glutathione is not only vital to sperm antioxidant defenses, but selenium and glutathione are essential to the formation of “phospholipids hydro peroxide glutathione peroxidase”– an enzyme present in spermatids which becomes a structural protein in the mid-piece of mature spermatozoa.

Both folate and zinc have antioxidant properties that counteract ROS.Thiols such as glutathione, balance the levels of ROS produced by spermatozoa and influence DNA compaction and stability and mortality of spermatozoa. Oocyte maturation , ovulation , luteolysis and follicle atresia are also affected by ROS .After fertilization , glutathione is important for sperm nucleus decondensation and pronucleus formation.Folate , Zinc,ROS and Thiols affect apoptosis which is important for sperm release, regulation of follicle atresia ,degeneration of the corpus luteum and endometrial shedding . Therefore, the concentrations of these nutrients may have substantial effects on reproduction.^[2,4,6,26]

ALPHA TOCOPHEROL (VITAMIN E):

Vitamin E is a lipid soluble called as chain breaking anti oxidant because of its ability to terminate a free radical chain reactions, whereby one free radical reaction leads to a generation of another free radical. Specifically Vitamin E inhibits peroxidation poly unsaturated fatty acids (PUFA).It is especially important in spermatozoa due to their poly unsaturated fatty acids content. Of the many naturally occurring Vitamin E compounds, d-alpha-tocopherol has the most biological activity and is mostly available in food. Studies also support a role for alpha tocopherol in the pathogenesis of male fertility. Alpha tocopherol was extratred from spermatozoa membranes, a positive correlation was found between alpha tocopherol content and percentage motile, living and morphologically normal sperm. And the levels of reactive oxygen species (ROS) normally limited by various antioxidant defense mechanisms such as alpha tocopherol that are present within the seminal plasma and plasma membrane. Vitamin E supplementation may also play a role in reducing DNA fragmentation. Some evidence suggest that a relationship between daily anti oxidant like Vitamin E intake gives better semen quality amongst healthy men.^{[17,18,27,31,33,35]}

CO-ENZYME Q

Coenzyme Q10 (CoQ10) is a nutrient used by the body in the production of energy. While it’s exact role in the formation of sperm is unknown, there is evidence that as little as 10 mg per day (over a two-week period) will increase sperm count and motility. The deep involvement of coenzyme Q (10) in mitochondrial bioenergetics and its antioxidant properties are at the basis of its role in seminal fluid. After the first invitro experiments, CoQ (10) was administered to a group of idiopathic asthenozoospermic infertile patients. Seminal analysis showed a significant increase of CoQ (10) both in seminal plasma and in sperm cells, together with an improvement in sperm motality.The increased concentration of CoQ (10) in seminal plasma and sperm cells, the improvement of semen kinetic features after treatment and evidence of a direct correlation between CoQ (10) concentrations and sperm motality strongly support a cause/effect relationship.^{[11,12,23,24,33]}

L-ARGININE AND L CARNITINE

L-ARGININE

Arginin an amino acid found in many foods, is needed to produce sperm, sperm maturation and the maintenance of sperm quality. It is found in the heads of sperm. Research, most of which is preliminary shows that several months of L-arginine supplementation increases sperm count, quality fertility. However when the initial sperm count was extremely low (such as less than 10 million per ml). L-arginine supplementation produced little or no benefit. For infertile men with sperm counts greater than 10 million per milliliter, many doctors recommend up to 4 grams of L-arginine per day for several months.^{[2,7,13,15,16,24,35]}

L-CARNITINE

Researchers have found that L-carnitine is found in much greater amounts in sperm than other cells. A deficiency of carnitine results in a decrease in fatty acid concentrations in the mitochondria and reduced energy production. Preliminary studies suggest that L-carntine and acetyl L-carnitine may be able to stimulate sperm motility in certain situation. The role of L-carnitine of sperm maturation and sperm quality is however still unclear. Several clinical studies have evaluated the effect of L-carnitine on men with a low sperm count, a reduction/loss in sperm movement or men with both conditions. These studies have evaluated only small no of men who took oral carnitine supplements for varying lengths of time. Some patients enrolled in these studies experienced increased sperm count and/or increased sperm motility.^{[2,7,13,15,16,22,24,35]}

METHYLCOBALAMIN (VITAMIN B₁₂)

Vitamin B₁₂ is involved in cell maturation, DNA and RNA synthesis with folate. These make up the blueprint for the genetic code of the entire body. Mild vitamin B ₁₂ deficiencies are relatively common in people over 60. A deficiency of Vitamin B₁₂ leads to reduced sperm counts and reduced sperm motility. Even if there is no deficiency of Vitamin-B_I2, its supplementation may be beneficial for men with sperm count less than 20 million/ml or a motility rate of less than fifty percent. The effect of methylcobalamin on sperm production in the oligozoospermic mice experimentally induced was evaculated quantitatively by means of equilibrium sedimentation in Percoll.After centrifugation the distribution profile of the sperm showed 2 peaks i.e the first peak near bottom consisting of mature sperm with good motality and the second peak containing immature and/or immotile sperm. By oral administration of methycobalamin (1mg/kg/day) to the oligozoospermic mice for 10 weeks, the sperm count sperm motality, motile sperm count, diameter of seminiferous tubules and the percentage of good motile sperm with higher apparent density were increased as compared with those of the control .These results suggest that Me-B 12 enhanced the testicular function, resulting in an increased output of mature sperm.^{[3,6,12,19,28,31,32,34]}

ASCORBIC ACID (VITAMIN C)

Ascorbic acid or Vitamin C is a major water soluble antioxidant acting as a scavenger for a wide range of ROS. It is present at approximately ten fold higher concentration in seminal plasma as compared to blood and is mostly secreted from seminal vesicles. Ascorbic acid acts as a powerful electron donor that reacts with superoxide, peroxide and hydroxyl radicals to form dehydroascorbic acid. It also recycles Vitamin E. It protects sperms against DNA damage induced by H₂O₂ radical and also reduces nitrite. But Vitamin C can also have a paradoxical effect as it can produce some ROS by its action on transition metal ions and so Vitamin C decreases sperm abnormalities and increases sperm number and quality.^{[2,5,8,29,30,31]}

Table 1. Nutritional Supplements that May Improve Sperm Parameters

Supplement	Dose	Benefit possible
Vitamin C	500mg/day	Decreases sperm agglutination (clumping)
Vitamin E	400IU/day	May improve fertilization rates in IVF
Zinc	25 mg/day	May improve sperm motility
Selenium	200mcg/day	Improved benefit
L-Carnitine	500mg/day	Improved count and motility
Folic Acid	400mcg/day	Formation of genetic materials
Coenzyme Q10	60 mg/d	Improved motility

CONCLSION:

Many environmental and biochemical factors are involved in male and female reproduction. The importance of many of these factors is not yet clearly understood. Still. In addition to other possible underlying mechanisms of infertility, the pathways in which nutrition, genetics, antioxidants and apoptosis are involved as reviewed in this article need to be further investigated.

Spermatozoa are under a continuous influence of Oxidative stress (OS) because ofexcessive generation of ROS. Although spermatozoa are affectedin different ways by OS, there are sufficient antioxidant protectionsthat can decrease the progression of the damage. However, whenan imbalance exists between levels of ROS and the natural antioxidantdefenses, various measures can be used to protect spermatozoaagainst the OS-induced injury. Diet forms an importantcomponent of the antioxidant protection system; it suppliesthe major antioxidants such vitamin C, vitamin E, vitamin B_12, l-arginine, l-carnitine and lycopene.Therefore, food rich in these elements should form a part ofthe daily diet. For those patients who are suspected to havehigh levels of ROS, antioxidant supplements can be considered.Nevertheless, further studies are required to validate theiruse in this group of patients. In certain cases, it is alsoessential to modify certain lifestyle behaviors because manyhabits and environmental factors increase the production ofROS and affect fertility.

ACKNOWLEDGEMENT:

Authors are very much thankful to the BM college of Pharmacy Education and research Indore, Radha Raman College of Pharmacy Bhopal and Vel’s College of Pharmacy, Chennai for providing necessary facilities.

REFERENCES:

1. Gupta NP ,Kumar R.Lycopene therapy in idiopathic male infertility a preliminary report.Int Urol Nephrol 2002;34(3):369-72.

2. Altman, Roberta, Michael J S. The Cancer Dictionary. New York: Facts on File, 1992.

3. http://www.pdrhealth.com/drug_info/drugprofiles/lycopene

4. Cook, Allan R. Alternative Medicine Sourcebook. Detroit: Omnigraphics, 1999.

5. Palan P,Naz R,Changes in various antioxidants levels in human seminal plasma related to immunoinfertility.Arch Androl.1996 March-April;36(2):139-43.

6. Claire Cassidy,James S. Gordon, Ralph W. Moss, Richard Pavek. Allen The Alternative Medicine Sourcebook and Health Reference Series.

7. Shalini S,Bansal MP,Role of selenium in regulation of spermatogenesis; involvement of activator protein 1, Biofactors.2005;23(3):151-62/

8. Ebisch I M ,Thomas CM ,Peters WH, Braat DD, Steegers –Theunissen RP,The importance of folate, zinc and antioxidants in the pathogenesis and prevention of subfertility. Hum Reprod Update.2007.March-April;13(2):163-74.

9. New England Journal of Medicine. 342.5 (2000):326-333.

10. Woodham, Anne, and David Peters. Encyclopedia of Healing Therapies. New York: Dorling Mancini A,De Marinis L,Littaru GP, Balercia G, An update of Coenzyme Q10 implication in male infertility:biochemical and therapeutic aspects. Biofactors 2005;25(1-4):165-74.

11. "Dietary Supplement Health and Education Act of 1994."CIS: Lexis-Nexis. 17 Feb. 2000<http://web.lexis-nexis.com/ congcom.

12. Morales ME ,Rico G, Bravo C, Tapia R, Alvarez C, Mendez JD, Progressive motality increase caused by L-argenine and polyamines in sperm from patients with idiopathic and diabetic asthenozoospermia,Ginecol Obstet Mex 2003 June ;71:297-303.

13. Wilk et al. v. the American Medical Association, Nos. 87-2672, 87-2777, U.S. Court of Appeals for the Seventh Circuit, 1990. Academic Universe: Lexis-Nexis.4 Mar. 2000,<http://web.lexis-nexis.com/univers.

14. Whitney, Eleanor Noss, and Sharon Rady Rolfes. Understanding Nutrition. 4th ed. Belmont:Wadsworth, 1999.

15. Oshio S,Ozaki S,Ohkawa I, Tajima T,Kaneko S ,Mohri H, Mecobalamin promotes mouse sperm maturation , Andrologia 1989 March-April;21(2):167-73.

16. http://www.fertilitymemphis.com/article_improving_male_fertility.aspes

17. http:// humupd.oxfordjournals.org/cgi/reprint/13/2/163.pdf

18. http://www.bodyandfitness.com/Information/Menhealth/infertility.htm

19. http://medind.nic.in/iaf/t09/i3/iaft09i3p312.pdf(vit-c)

20. http://www.berkeley.edu/news/media/releases/2001/02/26_diet.html

21. http://www.fertilaid.com/l-carnitine-fertility.asp

22. http://www.maleinfertility.org/lifestyle.html

23. http://dx.doi.org/10.1111/j.14...07.06804.x

24. http://www.holisticonline.com/remedies/infertility/inf_men_nutrition.htm

25. http://www.VitaminLore.com

26. http://www.maleinfertility.org/lifestyle.html

27. Chinoy N. J, Structure and physiology of mammalian vas deferens in relation to fertility regulation, J. Biosci. March 1985;7(2):215–221.

28. Sharma J.D. Lalita Sharma and Yadav Poonam, Antifertility Efficacy of Piper betle Linn. (Petiole) on Female Albino Rats, Asian J. Exp. Sci., 2007; 21(1):145-150.

29. Piyali Das, A R Choudhari, A Dhawan and Ramji Singh, Role of ascorbic acid in human seminal plasma against the oxidative damage to the sperms, Indian Journal of Clinical Biochemistry,2009;24(3):312-315.

30. American Society of Andrology, Journal of Andrology. November/December 2005.26(6).

31. Goyal. A, Chopra M, Lwaleed B.A, Birch B and Cooper A.J. (2007) the effects of dietary lycopene supplementation on human seminal plasma.BJU International, 99; 6:1456-1460.

32. http://www.agresearch.umd.edu/CFNAP/Outreach/Conference%20Proceedings/pdfs/Tomato_Lycopene_Final_Web.pdf

33. http://www.vasdoctor.com

34. http://www.holisticonline.com/remedies/infertility/inf_men_nutrition.htm

35. Agarwal. A, Kiran P, Shyam S,R. Allamanenimer, M. Said, Reproductive BioMedicine Online, June 2004;8(6); 616-627(12).

Received on 21.10.2010

Accepted on 28.11.2010

Research J. Pharmacology and Pharmacodynamics. 3(1): Jan. –Feb. 2011,10-14