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Influence of Male Obesity on Fertility

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Influence of Male Obesity on Fertility Acta Clin Croat 2016; 55:301-308 Review doi: 10.20471/acc.2016.55.02.18 INFLUENCE OF MALE OBESITY ON FERTILITY Miro Kasum1, Sonja Anić-Jurica1, Ermin Čehić2, Tajana Klepac-Pulanić3, Josip Juras1 and Kristina Žužul1 1Clinical Department of Obstetrics and Gynecology, Zagreb University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia; 2Zenica Cantonal Hospital, Zenica, Bosnia and Herzegovina; 3Zagreb-East Health Center, Department of Gynecology, Zagreb, Croatia SUMMARY – Th e aim of this review is to analyze current diagnostic approaches to obesity in adult men, the potential mechanisms linking obesity to infertility, and treatment options aimed at improving reproductive health. Obesity has become a worldwide epidemic with the estimated preva- lence increasing from 28.8% to 36.9% between 1980 and 2013. In terms of diagnosis, numerous simple techniques have been developed including body mass index, waist to hip ratio, waist circumfer- ence, bioelectrical impedance analysis, ultrasound and skinfold measurements. Additionally, several other less available but more accurate techniques have been suggested, such as air displacement pleth- ysmography, dual energy x-ray absorptiometry, computed tomography and magnetic resonance imag- ing. In addition to cardiovascular and other disorders, male obesity can negatively aff ect the male re- productive potential through abnormal reproductive hormone levels, reduced semen quality, increased release of adipose-derived hormones and adipokines, as well as thermal, genetic and sexual mecha- nisms. In the management of obesity related male infertility, natural weight loss is the cornerstone and regular exercise the fi rst-line treatment. Although bariatric surgery results in greater improvements in weight loss outcomes when compared to non-surgical interventions, further research is required to clarify its overall infl uence on male fertility. Key words: Male; Obesity – diagnosis; Obesity – complications; Infertility, male – therapy Introduction weight and obesity in adults worldwide has increased between 1980 and 2013 from 28.8% to 36.9% in men Over the past three decades, many countries in the and from 29.8% to 38.0% in women, reaching epidem- urbanized world have witnessed a growing epidemic of ic proportions with 2.1 billion adults aff ected2. Th e overweight and obesity. Th e epidemic is largely fueled obesity epidemic has received considerable attention by urbanization, economic growth, industrialization, as a major global health challenge because it is associ- mechanized transport, and the adoption of sedentary ated with an increased risk of a wide array of health lifestyle, coupled with the high availability of foods problems, including diabetes, heart disease, hyperten- with high caloric content1. Since the 1970s, the rates of sion, cancers, as well as many digestive diseases, exert- excess body weight in reproductive-age men have ing a heavy toll on the economy with its massive nearly tripled, so that in westernized countries be- healthcare costs3. tween 65% and 70% of adult men are currently over- Reproductive consequences of excess body weight weight or obese. Th e estimated prevalence of over- in women have received substantial attention because obese women are more likely to experience ovulatory Correspondence to: Prof. Miro Kasum, MD, PhD, Clinical Depart- or menstrual disorders and delayed fertility. Th e ongo- ment of Obstetrics and Gynecology, Zagreb University Hospital ing pregnancy rate/cycle among obese women was Center, Petrova 13, HR-10000 Zagreb, Croatia E-mail: [email protected] found to be lower than in normal weight women Received August 17, 2015, accepted November 12, 2015 (20.8% versus 28.3%)4. Moreover, obesity has been as- Acta Clin Croat, Vol. 55, No. 2, 2016 301 M. Kasum et al. Male obesity and fertility sociated with an increased rate of polycystic ovary syn- or reproductive diffi culties12. Furthermore, male obe- drome, infertility and treatment failure, multiple com- sity may be associated with various comorbidities, in- plications of pregnancy including miscarriages, gesta- cluding metabolic syndrome, hypercholesterolemia, tional diabetes, preeclampsia, fetal macrosomia and hyperleptinemia, psychological depression, sleep ap- cesarean delivery with poor neonatal and maternal nea, renal failure, type 2 diabetes mellitus and cardio- pregnancy outcomes5. vascular diseases, all of which have independently been Until recently, the reproductive consequences of linked to male subfertility. Th erefore, it seems that the obesity on the male reproductive potential have been eff ects of male obesity and comorbidities on fertility studied to a lesser extent, although it has equally been are multifactorial, infl uencing sperm parameters, preg- linked to male infertility. Th e studies reporting correla- nancy and subsequent child health. Because it is un- tions between obesity and fertility have generally been clear to what extent obesity aff ects the reproductive inconclusive because it remains unclear to what extent potential in men, it remains to be determined whether obesity aff ects the reproductive potential in men. In the exact eff ects occur through its higher level per se, an several studies, it has been suggested that overweight associated comorbidity, or a combination of both13. and obese men showed no signifi cantly increased rela- Th e purpose of the present review is to analyze the tive risk of abnormal semen parameters6-8. A system- current diagnostic methods used to defi ne obesity in atic review with meta-analysis of 31 studies on 6800 adult males, the underlying mechanisms contributing men revealed little association between increased body to male infertility, as well as the treatment options mass index (BMI), average sperm concentration and which may lead to improvements in reproductive total sperm count. Th ere was, however, strong evidence health. for a negative relationship between increased BMI and the levels of testosterone, sex hormone binding globu- Diagnosis of Overweight and Obesity lin (SHBG) and free testosterone6. Th ese results sup- port the earlier fi ndings in a study on 2139 cases where Currently, the terms ‘overweight’ and ‘obesity’ refer overweight and obese men had a markedly changed to abnormal or excessive fat accumulation that is sex hormone profi le in serum, whereas reduction of se- greater than what is generally considered healthy for a men quality was marginal7. Similarly, no signifi cant given height. Th e terms also identify ranges of weight correlation was found between BMI and semen pa- that have been shown to increase the likelihood of cer- rameters measured in a recently published cross-sec- tain diseases, as well as other health problems14. tional study on 511 men8. However, since recently, it is Numerous simple and accessible anthropometric being increasingly documented that male excess body techniques have been developed to evaluate the body weight has a negative impact on semen parameters9-11. fat content such as BMI, waist to hip ratio (WHR), A recent meta-analysis including 21 studies and a WC, bioelectrical impedance analysis (BIA), ultra- sample of 13 077 men concluded that overweight and sound and skinfold measurements15-23. Traditionally, obesity were associated with an increased prevalence of BMI has been the most widely used method in classi- azoospermia or oligozoospermia and a signifi cantly el- fying overweight and obesity in adult populations be- evated risk of abnormal sperm count, when compared cause it provides a relatively good estimate of the risks with normal weight subjects9. It seems that obesity associated with developing diseases that occur more leads to a higher risk of sperm DNA damage in infer- frequently in people with higher body fat content. Al- tile patients because the DNA fragmentation rate was though BMI provides a signifi cantly better representa- found to be signifi cantly higher in obese, but not in tion of the body fat content when compared to simply overweight men10. When examining semen parame- measuring body weight, it is only moderately corre- ters, ejaculate volume, sperm concentration and total lated with the body fat mass. BMI is calculated as body 2 sperm count were found to show linear decline with weight adjusted for height (weightkg/heightm ) and it is increasing BMI and waist circumference (WC)11. the most commonly used diagnostic tool for general- Moreover, erectile dysfunction and low testosterone ized obesity. Despite its frequent use, BMI cannot be are frequently accompanied by obesity, particularly used to diff erentiate between subcutaneous and vis- central obesity, which can also be a cause of infertility ceral fat compartments. A BMI greater than 25 kg/m2 302 Acta Clin Croat, Vol. 55, No. 2, 2016 M. Kasum et al. Male obesity and fertility is used to defi ne overweight, while a BMI over 30 kg/m2 tion of fat mass in a large sample of adults21. Despite a is characterized as obesity. Although BMI can be used nearly 50-year tradition of ultrasound usage to assess in most individuals, it may overestimate adiposity in body fat in addition to many other body composition men whose higher body weight can be attributed to techniques, this method has not been adopted. Ultra- greater muscle and bone mass. However, BMI may sound can provide a site-specifi c evaluation of the skin, also underestimate body fat in older people and others adipose tissue and muscle thicknesses, and it is being who have lost muscle mass. Th erefore, when BMI is increasingly used to discriminate between visceral and used to indicate adiposity, gender- and age-specifi c subcutaneous adipose tissue. A comparison of the body thresholds should also be taken into account15,16. In ad- fat measurements using a portable ultrasound to those dition to BMI, alternative measurements such as WC, measured by the calipers of the skinfold technique WHR and to a lesser extent the waist to height ratio demonstrated no signifi cant diff erences. Moreover, the can be used to more accurately describe the distribu- ultrasound procedure was shown to be faster and more tion of body fat. Th ese methods have been suggested as cost eff ective than the other laboratory methods.
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