Supplements containing zinc and folic acid that were previously used to treat infertility in men make no difference, U.S. Department of Health and Human Services National Health Institute (NHI) has found.

The study has been labelled a landmark for examining the effectiveness of supplements in treating infertility in men. While this is not the first study to look at this issue, it has brought forward the subject once again about the effects of zinc supplementation on male fertility.

In most Nigerian communities, children are considered an assured outcome of a marriage. Children are more often than not expected to follow a union; so much so that most people do not think of infertility as a possibility. However, it is estimated that 10-15 per cent of Nigerian couples grapple with infertility.

A study carried out by the think-tank – Guttmacher Institute– indicated that primary infertility is 31per cent in Nigerian couples, with variation among the states. It has also been shown that males and females contribute equally -50 per cent, to this burden.

What is Infertility?

Infertility is defined as the inability of a couple to get pregnant after a year of regular unprotected sexual intercourse (i.e engaging in sexual activity for at least three times a week for a whole year); or six months in a woman over the age of 35 (primary infertility). It also refers to the inability to stay pregnant (secondary infertility).

Couples, therefore, do not always have to wait a few years before realising their infertility problem.

The African Societal Narrative

We often forget that infertility is a problem shared by both the male and female party. The issue of male factor in infertility is obscure for reasons stemming from a societal notion of a woman’s ‘duty’ and ‘fault’, in every case of infertility. On the other hand, among men, it can be a rather shameful or taboo topic entirely.

There is a widespread supposition that Africa and Sub-Saharan Africa, in particular, are unaffected by the growing incidence of infertility in the world. This is primarily premised on the rate and accelerating population growth in these countries. The narrative is also one of an underdeveloped society fraught with abject poverty, malnutrition, high mortality and morbidity rates from communicable diseases. Indeed, data from the World Bank shows the rate of fertility is 4.7 in sub-Saharan Africa. This implies that births per woman are about four children in sub-Saharan Africa.

Comparing this number to our western counterparts puts the number into perspective. In the United States, for example, the birth rate per woman (fertility rate) is 1.7. This is the same number in the United Kingdom. In contrast, the average woman in Nigeria has or would have about five children during her childbearing years, as per the World Bank data.

Fertility on the decline

Nonetheless, we cannot deny that fertility rates have declined over the years. Where the rate was 6.49 in Nigeria in 1990 and 5.839 in 2010, it is now 5.457. In Sub-Saharan Africa, as a whole, the change is now more evident. The fertility rate was 6.348 as of 1990, 5.258 in 2010 and 4.765 in 2017.

Within a global context and to the astonishment of many fertility scientists, today’s generation is said to be half as fertile as the generation before us.

A study published in the Lancet showed that the global fertility rate of 4.7 in 1950, is now 2.4 and has, therefore, declined by more than half.

Fertility rate trends in Nigeria and Sub-Saharan Africa

Cause of male infertility

Hence, the supposition that Sub-Saharan Africa is unaffected by growing infertility rates is far from the truth. Interestingly, the rates are even said to be higher in Africa and largely attributed to the high incidences of sexually transmitted infections (STIs). These infections, especially when left untreated, have serious complications in terms of infertility as it reduces sperm count in men. Also, genetics, physical and hormonal abnormalities play a role in causing male infertility. Some exogenous factors also include diet, injuries, drugs and exposure to radiation and toxins.

Treating infertility

Infertility has social ramifications on a couple, especially in a gerontocratic, culture-oriented society like the Nigerian one. This is why several men suffering from infertility seek to find answers. Some will go to any length to find remedies, albeit even discreet and strange; modern and even alternative or traditional treatments are fair game to sort out infertility issues.

Recent developments from the NHI study suggests a treatment for male factor infertility in the form of zinc and folic acid supplements that was hitherto perceived to improve male fertility do not make much of a difference.

They found that “dietary supplements containing zinc and folic acid — marketed as a treatment for male infertility — do not appear to improve pregnancy rates, sperm counts or sperm function”.

In the study of 2370 couples, one research group took the daily supplements (404 births in the group) and the other a placebo (416 births in the group). Results established no difference in the sperm health of the male partners, as the group taking supplements had 404 births and the group taking the placebo, had a similar birth count of 416.

Expert opinion

“We [healthcare professionals] use drugs to treat infertility in men, but very rarely do we use nutritional/herbal supplements. My colleagues and I never prescribe supplements. This is not a conventional way of treating infertility. We certainly do not prescribe zinc and folic acid for treatment of infertility,” Abdulkarim Mairiga, a professor of Medicine at the University of Maiduguri Teaching Hospital, said.

Habib Sadauki, a senior gynaecologist and Vice President of the Society for Gynecology and Obstetrics Nigeria (SOGON), said there are protocols to follow, with a couple dealing with infertility.

First, “a diagnosis must be made to find out what is responsible for the man or woman’s infertility. STDs and the associated complications, or in some cases, an abnormality can hinder conception. With men, the standard test is to do a seminal fluid analysis for sperm count, motility and structural abnormality of the sperm cells; ascertaining any evidence of infection. The genital tract may also need to be assessed. In cases where the patients are not making sperm cells, biopsy of the testes is taken to study and find out the reason for the failure to form the sperm cells.”

Mr Mairiga reiterated that a healthcare professional will “usually try to identify the cause(s) of infertility” before recommending appropriate treatments. He explained: “Sperm cells are produced in the testes under the influence of normal testicular cell function, hormones from the brain and the testes itself, normal temperature and presence of nutrients such as zinc, folic acid and many others. One must identify which of these four main factors is or are deficient before treatment and the treatment will be channelled to the deficiency if known.”

“If a patient, however, is found to have some reason other than the aforementioned, Mr Sadauki said, “with hormonal issues, this can be corrected with hormonal replacement”.

Mr Mairiga highlighted that hormonal treatments for male infertility are actually quite common. They include “hormone boosters such as enhanz, bromocriptine, and clomiphene citrate.” He said, “in our clinical practice, we see that in every 10 cases of infertility 3 – 4 cases pertain to the man.”

It is worth noting, Mr Sadauki said, that “in others, it is a genetic failure and this may not have any treatment at all”. Indeed, “the success rate of any treatment just depends on the causative factors. While some causes can be corrected and fertility can be restored, in others it is difficult.”

For the cases that can be corrected, as this is where supplement uses will fall within, Mr Sadauki said, “supplements might be used a lot in the treatment of male infertility but these are treatments with no proven value as some patients are known to achieve pregnancy with or without these supplements.”

Mr Mairiga also said, “there is no clear mechanism of how supplements cure infertility and therefore, is of no use to us, the professionals”. It is the patients with some specific problems that receive targeted treatment.

For low sperm count, drugs are given to improve the production of sperm. Mr Mairiga said “surgical operation that can correct sperm quality and quantity include varicocelectomy (with the aim of reducing the blood flow to the testes and hence reducing the temperature around the testes), and a rarely performed surgery of Epididymovasostomy (in which the duct transmitting the sperm cells is cut and reconnected to re-establish the patency of the duct).”

“In modern days, due to advancement in reproductive technology, sperm cells can be aspirated from the testes for test tube baby procedures”, Mr Saduaki also noted.

Time will tell

Indeed, the study of andrology (the study of male reproductive systems; andrology is to men as gynaecology is to women) is still in its infancy, men faced with infertility still have much to hope for. Concerning the NHI study, it would seem more studies need to be done to conclusively say whether or not supplements, and in particular, zinc and folic acid supplements, have any effects, let alone, benefits.