Abdul Aziz et al (2020): Impact of vitamin D on male infertility Nov 2020 Vol.

23 Issue 20

Impact of Vitamin D on Male Iraqi Patients with

Infertility
Ali S. Abdul Aziz1, Zainab A. Razaq Al-Sharifi 2, Hussain K. Al- Dulaime 3
1
B.Sc, College of Pharmacy, Diyala Health Directorate, Ministry of Health, Iraq

2
Ph.D Clinical Chemistry, Department of Biochemistry, College of Medicine, University of Baghdad,
Iraq

3
PhD .infertility and Clinical Reproduction, Al-Batool Teaching hospital-Diala, Ministry of Health ,
Iraq

Abstract

Background: Male infertility complete or partial termed as subfertility, maybe due to reduce number
spermatozoa (oligozoospermia), sperm motility (asthenozoospermia), sperm vitality necrozoospermia),
and abnormal sperm morphology (teratozoospermia) or any combination of these. Vitamin D is a
steroid hormone 25-hydroxycholecalciferol (Vitamin D (25(OH) D; vit D), also called calciferol, is one
of the four fat soluble vitamins (A, D, E, and K) stored in body tissues vitamin D is the only vitamin
that can be synthesized by the human body can produce vitamin D in the skin when exposed to
sunlight, namely the ultraviolet B radiation (UVB) other sources of vitamin D include dietary
supplements and food. Vitamin D regulates hormone production and receptor expression in theca and
granulosa cells of developing follicles, this in turn affects follicle recruitment and maturation .Vitamin
D alters sperm motility and metabolism, and also impacts on the ability of sperm to undergo the
acrosome reaction and consequently the ability to fertilize eggs , vitamin D. indicates increased
expression, production or activity 3-β-hydroxysteroid dehydrogenase , anti-Mullerian hormone , anti-
Mullerian hormone receptor , oestrogen , follicle-stimulating hormone receptor , leutinizing hormone ,
progesterone , vitamin D response elements. Aim of study: Evaluate the effect of vitamin D
supplement at seminal fluid parameters and reproductive hormones (LH, FSH, and testosterone) in case
of infertile male with vitamin D deficiency. Subject, materials and methods: One hundred and
twenty infertile male were included in this randomized clinical trial study. Because of shorting of time
so the supplement (vit-D and L–carnitine) were given to 80 patients only attended to Al-Batool
teaching hospital for measurements serum levels of 25 [OH] D, free testosterone, FSH, LH,prolactin
also seminal fluid analysis, pretreatment investigation, divided into two groups Vit. D group (n =40);
L-carnitine group (n= 40). First group received vit. D (25000 IU per week) period of 2 months the
latter group received L-carnitine 1000 mg daily for 2 months, a second blood sample took from them
for measurement of serum level of 25 [OH] D free testosterone, FSH, LH, prolactinal so seminal fluid
analysis post treatment investigation. Results: The study showed normal sperm concentration ( ≥ 15
million/ ml) before vitamin D treatment was (24 million/ ml) (60%) with (p =0.03) , the concentration
increased after to (30 million/ ml) (75%) with (p=0.508) . Relationship between vitamin D and sperm
progressive motility was significant and P- value before vitamin D treatment was (p = 0.34) and after
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 Abdul Aziz et al (2020): Impact of vitamin D on male infertility Nov 2020 Vol. 23 Issue 20

vitamin D treatment was (p = 0.030). Relationship between vitamin D and sperm total motility was
significant and P- value before vitamin D treatment was (p = 0.887) and after vitamin D treatment (p =
0.069). There were significant differences between the values of prolactin before (p = 0.218) and after
vitamin D treatments (p = 0.012). sperm volume before treatment was(p = 0. 484) significantly less
than volume after treatment, (p = .001), with significant improvement sperm motility grade A,B,C and
D before vitamin D treatments was (-7.10 ,-5.83,4.700 and 9.225 ) respectively and p value after
vitamin D treatments was (p =< .001, p =< .001 , p =0.0067and p =0.00037) respectively. Conclusion:
The significant effect of vitamin D supplement in seminal fluid parameters, include sperm
concentration ,volume and sperm motility grade (A,B,C,D) and prolactin after 2 months therapy.

Keywords: Vitamin D, infertility, sperm concentration, sperm motility

How to cite this article: Abdul Aziz AS, Razaq ZA, et al (2020): Impact of vitamin D on male
Iraqi patients with infertility, Ann Trop Med & Public Health; 23(S20): SP232240. DOI:
http://doi.org/10.36295/ASRO.2020.232240

Introduction

Infertility is defined as the inability of sexually active couples taking no contraceptives to achieve pregnancy
within 1 year it is estimated that 15% of couples attempting to conceive are not able to do so within 1 year
,male factor infertility is present in 20–50% of these couples, either independently or in conjunction with
female factor infertility issues nearly 70 million couples are infertile worldwide, and assisted reproductive
technologies are expensive and particularly unaffordable for couples in developing countries around 40% of
all infertile couples exhibit a combination of factors, and about 15% of couples may not display any
objective alteration aiding in a definitive diagnosis (WHO,2017).

Vitamin D is a steroid hormone 25-hydroxycholecalciferol (Vitamin D (25(OH)D; Vit D)), also called
calciferol, is one of the four fat soluble vitamins (A, D, E, and K) stored in body tissues vitamin D is the only
vitamin that can be synthesized by the human body can produce vitamin D in the skin when exposed to
sunlight, namely the ultraviolet B radiation (UVB) other sources of vitamin D include dietary supplements and
food such as fortified milk, fortified cereals, fatty fish, cod-liver oil, mushrooms, and egg yolks, vitamin D a
lipid soluble vitamin this vitamin strongly known for its role in calcium and bone metabolism and maintaining
bone integrity ( Whiteman , 2014).

Role of vitamin D in spermatogenesis, further research highlighted the expression of vitamin D receptors
in human Leydig cells, seminiferous tubules, and the epididymis and the expression of vitamin D mRNA in
the head and neck of spermatozoa, suggesting that this vitamin is related to the occurrence and maturation of
spermatozoa with regard to in vitro effects, increasing evidence suggests that vitamin D has a positive impact
on human spermatozoa for example, studies have shown that vitamin D regulates human sperm cholesterol
outflows, affects sperm protein serine and threonine phosphorylation, and thus increases the survival ability of
Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232240
 Abdul Aziz et al (2020): Impact of vitamin D on male infertility Nov 2020 Vol. 23 Issue 20

spermatozoa additionally, other studies have also indicated that vitamin D enhances sperm vitality and the
acrosome reaction (Abbasihormozi et al ., 2017).

Molecular vitamin D studies in reproductive cells: Vitamin D regulates hormone production and receptor
expression in theca and granulosa cells of developing follicles this in turn affects follicle recruitment and
maturation vit D alters sperm motility and metabolism, and also impacts on the ability of sperm to undergo the
acrosome reaction and consequently the ability to fertilize eggs ,3βHSD, 3-β-hydroxysteroid dehydrogenase;
AMH, anti-Mullerian hormone; AMHR, anti-Mullerian hormone receptor; E2, oestrogen; FSHR, follicle-
stimulating hormone receptor; LH, leutinizing hormone; P4, progesterone; VDRE, vitamin D response
elements; VitD, vitamin D. indicates unconfirmed effect; indicates increased expression, production or
activity (Lerchbaum and Obermayer-Pietsch ,2012).

Role of vitamin D in oligoasthenospermia, deficiency in vitamin D has been linked to a series of adverse
reactions including hypertension, cardiovascular disease, stroke, diabetes, and cancer in recent decades,
research on vitamin D has extended the spectrum of its effects to the male reproductive system dating back to
the last century, the first study suggesting a role of vitamin D in reproductive function was conducted in
rodents male rats were divided into a vitamin D-sufficient group and a vitamin D-deficient group to observe
the results of mating with female rats the results indicated that the vitamin D-deficient group had lower mating
rates, fertility rates, and birth rates (Li ,2016).

Methods

This study was conducted in medical college /Baghdad University from the period of first October 2019 to
October 2020.Patients include in this randomized clinical trial study were 60 males infertility of age
range (20 -45) year and who are on treatment of infertility. Basal blood sample will be taken from each
patient for measurements serum levels of 25 [OH] D, free testosterone, FSH, LH, prolactin also seminal
fluid analysis, those 60 patients were diagnosis with vitamin D deficiency, those patients were be divided
into two groups as diagram 2-1group (A) 30 patients were treated with placebo (L–carnitine) for 3 months
group (B) 30 patients were treated with vit – D 50000 U/ week for 3 months and after the 3 months a
second blood sample took from them for measurement of serum level of 25 [OH] D free testosterone, FSH,
LH, prolactin also seminal fluid analysis and compare the vit D result and clinical improvement of infertile
patients ( if there is improvement in the seminal fluid analysis or progression of fertility)before and after
the treatment with vitamin D supplementation and placebo. Body mass index[BMI], waist circumference
[WC], area of sun exposure, occupation [indoor or outdoor] and month of blood sample collection were
evaluated and reported to be correlated with blood measurements.

Descriptive analysis was performed to summarize clinical and biochemical characteristics of the subjects.
Student’s t-Test and Mann-Whitney test were used for significance testing against the groups for

parametric and non-parametric variables respectively, chi square test were used to test significances among
categorical variables. Pearson correlation test were performed to evaluate the correlation among variables.
For comparisons across the two treatment conditions a Mixed Model ANOVA. A.K.A. repeated measure

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 Abdul Aziz et al (2020): Impact of vitamin D on male infertility Nov 2020 Vol. 23 Issue 20

ANOVA was used for different parameters of the study. When there were significant differences among
the groups, within subjects or interactions effect, a pair wise Post-hoc.

Results

The present study found that normal sperm concentration≥ 15 million/ ml before vitamin D treatment was
24 million/ ml (60%), the concentration increased after vitamin D treatment to become 30 million/ ml
(75%).Table 1.1

Table 1-1 Frequency Table for sperm concentration categories in the study groups

Variable L-carnitine VitD

Sperm Concentration before treatment
Low < 15 13 (32%) 16 (40%)
Normal > 15 27 (68%) 24 (60%)
Sperm Concentration after treatment
Low < 15 12 (30%) 10 (25%)

Normal > 15 28 (70%)

30 (75%)

Table 1-2 showed relationship between vitamin D and sperm progressive motility was significant and p
value before vitamin D treatment was (p = 0.34) and after vitamin D treatment was(p = 0.030).
Relationship between vitamin D and sperm total motility was significant and P- value before vitamin D
treatment was (p = 0.887) and after vitamin D treatment (p = 0.069).Table 1-2

Table 1-2: Summary Statistics Table for total and progressive motility by groups

Variable n = 40 M SD Median SEM Skewness Kurtosis P value

TM% before
L-carnitine 35.12 17.88 30 2.83 0.66 -0.20 0.887
Vit. D 34.52 19.70 30 3.11 0.41 -0.63
PM% before
L-carnitine 20.62 14.46 20 2.29 1.05 2.15 0.341
Vit. D 17.57 14.01 15 2.22 0.80 0.41
TM% after
L-carnitine 35.62 19.15 35 3.03 0.12 -1.04 0.069
Vit. D 42.75 15.10 40 2.39 0.16 -0.71
PM% after
L-carnitine 22.50 17.10 20 2.70 0.49 -0.57 0.030
VitD 30.50 15.27 25 2.41 0.29 -0.82

Table 1-3 showed there were significant differences between the values of prolactin before (p = 0.218) and
after vitamin D treatments (p = 0.012).

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 Abdul Aziz et al (2020): Impact of vitamin D on male infertility Nov 2020 Vol. 23 Issue 20

Table 1-3 The Marginal Means Contrasts for the Mixed Model ANOVA: prolactin

Contrast Difference SE df t p
group| L-carnitine
Prolactin before – Prolactin after 1.582 1.273 78 1.242 0.218
group| Vitamin D
Prolactin before – Prolactin after 3.285 1.273 78 2.580 0.012

Table 1-4 showed sperm volume before treatment was (P= 0. 484) significantly less than volume after
treatment, (p = .001).

Table 1-4 : The Marginal Means Contrasts for each Combination of Within-Subject Variables
for the Mixed Model ANOVA

Contrast Difference SE df t p
group| L-carnitine
Volume before – Volume after 0.11 0.16 78 0.70 .484
group| Vitamin D
Volume before – Volume after -0.54 0.16 78 -3.36 .001

The study showed significant improvement sperm motility grade A,B,C and D before vitamin D
treatments was (-7.10 ,-5.83,4.700 and 9.225 ) respectively and p value after vitamin D treatments was (p
=< .001, p =< .001 , p =0.0067and p =0.00037) respectively.

Table 1-5: The Marginal Means Contrasts for each Combination of Within-Subject Variables for
the Mixed Model ANOVA

Contrast Difference SE df t p
group| L-carnitine
Grade A before – grade A after -0.13 1.20 78 -0.10 .917
group| Vitamin D
grade A – grade A after -7.10 1.20 78 -5.93 < .001

Table 1-6: The marginal means contrasts for each combination of within-subject variables for the
Mixed Model ANOVA for grade B motility %

Contrast Difference SE df t p
group|L-carnitine
Grade B before – Grade B after -1.75 1.26 78 -1.39 .170
group|Vitamin D
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Grade B before – Grade B after -5.83 1.26 78 -4.61 < .001

Table 1-7: the grade C Marginal Means Contrasts for the Mixed Model ANOVA:

Contrast Difference SE df t p
group|L-carnitine
Grade C before – grade C after 1.375 1.687 78 0.815 0.4175
group|Vitamin D
Grade C before – grade C after 4.700 1.687 78 2.786 0.0067
Table 1-8: Grade D motility percentage Marginal Means Contrasts for the Mixed Model
ANOVA:

Contrast Difference SE df t p
group|L-carnitine
gradedbefore – gradedafter -0.125 2.479 78 -0.050 0.95991
group|Vitamin D
gradedbefore – gradedafter 9.225 2.479 78 3.721 0.00037

Discussion

The present study found that normal sperm concentration≥ 15 million/ ml before vitamin D
treatment was 24 million/ ml (60%), the concentration increased after vitamin D treatment to become 30
million/ ml (75%). This result comes along with Blomberg et al who showed that normal sperm
concentration, before vitamin D treatment was 30 million/ ml (60%), and increase after vitamin D
treatment to 40 million/ ml (80%).(Blomberg et al.,2018).A study of Jueraitetibaike et al reviled normal
sperm concentration before vitamin D 62.23 million/ ml. (Jueraitetibaike et al.,2019). Similar study by
Rehman et al, showed that sperm concentration, before vitamin D treatment which was 20 million/ ml,
and increase after vitamin D treatment to 39 million/ml. (Rehman et al.,2018). The current study
confirmed that before vitamin supplements, both total motility and progressive motility percentages
show no significant difference between the two groups. Total sperm motility had For L-carnitine and
vitamin D (p = 0.887) with a progressive motility For L-carnitine and vitamin D (p = 0.341) , Total
motility increased slightly in both groups after treatment, for L-carnitine and vitamin D (p = 0.069) , with
progressive motility For L-carnitine and vitamin D (p = 0.030) . Progressive motility before and after
treatment was significantly. In the L-carnitine group was not significant (p = .356) and for vitamin D
group was significant ( p< .001).These results are agreed with other studies which reviled that before
vitamin supplements, both total motility and progressive motility percentages show no significant , after
treatment both total motility and progressive motility show increased slightly. Progressive motility
before and after treatment was significantly, in the L-carnitine group was not significant and for vitamin
D group was significant. (Moghadam et al., 2020) and (Blomberg et al., 2016). These results are
disagreed with study by Abbasihormozi et al showed not observe any correlation between vitamin D
levels and progressive motility and total motility before and after treatment in total subjects
(Abbasihormozi et al., 2017).Prolactin before was significantly greater than prolactin after (Yilmaz et al.,
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 Abdul Aziz et al (2020): Impact of vitamin D on male infertility Nov 2020 Vol. 23 Issue 20

2018) and (Jannatifar et al., 2019). But contradiction with study by Tammy et al, that found there were
not significant differences between the values of prolactin before and prolactin after treatments (Tammy
et al., 2015).The current study found that for grade A grade A was significantly less than grade A after,
(p < .001).grade B before was significantly less than grade B after (p < .001).grade C before was
significantly greater than grade C after (p = .007).grade D before was significantly greater than grade D
after (p < .001). Similar with studies by (Alzoubi et al., 2017) and (Majzoub et al., 2018). Also similar
study by Savoie et al, showed that the same result at above (Savoie et al., 2019) .

Conclusion

Significant effect on the sperm concentration following two months therapy. Significant improvement
sperm motility grade A,B,C and D. progressive and total motility .Significant effect on prolactin.
Significant effect on the semen volume after therapy. No significant effect on the hormones(LH, FSH,
and testosterone).These findings are important because, although there are many factors that can cause
infertility, vitamin D deficiency may be an explanation for some of the unexplained infertility cases or
a contributor to the other causes of infertility .The high prevalence of vitamin D deficiency and the
beneficial role of vitamin D in overall health and human reproduction provide support for screening
and supplementation when evaluating couple with infertility. Besides, vitamin D supplementation is
safe, accessible and inexpensive.

References

1-World Health Organization (2017) Infertility is a global public health issue.

http://www.who.int/reproductivehealth/topics/infertility/perspective/en/.Accessed16.12.2017.

2- Whiteman H: Vitamin D deficiency linked to poor brain function, death after cardiac arrest .Medical News Today.
2014, Accessed: July 4, 2018: https://www.medicalnewstoday.com/articles/283971.php.

3- Abbasihormozi S, Kouhkan A, Alizadeh AR, et al. Association of vitamin D status with semen quality and
reproductive hormones in Iranian subfertile men. Andrology. 2017;5(1):113-118. doi:10.1111/andr.12280.

4- Lerchbaum E Obermayer-PietschB2012Vitamin D and fertility: a systematic review. European Journal of

Endocrinology166765–778. (doi:10.1530/EJE-11-0984).

5- Li HW, Brereton RE, Anderson RA, Wallace AM & Ho CK. Vitamin D deficiency is common and associated with
metabolic risk factors in patients with polycystic ovary syndrome. Metabolism 2016 60 1475–1481.
(doi:10.1016/j.metabol. 2016.03.002.

6- Blomberg Jensen M, Lawaetz JG, Petersen JH, Juul A, Jørgensen N. Effects of Vitamin D Supplementation on
Semen Quality, Reproductive Hormones, and Live Birth Rate: A Randomized Clinical Trial. J Clin Endocrinol
Metab. 2018;103(3):870-881. doi:10.1210/jc.2017-01656.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232240

 Abdul Aziz et al (2020): Impact of vitamin D on male infertility Nov 2020 Vol. 23 Issue 20

7- Jueraitetibaike K, Ding Z, Wang DD, et al. The effect of vitamin D on sperm motility and the underlying
mechanism. Asian J Androl. 2019;21(4):400-407. doi:10.4103/aja.aja_105_18.

8- Rehman R, Lalani S, Baig M, Nizami I, Rana Z, Gazzaz ZJ. Association Between Vitamin D, Reproductive
Hormones and Sperm Parameters in Infertile Male Subjects. Front Endocrinol (Lausanne). 2018;9:607.
Published 2018 Oct 16. doi:10.3389/fendo.2018.00607.

9- Moghadam MT, Hosseini G, Absalan F, Tabar MH, Nikbakht R. Effects of Vitamin D on Apoptosis and Quality of
Sperm in Asthenozoospermia [published online ahead of print, 2020 Jul 14]. JBRA Assist Reprod.
2020;24(3):316-323. doi:10.5935/1518-0557.20200009.

10- Blomberg Jensen M, Gerner Lawaetz J, Andersson AM, et al. Vitamin D deficiency and low ionized calcium are
linked with semen quality and sex steroid levels in infertile men. Hum Reprod. 2016;31(8):1875-1885.
doi:10.1093/humrep/dew152.

11- Yilmaz N, Ersoy E, Tokmak A, et al. Do Serum Vitamin D Levels Have Any Effect on Intrauterine Insemination
Success?. Int J Fertil Steril. 2018;12(2):164-168. doi:10.22074/ijfs.2018.5256.

12- Jannatifar R, Parivar K, Roodbari NH, Nasr-Esfahani MH. Effects of Vitamin D supplementation on sperm quality,
chromatin integrity and level of oxidative stress in infertile men. Reprod Biol Endocrinol. 2019;17(1):24.
Published 2019 Feb 16. doi:10.1186/s12958-019-0468-9.

13- TAMMY J. LINDSAY, MD, Saint Louis University Family Medicine Residency, Belleville, Illinois KIRSTEN R.
VITRIKAS, MD, David Grant Medical Center Family Medicine Residency, Travis Air Force Base, California
Am Fam Physician. 2015 Mar 1;91(5):308-314.

15- Alzoubi A, Mahdi H, Al Bashir S, et al. NORMALIZATION OF SERUM VITAMIN D IMPROVES SEMEN
MOTILITY PARAMETERS IN PATIENTS WITH IDIOPATHIC MALE INFERTILITY. Acta Endocrinol
(Buchar). 2017;13(2):180-187. doi:10.4183/aeb.2017.180.

16- Majzoub A, Agarwal A. Systematic review of antioxidant types and doses in male infertility: Benefits on semen
parameters, advanced sperm function, assisted reproduction and live-birth rate. Arab J Urol. 2018;16(1):113-
124. Published 2018 Jan 2. doi:10.1016/j.aju.2017.11.013.

17- Savoie MB, Paciorek A, Zhang L, et al. Vitamin D Levels in Patients with Colorectal Cancer Before and After
Treatment Initiation. J Gastrointest Cancer. 2019;50(4):769-779. doi:10.1007/s12029-018-0147-7.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232240