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Tabitha McIntosh

Modifiable aspects of Male Fertility

Joining us today is Tabitha McIntosh, a Naturopath who is currently doing her Masters of Reproductive Medicine.

Today we’ll be discussing an often forgotten topic of how we as clinicians can assist and modify aspects of male fertility.

About Tabitha:
Tabitha is the founder of awaken your health, and is a qualified and experienced Naturopath, Clinical Nutritionist, and educator, having run her own private clinical practice for over 10 years. As director and principal Naturopath at awaken your health, Tabitha takes great pride in providing her clients and their families with high quality naturopathic clinical care, in a supportive and nurturing environment.

After completing her Medical Science degree in 2001, Tabitha went on to pursue her passion for Natural Integrative Healthcare with post-graduate studies in Naturopathy, Western Herbal Medicine, Nutritional Medicine & Environmental Medicine. She now elegantly combines the above approaches to health: integrating Naturopathic healing principles with the latest scientific research, to educate and further the health & wellbeing of her clients.

Connect with Tabitha:
Website: 
awakenyourhealth.com.au

References

Foods high in folate – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488002/

Choline articles:

Iodine articles

Inositol Cochrane Review: https://pubmed.ncbi.nlm.nih.gov/30570133/

Vitamin E as an Antioxidant in Female Reproductive Health, 2018: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836012/

Transcript

Introduction

Andrew: Welcome to “Wellness by Designs.” I’m your host, Andrew Whitfield-Cook. Today, we are talking with Tabitha McIntosh, a naturopath who is currently doing her Masters of Reproductive Medicine at the University of New South Wales, School of Medicine in Sydney, Australia. Welcome to “Wellness by Designs.” Tabitha. How are you going?

Tabitha: I’m really well, Andrew. It’s always a pleasure having a conversation with you.

Andrew: It’s great to be chatting again. Now, let’s get straight into our topic, and that is, we are discussing modifiable aspects of male fertility. So, I guess to start the first question off, what sprung your interest in male fertility?

Tabitha: Well, honestly, what’s not to like about sperm, Andrew? They are goal-oriented, they’re fast, usually. But no, no, no. In all seriousness, sorry for being cheeky. I think that I’ve always been fascinated in the intersection of environmental medicine with reproductive health and human health outcomes. And for me, studying fertility and reproductive medicine is, it kind of feels like a coming home because my very first degree, straight out of high school, was a medical science degree at the University of New South Wales, where my major was in reproductive physiology, reproductive medicine and physiology.

And all of my subsequent study after that, in natural medicine, clinical nutrition, and herbal medicine, and environmental medicine, has kind of brought me back around to studying reproductive medicine again because, especially when it comes to male fertility and male reproductive health, considering sperm are the smallest cell of the entire human body, actually 100,000 times smaller than the ovulated ova, which is visible to the human eye at ovulation under laparoscopic camera, whereas the sperm are 100,000 times smaller. It makes them so entirely vulnerable to environmental influences, whether that be sort of heat, or radiation, or chemical exposure. So, I can’t see a better marriage of my interest in nutritional medicine, environmental medicine, and reproductive medicine than when it comes to male reproductive health.

Andrew: I’ve gotta say, I agree with you on the interesting anatomy, if you like, of the sperm. I mean, it’s just an energy powerhouse with, like, as you say, it’s very directed sort of course of action. And I guess we can talk about that later. But to start with, most fertility issues or consultations are discussed with the female and yet the male is the other half of that counterpart, you know, of that couple. So, how do you get the attention of the preconception male?

Tabitha: Well, I’ll share with you how all of this grabbed my attention first, and then we’ll get into that and the sorts of questions and how I work to get my men on board. But I’d wholeheartedly agree with you that there’s this common presumption with infertility and also miscarriage that the focus is female factor predominant. Whereas, it’s really, over the last 10 years of research being published, that our awareness has improved to understand that male factor infertility contributes to at least 50% of the cause of infertility in heterosexual couples.

Abnormalities in male reproductive cells and sperm are the sole cause of infertility in about 30% of cases, or one in three couples infertility cases. But they also are a contributing factor in another sort of 15% to 20% of cases combined with females. So, you know, the other thing that’s happened over the last several years is that we’ve had this awareness that reproductive problems in men are rising at an alarming rate. And who got my attention most of all was professor Shanna Swan, who is an epidemiologist. And she was a major contributor to a paper published in 2017, which I’m going to talk you through, and I’d love to include in the show notes.

But she went on to take her understanding of the significant drops in male sperm counts over the last 50 years that we’ve experienced, halving of male sperm counts. She went on to take her knowledge about this and publish a book in 2021, just in April, which I read, called “Count Down,” which is a fabulous read for anyone who’s interested in working in fertility.

Andrew: Okay. So, because this has really interested me, and I’ll always remember, it was a cartoon, and it was talking about the issues of endocrine disruptors in society. The cartoon explained, I’ll see if I can find this cartoon so that we can put it in the show notes, but it was basically humans in the future looking back in an archeological dig at the 21st century. And it said, and this was the famous, you know, line where endocrine disruptors became common. And when you look at the males in the cartoon, the males have got breasts and the females have got beards, and it’s really, like, this quite…you know, it’s poking fun at, but it’s actually a serious issue.

Tabitha: It absolutely is.

Andrew: So, when you’re talking about these endocrine disruptors or the issues with sperm counts going down, is it simply and solely endocrine disruptors? Or has it got to do with that, the older theory of, you know, pheromones, and population density, and that sort of stuff?

Tabitha: No, the lead authors really propose, they have some fantastic quotes where they say, really, we can use sperm counts as a surrogate marker for cumulative environmental exposures. Not only just over the life course but also to developing babies in-utero still. So, really, they talk about sperm counts and the changes. So the drop of 50% over the last 50 years in otherwise healthy men, so between 1973 through to 2011. It was an enormous meta-analysis looking at 43,000 otherwise healthy men, and a very large meta aggression analysis. And it was looking at sperm counts from men all over the world. So, America, Europe, Australia, New Zealand were included. It was very rigorous.

And, yes, one of the lead contributing authors was quoted in some popular media as saying, you know, “We are producing half the sperm our grandfathers did.” And the paper goes on, in its discussion, to quote, “Sperm count may sensitively reflect the impacts of modern environmental exposures on male health throughout the life course.” So, it’s all of the ways that sperm… Well, actually even male reproductive organ development in-utero, in the first half of gestation. For example, when mum’s exposed to some significant endocrine-disrupting chemicals, that can have a permanent impact on the number of Sertoli cells that are the spermatogenesis cells produced in the testes so that they become a finite number, limiting that future young man’s reproductive potential.

So, the points that this paper makes is that it’s likely a surrogate marker for environmental exposures, but they are not just exposures in that 72 to 100 and so days of spermatogenesis and sperm storage in the epididymis and the ejaculatory ducts. But it’s likely also a result of exposures to male developing fetuses in-utero having epigenetic unchangeable outcomes.

Andrew: Yeah. So, that’s almost like it’s ringing bells with the diethylstilbestrol issue with the daughters of mothers experiencing the cancers and things like that.

Tabitha: It’s exactly right.

Andrew: So, is this along those same lines?

Tabitha: Along very similar lines, insofar as most of the endocrine-disrupting chemicals that we are talking to, that have just, they’re ubiquitous with modern living and they’ve become just a part of our conveniences and the way that we live, whether, you know, food packaging, personal care products, fragrances, and things like that. But it’s sort of cumulative and synergistic. And most of these chemicals block androgens or mimic estrogen, that’s why we are seeing particular outcomes in men.

Andrew: Okay. So, what impact does environmental toxins have on sperm? Are we talking morphology only? Are we talking activity of sperm? Take us through it.

Tabitha: No. Well, I’d love to take you through it. Shall I go back and answer your question, though, more accurately about how I get the attention of men in clinic? Because I think it’s really important that clinicians feel confident in tackling this.

Andrew: Yeah.

Tabitha: And how I get the attention of my men, you know, I argue that it’s really important that both people in the heterozygous couple be assessed in parallel so that men don’t feel triangulated. I think it’s very important that they appreciate that they’re a big piece of the puzzle, and they don’t feel like I’m targeting them with my questions. But certainly, to get their attention, I will talk to them about that published paper by Levine and Swan, which I’ll include in your show notes. And I’ll talk about how chemicals in our environment are being linked to a decline in fertility and an increase in miscarriage rates.

And I also talk about the story of conception. So, I highlight, almost like a skit. I try to be entertaining in that first appointment, where I talk about what happens at the moment of conception and the size of the sperm compared to the size of the egg and how the size of the sperm makes it particularly vulnerable to these exposures. And I ask that gentleman sitting there in the couple with me, if they’d be willing to fill out a form for me. And on their form, I tell them I’m going to gain clues to their history and clues to their current-day exposures that might help me to guide them with making more informed decisions to really stack the odds in their corner for getting the best pregnancy and fertility outcomes.

So, quicker time to pregnancy, less likelihood of pregnancy loss. And when we talk about how the efforts that they make in the three months leading into conception can actually have an impact on the health, not just of their offspring or their baby-to-be, but even on their grandchildren’s health, that tends to get their attention.

Andrew: That, I tell you, you’re speaking volumes to me here because I’m remembering the days, you know, in the ’60s and things like that when DDT and all of those horrible chemicals were around. And my dad used to tell me stories, he was a farmer. And I can still remember him telling me stories of the rep coming around with DDT, mixing it up in a bucket with his hand, saying, “You can drink this stuff, it’s so safe.”

Tabitha: Wow.

Andrew: Obviously, it’s not.

Tabitha: And you turned that right?

Andrew: No, I don’t know about that. But, you know, we always thought about, whatever happened to that rep? Like, you know, he didn’t just go around to dad’s farm, he went around to every farm mixing this stuff with his hands and, you know, gynecomastia, anyone?

Tabitha: No, cancers and things like that.

Andrew: So, I’ve got to ask the question though, about, we are talking about some things are genetic, so they’re irreversible. How much is reversible, and where do we intercede? You were talking about the 90 days prior to conception, and I’m gathering that’s where most sort of couples are gonna present to a naturopath for help.

Tabitha: Well, sometimes we’re not so lucky. But yes, you know, when I can start that conversation about why men have less sperm than they did 50 years ago. And I can sort of go through with them as a, almost as a checklist, whether it be nutritional deficiencies, combined with emotional stress, combined with environmental exposures, and food packaging chemicals, and obviously, occupational exposures as well.

So, I didn’t mention earlier, but there are, you know, just for the clinicians listening, there are definitely some occupations that are going to warrant more investigation, and more poking, and prodding, and questioning. And these include things like welders, and panel beaters, and carpenters, who may be using adhesives, and things like that. But also, I’ve had, you know, hairdressers, taxi drivers, truck drivers, who may be sitting for extended periods of time because, obviously, the testes hang low for a reason. They function better at room temperature than they do at body temperature. But I’ve even had a very interesting case of subfertility in a gentleman who was in medicine but he worked in radiology, and he wasn’t wearing a gonad shield.

Andrew: An apron.

Tabitha: Yeah, he wasn’t wearing, he was a bit maybe like your own dad where he was, “You know, she’ll be all right. It’s no big deal. We’re doing it all day. It’s just no problem.” But getting them over the line to do something like a semen analysis, which is actually really non-invasive. And it’s good to have a sense of humour about it. I think for the clinicians out there that feel they’d like to gain more confidence in referring for semen analysis, I think it’s really important to contact some of the high-quality andrology labs around and ask for a tour, just to get an idea of what the rooms are like, what the process is like for these men who can obviously find it really intimidating. But it’s easy to balance out in conversation when we think about some of the interventions that are far more invasive that women have to go through.

But ultimately, yeah, semen analysis is kind of like gold standard, because I’d say in evaluating our male patients that come in, we’ve got some really important questions to be asking obviously about things like their, how long they’ve been trying to conceive, you know, previous surgeries, long-term medications. There are medications that are used for some inflammatory and autoimmune conditions like rheumatoid arthritis, or Crohn’s, ulcerative colitis, that can have some reversible, but even some irreversible impacts on sperm parameters, and DNA fragmentation, and things like that.

Methotrexate, sometimes prescribed for rheumatoid arthritis, and certainly, as an oncology treatment, very dangerous to sperm parameters and DNA fragmentation. But even some antidepressant medications. Some SSRIs can have a really profound impact on sexual function, and arousal, and climax, and libido, and things like this. So, these sorts of questions are really critical to be asking in the evaluation stage.

And then there should be some physical exam, but this is a limit of our practice or a limit to the scope of our practice. So, for physical examination, obviously, we need to be sending people off to their GPs, possibly also fertility specialists, or fertility centres for that sort of physical exam.

And then we’ve got to consider, as also part of our evaluation, blood tests. And there are some blood tests that I’ll run just because, again, semen or sperm parameters can reflect just general overall health. If there are chronic diseases like poorly managed Type 2 diabetes, or iron overload. When the ferritin is very high, this can cause a real aggravation to oxidative damage to the sperm, which are very vulnerable and susceptible to reactive oxygen species. So, you know, there are bloods I’ll do, but really the semen analysis is considered the gold standard in assessment.

And we also try not to make any really big and sweeping decisions, just based on one semen analysis. If there are some parameters out of range, low, or looking not quite right, before we panic, we order a repeat semen analysis, no sooner than four weeks. But things can go wrong. Guys can spill some of the sample, which is very awkward for them to talk about. They can not catch it all, but also, they may have had a fever, or been spending a lot of time in saunas, all these sorts of things. So, we do a second semen analysis before we make any big decisions for intervention with ART.

Andrew: I’ve got a few questions here, forgive me. One of them was just on actually the test. Do you find, because you’ve got the seminal fluid, then you’ve got the semen, do you find any issues with getting a good sample with, forgive me, I’m thinking about foremilk and hindmilk with breasts, and I know that’s a female sort of thing. But I’m wondering about if you get an uneven mixture in ejaculate so that you’ve gotta be taking samples from various places of the ejaculate, not just one sample from one spot.

Tabitha: I think the most important thing is that the men giving their samples catch the entire sample. But my understanding is, the worst part of the sample to miss is the first part. So, interesting analogy with the breast milk, but kind of like flipped on its head. With the breast milk, the foremilk’s very watery, high in lactose, and it’s the hindmilk that’s the most concentrated in the protein, and the fats, and things like that. Whereas, I believe, it’s the opposite with ejaculate. So, it’s the first part that the semen will be most concentrated in. But ultimately, they’re working together, the entire sample.

Andrew: I’m glad it wasn’t such a stupid question, but anyway. The other thing I was wondering about was, you were mentioning certain occupations and, you know, I’m thinking, you know, builders. We used to have chromium copper arsenic, CCA, and now the building materials are now, because they’ve gotta be termite-proof, they’re now impregnated with Bifenthrins, so, these insecticides. I don’t their action with sperm, if it’s got any activity. But I’m just thinking about all of these chemicals, you know, the volatile chemicals that are given off as fumes from various paints, la, la, la, la, la, la, la, la, la.

Tabitha: The electronics.

Andrew: Yeah. The other thing I was thinking about was Dr. Mark Donohoe was instrumental in exposing this issue about the Italian families fishing in areas, I think it was around Homebush from the Sydney Olympic Park. When they did the building and they displaced dioxins. And they had dioxins in the seawater, and therefore, the fish. So, these chemicals aren’t just in polluted lakes and rivers, they’re in, you know, relatively “clean” environments.

Tabitha: It’s exactly right. And we tend to be creatures of habit. And, you know, as you were saying with your dad, you know, we pass these things down. The discussions that we have around these things, and even some of the questionnaires, like, I find with my female clients, not to generalize too much, but they’re quite happy for an extensive conversation with lots of questioning and sort of convoluted questioning where we’re always having to bring ourselves back. Whereas, I find it’s very time saving to create a thorough, comprehensive, you know, medical history, but also exposure questionnaire for the men where they can sort of tick boxes. Yes, no, yes, no, yes, no.

And I would agree with you that even just the questionnaire can sometimes elicit a bit of a thought process in these gentlemen to think, “Wow, I didn’t realize that might have an import, or the fact that I play a lot of golf with all of the herbicide and weedicide used on golf courses, or the fact that I do a 30K bike ride twice a week, or I have a smoke of marijuana with my friends on a weekend just to relax.” They may not be thinking that these things, reheating food in the microwave in a plastic container where things like this bisphenol and phthalates will leach into the contents of the food. Even just the questionnaire, I think, gets guys considering all of the sorts of things that can be implicated in affecting the quality of sperm.

Andrew: Yeah. There was another thing that you tweaked in me, and that was, when you’re talking about generational issues with sperm…sorry, it was gonadal function and development, wasn’t it?

Tabitha: Yes. That’s right.

Andrew: So, if you’re talking about that and the Sertoli cells and things like that, that was what it was. The Sertoli cells, they make pregnenolone, and then that’s quickly changed to testosterone, which is secreted, but they actually make pregnenolone. Yeah. So, if you have a decrease in that sort of function, wouldn’t that also, I’m thinking about the action of progesterone, wouldn’t that also not be an answer to, but maybe play some factor in the increasing incidence of anxiety because of lack of progesterone?

Tabitha: I guess, look, there’s a neurohormonal cycle, whereas the impacts of stress have outcomes on sex hormone production. But also, I hear what you’re saying, can changes to sex hormone production also impact our experience of stress or our emotional resilience? And absolutely, it’s bidirectional. And there are feedback loops that are implicated here. Absolutely. But, you know, even having high prolactin, you know, there are dietary and lifestyle things that we can do day-to-day that can reduce testosterone production in men. And I see sort of tanking testosterone in so many of my male presentations, whether they’re presenting for fertility or not.

But, you know, obesity, for example, has doubled in the last 50 years, according to the World Health Organization. And the higher the amount of adipose tissue, the higher the amount of aromatization to estrogens in the blood of men, which can compromise teste function and semen parameters, but also mood, overwork, and exhaustion, all of these sorts of things. I see mood changes, cognitive decline, irritability. The stress everyone’s been enduring with, obviously, these extended lockdowns, big impacts on sexual function and libido. So, I’d say very much that there’s a huge neurohormonal interplay, where there’s lots of bidirectional conversations happening. Even under-functioning thyroid, which, of course, is far less common in men than in women. But an under-functioning thyroid can have repercussions to fertility in men as well.

Andrew: I’m so glad I’m speaking with you, who can eloquently recap what I’m trying to get across.

Tabitha: I gotcha.

Andrew: Yeah. One of the other medications I was thinking of as well, when you were mentioning them, was some statins. Because, you know, “cholesterol” is bad. We’re actually talking about lipoproteins, but we always say that word cholesterol. But what can happen with the statin, because it actually does decrease the formation, the synthesis of cholesterol in the body is that you can get lower testosterone as well. So, how big an issue do you find that when you are sort of balancing the benefits, if you like, of a statin versus the issue of having low testosterone caused by the medicine?

Tabitha: Yeah, I think it’s an excellent question. And it is something that I will always reflect back to a gentleman that shows me his cholesterol studies or his lipid profile, and it’s being managed too tightly. I will remind them that cholesterol is actually the very building block for them to be able to make their testosterone. So, I’ll ask them about things like hair loss, or loss of muscle mass, or changes to body weight and changes to sex drive, libido performance, things like that.

Statins and some of the fat blockers that actually block absorption of fat at the gut, I think can also be dangerous for some of these semen parameters, because actually there’s a large concentration of polyunsaturated fatty acids or DHA at the head of the sperm. Having a good amount of this actually is very protective for the membrane stability and then the acrosome reaction. So, the head of the sperm, in addition to having a huge concentration of the DHA, actually also contains enzymes that effectively, for want of a better word, pierce or contribute to effective fertilization.

So, theoretically, being on a statin and having low cholesterol can impact testosterone production, absolutely. And I’m talking total testosterone, then we have things like free androgen index, which is another marker that we need to look at. And just another little thing about testosterone, if we’re gonna be testing it in the blood, it’s very important to test it at a pretty consistent time of day, around about 8 or 9 in the morning, because it does have some diurnal rhythm, much like the thyroid hormones. And testosterone should be really tested alongside FSH, and LH, and prolactin in a man.

Andrew: Gotcha.

Tabitha: But it’s true that with the fat blockers or not having quite enough essential fatty acids coming, that can have an adverse impact on the head, the morphology of the head, and the functioning of the head of the sperm, and its acrosome reactions, and its capacity to fertilize an egg, which is obviously very critical to pregnancy outcome.

Andrew: Well, let’s look further into these nutritional aspects. So, not just the morphology of the head, but you’ve also got mitochondria packed in the tail, at the head of the tail.

Tabitha: Packed in the midsection, actually.

Andrew: Yeah, the midsection. Yeah, yeah. The head of the tail, which…then you’re looking at, you know, mitochondrial function. So, do you find that you then have to take into consideration the old nutrients that we’d use for energy? Like, good old CoQ10, you know, iron, for instance. You were talking about too much iron, but then too little iron. Yeah. So, can you go through these for us?

Tabitha: Yes, I can. So, I think that probably where we’ve come to, so, you know, the three main impacts of these exposures, endocrine disruption and changes that can be short-term or permanent to hormone production. And just in terms of the epigenetics, remembering that the endocrine systems at peak function in-utero, at infancy, and at adolescence. So these are some of our most vulnerable windows to exposures. But actually, what we’re alluding to here and how we can use nutrition to protect against some of these exposures is that most of these exposures work cumulatively from a reactive oxygen species to cause lipid peroxidation, they promote structural changes to the sperm membrane, they can interfere with the motility, they can interfere with the acrosome reaction in fertilization, and they can take away from mitochondrial function and capacity to move well as well. And they can damage the DNA getting passed on to the next generation.

So, I would be absolutely generalizing to talk you through some of the nutrients that we use. And I’m a big advocate for personalized prescriptions, but it is true that I might be thinking about things like essential fatty acids, like DHA, to protect the head, and fat-soluble antioxidants like vitamin E to assist in protecting the head. When it comes to that midsection and motility, I might be thinking about things like ubiquinol, Coenzyme Q10, and also the amino acid carnitine, which is very important for energy production. We have some good research that both CoQ10 and carnitine in combination can work to improve motility very much in sperm.

But, you know, ultimately, when we think of how we can sort of dampen the oxidation caused cumulatively by all of these exposures, we’re just thinking about our antioxidants. And I talk about it with my male clients as if it were…you know, obviously, we’ve got our avoidance strategies, you know, and that’s very high on the list because I think the reason some of the published papers looking at antioxidant supplementation for three months, not having big impacts on semen parameters or pregnancy is because there are some papers. Look, the evidence is really mixed actually. And I wanna share one of the most famous recent papers called the MOXI study in the show notes for people to read themselves.

But ultimately, I think that if there’s a continual exposure that’s not being addressed, antioxidant supplementation’s only going to do so much. It really comes down to avoidance strategies. And I feel so strongly about that, as you know with my book, “One Bite at a Time,” and my ebook, “Be Your Own Solution.” These are really important things for couples to be putting into place months before trying to conceive. And in terms of avoidance, I also have those really tricky conversations about alcohol, and marijuana, and coffee, and even mobile phone use, and how far the phone is away from the body. And I’m very happy to come back to all of those points, if you like.

But, you know, reducing transfats, and seed oils, and high-sugar diets, and things like this, all of these things can just add again to the load on the body. But we can mitigate some of these exposures using our antioxidants. And considering semen is literally a byproduct of the body. And, you know, that is, it’s the liquid that the sperm swim in, and we want it to have as much antioxidant content as possible. And we know that in the semen plasma, for want of a better word, the more fertile men have higher concentrations of vitamin C.

And this takes me back to the undergraduate degree that I graduated in 2000 from, and I remember distinctly all those years ago when we were looking at the cadavers, for example, the two or three organs in the body that sequestered most of the dietary and blood levels of vitamin C were the ovaries, the testes, and the adrenal glands. So, we were able to assess these three different types of tissues from the cadavers. And these were the tissues that had the highest concentrations of vitamin C.

And I just think that’s such an elegant function of nature. But, yes, vitamin C, I think of as a really important antioxidants, kind of, in my mind’s eye, it’s the first bucket of water standing there ready to put the fire out. Closely behind it, we have vitamin E, which, again, being fat-soluble is really important, just at standard doses of mixed tocopherols. But also we’ve got selenium and zinc. So, those four, they’re like a team that I feel are really critical in protecting and mitigating some of the expo zone, just by continually having these things available. If I were to go back a step though, Andrew, diet’s huge. So, I’m happy to discuss a Mediterranean diet and the importance of all of those phytochemicals coming in as well.

Andrew: Can I just ask one question about vitamin E? This is one of those misnomers like cholesterol for lipoproteins. Vitamin E is tocopherol and tocotrienol. And I spoke to Dr. Barrie Tan about the assumption, if you like, of what happened along the way with research with vitamin E and where we were sourcing it from, how we were synthesizing it, all that sort of thing. How we were extracting it, if you like. But do you favor tocotrienol? So you mentioned tocopherol, are you still using the tocopherols?

Tabitha: I think that the product that I’m favouring uses a mixture of the two, I understand, as reflected in nature, but I’m also advocating for avocados, and almonds, and things like that. But yes. Pertaining to smoking studies, I know when we use single synthetic versions of vitamin E in smokers, I remember a trial published a decade ago, we had increased risk of lung cancers and things like that. So, I think it’s really difficult to study nutrients in isolation, particularly when they’re in their synthetic forms. And we wanna be using things that as best mimic natural presentation as possible.

Andrew: Gotcha. Another thing, forgive me, and I’m backtracking here, but I just wanted to correct myself or catch myself. And that was my vernacular, because I use this binary gender-specific male to female, as if that’s the normal thing with couples. Of course, I voted yes. And we are now in a day that we’re a lot more open about homosexual relationships. Do you find that one of the male or, well, no, let’s concentrate on the males, one of the male partners prefers to use their own sperm? Do you have issues that you might have to talk about when, you know, one might present with issues with morphology with their sperm, so they might choose the other male partner to be the donor for that?

Tabitha: Do you know, I’m embarrassed to tell you, Andrew, I’ve worked with so many same-sex couples in my clinic over the last 17 or 18 years, and they’ve all been female to female. So, I don’t know if that is a reflection of…I do see a lot of men in the clinic, but I don’t know if that’s a reflection of women, you know, I’m just thinking about myself and my husband, you know, I’m the one to ask for directions, he won’t. I don’t know if that reflects, you know, women are more open and on the front foot for sort of seeking and gathering as much data and support as they can.

But I would imagine, and forgive me anyone who’s listening who’s worked in this area before, but I would imagine it would be a bit of a tally up, like a risk-benefit assessment. There’d be all sorts of emotive factors driving into decision-making. But it would be, are there other conditions? Is there a medication history? Did one of those two men in that male couple have teste trauma or take medications that would compromise things? And it would be looking at semen analyses. And also, which of the partner were most open and receptive to making lifestyle and dietary changes before being the donor for their own child. Yeah. I hope that helps. And I’m sure that all of the andrology centres and fertility clinics have genetic counselling, but also counselling facilities that can be leaned into.

Andrew: So, male-to-male couples out there, if you’ve uncovered an issue that we haven’t covered today, I’d love to know about it. Like, maybe there’s some hurdle, some blockage that’s put up for you with regards to donating sperm. I’m not sure. I really wouldn’t know, but I’d love to know. It’d be great to find out in the show notes or in the feedback on the social media. I’d love to know.

Tabitha: That’s a fascinating question.

Andrew: I mean, we could talk for hours about this, Tabitha, you are so good at this. What’s our recap, what’s our biggest message that we need to get across to males?

Tabitha: I think it’s really important for men to recognize what a significant part of the tapestry they are, not just to pregnancy outcomes, fertility and pregnancy outcomes, but also to the health of their offspring and their offspring’s offspring. I feel like it’s nothing to be ashamed of. But in seeing a lot of guys, again, I’m generalizing, but they love working with numbers rather than hearsay. So, to have a semen analysis report or two, possibly even that includes a DNA fragmentation. In fact, every time I run a semen analysis, I will add on a DFI or a DNA fragmentation index. And obviously, we are looking for the least amount of DNA fragmentation as possible. So, you know, under 15% where we can work towards that.

But when they can see the numbers or they can see that one of the parameters is at, like the DNA fragmentation is elevated, which we know is linked to increased risk of miscarriage and all of the emotional turmoil that that comes with, or they can see that their count is low, or that their morphology is a little bit low. When they can see those things, they end up…you know, that information can be a motivator for action and for positive change.

So, I think it’s really important that these guys know, it’s not just about the woman or their female partner in a man-to-woman hetero, I keep wanting to say heterozygous, heterosexual relationship. It’s not just about the woman being on a prenatal for three months prior. It’s also about that male, you know, really upgrading his diet and lifestyle. I call it the personal protection plan, where I may put them on a good men’s multivitamin that contains some trace minerals, including zinc, selenium, and things like that, possibly active forms of B vitamins, just to support them with their methylation. And I may add in some additional antioxidants, like some vitamin C, and potentially some ubiquinol. There’s been some amazing literature published on N-acetylcysteine, actually, in improving all semen parameters. So, motility and count, just at a dose of 600 milligrams a day, most likely because it’s a precursor, it’s an antioxidant in its own right, but it’s a precursor to glutathione, to protect from all of this ROS. But, yeah. A Mediterranean diet, that’s really colourful, and critical.

Andrew: Yep. Yep. So, apart from reading your book, “One Bite at a Time.” Now, if there’s a subtitle, there was a subtext, “One Bite at a Time: Eating your way to a healthier world?” Is that…?

Tabitha: Eating the world you want. Eating the world you want.

Andrew: That’s the one, that’s the one.

Tabitha: That’s right.

Andrew: And I love the topics that you discuss in there about, you know, getting your bang for buck from your organic dollar.

Tabitha: That’s exactly right.

Andrew: And I loved that concept, I remember us podcasting about it. So, we’ll definitely put that up on the show notes so that people can access that, because that should be a text. It’s a brilliantly written book. It’s so well done with you and Sarah Lantz.

Tabitha: Thanks, Andrew.

Andrew: No, thank you for joining us today and for sharing just the tip of the iceberg. I mean, there’s obviously so much more to go into. But thanks for sharing the tip of the iceberg of your wealth of knowledge with regards to male fertility today on “Wellness by Designs,” Tabitha McIntosh.

Tabitha: Andrew, it’s such a pleasure. And to your point, I feel, that the more I learn in this masters, the more I appreciate how much environmental medicine really needs to become a part of education and clinical practice. So, the resources that I wanna share with the listeners in the notes are really resources that are super informative, that can really enhance and accelerate your understanding of this, what I think is a really undeveloped area in naturopathic medicine. We need to be far more proficient and confident in evaluating and managing our men.

Andrew: Wise words from an expert. Well said, Tabitha McIntosh. And thank you for joining us today on “Wellness by Designs.” As we said before, we’ll definitely put these papers and other learning things up on the show notes on the wellness…oh, forgive me, on the “Designs for Health” website. I’m Andrew Whitfield-Cook. This is “Wellness by Designs.”