Sperm morphology assessment: diagnostic potential and comparative analysis of strict or WHO criteria in a fertile and a subfertile population

This prospective study compared the diagnostic and predictive potential of sperm morphology assessments in a fertile vs. a subfertile population, evaluated in three different laboratories. The fertile population included 144 men who had recently fertilized their partners. As subfertile controls, 136 men with a history of subfertility for more than 12 months were used. All semen samples (280) were evaluated in three different centres in a blind fashion, without any patient information. The evaluation of sperm morphology was performed according to the criteria normally used in the different laboratories: WHO (1992) criteria for laboratory A, and Tygerberg strict criteria for laboratories B and C. Using ROC analysis, the predictive power of sperm morphology turned out to be different in the three laboratories (area under ROC curve: 69% for lab A, 72% for lab B and 78% for lab C). Using percentile 10 of the fertile population as the cut-off value for normality, we obtained the following results: 2, 1 and 5% for laboratories A, B and C, respectively. Using ROC analysis cut-off values with optimal specificity and sensitivity were 6, 1 and 10%, respectively. Although our data highlight a reasonable predictive power of sperm morphology in centres using different or the same criteria, cut-off values for normality were different, even when the same criteria were applied. These results stress the importance of standardization in sperm morphology evaluation and the need for examining a reference population in estimating the real threshold value in different laboratories.

Increased serum IL-6 and IL-1 receptor antagonist concentrations in major depression and treatment resistant depression

There is now some evidence that major depression is accompanied by an immune response with an increased production of pro-inflammatory cytokines, such as interleukin 1(IL-1), IL-6 and interferon gamma (IFN-gamma). The aims of the present study were to examine serum IL-6, IL-1 receptor antagonist (IL-1Ra), IL-6R, Clara cell protein (CC16) and the soluble CD8 (sCD8) molecule in chronic, treatment resistant depression (TRD) both before and after subchronic treatment with antidepressants. Serum IL-6 and IL-1Ra were significantly higher in subjects with major depression and TRD than in normal controls. Subchronic treatment with antidepressants had no significant effects on serum IL-6, IL-1Ra, CC16 or sCD8, but reduced serum sIL-6R levels significantly. There were significant and positive correlations between serum IL-6, on the one hand, and sIL-6R, IL-1Ra, sCD8, number of peripheral blood leukocytes, neutrophils, CD2(+)T and CD19(+)B cells (all positive) and serum zinc (negative), on the other. These results suggest that: (1) major depression and TRD are accompanied by an activation of the monocytic arm of cell-mediated immunity; (2) the latter may be related to the immune an acute phase response in major depression; and (3) the above disorders may persist despite successful antidepressive treatment.

Purification and characterization of hepatocyte growth factor (HGF) from human seminal plasma

Naturally occurring forms of hepatocyte growth factor/scatter factor (HGF/SF) have been purified by heparin-Sepharose chromatography, followed by cation exchange chromatography from a pool of human seminal plasma. Using an enzyme-linked immunosorbant assay, MDCK scatter assay, and Western blot analysis, it was found that, after heparin-Sepharose chromatography, human HGF/SF present in seminal plasma eluted in two different fractions, between 0.72 and 0.85 M NaCl (fraction I) and between 0.95 and 1.10 M NaCl (fraction II). Further purification of fraction I by cation exchange chromatography resulted again in two fractions which eluted at 0.2-0.4 and at 0.6-0.8 M NaCl. The fraction which eluted at 0.2-0.4 M NaCl consisted of two biologically less active heavy chains of the heterodimeric form of HGF/SF (107.1 U/ng immunoreactive HGF), with approximate molecular weights of 65 and 62 kDa under reducing conditions. The second fraction, which eluted at 0.6-0.8 M NaCl, revealed three bands with molecular weights of 87, 65 and 62 kDa, respectively. The 87 kDa form is thought to be a single chain precursor of HGF/SF devoid of biological activity. After subjecting fraction II to cation exchange chromatography, only one major peak eluted between 0.9 and 1.0 M NaCl, and consisted of two biologically active heavy chains of the heterodimeric form of HGF/SF (708.3 U/ng immunoreactive HGF), with approximate molecular weights of 65 and 62 kDa under reducing conditions. Nonreducing conditions for both fraction I and fraction II revealed only one band with a molecular weight of 68 kDa. The ratio ofpro-HGF/SF and less biologically active HGF/ SF (fraction I) over mature heterodimeric HGF/SF (fraction II) was approximately 1:3, in seminal plasma from sperm donors. In seminal plasma, pro-HGF/SF represents an 87 kDa glycoprotein which, apparently, is converted by limited proteolysis into several bands with molecular weights of 65 and 62 kDa. This is the first report showing the presence of pro-HGF/SF and heterodimeric mature HGF/SF, as well as less biologically active forms of HGF/SF in human seminal plasma.

The effects of anticoagulation and processing on assays of IL-6, sIL-6R, sIL-2R and soluble transferrin receptor

Levels of plasma cytokines, their receptors or immune-related peptides, are used in experimental and clinical medicine. However, no standards are available regarding the use of anticoagulants or blood processing including the technique of blood collection or time delay between blood sampling and centrifugation. Blood was collected from 10 patients in order to assay interleukin 6, soluble interleukin 6 receptor, soluble interleukin 2 receptor and soluble transferrin receptor by enzyme-linked immunosorbent assay (ELISA). At the time of sampling, five different collecting tubes were used: allowing coagulation, in the presence of EDTA, with EDTA being administered to the serum after its separation, in citrated and in heparinized blood. Blood was centrifuged 10 min after collection and separated serum or plasma was immediately frozen at -20 degrees C. To study the effect of time delay between blood sampling and processing, blood from 11 other patients was sampled, allowing coagulation; or in EDTA tubes and stored at 4 degrees C. The blood was centrifuged 10 min, 8 h and 24 h later, and the separated serum or EDTA plasma was stored at -20 degrees C until thawed for protein determination. Plasma interleukin 6 and soluble interleukin 6 receptor concentrations did not depend on the type of anticoagulant used or the time delay between sampling and processing. Soluble interleukin 2 receptor concentrations were not influenced by time delay before centrifugation, but concentrations were increased 10-fold in EDTA plasma exclusively when EDTA had contact with blood cells. Soluble transferrin receptor concentrations rose progressively with storage time before centrifugation. Contact of EDTA to whole blood or serum resulted in the same increase of soluble transferrin receptor concentration. The results suggest that standardization of the use of anticoagulant and time delay before centrifugation and serum or plasma separation is necessary for soluble interleukin 2 receptor and soluble transferrin receptor.

In vivo immunomodulatory effects of clozapine in schizophrenia

Recently, there have been some reports that schizophrenia is accompanied by an immune-inflammatory response, characterized by increased secretion of interleukin-6 (IL-6), soluble IL-2 receptor (sIL-2) and lower plasma levels of CC16 (Clara cell protein), an endogenous anti-cytokine. It was shown that clozapine, an atypical antipsychotic drug, may increase the plasma levels of sIL-2R and pro-inflammatory cytokines. This study was carried out in order to examine serum IL-6, IL-6R, CC16, IL-1R antagonist (IL-1RA), transferrin receptor (TfR) and sCD8 antigen, both before and after treatment with clozapine in schizophrenic subjects versus normal controls. Schizophrenic patients showed significantly higher plasma IL-6R and IL-1RA and lower plasma CC16 than normal controls. Treatment with clozapine significantly increased plasma sCD8, IL-6, CC16 and IL-1RA concentrations. The clozapine-induced increments in plasma IL-6 and CC16 appeared during the first 2 weeks of treatment, whereas the increases in plasma sCD8 and IL-1RA appeared after 5 weeks. Clozapine appears to have complex in vivo immunomodulatory effects.

Intrauterine insemination after ovarian stimulation with clomiphene citrate: predictive potential of inseminating motile count and sperm morphology

This retrospective study aimed to evaluate the prognostic value of the inseminating motile count (IMC) and sperm morphology (using strict criteria) on success rates after homologous intrauterine insemination (IUI) combined with clomiphene citrate (CC) stimulation. A total of 373 couples underwent 792 IUI cycles in a predominantly (87.4%) male subfertility group. The overall cycle fecundity (CF) and baby take-home rate (BTH) was 14.6 and 9.9% respectively. The cumulative CF and BTH (per couple) after three cycles were 30.6 and 21.1% respectively. Overall, sperm morphology and IMC were of no prognostic value using receiver operating characteristic (ROC) curve analysis, but after classifying the study population into different subgroups according to IMC, sperm morphology turned out to be a valuable prognostic parameter in subgroup 1, i.e. IMC <1 x 10(6). In this subgroup, no pregnancies were seen when the morphology score was <4% and the mean value of sperm morphology was significantly different in the pregnant (8.3%) versus non-pregnant group (5.0%; P <0.05). The cumulative CF and BTH after three IUI cycles were comparable for all couples with the exception of those cases in which the IMC was <1 x 10(6) with a morphology score of <4% normal forms. We recorded only two twin pregnancies (2.5%) and no moderate or severe ovarian hyperstimulation syndrome. We conclude that in a selected group of patients without CC resistance and normal ovarian response following CC stimulation [maximum of three follicles with a diameter of >16 mm at the time of administration of human chorionic gonadotrophin (HCG)], IUI combined with CC-HCG can be offered as a very safe and non-expensive first-line treatment, at least with an IMC of >1 x 10(6) spermatozoa. In cases with <1 x 10(6) spermatozoa, CC-IUI remains important as a first-choice therapy provided the morphology score is > or =4%.

Treatment of male infertility due to sperm surface antibodies: IUI or IVF?

This prospectively designed study was aimed at comparing the results of two different treatment protocols in 29 infertile couples with proven male immunological infertility, i.e. a positive (>50%) mixed antiglobulin reaction (MAR) test (IgG and/or IgA). In the first protocol (group I, n = 14) couples were treated with ovarian stimulation/ intrauterine insemination (IUI), followed by in-vitro fertilization (IVF) if no pregnancy occurred after three IUI cycles. In the second protocol (group II, n = 15), patients were treated with IVF as a first choice procedure. The decision to follow protocol 1 or 2 was made by the couples after information about financial costs and expected success rates (according to the literature) for both treatment options. In group I, nine patients (64.3%) conceived after a maximum of three IUI cycles whereas seven patients (46.6%) of group II became pregnant during the first IVF cycle. The take-home baby rate per started IUI or IVF cycle was 27.3% (9/33) and 44.4% (16/36) respectively with a take-home baby rate of 64.3% after three IUI cycles and 93.3% after three IVF attempts. To conclude, both IUI and IVF yielded unexpectedly high pregnancy rates in this selected group of patients with long-standing infertility due to sperm surface (predominantly IgG) antibodies. Since cost benefit analysis comparing superovulation IUI with IVF may favour a course of four IUI cycles, we advocate superovulation IUI as the first line therapy in male immunological infertility.

Posttraumatic pneumomediastinum: not always cause for alarm

A case of pneumomediastinum following a minor blunt thoracic trauma is presented. As no underlying organic lesion could be found, the pathophysiology must have been that of a spontaneous pneumomediastinum, i.e. alveolar rupture with subsequent dissection of air along the bronchovascular sheats to the mediastinum. The pathophysiology, clinical presentation, diagnosis and treatment of the spontaneous pneumomediastinum are discussed. With regard to the treatment it seems most important not to be too aggressive, because spontaneous pneumomediastinum is a benign and self-limiting condition. Spontaneous regression within a week can be expected.

Human Leydig cells and Sertoli cells are producers of interleukins-1 and -6

Interleukins (IL)-1 and -6 have been shown to be produced by several categories of cells in the rat testis and involved in the paracrine control of testicular function. Evidence of high amounts of IL-1 have been shown in the human testis, but nothing is known about its cellular origin. Furthermore, to our knowledge, the presence of IL-6 in the human testis has not yet been investigated. Therefore, the present study was aimed at identifying IL-1 and -6 expression and production within the human testis, using RT-PCR, bioassays, and enzyme linked immunosorbent assays. We demonstrated that IL-1 and -6 messenger RNA and proteins were produced constitutively in vitro by human Leydig cell- and Sertoli cell-enriched preparations. FSH only stimulated IL-6 production by Sertoli cell-enriched preparations, but increased the release of both IL-1 and -6 in germ cell-depleted Sertoli cell cultures. In addition, lipopolysaccharides and latex beads enhanced the production of both cytokines by Sertoli cell cultures, whereas human chorionic gonadotropin and lipopolysaccharides enhanced the release of both cytokines by Leydig cells. Enzyme linked immunosorbent assays and neutralization experiments revealed that human Sertoli cells produce essentially the alpha form of IL-1, whereas both forms, alpha and beta, are present in Leydig cells. The demonstration that human Leydig and Sertoli cells produce IL-1 and -6 under the control of gonadotropin hormones and exogenous factors, opens the possibility to study the involvement of these cytokines in the control of testis function, in normal and pathological conditions in men.

Semen parameters in a fertile versus subfertile population: a need for change in the interpretation of semen testing

This prospectively designed study was conducted to compare a fertile and a subfertile population so as to define normal values for different semen parameters. Semen analyses were performed according to the World Health Organization (WHO) guidelines, except for sperm morphology (strict criteria). In the fertile population (n = 144), all patients had recently achieved pregnancy, within 12 months of unprotected coitus. As subfertile controls we examined semen samples from 143 consecutive men attending our infertility clinic during the same study period. Couples with tubal factor infertility and/or ovulatory disorders were excluded from our study. Using receiver operating characteristic (ROC) curve analysis we determined the diagnostic potential and cut-off values for single and combined sperm parameters. Sperm morphology scored best, with a value of 78% (area under the ROC curve). Summary statistics showed a shift towards abnormality for most semen parameters in the subfertile population. Using the 10th percentile of the fertile population as the cut-off value, the following results were obtained: 14.3 x 10(6)/ml for sperm concentration, 28% for progressive motility and 5% for sperm morphology. Using ROC analysis, cut-off values were 34 x 10(6)/ml, 45% and 10% respectively. Cut-off values for normality were different from those described in the WHO guidelines. Routine bacterial and non-bacterial cultures turned out to be of little prognostic value.

Results of a questionnaire on sperm morphology assessment

This survey describes the results of a questionnaire on the methodology of sperm morphology assessment. A questionnaire form was sent to 410 fertility centres. A total of 170 answer forms (41.5%) from 40 different countries was evaluated. Most responding centres (147 or 86.5%) treat more than 200 new couples per year. According to our results, a wide and complex variation in different methods of sperm preparation, staining procedures and classification systems is observed world wide. WHO recommendations for sperm preparation seem to be poorly followed. Only 86 centres (50.6%) reported the use of a single approach to both semen preparation and sperm morphology evaluation. Our results indicate an urgent need for standardization and consensus on sperm morphology methodology to regain the power of this important sperm parameter.

The hemizona assay: a simplified technique

The hemizona assay is an important diagnostic tool in assessing human sperm fertilizing potential. Previous hemizona assay results have proven that this functional test is a good predictor of fertilization in vitro and can be used in clinical practice to supply additional information in male factor subfertility cases. The objective of this study was to compare two methods for cutting human zona pellucida into equal halves (manual handcutting versus micromanipulation) in order to examine the necessity of an expensive micromanipulator in performing this assay. Comparable results for recovery rate, diameter size of the hemizonae, and sperm binding were achieved with both methods. According to these results, the use of an expensive micromanipulator is not essential in performing the hemizona assay.

CD8+ cells and not CD4+ T cells are hyporesponsive to CD28- and CD40L-mediated activation in HIV-infected subjects

T cell dysfunction in HIV-infected subjects could be the consequence of altered sensitivity of CD4+ or CD8+ T cells to various costimulatory signals. Therefore, we studied proliferation and cytokine production in highly purified CD8+ and CD4+ T cells from HIV-infected and HIV- subjects, induced by co-activation via cell-bound CD80, CD86 and CD40 or by allo-activation. Regardless of the nature of the first and the costimulatory signal, CD8+ T cells from patients proliferated consistently less than controls, while responses from CD4+ T cells were similar in patients and controls. This phenomenon was observed after ligation of CD28 combined with anti-CD3 or phorbol myristate acetate (PMA), but also after allogeneic stimulation and after activation by CD40 and anti-CD3. Anti-CD3 combined with CD80 or CD86 induced a mixed Th1/Th2-type cytokine profile in both CD4+ and CD8+ T cells from controls, whereas anti-CD3 plus CD40 induced only low levels of Th2-type cytokines and no interferon-gamma (IFN-gamma) in CD4+ T cells. Compared with controls, CD4+ T cells from patients produced slightly lower levels of IL-10 but equal amounts of IFN-gamma, IL-4 and IL-5, while CD8+ T cells from patients produced less of all cytokines tested. In conclusion, responses of purified CD4+ T cells from HIV+ subjects to various costimulatory pathways are relatively intact, whereas CD8+ T cells are hyporesponsive at the level of proliferation and cytokine production. A generalized intrinsic CD8+ T cell failure might contribute to viral and neoplastic complications of HIV infection.

Components of biological variation in serum soluble transferrin receptor: relationships to serum iron, transferrin and ferritin concentrations, and immune and haematological variables

We investigated the components of biological variation in serum soluble transferrin receptor (TfR) in relation to serum iron, transferrin (Tf), ferritin, soluble interleukin-2 receptor (sIL-2R), sIL-6R, and number of erythrocytes, haemoglobin (Hb), haematocrit (Ht), mean corpuscular volume (MCV), mean cell haemoglobin (MCH), and erythrocyte distribution width (RDW). We took monthly blood samples during 1 calendar year from 26 healthy subjects for assay of the above variables. The estimated CVs for TfR were interindividual CVg = 20.8%, and intra-individual CVi = 13.6%; for Tf, CVg = 14.4% and CVi = 6.7%; for iron, CVg = 16.8% and CVi = 29.2%; and for ferritin, CVg = 71.1% and CVi = 26.5%. There was a statistically significant seasonal pattern in the four variables with significant annual, biannual and/or trimonthly rhythms, which were expressed as a group phenomenon. The peak-trough differences in the yearly variations, expressed as a percentage of the mean, were: for TfR, 11.7%; for iron, 39.2%; for Tf, 11.7%; and for ferritin, 29.3%. Up to 34.2% of the within-subject variability in TfR (which reflects changes over time) could be explained by the regression on iron, ferritin, Tf, sIL-2R, sIL-6R and MCH values. Up to 67.2% of the between-subject variability in TfR (which reflects differences in the homeostatic setpoint during the study year) could be explained by the regression on gender, iron, Tf, and ferritin values.

Increased serum soluble CD8 or suppressor/cytotoxic antigen concentrations in depression: suppressive effects of glucocorticoids

There is now some evidence that depression and, in particular, major depression, is accompanied by signs of an immune response, and that there are reciprocal relationships between immune function and increased hypothalamic-pituitary-adrenal (HPA) axis activity in depression. To further examine the above phenomena, this study has assayed serum soluble CD8 (sCD8) concentrations in 22 normal controls, 27 minor depressed, 37 major depressed, and 26 melancholic depressed patients. Serum sCD8 was significantly higher in depressed patients versus normal controls. Thirty-five percent of the depressed subjects had increased sCD8 serum levels (i.e., > 560 U/mL) with a specificity of 95.4%. Dexamethasone administration (1 mg PO) had a significant suppressive effect on serum sCD8. In depressed subjects, there were significant and negative relationships between serum sCD8 and postdexamethasone cortisol values. The results suggest the presence of an ongoing lymphocyte activation in depression, which may be down-regulated by increased HPA axis activity in that illness.

The relation between reactive oxygen species and cytokines in andrological patients with or without male accessory gland infection

The presence of various cytokines, namely hepatocyte growth factor (HGF), interleukin-1 receptor antagonist (IL-1 RA), and interleukins (IL-1 alpha, IL-6, and IL-8), as well as the production of reactive oxygen species (ROS) was investigated in seminal plasma of fertile and infertile patients in order to evaluate the possible value of measuring these substances for the diagnosis of male accessory gland infection, and to assess the possible relationship between oxidative stress and cytokines during leucocytospermia and male accessory gland infection (MAGI). Our findings indicate that all of the measured cytokines seem to be produced locally as well as by white blood cells (WBC) and that, due to the presence of higher numbers of WBC, accessory gland infection may exert a deleterious effect on sperm quality through the production of ROS and/or of particular cytokines such as IL-1 alpha, IL-1 RA, and IL-8. The most specific marker for a sensitivity of 95% in discriminating between cases with or without MAGI is the measurement of IL-6 in seminal plasma. In the absence of WBC several cytokines are constitutively produced and correlate with sperm concentration (HGF, IL-8), alpha-glucosidase (IL-6), and gamma-glutamyltransferase activity (HGF). The measurement of these cytokines in semen may provide clinically useful information for the diagnosis of male accessory gland infection, as well as in the absence of WBC where it can provide information about certain mechanisms of male reproductive function and dysfunction.

Imbalance in production of cytokines by bone marrow stromal cells following cytomegalovirus infection

The effect of cytomegalovirus (CMV) infection on the production of growth factors and negative regulators in unstimulated or lipopolysaccharide-stimulated human bone marrow stromal cells was assessed. After 5 days, the constitutive and lipopolysaccharide-stimulated production of growth factors was significantly decreased in CMV-infected compared with uninfected stromal cells. This decrease was noted as early as 72 h after infection and appeared to be strictly related to viral replication. On the other hand, the production of inhibitory factors was increased after CMV infection, and this increased release was detectable as early as 24 h after infection. No modulation in the production of interleukin-10 was observed after CMV infection. These data suggest that CMV disturbs the balanced cytokine network, which controls proliferation and differentiation of hematopoietic progenitors. CMV-induced myelosuppression results from this lack of production of growth factors and excess production of inhibitory factors.

High levels of leukaemia inhibitory factor in ARDS

Although elevated concentrations of a few cytokines have been shown to be present in the bronchoalveolar lavage (BAL) fluid (BALF) of patients with the acute (adult) respiratory distress syndrome (ARDS), the pathogenesis of ARDS is largely unknown. Leukaemia inhibitory factor (LIF), a growth factor recently recognised as a polyfunctional cytokine integrated in cytokine networks was measured in unconcentrated BALF of patients from different patient groups. LIF was measured in BALF by means of a specific and sensitive ELISA (detection limit 10 pg/ml) in BALF (lavage of 3 x 50 ml in the right middle lobe). LIF was not detected in the BALF of 13 healthy control patients and in only one (34 pg/ml) out of 25 patients at risk for ARDS (after cardiopulmonary bypass surgery) who underwent BAL 4 h after the end of the extracorporeal circulation. High and detectable levels were found in the unconcentrated BALF of 10 out of 12 patients with full-blown ARDS (212 +/- 116, mean +/- SEM, range 10-985 pg/ml). There was a good correlation between the level of LIF in the BALF and a number of markers of inflammation such as neutrophils/ml, albumin and protein levels. The biological role of LIF in these BALFs is not readily explained by its currently known actions and it is unknown whether LIF contributes to or is a response to local tissue damage. Our results indicate that this cytokine is part of the inflammatory cytokine cascade in ARDS.

Indicators of immune activation in major depression

Immune-inflammatory markers and their correlations were examined in patients with major depression. Plasma concentrations of interleukin-6 (IL-6), soluble IL-6 receptor (sIL-6R), soluble interleukin-2 receptor (sIL-2R), transferrin receptor (TfR), C-reactive protein (CRP), and alpha 1-acid glycoprotein (AGP), as well as the microheterogeneity of AGP, were measured in 49 major depressed patients during an acute phase of the illness and compared with concentrations in 15 normal control subjects. Plasma concentrations of IL-6, sIL-6, sIL-2R, TfR, CRP, and AGP were significantly higher in major depressed patients than in healthy control subjects. Patients with higher values of AGP microheterogeneity coefficient (AGP-RC > 1.5) had significantly higher concentrations of AGP, IL-6, and TfR. The correlations between cytokines and acute phase proteins studied point to a significant role of elevated IL-6 secretion in the induction of Type I AGP microheterogeneity changes that are characteristic of some inflammatory conditions.

Chronobiological fluctuations in semen parameters with a constant abstinence period

This study examined the seasonal variation in three semen parameters (total sperm count, % grade a progressive motility and sperm morphology according to strict criteria) with an identical abstinence period of 24 h. A total of 340 spermiograms of 107 different men enrolled in an intrauterine insemination (IUI) program were examined. To reduce variation due to interindividual disparities in semen quality, differences of each test result from the mean value obtained for that individual were analyzed. Mean values resulted from at least 3 observations during different IUI cycles. Using ANOVA and spectral analysis, no differences in semen parameter results in function of the month of the year were observed. The lack of any significant periodicity may be explained by the large biological variation for individual semen parameters and/or the lack of significant differences regarding light exposure and temperature between summer and winter months in moderate climates.