Antioxidant treatment with carnitines is effective in infertile patients with prostatovesiculoepididymitis and elevated seminal leukocyte concentrations after treatment with nonsteroidal anti-inflammatory compounds

Antioxidant therapy in male infertility

Although reports have suggested the benefit of antioxidant treatment of infertile men, many studies also show no effect. Most studies in the literature are not randomized, placebo controlled, or double blinded in design, which makes it difficult to differentiate regression toward the mean from true positive treatment effects. The small patient sample sizes and varying male populations also add to the difficulty in comparing studies. Pregnancy, the most relevant outcome parameter, is rarely reported. Ideally, patients would be selected based on oxidative stress levels, and improvement in these levels would be correlated to improvement in pregnancy rates. Until those studies are performed, the use of antioxidants for the treatment of male infertility remains empiric.

Coenzyme Q10 treatment in infertile men with idiopathic asthenozoospermia: a placebo-controlled, double-blind randomized trial

OBJECTIVE

To evaluate the effectiveness of coenzyme Q(10) treatment in improving semen quality in men with idiopathic infertility.

DESIGN

Placebo-controlled, double-blind randomized trial.

SETTING

Andrology Unit, Department of Internal Medicine, Polytechnic University of Marche, Italy.

PATIENT(S)

Sixty infertile patients (27-39 years of age) with the following baseline sperm selection criteria: concentration >20 x 10(6)/mL, sperm forward motility <50%, and normal sperm morphology >30%; 55 patients completed the study.

INTERVENTION(S)

Patients underwent double-blind therapy with coenzyme Q(10), 200 mg/day, or placebo; the study design was 1 month of run-in, 6 months of therapy or placebo, and 3 months of follow-up.

MAIN OUTCOME MEASURE(S)

Variations in semen parameters used for patient selection and variations of coenzyme Q(10) and ubiquinol concentrations in seminal plasma and spermatozoa.

RESULT(S)

Coenzyme Q(10) and ubiquinol increased significantly in both seminal plasma and sperm cells after treatment, as well as spermatozoa motility. A weak linear dependence among the relative variations, baseline and after treatment, of seminal plasma or intracellular coenzyme Q(10) and ubiquinol levels and kinetic parameters was found in the treated group. Patients with a lower baseline value of motility and levels of coenzyme Q(10) had a statistically significant higher probability to be responders to the treatment.

CONCLUSION(S)

The exogenous administration of coenzyme Q(10) increases the level of the same and ubiquinol in semen and is effective in improving sperm kinetic features in patients affected by idiopathic asthenozoospermia.

Oxidative stress and male infertility--a clinical perspective

Oxidative stress occurs when the production of potentially destructive reactive oxygen species (ROS) exceeds the bodies own natural antioxidant defenses, resulting in cellular damage. Oxidative stress is a common pathology seen in approximately half of all infertile men. ROS, defined as including oxygen ions, free radicals and peroxides are generated by sperm and seminal leukocytes within semen and produce infertility by two key mechanisms. First, they damage the sperm membrane, decreasing sperm motility and its ability to fuse with the oocyte. Second, ROS can alter the sperm DNA, resulting in the passage of defective paternal DNA on to the conceptus. This review will provide an overview of oxidative biochemistry related to sperm health and will identify which men are most at risk of oxidative infertility. Finally, the review will outline methods available for diagnosing oxidative stress and the various treatments available.

Determination of free l-carnitine in human seminal plasma by high performance liquid chromatography with pre-column ultraviolet derivatization and its clinical application in male infertility

BACKGROUND

To develop and validate a simple and reliable high performance liquid chromatographic (HPLC) method for the analysis of free L-carnitine in human seminal plasma and to investigate its clinical significance as a potentially additional means of evaluating the infertile male.

METHODS

After proteins in seminal plasma are precipitated with a mixture of acetonitrile and methanol (9:1; v/v), free L-carnitine in seminal plasma was derivatized to form its UV-absorbing ester. HPLC separation of the sample solution was performed on a Lichrospher SiO2 column and detected by ultraviolet absorbance at 260 nm. A mobile phase composed of acetonitrile-citric acid buffer (containing 12 mmol/L triethanolamine, pH 5.0) was found to be the most suitable for this separation at a flow rate of 1.2 mL/min and enabled the baseline separation of the free L-carnitine from interferences with isocratic elution. The free L-carnitine levels in seminal plasma were studied in both 30 control subjects and 87 patients with infertility. Ejaculates were classified into studied subgroups and defined as: asthenozoospermia (n=29), oligozoospermia (n=19) and oligoasthenoteratozoospermia (n=39).

RESULTS

Under the chromatographic conditions described, the free L-carnitine derivative had a retention time of approximately 13 min. Good separation and detectability of free L-carnitine in human seminal plasma sample were obtained. The method proved to be linear in the range of L-carnitine from 0 micromol/L to 1000 micromol/L. The relative standard deviations of within- and between-assay for free L-carnitine analysis were 1.23 and 1.36 %, respectively. The recoveries were 91.6-96.5% for the human seminal plasma samples. Free L-carnitine concentrations in the populations were 392.66+/-107.18 micromol/L in the fertile group (n=30), 270.00+/-83.92 micromol/L in asthenozoospermia group, 187.97+/-43.90 micromol/L in oligozoospermia group and 175.65+/-67.07 micromol/L in oligoasthenozoospermia group. The large difference (P<0.01) between the fertile and infertile populations is evident and the difference between the subdivided groups in the infertile group is not significant (P>0.05).

CONCLUSION

The determination of free L-carnitine level in seminal plasma may prove useful as a potentially biochemical marker of fertility and this is a useful guidance for the clinic therapy and the mechanismic study on the male reproduction.

Correlation of leukocytospermia with clinical infection and the positive effect of antiinflammatory treatment on semen quality

OBJECTIVE

To investigate the correlation between leukocytospermia, bacteriospermia, and clinical signs of infection and to evaluate antiinflammatory therapy.

DESIGN

Prospective nonrandomized study.

SETTING

Andrologic clinic at university hospital.

PATIENT(S)

A total of 56 patients were evaluated, and 12 of them received further treatment with a Cox-2 inhibitor.

INTERVENTION(S)

Semen analysis and clinical investigation were done according to World Health Organization guidelines. Serum levels of leukocytes, C-reactive protein (CRP), and prostate-specific antigen (PSA) were measured from blood samples.

MAIN OUTCOME MEASURE(S)

Sperm concentration, leukocyte concentration, serum leukocyte count, CRP, PSA, bacterial growth.

RESULT(S)

Leukocytospermia (>1 x 10(6)/mL) was present in 60.7% of the semen samples, significant pathogenic bacterial growth was detectable in 35.7%, and 14.3% of the samples fulfilled the criteria for ejaculate signs of infection. All serum parameters were within the normal range. In abacterial leukocytospermia, treatment with a Cox-2 inhibitor decreased leukocytospermia from 5.5 x 10(6)/mL to 1.0 x 10(6)/mL (P=.001) and increased sperm concentration from 22.5 x 10(6)/mL to 48.0 x 10(6)/mL (P=.02).

CONCLUSION(S)

There was no evidence of an immune response in the peripheral blood system. In abacterial leukocytospermia, treatment with a Cox-2 inhibitor seems to be able to reduce leukocytospermia and increase sperm count.

Effects of L-carnitine on oxidant/antioxidant status in acetic acid-induced colitis

Recently, the role of oxidative stress in the pathogenesis of ulcerative colitis has been investigated. This study was designed to evaluate the possible beneficial effects of L-carnitine on tissue injury and oxidative stress in acetic acid-induced colitis in rats. Acetic acid administration induced severe damage macroscopically and histopathologically in colon and significantly increased the levels of malondialdehyde and myeloperoxidase in colonic tissue. Supplementation of L-carnitine to acetic acid-treated rats did not prove to induce any improvements in macroscopic scores, while L-carnitine administration improved histopathologic scores and significantly decreased malondialdehyde and myeloperoxidase levels in treatment groups. Acetic acid administration significantly decreased reduced glutathione, superoxide dismutase, and catalase levels in colonic homogenate. Supplementation of L-carnitine prevented the depletion of reduced glutathione levels but significantly increased superoxide dismutase levels. On the other hand, no significant change in catalase activity was observed. In conclusion, these results may reflect that L-carnitine could be beneficial as a complementary agent in treatment of ulcerative colitis.

Medical treatment to improve sperm quality

Approximately 30% of cases of couple infertility are due to a male factor. Several conditions can interfere with spermatogenesis and reduce sperm quality and production. Treatable conditions, such as hypogonadism, varicocele, infections and obstructions, should be diagnosed and corrected, but many aspects of male factor infertility remain unclear. Various agents have been used in the attempt to increase the fertility potential of subjects with idiopathic oligoteratoasthenozoospermia. The rationale of medical treatment to improve sperm quality in these subjects has been questioned by the introduction of assisted reproductive technologies. However, there is now growing awareness of the importance of good quality spermatozoa for embryonic development and higher birth rates. Confounding factors in assessing the efficacy of male infertility treatments have erroneously inflated the superiority of assisted reproductive technologies over conventional approaches. A systematic review is given of relevant randomized controlled trials and effects on semen parameters. The analysis reveals that although results are heterogeneous, gonadotrophins, anti-oestrogens, carnitine and trace elements may be beneficial in improving sperm quality, although their effect on pregnancy rate remains controversial. The most common drug regimens are compared and an estimate of the results expected from these treatments provided.

Sperm parameter abnormalities, low seminal fructose and reactive oxygen species overproduction do not discriminate patients with unilateral or bilateral post-infectious inflammatory prostato-vesiculo-epididymitis

We have shown that patients with prostato-vesiculo-epididymitis (PVE) have the worst sperm output compared to patients with prostato-vesiculitis or prostatitis alone. The present study was undertaken to closely examine whether unilateral or bilateral PVE had a different impact on sperm parameters, seminal fructose levels and reactive oxygen species (ROS) overproduction. To accomplish this, 78 patients with persistent post-infectious inflammatory PVE, clearly identified by scrotal and transrectal ultrasonography, and 30 patients with asymptomatic post-infectious inflammatory prostatitis (control group) underwent semen analysis (including seminal leukocyte concentration and number of spermiophagies), seminal fructose measurement and sperm ROS production from 45 and 90% Percoll fractions. Fifty patients turned out to have PVE bilaterally, whereas the remaining 28 had unilateral PVE. Patients with bilateral PVE had sperm concentration and total sperm number significantly lower than those found in patients with unilateral PVE. The other sperm parameters, the physicochemical properties (hyperviscosity, the presence of nonspecific agglutination, delayed liquefaction), seminal fructose levels and ROS production in both 45 and 90% Percoll fractions turned out similar between the two groups. Patients with bilateral or unilateral PVE had sperm parameters, seminal fructose levels and ROS production significantly worst than those found in patients with prostatitis alone. In conclusion, although patients with bilateral PVE had a decreased number of spermatozoa, the other sperm parameters and seminal fructose levels did not reflect the extension of PVE. Therefore, the diagnosis of unilateral or bilateral involvement of this complicated form of male accessory gland infection relies on scrotal and transrectal ultrasonography.

Placebo-controlled double-blind randomized trial on the use of L-carnitine, L-acetylcarnitine, or combined L-carnitine and L-acetylcarnitine in men with idiopathic asthenozoospermia

OBJECTIVE

To evaluate the effectiveness of L-carnitine (LC) or L-acetyl-carnitine (LAC) or combined LC and LAC treatment in improving semen kinetic parameters and the total oxyradical scavenging capacity in semen.

DESIGN

Placebo-controlled, double-blind, randomized trial.

SETTING

Andrology unit, Department of Internal Medicine, Polytechnic University of Marche, Italy.

PATIENT(S)

Sixty infertile men, ages 20 to 40 years, with the following baseline sperm selection criteria: concentration > 20 x 10(6)/mL, sperm forward motility < 50%, and normal sperm morphology > 30%; 59 patients completed the study.

INTERVENTION(S)

Patients underwent a double-blind therapy of LC 3 g/d, LAC 3 g/d, a combination of LC 2 g/d and LAC 1 g/d, or placebo. The study design was 1 month of run in, 6 months of therapy or placebo, and 3 months of follow-up evaluation.

MAIN OUTCOME MEASURE(S)

Variations in semen parameters used for patient selection, and variations in total oxyradical scavenging capacity of the seminal fluid.

RESULT(S)

Sperm cell motility (total and forward, including kinetic features determined by computer-assisted sperm analysis) increased in patients to whom LAC was administered both alone or in combination with LC; combined LC + LAC therapy led to a significant improvement of straight progressive velocity after 3 months. The total oxyradical scavenging capacity of the semen toward hydroxyl and peroxyl radicals also increased and was positively correlated with the improvement of kinetic features. Patients with lower baseline values of motility and total oxyradical scavenging capacity of the seminal fluid had a significantly higher probability of responding to the treatment.

CONCLUSION(S)

The administration of LC and LAC is effective in increasing sperm kinetic features in patients affected by idiopathic asthenozoospemia and improves the total oxyradical scavenging capacity of the seminal fluid in the same population.

Decreasing Oxidative Stress with Choline and Carnitine in Women

OBJECTIVE

Fatty acid oxidation is predominantly a mitochondrial event, which is enhanced by dietary choline and carnitine supplementation resulting in extra reactive oxygen species (ROS) load. The objective was to assess oxidative stress level by thiobarbituric acid reactive substances [TBARS] in choline and carnitine supplemented healthy women before and after mild exercise.

METHODS

Nineteen free-living women completed the placebo control study in which choline and/or L-carnitine was orally taken for 21 days. Anthropometric measurements, dietary recall, exercise routine and blood samples were analyzed to determine body composition, nutrients intake, distance walked and biochemical markers related to oxidative stress.

RESULTS

TBARS were significantly lower in the groups supplemented with choline, carnitine or both and the mild exercise (walking) was not a deterrent in this effect of the supplements. Serum vitamin A and E concentrations were higher in the supplemented groups even though the consumption of these nutrients was not different among the groups.

CONCLUSION

Choline and carnitine supplementation lowers lipid peroxidation, and promotes conservation of retinol and alpha-tocopherol in free-living women.

Correlation between seminal carnitine and functional spermatozoal characteristics in men with semen dysfunction of various origins

BACKGROUND AND OBJECTIVE

L-carnitine is an essential molecule involved in mitochondrial metabolism, controlling the transport of acetyl and acyl groups across the mitochondrial inner membrane. Carnitine and acetylated carnitine (L-acetylcarnitine) are found in high concentrations in the epididymis, where they also act as antioxidants, protecting spermatozoa against damage caused by reactive oxygen species. In this open study we investigated the correlation between seminal carnitine levels and spermatozoal function, and the effect of combined L-carnitine + L-acetylcarnitine therapy, in infertile men.

PATIENTS AND METHODS

170 infertile men were enrolled in this study. Patients were divided into those with a total sperm motility below the normal WHO range (<50% motility, group 1 [n = 102]) and those with total sperm motility within the normal range (> or =50% motility, group 2 [n = 68]). Patients in group 1 were further divided into two groups: those with primary or secondary azoospermia (1B [n = 36]), and those without (1A [n = 66]). Patients in group 1A received L-carnitine 1 g/day and L-acetylcarnitine 500 mg twice daily for 6 months. Seminal carnitine levels were measured and correlated with sperm count and motility, eosin test, hypo-osmotic swelling test, acridine orange test for sperm nuclear DNA integrity and sperm kinetics evaluated by computer-assisted sperm analysis in all patients.

RESULTS

There was a significant correlation between seminal carnitine concentration and sperm concentration, total sperm count, sperm total motility, rapid forward progression, live sperm count, membrane function, nuclear DNA integrity, capacity for cervical mucus penetration, linearity of spermatic movement, and amplitude of lateral sperm head movement (all p < 0.0001) in the entire study population. In group 1A, there was a significant increase in total motility, live sperm count, membrane integrity and linearity of spermatic movement after 3 and 6 months of L-carnitine/L-acetylcarnitine treatment, and in capacity for cervical mucus penetration after 6 months of treatment, compared with baseline.

CONCLUSION

Seminal carnitine concentration may be an appropriate marker of sperm and epididymal function. L-carnitine/L-acetylcarnitine treatment may be an effective therapy to improve mainly functional seminal parameters.

Effect of L-carnitine administration on the seminal characteristics of oligoasthenospermic stallions

The effect of orally administered l-carnitine on the quality of semen obtained from stallions with different semen qualities was investigated. Four stallions with proven fertility (high motility group, HM) and with normal seminal characteristics (>50% progressive motility and > 80 x 10(6) spermatozoa/ml), and four questionable breeders (low motility group, LM) with <50% of sperm progressive motility and < 80 x 10(6) spermatozoa/ml, received p.o. 20 g of l-carnitine for 60 days. Blood and semen samples were collected before treatment (T0) and after 30 (T1) and 60 days (T2). Semen evaluation were performed on five consecutive daily ejaculates (n = 120 ejaculates) and conventional semen analysis was carried out on each ejaculate, both at collection and after refrigeration for 24, 48, and 72 h. Furthermore l-carnitine, acetylcarnitine, pyruvate, and lactate concentrations, and carnitine acetyltransferase activity (CAT) were determined both in raw semen and seminal plasma. There were an increase in progressive motile spermatozoa only in the LM group (26.8 +/- 12.9, 39.1 +/- 15.5, and 48.8 +/- 8.6 for T0, T1, and T2, respectively). Free seminal plasma carnitine concentration was higher in the LM group compared to the HM one. Both pyruvate and lactate were higher in the LM group. Raw semen and seminal plasma carnitine and acetylcarnitine levels correlate positively with both sperm concentration and progressive motility; moreover, acetylcarnitine content was positively correlated with total motile morphologically normal spermatozoa. In conclusion, oral administration of l-carnitine to stallions with questionable seminal characteristics may improve spermatozoa kinetics and morphological characteristics; whereas, it seem to be ineffective in normospermic animals.

A placebo-controlled double-blind randomized trial of the use of combined l-carnitine and l-acetyl-carnitine treatment in men with asthenozoospermia

OBJECTIVE

To determine the efficacy of combined l-carnitine and l-acetyl-carnitine therapy in infertile males with oligo-astheno-teratozoospermia.

DESIGN

Placebo-controlled double-blind randomized trial.

SETTING

University tertiary referral center.

PATIENT(S)

Sixty infertile patients (aged 20-40 years) with the following baseline sperm selection criteria: concentration, 10 to 40 x 10(6)/mL; forward motility, <15%; total motility, 10% to 40%; and atypical forms, <80%. Fifty-six patients completed the study.

INTERVENTION(S)

Patients were submitted to a combined treatment of l-carnitine (2 g/d) and l-acetyl-carnitine (1 g/d) or of placebo; the study design was 2 months' wash-out, 6 months of therapy or of placebo, and 2 months' follow-up.

MAIN OUTCOME MEASURE(S)

Variation in the semen parameters that were used for patient selection.

RESULT(S)

Even though increases were seen in all sperm parameters after combined carnitine treatment, the most significant improvement in sperm motility (both forward and total) was present in patients who had lower initial absolute values of motile sperm (<4 x 10(6) forward or <5 x 10(6) total motile spermatozoa per ejaculate).

CONCLUSION(S)

Combined treatment with l-carnitine and l-acetyl-carnitine in a controlled study of efficacy was effective in increasing sperm motility, especially in groups with lower baseline levels.

Role of antioxidants in treatment of male infertility: an overview of the literature

Seminal oxidative stress in the male reproductive tract is known to result in peroxidative damage of the sperm plasma membrane and loss of its DNA integrity. Normally, a balance exists between concentrations of reactive oxygen species and antioxidant scavenging systems. One of the rational strategies to counteract the oxidative stress is to increase the scavenging capacity of seminal plasma. Numerous studies have evaluated the efficacy of antioxidants in male infertility. In this review, the results of different studies conducted have been analysed, and the evidence available to date is provided. It was found that although many clinical trials have demonstrated the beneficial effects of antioxidants in selected cases of male infertility, some studies failed to demonstrate the same benefit. The majority of the studies suffer from a lack of placebo-controlled, double-blind design, making it difficult to reach a definite conclusion. In addition, investigators have used different antioxidants in different combinations and dosages for varying durations. Pregnancy, the most relevant outcome parameter of fertility, was reported in only a few studies. Most studies failed to examine the effect of antioxidants on a specific group of infertile patients with high oxidative stress. Multicentre, double-blind studies with statistically accepted sample size are still needed to provide conclusive evidence on the benefit of antioxidants as a treatment modality for patients with male infertility.

Carnitines and male infertility

L-Carnitine (LC) and acetyl-L-carnitine (ALC) are highly concentrated in the epididymis and play a crucial role in sperm metabolism and maturation. They are related to sperm motility and have antioxidant properties. The objective of this review is to summarize the multiple roles played by LC and ALC in male reproduction, and to highlight their limitations as well as their benefits in the treatment of male infertility. A variety of studies support the conclusion that LC and/or ALC at total daily amounts of at least 3 g per day can significantly improve both sperm concentration and total sperm counts among men with astheno- or oligoasthenozoospermia. Although many clinical trials have demonstrated the beneficial effects of LC and ALC in selected cases of male infertility, the majority of these studies suffer from a lack of placebo-controlled, double blind design, making it difficult to reach a definite conclusion. Additional, well-designed studies are necessary to further validate the use of carnitines in the treatment of patients with male infertility, specifically in men with poor semen quality.