Cigarette Smoking and Semen Quality: A New Meta-analysis Examining the Effect of the 2010 World Health Organization Laboratory Methods for the Examination of Human Semen

Preconception lifestyle advice for people with infertility

BACKGROUND

Infertility is a prevalent problem that has significant consequences for individuals, families, and the community. Modifiable lifestyle factors may affect the chance of people with infertility having a baby. However, no guideline is available about what preconception advice should be offered. It is important to determine what preconception advice should be given to people with infertility and to evaluate whether this advice helps them make positive behavioural changes to improve their lifestyle and their chances of conceiving.

OBJECTIVES

To assess the safety and effectiveness of preconception lifestyle advice on fertility outcomes and lifestyle behavioural changes for people with infertility.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, CINAHL, trial registers, Google Scholar, and Epistemonikos in January 2021; we checked references and contacted field experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), randomised cross-over studies, and cluster-randomised studies that compared at least one form of preconception lifestyle advice with routine care or attention control for people with infertility.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Primary effectiveness outcomes were live birth and ongoing pregnancy. Primary safety outcomes were adverse events and miscarriage. Secondary outcomes included reported behavioural changes in lifestyle, birth weight, gestational age, clinical pregnancy, time to pregnancy, quality of life, and male factor infertility outcomes. We assessed the overall quality of evidence using GRADE criteria.

MAIN RESULTS

We included in the review seven RCTs involving 2130 participants. Only one RCT included male partners. Three studies compared preconception lifestyle advice on a combination of topics with routine care or attention control. Four studies compared preconception lifestyle advice on one topic (weight, alcohol intake, or smoking) with routine care for women with infertility and specific lifestyle characteristics. The evidence was of low to very low-quality. The main limitations of the included studies were serious risk of bias due to lack of blinding, serious imprecision, and poor reporting of outcome measures. Preconception lifestyle advice on a combination of topics versus routine care or attention control Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.79 to 1.10; 1 RCT, 626 participants), but the quality of evidence was low. No studies reported on adverse events or miscarriage. Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice on a combination of topics affects lifestyle behavioural changes: body mass index (BMI) (mean difference (MD) -1.06 kg/m², 95% CI -2.33 to 0.21; 1 RCT, 180 participants), vegetable intake (MD 12.50 grams/d, 95% CI -8.43 to 33.43; 1 RCT, 264 participants), alcohol abstinence in men (RR 1.08, 95% CI 0.74 to 1.58; 1 RCT, 210 participants), or smoking cessation in men (RR 1.01, 95% CI 0.91 to 1.12; 1 RCT, 212 participants). Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of women with adequate folic acid supplement use (RR 0.98, 95% CI 0.95 to 1.01; 2 RCTs, 850 participants; I² = 4%), alcohol abstinence (RR 1.07, 95% CI 0.99 to 1.17; 1 RCT, 607 participants), and smoking cessation (RR 1.01, 95% CI 0.98 to 1.04; 1 RCT, 606 participants), on low quality evidence. No studies reported on other behavioural changes. Preconception lifestyle advice on weight versus routine care Studies on preconception lifestyle advice on weight were identified only in women with infertility and obesity. Compared to routine care, we are uncertain whether preconception lifestyle advice on weight affects the number of live births (RR 0.94, 95% CI 0.62 to 1.43; 2 RCTs, 707 participants; I² = 68%; very low-quality evidence), adverse events including gestational diabetes (RR 0.78, 95% CI 0.48 to 1.26; 1 RCT, 317 participants; very low-quality evidence), hypertension (RR 1.07, 95% CI 0.66 to 1.75; 1 RCT, 317 participants; very low-quality evidence), or miscarriage (RR 1.50, 95% CI 0.95 to 2.37; 1 RCT, 577 participants; very low-quality evidence). Regarding lifestyle behavioural changes for women with infertility and obesity, preconception lifestyle advice on weight may slightly reduce BMI (MD -1.30 kg/m², 95% CI -1.58 to -1.02; 1 RCT, 574 participants; low-quality evidence). Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice affects the percentage of weight loss, vegetable and fruit intake, alcohol abstinence, or physical activity. No studies reported on other behavioural changes. Preconception lifestyle advice on alcohol intake versus routine care Studies on preconception lifestyle advice on alcohol intake were identified only in at-risk drinking women with infertility. We are uncertain whether preconception lifestyle advice on alcohol intake affects the number of live births (RR 1.15, 95% CI 0.53 to 2.50; 1 RCT, 37 participants; very low-quality evidence) or miscarriages (RR 1.31, 95% CI 0.21 to 8.34; 1 RCT, 37 participants; very low-quality evidence). One study reported on behavioural changes for alcohol consumption but not as defined in the review methods. No studies reported on adverse events or other behavioural changes. Preconception lifestyle advice on smoking versus routine care Studies on preconception lifestyle advice on smoking were identified only in smoking women with infertility. No studies reported on live birth, ongoing pregnancy, adverse events, or miscarriage. One study reported on behavioural changes for smoking but not as defined in the review methods.

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births. Evidence was insufficient to allow conclusions on the effects of preconception lifestyle advice on adverse events and miscarriage and on safety, as no studies were found that looked at these outcomes, or the studies were of very low quality. This review does not provide clear guidance for clinical practice in this area. However, it does highlight the need for high-quality RCTs to investigate preconception lifestyle advice on a combination of topics and to assess relevant effectiveness and safety outcomes in men and women with infertility.

Use of e-cigarettes associated with lower sperm counts in a cross-sectional study of young men from the general population

STUDY QUESTION

Are use of e-cigarettes and snuff associated with testicular function as previously shown for conventional cigarettes and marijuana?

SUMMARY ANSWER

Use of e-cigarettes is associated with reduced semen quality but not with higher serum testosterone level as observed for conventional cigarette use. Snuff use was not associated with markers of testicular function.

WHAT IS KNOWN ALREADY

Cigarette smoking has previously been associated with higher testosterone levels and impaired semen quality, whereas it is unresolved whether use of e-cigarettes or snuff influence the testicular function.

STUDY DESIGN, SIZE, DURATION

This cross-sectional population-based study included 2008 men with information on cigarette and marijuana use (enrolled between 2012 and 2018), among whom 1221 men also had information on e-cigarette and snuff use (enrolled between 2015 and 2018).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Men (median age 19.0 years) from the general population provided a semen and blood sample and filled out a questionnaire on lifestyle including information on smoking behaviour. Associations between different types of smoking (e-cigarettes, snuff, marijuana and cigarettes) and reproductive hormones (total and free testosterone, sex hormone-binding globulin, LH, oestradiol and ratios of inhibin B/FSH, testosterone/LH and free testosterone/LH) and semen parameters (total sperm count and sperm concentration) were examined using multiple linear regression analyses adjusted for relevant confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Approximately half of the men (52%) were cigarette smokers, 13% used e-cigarettes, 25% used snuff and 33% used marijuana. Users of e-cigarettes and marijuana were often also cigarette smokers. Compared to non-users, daily e-cigarette users had significantly lower total sperm count (147 million vs 91 million) as did daily cigarette smokers (139 million vs 103 million), in adjusted analyses. Furthermore, significantly higher total and free testosterone levels were seen in cigarette smoking men (6.2% and 4.1% higher total testosterone and 6.2% and 6.2% higher free testosterone in daily smokers and occasional smokers, respectively, compared to non-smoking men), but not among e-cigarette users. Daily users of marijuana had 8.3% higher total testosterone levels compared to non-users. No associations were observed for snuff in relation to markers of testicular function.

LIMITATIONS, REASONS FOR CAUTION

We cannot exclude that our results can be influenced by residual confounding by behavioural factors not adjusted for. The number of daily e-cigarette users was limited and findings should be replicated in other studies.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first human study to indicate that not only cigarette smoking but also use of e-cigarettes is associated with lower sperm counts. This could be important knowledge for men trying to achieve a pregnancy, as e-cigarettes are often considered to be less harmful than conventional cigarette smoking.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from the Danish Ministry of Health (1-1010-308/59), the Independent Research Fund Denmark (8020-00218B), ReproUnion (20200407) and the Research Fund of the Capital Region of Denmark (A6176). The authors have nothing to disclose.

TRIAL REGISTRATION NUMBER

NA.

Impaired semen quality in trans women: prevalence and determinants

STUDY QUESTION

What is the semen quality in trans women at time of fertility preservation, prior to the start of gender-affirming hormone treatment?

SUMMARY ANSWER

Before the start of gender-affirming hormone treatment, semen quality in trans women was already strongly decreased compared to the general population.

WHAT IS KNOWN ALREADY

Hormone treatment for -trans women (birth-assigned males, female gender identity) consists of anti-androgens combined with estrogens in order to achieve feminization and it is accompanied by a loss of reproductive capability. Trans women can opt for semen cryopreservation prior to their medical transition to retain the possibility to parent genetically related offspring. Post-thaw semen parameters determine which ART can be used. Knowledge of semen quality and the factors negatively influencing semen parameters in trans women are important to improve semen quality before fertility preservation.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study was performed between 1972 and 2017. In total, 260 trans women were included for this study. Due to the study design, there was no loss to follow-up or attrition.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied the quality of the preserved semen in trans women, prior to their medical transition, who visited our gender clinic. Semen parameters were collected, as well as data on age, alcohol consumption, smoking, cannabis use, BMI, previous use of estrogens or anti-androgens and endocrine laboratory results. Semen parameters were categorized using reference values for human semen of the World Health Organization (WHO) and compared with data from the general population. Logistic regression analyses were performed to analyze the extent to which factors known to have a negative impact on semen quality in the general population explained the impaired semen quality in the cohort.

MAIN RESULTS AND THE ROLE OF CHANCE

The cohort consisted of 260 trans women between the age of 16 and 52 years. Semen quality in trans women was significantly decreased compared to WHO data from the general population. In total, 21 trans women had an azoospermia and median semen parameters for the remaining trans women and the general population, respectively, were as follows: volume 2.7 and 3.2 ml (P < 0.05), sperm concentration 40 and 64 million/ml (P < 0.05), total sperm number 103 and 196 million (P < 0.05) and progressive motility 41% and 57% (P < 0.05). Smoking (odds ratio (OR) 2.35 (95% CI 1.06–5.21)) and a higher age at time of fertility preservation (OR 1.04 (95% CI 1.00–1.08)) were found to correlate with an impaired progressive motility. Twelve trans women reported to have used anti-androgens and estrogens, and all had discontinued for at least 3 months prior to the first attempt for semen cryopreservation. No correlation was found between previous gender-affirming hormone use and decreased semen parameters. The median post-thaw total motile sperm count was 1.0 million per vial (interquartile range 0.1–3.1) and in only 26.4% of thawed semen samples was the quality adequate for a minimally invasive IUI.

LIMITATIONS, REASONS FOR CAUTION

Limitations include the retrospective design and insufficient data on transgender-specific factors, such as bringing the testes into the inguinal position (tucking), wearing tight underwear and low masturbation frequency.

WIDER IMPLICATIONS OF THE FINDINGS

Semen quality in trans women was decreased compared to the general population, which could not be explained by known risk factors, such as BMI, alcohol consumption, cannabis use, gender-affirming hormone use or abnormal endocrine laboratory results. Although a negative impact of smoking was observed, it was insufficient to explain the overall decreased semen quality in this cohort. Since low pre-freeze semen quality results in an even lower post-thaw semen quality, the majority of trans women and their female partner or surrogate may need an invasive and burdensome treatment to establish a pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

For this study, no external funding was obtained and there were no competing interests.

TRIAL REGISTRATION NUMBER

NA.

Effects of exposure to methylglyoxal on sperm motility and embryonic development after fertilization in mice

Methylglyoxal (MG) is a precursor for the generation of endogenous advanced glycation end-products involved in various diseases, including infertility. The present study evaluated the motility and developmental competence after in vitro fertilization of mouse sperm which were exposed to MG in the capacitation medium for 1.5 h. Sperm motility was analyzed using an SQA-V automated sperm quality analyzer. Intracellular reactive oxygen species (ROS), membrane integrity, mitochondrial membrane potential, and DNA damage were assessed using flow cytometry. The matured oocytes were inseminated with MG-exposed sperm, and subsequently, the fertilization and embryonic development in vitro were evaluated in vitro. The exposure of sperm to MG did not considerably affect the swim-up of sperm but resulted in a deteriorated sperm motility in a concentration-dependent manner, which was associated with a decreased mitochondrial activity. However, these effects was not accompanied by obvious ROS accumulation or DNA damage. Furthermore, MG diminished the fertilization rate and developmental competence, even after normal fertilization. Collectively, a short-term exposure to MG during sperm capacitation had a critical impact on sperm motility and subsequent embryonic development after fertilization. Considering that sperm would remain in vivo for up to 3 days until fertilization, our findings suggest that sperm can be affected by MG in the female reproductive organs, which may be associated with infertility.

Systematic review of fertility preservation options in transgender patients: a guide for plastic surgeons

Transgender patients often desire to have biological children. However, their reproductive potential is often negatively impacted by gender affirming surgery (GAS) such as gender confirmation surgery (bottom surgery) and medical hormone therapy. Therefore, counselling patients on fertility preservation options before initiating gender-affirming treatments is prudent to avoid reducing their reproductive potential. A systematic review of English, Spanish, Chinese, French and Turkish languages from 2000 to December 23rd, 2019, using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines, was conducted. The search strategy was designed and conducted by an experienced librarian with input from the study's principle investigator. Fifteen articles that report outcomes of fertility preservation options in transgenders were included. Eight articles described options for transgender women, six reported options for transgender men and one included both transgender women and transgender men. Semen cryopreservation and oocyte cryopreservation are the most common and available methods for fertility preservation in transgenders. Physician awareness of fertility preservation options in transgender patients is crucial to ensure informed discussions regarding reproductive options in the early phase of transition.

Adolescent Transgender Females Present Impaired Semen Quality That Is Suitable for Intracytoplasmic Sperm Injection Even Before Initiating Gender-Affirming Hormone Treatment

The present study aimed to determine the semen quality and cryopreservation outcomes among adolescent transgender females at the time of fertility preservation (FP) before initiating gender-affirming hormone (GAH) treatment. This retrospective cohort study included 26 adolescent transgender females who underwent FP in our Fertility Institute between 06/2013 and 10/2020. Pre-freezing semen parameters were compared to WHO 2010 reference values. Post-thaw semen parameters were used to determine the adequate assisted reproductive technology (ART). A multivariate linear regression analysis was performed to assess the impact of medical and lifestyle factors on semen quality. The mean age at which adolescent transgender females underwent FP was 16.2 ± 1.38 years. The median values of all semen parameters in our study group were significantly lower compared to the WHO data, including volume (1.46 mL vs 3.2 mL, respectively, P = 0.001 ), sperm concentration (28 × 10⁶/mL vs 64 × 10⁶/mL, P < 0.001), total sperm number (28.2 × 10⁶ vs 196 × 10⁶, P < 0.001), total motility (51.6% vs 62%, P < 0.001), and normal morphology (2% vs 14%, P < 0.001). The frequency of semen abnormalities was teratozoospermia 72%, hypospermia 52%, oligozoospermia 28%, and azoospermia 4%. The median post-thaw total motile count was 0.17 × 10⁶/vial, and the quality was adequate only for ICSI in 87.7% of the thawed semen samples. No correlation was found between selected medical and lifestyle factors and poor semen parameters. Semen quality is strongly reduced among adolescent transgender females before hormone therapy and their stored sperm samples are suitable for intracytoplasmic sperm injection (ICSI) rather than conventional IVF/intrauterine insemination (IUI).

Male Preconception Marijuana Use and Spontaneous Abortion: A Prospective Cohort Study

BACKGROUND

Male marijuana use has increased steadily over the last decade, but its effect on risk of spontaneous abortion to our knowledge has not been studied.

METHODS

We analyzed data from Pregnancy Study Online, a North American prospective cohort study of pregnancy planners (2013-2019). During the preconception period, male and female participants completed baseline questionnaires on demographics, medical history, and behavioral factors, including marijuana use. Female participants identified pregnancy losses on bimonthly follow-up questionnaires and questionnaires completed in early and late pregnancy. We categorized frequency of male marijuana use in the 2 months before baseline as none, <1 time/week, or ≥1 time/week. We estimated the association between preconception male marijuana use and spontaneous abortion, adjusting for male and female confounders.

RESULTS

Among 1535 couples who conceived during follow-up, 9% of men reported preconceptional marijuana use <1 time/week and 8% ≥1 time/week. Nineteen percent of pregnancies ended in spontaneous abortion. Compared with no use, adjusted hazard ratios (HRs) for male marijuana use were 1.1 (95% confidence interval [CI] = 0.64, 1.7) for <1 time/week and 2.0 (95% CI = 1.2, 3.1) for ≥1 time/week. The association for ≥1 time/week persisted after restricting to couples where the female partner did not use marijuana (HR = 2.0, 95% CI = 1.1, 3.3), and was stronger for losses at <8 weeks' gestation (HR = 2.5, 95% CI = 1.4, 4.3) and among males aged ≥35 years (HR = 4.1, 95% CI = 1.54, 11).

CONCLUSIONS

Couples with male partners who used marijuana ≥1 time/week during preconception had greater risk of spontaneous abortion than couples with males who did not use marijuana.

Sperm DNA fragmentation testing: Summary evidence and clinical practice recommendations

We herein summarise the evidence concerning the impact of sperm DNA fragmentation in various clinical infertility scenarios and the advances on sperm DNA fragmentation tests. The collected evidence was used to formulate 41 recommendations. Of these, 13 recommendations concern technical aspects of sperm DNA fragmentation testing, including pre-analytical information, clinical thresholds and interpretation of results. The remaining 28 recommendations relate to indications for sperm DNA fragmentation testing and clinical management. Clinical scenarios like varicocele, unexplained infertility, idiopathic infertility, recurrent pregnancy loss, intrauterine insemination, in vitro fertilisation/intracytoplasmic sperm injection, fertility counselling for men with infertility risk factors and sperm cryopreservation have been contemplated. The bulk evidence supporting the recommendations has increased in recent years, but it is still of moderate to low quality. This guideline provides clinicians with advice on best practices in sperm DNA fragmentation testing. Also, recommendations are provided on possible management strategies to overcome infertility related to sperm DNA fragmentation, based on the best available evidence. Lastly, we identified gaps in knowledge and opportunities for research and elaborated a list of recommendations to stimulate further investigation.

Perspectives of Nanoparticles in Male Infertility: Evidence for Induced Abnormalities in Sperm Production

Advancement in the field of nanotechnology has prompted the need to elucidate the deleterious effects of nanoparticles (NPs) on reproductive health. Many studies have reported on the health safety issues related to NPs by investigating their exposure routes, deposition and toxic effects on different primary and secondary organs but few studies have focused on NPs’ deposition in reproductive organs. Noteworthy, even fewer studies have dealt with the toxic effects of NPs on reproductive indices and sperm parameters (such as sperm number, motility and morphology) by evaluating, for instance, the histopathology of seminiferous tubules and testosterone levels. To date, the research suggests that NPs can easily cross the blood testes barrier and, after accumulation in the testis, induce adverse effects on spermatogenesis. This review aims to summarize the available literature on the risks induced by NPs on the male reproductive system.

Effects of Mediterranean diet on semen parameters in healthy young adults: a randomized controlled trial

BACKGROUND

Dietary regimens have so far been studied as possible determinants of semen quality and fertility. The aim of this study was to evaluate the effects of a Mediterranean diet, as compared with a low-fat diet, on seminal parameters of young healthy adults from southern Italy.

METHODS

In a randomized controlled trial, 160 young adults aged 18-30 years were assigned to Mediterranean diet (N.=80) or a low-fat diet (N.=80). The primary outcome measures were changes in semen parameters after six months.

RESULTS

Mean age of participants in the study was 24.7 years. There was no difference in baseline semen parameters of men randomized to Mediterranean diet or low-fat diet. After the entire follow-up, participants in both groups showed a significant increase in sperm concentration and sperm total count, with significant differences favoring the Mediterranean diet group (sperm concentration, 1.93 M/mL 95% CI [1.22 to 3.64], P=0.027; total sperm count 8.02 M 95% CI [1.51 to 15.45], P=0.035). No differences in other semen parameters were found between groups.

CONCLUSIONS

In healthy young adults, the consumption of Mediterranean diet was associated with an improvement of both sperm concentration and total count, as compared with a low-fat diet.

Male infertility

It is estimated that infertility affects 8-12% of couples globally, with a male factor being a primary or contributing cause in approximately 50% of couples. Causes of male subfertility vary highly, but can be related to congenital, acquired, or idiopathic factors that impair spermatogenesis. Many health conditions can affect male fertility, which underscores the need for a thorough evaluation of patients to identify treatable or reversible lifestyle factors or medical conditions. Although semen analysis remains the cornerstone for evaluating male infertility, advanced diagnostic tests to investigate sperm quality and function have been developed to improve diagnosis and management. The use of assisted reproductive techniques has also substantially improved the ability of couples with infertility to have biological children. This Seminar aims to provide a comprehensive overview of the assessment and management of men with infertility, along with current controversies and future endeavours.

Male infertility due to testicular disorders

CONTEXT

Male infertility is defined as the inability to conceive following 1 year of regular unprotected intercourse. It is the causative factor in 50% of couples and a leading indication for assisted reproductive techniques (ART). Testicular failure is the most common cause of male infertility, yet the least studied to date.

EVIDENCE ACQUISITION

The review is an evidence-based summary of male infertility due to testicular failure with a focus on etiology, clinical assessment, and current management approaches. PubMed-searched articles and relevant clinical guidelines were reviewed in detail.

EVIDENCE SYNTHESIS/RESULTS

Spermatogenesis is under multiple levels of regulation and novel molecular diagnostic tests of sperm function (reactive oxidative species and DNA fragmentation) have since been developed, and albeit currently remain as research tools. Several genetic, environmental, and lifestyle factors provoking testicular failure have been elucidated during the last decade; nevertheless, 40% of cases are idiopathic, with novel monogenic genes linked in the etiopathogenesis. Microsurgical testicular sperm extraction (micro-TESE) and hormonal stimulation with gonadotropins, selective estrogen receptor modulators, and aromatase inhibitors are recently developed therapeutic approaches for men with the most severe form of testicular failure, nonobstructive azoospermia. However, high-quality clinical trials data is currently lacking.

CONCLUSIONS

Male infertility due to testicular failure has traditionally been viewed as unmodifiable. In the absence of effective pharmacological therapies, delivery of lifestyle advice is a potentially important treatment option. Future research efforts are needed to determine unidentified factors causative in "idiopathic" male infertility and long-term follow-up studies of babies conceived through ART.

Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple

Capsule

This expert opinion summarizes current knowledge on risk factors for infertility and identifies a practical clinical and diagnostic approach for the male and female partners of an infertile couple aimed to improve the investigation and management of fertility problems.

Background

Infertility represents an important and growing health problem affecting up to 16% of couples worldwide. In most cases, male, female, or combined factor can be identified, and different causes or risk factors have been related to this condition. However, there are no standardized guidelines on the clinical-diagnostic approach of infertile couples and the recommendations concerning infertility are sometimes lacking, incomplete, or problematic to apply.

Objective

The aim of this work is to provide an appropriate clinical and diagnostic pathway for infertile couples designed by a multidisciplinary-team of experts. The rationale is based on the history and physical examination and then oriented on the basis of initial investigations. This approach could be applied in order to reduce variation in practice and to improve the investigation and management of fertility problems.

Methods

Prominent Italian experts of the main specialties committed in the ART procedures, including gynecologists, andrologists, embryologists, biologists, geneticists, oncologists, and microbiologists, called "InfertilItaly group", used available evidence to develop this expert position.

Outcomes

Starting from the individuation of the principal risk factors that may influence the fertility of females and males and both genders, the work group identified most appropriate procedures using a gradual approach to both partners aimed to obtain a precise diagnosis and the most effective therapeutic option, reducing invasive and occasionally redundant procedures.

Conclusions

This expert position provides current knowledge on risk factors and suggests a diagnostic workflow of infertile couples. By using this step-by-step approach, health care workers involved in ART, may individuate a practical clinical management of infertile couples shared by experts.

Hydrogen Gas: A Novel Type of Antioxidant in Modulating Sexual Organs Homeostasis

Sex is a science of cutting edge but bathed in mystery. Coitus or sexual intercourse, which is at the core of sexual activities, requires healthy and functioning vessels to supply the pelvic region, thus contributing to clitoris erection and vaginal lubrication in female and penile erection in male. It is well known that nitric oxide (NO) is the main gas mediator of penile and clitoris erection. In addition, the lightest and diffusible gas molecule hydrogen (H2) has been shown to improve erectile dysfunction (ED), testis injuries, sperm motility in male, preserve ovarian function, protect against uterine inflammation, preeclampsia, and breast cancer in female. Mechanistically, H2 has strong abilities to attenuate excessive oxidative stress by selectively reducing cytotoxic oxygen radicals, modulate immunity and inflammation, and inhibit injuries-induced cell death. Therefore, H2 is a novel bioactive gas molecule involved in modulating sexual organs homeostasis.

Does methylphenidate use affect sperm parameters in patients undergoing infertility investigation? A retrospective analysis of 9769 semen samples

OBJECTIVES

Methylphenidate (MPH) is the most widely prescribed therapy for attention deficit hyperactivity disorder. Animal studies have shown a potential adverse effect of MPH exposure on male fertility. We examined the impact of MPH on human male sperm parameters.

DESIGN

Sperm parameters of 9769 samples from patients 18 years of age or older, collected as part of the basic evaluation of couples referred to the Infertility Clinic were analyzed retrospectively. We divided the study population into three groups according to MPH purchasing information: MPH purchased ≤ 90 days prior to sperm analysis-current users (n = 83), MPH purchased > 90 days prior to sperm analysis-past users (n = 293), and MPH-naïve patients (n = 9393).

METHODS

All sperm samples were analyzed by the same laboratory technician team for the following routine parameters: semen volume, sperm concentration, percentage of motile sperm, and percentage of normal morphology according to World Health Organization. The analysis of the samples was completed by evaluation of total sperm count, total sperm motility, and percentage of fast and slow motile cells. Sperm morphology was evaluated by a laboratory technician using methodological examination according to the strict Kruger-Tygerberg criteria.

RESULTS

Methylphenidate exposure did not affect sperm morphology but was associated with increased sperm concentration as well as increased total sperm count and total sperm motility among current and past users compared with MPH-naïve patients. In particular, progressive motility and total motile sperm count were significantly increased following MPH use. A multivariate analysis adjusting for age and current smoking was conducted, further supporting a positive correlation between current MPH use and increased values of total sperm count and total sperm motility.

LIMITATIONS

Our study has several inherent weaknesses, foremost of which is its retrospective nature. Another notable weakness is that medication purchasing data may not accurately reflect MPH exposure in the study population. Patients may be purchasing MPH and not taking it as prescribed.

CONCLUSIONS

In the present study, we could not demonstrate a negative impact of methylphenidate treatment on sperm parameters in adults with ADHD. Hence, we may assume that methylphenidate does not negatively affect male fertility.

The Prevalence and Components of Metabolic Syndrome in Men from Infertile Couples and Its Relation on Semen Analysis

PURPOSE

Metabolic syndrome (MetS) has been reported as a deleterious factor in male fertility potential, associated with hypogonadism, impaired spermatogenesis, decreased sperm concentration and motility, and increased sperm DNA damage. This study aimed to determine the prevalence of MetS in men from infertile couples and evaluate its effect on semen analysis (SA).

PARTICIPANTS AND METHODS

A cross-sectional descriptive study was performed in men from infertile couples diagnosed based on the World Health Organization 2010 criteria and treated at the Hue Center for Reproductive Endocrinology and Infertility, Vietnam. General information included medical history, lifestyle, MetS factors, SA, and sperm DNA fragmentation test were collected. Based on the diagnostic criteria of the American Heart Association and the National Heart, Lung, and Blood Institute for Asian men, the study population was divided into two groups: MetS and non-MetS groups. The outcomes were analyzed for any relationship between MetS and the SA index and the DNA fragmentation index (DFI).

RESULTS

A total of 534 men from infertile couples were included in this study. The prevalence of MetS was 23.4%, and abnormal semen analysis accounted for 93.8%. Age, body mass index (BMI), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), hepatitis B and total cholesterol were related to the occurrence of MetS in infertile men (p <0.05). MetS did not reveal any impact on the parameters of SA. There was a positive correlation between waist circumference (WC), WHR, WHtR, and systolic blood pressure (BP) with abnormal sperm head and DFI (p <0.05).

CONCLUSION

Although the prevalence of MetS was remarkable in men from infertile couples, there was no association between MetS and semen quality. However, WC, WHR, WHtR, and systolic BP were found to be significantly associated with abnormal sperm head and DFI.

The effect of cigarette smoking on the semen parameters of infertile men

INTRODUCTION

36.9% of men worldwide use tobacco. Previous studies suggest a negative effect of cigarette smoking on semen quality, but the results are contradictory. We have studied the effects of smoking on the semen characteristics such as sperm concentration, semen volume, sperm motility, sperm vitality and sperm morphology in a large group of infertile men.

METHODS

This retrospective study was conducted on a total of 5146 infertile men with at least one year of idiopathic infertility, who admitted to the Centre for Reproductive medicine (CRG) at the Brussels University Hospital, Belgium between 2010 and 2017. The smokers were classified as mild (1-10 cigarettes/d), moderate (11-20 cigarettes/d) or heavy smokers (> 20 cigarettes/d). Semen analysis was performed for all patients. Statistical analysis was performed using the R software package and t-test or Mann-Whitney U tests were used, group comparisons were performed using ANOVA, ANCOVA or Kruskal-Wallis tests as appropriate. A p-value <0.05 was considered as statistically significant.

RESULTS

Comparing the semen parameters in the two global groups showed that smoking had a significant decrease in semen volume (p=0.04074) and sperm concentration (p=0.029). ANOVA testing on the different smoking groups versus non-smoking group showed a significant decrease in sperm concentration (p=0.0364). After adjusting for the confounders, age and testosterone, ANCOVA testing showed significant effect on the sperm concentration (p=0.03871) in smokers versus non-smokers. No significant correlation was detected between the other semen characteristics.

CONCLUSION

We concluded that smoking had a significant and independent effect on the sperm concentration in a semen analysis. Other parameters, like semen volume, sperm motility, sperm vitality and sperm morphology were not influenced by smoking.

Impact of environmental toxin exposure on male fertility potential

Idiopathic infertility is the most common individual diagnosis in male infertility, representing nearly 44% of cases. Research studies dating over the last half-century consistently demonstrate a decline in male fertility that is incompletely explained by obesity, known genetic causes, or diet and lifestyle changes alone. Human exposures have changed dramatically over the same time course as this fertility decline. Synthetic chemicals surround us. Some are benevolent; however, many are known to cause disruption of the hypothalamic-pituitary-gonadal axis and impair spermatogenesis. More than 80,000 chemicals are registered with the United States National Toxicology Program and nearly 2,000 new chemicals are introduced each year. Many of these are known toxins, such as phthalates, polycyclic aromatic hydrocarbons, aromatic amines, and organophosphate esters, and have been banned or significantly restricted by other countries as they carry known carcinogenic effects and are reproductively toxic. In the United States, many of these chemicals are still permissible in exposure levels known to cause reproductive harm. This contrasts to other chemical regulatory legislature, such as the European Union's REACH (Registration, Evaluation, Authorization and Restriction of Chemicals) regulations which are more comprehensive and restrictive. Quantification of these diverse exposures on an individual level has proven challenging, although forthcoming technologies may soon make this data available to consumers. Establishing causality and the proportion of idiopathic infertility attributable to environmental toxin exposures remains elusive, however, continued investigation, avoidance of exposure, and mitigation of risk is essential to our reproductive health. The aim of this review is to examine the literature linking changes in male fertility to some of the most common environmental exposures. Specifically, pesticides and herbicides such as dichlorodiphenyltrichloroethane (DDT), dibromochloropropane (DBCP), organophosphates and atrazine, endocrine disrupting compounds including plastic compounds phthalates and bisphenol A (BPA), heavy metals, natural gas/oil, non-ionizing radiation, air and noise pollution, lifestyle factors including diet, obesity, caffeine use, smoking, alcohol and drug use, as well as commonly prescribed medications will be discussed.

Pretreatment maternal lifestyle and outcomes of assisted reproduction: an Italian cohort study

OBJECTIVE

We investigated whether lifestyle affects assisted reproduction technology (ART) outcomes.

DESIGN

Cohort study.

SETTING

Italian fertility unit.

PARTICIPANTS

From September 2014 to December 2016, women from couples presenting for evaluation and eligible for ART were invited to participate. Information on alcohol intake, current smoking and leisure physical activity (PA) during the year before the interview was collected, using a structured questionnaire. We considered the ART outcomes of the cycle immediately following the interview.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was cumulative pregnancy rate per retrieval. Secondary measures were number of retrieved oocytes, embryo transfer and live birth.

RESULTS

In 492 women undergoing an ART cycle, 427 (86.8%) underwent embryo transfer, 157 (31.9%) had at least one clinical pregnancy and 121 (24.6%) had live birth. The cumulative pregnancy rate per retrieval was 33.3% (95% CI 28.5% to 38.7%). In women in the third tertile of alcohol intake, adjusted relative risk was 0.97 (95% CI 0.87 to 1.08), 0.90 (95% CI 0.62 to 1.30) and 0.89 (95% CI 0.57 to 1.37) for embryo transfer, clinical pregnancy and live birth, respectively. The corresponding figures in women currently smoking more than 5 cigarettes/day were 1.00 (95% CI 0.88 to 1.16), 0.94 (95% CI 0.60 to 1.48) and 1.14 (95% CI 0.68 to 1.90), and in women with PA ≥5 hours/week were 0.93 (95% CI 0.79 to 1.08), 0.44 (95% CI 0.22 to 0.90) and 0.48 (95% CI 0.22 to 1.05), respectively.

CONCLUSION

There were no significant differences in in vitro fertilisation outcomes among women who used alcohol or tobacco in the year prior to treatment. Conservatively, all women should be advised to limit substance abuse. Moreover, our study suggested that maintaining a moderate, but not high, level of PA could be beneficial.

A qualitative study of factors influencing male participation in fertility research

BACKGROUND

Although fertility is a couple-based outcome, fertility studies typically include far fewer males than females. We know little about which factors facilitate or inhibit male participation in fertility research. In this study we aimed to explore factors that influence male participation in fertility research among North American couples trying to conceive.

METHODS

We conducted a qualitative research study of male participation in Pregnancy Study Online (PRESTO), a prospective preconception cohort of couples actively trying to conceive in Canada and the United States. Between January-August 2019, we carried out 14 online one-on-one in-depth interviews and one online focus group of males and females with varying levels of participation. The in-depth interviews included females who enrolled in PRESTO but declined to invite their male partners to participate (n = 4), males who enrolled in PRESTO (n = 6), and males who declined to participate in PRESTO (n = 4). The focus group included 10 males who enrolled in PRESTO. We analyzed the transcriptions using inductive content analysis.

RESULTS

Male and female participants perceived that fertility is a women's health issue and is a difficult topic for men to discuss. Men expressed fears of infertility tied to masculinity. However, men were motivated to participate in fertility research to support their partners, provide data that could help others, and to learn more about their own reproductive health.

CONCLUSIONS

Male participation in fertility studies will improve our understanding of male factors contributing to fertility and reproductive health issues. Results indicate a need for more education and health communication on male fertility to normalize male participation in fertility and reproductive health research. Men are much less likely than women to participate in research on fertility and pregnancy. However, it is important for men to participate in fertility research so that we gain a better understanding of male factors that impact fertility and pregnancy outcomes. In this qualitative study, we interviewed men and women from Canada and the United States who were trying to become pregnant to understand why men choose to participate in fertility research, why men choose not to participate in fertility research, and why women choose not to invite their male partners to participate in fertility research. We found that both men and women believe fertility is a woman's health issue. Men find it difficult to talk about pregnancy and fertility and have fears of infertility tied to masculinity. However, men are motivated to participate in fertility research to support their partners, to help others, and to learn more about their own reproductive health.

Regional difference in semen quality of young men: a review on the implication of environmental and lifestyle factors during fetal life and adulthood

The prevalence of low semen quality and the incidence of testicular cancer have been steadily increasing over the past decades in different parts of the World. Although these conditions may have a genetic or epigenetic origin, there is growing evidence that multiple environmental and lifestyle factors can act alone or in combination to induce adverse effects. Exposure to these factors may occur as early as during fetal life, via the mother, and directly throughout adulthood after full spermatogenic capacity is reached. This review aims at providing an overview of past and current trends in semen quality and its relevance to fertility as well as a barometer of men’s general health. The focus will be on recent epidemiological studies of young men from the general population highlighting geographic variations in Europe. The impact of some lifestyle and environmental factors will be discussed with their role in both fetal life and adulthood. These factors include smoking, alcohol consumption, psychological stress, exposure to electromagnetic radiation, and Endocrine Disrupting Chemicals (EDCs). Finally, the challenges in investigating the influence of environmental factors on semen quality in a fast changing world are presented.

The impact of selected modifiable lifestyle factors on male fertility in the modern world

Introduction

The modern man during his reproductive period is exposed to the negative influence of widespread lifestyle-related habits. The available studies show a significant decline in the quality of young men's sperm, which results in male and female infertility factors being given equal consideration. The progressive decline of sperm quality has lowered the spermiogram parameters proposed by the World Health Organization.

Material and methods

We performed a review of the literature on the most common unhealthy habits in the modern world, such as obesity, mobile phone usage, smoking and alcohol intake, and their reported effects on male fertility. Several papers including original, review and meta-analysis were searched using the ScienceDirect and Web of Science databases.

Results

All the factors under analysis contribute to a significant deterioration of sperm quality, mainly through decreased sperm concentration, vitality, motility and morphology.

Conclusions

Lifestyle-related factors are a significant cause of male infertility in the world today. Studies have shown that sperm quality is essentially determined by: obesity, nicotine addiction, heavy exposure to electromagnetic compatibility radiation-emitting devices and alcohol consumption. Weight loss and cessation or limitation of unhealthy lifestyle-related factors might represent the best course of action for any couple trying to achieve pregnancy.

Sperm DNA Fragmentation: A New Guideline for Clinicians

Sperm DNA integrity is crucial for fertilization and development of healthy offspring. The spermatozoon undergoes extensive molecular remodeling of its nucleus during later phases of spermatogenesis, which imparts compaction and protects the genetic content. Testicular (defective maturation and abortive apoptosis) and post-testicular (oxidative stress) mechanisms are implicated in the etiology of sperm DNA fragmentation (SDF), which affects both natural and assisted reproduction. Several clinical and environmental factors are known to negatively impact sperm DNA integrity. An increasing number of reports emphasizes the direct relationship between sperm DNA damage and male infertility. Currently, several assays are available to assess sperm DNA damage, however, routine assessment of SDF in clinical practice is not recommended by professional organizations. This article provides an overview of SDF types, origin and comparative analysis of various SDF assays while primarily focusing on the clinical indications of SDF testing. Importantly, we report four clinical cases where SDF testing had played a significant role in improving fertility outcome. In light of these clinical case reports and recent scientific evidence, this review provides expert recommendations on SDF testing and examines the advantages and drawbacks of the clinical utility of SDF testing using Strength-Weaknesses-Opportunities-Threats (SWOT) analysis.

People smoke for nicotine, but lose sexual and reproductive health for tar: a narrative review on the effect of cigarette smoking on male sexuality and reproduction

PURPOSE

To systematically review the impact of smoking habits on cardiovascular (CV) as well as on male sexual and reproductive function and to provide updated evidence on the role of electronic cigarettes (e-Cig) on the same topics.

METHODS

A comprehensive Medline, Embase, and Cochrane search was performed including the following words: smoking, CV system, CV risk, erectile dysfunction (ED), and male fertility. Publications from January 1, 1969 up to February 29, 2020 were included.

RESULTS

Smoking has a tremendous negative impact on CV mortality and morbidity. Current smoking behavior is also negatively associated with erectile dysfunction (ED) and impaired sperm parameters. E-Cig can release significantly lower concentrations of harmful substances when compared to regular combustible cigarettes. Whether or not the latter can result in positive CV, sexual, and fertility outcomes is still under study. Preliminary studies showed that exposure to e-Cig leads to lower vascular damage when compared to the traditional cigarette use. However, data on the long-term effects of e-Cig are lacking. Similarly, preliminary data, obtained in animal models, have suggested a milder effect of e-Cig on erectile function and sperm parameters.

CONCLUSION

Available evidence showed that e-Cig are much less dangerous when compared to the traditional tobacco use. However, it should be recognized that the risk related to e-Cig is still higher when compared to that observed in non-smoking patients. Hence, e-Cig should be considered as a potential tool, in the logic of harm reduction, to reduce the CV, sexual and fertility risk in patients refractory to the fundamental, healthy choice to definitively quit smoking.

Identifying critical exposure windows for ambient air pollution and semen quality in Chinese men

Emerging studies documented the association between ambient air pollution exposure and semen quality, but the critical exposure windows have not been comprehensively studied. To identify susceptible windows for associations of exposure to ambient respirable particulate matter (PM₁₀), nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and ozone (O₃) with sperm concentration, sperm count, total motility, and progressive motility, we recruited 1061 men attending an infertility clinic in Wuhan, China, between 2011 and 2013. We used a distributed lag multivariate linear regression to assess the exposure-lag-response relationship between semen quality and weekly air pollution exposure. The critical exposure windows were during the 6th to 12th sperm development weeks for PM₁₀, 10th to 11th weeks for O₃, and 0 to 5th weeks for SO₂. Over the entire 12 weeks of spermatogenesis period, an interquartile range increase (IQR) increase in PM₁₀ was associated with declined sperm concentration [-45.64% (95% CI: -59.97%, -26.18%) percent decrease], declined sperm count [-49.42% (95% CI: -64.42%, -28.09%) percent decrease], reduced total motility [-12.42 (95% CI: -20.47, -4.37)], and reduced progressive motility [-8.81 (95% CI: -16.00, -1.61)], SO₂ per IQR increase was associated with reduced sperm concentration [-39.73% (95% CI: -55.96%, -17.51%) percent decrease] and total motility [-8.64 (95% CI: -16.90, -0.38)], but NO₂ and O₃ were not associated with any of the four sperm quality parameters. Our findings suggest that exposure to PM₁₀ during spermatidogenesis period, exposure to SO₂ during spermatocytogenesis period, and exposure to O₃ during spermiogenesis period were associated with impaired semen quality, which implies air pollutants impair semen quality through varied pathways.

Designing and psychometric of reproductive health related behaviors assessment tool in Iranian males: an exploratory mixed method study protocol

BACKGROUND

Male reproductive health is a relatively new concept, and most men are neglected in reproductive health discussions. Therefore, it appears that there is insufficient information about the male reproductive health. This study aims to design a psychometric instrument for assessing the male reproductive health-related behavior.

METHODS/DESIGN

This is a sequential exploratory mixed-method study with a classical instrument development design. It will be conducted in two qualitative and quantitative phases on the studied units including the men living in Tehran. In the first phase, a qualitative study of a contractual content analysis approach will be conducted in order to perceive the concept of male reproductive health-related behavior, determine the dimensions of the questionnaire, and explore the items. In the second phase, a quantitative study will be carried out to evaluate the psychometric properties as well as (form, content, and construct) validity and reliability of the instrument designed in the first phase. Finally, the instrument will be scored and interpreted.

DISCUSSION

Discovering men's perception of concept of reproductive health-related behavior can help design a valid and reliable questionnaire which can be used in studies evaluating the male reproductive health-related behavior.

ETHICAL CODE

IR.TUMS.FNM.REC.1397.157.

Potential causes of male and female infertility in Qatar

A steady decline in the fertility rate has been observed in Qatar during the past fifty years. Therefore, infertility is considered a national priority in Qatar, a pronatalist society. This review article summarises the potential causes of infertility that are particularly prevalent in the Qatari population. The high rate of consanguinity leading to genetic abnormalities, the high incidence of metabolic disease, environmental contamination due to the rapid urbanization and oil and natural gas extraction procedures are discussed. In addition, the particular lifestyle of the Qatari population and the influence of religion and culture on sexual and reproductive behavior in an Arab/Islamic society are considered. The active response of the state of Qatar in implementing ways to mitigate the effects of these factors to protect fertility are also presented.

Prospective study of cigarette smoking and fecundability

STUDY QUESTION

To what extent is cigarette smoking associated with reduced fecundability?

SUMMARY ANSWER

Current female smokers, particularly those who had smoked ≥10 cigarettes/day for ≥10 years, had lower fecundability than never smokers, but current male smoking and passive smoking in either partner showed little association with reduced fecundability.

WHAT IS KNOWN ALREADY

Female smoking has been identified as a cause of infertility, yet there has been limited characterization of the dose and duration at which an effect is observed. Results for male active smoking and passive smoking in both partners are less consistent.

STUDY DESIGN, SIZE, DURATION

We analyzed data from a North American internet-based preconception cohort study of 5473 female and 1411 male pregnancy planners, enrolled from 2013 to 2018. Participants had been attempting conception for ≤6 menstrual cycles at study entry.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We collected information on active and passive smoking history on baseline questionnaires. Pregnancy was reported on female bi-monthly follow-up questionnaires. We calculated fecundability ratios (FR) and 95% CI using proportional probabilities regression models, adjusted for demographic, behavioral, medical, reproductive and dietary variables.

MAIN RESULTS AND THE ROLE OF CHANCE

Female current regular smoking (FR = 0.90, 95% CI: 0.77, 1.07), current occasional smoking (FR = 0.88, 95% CI: 0.73, 1.06), and former smoking (FR = 0.89, 95% CI: 0.81, 0.98) were associated with small reductions in fecundability. Results were stronger among women who smoked ≥10 cigarettes/day for ≥10 years (FR = 0.77, 95% CI: 0.53, 1.10). Male current regular and former smoking, and current passive smoking in either partner were not meaningfully associated with reduced fecundability. In utero exposure to ≥10 cigarettes/day among females was associated with reduced fecundability (FR = 0.75, 95% CI: 0.52, 1.06).

LIMITATIONS, REASONS FOR CAUTION

Numbers of cigarette smokers, particularly within categories of intensity and duration, were small. Under-reporting of smoking may have resulted in non-differential misclassification, and smokers were more likely to be lost to follow-up.

WIDER IMPLICATIONS OF THE FINDINGS

Given the consistency of our findings with results from previous studies and our observation of a dose-response relation in intensity of smoking, this study supports an association between female cigarette smoking and lower fecundability.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the National Institute of Child Health and Human Development (R01-HD086742, R21-HD072326, R03-HD090315 and T32-HD052458). The authors declare no competing interests.

The preconception environment and sperm epigenetics

BACKGROUND

Infertility is a common reproductive disorder, with male factor infertility accounting for approximately half of all cases. Taking a paternal perceptive, recent research has shown that sperm epigenetics, such as changes in DNA methylation, histone modification, chromatin structure, and noncoding RNA expression, can impact reproductive and offspring health. Importantly, environmental conditions during the preconception period has been demonstrated to shape sperm epigenetics.

OBJECTIVES

To provide an overview on epigenetic modifications that regulate normal gene expression and epigenetic remodeling that occurs during spermatogenesis, and to discuss the epigenetic alterations that may occur to the paternal germline as a consequence of preconception environmental conditions and exposures.

MATERIALS AND METHODS

We examined published literature available on databases (PubMed, Google Scholar, ScienceDirect) focusing on adult male preconception environmental exposures and sperm epigenetics in epidemiologic studies and animal models.

RESULTS

The preconception period is a sensitive developmental window in which a variety of exposures such as toxicants, nutrition, drugs, stress, and exercise, affects sperm epigenetics.

DISCUSSION AND CONCLUSION

Understanding the environmental legacy of the sperm epigenome during spermatogenesis will enhance our understanding of reproductive health and improve reproductive success and offspring well-being.

Empiric therapy for idiopathic oligoasthenoteratozoospermia

Male infertility accounts for 50% of the causes of infertile couples, being more than 30% of unknown etiology. In these cases, empiric treatment can be an option prior to the application of assisted reproduction techniques. Empiric treatment can be categorized as hormonal, such as gonadotropins, antiestrogens and aromatase inhibitors, and antioxidant, with vitamins, trace elements and carnitine, among others. Although scientifically acceptable evidence is limited due to the absence of large randomized and controlled clinical trials, recent systematic reviews and meta-analyses show that treatment with gonadotropins, antiestrogens and antioxidants increases pregnancy and live birth rates and improves seminal parameters. Empiric medical treatment for idiopathic infertility can be considered in specific cases in order to improve semen quality and spontaneous fertility.

Colonisation of the male reproductive tract in asymptomatic infertile men: Effects on semen quality

The objective was to explore presence/detection of microorganisms in the male reproductive tract (PMMRT) in asymptomatic patients undergoing infertility treatment and their effects on semen quality in our region. This study enrolled 205 men (mean age, 35.9 years) in a single-centre, tertiary university hospital from December 2015 to December 2016. We used the modified Meares-Stamey test, real-time polymerase chain reaction (rt-PCR) and the National Institutes of Health Chronic Prostatitis Sympton Index (NHI-CPSI) questionnaire to address this issue. No patient met the prostatitis criteria by the modified Meares-Stamey 4-sample test, 33 (16.1%) were positive for rt-PCR in the first-voided urine for any of the Mycoplasma (Ureaplasma urealyticum/parvum, Mycoplasma hominis/genitalium) and C. trachomatis was detected in two cases (1%), and three for rt-PCR in semen for HPV high-risk genotypes non-16/18 (1.5%). Significant statistical differences were reported among patients with and without PMMRT in terms of lower rate of progressive spermatozoa (PR) (p < .034), total motile sperm count (p < .028), normal morphologic forms, especially in the sperm head (p < .001) and highest viscosity (p < .012). It was concluded that PMMRT, specially Mycoplasmas, in asymptomatic infertility men, affects semen quality. The NIH-CPSI questionnaire was not a valid initial screening to subsequently evaluate the presence of prostatitis/PMMRT.

Diet and Nutritional Factors in Male (In)fertility-Underestimated Factors

In up to 50% of cases, infertility issues stem solely from the male. According to some data, the quality of human semen has deteriorated by 50%–60% over the last 40 years. A high-fat diet and obesity, resulting from an unhealthy lifestyle, affects the structure of spermatozoa, but also the development of offspring and their health in later stages of life. In obese individuals, disorders on the hypothalamic-pituitary-gonadal axis are observed, as well as elevated oestrogen levels with a simultaneous decrease in testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels. Healthy dietary models clearly correlate with better sperm quality and a smaller risk of abnormalities in parameters such as sperm count, sperm concentration and motility, and lower sperm DNA fragmentation. Apart from mineral components such as zinc and selenium, the role of omega-3 fatty acids and antioxidant vitamins should be emphasized, since their action will be primarily based on the minimization of oxidative stress and the inflammation process. Additionally, the incorporation of carnitine supplements and coenzyme Q10 in therapeutic interventions also seems promising. Therefore, it is advisable to have a varied and balanced diet based on vegetables and fruit, fish and seafood, nuts, seeds, whole-grain products, poultry, and low-fat dairy products.

High Sperm DNA Damage: Does Testicular Sperm Make Sense?

Sperm DNA damage reduces pregnancy rates in couples undergoing in vitro fertilization (IVF). Because it has been shown that testicular sperm have lower DNA damage than ejaculated sperm, it is an attractive idea to consider using testicular sperm for IVF for men with high sperm DNA damage. In fact, there are multiple centers throughout the world now offering sperm retrieval for IVF to manage this condition. However, there is insufficient evidence to conclude that testicular sperm improves pregnancy/live birth rates. Further studies are required before offering sperm retrieval as a standard of care to manage high sperm DNA damage.

Gendered Conceptions of Preconception Health: A Thematic Analysis of Men's and Women's Beliefs about Responsibility for Preconception Health Behavior

Preconception health (PCH) focuses on taking steps before a pregnancy to safeguard the health of the woman and future baby. Although recommendations to improve PCH target all people of reproductive age, research shows most interventions and messages focus primarily on women, which may contribute to existing normative beliefs that women are more responsible for protecting children's health. In this study, we explore society's gendered expectations of responsibility for engaging in recommended PCH behaviors (i.e., avoiding smoking, drinking, and environmental toxins). An applied thematic analysis of online survey responses from U.S. men and women (N = 573) identified five main themes and related subthemes: body and health, shared responsibility, choice and moral obligation, gender stereotypes, and doubt and uncertainty. Both men and women frequently referenced biological connections between prospective parents and offspring as justification for PCH behaviors. When challenging PCH recommendations, respondents mentioned excessive control of women and men's secondary role in reproduction. Overall, gender stereotypes were more commonly expressed in relation to men yet reflected both traditional and contemporary male roles (i.e., as supporters, co-parents). When judging personal responsibility, women commonly viewed PCH behaviors as the 'duty of a good mother'. Implications for PCH communication research and practice are discussed.

Gamete quality in a multistressor environment

Over the past few decades, accumulated evidence confirms that the global environment conditions are changing rapidly. Urban industrialization, agriculture and globalization have generated water, air and soil pollution, giving rise to an environment with a growing number of stress factors, which has a serious impact on the fitness, reproduction and survival of living organisms. The issue raises considerable concern on biodiversity conservation, which is now at risk: it is estimated that a number of species will be extinct in the near future. Sexual reproduction is the process that allows the formation of a new individual and is underpinned by gamete quality defined as the ability of spermatozoa and oocytes to interact during fertilization leading to the creation and development of a normal embryo. This review aimed to provide the current state of knowledge regarding the impact of a broad spectrum of environmental stressors on diverse parameters used to estimate and evaluate gamete quality in humans and in canonical animal models used for experimental research. Effects of metals, biocides, herbicides, nanoparticles, plastics, temperature rise, ocean acidification, air pollution and lifestyle on the physiological parameters that underlie gamete fertilization competence are described supporting the concept that environmental stressors represent a serious hazard to gamete quality with reproductive disorders and living organism failure. Although clear evidence is still limited, gamete capacity to maintain and/or recover physiological conditions is recently demonstrated providing further clues about the plasticity of organisms and their tolerance to the pressures of pollution that may facilitate the reproduction and the persistence of species within the scenario of global change. Changes in the global environment must be urgently placed at the forefront of public attention, with a massive effort invested in further studies aimed towards implementing current knowledge and identifying new methodologies and markers to predict impairment of gamete quality.

Do lifestyle practices impede male fertility?

Alongside an increasing prevalence of couple and male infertility, evidence suggests there is a global declining trend in male fertility parameters over the past few decades. This may, at least in part, be explained through detrimental lifestyle practices and exposures. These include alcohol and tobacco consumption, use of recreational drugs (e.g., cannabis, opioids and anabolic steroids), poor nutritional habits, obesity and metabolic syndrome, genital heat stress (e.g., radiation exposure through cell phones and laptops, prolonged periods of sitting, tight-fitting underwear and recurrent hot baths or saunas), exposure to endocrine-disrupting chemicals (e.g., pesticide residue, bisphenol A, phthalates and dioxins) and psychological stress. This review discusses these lifestyle practices and the current evidence associated with male infertility. Furthermore, known mechanisms of action are also discussed for each of these. Common mechanisms associated with a reduction in spermatogenesis and/or steroidogenesis due to unfavourable lifestyle practices include inflammation and oxidative stress locally or systemically. It is recommended that relevant lifestyle practices are investigated in clinical history of male infertility cases, particularly in unexplained or idiopathic male infertility. Appropriate modification of detrimental lifestyle practices is further suggested and recommended in the management of male infertility.

Role of genetics and epigenetics in male infertility

Male infertility is a complex condition with a strong genetic and epigenetic background. This review discusses the importance of genetic and epigenetic factors in the pathophysiology of male infertility. The interplay between thousands of genes, the epigenetic control of gene expression, and environmental and lifestyle factors, which influence genetic and epigenetic variants, determines the resulting male infertility phenotype. Currently, karyotyping, Y-chromosome microdeletion screening and CFTR gene mutation tests are routinely performed to investigate a possible genetic aetiology in patients with azoospermia and severe oligozoospermia. However, current testing is limited in its ability to identify a variety of genetic and epigenetic conditions that might be implicated in both idiopathic and unexplained infertility. Several epimutations of imprinting genes and developmental genes have been postulated to be candidate markers for male infertility. As such, development of novel diagnostic panels is essential to change the current landscape with regard to prevention, diagnosis and management. Understanding the underlying genetic mechanisms related to the pathophysiology of male infertility, and the impact of environmental exposures and lifestyle factors on gene expression might aid clinicians in developing individualised treatment strategies.

Low-level lead exposure is associated with aberrant sperm quality and reproductive hormone levels in Chinese male individuals: Results from the MARHCS study low-level lead exposure is associated with aberrant sperm quality

Studies in animals suggest an adverse effect of high-level lead exposure on male reproductive outcomes. However, evidence of the effects of low-level lead exposure is inconsistent. The purpose of our study was to explore the relationship between low-level lead exposure from daily environmental contaminants and semen quality in a community population without occupational exposure. We recruited 751 students in the Male Reproductive Health in Chongqing College Students (MARHCS) study and 190 community males from Bishan, Chongqing. Eight urinary metals (Pb, Cd, As, Cu, Zn, Ni, Mn, and Cr), semen quality, and serum sex hormones were detected. Even if the blood lead concentration was below the US lead poisoning standard for children (100 μg/L), a significant dose-response relationship was found between lead exposure and a decrease in semen quality. Multilinear regression showed that urinary Pb was negatively associated with sperm concentration, total sperm count, progressive motility and total sperm motility (regression coefficient: -0.074, -0.103, -0.024, and -0.014, respectively; p: <0.001, <0.001, 0.007, and <0.001, respectively), accompanied by decreased serum follicle-stimulating hormone, serum testosterone and the testosterone/luteinizing hormone ratio (β coefficient: -0.090, -0.082, and -0.020, respectively; p: 0.002, <0.001, and 0.021, respectively). Logistic regression also indicated that the risk of having abnormal semen quality was higher in the high Pb group (OR: 2.501, 95% CI: 1.411, 4.435, p = 0.002) than in the low Pb group after adjusting for confounders, with a dose-response relationship in the trend test (p = 0.007). Our results revealed an inverse association between Pb exposure at low levels and semen quality.

Men With Inflammatory Bowel Disease: Sexual Function, Fertility, Medication Safety, and Prostate Cancer

Half of patients with inflammatory bowel disease (IBD) are men, yet less attention has been focused on their sexual issues despite higher rates of sexual dysfunction and infertility than the general population. Depression and IBD disease activity are the most consistently reported risk factor for sexual dysfunction among men with IBD. Methotrexate and sulfasalazine have been rarely associated with impotence. Sulfasalazine reversibly reduces male fertility. No other medications used in IBD significantly affect fertility in humans. There is no increase in adverse fetal outcomes among offspring of fathers with IBD. Patients with IBD seem to be at a higher risk for prostate cancer; therefore, screening as recommended for high-risk patients should be considered.

The potential role of central obesity in male infertility: body mass index versus waist to hip ratio as they relate to selected semen parameters

Background

Little is known about the potential role of central obesity among men. Our first aim was to confirm what is already known from prior research, namely that both BMI and WHR are inversely associated with selected semen parameters. Our second aim was to examine the potential role of central obesity by assessing if there was a difference between BMI and WHR regarding their relationships to these selected semen parameters.

Methods

In this cross-sectional study between January 2011 to January 2018, we analyzed semen samples from 1169 patients who visited an andrology clinic in Budapest for infertility reasons. Variables assessed were: body measurements (height, weight, waist circumference, and hip circumference), and the results of semen analysis (sperm concentration, total sperm count, progressive sperm motility, and normal sperm morphology).

Results

The mean height and weight were 180.6 cm and 87.3 kg, respectively – the mean BMI was 26.8. The mean waist and hip circumferences were 100.9 cm and 94.8 cm, respectively – the mean waist to hip ratio was 0.94. The mean sperm concentration, total sperm count, and percents of progressive motility and normal morphology were 48.7 M/ml, 165 million, 21.2, and 4.8%, respectively. Both BMI and WHR were significant correlates in all semen parameter regression models. When comparing the parameter estimates for BMI with those for WHR for each semen parameter, the parameter estimate for WHR was significantly lower (indicating a stronger negative association) than that for BMI for progressive motility and total sperm count, but not for normal morphology or concentration.

Conclusions

Our study is the first to examine, using a large patient sample, the potential role of central obesity by comparing the difference between BMI and WHR as they relate to selected semen parameters. Our findings indicate a potential role of central obesity for progressive motility and total sperm count, but not for normal morphology and concentration. Despite the limitations and the exploratory nature of this study, we can conclude that our results point to a potential role of central obesity in male infertility, but this finding should be confirmed and further explored in future research.

Trial registration

The trial was retrospectively authorized after the data collection on September 24, 2018. Registration number: SE RKEB: 169/2018.

Association between ambient temperature and semen quality: A longitudinal study of 10 802 men in China

Semen quality is a vital determinant for male fertility. The process of spermatogenesis is highly sensitive to fluctuations in temperature. However, the impact of ambient temperature on semen quality remains unclear. We aimed to quantitatively assess the association between ambient temperature and semen quality. Using data from Hubei provincial human sperm bank in Wuhan, China, we conducted a longitudinal study including 10 802 volunteers who lived in Wuhan and passed the initial physical examination for sperm donation between Mar 27, 2013 and April 9, 2018. Semen quality parameters including sperm concentration, total sperm number, total motility, progressive motility, total motile sperm count and progressively motile sperm count were determined in the sperm bank. We used linear mixed models to identify estimate changes of outcomes in relation to ambient temperature (i.e., air temperature and apparent temperature) exposure measured as the mean daily temperature during the 0-90 days before semen collection. Among 10 802 subjects who underwent 41 689 semen examinations, we observed inverted U-shaped exposure-response associations between air temperature exposure and all semen quality parameters, with an identical threshold exposure of 13 °C. For air temperature exposure <13 °C, each 5 °C lower temperature was significantly associated with 1.94 × 10⁶/ml, 7.12 × 10⁶, 0.77%, 0.81%, 6.48 × 10⁶, and 5.87 × 10⁶ decrease in sperm concentration, total sperm count, total motility, progressive motility, total motile sperm count and progressively motile sperm count, respectively. When air temperature exposure was ≥13 °C, each 5 °C higher temperature was significantly associated with 0.70 × 10⁶/ml, 4.09 × 10⁶, 1.01%, 1.06%, 4.31 × 10⁶, and 4.20 × 10⁶ decrease in sperm concentration, total sperm count, total motility, progressive motility, total motile sperm count and progressively motile sperm count, respectively. Age, BMI and smoking did not significantly modify these associations. Similar results were observed for apparent temperature. This study provides a comprehensive picture of nonlinear association between ambient temperature and semen quality, as well as an optimal temperature for the benefit of semen quality. Both lower and higher ambient temperature exposures compared with the optimal temperature were significantly associated with decreased semen quality. The findings highlight the needs and importance to reduce extreme ambient temperature exposures in maintaining optimal semen quality for men. Further investigation is warranted to determine the causality of the association and the underlying mechanisms.

The effects of tobacco consumption on paternity rates of adults with a history of cryptorchidism

OBJECTIVE

To determine the effect of tobacco consumption on paternity rates in men with a history of cryptorchidism. To compare the paternity rates between formerly unilateral, bilateral cryptorchid smokers, and nonsmokers.

METHODS

A retrospective cohort study of 153 men who had undergone orchiopexy between 1961 and 1985 at the Miguel Servet University Hospital (116 unilateral and 37 bilateral) and a control group of 100 men were evaluated by review of medical records and a questionnaire.

RESULTS

A total of 197 men filled the questionnaire (76.7%). There was no difference in paternity rates between smokers compared to nonsmokers (P = 0.21). In the unilateral cryptorchid men (ULC) group, there is no difference in paternity rates when compared with the controls (P = 0.079) or when comparing ULC smokers to ULC nonsmokers (P = 0.35). In the bilateral cryptorchid men (BLC) group, there is no difference in paternity rates when compared to controls (P = 0.075) or when comparing BLC smokers to BLC nonsmokers (P = 0.36). When comparing according to consumption, there is no difference between mild, moderate or heavy smoker cases and controls.

CONCLUSION

There is no difference in paternity rates between men with a history of cryptorchidism that consume tobacco compared to nonsmokers or controls. More studies are needed to determine the impact of tobacco consumption in formerly cryptorchid men.

Causes and Prevalence of Factors Causing Infertility in a Public Health Facility

Background:

Infertility causes change according to local demographics. There is thus the need to find the causes of infertility in context to local population to aid and direct management strategies accordingly.

Aims:

The aims were to study the causes of infertility and to calculate the proportion of the individual factors contributing to it in the population coming to a tertiary level public health facility. Setting and Design: This cross-sectional, observational study was done in an infertility clinic in a medical college and government hospital.

Materials and Methods:

The study comprised 120 couples who came for infertility evaluation and treatment. Cause of infertility in the couple was assigned on the basis of history and examination findings. The prevalence of each cause was evaluated.

Statistical Analysis:

Results were tabulated, and the prevalence of individual factors was calculated. Intratable analysis was done using SPSS 16.0.

Results:

Primary infertility (57.5%) was more prevalent than secondary infertility (42.5%). Female factor accounted for 46.6% of the cases with polycystic ovarian syndrome (PCOS) being the leading cause (46%). Infertility was seen equally in lean and obese PCOS cases. Infectious causes such as pelvic inflammatory disease and tuberculosis were significantly associated with tubal factor infertility (P = 0.001). Infertility causes changed as the age of marriage increased. In couples married for less than 5 years, PCOS was the main cause whereas later,male factor and unexplained infertility were the most common causes seen. Male factor contributed to 20% of the cases of infertility, and both tobacco and alcohol consumption were significantly associated with abnormal semen reports (P = 0.001).

Conclusion:

Causes of infertility vary according to the age of the couples and age of marriage. Although PCOS remains the main cause, infections are a major cause of tubal factor infertility, and tobacco and alcohol worsen the male factor. One-third of the cases still remain unexplained.

4,977-bp human mitochondrial DNA deletion is associated with asthenozoospermic infertility in Jordan

Male infertility is commonly associated with sperm abnormalities including asthenozoospermia. The molecular basis of asthenozoospermia was linked to mitochondrial DNA (mtDNA) mutations. The 4,977-bp human mtDNA deletion is one of the most common mutations of spermatozoa and results in loss of about 33% of the mitochondrial genome. In this preliminary study, we aimed to investigate the presence of 4,977-bp mtDNA deletion in asthenozoospermic infertile men in Jordan. Semen specimens of 120 asthenozoospermic infertile men and 80 normozoospermic individuals were collected at the in vitro fertilization unit. MtDNA was extracted after the enrichment of spermatozoa; then, polymerase chain reaction was performed using 4,977-bp mtDNA deletion-specific primers. The deletion of 4,977-bp mtDNA was detected in 79.2% of asthenozoospermic patients compared to 10% in normozoospermic controls. The results showed a significant association between the presence of 4,977-bp mtDNA deletion and the asthenozoospermia and infertility (OR = 34.2000, 95% CI = 14.57-80.26, p-value < .001). In conclusion, our findings underscored a strong association between 4,977-bp mtDNA deletion and asthenozoospermia in the Jordanian population.

Relationship Between Smoking Habit and Sperm Parameters Among Patients Attending an Infertility Clinic

Background

This study aimed to estimate stress markers, oxidative stress (OS), reproductive hormones and sperm parameters in male smokers and non-smokers and observe the impact of oxidative stress markers and smoking on sperm count, motility and morphology in a selected population of Karachi, Pakistan.

Methods

This cross-sectional study was conducted from July 2017 to July 2018 at Aga Khan University (AKU), in Karachi, Pakistan. The subjects were recruited from the Sindh Institute of Reproductive Medicine (SIRM), Karachi based on defined inclusion criteria. The subjects were categorized into fertile and infertile based on cut off values of sperm parameters as recommended by the WHO i.e., sperm count/ejaculate of 39 × 10⁶/ml, sperm motility 40% and normal morphology 4%. Two hundred eleven fertile and 165 infertile male subjects were included in the study. Serum cortisol, adrenaline, superoxide dismutase (SOD), and glutathione peroxidase (GPX) were analyzed by ELISA kits. Data was analyzed on SPSS-22. A p-value of <0.05 was considered statistically significant.

Results

Age, Body Mass Index (BMI), and body fat were similar among smokers and non-smokers. Age was significantly lower, while mean BMI and body fat were significantly higher among infertile smokers vs. fertile smokers (p-value < 0.05). The testosterone levels were significantly reduced among smokers as compared to non- smokers (p-value < 0.05). The median cortisol levels were increased as well as GPX, and steroid hormone-binding globulin (SHBG) were significantly reduced among smokers as compared to non-smokers. Additionally, the same findings with a significant difference have also been observed among infertile smokers as compared to fertile smokers (p-value < 0.05). This study has shown that the semen parameters (total count, motility, and morphology) are decreased in infertile smokers as compared to infertile non-smokers. Furthermore, the multivariate analysis showed that smoking causes a significant decrease in sperm count and morphology but it did not have any significant effect on motility.

Conclusion

Smoking has a significant effect on fertility, specifically sperm count and normal morphology of sperm. This might be due to OS produced by smoking, which has devastating effects on semen parameters, thus reducing male fertility. Infertility specialist should counsel their patients about the ill effects of smoking on their fertility status and should advise maintaining a healthy lifestyle, including normal weight and avoiding smoking, to prevent future health problems. Hence smokers should quit smoking for their next generation.