Regional differences in semen quality in Europe

Sperm quality before treatment in patients with early stage Hodgkin's lymphoma enrolled in EORTC-GELA Lymphoma Group trials

BACKGROUND

Although widely recommended, cryopreservation of sperm is sometimes not performed for patients with Hodgkin's lymphoma because of presumed poor sperm quality related to the disease. We investigated sperm quality and factors determining it in untreated patients with early stage Hodgkin's lymphoma.

DESIGN AND METHODS

Of 2362 males who participated in EORTC H6-H9 trials, 474 (20%) had data available. Sperm quality was defined according to World Health Organization guidelines. Determining factors were studied by logistic regression analysis.

RESULTS

The median sperm concentration was 40x10(6)/mL (range, 0-345x10(6)/mL) and the median motility 50% (range, 0-90%). Sperm quality was good (concentration >or=20x10(6)/mL and motility >or=50%), intermediate (concentration >or=5x10(6)/mL) and poor (concentration <5x10(6)/mL but >0) in 41%, 49% and 7% of patients, respectively. Three percent of the patients were azoospermic. No relation was found between sperm quality and age or clinical stage of the Hodgkin's lymphoma, but B-symptoms and elevated erythrocyte sedimentation rate predicted poor sperm quality. The odds ratios for the association of poor sperm quality with the variables examined were: presence of B-symptoms, 2.77 (95% CI, 1.50-5.12; p=0.001); erythrocyte sedimentation rate of 50 mm/h or greater, 2.35 (95% CI, 1.24-4.43; p=0.009); fever, 3.22 (95% CI, 1.41-7.33; p=0.005), and night sweats, 3.78 (95% CI, 1.97-7.26; p<0.001). There was no relation between sperm quality and pre-treatment follicle stimulating hormone level.

CONCLUSIONS

In this large study of males with Hodgkin's lymphoma, 90% had good or intermediate sperm quality. Three percent were azoospermic. There was an association between sperm quality and the presence or absence of B-symptoms, in particular fever and night sweats. With modern fertilization techniques, in most patients with early-stage Hodgkin's lymphoma sperm quality before treatment is good enough for future fatherhood.

Association of CYP1A1*2A polymorphism with male infertility in Indian population

BACKGROUND

The CYP1A1 gene is a polymorphic gene and encodes for the CYP1A1 enzyme that catalyzes the bioactivation of polycyclic aromatic hydrocarbons (PAHs). PAHs are ubiquitous pollutants in the natural environment, which are capable of forming DNA adducts once being activated to generate DNA reactive metabolites. DNA adducts in sperm cells could be considered as a sign of severe DNA damage, which played an important role in meiotic division during spermatogenesis and could be associated with infertility. Lipophilic compounds undergo metabolic activation by phase I enzymes, which introduce a reactive center into the molecule, followed by phase II conjugation reaction resulting in a water soluble product.

METHODS

We genotyped CYP1A1*2A, using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay in a hospital based case-control study including 206 infertile men and 230 healthy fertile (control) subjects.

RESULTS

Analysis showed that CYP1A1*2A CC genotype is associated with increased risk of male infertility (OR=6.08, 95% CI=1.91-25.27), while TC genotype showed a non-significantly increased risk of male infertility (OR=1.35 95% CI=0.89-2.05). Further, when the variant genotypes were combined (CYP1A1*2A TC+CC) assuming a co-dominant allele effect, TC plus CC genotypes were also found to be significant with increased risk of male infertility (OR=1.57 95% CI=1.05-2.35 p=0.02). Allele frequencies are calculated for each genotype of CYP1A1*2A and the differences for allele frequencies between the infertile and fertile men are determined using Fisher's exact test. T and C allele frequencies in infertile men are 71% and 29% as against 80% and 20% in fertile men. The differences for allele frequencies are found to be statistically significant (p=0.002). The results showed a drastic decrease in the sperm count and motility and increase in dead sperms in CC genotype when compared to other genotypes in infertile men.

CONCLUSION

Based on Indian study we conclude that CC genotype of CYP1A1 is associated in the pathogenesis of male infertility.

EFFECT OF LIFESTYLE FACTORS ONINFERTILITY IN MEN

Environmental factors, changes in lifestyle and occupational exposures are responsible for declining human semen quality. We investigated the effects of history of surgery and lifestyle choices on infertility of 271 infertile men and 251 healthy volunteers. The frequency of varicocelectomy was significantly higher in infertile men (2.9%) than in controls (0.4%; P < 0.05). Alcohol use was significantly more common in infertile men (92%) than in controls (80%; P < 0.01). Satisfaction with sexual life was greater in controls (85%) than in infertile men (77%; P < 0.05). Other factors had no effect.

Sperm chromatin integrity in young men with no experiences of infertility and men from idiopathic infertility couples

Damage to the genetic component of spermatozoa seems to play the main role in a majority of cases where current approaches fail to reveal the specific cause of male infertility. In this study, we compared semen quality in men assigned to two defined groups: men from couples with unexplained infertility - idiopathic infertility (A) and young men with no experiences of infertility (B). All samples were examined by standard ejaculate analysis and sperm chromatin structure assay (SCSA). Sperm chromatin damage was significantly higher in men from group A than in those from group B. Similar results were obtained by comparison of men from group A (all men were normozoospermic) with normozoospermic men from group B. According to these results, we can suppose that chromatin disorders may be the causal factor of subfertility or infertility in some of these men. No evidence for a strong association between chromatin disorders and standard parameters of ejaculates was found. We failed to confirm a relationship between smoking and sperm quality in men from any of the investigated groups. SCSA is a method that facilitates the identification of infertile men who otherwise show normal semen variables.

Associations between andrological measures, hormones and semen quality in fertile Australian men: inverse relationship between obesity and sperm output

BACKGROUND

The World Health Organization developed a time to pregnancy (TTP) study (number of menstrual cycles taken to conceive) to determine whether the average TTP is increasing and semen quality decreasing with time. The present study describes clinical, semen and hormone characteristics obtained from male partners of pregnant women in Melbourne, Australia, and examines the associations between these characteristics.

METHODS

Male partners (n = 225) of pregnant women (16-32 weeks) who conceived naturally had physical examination, health and lifestyle questionnaires, semen and hormone (FSH, LH, sex hormone-binding globulin, testosterone and Inhibin B) analyses.

RESULTS

Previously known associations between semen, hormone and clinical variables were confirmed as significant: sperm numbers (concentration and total sperm count) correlated positively with Inhibin B and inversely with FSH and left varicocele, while total testicular volume correlated positively with sperm numbers and Inhibin B and inversely with FSH. However, only abstinence, total testicular volume, varicocele grade and obesity (BMI > 30 kg/m2) were independently significantly related to total sperm count. Compared with those with BMI < 30 (n = 188), obese subjects (n = 35) had significantly lower total sperm count (mean 324 versus 231 million, P = 0.013) and Inhibin B (187 versus 140 pg/ml, P < 0.001) but not FSH (3.4 versus 4.0 IU/l, P = 0.6).

CONCLUSIONS

Obese fertile men appear to have reduced testicular function. Whether this is cause or effect, i.e. adiposity impairing spermatogenesis or reduced testicular function promoting fat deposition, remains to be determined.

Low semen volume in 47 adolescents and adults with 47,XXY Klinefelter or 46,XX male syndrome

Klinefelter syndrome is characterized by progressive testicular failure causing androgen deficiency and azoospermia in most patients. The aim of this study was to evaluate semen quality in consecutive patients with an additional X chromosome as compared with healthy males. Forty-seven males with non-mosaic 47,XXY (n = 40) or SRY-positive 46,XX male (n = 7) karyotypes aged 26.1 (range: 15.0-51.7) years participated. Semen quality was compared with 2136 (control group I) men from the general population aged 18.9 (17.9-28.6) years and with 349 fertile men (control group II) aged 30.9 (22.0-43.8) years. Semen volume adjusted for duration of abstinence was significantly smaller in the patients [2.0 (0.2-5.7) mL] when compared with control group I [3.1 (0.3-12.5) mL, p < 0.0001] and group II [3.6 (0.6-12.5) mL, p < 0.0001]. There was no difference in semen volume between 47,XXY and 46,XX males. All patients had azoospermia except two 47,XXY males aged 29 years who had sperm concentrations of 0.5 and 1.6 million/mL, respectively. We found significantly smaller semen volume in the patients when compared with controls, and the presence of motile spermatozoa in two out of 47 patients. The small semen volume supports the notion of 47,XXY patients being androgen insufficient despite serum testosterone levels within the normal range.

Semen quality in sub-fertile range for a significant proportion of young men from the general German population: a co-ordinated, controlled study of 791 men from Hamburg and Leipzig

Population studies have shown that a high proportion of Nordic men may have so poor semen quality that they can be classified as sub-fertile according to international standards. A question is whether the Nordic data are specific for the Nordic countries or they should be seen as an expression of a general trend in Europe. We therefore carried out a prospective study of semen quality of young men raised in the former East Germany (Leipzig) and West Germany (Hamburg). To enable inter-regional comparisons, we utilized a common European research protocol previously used in studies in the Nordic-Baltic region. Three hundred and thirty-four young men representative of the general population from Hamburg, and 457 from Leipzig delivered semen samples, underwent physical examinations and provided information on life-style and reproductive health parameters. The study period in Hamburg was February 2003--July 2004, and in Leipzig July 2003--April 2005. No significant differences were observed in sperm concentration (median 46, 42, and 44 million/mL for men from Hamburg, Leipzig and the combined Hamburg-Leipzig group respectively) or total sperm count (154,141 and 149 million), whereas the differences for morphologically normal spermatozoa (9.4 and 8.4%) and motile spermatozoa (67 and 81%) were significantly different. Previously published studies have shown reduced fertility with decreasing sperm concentrations below 40-55 millions/mL and normal sperm morphology below 9-19%. Thus, a large fraction of young German men seem to have impaired semen quality that may reduce their natural fertility. However, it remains to be investigated to what extent poor semen quality contributes to the low German fertility rates.

Declining trends in conception rates in recent birth cohorts of native Danish women: a possible role of deteriorating male reproductive health

Recent findings of poor semen quality among at least 20% of normal young men in Denmark prompted us to use unique Danish registers on births and induced abortions to evaluate a possible effect of the poor male fecundity on pregnancy rates among their presumed partners--the younger cohorts of women. We have analysed data from the Danish birth and abortion registries as well as the Danish registry for assisted reproduction (ART) and defined a total natural conception rate (TNCR), which is equal to fertility rate plus induced abortion rate minus ART conception rate. A unique personal identification number allowed the linkage of these databases. Our database included 706,270 native Danish women born between 1960 and 1980. We used projections to estimate the fertility of the later cohorts of women who had not yet finished their reproduction. We found that younger cohorts had progressively lower TNCR and that in terms of their total fertility rate, the declining TNCR is compensated by an increasing use of ART. Our hypothesis of an ongoing birth cohort-related decline in fecundity was also supported by our finding of increasing and substantial use of ART in the management of infertility of relatively young couples in the later cohorts. Furthermore, the lower rates of induced abortion among the younger birth cohorts, often viewed as a success of health education programs, may not be fully explained by improved use of contraception. It seems more likely that decreased fecundity because of widespread poor semen quality among younger cohorts of otherwise normal men may explain some of the observed decline in conception rates. This may imply increasing reproductive health problems and lower fertility in the future, which is difficult to reverse in the short term. The current and projected widespread use of ART in Denmark may be a sign of such an emerging public health problem.

PON1Q192R genetic polymorphism modifies organophosphorous pesticide effects on semen quality and DNA integrity in agricultural workers from southern Mexico

Pesticide exposure, including organophosphorous (OP) insecticides, has been associated with poor semen quality, and paraoxonase (PON1), an enzyme involved in OP deactivation, may have a role on their susceptibility, due to PON1 polymorphisms. Our objective was to evaluate the role of PON1Q192R polymorphism on the susceptibility to OP toxicity on semen quality and DNA integrity in agricultural workers. A cross-sectional study was conducted in farmers with Mayan ascendancy from southeastern Mexico chronically exposed to pesticides; mostly OP. Fifty four agricultural workers (18-55 years old) were included, who provided semen and blood samples. Semen quality was evaluated according to WHO, sperm DNA damage by in situ-nick translation (NT-positive cells), PON1Q192R polymorphism by real-time PCR and serum PON1 activity by using phenylacetate and paraoxon. Two OP exposure indexes were created: at the month of sampling and during 3 months before sampling, representing the exposure to spermatids-spermatozoa and to cells at one spermatogenic cycle, respectively. PON1 192R and 192Q allele frequencies were 0.54 and 0.46, respectively. Significant associations were found between OP exposure at the month of sampling and NT-positive cells and sperm viability in homozygote 192RR subjects, and dose-effect relationships were observed between OP exposure during 3 months before sampling and sperm quality parameters and NT-positive cells in homozygote 192RR farmers. This suggests that cells at all stages of spermatogenesis are target of OP, and that there exists an interaction between OP exposure and PON1Q192R polymorphism on these effects; farmers featuring the 192RR genotype were more susceptible to develop reproductive toxic effects by OP exposure.

Testicular cancer and hormonally active agents

Testicular cancer (TC) is a rare form of cancer, accounting for 1% of all new cancer cases in Canadian males. TC is the most common malignancy among young men, aged 25-34 yr old. Over previous decades, the incidence of TC has increased in many Western countries. Countries with a sufficiently long period of cancer registration, such as Denmark, document this trend back to the first half of the 20th century. The etiology of TC remains poorly understood. Most of the established risk factors are likely related to in utero events, including some factors that are purported to be surrogate measures for exposure to endogenous estrogens. The correlation of TC with other testicular abnormalities and with pregnancy factors led to the proposal that these conditions are a constellation of sequelae of impairment of testicular development called testis dysgenesis syndrome. There is some limited evidence suggesting that exposure to pharmacological estrogens may contribute to some cases of TC. There is currently no compelling evidence that exposure to environmental estrogenic or other hormonally active substances is contributing to the rise in TC incidence observed in Western nations over the last several decades; however, this question has not been extensively studied. The (1) rarity of this condition in the population, (2) long lag time between the presumed sensitive period during fetal development and clinical appearance of the condition, and (3) lack of a good animal model to study the progression of the disease have greatly hindered the understanding of environmental influences on TC risk.

Human exposure to endocrine disrupters and semen quality

Reproductive pathology in the male represents about 20% of infertility cases. Male infertility may be attributed to a number of causes, including genetic and congenital abnormalities, infection, multisystemic diseases, varicocele, and others; however, a significant number of cases are idiopathic. Global declines in semen quality were suggested to be associated with enhanced exposure to environmental chemicals that act as endocrine disrupters as a result of our increased use of pesticides, plastics, and other anthropogenic materials. A significant body of toxicology data based upon laboratory and wildlife animals studies suggests that exposure to certain endocrine disrupters is associated with reproductive toxicity, including (1) abnormalities of the male reproductive tract (cryptorchidism, hypospadias), (2) reduced semen quality, and (3) impaired fertility in the adult. There is, however, a relative paucity of studies designed to measure exposure to endocrine disrupters on semen quality parameters (sperm concentration, motility, morphology). An overview of the human semen quality literature is presented that examines the role of endocrine disrupters including organochlorines (OC), dioxins, phthalates, phytoestrogens, and chemical mixtures (pesticides and tobacco smoke).

Interpreting trends in fecundity over time

Is complicated by the lack of direct markers

Rapid decline of persistent organochlorine pollutants in serum among young Swedish males

To investigate a possible time trend in serum concentrations of persistent organochlorine pollutants (POPs), representative samples of the young (median age 18 years) Swedish male population were investigated in the years 2000 and 2004. Due to their low age, these men were assumed not to have reached steady state of body burdens of POPs, why their serum concentrations were considered to represent ongoing dietary exposure. Serum concentrations of 2,2',4,4',5,5'-hexachlorobiphenyl (CB-153) and 1,1-dichloro-2,2-bis(4-chlorophenyl)-ethylene (p,p'-DDE), two biomarkers of exposure to POPs, were available for 274 and 223 men, respectively, in 2000 and for 200 men in 2004. The percentage of men with CB-153 or p,p'-DDE below the limit of detection (LOD) was significantly higher in 2004 than in 2000 (30% vs. none, p < 0.001 for CB-153 and 65% vs. 6%, p < 0.001 for p,p'-DDE). Moreover, the median serum concentration of CB-153 decreased from 66 ng g(-1) lipid to 19 ng g(-1), corresponding to a yearly decrease of about 26%. The analogous analysis was not done for p,p'-DDE since the median serum concentration in 2004 was below the LOD.

Influence of endocrine disruptors on human male fertility

It has been suggested that during the past five decades human sperm counts have declined and the incidence of testicular cancer, hypospadias and cryptorchidism has increased. Furthermore, geographical differences, with respect to these markers of male reproductive function, have been reported. According to a recent hypothesis, all these abnormalities of the male genital system do have a common cause, namely exposure to endocrine disruptors affecting the male in early fetal life. Reduced sperm production as well as congenital abnormalities of male genitalia can be evoked in laboratory animals by exposing them to chemicals with endocrine-disrupting effect, and in humans similar effects have been seen following accidental exposures to very high concentrations of these environmental toxicants. However, the evidence for association between levels of exposure found in the general population and serious adverse effects on male reproduction, including fertility, is still lacking. A recent European Union-supported study, on the effect of persistent organohalogen pollutants on human reproduction, failed to show any correlation between post-natal exposure levels and fertility. Future studies will reveal whether prenatal exposure does more strongly affect male fertility and whether genetic predisposition regulates the susceptibility of an individual to the adverse effects of endocrine disruptors.

Adverse trends in male reproductive health: we may have reached a crucial 'tipping point'

Healthy men produce an enormous number of sperms, far more than necessary for conception. However, several studies suggest that semen samples where the concentration of sperms is below 40 mill/mL may be associated with longer time to pregnancy or even subfertility, and specimens where the concentration of sperms is below 15 mill/mL may carry a high risk of infertility. Historic data from the 1940s show that the bulk of young men at that time had sperm counts far above 40 mill/mL with averages higher than 100 mill/mL. However, recent surveillance studies of young men from the general populations of young men in Northern Europe show that semen quality is much poorer. In Denmark approximately 40 percent of the men have now sperm counts below 40 mill/mL. A simulation assuming that average sperm count had declined from 100 mill/mL in ‘old times’ to a current level close to 40 mill/mL indicated that the first decline in average sperm number of 20–40 mill/mL might not have had much effect on pregnancy rates, as the majority of men would still have had counts far above the threshold value. However, due to the assumed decline in semen quality, the sperm counts of the majority of 20 year old European men are now so low that we may be close to the crucial tipping point of 40 mill/mL spermatozoa. Consequently, we must face the possibility of more infertile couples and lower fertility rates in the future.

Dioxin exposure, from infancy through puberty, produces endocrine disruption and affects human semen quality

BACKGROUND

Environmental toxicants are allegedly involved in decreasing semen quality in recent decades; however, definitive proof is not yet available. In 1976 an accident exposed residents in Seveso, Italy, to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD).

OBJECTIVE

The purpose of this study was to investigate reproductive hormones and sperm quality in exposed males.

METHODS

We studied 135 males exposed to TCDD at three age groups, infancy/prepuberty (1-9 years), puberty (10-17 years), and adulthood (18-26 years), and 184 healthy male comparisons using 1976 serum TCDD levels and semen quality and reproductive hormones from samples collected 22 years later.

RESULTS

Relative to comparisons, 71 men (mean age at exposure, 6.2 years; median serum TCDD, 210 ppt) at 22-31 years of age showed reductions in sperm concentration (53.6 vs. 72.5 million/mL; p = 0.025); percent progressive motility (33.2% vs. 40.8%; p < 0.001); total motile sperm count (44.2 vs. 77.5 x 10(6); p = 0.018); estradiol (76.2 vs. 95.9 pmol/L; p = 0.001); and an increase in follicle-stimulating hormone (FSH; 3.58 vs. 2.98 IU/L; p = 0.055). Forty-four men (mean age at exposure, 13.2 years; median serum TCDD, 164 ppt) at 32-39 years of age showed increased total sperm count (272 vs. 191.9 x 10(6); p = 0.042), total motile sperm count (105 vs. 64.9 x10(6); p = 0.036), FSH (4.1 vs. 3.2 UI/L; p = 0.038), and reduced estradiol (74.4 vs. 92.9 pmol/L; p < 0.001). No effects were observed in 20 men, 40-47 years of age, who were exposed to TCDD (median, 123 ppt) as adults (mean age at exposure, 21.5 years).

CONCLUSIONS

Exposure to TCDD in infancy reduces sperm concentration and motility, and an opposite effect is seen with exposure during puberty. Exposure in either period leads to permanent reduction of estradiol and increased FSH. These effects are permanent and occur at TCDD concentrations < 68 ppt, which is within one order of magnitude of those in the industrialized world in the 1970s and 1980s and may be responsible at least in part for the reported decrease in sperm quality, especially in younger men.

Semen quality of Asian men

After the controversial report by Carlsen et al. in 1992 showing a possible decline in human semen quality over the past 50 years, many laboratories investigated their own records of semen findings that had been kept for the past decades, and a significant decrease in sperm quality was reported from some laboratories, but not others. At the beginning of the 21st century, a definitive interpretation of this issue has not yet been offered; however, it seems plausible that there are large regional differences in semen quality. Decreases in semen quality have been reported from various regions around the world, and a concurrent rise in the incidence of other reproductive problems, such as testicular cancer and genital abnormalities, has been observed in many regions. However, most of the reports showing regional differences were from Western or Western-derived countries, despite the fact that Asia is the region with the highest population on earth. Recently we undertook a cross-sectional study on fertile men in Japan to describe the current status of semen quality of Japanese men. We took confounders into consideration to allow a comparison with a previous European study. Japanese fertile men proved to have a semen quality at the level of Danish men, who were reported to have the lowest level among the men examined in the European study. This low level of sperm concentration in fertile Japanese men may result from differences in lifestyle or other environmental factors, but we cannot rule out the possibility of ethnic differences caused by different genetic variation or combination. To address this issue we need more information on the reproductive function in Asian men, who have been reported to have certain differences in reproductive characteristics from Caucasian men. This article is an attempt to review our present knowledge concerning the current status of semen quality in healthy Asian men on the basis of the limited publications from Asia. (Reprod Med Biol 2007; 6: 185-193).

Testicular cancer trends as 'whistle blowers' of testicular developmental problems in populations

Recently a worldwide rise in the incidence of testicular germ cell cancer (TGCC) has been repeatedly reported. The changing disease pattern may signal that other testicular problems may also be increasing. We have reviewed recent research progress, in particular evidence gathered in the Nordic countries, which shows strong associations between testicular cancer, undescended testis, hypospadias, poor testicular development and function, and male infertility. These studies have led us to suggest the existence of a testicular dysgenesis syndrome (TDS), of which TGCC, undescended testis, hypospadias/disorders of sex differentiation and male fertility problems may be symptoms with varying penetration. In spite of their fetal origin, most of the TDS symptoms, including TGCC and poor semen quality, can only be diagnosed in adulthood. Data from a Danish-Finnish research collaboration strongly suggest that trends in TGCC rates of a population may be 'whistle blowers' of other reproductive health problems. As cancer registries are often of excellent quality - in contrast to registries for congenital abnormalities - health authorities should consider an increase in TGCC as a warning that other reproductive health problems may also be rising.

Reproductive toxicity of low-level lead exposure in men

Parameters of semen quality, seminal plasma indicators of secretory function of the prostate and seminal vesicles, sex hormones in serum, and biomarkers of lead, cadmium, copper, zinc, and selenium body burden were measured in 240 Croatian men 19-52 years of age. The subjects had no occupational exposure to metals and no known other reasons suspected of influencing male reproductive function or metal metabolism. After adjusting for age, smoking, alcohol, blood cadmium, and serum copper, zinc, and selenium by multiple regression, significant (P<0.05) associations of blood lead (BPb), delta-aminolevulinic acid dehydratase (ALAD), and/or erythrocyte protoporphyrin (EP) with reproductive parameters indicated a lead-related increase in immature sperm concentration, in percentages of pathologic sperm, wide sperm, round sperm, and short sperm, in serum levels of testosterone and estradiol, and a decrease in seminal plasma zinc and in serum prolactin. These reproductive effects were observed at low-level lead exposure (BPb median 49 microg/L, range 11-149 microg/L in the 240 subjects) common for general populations worldwide. The observed significant synergistic effect of BPb and blood cadmium on increasing serum testosterone, and additive effect of a decrease in serum selenium on increasing serum testosterone, may have implications on the initiation and development of prostate cancer because testosterone augments the progress of prostate cancer in its early stages.

Is sperm evaluation useful in predicting human fertility?

Traditionally, the diagnosis of male infertility has relied upon microscopic assessment and biochemical assays to determine human semen quality. The conventional parameters given most importance have been the concentration, motility, and morphology of sperm in the ejaculate. Most laboratories also include ‘sperm suitability’ tests where the subpopulations of sperm more likely to finish the marathon journey to the oocyte are separated by density centrifugation. These tests are essential to provide the fundamental information on which clinicians base their initial diagnosis. However, none of these parameters addresses sperm function and their clinical value in predicting fertility is questionable. The advent of intracytoplasmic sperm injection (ICSI) has further reduced the significance and perceived need for sperm quality tests since ICSI requires only one sperm, not subject to classic, or indeed any, tests for the procedure to be successful. Over the past decade, a number of laboratory tests have been developed to determine properties of sperm function. These include quantitative sperm motion parameters, capacitation, basal and induced acrosome reactions, sperm–zona pellucida interactions and nuclear and mitochondrial sperm DNA but few have been adopted into routine clinical use. International collaborations should be initiated to develop clinically relevant molecular and functional tests with agreed protocols and clinical thresholds as a matter of urgency.

Self-rated health and semen quality among 3,457 young Danish men

OBJECTIVE

To study the relationship between self-rated health (SRH) and semen quality.

DESIGN

Cross-sectional study of men attending a compulsory physical examination to determine their fitness for military service from 1996 to 2005.

SETTING

Young men were approached when they were summoned for a compulsory physical examination to determine their fitness for military service in two major Danish cities.

PATIENT(S)

A total of 3,457 Danish young men delivered a semen sample, had a physical examination performed, and responded to a questionnaire including a question about SRH.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Semen quality and testis size.

RESULT(S)

After control for confounders, men with good and poor SRH had, respectively, 0.5 mL (95% CI: -0.8, -0.1) and 0.8 mL (95% CI: -2.4, 0.8) smaller testes size compared to men with very good SRH, the trend was statistically significant. Men with good and poor SRH had, respectively, 12.2% (95% CI: -21.2%, -2.2%) and 26.9% (95% CI: -55.7%, 20.8%) lower total sperm count compared to men with very good SRH, the trend was statistically significant, and had +0.4% (-1.4%, 2.2%) and 1.4% (-3.5%, 0.7%) fewer morphologically normal sperms (trend statistically significant). Percentages of motile spermatozoa and semen volume were not significantly associated with SRH.

CONCLUSION(S)

We found significant associations between SRH and semen quality and testicular size. Given the cross-sectional study design, we cannot establish a causal relationship but argue that SRH may be associated with semen quality. Our findings need to be validated and confirmed with other study designs (preferably prospective) and in populations of different age structure and fertility status.

Within-subject variation of seminal parameters in men with infertile marriages

As little information exists on the semen variability in infertile men, this study aimed at analysing the within-subject variability of semen from men with infertile marriages included in an intrauterine insemination (IUI) programme. Five ejaculates from each of 436 men (2180 specimens) were analysed. The within-subject coefficients of variation (CV(w)) were high for all parameters (semen volume, sperm concentration, forward motility and combined parameters), ranging from 0.73 for the total motile sperm count to 0.27 for the semen volume. Nevertheless, within-subject fluctuations were smaller than the between-subject variability, as indicated by high Intraclass Correlation Coefficient (ICC) values, which, however, significantly lowered when <or=3 samples were analysed against five samples. Neither seasonality nor the length of abstinence between 3 and 7 days significantly affected within-subject semen variability, whereas total motile sperm count was significantly and negatively affected at 2 days of abstinence. In 253 cycles of double IUI, performed in two consecutive days, semen volume and parameters including volume decreased in the second sample, but semen quality improved in most cases of oligo- and/or asthenozoospermia. Useful information for clinical purposes is provided.

Semen quality in a population of volunteers from the province of Barcelona

A prospective study was carried out on 1005 male volunteers residing in the province of Barcelona. Participants were asked to complete a questionnaire concerning their health status and lifestyle, and provided a semen sample for analysis. Sperm concentration and percentages of motile, and normal forms were evaluated. The effect of smoking, alcohol consumption, stress and previous disease on semen parameters was also evaluated. Normal parameters were found in 22% of volunteers and sperm counts and/or percentage motility below normal threshold values were found in 78%. Asthenozoospermia detected in 62% and oligozoospermia in 17% of volunteers. No statistically significant association was found between semen quality and age, with the exception of a decrease in semen volume (P = 0.04) and progressive motility (P = 0.01). No statistically significant differences in semen parameters were found between smokers and non-smokers or between males who consumed alcohol versus those that did not. However, stress had a negative effect on sperm concentration. In conclusion, the prevalence of normal semen parameters in the study population evaluated was markedly lower than that reported for the general population (60-70%). Since sperm concentration did not appear to decrease with age, the decrease observed in the last decades may be related to exposure to environmental toxicants during the fetal period, as previously suggested.

Gonad evaluation in male systemic lupus erythematosus

OBJECTIVE

To assess gonad function in male patients with systemic lupus erythematosus (SLE).

METHODS

Thirty-five consecutive male patients with SLE according to the criteria of the American College of Rheumatology were prospectively evaluated for demographic and clinical features as well as previous and current treatment. Patients underwent urologic evaluation and testicular Doppler ultrasound. We obtained a hormone profile and performed a semen analysis including morphology and testing for the presence of antisperm antibodies. Patients were compared with 35 age-matched healthy controls.

RESULTS

Compared with controls, SLE patients had lower median testicular volumes in both testes, a lower median total sperm count, and a lower median total motile sperm count. The mean sperm volume and percentage of normally formed sperm were lower in SLE patients than in controls. Since all SLE patients had semen alterations, they were further subdivided into 2 groups according to the severity of these abnormalities (group 1, with teratozoospermia [n = 18], and group 2, with azoospermia or teratozoospermia in combination with oligozoospermia and/or asthenozoospermia [n = 17]). The frequency of treatment with intravenous cyclophosphamide (IV CYC) after the first ejaculation was higher in group 2 than in group 1. The median testicular volumes measured by ultrasound in both testicles were lower in group 2 than in group 1. Follicle-stimulating hormone levels were higher in group 2 than in group 1. The overall frequency of antisperm antibodies in SLE patients was 40%. The apparent higher frequency of antisperm antibodies in group 1 than in group 2 did not reach significance.

CONCLUSION

SLE patients have a high frequency of sperm abnormalities associated with reduced testicular volume. Postpubertal IV CYC treatment was the major factor in potential permanent damage to the testes.

The healthy men study: design and recruitment considerations for environmental epidemiologic studies in male reproductive health

OBJECTIVE

To describe study design, conduct and response, and participant characteristics.

DESIGN

Prospective cohort study.

SETTING

Participants were male partners of women who were enrolled in a community-based prospective cohort study of drinking water disinfection by-products and pregnancy health.

PATIENT(S)

Two hundred thirty presumed fertile men recruited from 3 study sites in the United States.

INTERVENTION(S)

Men completed a telephone interview about demographics, health history, and exposures and provided a semen sample that was express mailed to the study laboratory.

MAIN OUTCOME MEASURE(S)

Response and participation rates, participant demographics, and lifestyle exposures.

RESULT(S)

We obtained a high participation rate (84%) among men who were located, but a low overall response rate (25%). Participants were more likely to be white, more highly educated, be married, and have a higher household income than the underlying study cohort.

CONCLUSION(S)

Our multisite study design may be applicable to the study of community environmental factors and reproductive health of men. Our design was efficient in that men from geographically disparate sites could be recruited, a semen sample was collected at home, and a telephone interview was conducted from a central study site. Despite these design features, the low response rates may suggest selection bias that can be addressed partially in the analysis.

Twin pregnancy possibly associated with high semen quality

BACKGROUND

Recent studies found an association between a long waiting time to pregnancy (TTP) and reduced probability of twinning and a reduced dizygotic (DZ) twinning rate in subfertile men. However, it remains unsolved whether semen quality is associated with twin offspring. We therefore studied the semen quality in a group of fathers of naturally conceived twins.

METHODS

In this study, 37 fathers of DZ twins and 15 fathers of monozygotic (MZ) twins participated, and 349 normal fertile men served as a reference group. All men delivered a semen sample, underwent a physical examination and completed a questionnaire.

RESULTS

After adjustment, fathers of DZ and MZ twins had 3.6 (95% CI 1.7; 5.4) and 4.6 (95% CI 2.0; 7.2) percentage points higher percentage of sperm cells with normal morphologic features and percentages of motile sperm cells were 11.5 (95% CI 7.2; 15.9) and 12.5 (95% CI 6.3; 18.6) percentage points higher than the reference group (P < 0.01). Fathers of DZ twins and MZ twins had 24.7 (95% CI; -9.1; 71.3) and 17.0% (-25.2%; 83.0%) higher sperm concentration than the reference group.

CONCLUSIONS

Fathers of DZ twins had a better semen quality than the reference group, which supports the assumption that spontaneous DZ twinning rate can be used as a sensor of male fecundity of a population.

Seasonality of serum prostate-specific antigen levels: a population-based study

OBJECTIVE

The measurement of PSA serum levels is central to all early detection programs for prostate cancer. Although individual PSA values were known to fluctuate in the short and long term, the influence of insolation and seasons on PSA had not been addressed to date. To assert the relationship between total and free PSA and meteorological data in 8644 participants (55-70 years) in the French arm of the ERSPC study.

METHODS

Blood sample was taken at the local laboratory after informed consent and frozen sera were sent for central testing of total and free PSA. PSA measurement was performed within 7 days on the Access 1.0 automat with Hybritech reagents. Monthly meteorological data -- insolation, daily temperatures and rain precipitations -- were obtained from the local branches of the National Meteorology Agency.

RESULTS

Total PSA -- but not free PSA -- was correlated with insolation, that is the monthly accrual in hours of sunshine during which the intensity was higher than 120 Watt x m(-2) (r = 0.05 (95%CI: 0.03-0.07; p < 0.0001)) while no relationships were shown between insolation and percent-free PSA (free PSA divided by the total PSA). Interdependence between total PSA and insolation was also apparent with respect to the 3 ng/mL ERSPC cutoff for recommending biopsies (213.1 vs. 206.2 hours, p = 0.004). Such relationship was even more evident in summer when the tested participants more often had a PSA > 3 ng/mL (17.1% vs. 14.3%, p = 0.0006) than in the rest of the year, resulting in 23% more chances of being referred for biopsies (Odds ratio 1.23, 95%CI: 1.10-1.40).

CONCLUSIONS

Total PSA was shown to be strongly associated with insolation and seasons while the percent-free PSA was not influenced.

Semen quality in a residential, geographic and age representative sample of healthy Chinese men

BACKGROUND

Population-based study of semen quality is rare in literature.

METHODS

Healthy men aged 20-60 years from six Chinese provinces were invited to participate in the study between December 2000 and November 2002. Posters were distributed in the participating counties to enroll 200 subjects from each province. Medians, percentiles, and proportions below lower threshold of the WHO criteria for semen parameters were calculated. Generalized linear models were used to examine the determinants of semen quality.

RESULTS

Semen samples from 1191 healthy Chinese men were collected and analysed. The medians (5th and 95th percentiles) were 2.3 ml (1.0-4.5) for semen volume, 65 x 10(6)/ml (20-150) for semen concentration, 154 x 10(6)/ejection (29-421) for sperm count, 19% (5-32) for rapid progressive motility, 46% (29-66) for progressive motility, 67% (47-81) for total motile spermatozoa, 70% (48-88) for sperm viability and 39% (23-76) for normal morphology. Many healthy Chinese men had semen parameter values below the lower threshold of the WHO criteria. Region, age, abstinence duration and season were important determinants of semen quality.

CONCLUSIONS

Chinese men have lower values of semen parameters according to WHO standard, and a lower threshold for normal semen parameters for Chinese men should be considered.

Larger testes and higher inhibin B levels in Finnish than in Danish newborn boys

CONTEXT

Recent studies showed that male reproductive health problems, such as cryptorchidism, hypospadias, testicular cancer, and low sperm quality, are more prevalent in Denmark than in Finland.

OBJECTIVES

We hypothesized that, if fetal testicular dysgenesis contributed to these observations, differences in gonadal development and the hypothalamus-pituitary-testis axis would already be detectable perinatally. Thus, we investigated healthy newborn boys in both countries.

DESIGN

This was a prospective, longitudinal population-based study.

SETTING

Two primary obstetric centers were included at the University Hospitals of Copenhagen, Denmark, and Turku, Finland.

PARTICIPANTS

The participants of the study included 633 Danish and 1044 Finnish boys, born at term with appropriate weight for gestational age.

INTERVENTIONS

Ultrasound determination of testis size at 0, 3, and 18 months and blood sampling (n = 727) at 3 months were analyzed.

MAIN OUTCOME MEASURES

Testicular volume and reproductive hormones were measured.

RESULTS

Testis volume was significantly higher at all ages in Finnish than in Danish boys (medians, 98 vs. 95, 185 vs. 119, and 188 vs. 136 mm(3), respectively; P < 0.00001). Testis growth from birth to 3 months was larger in Finnish than in Danish boys (mean, 75 vs. 26 mm(3); P < 0.0001). Serum hormone levels were higher in Finnish than Danish boys for inhibin B (median, 456 vs. 385 pg/ml; P < 0.0001), FSH (1.33 vs. 1.21 IU/liter; P < 0.036), and SHBG (143 vs. 136 nmol/liter; P < 0.022). Inhibin B was significantly positively correlated to testicular volume (r = 0.25; P < 0.006).

CONCLUSIONS

The larger testes and higher inhibin B levels most likely represent a bigger volume of seminiferous tubules in Finnish compared with Danish boys. Although this phenomenon may be attributable to a genetic difference between the two countries, it may also reflect environmental factors influencing testicular development.

Male idiopathic oligoasthenoteratozoospermia

Idiopathic oligoasthenoteratozoospermia (iOAT) affects approximately 30% of all infertile men. This mini-review discussed recent data in this field. Age, non-inflammatory functional alterations in post-testicular organs, infective agents (Chlamydia trachomatis, herpes virus and adeno-associated viruses), alterations in gamete genome, mitochondrial alterations, environmental pollutants and "subtle" hormonal alterations are all considered possible causes of iOAT. Increase of reactive oxygen species in tubules and in seminal plasma and of apoptosis are reputed to affect sperm concentration, motility and morphology. iOAT is commonly diagnosed by exclusion, nevertheless spectral traces of the main testicular artery may be used as a diagnostic tool for iOAT. The following can be considered therapies for iOAT: 1) tamoxifen citrate (20 mg/d) + testosterone undecanoate (120 mg/d) (pregnancy rate per couple/month [prcm]: 3.8%); 2) folic acid (66 mg/d) + zinc sulfate (5 mg/d); 3) L-carnitine (2 g/d) alone or in combination with acetyl-L-carnitine (1 g/d) (prcm: 2.3%); and 4) both carnitines = one 30 mg cinnoxicam suppository every 4 days (prcm: 8.5%). Alpha-blocking drugs improved sperm concentration but not morphology, motility or pregnancy rate. Tranilast (300 mg/d) increased sperm parameters and pregnancy rates in an initial uncontrolled study. Its efficacy on sperm concentration (but not on sperm motility, morphology or prcm) was confirmed in subsequent published reports. The efficacy of tamoxifen + testosterone undecanoate, tamoxifen alone, and recombinant follicle-stimulating hormone is still a matter for discussion.