Relationship between antisperm antibodies and testicular histologic changes in humans after vasectomy

Impact of Vasectomy on the Development and Progression of Prostate Cancer: Preclinical Evidence

Some observational studies have implied a link between vasectomy and an elevated risk of prostate cancer. We investigated the impact of vasectomy on prostate cancer outgrowth, mainly using preclinical models. Neoplastic changes in the prostate were compared in transgenic TRAMP mice that underwent vasectomy vs. sham surgery performed at 4 weeks of age. One of the molecules identified by DNA microarray (i.e., ZKSCAN3) was then assessed in radical prostatectomy specimens and human prostate cancer lines. At 24 weeks, gross tumor (p = 0.089) and poorly differentiated adenocarcinoma (p = 0.036) occurred more often in vasectomized mice. Vasectomy significantly induced ZKSCAN3 expression in prostate tissues from C57BL/6 mice and prostate cancers from TRAMP mice. Immunohistochemistry showed increased ZKSCAN3 expression in adenocarcinoma vs. prostatic intraepithelial neoplasia (PIN), PIN vs. non-neoplastic prostate, Grade Group ≥3 vs. ≤2 tumors, pT3 vs. pT2 tumors, pN1 vs. pN0 tumors, and prostate cancer from patients with a history of vasectomy. Additionally, strong (2+/3+) ZKSCAN3 expression (p = 0.002), as an independent prognosticator, or vasectomy (p = 0.072) was associated with the risk of tumor recurrence. In prostate cancer lines, ZKSCAN3 silencing resulted in significant decreases in cell proliferation/migration/invasion. These findings suggest that there might be an association between vasectomy and the development and progression of prostate cancer, with up-regulation of ZKSCAN3 expression as a potential underlying mechanism.

The Association Between Vasectomy and Prostate Cancer: A Systematic Review and Meta-analysis

Importance

Despite 3 decades of study, there remains ongoing debate regarding whether vasectomy is associated with prostate cancer.

Objective

To determine if vasectomy is associated with prostate cancer.

Data Sources

The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched for studies indexed from database inception to March 21, 2017, without language restriction.

Study Selection

Cohort, case-control, and cross-sectional studies reporting relative effect estimates for the association between vasectomy and prostate cancer were included.

Data Extraction and Synthesis

Two investigators performed study selection independently. Data were pooled separately by study design type using random-effects models. The Newcastle-Ottawa Scale was used to assess risk of bias.

Main Outcomes and Measures

The primary outcome was any diagnosis of prostate cancer. Secondary outcomes were high-grade, advanced, and fatal prostate cancer.

Results

Fifty-three studies (16 cohort studies including 2 563 519 participants, 33 case-control studies including 44 536 participants, and 4 cross-sectional studies including 12 098 221 participants) were included. Of these, 7 cohort studies (44%), 26 case-control studies (79%), and all 4 cross-sectional studies were deemed to have a moderate to high risk of bias. Among studies deemed to have a low risk of bias, a weak association was found among cohort studies (7 studies; adjusted rate ratio, 1.05; 95% CI, 1.02-1.09; P < .001; I2 = 9%) and a similar but nonsignificant association was found among case-control studies (6 studies; adjusted odds ratio, 1.06; 95% CI, 0.88-1.29; P = .54; I2 = 37%). Effect estimates were further from the null when studies with a moderate to high risk of bias were included. Associations between vasectomy and high-grade prostate cancer (6 studies; adjusted rate ratio, 1.03; 95% CI, 0.89-1.21; P = .67; I2 = 55%), advanced prostate cancer (6 studies; adjusted rate ratio, 1.08; 95% CI, 0.98-1.20; P = .11; I2 = 18%), and fatal prostate cancer (5 studies; adjusted rate ratio, 1.02; 95% CI, 0.92-1.14; P = .68; I2 = 26%) were not significant (all cohort studies). Based on these data, a 0.6% (95% CI, 0.3%-1.2%) absolute increase in lifetime risk of prostate cancer associated with vasectomy and a population-attributable fraction of 0.5% (95% CI, 0.2%-0.9%) were calculated.

Conclusions and Relevance

This review found no association between vasectomy and high-grade, advanced-stage, or fatal prostate cancer. There was a weak association between vasectomy and any prostate cancer that was closer to the null with increasingly robust study design. This association is unlikely to be causal and should not preclude the use of vasectomy as a long-term contraceptive option.

Vasectomy and prostate cancer risk: a historical synopsis of undulating false causality

The potential influence of vasectomy being a risk factor for the development of prostate cancer is not a new concept, with more than 30 publications addressing the topic. Given the global frequency of vasectomy and the prevalence of prostate cancer, this subject justifiably deserves scrutiny. Several articles have claimed that vasectomy puts men at risk for future development of prostate cancer. We explore articles that have shown the contrary (no link), explore the studies’ strengths and weaknesses, describe possible prostate cancer pathophysiologic mechanisms, and apply Bradford Hill criteria to help discern correlation with causation. The risk and interest of association of prostate cancer with vasectomy has waxed and waned over the last three decades. Based on our review, vasectomy remains a safe form of sterilization and does not increase prostate cancer risk.

Abnormal Accumulation of Collagen Type I Due to the Loss of Discoidin Domain Receptor 2 (Ddr2) Promotes Testicular Interstitial Dysfunction

Background

Loss of functional allele for discoidin domain receptor 2 (Ddr2) results in impaired Leydig cell response to luteinizing hormone (LH), low testosterone production and arrested spermatogenesis in older male Ddr2^slie/slie mice. However, the underlying mechanism responsible for this phenotype remains unknown. Herein, we reported for the first time that the deregulated expression of Ddr2 cognate ligand, namely collagen type I (COL1), may account for the disruption of the testicular steroidogenesis in Ddr2^slie/slie mutant testes.

Methodology/Principal Findings

Expression of Ddr2 increased gradually along postnatal development, whereas COL1 expression became negligible from adulthood onwards. In Ddr2^slie/slie mutant testis, however, in contrast to the undetectable staining of Ddr2, COL1 expression was constantly detected, with the highest values detected during adulthood. In the experimental vasectomy model, Ddr2^slie/slie mutant mice exhibited an early androgen deficiency than wild-type mice, along with the accumulation of fibrotic tissue in the interstitium. Functionally, ablation of endogenous Ddr2 resulted in a significant decrease of testosterone (T) level in TM3 cells in the presence of higher concentration of COL1 treatment. Conversely, overexpression of Ddr2 could help TM3 cells to maintain a normal testicular steroidogenesis even in the presence of high concentration of COL1. Additionally, attenuated expression of Ddr2 correlates to the deregulated level of serum T levels in human pathological testes.

Conclusions

Abnormal accumulation of interstitial COL1 may be responsible for the steroidogenic dysfunction in Ddr2^slie/slie mutant testes.

Long-term study of vasectomy in Macaca radiata--histological and ultrasonographic analysis of testis and duct system

This study was aimed to investigate the long-term effect of vasectomy using the bonnet monkey (Macaca radiata) as a primate animal model. Animals weighing around 6 to 8 kg were randomly chosen for bilateral, unilateral vasectomy and sham-control. The postoperative periods of six months and two years were considered as short and long-term, respectively. Sperm were collected and subjected to analysis before euthanasia. The testes and epididymides were excised from euthanized animals then embedded in paraffin. Normal histological changes were observed in sham-operated animals and short-term contralateral testes. In contrast, marked alterations were observed in the testes and epididymides of both short and long-term groups. Seminiferous epithelium was thinned out showing marked depletion of germ cells in long-term; only a thin layer of Sertoli cells, spermatogonia, and fewer spermatocytes were seen. Exfoliation of germ cells and the occurrence of multinucleated giant cells were common features in these tubules. The epididymal tubular lumens were greatly dilated with accumulated spermatozoa in short and long-term animals; significant defects were observed in the epithelium of the long-term animals. Microscopic spermatic granulomas were noticed in epididymides and the vas deferens. Large granulomas were seen in long-term vasectomized monkeys, frequently compressing the surrounding structures. These granulomas could be visualized in ultrasound, however, only at the late stage of its occurrence. Sperm collected from the unilateral vasectomized animals showed a poor motility score in the capillary mucus penetration test (CMPT). Results indicate that the changes observed after vasectomy might be due to pressure initially, whereas in the long-term the damage was supplemented by autoimmune attack. With immunoglobulin (IgG) deposition in contra-lateral unoperated testis of unilateral vasectomized animals it also showed degenerative changes and a concomitant drop in sperm quality. Although, granulomatous reactions were observed in the epididymis and vas deferens but testes were spared from such reactions even in the long-term.

Effect of Vasectomy on Sperm Nuclear Chromatin Condensation in the Rabbit

Histone-to-protamine exchange in haploid spermatids is known to play a central role for male fertility. The present study investigates, for the first time, the effects of vasectomy on the expression of protamines in the rabbit. During normal spermatogenesis, protamine-1 and protamine-2 mRNA were expressed from step 5 round spermatids to step 11 elongated spermatids. In unilaterally vasectomized animals, control testes revealed normal spermatogenesis with normal protamine expression, while vasectomized testes exhibited both normal spermatogenesis and spermatogenic arrest. Some testes with normal spermatogenesis revealed delayed expression of both protamine-1 and protamine-2. Furthermore, multinucleated round spermatids were a regular finding in these testes. In both treated and untreated animals, a higher percentage of spermatozoa from the cauda epididymis had highly condensed chromatin when compared with those from the testis. The percentage of spermatozoa with highly condensed chromatin from testes and epididymides from the vasectomized side of treated animals remained unchanged from controls. As the integrity of nuclear chromatin is important for oocyte fertilization, especially in intracytoplasmic sperm injection (ICSI), where most of the natural selection mechanisms are bypassed, our data add valuable information for the treatment of infertility by ICSI, showing that vasectomy may affect nuclear chromatin integrity of testicular spermatids but not epididymal spermatozoa. Microsurgical epididymal sperm aspiration (MESA), therefore, may be superior to testicular sperm extraction (TESE) in vasectomized patients.

Long-term reproductive consequences of no-scalpel vasectomy in beagles

The effects of vasectomy on the reproductive organs in various species are controversial. This study investigated the morphological change and apoptosis of the testis, epididymis, and vas deferens in beagle dogs 12 months after vasectomy. The male beagles were divided into two groups: vasectomized and sham-operated groups (n=5 in each). Histopathological, ultrastructural, and TUNEL evaluation of the changes in the testis, epididymis, and ductus deferens of each animal were conducted 12 months after surgery. The mean lumen diameter, cellular thickness, mean interstitial distance, and lumen area fraction of each seminiferous tubule and ductus epididymis were measured by stereological analysis. The results showed that, compared with the sham-operated group, the seminiferous tubular epithelial cells of the testes in the vasectomized group were disorderly arranged and scattered. Significant atrophy and apoptosis were found in the endothelial cells, and a range of ultrastructural variations were observed in the cells of testes, epididymis, and vas deferens in vasectomized group. It was concluded that complete obstruction of the vas deferens as a traditional contraception method is not absolutely safe in terms of the reversal of fertility in the long run. Techniques of relieving the inner pressure in the vas deferens while maintaining the efficacy of male contraception need to be explored.

Comparison of spermatogenic damage induced at 6 months after ligation of the vas deferens at proximal and distal locations in the rabbit

Recent study in rabbits demonstrated that vasectomy via the inguinal canal did not result in any spermatogenic damage 3 months postoperation; this study aimed to determine whether the damage would occur in a longer term. The left or right vas deferens was ligated near the epididymal head (unilateral proximal vasectomy, 12 animals) or via the inguinal canal (unilateral distal vasectomy, 11 animals) in adult male rabbits, with a sham operation being performed on the contralateral side. Six months postoperation, testes, epididymides and vasa deferentia were removed and methacrylate resin-embedded sections prepared to evaluate spermatogenesis by histological (qualitative) and stereological (quantitative) studies. The juxta-epididymal segment of the occluded vas deferens was severely distended (filled with sperm) in 10 of the 11 animals with distal vasectomy and moderately or slightly distended in nine of the 12 animals with proximal vasectomy. Severe spermatogenic damage occurred in seven animals with proximal vasectomy (the juxta-epididymal vas moderately or slightly distended), in only one animal with distal vasectomy (the vas not severely distended). In conclusion, spermatogenic damage occurred at 6 months postvasectomy in some animals, especially those with proximal vasectomy and therefore shorter occluded reproductive tract for sperm storage; the damage was probably intra-tract pressure mediated.

Putative health risks associated with vasectomy

Vasectomy is widely regarded as a safe method of contraception, but over the years there have been many reports suggesting putative health risks associated with the procedure. Concerns over the possible association of vasectomy with a number of medical conditions, including cardiovascular disease, testicular cancer, prostate cancer, psychologic distress, and a variety of immune complex-mediated disease processes have been reported. Most recently, a manuscript from the neurology literature has described an association between vasectomy and primary progressive aphasia, a rare variety of frontotemporal dementia. This article reviews the literature surrounding each of these purported health concerns. Because the ultimate findings have important ramifications for both informed consent of vasectomy patients and for public health, the reported health risks in question should be critically evaluated.

Incidence of antisperm antibodies in males with systemic autoimmune diseases

PROBLEM

To investigate if systemic autoimmune diseases could be one of the risk factors for developing antisperm antibodies (ASA) in males.

METHOD OF STUDY

Antisperm antibodies in the sera of 70 males with systemic autoimmune diseases and 80 healthy controls were examined, by using the indirect-immunobead test (I-IBT). The sperm immobilization test (SIT) was also performed to detect sperm immobilizing antibodies to the patients who were positive in I-IBT.

RESULTS

Among 70 males with systemic autoimmune diseases, five were I-IBT positives, with incidence of 7.1%. However, no positives existed in 80 healthy males. Compared with the healthy controls, the incidence of ASA in males with systemic autoimmune diseases was significantly higher (P = 0.020). None of these five ASA-positive patients had sperm immobilizing antibodies.

CONCLUSION

The incidence of ASA in males with systemic autoimmune diseases was significantly higher than in the healthy controls. Systemic autoimmune diseases may be one of the risk factors for developing ASA in men.

Intrauterine insemination and male subfertility

In this article we define male subfertility, review clinical indications for the use of intrauterine insemination, evaluate insemination preparation and administration technique, and ultimately advocate for its use as a first-line therapy in the treatment of infertile couples with male subfertility.

Clinical, ultrasonographic and pathological features following unilateral vasectomy in rams

The effects of vasectomy on testes and related structures of animal species and men are largely disputable. These possible effects were studied in the ram, an established experimental animal model used to investigate genitalia pathophysiology. In each of five rams, vasectomy in the left spermatic cord was carried out; subsequently, the clinical and ultrasonographic features were monitored up to 12 months post-operatively. The rams were sequentially euthanatized 1, 3, 6, 9 and 12 months post-operatively; gross- and histo-pathological examination of their testes and related structures were carried out. Four of the five rams developed sperm granulomas at the proximal to the testis end of vas deferens or/and at the tail of the epididymis; these were palpable from the first and the third month after vasectomy, respectively. Ultrasonographic findings on the vasectomy side were increased size and echogenicity of the epididymal tail, as well as anechoic areas, representing sperm granulomas, visible in the epididymal tail 1 week after vasectomy and in the proximal to the testis end of vas deferens 4 weeks after vasectomy. Gross pathological findings were limited on the vasectomy side and included adhesions between the parietal and the visceral vaginal tunic, enlarged and firm epididymal tail and presence of sperm granulomas at the epididymal tail or/and at the proximal to the testis end of vas deferens; the granulomas contained creamy material. Histopathological changes were observed mainly in the epididymal tails, consisting of a central mass of spermatozoa, surrounded by a layer of macrophages, surrounded in turn by loose vascular connective tissue rich in lymphocytes and plasma cells. With the exception of signs of mild hypospermatogenesis observed in one ram euthanatized 9 months after surgery, and of a slight increase in seminiferous tubule diameter and in seminiferous epithelium height in the rams euthanatized 6 and 9 months after surgery, which are both findings of no clinical importance, no clinical, ultrasonographic, gross- or other histo-pathological changes were observed in the testicular parenchyma during a 12-month post-operative period. These results demonstrate that vasectomy has little if any detrimental effect on the morphologic characteristics of the spermatogenesis in rams.

Seminal Factor VIII and von Willebrand Factor: a possible role of the conventional clotting system in human semen?

Factor (F) VIII circulates in blood complexed with von Willebrand Factor (vWF). Deficiency or defect accounts for haemophilia A and vWF disease. In blood, FVIII functions as a co-factor for FIXa in the activation of FX. Human semen coagulates and liquefies in a process that resembles and has some links with the conventional haemostatic process. A study elsewhere has detected traces, but not measurable levels, of FVIII coagulant activity (FVIII:C). In the present study we have assessed FVIII antigen (FVIII:Ag), FVIII:C and vWF antigen (vWF:Ag) levels in 159 semen specimens obtained from sub-fertile (n = 21), normally fertile (n = 38), fertile donors (n = 32), and vasectomized men (n = 57). Seminal FVIII:Ag levels were also measured in a group defined by several parameters derived from the World Health Organization (WHO) fertility criteria, termed "pooled normal semen parameters" (PNSP). Factor VIII:Ag levels were compared with conventional fertility parameters. In addition, both FVIII:C and vWF:Ag were assessed in a separate group of normal individuals (n = 11). Factor VIII:Ag, FVIII:C and vWF were present and quantifiable in human semen. Factor VIII:Ag levels were significantly lower in vasectomy subjects compared with donors (p = 0.01) or PNSP group (p = 0.01). Several trends taken together suggest an associations between FVIII:Ag and semen quality. Parallel investigations demonstrate FV, FVII, FVIIa, FIX, FIXa, FXa, FXI, FXII, tissue factor (TF) and tissue factor pathway inhibitor (TFPI) in semen. The present report therefore provides further evidence for the presence of a functioning clotting system in human semen.

Stereological analysis of the human testis after vasectomy indicates impairment of spermatogenic efficiency with increasing obstructive interval

OBJECTIVE

To quantify germ cell loss and the extent of testicular fibrosis in vasectomized patients of varying obstructive intervals.

DESIGN

Retrospective study.

SETTING

Specialized male reproductive surgery and endocrinology service.

PATIENT(S)

Thirty-four vasectomized patients 1-20 years after surgery and 10 normal subjects.

INTERVENTION(S)

Thirty-four testicular biopsies taken at the time of vasectomy reversal (vasovasostomy). Control biopsies taken from 10 normal men at the time of vasectomy.

MAIN OUTCOME MEASURE(S)

Stereological assessment of testicular germ cell populations and testicular fibrosis.

RESULT(S)

Vasectomy caused a significant decrease in germ cells in the later stages of spermatogenesis, with significant reductions in pachytene spermatocytes (by 18%), round spermatids (by 40%), elongating spermatids (by 23%), and elongated spermatids (by 39%). The loss of spermatids showed a significant relationship with obstructive interval. A significant 2.7-fold increase in total (peritubular plus interstitial) fibrosis was observed, which showed a positive relationship with obstructive interval. Decreased germ cell populations and fibrosis did not seem to be related to sperm antibody levels nor to sperm counts obtained up to 2 years after vasovasostomy.

CONCLUSION(S)

Vasal obstruction results in significant reductions in germ cells in the later stages of spermatogenesis and increases in testicular fibrosis, both worsening with an increasing obstructive interval. Testicular damage after vasectomy might impact upon the prospects for reversal.

Serial follow-up study of serum testosterone and antisperm antibodies in patients with non-obstructive azoospermia after conventional or microdissection testicular sperm extraction

Testicular sperm extraction (TESE) combined with intracytoplasmic sperm injection is becoming a first-line treatment even for non-obstructive azoospermia. The current focus of TESE is the identification of seminiferous tubules that contain spermatozoa and minimization of testicular damage. Although microdissection TESE has been introduced as a preferred procedure for sperm retrieval, no serial follow-up studies of testicular damage have been reported. In the present study, we assayed serum testosterone concentrations and for the presence of antisperm antibodies (ASA) for 1 year after conventional multiple TESE or microdissection TESE and compared postoperative testicular damage between procedures. Thirteen patients who underwent conventional multiple TESE and 12 patients who underwent microdissection TESE were included in this study. Serum total and free testosterone concentrations were evaluated before operation and 1, 6 and 12 months after TESE. Serum ASA was also evaluated before and 12 months after TESE. Serum total and free testosterone concentrations in all patients in both groups showed no significant postoperative decrease. A comparison between the two groups of serum total and free testosterone concentrations showed no significant difference (total testosterone, p = 0.2477; free testosterone, p = 0.3098). No incidence of new ASA formation was identified in the present study. In conclusion, TESE procedures cause neither a decrease of serum testosterone nor formation of ASA. Serum testosterone concentration are similar between patients in the conventional multiple TESE and microdissection groups. Therefore, microdissection TESE is safe with respect to testicular damage, particularly for patients with hypogonadism.

Percutaneous epididymal sperm aspiration: a diagnostic tool for the prediction of complete spermatogenesis

The classification of azoospermia into obstructive or non-obstructive is largely based on medical history, physical examination and biochemical markers in serum and semen. However, the most accurate parameter for diagnosis is the testicular histology. The predictive value of the percutaneous epididymal sperm aspiration (PESA), FSH, LH, testosterone, inhibin-B and testicular volume was investigated for their accuracy to predict a complete spermatogenesis (Johnsen score > or =8) in order to replace the testicular histology. The specificity and sensitivity of FSH, inhibin-B, LH, testosterone, testicular volume, and the presence of sperm in a PESA procedure was evaluated in 147 azoospermic males attending the centre for infertility diagnosis. A positive PESA outcome presented the highest sensitivity and specificity to predict a Johnsen score > or =8 (93 and 94% respectively) compared with FSH (90 and 19%), inhibin-B (88 and 57%) and testicular volume (95 and 45%). Differences in clinical presentation were observed between patients with positive sperm retrieval with PESA, depending on the aetiology of obstruction. In conclusion, the presence of spermatozoa in the epididymis (PESA+) correlates with a Johnsen score > or =8 and is the most accurate parameter to predict complete spermatogenesis compared with clinical or biochemical parameters. Between obstructive azoospermic patients, the clinical parameters observed varied according to the aetiology.

Vasectomy and the risk of prostate cancer: a meta-analysis examining vasectomy status, age at vasectomy, and time since vasectomy

The aim of this study was to conduct a quantitative review of prostate cancer studies to pool relative risk (RR) estimates on the association between prostate cancer and vasectomy, in an attempt to determine whether there is an association, and if so, its magnitude. Random-effects models were examined along with a linear model for time since vasectomy. The pooled RR estimate was 1.37 (95% CI=1.15-1.62) based on five cohort studies and 17 case-control studies. The RR estimate varied by study design with the lowest risk for population-based case-control studies. No difference was seen in risk by age at vasectomy. A linear trend based on the 16 studies reporting time since vasectomy suggested an 10% increase for each additional 10 y or a RR of 1.32 (95% CI=1.17-1.50) for 30 y since vasectomy. When null effects were assumed for the six studies not reporting information, the linear RR for the 22 studies was 1.07 (1.03-1.11) and 1.23 (1.11-1.37) for 10 and 30 y since vasectomy, respectively. These results suggest that men with a prior vasectomy may be at an increased risk of prostate cancer, however, the increase may not be causal since potential bias cannot be discounted. The overall association was small and therefore could be explained by bias. The latency effect shown here for time since vasectomy should be examined further.

Morphometric study of testis of Wistar rat after open-ended vasectomy

The effects on the testis of open-ended vasectomy in the Wistar rat have been assessed morphometrically and evaluated statistically at 1, 4, 12, and 24 weeks after operation, and compared to those in sham-operated controls. The open-ended technique, ie, without ligation of the epididymal end of the cut ductus deferens, allowed drainage of sperm into the spermatic cord. During the period of our study, it did not affect the structure of the testis; although the germinal epithelium, basement membrane, and the stroma and cells of the interstitial space all showed variations when compared to the control group, these were not statistically significant.

Influence of interstitial fibrosis on spermatogenesis after vasectomy and vasovasostomy

This study focused on the testicular interstitial fibrosis after vasectomy and the intraseminiferous status [i.e., Johnsen's score, proliferative cell nuclear antigen (PCNA) expression] following vasectomy reversal. Testicular biopsy specimens from 21 consecutive men were obtained at vasovasostomy. Percent of interstitial fibrosis was determined quantitatively by NIH-image after Masson Trichrome staining. PCNA-labeling index (LI) was calculated on each testis. The associations between the obstructive interval and each parameter were examined. These parameters were also analyzed on whether patency or pregnancy was achieved or not. Significant decrease in PCNA-LI and increase in interstitial fibrosis were observed along with the obstructive interval (p <0.0001, p = 0.0005, respectively). Interstitial fibrosis of the patients without patency/fertility was significantly greater than that of the patients with patency/fertility (47.5%/39.0% versus 33.4%/32.3%, p = 0.02/0.04, respectively). PCNA-LI and Johnsen's score did not predict the treatment outcome. Interstistial fibrosis, but not the extent of germ cell differentiation or DNA synthesis, reflects the treatment outcome after vasectomy reversal. Interstistial fibrosis contributes to the irreversible damage of vasectomized testes.

Serial ultrasonography, hormonal profile and antisperm antibody response after testicular sperm aspiration

BACKGROUND

In many fertility centres, intracytoplasmic sperm injection (ICSI) with epididymal or testicular spermatozoa is a routine treatment for men with azoospermia. In this prospective study, the physiological consequences after testicular sperm aspiration (TESA), using suction and a 19 gauge needle, were evaluated.

METHODS AND RESULTS

Thirty-five consecutive men with azoospermia underwent TESA. Testicular ultrasonography with Doppler flow imaging was performed and testicular volumes were evaluated pre-operatively and 3 months after aspiration. If focal testicular lesions were found, further examinations were performed 6 and 9 months after TESA. Serum FSH, testosterone and antisperm antibodies (ASA) were analysed. Focal testicular lesions were seen in four out of 61 testes (6.6%) at the 3 month investigation point. Three lesions were resolved after 6 months and all after 9 months. Testicular echogenicity remained unchanged in 50 cases (82%) 3 months after TESA. Four men (11.4%) reported severe subjective discomfort post-operatively, but only one had a medical consultation where an intratesticular haematoma was diagnosed. There were no significant changes in FSH and testosterone after surgery and testicular volumes were similar after 3 months. There were three borderline cases of ASA in serum, but none was classified as ASA-positive.

CONCLUSIONS

The puncture method of testicular sperm aspiration seems to be a safe method for sperm retrieval, with minimal physiological consequences.

Cellular responses to vasectomy

A number of cell populations in the reproductive tract show a response to vasectomy. Some cell types show similar responses in man and all laboratory species, whereas others show marked species variations. This chapter describes these effects in a broadly chronological order and, in a general way, considers changes close to the site of vasectomy first and the longer term effects on the testis itself later. Following vasectomy, epididymal distension and sperm granuloma formation result from raised intraluminal pressure. The sperm granuloma is a dynamic structure and a site of much spermatozoal phagocytosis by its macrophage population. In many species, spermatozoa in the obstructed ducts are destroyed by intraluminal macrophages, and degradation products, rather than whole sperm, are absorbed by the epididymal epithelium. Humoral immunity against spermatozoal antigens following vasectomy is well established and there is evidence of modest T-lymphocyte activity. The role of lymphocytes in the reproductive tract epithelium and interstitium following vasectomy is poorly defined. In laboratory animals, there is evidence that pressure-mediated damage to the seminiferous epithelium can follow sperm granuloma formation and obstruction in the epididymal head. However, the contribution of lymphocytes and antisperm antibodies to testicular damage after vasectomy is far from clear. A number of studies have suggested that testicular changes may follow vasectomy in man but their validity and mechanism of occurrence require further study.

Degeneration of the seminiferous epithelium following epididymal obstruction in prepubertal rats

The development of the testes was studied in rats following prepubertal obstruction of the epididymis. Male rats received bilateral ligation of the corpus epididymidis or a sham operation at 10 days of age, and temporal changes in testicular morphology and weights of reproductive organs were determined at intervals spanning sexual maturation. Development of the testes was normal through 35 days of age. The initial histological changes in the testes of ligated animals, observed at 56 days, included an increased diameter of the seminiferous tubule lumen, depletion of spermatids, and the presence of multinucleate spermatids. Subsequently, germ cells were greatly depleted in the testes of 91- and 128-day-old rats with ligated epididymides. After puberty, testicular weight and volume declined relative to corresponding sham-operated animals. On the other hand, the weights of the epididymides in ligated animals prior to puberty significantly exceeded those of sham-operated rats but weighed significantly less than those of rats in the sham group after sexual maturation. Testicular alterations occurred after increases in the weights of the epididymides. Testicular changes may have contributed to rather than resulted from an autoimmune response to spermatozoa because testicular alterations preceded increases in antisperm autoantibodies.

Testicular effects of vasectomy in rats: an ultrastructural and immunohistochemical study

OBJECTIVES

The correlation between infertility and morphofunctional alterations following vasal occlusion is not clearly understood. Although a correlation has been found between the expression of a high titer of antisperm antibodies and the status of infertility, the relationship between the immunoglobulin (Ig) depositions in the testis and ultrastructural alterations of the peritubular structures has not been clearly established. The objective of this study is to explain the etiopathogenesis of diffuse and focal testicular lesions caused by vasal obstruction.

METHODS

Unilateral vasectomy was performed on adult male rats. Ultrastructural changes of testicular tissues and immunostaining affinity of peritubular structures with anti-actin, anti-vimentin, anti-laminin, and anti-immunoglobulin G (anti-IgG) antibodies were analyzed.

RESULTS

In an ultrastructural study, vasectomized animals presented abundant collagen fibril accumulation in the peritubular area. In testis with intense IgG antibodies, staining revealed weak immunostaining of peritubular myoid cells with anti-actin antibodies, but intense immunostaining with anti-vimentin antibodies. The tubules of rats with no IgG deposition on peritubular structures revealed intense immunostaining with anti-actin antibodies but scant immunostaining with anti-vimentin antibodies. Anti-laminin deposits decreased severely in most of the tubules demonstrating intense IgG deposition.

CONCLUSIONS

Our findings suggest that spermatogenesis deteriorates more severely in testes with dense IgG deposition. The sclerosis of the lamina propria in cases with vasal occlusion is secondary to alterations in the peritubular myoid cells. With the progressive changes that occur in the peritubular myoid cells or differentiation of the peritubular myoid cells that acquire active cell characteristics, collagen accumulation adjacent to these cells increases markedly. The alterations of the peritubular myoid cells reported here may be caused by alterations in basement membrane structures.

Analysis of the relationship between histologic alterations and the generation of reactive oxygen species in vasectomized rat testes

OBJECTIVES

To evaluate the effects of vasal obstruction on testicular structure, to determine if tissue and/or cell damage can cause significant reactive oxygen species (ROS) generation, and to correlate the histologic alterations to the measured levels of ROS products.

METHODS

To evaluate the effects of ROS generation in vasectomized testes, unilateral vasectomy was performed on 17 rats and tissue samples were examined by light microscopy. The histologic alterations were correlated to the measured tissue malondialdehyde levels by thiobarbituric acid analysis as an indicator of the ROS-induced tissue damage.

RESULTS

Unilateral vasectomy significantly affected the weights of the ipsilateral testes, but not the contralateral testes. No significant changes were noted in plasma estradiol, follicle-stimulating hormone, luteinizing hormone, and testosterone levels. The mean values of malondialdehyde were found to be significantly higher in vasectomized rats than in control rats (0.025 +/- 0.008 versus 0.018 +/- 0.007 nmol/mg protein) (P < 0.01). The malondialdehyde level was a mean of 28% lower in the contralateral testes tissue as compared to that found in ipsilateral testes (P < 0.01). Malondialdehyde output from vasectomized rats had a parallel correlation to tissue destruction.

CONCLUSIONS

Our results indicate that overproduction of ROS may be involved in vasectomy-induced testicular damage.

Multivariant analysis of men from infertile couples with and without antisperm antibodies

PROBLEM

Research studies in animal and human systems have demonstrated conclusively that antisperm antibodies can interfere with fertilization. In the male, autoantibodies to sperm can be detected both in the sera and seminal plasma.

METHOD OF STUDY

Ninety-seven men who were tested for antisperm antibodies as a part of an infertility evaluation were identified. Complete medical history was obtained, including information related to events suspected of being associated with antisperm antibodies. History of surgery (varicocele repair, hernia repair, and vas reversal) and infection (epididymitis, sexually transmitted disease, and orchitis) were compared with semen parameters (motility less than 60%, concentration less than 20 x 10(6), and volume less than 2 cc). These were compared to antisperm antibody results of mixed agglutination reaction (MAR) and direct immunobead binding test (IBT) for immunoglobulin G (IgG). Statistical analysis was performed using Fishers exact two-tailed test.

RESULTS

As expected, prior vas reversal was significantly associated with the presence of antisperm antibodies (P = 0.0002) by MAR or IBT with a fivefold increased relative risk (95% confidence interval, 1.97-12.38). Other surgeries manipulating the cord structures independent of vas reversal were not associated with antisperm antibodies (P = 0.09). Prior infections, independent of vas reversal, were significantly associated with antisperm antibodies by MAR (P = 0.04) with a 3.8-fold increased relative risk (95% confidence interval, 1.06-13.87) but not by IBT. Sperm concentration less than 20 x 10(6), motility less than 60%, and a volume less than 2 cc were not associated with antisperm antibodies by MAR or IBT.

CONCLUSION

These findings suggest that manipulation of the cord structures excluding the vas were not associated with antisperm antibodies; however, vas reversal and prior infection are significant risk factors for the development of antisperm antibodies.

Infertility due to antisperm antibodies

Immunoinfertility is an important problem, involving a significant number of infertile couples. Although the presence of antibodies on sperm has better prognostic value than those in serum or seminal plasma, it may not be the sole authentic evidence of immunoinfertility. Infertility from antisperm antibodies is likely only when they bind to a relevant sperm antigen involved in a specific fertility function. The variance in functional deficits seen in immunologic infertility is most likely related to antibodies directed at different sperm antigens or different class, subclass, or isotypes. Antibodies to FA-1 seem to be of significant importance in human immunoinfertility. In approaching couples with infertility, a high index of suspicion for antibodies is necessary to avoid misdiagnosis. In the optimal situation, all semen analyses should be screened for sperm-bound antibodies, but if this is impractical, testing should be performed on high-risk individuals (Table I). In couples in which the man has sperm-bound antibodies, and in whom there is no identifiable female factor, treatment should be instituted. Most treatments for immunoinfertility have been disappointing because of poor results, adverse effects, or high cost. Corticosteroid therapy has shown some promise in published reports (mostly poorly designed studies), but increase in pregnancy rate is modest and adverse effects may be significant. In our opinion, informed consent should be documented prior to institution of corticosteroid therapy, and subjects should be closely monitored. Advanced reproductive technologies offer a higher safety profile, and, with increasing technology, higher pregnancy rates. We recommend progressing from "low-tech" procedures, such as IUI and reserving the higher level procedures, such as IVF and ICSI, for those couples in whom pregnancy does not occur. The highest level reproductive technologies give the best current prospects for pregnancy in patients with this difficult problem but also are invasive and costly. It is hoped that further work in the laboratory will give rise to newer, safer, and less expensive effective treatments in the very near future.