Novel associations between specific sperm morphological defects and leukocytospermia

PPARγ Expression in Human Spermatozoa and Its Relationship with Seminal F2-Isoprostanes and Resolvin D1 in the Presence of Varicocele and Urogenital Infections

Peroxisome Proliferator-Activated Receptor Gamma (PPARγ) is a regulating agent in antioxidant response also involved in controlling inflammation. The impact of varicocele and urogenital infections on sperm PPARγ expression was studied. The PPARγ gene expression was investigated in spermatozoa of 26 normozoospermic men grouped according to their clinical conditions: normal semen parameters (N), normal semen parameters and varicocele (N + V), and normal semen parameters and urogenital infections (N + UI). Sperm PPARγ expression was correlated with F2-isoprostanes (F2-IsoPs), as markers of lipid peroxidation, and Resolvin D1 (RvD1), a pro-resolving mediator in inflammation. Sperm PPARγ expression was evaluated through comparative real-time PCR, and F2-IsoPs and RvD1 were quantified in the seminal plasma via GC/NCI-MS/MS and immunoassay, respectively. PPARγ expression correlates positively with sperm morphology and vitality and negatively with F2-IsoPs and RvD1. Sperm morphology positively correlates with vitality and negatively with F2-IsoP and RvD1 levels. Despite the normozoospermia in the three examined groups, sperm morphology and PPARγ expression were significantly reduced in N + V and N + UI groups compared to the N group. Additionally, F2-IsoP and RvD1 levels were elevated in N + V and N + UI patients. These data suggest that PPARγ expression is compromised by inflammation and lipoperoxidation, providing new insights to further explore new possibilities of targeted treatment of male infertility.

Testicular immunity

The testis is a unique environment where immune responses are suppressed to allow the development of sperm that possess autoimmunogenic antigens. There are several contributors responsible for testicular immune privilege, including the blood-testis barrier, testicular immune cells, immunomodulation by Sertoli cells, and high levels of steroid hormones. Despite multiple mechanisms in place to regulate the testicular immune environment, pathogens that disrupt testicular immunity can lead to long-term effects such as infertility. If testicular immunity is disturbed, autoimmune reactions can also occur, leading to aberrant immune cell infiltration and subsequent attack of autoimmunogenic germ cells. Here we discuss cellular and molecular factors underlying testicular immunity and how testicular infection or autoimmunity compromise immune privilege. We also describe infections and autoimmune diseases that impact the testis. Further research into testicular immunity will reveal how male fertility is maintained and will help update therapeutic strategies for infertility and other testicular disorders.

Role of Leukocytospermia in the Management of Male Infertility: Decoding a Mystery for the Busy Clinicians

Leukocytospermia, defined as a leukocyte concentration in semen exceeding 1×106 leukocytes/mL, significantly impacts male reproductive health by affecting sperm functionality and fertility outcomes. This condition arises from various etiological factors, including infections, autoimmune responses, lifestyle factors, and other physiological conditions. Adverse effects on sperm associated with leukocytospermia include acrosome damage and abnormalities in the sperm midpiece and tail. The review explores the complex interplay between leukocytospermia and oxidative stress, emphasizing the harmful effects on sperm DNA integrity and overall sperm quality. Due to the multifactorial nature of leukocytospermia, diagnosing this condition presents several challenges. Effective management strategies discussed include the use of antibiotics, anti-inflammatory agents, and assisted reproductive technologies. Diagnostic methods range from traditional peroxidase staining to more advanced techniques such as immunocytochemistry and flow cytometry, which offer higher sensitivity and specificity. Infections of the male genital tract, particularly male accessory gland infection and male genital tract infection, play a significant role in the etiology of leukocytospermia. These infections lead to an inflammatory response, resulting in leukocyte infiltration into the semen. Systemic conditions like diabetes mellitus and autoimmune disorders also contribute to leukocytospermia by provoking inflammatory responses that facilitate leukocyte presence in semen. This review underscores the importance of a comprehensive diagnostic approach that includes patient history, physical examination, and advanced laboratory tests. Treatment is tailored to the identified underlying cause, whether infectious or non-infectious. Lifestyle modifications, such as reducing stress, improving diet, and avoiding environmental toxins, are also recommended to enhance semen quality. For clinicians, this review provides a concise yet thorough overview of leukocytospermia, integrating the latest research findings and clinical insights to aid in the effective management of this condition, ultimately aiming to improve patient care in male reproductive health.

Male reproductive function before and after the adjustment of the COVID-19 prevention policy: a multicenter study in China

At the end of 2022, the adjustment of the coronavirus disease 2019 (COVID-19) pandemic control policy in China resulted in a large-scale increase in public infection. To compare the fertility parameters of male patients before and after the adjustments of the COVID-19 pandemic control policy in China, we collected data on patients' medical histories and laboratory examinations on their first visits between June 2022 and March 2023 in five different hospitals. Data were divided into five groups according to the timeline of the policy adjustment. The data we collected from male patients included semen quality and serum reproductive hormone levels, and intergroup comparisons were made using the Mann-Whitney U and Chi-square tests. In total, 16 784 cases underwent regular semen analysis, 11 180 had sperm morphology assessments, and 7200 had reproductive hormone analyses. The data showed declining trends in semen volume, sperm motility, and the progressive sperm motility rate after the policy adjustment. Subgroup comparison revealed an initial decrease and gradual recovery in progressive motility rate. Sperm morphology analysis showed increased neck and tail abnormalities after the policy adjustment. No significant change in hormone levels was observed. Following the adjustment of the COVID-19 prevention policy in China, a decline in sperm motility and morphology was observed. This trend may gradually recover over 2 months. After the policy adjustment, reproductive hormone levels were relatively stable throughout, except for an increase in luteinizing hormone (LH). These changes in semen parameters suggest that the policy adjustment had a short- to medium-term impact on male reproductive function.

Mitochondrial function and reactive oxygen species production during human sperm capacitation: Unraveling key players

Sperm capacitation is a critical process for male fertility. It involves a series of biochemical and physiological changes that occur in the female reproductive tract, rendering the sperm competent for successful fertilization. The precise mechanisms and, specifically, the role of mitochondria, in sperm capacitation remain incompletely understood. Previously, we revealed that in mouse sperm mitochondrial activity (e.g., oxygen consumption, membrane potential, ATP/ADP exchange, and mitochondrial Ca2+ ) increases during capacitation. Herein, we studied mitochondrial function by high-resolution respirometry (HRR) and reactive oxygen species production in capacitated (CAP) and non-capacitated (NC) human spermatozoa. We found that in capacitated sperm from normozoospermic donors, the respiratory control ratio increased by 36%, accompanied by a double oxygen consumption rate (OCR) in the presence of antimycin A. Extracellular hydrogen peroxide (H2 O2 ) detection was three times higher in CAP than in NC sperm cells. To confirm that H2 O2 production depends on mitochondrial superoxide (O 2 · - $$ {\mathrm{O}}_2^{\cdotp -} $$ ) formation, we evaluated mitochondrial aconitase (ACO2) amount, activity, and role in the metabolic flux from the sperm tricarboxylic acid cycle. We estimated that CAP cells produce, on average by individual, (59 ± 22)% moreO 2 · - $$ {\mathrm{O}}_2^{\cdotp -} $$ in the steady-state compared to NC cells. Finally, we analyzed two targets of oxidative stress: lipid peroxidation by western blot against 4-hydroxynonenal and succinate dehydrogenase (SDH) activity by HRR. We did not observe modifications in lipoperoxidation nor the activity of SDH, suggesting that during capacitation, the increase in mitochondrial H2 O2 production does not damage sperm and it is necessary for the normal CAP process.

Effect of leukocytes on semen quality in men from primary and secondary infertile couples: A cross-sectional study

Background and Aims

Leukocytospermia (LCS) is a known cause of male infertility. However, the relationship between seminal leukocytes and semen quality among infertile couples remains controversial. This study aims to investigate the association between semen quality and LCS in male partners of infertile couples.

Methods

Semen samples were collected from 512 men who asked for a fertility evaluation in a reproductive center in China. Seminal leukocytes were counted following peroxidase staining with benzidine. Other semen parameters were compared in subfertile men with and without LCS.

Results

Poor semen quality (e.g., low semen volume, sperm concentration, and sperm progressive/total motility) was observed among men with LCS compared to those without LCS. Men with LCS had a higher risk of low sperm progressive motility (OR = 0.99, 95% CI = 0.98-0.99, p = 0.02) and total motility (OR = 0.99, 95% CI = 0.98-0.99, p = 0.02), even after adjustment for potential confounders (both OR = 0.99, 95% CI = 0.98-0.99, p = 0.03). Lower sperm viability was observed in LCS from male partners of secondary couples, while no significant difference in semen parameters was found between men with and without LCS in male partners of primary infertile couples. Low sperm motility and viability were associated with LCS in men from secondary infertile couples after adjusting for confounders (OR = 0.97, 95% CI = 0.95-0.99, p = 0.04; OR = 0.94, 95% CI = 0.89-0.99, p = 0.04, respectively).

Conclusions

Our findings indicate that a higher risk of abnormal semen parameters was correlated with an increased number of leukocytes in men from secondary infertile couples.

[Infections and male infertility]

BACKGROUND

The role of urogenital infections in male infertility has long been the subject of debate.

METHODS

A bibliographic search limited to English-language literature on human subjects published before 5/2023 resulted in the selection of 189 articles.

RESULTS

Male infertility is often of multifactorial aetiology, and to optimise the prognosis it is important to manage all the factors that can be corrected, including infectious causes, which represent one of the most frequent aetiologies. The infectious agents involved in urogenital infections are most often bacterial or viral, and more rarely parasitic. They can infect the seminal tract, male accessory glands and/or testicles, and usually result in inflammation and increased oxidative stress. These infections reduce male fertility, in particular by altering spermogram parameters and increasing sperm DNA fragmentation. For these reasons, the search for a urogenital infection should be systematic, involving a careful history and clinical examination, ultrasound and systematic bacteriological tests guided by clinical findings. Aetiological treatment may be proposed depending on the picture and the germ involved.

CONCLUSION

This review should help the urologist to establish an accurate diagnosis of the form and extent of the infection, and enable him to define an appropriate therapeutic strategy, tailored to the patient, in order to obtain the best chances of improving male fertility.

Age-Related COVID-19 Influence on Male Fertility

The impact of coronavirus on the reproductive health of men attracts the special attention of many researchers. While studies suggest changes in sperm parameters and the possibility of testicular inflammation, further studies are needed to elucidate any potential age-related changes in these findings, which is the purpose of the present study. The semen quality parameters, cytokine concentration, and markers of the pro- and antioxidant system were assessed in 60 men five to seven months after the coronavirus infection and in 77 controls (without a history of coronavirus infection). Additionally, participants were divided into two age groups: less than 35 years and 35 years or older. Notably increased round cell count in ejaculate and reduced sperm hyaluronan binding ability were observed among post-infection patients younger than 35 years. In the same group, a decline in seminal plasma zinc levels and nitrotyrosine in the cell fraction was found. In men over 35 years of age, Coronavirus Disease 2019 (COVID-19) led to increased sperm DNA fragmentation, a decrease in the total antioxidant capacity, and an elevation in the levels of interleukin-1β and interleukin-10. The concentration of interleukin-1β decreased over time following recovery in all affected patients. The data obtained suggest the potential adverse impact of the coronavirus infection on male reproductive health; however, these effects appear to be age-dependent.

Validation of the volumetric flow cytometry for bovine sperm concentration

Sperm concentration is a stronghold of the andrological evaluation and the production of insemination doses. The use of haemocytometers, although considered the gold standard, is difficult to apply in field conditions because it is subjective and time-consuming. The present study was designed to validate the volumetric flow cytometry (volFC) in order to estimate bovine sperm concentration, comparing it with the performances of haemocytometer, NucleoCounter, and flow cytometry with the use of fluorospheres. Compared with other methods, volFC appeared less affected by large dilution of the sample, with similar concentrations calculated in the range of dilution 1:200-1:800. Using volFc the population detected on the basis of morphological criteria and fluorescence of DNA better represents the real concentration of sperm in the sample. The volFC showed high repeatability compared with the haemocytometer (coefficient of variation 1.85% and 4.52%, respectively) and stable performances with cryopreserved samples, with negligible effects of the medium components. The present study showed that volFC is as accurate and precise as other techniques to estimate sperm concentration in bovine fresh and frozen semen, but it is less affected by operative conditions, such as sample dilution. The possibility to quantify sperm functional subpopulations by volFC could potentially implement the study of the relationship between sperm attributes and fertility.

Ejaculation: the Process and Characteristics From Start to Finish

Purpose of Review

Semen analysis serves as the initial step in the evaluation of male infertility. However, given the difficulty in interpreting abnormal findings, physicians and patients often struggle with understanding the results. In this review, we aim to review the normal physiology of ejaculation and create an accessible resource for interpreting abnormal semen volume, viscosity, liquefaction, pH, appearance, and color.

Recent Findings

Emerging evidence has revealed that men with genitourinary tract infections have a greater number of seminal leukocytes, which may result in clumping of motile sperm and altered morphology. Hence, these patients may have abnormal sperm parameters secondary to their health status. Recent findings have further characterized the semen liquefaction process, suggesting that increased levels of semenogelin and decreased levels of proteases and plasminogen activators (e.g., urokinase and chymotrypsin) may be associated with the failure of semen to convert to a watery consistency.

Summary

This article creates a resource which may be referenced when abnormalities in semen analysis are encountered. We offer a comprehensive overview of normal ejaculation physiology and abnormal variants in male ejaculate volume-including aspermia, anejaculation, retrograde ejaculation, and hypo- and hyperspermia-and their potential etiologies. Additionally, we discuss several processes (infection, inflammation, and dysfunction of male sex glands) which may affect semen viscosity, liquefaction, and pH. Finally, our discussion of the potential colors of male ejaculate is meant to reduce the anxiety of both patient and provider. Through a better understanding of the process and varying characteristics of ejaculation, physicians may adequately counsel their patients on abnormal findings and concerns regarding infertility.

The Effect of Long COVID-19 Infection and Vaccination on Male Fertility; A Narrative Review

Earlier research has suggested that the male reproductive system could be particularly vulnerable to SARS-CoV-2 (COVID-19) infection, and infections involving this novel disease not only pose serious health threats but could also cause male infertility. Data from multi-organ research during the recent outbreak indicate that male infertility might not be diagnosed as a possible consequence of COVID-19 infection. Several review papers have summarized the etiology factors on male fertility, but to date no review paper has been published defining the effect of COVID-19 infection on male fertility. Therefore, the aim of this study is to review the published scientific evidence regarding male fertility potential, the risk of infertility during the COVID-19 pandemic, and the impact of COVID-19 vaccination on the male reproductive system. The effects of COVID-19 infection and the subsequent vaccination on seminal fluid, sperm count, sperm motility, sperm morphology, sperm viability, testes and sex hormones are particularly reviewed.

Relevance of Leukocytospermia and Semen Culture and Its True Place in Diagnosing and Treating Male Infertility

The current WHO 2010 manual for human semen analysis defines leukocytospermia as the presence of peroxidase-positive leukocytes at a concentration >1×106/mL of semen. Granular leukocytes when activated are capable of generating high levels of reactive oxygen species in semen resulting in oxidative stress. Oxidative stress has been correlated with poor sperm quality, increased level of sperm DNA fragmentation and low fertility potential. The presence of leukocytes and pathogens in the semen may be a sign of infection and/or localized inflammatory response in the male genital tract and the accessory glands. Common uro-pathogens including Chlamydia trachomatis, Ureaplasma urealyticum, Neisseria gonorrhoeae, Mycoplasma hominis, and Escherichia coli can cause epididymitis, epididymo-orchitis, or prostatitis. The relationship between leukocytospermia and infection is unclear. Therefore, we describe the pathogens responsible for male genital tract infections and their association with leukocytospermia. The review also examines the diagnostic tests available to identify seminal leukocytes. The role of leukocytospermia in male infertility and its management is also discussed.

Effects of leukocytospermia on the outcomes of assisted reproductive technology

Leukocytospermia is one of the common causes of male infertility, and its effects on the clinical outcomes of assisted reproduction are controversial. There are no recommendations for the management of leukocytospermia in cases of assisted reproductive technology (ART). To investigate the impact of leukocytospermia on ART, we retrospectively compared the clinical outcomes in ART couples with or without leukocytospermia and further analysed the impact of the insemination method itself by split insemination treatment in ART couples with leukocytospermia. In this study, leukocytospermia was detected in 133 patients, namely 63 in the conventional in vitro fertilization (IVF) group, 38 in the intracytoplasmic sperm injection (ICSI) group and 32 in the split insemination group. Leukocytospermia has a negative influence on the parameters of semen samples; however, leukocytospermia did not affect the clinical outcomes of IVF or ICSI. Different insemination methods did not affect the fertilization, clinical pregnancy or live birth rates. In the split insemination study, no significant differences in clinical pregnancy and live birth rates between the IVF and ICSI groups were found; however, the numbers of two pronuclei (2PN), available embryos and good‐quality embryos in the ICSI group were higher than those in the IVF group. Leukocytospermia may be a risk factor affecting semen parameters, and more attention should be given to IVF insemination. Leukocytospermia has no significant negative effect on the outcomes of ART. ICSI may obtain better embryos than IVF, but it cannot improve the clinical pregnancy and live birth rates.

COVID-19 and Male Reproduction: A Thorny Problem

With the global epidemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the increasing number of infections, little is known about how SARS-CoV-2 affects the male reproductive system during infection or after recovery. Based on the existing research data, we reviewed the effects of SARS-CoV-2 on the male reproductive system and discussed its possible mechanism of action. SARS-CoV-2 enters host cells through the angiotensin-converting enzyme 2 (ACE2)/transmembrane serine protease 2 (TMPRSS2) pathway, and males are more susceptible than females. After infection, immunopathological damage is noticed in the testicles, and the semen index is significantly reduced. Second, abnormalities of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (T) levels were also observed, suggesting that there may be dysfunction of the hypothalamic–pituitary–gonadal (HPG) axis. Even after recovery, the effect of SARS-CoV-2 on the male reproductive system can last for at least a period. There are still many unresolved questions about the effect of SARS-CoV-2 infection on the male reproductive tract. Other receptors involved during the invasion of human cells by SARS-CoV-2 remain to be identified. Will the mutation of SARS-CoV-2 increase the diversity of receptors? How does SARS-CoV-2 affect the HPG axis? The long-term effects of SARS-CoV-2 on the male reproductive system remain to be evaluated. SARS-CoV-2 infection can affect male reproductive function. Standard treatment strategies should be developed in time to protect the fertility of infected patients. For recovered patients with fertility requirements, fertility assessments should be performed and professional fertility guidance should be provided at the same time.

Papanicolaou-Stained Cytosmear Preparations in the Evaluation of Leucocytospermia: A Tertiary Centre Experience and Assessment of Utility

Objectives Leucocytospermia is a rare cause of infertility with a variable incidence in infertile men. In many andrology laboratories, semen analysis is primarily centered on analyzing basic parameters (sperm count, motility, and viability). We examined the role of cytomorphological analysis on Papanicolaou (PAP)-stained smears in the work up of male infertility, with special reference to leukocytospermia and assessed the morphological features of sperms in these cases. Materials and Methods All cases signed out as "leukocytospermia" between November 2017 and January 2018 were evaluated. Cases showing pus cells (≥ 1/5hpf) on cytosmear evaluation were also analyzed. Parameters obtained on modified Neubauer's chamber, wet mount preparations, and autoanalyzer SQA-IIC-P (Medical Electronic Systems, Israel) were tabulated. PAP-stained smears were examined to assess morphological defects and other findings, if any. Results Out of 348 semen samples, 6 (1.72%) were diagnosed as leukocytospermia, all displaying pus cells on cytomorphological evaluation. Five cases having white blood cells < 1 × 10 ⁹ /L were analyzed, which displayed the presence of pus cells (≥ 1/5 hpf) on cytosmear preparations (1.43%). Nine cases (81.8%) showed reduced motile sperm concentration, functional sperm concentration, and sperm motility index. Morphological evaluation of the PAP-stained smears showed mid-piece defects in 18.1% cases. Conclusion Diligent cytomorphological evaluation of semen is essential to diagnose leukocytospermia, assess morphological defects, and serve as a quality control measure.

A Comparative Analysis of the Altered Levels of Human Seminal Plasma Constituents as Contributing Factors in Different Types of Male Infertility

(1) Background: The relationships between the biochemical and immunological components in seminal plasma and their physiological effects on male reproductive system have been underreported. In this study, we evaluated the potential of several seminal plasma biochemical and immunological markers in the pathophysiological developments of the infertile male patients. The study was designed to identify and assess different markers that may be associated with semen functions in different types of male infertility. (2) Methods: A total of 50 infertile male patients who underwent checkup for fertility assessment and 50 fertile controls were included in this study. The complete medical history of each recruited participant was reviewed. The infertile sub-groups (non-obstructive azoospermia (NOA), asthenozoospermia (AS), normozoospermic infertile (NI), and oligozoospermia (OZ)) were characterized based on sperm motility and concentration, while NI patients were included after a thorough check up of their female partners as well. We investigated each sample for 21 different analytes, enzymes, trace elements, and immunological markers to find crucial markers posing as contributing factors to a specific type of male infertility. (3) Results: The levels of 15 out of 21 markers, assayed from the seminal plasma of infertile males, were significantly altered in comparison to fertile controls (p < 0.05). For the first time, microprotein levels were also analyzed. The presence of monocytes, lymphocytes, and granulocytes was limited to semen from NOA patients, while a significant increase in the level of platelets was observed in AS. Hierarchical clustering and ROC-AUC analysis identified the three most significant markers (zinc, LDH, and TG) for the healthy control group and asthenozoospermic group (AUC, of 0.92 and 0.81, respectively). (4) Conclusions: The altered levels of biochemical and immunological markers in seminal plasma might be associated with the different male infertility profiles and could be required for the sperm metabolism and maintenance. However, a larger sample size and follow up analysis is required for establishing the hypothesized panel of markers as biomarkers at clinical stage.

Oxidative Stress, Testicular Inflammatory Pathways, and Male Reproduction

Inflammation is among the core causatives of male infertility. Despite male infertility being a serious global issue, "bits and pieces" of its complex etiopathology still remain missing. During inflammation, levels of proinflammatory mediators in the male reproductive tract are greater than usual. According to epidemiological research, in numerous cases of male infertility, patients suffer from acute or chronic inflammation of the genitourinary tract which typically occurs without symptoms. Inflammatory responses in the male genital system are inextricably linked to oxidative stress (OS). OS is detrimental to male fertility parameters as it causes oxidative damage to reproductive cells and intracellular components. Multifarious male infertility causative factors pave the way for impairing male reproductive functions via the common mechanisms of OS and inflammation, both of which are interlinked pathophysiological processes, and the occurrence of any one of them induces the other. Both processes may be simultaneously found in the pathogenesis of male infertility. Thus, the present article aims to explain the role of inflammation and OS in male infertility in detail, as well as to show the mechanistic pathways that link causative factors of male reproductive tract inflammation, OS induction, and oxidant-sensitive cellular cascades leading to male infertility.

Effect of COVID-19 on Male Reproductive System - A Systematic Review

Background

Angiotensin-converting enzyme II (ACE2), a receptor for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) to enter host cells, is widely expressed in testes and prostate tissues. The testis and prostate produce semen. At present, there are contradictory reports about whether SARS-CoV-2 can exist in the semen of infected men.

Objective

To provide a comprehensive overview of the topic of whether COVID-19 can impact on male reproductive system.

Methods

We reviewed the relevant publications on the possible impact of Coronavirus Disease 2019 (COVID-19) on male reproductive system and summarized the latest and most important research results so far. Literature published in English from December 2019 to January 31, 2021 regarding the existence of SARS-CoV-2 in semen, testis, and prostatic fluid and the effects of COVID-19 on male reproductive were included.

Results

We identified 28 related studies, only one of which reported the presence of SARS-CoV-2 in semen. The study found that the semen quality of patients with moderate infection was lower than that of patients with mild infection and healthy controls. The impaired semen quality may be related to fever and inflammation. Pathological analysis of the testis/epididymis showed that SARS-CoV-2 viral particles were positive in 10 testicular samples, and the spermatogenic function of the testis was impaired. All 94 expressed prostatic secretion (EPS) samples were negative for SARS-CoV-2 RNA.

Conclusion

The likelihood of SARS-CoV-2 in the semen of COVID-19 patients is very small, and semen should rarely be regarded as a carrier of SARS-CoV-2 genetic material. However, COVID-19 may cause testicular spermatogenic dysfunction via immune or inflammatory reactions. Long-term follow-up is needed for COVID-19 male patients and fetuses conceived during the father's infection period.

Pyospermia: background and controversies

Pyospermia (or leukocytospermia) is suspected based on the presence of >1 × 10⁶ round cells/mL of ejaculate and diagnosed using peroxidase stain revealing >1 × 10⁶ white blood cells/mL. The presence of white blood cells is a concern for overt infections or excessive inflammation, both of which have been postulated to negatively impact bulk semen parameters and fertilization capability. The threshold for pyospermia has been debated upon in the literature, as has the optimal treatment method. In the absence of clinical infectious symptoms, it appears that antibiotics, anti-inflammatory agents, and/or frequent ejaculation may improve bulk semen parameters in men with pyospermia. Further research is needed to adequately assess the effect of these methods on pregnancy and live birth outcomes, especially among couples attempting natural conception compared to those attempting intrauterine insemination or in vitro fertilization.

Impaired spermatogenesis in COVID-19 patients

BACKGROUND

The current study aimed to determine the impact of SARS-CoV-2 infection on male fertility.

METHODS

This is a single-center, hospital-based observational study that included autopsied testicular and epididymal specimens of deceased COVID-19 male patients (n=6) and recruited recovering COVID-19 inpatients (n=23) with an equal number of age-matched controls, respectively. We performed histopathological examinations on testicular and epididymal specimens, and also performed TUNEL assay and immunohistochemistry. Whereas, we investigated the semen specimen for sperm parameters and immune factors.

FINDINGS

Autopsied testicular and epididymal specimens of COVID-19 showed the presence of interstitial edema, congestion, red blood cell exudation in testes, and epididymides. Thinning of seminiferous tubules was observed. The number of apoptotic cells within seminiferous tubules was significantly higher in COVID-19 compared to control cases. It also showed an increased concentration of CD3+ and CD68+ in the interstitial cells of testicular tissue and the presence of IgG within seminiferous tubules. Semen from COVID-19 inpatients showed that 39.1% (n=9) of them have oligozoospermia, and 60.9% (n=14) showed a significant increase in leucocytes in semen. Decreased sperm concentration, and increased seminal levels of IL-6, TNF-α, and MCP-1 compared to control males were observed.

INTERPRETATION

Impairment of spermatogenesis was observed in COVID-19 patients, which could be partially explained as a result of an elevated immune response in testis. Additionally, autoimmune orchitis occurred in some COVID-19 patients. Further research on the reversibility of impairment and developing treatment are warranted.

FUNDING

This study was supported by Ministry of Science and Technology of China Plan, Hubei Science and Technology Plan, National Key Research and Development Program of China, HUST COVID-19 Rapid Response Call, China and National Natural Science Foundation of China; these funding bodies are public institutions, and they had no role in study conception, design, interpretation of results, and manuscript preparation.

Myeloperoxidase and lactoferrin expression in semen fluid: Novel markers of male infertility risk?

RESEARCH QUESTION

Infections and/or inflammation processes of male genital tract are highly prevalent and often associated with risk of infertility. These conditions represent a possible cause of leukocytospermia, which is still under debate. Leukocytes are key-factors to reactive oxygen species (ROS) production and the increase of ROS in semen fluid is associated with the worsening of semen parameters. At present, there are not appropriate andrological tests to identify asymptomatic inflammatory conditions when the amount of leukocytes is in the normal range.

DESIGN

We studied the innate immunity profile of myeloperoxidase and lactoferrin (MPO/LAC) proteins expressed in the semen fluid of 39 men evaluated for couple infertility, in the absence of leukocytospermia.

RESULTS

The presence of both MPO and LAC proteins was associated with a decrease of sperm concentration and of progressive/total motility, whereas the increase of MPO-/LAC + indicated a worse sperm morphology. It is worth to report the predictive potential of MPO+/LAC + pattern (above 4.36 %) as a biological marker to distinguish normozoospermic from pathological patients.

CONCLUSION

Our findings indicate MPO/LAC analysis as a potential diagnostic tool to identify asymptomatic conditions eventually related to male infertility, even when the number of leukocytes in semen fluid is below 1 million/mL.

The role of infections and leukocytes in male infertility

Declining birth rates are one of the problems facing society today. Male counterparts are responsible for about half of the infertility cases, and genitourinary tract infections may play a contributing role in approximately 15% of male infertility cases. Leukocytospermia is an established indicator of infection in the male urogenital tract, although other microorganisms such as bacteria and virus may also be contributors to the etiology of male infertility. The pathophysiology of these infectious agents may be initiated by a local inflammatory reaction resulting in an increase in reactive oxygen species (ROS). This results in testicular injury, thereby affecting sperm morphology, sperm motility, sperm viability and elevation of the seminal leukocyte as a result of the genital tract infection. The infectious and inflammatory changes can result in male infertility. It is proposed that high concentrations of seminal leukocyte and infectious agents may affect sperm function resulting in clumping of motile spermatozoa, decreasing acrosomal functionality and also causing alterations in sperm morphology. However, the literature has poorly clarified the role of infection in male infertility, provoking further debate and research on this topic.

Laboratory and clinical management of leukocytospermia and hematospermia: a review

Leukocytospermia and hematospermia are defined as the presence of abnormally high white blood cell and red blood cell concentration in the semen, respectively. Numerous etiologies and various implications on fertility have been identified. In a small proportion of men, the presence of white blood cells or red blood cells can adversely affect sperm quality by the production of reactive oxygen species. Several methods have been used to assess the presence of white blood cells and red blood cells in samples, such as identification of round cells, immunohistochemical staining using monoclonal antibodies, the Endtz test, the peroxidase test, and flow cytometry or microscopy. In addition, techniques have been identified to separate sperm samples from white blood cells and red blood cells for cryopreservation to improve outcomes in assisted reproductive technology. In this review, laboratory and clinical management of leukocytospermia and hematospermia are discussed. Currently available diagnostic methods and treatment options are outlined, and available optimal cryopreservation techniques for samples with white blood cells or red blood cells are summarized.

Seminal oxidation-reduction potential levels are not influenced by the presence of leucocytospermia

Oxidative stress (OS) is characterised by an excessive amount of reactive oxygen species (ROS) which negatively affect sperm functions. In this study, the influence of leucocytes on seminal oxidation-reduction potential (ORP) and sperm DNA fragmentation (SDF) was investigated in 1,068 men. Seminal leucocyte concentration did not correlate with SDF, unadjusted ORP, ORP normalised for sperm concentration (sORP), ORP normalised for total motile sperm concentration (motORP) or total motile sperm count (TMSC-ORP). Although receiver operator characteristic (ROC) curve analyses show that leucocytospermia does not predict high sORP values (>1.34 mV/10⁶ spermatozoa/ml), the motORP (AUC: 0.666) and TMSC-ORP (AUC: 0.683) predict the rate of leucocytospermia significantly (p = .0195 and p = .0085 respectively). Moreover, SDF can significantly predict leucocytospermia (AUC: 0.679; p = .011) and vice versa (AUC: 0.657, p = .0298). Our data confirm the association between OS and SDF. In conclusion, motORP and TMSC-ORP may be better predictive factors of leucocytospermia, probably because sperm motility, included in motORP and TMSC-ORP calculation, is the first seminal parameter to be affected by OS. Although all these parameters are indicative of OS, ORP values, SDF and leucocytospermia should be considered independently for the evaluation of redox seminal status, as they probe distinct seminal features.

Relationship between leukocytospermia, reproductive potential after assisted reproductive technology, and sperm parameters: a systematic review and meta-analysis of case-control studies

BACKGROUND

The association of leukocytospermia with male fertility is still under debate.

OBJECTIVE

To evaluate the impact of leukocytospermia (≥1 × 10⁶  white blood cells/mL of semen, according to the World Health Organization) in men attending a fertility clinic for couple subfertility, on fertility outcomes after assisted reproductive technology (ART) and on semen quality.

MATERIALS AND METHODS

A systematic review with meta-analysis of case-control studies reporting mean ± standard deviation for values of different seminal parameters (sperm concentration, progressive motility, sperm morphology, sperm DNA fragmentation, semen volume, and Ph) and fertilization rate (FR), or the odds ratio (OR) for clinical pregnancy rate (PR) per cycle after ART in leukocytospermic and non-leukocytospermic patients was performed. A literature search was carried out in MEDLINE and SCOPUS for English-language studies published till June 2018.

RESULTS

Twenty-eight case-controlled retrospective studies met the inclusion criteria, comparing fertility outcomes after ART or semen parameters in men with or without leukocytospermia. FR and PR after ART were not significantly different in the two groups. Leukocytospermic samples showed a lower sperm concentration (pooled SMD = -0.14; 95% CI: -0.28, -0.01, I²  = 71%, p_{for heterogeneity}  < 0.00001) and a lower progressive motility (pooled SMD = -0.18; 95% CI: -0.29, -0.06; I²  = 59%, p_{for heterogeneity}  < 0.0001). However, the significant differences disappeared, along with the large inter-study heterogeneity, when analyses were restricted to studies clearly reporting the inclusion of men without clinical evidence of seminal tract infection.

DISCUSSION AND CONCLUSION

Leukocytospermia in men seeking consultation for couple subfertility is not associated with a reduced fertility after ART and with altered semen quality in populations asymptomatic for genital tract infection. Therefore, the current clinical criteria for definition of leukocytospermia should be re-assessed in subfertile couples attending a fertility clinic.

In vitro antioxidation effect of Quercetin on sperm function from the infertile patients with leukocytospermia

PROBLEM

Quercetin has been shown to display intensive antioxidant activity against ROS-mediated damage in chilled semen, and the effects and molecular mechanisms of Quercetin on sperm function in the infertile patients with leukocytospermia remain largely unknown.

METHODS

Semen samples were collected from the infertile men with leukocytospermia (n = 56) and fertile men (n = 44). Computer-assisted semen analysis (CASA) was used to determine sperm motility before and after Quercetin incubation (10 μmol/L). Changes in H₂ O₂ , sperm mitochondrial DNA (mtDNA), cytochrome B (Cty B), and NADH dehydrogenase 5 (NADH5) contents were measured. Furthermore, hyperactivated motility (HA) and acrosome reaction rates were detected after the stimulation by progesterone with or without Quercetin, respectively.

RESULTS

Quercetin could significantly improve sperm motility from the leukocytospermic patients. The level of H₂ O₂ was significantly decreased in the supernatant of leukocytospermic patients after Quercetin treatment. The content of mtDNA in sperm was significantly decreased, whereas the contents of Cyt B and NADH 5 in sperm were significantly increased. Sperm hyperactivated motility and acrosome reaction induced by progesterone were enhanced by Quercetin in sperm from the infertile men with leukocytospermia.

CONCLUSION

These data indicate Quercetin could display protective effects against oxidative damage on sperm from the infertile men with leukocytospermia.

Sperm DNA Integrity in Leukocytospermia and Its Association with Seminal Adenosine Deaminase

Background:

The study aimed to examine the effect of leukocytospermia on sperm quality and the levels of seminal adenosine deaminase (ADA) enzyme in males attending an infertility clinic in a tertiary hospital and to detect the association, if any, between seminal ADA and sperm quality.

Methodology:

Consenting male subjects, between 21 and 45 years, attending the infertility clinic and qualifying the eligibility criteria were recruited following informed consent. The collected semen samples were analyzed for the routine parameters based on the WHO protocols and for sperm DNA fragmentation. The seminal leukocyte count was detected using the peroxidase method, and the seminal ADA was assessed using spectrophotometry.

Results:

Samples from 110 participants were included in the study; leukocytospermia was detected in 33% of the samples. A significant reduction in the sperm quality with respect to conventional semen parameters (sperm motility and sperm vitality) and sperm DNA fragmentation index (SDFI) was noted in the presence of leukocytospermia. Furthermore, a significant positive correlation between the levels of seminal ADA and SDFI was noted (P = 0.000, r = 0.412).

Conclusion:

The sperm motility and DNA integrity are significantly compromised in the presence of leukocytospermia when the leukocyte count is > 1 million/mL of semen as well as 0.5–1 million/mL of semen. The positive correlation noted between seminal ADA levels and increased sperm DNA damage paves way for the possibility of seminal ADA to be an indicator of silent male genital tract inflammation as well as low-quality semen.

Laboratory tests for oxidative stress

INTRODUCTION

Oxidative stress (OS) is considered a significant contributor to male infertility. A number of laboratory techniques have been developed to evaluate oxidative stress in the semen. We review these tests and their current use.

METHODS

A literature review was performed utilizing the PubMed search engine for articles studying OS etiology and impact on male fertility, and the laboratory tests used in its assessment.

RESULTS

The state of OS results from exaggerated production of oxygen-derived free radicals, also known as reactive oxygen species, to an extent overwhelming the body's antioxidant defense mechanisms. Several laboratory tests have been utilized in OS measurement during male fertility evaluation. These tests are classified into direct assays which measure the degree of oxidation within a sperm cell and indirect assays which estimate the detrimental effects of OS. The chemiluminescence assay, flow cytometry, nitroblue tetrazolium assay, and cytochrome c reduction are examples of direct assays while the myeloperoxidase test and measurements of lipid peroxidation, oxidation-reduction potential, and total antioxidant capacity are examples of the indirect assays.

CONCLUSION

OS measurement is an important tool that may help in understanding the pathophysiology of male infertility and provide valuable information that would guide treatment decisions and patient follow-up.

Treatment of Leukocytospermia in Male Infertility: A Systematic Review

Male factors account for 20% to 50% of infertility cases, and infection in the genitourinary tract may play a contributing role in up to 15% of male infertility. Leukocytospermia is a well-known indicator of infection or inflammation in the male sex glands and the urogenital tract. Although great deal of effort has been expended to elucidate definite management strategies in infertile men with leukocytospermia, the gold standard of treatment remains unclear. Until recently, broad spectrum antibiotics and antioxidants have been used in the treatment of leukocytospermia for male infertility to eliminate infection and reduce reactive oxygen free radicals produced inside cellular mitochondria as a result of inflammation. The present review reveals that antibiotics might improve sperm parameters, the rate of resolution of leukocytospermia, the bacteriologic cure rate, and even the pregnancy rate, although some reports conflict. Antioxidants might also have clinical benefits for sperm function as shown by in vitro studies. However, the data are insufficient to conclude whether antibiotics and antioxidants for the treatment of infertile men with leukocytospermia are effective or not. Better designed investigations into leukocytospermia are needed.

Hormonal treatment with transdermal testosterone in patients with male accessory gland inflammation (MAGI): Effects on sperm parameters

Recently, it has been reported that treatment with testosterone (T) could have favourable effects on prostate inflammation; however, the data appear inconsistent. The main evidences concern experimental studies, and there is lower information obtainable from clinical studies. This study was conducted on patients with diagnosis of male accessory gland infection (MAGI) and a concomitant hormonal condition of acquired hypergonadotropic hypogonadism and has evaluated the effects on sperm parameters of the administration of a transdermal formulation of T gel for 3 months. The treated patients showed a significantly increased percentage of spermatozoa with normal form and progressive motility (p < .05 vs baseline), a significant reduction of CD45pos leucocytes in the semen (p < .05 vs baseline) and finally a significant increase of the seminal concentrations of zinc, fructose and alpha-glucosidase (p < .05 vs baseline) identified as key parameters associated to secretory function of the male accessory glands. The results of this study suggest the use of transdermal T in hypogonadal patients with MAGI for favourable effects on sperm parameters.

Different levels of Cd45pos leukocytes in the semen of patients with low testicular volume

The aim of this study was to evaluate the concentrations of CD45pos leukocytes in the semen samples of infertile patients with low testicular volume (TV) compared to subjects with normal TV. The testis was considered normal in size when it had a volume between 15 and 25 cm3, low–normal with a volume between 10 and 12 cm3 and hypotrophic when the volume was <10 cm3. The patients with low testicular volume (<10 cm3) showed significantly higher concentrations of CD45pos leukocytes compared to other groups ( P <0.05). The correlation analysis showed the presence of a positive linear relationship between CD45pos leukocytes and the percentage of immature germ elements (r = 0.88; P <0.05) and between CD45pos leukocytes and the percentage of spermatozoa with phosphatidylserine externalisation (r = 0.90; P <0.05) as well as a negative linear relationship between the percentage of spermatozoa with normal morphology and the seminal CD45pos leukocyte concentrations ( r = −0.75; P <0.05). The results of this study showed that patients with low testicular volume (<10 cm3) have significantly increased CD45pos leukocyte concentrations associated with increased percentages of immature germ elements, spermatozoa with signs of early apoptosis and spermatozoa with abnormal morphology.

Another functional frame-shift polymorphism of DEFB126 (rs11467497) associated with male infertility

DEFB126 rs140685149 mutation was shown to cause sperm dysfunction and subfertility. Indel rs11467497 is another 4-nucleotide frame-shift mutation (151bp upstream of rs140685149) that leads to the premature termination of translation and the expression of peptide truncated at the carboxyl terminus. In the present study, we performed a comprehensive association study to check the contribution of rs140685149 and rs11467497 to male infertility. Our results confirmed the previous findings that there was no association between rs140685149 and sperm motility. In contrast, we found a significant association of another indel rs11467497 with male infertility. Moreover, rs11467497 was shown to be associated with higher number of round cells in the infertile males with low sperm motility. Surprisingly, the two mutations commonly existed in the sperm donors (n = 672), suggesting a potential application of the two indels in the screening for eligible sperm donors. Western blotting assays showed the sperms with rs140685149 2-nt deletion tended to have unstable DEFB126 protein in contrast of no DEFB126 protein expressed in the sperms with rs11467497 4-nt deletion, suggesting a more severe consequence caused by rs11467497 mutation. In conclusion, our study presented a significant contribution of another functional frame-shift polymorphism of DEFB126 (rs11467497) to male infertility.

Increased Lymphocyte Concentration in the Semen of Patients with Reduced Testicular Volume

Low testicular volume (TV) is associated with a decreased testicular function. Several studies explored the conventional sperm parameters and the endocrine function in patients with low TV. No other parameters have been examined. On the basis of these premises, the aim of this study was to evaluate a non-conventional seminal parameter: seminal lymphocyte characterisation in men with low TV compared with that of subjects with normal TV. A further comparison was made between fertile men and infertile patients with low or normal TV (78 patients). The testis was considered normal in size when it had a volume between 15 and 25 cm3, low-normal with a volume between 10 and 12 cm3 and hypotrophic when the volume was <10 cm3. Statistically significant differences were observed in the following sperm parameters: percentage of immature germ elements, peroxidase-positive leukocyte concentration and CD45pos leukocytes (p<0.05). A correlation analysis showed the presence of a positive linear relationship between CD45pos leukocytes and the percentage of immature germ elements (r=0.88; p<0.05) and between CD45pos leukocytes and the percentage of spermatozoa with phosphatidylserine externalisation (r=0.90; p<0.05) as well as a negative linear relationship between the percentage of spermatozoa with normal morphology and the seminal CD45pos leukocyte concentration (r=-0.75; p<0.05). The results of this study showed that patients with low testicular volume (<10 cm3) have a significantly increased CD45pos concentration that is associated with increased percentages of immature germ elements, spermatozoa with signs of early apoptosis, and spermatozoa with abnormal morphology.

Ketotifen, a mast cell blocker improves sperm motility in asthenospermic infertile men

AIM

This study aimed to evaluate the efficacy of ketotifen on sperm motility of asthenospermic infertile men.

SETTING AND DESIGN

It is a prospective study designed in vivo.

MATERIALS AND METHODS

In this interventional experimental study, a total of 40 infertile couples with asthenospermic infertility factor undergoing assisted reproductive technology (ART) cycles were enrolled. The couples were randomly assigned to one of two groups at the starting of the cycle. In control group (n = 20), the men did not receive Ketotifen, while in experiment group (n = 20), the men received oraly ketotifen (1 mg Bid) for 2 months. Semen analysis, under optimal circumferences, was obtained prior to initiation of treatment. The second semen analysis was done 2-3 weeks after stopped ketotifen treatment and sperm motility was defined. Clinical pregnancy was identified as the presence of a fetal sac by vaginal ultrasound examination.

STATISTICAL ANALYSIS USED

All data are expressed as the mean ± standard error of mean (SEM). t test was used for comparing the data of the control and treated groups.

RESULTS

The mean sperm motility increased significantly (from 16.7% to 21.4%) after ketotifen treatment (P < 0.001). This sperm motility improvement was more pronounced in the primary infertility cases (P < 0.003). The rate of pregnancy was 12.5% in infertile couples that their men receiving 1 mg/twice a day ketotifen. In 52% of infertile men's semen, the percentage of sperm motility was increased from 5% to 35% and this sperm motility improvement was also observed in 33% of necrospermia (0% motility) cases.

CONCLUSION

These results suggest that ketotifen may represent as a novel therapeutic approach to improve sperm motility in the infertile men with cause of asthenospermia or necrospermia.

Association between Pus Cells and Semen Parameters in Infertile Pakistani Males

OBJECTIVES

This study evaluated the association between pus cells and semen parameters in infertile Pakistani males.

METHODS

A cross-sectional descriptive study was carried out in the Department of Reproductive Physiology/Health, National Institute of Health, Islamabad, Pakistan, from 2004 to 2009. A total of 1,521 subjects were analysed, along with 97 proven fathers as controls.

RESULTS

The mean of pus cells was 7.43 ± 0.43, 4.35 ± 0.34, and 4.26 ± 0.17 per high field in teratozoospermic, oligoasthenozoospermic, and asthenozoospermic groups, respectively, while it was 3.25 ± 0.26, 3.10 ± 0.19, and 2.98 ± 0.04 per high field in azoospermic, oligozoospermic and the proven father groups, respectively. The fewest pus cells were observed among proven fathers, which varied non-significantly (P >0.05) with all cases, except with teratozoospermic, oligozoospermic, and oligoasthenozoospermic cases. Pus cells showed an inverse relationship to sperm motility and count, except in azoospemia cases. Similarly, the fewest pus cells were observed among groups where normal forms where significantly more frequent (P <0.05). More pus cells were observed in cases where motility, and concentration or morphology was compromised. Similarly, low pus cell counts were seen in cases where sperm had the fewest head and neck defects. All kinds of sperm defects varied non-significantly (P >0.05) between proven fathers and normal concentration cases.

CONCLUSION

High pus cell counts were observed in various subclasses of infertile patients. Ignorance of this pyospermic factor will make pyospermic patients to be misdiagnosed as normozoospermic. Therefore, the presence of pyospermia must be considered by physicians as a male infertility factor.

The influence of leukocytospermia on the outcomes of assisted reproductive technology

BACKGROUND

It is not well established whether the increased number of leukocytes in the seminal fluid impairs the outcomes of assisted reproductive technology (ART). This investigation analysed the outcomes of the intracytoplasmic sperm injection (ICSI) and intracytoplasmic morphologically selected sperm injection (IMSI) cycles in couples in which the male partner exhibited leukocytospermia.

METHODS

A total of 100 cycles in 100 couples were included in this study. For the ICSI or IMSI procedures, the patients were divided into two groups according to the presence or absence of leukocytospermia and then matched by (female) age: ICSI: Group I (n = 25): Leukocytospermia - semen samples with a leukocyte count of greater than or equal to 1 × 10(6)/mL; and Group II (n = 25): Non-leukocytospermia - semen samples with a leukocyte count < 1 × 10(6)/mL. IMSI: Group I (n = 25): Leukocytospermia; and Group II (n = 25): Non-leukocytospermia.The endpoints included the rates of fertilisation, implantation, clinical pregnancy, miscarriage, ongoing pregnancy and live birth. Student's t-tests, Mann-Whitney tests and Chi-square tests were performed, and P < 0.05 was considered significant.

RESULTS

The data from the ICSI groups showed that leukocytospermia did not have a negative influence on the rates of fertilisation (Group I: 57.9+/-30.2%, Group II: 61.9+/-27.7%; P = 0.74), implantation (Group I: 12.3%; Group II: 13.5%; P = 0.93), clinical pregnancy (Group I: 24%; Group II: 24%; P = 1.0), miscarriage (Group I: 0, Group II: 0), ongoing pregnancy (Group I: 24%; Group II: 24%; P = 1.0), or live births (Group I: 24%; Group II: 24%; P = 1.0). Similarly, the data from the IMSI groups also showed that the leukocytospermia did not have a negative influence on the rates of fertilisation (Group I: 67.6+/-24.6%, Group II: 59.5+/-28.1%; P = 0.36), implantation (Group I: 17.5%; Group II: 16.7%; P = 0.90), clinical pregnancy (Group I: 28%; Group II: 24%; P = 1.0), miscarriage (Group I: 14.3%; Group II: 0; P = 0.33), ongoing pregnancy (Group I: 24%; Group II: 24%; P = 1.0), or live births (Group I: 24%, 6/25; Group II: 24%, 6/25; P = 1.0).

CONCLUSIONS

The results indicate that the leukocytospermia may not have a negative effect on the outcomes of ICSI or IMSI cycles. Nevertheless, it seems that it is necessary to more precisely determine the effects, if any, of seminal leukocytes on fertilisation and implantation processes. Such efforts will help to establish a more reliable leukocyte threshold, which could eventually demonstrate whether there is a negative influence on the ART procedures.