“Oligozoospermia,” “azoospermia,” and other semen-analysis terminology: the need for better science

A review of testicular histopathology in nonobstructive azoospermia

One major challenge in male factor infertility is nonobstructive azoospermia (NOA), which is characterized by spermatozoa-deficient semen without physical duct blockage. This review offers a thorough overview of the histopathology of the testes in NOA cases, clarifying its complex etiology and emphasizing the possible value of histopathology inspection for both diagnosis and treatment. Variable histopathological findings have been linked to NOA, such as tubular hyalinization, Sertoli cell-only syndrome, hypospermatogenesis, and germ cell arrest. Understanding the pathophysiology and forecasting the effectiveness of treatment are further enhanced by both morphometric and ultrastructural analyses. The potential significance of testicular biopsy in forecasting reproductive outcomes is assessed, especially concerning assisted reproductive technologies like intracytoplasmic sperm injection (ICSI). Besides, testicular microlithiasis, serum hormone profiles, and testicular size are investigated concerning NOA histopathology. It is concluded that understanding the histopathological patterns in NOA is crucial for its accurate diagnosis and appropriate management. Further research is still warranted to improve understanding of the complex pathophysiology underlying NOA.

Implementing a preimplantation proteomic approach to advance assisted reproduction technologies in the framework of predictive, preventive, and personalized medicine

The evolution of the field of assisted reproduction technology (ART) in the last 40 years has significantly contributed to the management of global infertility. Despite the great numbers of live births that have been achieved through ART, there is still potential for increasing the success rates. As a result, there is a need to create optimum conditions in order to increase ART efficacy. The selection of the best sperm, oocyte, and embryo, as well as the achievement of optimal endometrial receptivity, through the contribution of new diagnostic and treatment methods, based on a personalized proteomic approach, may assist in the attainment of this goal. Proteomics represent a powerful new technological development, which seeks for protein biomarkers in human tissues. These biomarkers may aid to predict the outcome, prevent failure, and monitor in a personalized manner in vitro fertilization (IVF) cycles. In this review, we will present data from studies that have been conducted in the search for such biomarkers in order to identify proteins related to good sperm, oocyte, and embryo quality, as well as optimal endometrial receptivity, which may later lead to greater results and the desirable ART outcome.

Inflammation and Oxidative Stress in Seminal Plasma: Search for Biomarkers in Diagnostic Approach to Male Infertility

Oxidative and inflammatory damage underlie several conditions related to male infertility, including varicocele. Free light chains of immunoglobulins (FLCs) are considered markers of low-grade inflammation in numerous diseases. Coenzyme Q10 (CoQ10), a lipidic antioxidant and anti-inflammatory compound, is involved in spermatozoa energy metabolism and motility. We aimed to evaluate FLCs’ seminal levels in patients with varicocele in comparison to control subjects and to correlate them with CoQ10 and Total Antioxidant Capacity (TAC) in human semen. Sixty-five patients were enrolled. Semen analysis was performed; patients were divided into three groups: controls, 12 normozoospermic patients, aged 34 (33–41) years; varicocele (VAR), 29 patients, aged 33 (26–37) years; and idiopathic, 24 oligo-, astheno- and oligoasthenozoospermic patients aged 37 (33.5–40.5) years. FLCs (κ and λ) were assayed by turbidimetric method; CoQ10 by HPLC; TAC by spectrophotometric method. λ FLCs showed a trend toward higher levels in VAR vs. controls and the idiopathic group. VAR showed a trend toward lower κ FLCs levels vs. the other two groups. When comparing κ/λ ratio, VAR showed significantly lower levels vs. controls and idiopathic. Moreover, CoQ10 seminal levels showed higher levels in VAR and idiopathic compared to controls. Data reported here confirm lower levels of κ/λ ratio in VAR and suggest a possible application in personalized medicine as clinical biomarkers for male infertility.

Lack of association between single polymorphic variants of the mitochondrial nicotinamide adenine dinucleotide dehydrogenase 3, and 4L (MT-ND3 and MT-ND4L) and male infertility

Male infertility is a multifactorial condition associated with different genetic abnormalities in at least 15%-30% of cases. The purpose of this study was to identify suspected correlations between infertility and polymorphisms in mitochondrial NADH dehydrogenase subunits 3 and 4L (MT-ND3 and MT-ND4L) in subfertile male spermatozoa. Sanger sequencing of the mitochondrial DNA target genes was performed on 68 subfertile and 44 fertile males. Eight single nucleotide polymorphisms (SNPs) in MT-ND3 (rs2853826, rs28435660, rs193302927, rs28358278, rs41467651, rs3899188, rs28358277 and rs28673954) and seven SNPs in MT-ND4L (rs28358280, rs28358281, rs28358279, rs2853487, rs2853488, rs193302933 and rs28532881) were detected and genotyped. The genotypes and allele frequencies of the study population have shown a lack of statistically significant association between MT-ND3 and MT-ND4L SNPs and male infertility. However, no statistically significant association was found between the asthenozoospermia, oligozoospermia, teratozoospermia, asthenoteratozoospermia, oligoasthenoteratozoospermia and oligoteratozoospermia subgroups of subfertile males. However, rs28358278 genotype of the MT-ND3 gene was reported in the subfertile group but not in the fertile group, which implies a possible role of this SNP in male infertility. In conclusion, the investigated polymorphic variants in the MT-ND3 and MT-ND4L genes did not show any significant association with the occurrence of male infertility. Further studies are required to evaluate these findings. Moreover, the subfertile individuals who exhibit a polymorphism at rs28358278 require further monitoring and evaluation.

Lack of trusted diagnostic tools for undetermined male infertility

Semen analysis is the cornerstone of evaluating male infertility, but it is imperfect and insufficient to diagnose male infertility. As a result, about 20% of infertile males have undetermined infertility, a term encompassing male infertility with an unknown underlying cause. Undetermined male infertility includes two categories: (i) idiopathic male infertility-infertile males with abnormal semen analyses with an unknown cause for that abnormality and (ii) unexplained male infertility-males with "normal" semen analyses who are unable to impregnate due to unknown causes. The treatment of males with undetermined infertility is limited due to a lack of understanding the frequency of general sperm defects (e.g., number, motility, shape, viability). Furthermore, there is a lack of trusted, quantitative, and predictive diagnostic tests that look inside the sperm to quantify defects such as DNA damage, RNA abnormalities, centriole dysfunction, or reactive oxygen species to discover the underlying cause. To better treat undetermined male infertility, further research is needed on the frequency of sperm defects and reliable diagnostic tools that assess intracellular sperm components must be developed. The purpose of this review is to uniquely create a paradigm of thought regarding categories of male infertility based on intracellular and extracellular features of semen and sperm, explore the prevalence of the various categories of male factor infertility, call attention to the lack of standardization and universal application of advanced sperm testing techniques beyond semen analysis, and clarify the limitations of standard semen analysis. We also call attention to the variability in definitions and consider the benefits towards undetermined male infertility if these gaps in research are filled.

Metabolic and transcriptional changes in seminal plasma of asthenozoospermia patients

This study was designed to investigate the metabolic and transcriptional alterations in seminal fluid caused by asthenozoospermia (AS). To address these issues, a method of metabonomics based on ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and real-time quantitative PCR (RT-qPCR) was performed to identify some crucial biomarkers and transcription levels of the enzymes in seminal fluid. Seminal fluid samples were collected from 87 AS patients and 73 healthy males with normozoospermia. The quantitative analysis by UPLC-MS/MS showed that 19 metabolites in seminal plasma were associated with AS, and they were involved in several metabolic pathways, such as energy metabolism, purine metabolism, methionine cycle, and branched chain amino acid metabolism. Among these metabolites, the levels of citric acid, malic acid, succinic acid, and pyruvic acid, which are related to energy metabolism, were collectively reduced in the AS group, whereas the lactic acid level was enhanced. These results indicated that lesser energy source (adenosine triphosphate) was produced through the anaerobic glycolysis pathway rather than via aerobic catabolism of suger and tricarboxylic acid cycle, resulting in reduced power of sperms. Meanwhile, partial least squares discriminant analysis showed significant differences in metabolic profiles between the AS and control groups. In addition, RT-qPCR results revealed that the expression levels of four genes encoding fructokinase citrate synthase, succinate dehydrogenase, and spermine synthase, which were related to energy metabolism, were decreased in the AS group. The 23 descriptors with differential expression in AS may be valuable for the diagnosis and sequential study on AS. These results will help highlight the role of sperm inactivity in AS pathogenesis.

Metabolomics analysis of seminal plasma in patients with idiopathic Oligoasthenoteratozoospermia using high-resolution NMR spectroscopy

BACKGROUND

Male infertility is a global health issue caused by a combination of different factors. Specialists generally rely on semen analysis to diagnose male infertility. However, it is known that diagnostic semen analysis fails to identify about 50% of male infertility disorders. Recently, metabolomics has been proven to be a powerful technique for the diagnosis of different diseases.

OBJECTIVE

To determine whether metabolites could be used as potential biomarkers for the diagnosis of male factor infertility through comparing seminal plasma samples from infertile men with oligoasthenoteratozospermia (OAT) and samples from normozoospermic controls.

MATERIALS AND METHODS

This study utilized high-resolution ¹ H NMR spectroscopy to reveal whether the metabolomic changes of seminal plasma obtained from 31 patients with oligoasthenoteratozospermia (OAT) are different from the ones obtained from 28 normozoospermic controls.

RESULTS

Multivariate statistical analysis of NMR data concluded that the metabolomic profile of samples from patients with OAT exhibits statistically significant differences when compared to the controls. The differences were based on the metabolites lactate, citrate, lysine, arginine, valine, glutamine, creatinine, α-ketoglutaric acid, spermine, putrescine, and tyrosine. Except the tyrosine, levels of the above metabolites were significantly decreased in patients with OAT compared to the controls. The levels of citrate, choline, spermine, putrescine, α-ketoglutaric acid, valine, and tyrosine were significantly different (p < 5 × 10^-4 ) between two groups. On the other hand, levels of lactate, creatinine, lysine, arginine, and glutamine were also statistically significant (0.001 < p < 0.05). However, considering the p-values, the physiological relevance of these metabolites may be lower when compared to the others. A PLS-DA model built on the NMR data achieved 89.29% sensitivity and 93.55% specificity results in a leave-one-out cross-validation process.

DISCUSSION AND CONCLUSION

¹ H NMR spectroscopy-based metabolomic analysis could be used as a diagnostic tool for the diagnosis of oligoasthenoteratozospermia.

Antisperm protein targets in azoospermia men

BACKGROUND:

The number of couples that meet the definition of infertility at reproductive ages is increasing worldwide. One of the most known conditions of infertility in males is azoospermia, defined as complete absence of spermatozoa in the semen. Azoospermia manifests in two forms, namely obstructive and non-obstructive azoospermia. Although the presence of antisperm antibody (ASA) has been reported in 88% of the patients with obstructive azoospermia (OA), interestingly, there is no data regarding ASA targets in OA individuals.

AIM:

The present study aimed to identify sperm antibody targets in a group of OA men.

SETTINGS AND DESIGN:

The present study was carried out on 27 OA infertile men and 27 healthy fertile age-matched males as cases and controls, respectively.

SUBJECTS AND METHODS:

The sperm proteome was separated using two-dimensional gel electrophoresis technique, transferred onto the polyvinylidene fluoride membrane, and blotted with the sera of a group of OA men. Then, it was compared with the membranes blotted with the sera of a group of healthy fertile men. Matrix-assisted laser desorption/ionization time-of-flight/time-of-flight (MALDI TOF/TOF) mass spectrometry was used to identify the different blotted spots and finally the results of the mass analysis were confirmed using reverse transcriptase polymerase chain reaction method.

RESULTS:

The results indicated that OA patients might produce antibody against two sperm proteins, Tektin-2 and triose phosphate isomerase. Moreover, the expressions of the two targeted proteins were confirmed at RNA level.

CONCLUSIONS:

The findings of the present study revealed two functionally important sperm proteins as antibody targets in azoospermic men.

Imaging the Cell's Third Dimension

Shape and size are among the most basic and obvious characteristics of a cell (or of any physical object, for that matter). When a cell is observed through a microscope, one only sees its projection onto the image plane. Rather paradoxically, there are no easy techniques to visualize and measure cell's third dimension—thickness. For example, confocal microscopy requires fluorescent labeling, multiple scanning with a high-power objective, possibly correction for the refractive index mismatch, and even then, generation of a complete three-dimensional profile is not very straightforward or precise. Other techniques for imaging the cell vertical profile, such as ion conductance, digital holographic, or atomic force microscopy, are rather complex and not available to most users.

Steroid hormones for contraception in men

BACKGROUND

Male hormonal contraception has been an elusive goal. Administration of sex steroids to men can shut off sperm production through effects on the pituitary and hypothalamus. However, this approach also decreases production of testosterone, so 'add-back' therapy is needed.

OBJECTIVES

To summarize all randomized controlled trials (RCTs) of male hormonal contraception.

SEARCH METHODS

In January and February 2012, we searched the computerized databases CENTRAL, MEDLINE, POPLINE, and LILACS. We also searched for recent trials in ClinicalTrials.gov and ICTRP. Previous searches included EMBASE. We wrote to authors of identified trials to seek additional unpublished or published trials.

SELECTION CRITERIA

We included all RCTs that compared a steroid hormone with another contraceptive. We excluded non-steroidal male contraceptives, such as gossypol. We included both placebo and active-regimen control groups.

DATA COLLECTION AND ANALYSIS

The primary outcome measure was the absence of spermatozoa on semen examination, often called azoospermia. Data were insufficient to examine pregnancy rates and side effects.

MAIN RESULTS

We found 33 trials that met our inclusion criteria. The proportion of men who reportedly achieved azoospermia or had no detectable sperm varied widely. A few important differences emerged. 1) Levonorgestrel implants (160 μg daily) combined with injectable testosterone enanthate (TE) were more effective than levonorgestrel 125 µg daily combined with testosterone patches. 2) Levonorgestrel 500 μg daily improved the effectiveness of TE 100 mg injected weekly. 3) Levonorgestrel 250 μg daily improved the effectiveness of testosterone undecanoate (TU) 1000 mg injection plus TU 500 mg injected at 6 and 12 weeks. 4) Desogestrel 150 μg was less effective than desogestrel 300 μg (with testosterone pellets). 5) TU 500 mg was less likely to produce azoospermia than TU 1000 mg (with levonorgestrel implants). 6) Norethisterone enanthate 200 mg with TU 1000 mg led to more azoospermia when given every 8 weeks versus 12 weeks. 7) Four implants of 7-alpha-methyl-19-nortestosterone (MENT) were more effective than two MENT implants. We did not conduct any meta-analysis due to intervention differences.Several trials showed promising efficacy in percentages with azoospermia. Three examined desogestrel and testosterone preparations or etonogestrel and testosterone, and two examined levonorgestrel and testosterone.

AUTHORS' CONCLUSIONS

No male hormonal contraceptive is ready for clinical use. Most trials were small exploratory studies. Their power to detect important differences was limited and their results imprecise. In addition, assessment of azoospermia can vary by sensitivity of the method used. Future trials need more attention to the methodological requirements for RCTs. More trials with adequate power would also be helpful.

Impact de la varicocélectomie chez les patients ayant une azoospermie non obstructive ou une oligozoospermie sévère

But

Évaluer les résultats de la ligature haute rétropéritonéale des veines spermatiques chez les hommes infertiles ayant une azoospermie non obstructive ou une oligozoospermie sévère.

Patients et méthodes

Étude rétrospective colligeant 61 cas de varicocèle dont 46 (75,4 %) ayant une oligozoospermie sévère (groupe I) et 15 (24,6 %) ayant une azoospermie non obstructive (groupe II).

Résultats

Dans le groupe I (oligozoospermie sévère), l’âge moyen des patients était de 35,5 ± 6,4 ans (23–47 ans). La durée moyenne de l’infertilité était de 4,9 ± 3,4 ans (1–13 ans). La varicocèle était bilatérale chez 41 patients (89,1 %) et unilatérale gauche chez cinq patients (10,9 %). Cette varicocèle a été classée de grade I dans deux cas (4,3 %), de grade II dans 39 cas (84,7 %) et de grade III dans cinq cas (10,9 %). En préopératoire, la concentration moyenne des spermatozoïdes était de 1,85 ± 1,4 millions/ml. La mobilité normale à la première heure des spermatozoïdes était en moyenne de 43,3 ± 21,5 %. Les spermatozoïdes de morphologie anormale représentaient 65,05 ± 21,6 % en moyenne. Après varicocélectomie, la concentration moyenne des spermatozoïdes était de 8,3 ± 10,3 millions/ml. La mobilité normale était en moyenne de 47,6 ± 29,2 %, et les spermatozoïdes de morphologie anormale de 50,08 ± 26,9 %. Après un recul moyen de 26,2 ± 11,6 mois, 12 couples (26,1 %) avaient rapporté des grossesses spontanées. Dans le groupe II (azoospermie), l’âge moyen des patients était de 40,8 ± 7,2 ans (27–47 ans). La durée moyenne de l’infertilité était de 6 ± 3,1 ans (3–15 ans). Après varicocélectomie, une induction de la spermatogenèse avec présence de spermatozoïdes mobiles dans l’éjaculat a été observée chez trois patients (20 %). Dans ce groupe, un seul couple avait rapporté une grossesse qui s’est terminée par une fausse couche.

Conclusion

La varicocélectomie chez les hommes infertiles ayant une azoospermie non obstructive peut entraîner une apparition dans l’éjaculat de spermatozoïdes mobiles utilisables dans le cadre d’une assistance médicale à la procréation (AMP). Elle entraîne une amélioration significative de la qualité de la spermatogenèse et de la fertilité en cas d’oligozoospermie sévère. La réalisation de cette intervention chez de tels hommes est donc une option raisonnable.

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.

Steroid hormones for contraception in men

BACKGROUND

Male hormonal contraception has been an elusive goal. Administration of sex steroids to men can shut off sperm production through effects on the pituitary and hypothalamus. However, this approach also decreases production of testosterone, so 'add-back' therapy is needed.

OBJECTIVES

To summarize all randomized controlled trials of male hormonal contraception.

SEARCH STRATEGY

We searched the computerized databases CENTRAL, MEDLINE, EMBASE, POPLINE, and LILACS (each from inception to March 2006) for randomized controlled trials of hormonal contraception in men. We wrote to authors of identified trials to seek unpublished or published trials that we might have missed.

SELECTION CRITERIA

We included all randomized controlled trials in any language that compared a steroid hormone with another contraceptive. We excluded non-steroidal male contraceptives, such as gossypol. We included both placebo and active-regimen control groups. All trials identified included only healthy men with normal semen analyses.

DATA COLLECTION AND ANALYSIS

Azoospermia (absence of spermatozoa on semen examination) was the primary outcome measure. Data were insufficient to examine pregnancy rates and side effects.

MAIN RESULTS

We found 30 trials that met our inclusion criteria. The proportion of men who achieved azoospermia varied widely in reports to date. A few important differences emerged from these trials: levonorgestrel implants combined with injectable testosterone enanthate (TE) were more effective than levonorgestrel 125 microg daily combined with testosterone patches; levonorgestrel 500 mug daily improved the effectiveness of TE 100 mg injected weekly; desogestrel 150 mug was less effective than desogestrel 300 mug (with testosterone pellets); testosterone undecanoate (TU) 500 mg was less likely to produce azoospermia than TU 1000 mg (with levonorgestrel implants); norethisterone enanthate 200 mg with TU 1000 mg led to more azoospermia when given every 8 weeks versus 12 weeks; four implants of 7-alpha-methyl-19-nortestosterone (MENT) were more effective than two MENT implants. Several trials showed promising efficacy in terms of percentages with azoospermia. Three examined desogestrel and testosterone preparations or etonogestrel (metabolite of desogestrel) and testosterone, and two examined levonorgestrel and testosterone.

AUTHORS' CONCLUSIONS

No male hormonal contraceptive is ready for clinical use. Most trials were small exploratory studies. As a result, their power to detect important differences was limited and their results imprecise. In addition, the definition of oligozoospermia has been imprecise or inconsistent. To avoid bias, future trials need more attention to the methodological requirements for randomized controlled trials. More trials with adequate power would also be helpful.