Successful pregnancy by insemination of spermatozoa in a woman with a human seminal plasma allergy: should in vitro fertilization be considered first?

Seminal plasma hypersensitivity: A systematic review of clinical presentation, diagnostics, and management options

INTRODUCTION

Seminal plasma hypersensitivity (SPH) is a rare and often misdiagnosed condition characterized by local and/or systemic reactions to seminal plasma proteins following exposure to semen. We aimed to summarize key symptomatology, diagnostic features, and management options for SPH.

METHODS

The databases PubMed, EMBASE, Web of Science, Google Scholar, and Cochrane Review were searched with key words "seminal plasma hypersensitivity" and "seminal fluid allergy" through September 2023. Exclusion criteria included non-English articles, in vitro studies, publication before 1990, duplicates, and articles with no clinical relevance to SPH in women.

RESULTS

The search yielded 53 articles for review. Of these, 60.5% described systemic SPH and 39.5% described localized.

CONCLUSION

Diagnosis of SPH relies on a thorough patient history and confirmatory skin prick testing. The use of IgE assays is controversial and less accurate for cases of localized SPH. Knowledge of disease immunopathology, systemic versus localized symptom presentation, patient preference, and desire to conceive should guide management options. Artificial insemination has the potential for severe adverse reactions in systemic SPH so necessitates extra procedural precautions. SPH does not appear to impair fertility. Additional research on specific allergens implicated in SPH can aid in the development of more targeted immunotherapy approaches with improved safety and efficacy.

An Overview of Seminal Plasma Hypersensitivity and Approach to Treatment

Seminal plasma hypersensitivity (SPH) presents with localized vaginal and/or systemic allergic symptoms on exposure to protein components of seminal plasma. Although the true incidence is unclear, it is a likely underdiagnosed but an important cause of vulvovaginitis and dyspareunia that affects women across the entire globe. Systemic SPH is likely elicited by an IgE-mediated reaction to seminal plasma proteins other than spermatozoa. Localized reactions are likely mediated by a non-IgE immunologic mechanism. The diagnosis of both conditions is made clinically. Clinical presentation typically involves local vaginal discomfort and/or systemic symptoms including urticaria, angioedema, wheezing, dyspnea, gastrointestinal symptoms, or frank anaphylaxis. In roughly half of cases of localized SPH, reactions occur after first-time intercourse. Use of a condom prevents reactions, which aids confirming a diagnosis. In addition to a detailed history, skin prick and/or serologic testing may assist in making the diagnosis. Both local and systemic SPH are managed by the use of barrier contraception or intravaginal graded desensitization. Although SPH has not been shown to directly cause infertility, it may make conception challenging due to the discomfort or systemic symptoms caused by unprotected vaginal intercourse. Data indicate that women with localized reactions have variable fertility outcomes, although the majority are able to have resolution of symptoms after desensitization and have normal term pregnancies. This review provides a step-by-step approach for evaluating and treating women with localized or systemic SPH.

[Semen allergy]

A semen allergy is a type I reaction. Reliable figures about incidence/prevalence are not available. Symptoms can be characterized as local and systemic. After exposure to ejaculate, the patient may experience itching and swelling at points of contact, while systemically it may also lead to generalized urticaria with angioedema or higher grade anaphylaxis. As triggering allergens, substances in seminal plasma (SP) have been identified, which can be SP typical or SP atypical. Reactions against spermatozoa have not yet been clearly proven. With regard to SP-typical allergens, prostate-specific antigen (PSA) has been identified, while for SP-atypical allergens, medications or food allergens have been reported, which apparently accumulate in the SP and can then trigger symptoms in women with existing sensitization. The main criteria for the diagnosis of sperm allergy is freedom from symptoms when condoms are used during intercourse. In addition, skin prick tests and determination of allergen-specific IgE are used. In patients with a desire for children, washed, SP-free spermatozoa can be used for insemination. In addition, desensitization may be considered.

Testing for hypersensitivity to seminal fluid-free spermatozoa

Hypersensitivity to human semen (HHS) is an increasingly reported condition with symptoms manifested locally and systemically, which in some cases may result in anaphylaxis. This report describes four cases of HHS all with positive allergy skin prick tests to partner's whole semen. None of the patients elicited a response to seminal fluid-free washed spermatozoa. In cases of high risk of anaphylaxis, we recommend avoiding exposure to semen. By carrying out an allergy skin prick test on seminal fluid-free washed spermatozoa, the risk of immunogenic reaction to the spermatozoa could be eliminated.