Evaluation of human papilloma virus in semen as a risk factor for low sperm quality and poor in vitro fertilization outcomes: a systematic review and meta-analysis

Diagnosis and management of infertility: NICE-adapted guidelines from the Italian Society of Human Reproduction

In Italy the fertility rate is very low, and an increasing number of patients are infertile and require treatments. The Italian Law concerning the safety of patient care, and the professional liability of health professionals, indicates that health professionals must comply with the recommendations set out in the guidelines developed by public and private bodies and institutions, as well as scientific societies and technical-scientific associations of the health professions, except for specific cases. Unfortunately, no guideline for the diagnosis and the management of infertility is currently available in Italy. In 2019, the Italian Society of Human Reproduction pointed out the need to produce Italian guidelines and subsequently approved the establishment of a multidisciplinary and multiprofessional working group (MMWG) to develop such a guideline. The MMWG was representative of 5 scientific societies, one national federation of professional orders, 3 citizens' and patients' associations, 5 professions (including lawyer, biologist, doctor, midwife, and psychologist), and 3 medical specialties (including medical genetics, obstetrics and gynecology, and urology). The MMWG chose to adapt a high-quality guideline to the Italian context instead of developing one from scratch. Using the Italian version of the Appraisal of Guidelines for Research and Evaluation II scoring system, the National Institute of Clinical Excellence guidelines were selected and adapted to the Italian context. The document was improved upon by incorporating comments and suggestions where needed. This study presents the process of adaptation and discusses the pros and cons of the often-neglected choice of adapting rather than developing new guidelines.

Human Papillomavirus and Male Infertility: What Do We Know?

In recent years, increasing attention has been paid to understanding the causes of infertility, which is being recognized as a growing health problem affecting large numbers of couples worldwide. Male infertility is a contributing factor in approximately 30-40% of cases, and one of its etiological causes is sexually transmitted infections (STIs). Among sexually transmitted pathogens, human papillomavirus (HPV) can contribute in various ways to the failure of spontaneous and assisted reproduction, acting in the different phases of conception, especially in the early ones. In particular, HPV infection can affect sperm DNA integrity, sperm motility, count, viability, and morphology and can induce the production of anti-sperm antibodies (ASAs). In this narrative review, we aimed to provide an overview of existing research on the potential adverse effects of HPV infection on male reproductive health. Furthermore, we analyzed how limiting the spread of the infection, particularly with gender-neutral vaccination, could be a possible therapeutic tool to counteract male and female fertility problems.

Seminal human papillomavirus infection: a narrative review

BACKGROUND

Human papillomavirus (HPV) infection is one of the most prevalent sexually transmitted infections that can lead to malignant pathologies as well as fertility problems. The aim of this study was to evaluate the prevalence of HPV infection in males, its impact on semen parameters, and reproductive consequences. We also evaluated potential measures that could prevent negative outcomes of HPV infection in males.

METHODS

A systematic literature search using PubMed/Medline and Embase databases was performed to search for English articles published until July 2023. We explored three different aspects: (1) prevalence of HPV semen infection and its impact on seminal parameters; (2) the relationship between HPV semen infection and infertility risk and reproductive outcomes; and (3) potential measures that could prevent the negative outcomes related to HPV seminal infection. The identified studies were first screened and assessed independently by one author, and then validated by two additional authors. Data were extracted from 19 studies.

RESULTS

The prevalence of seminal HPV infection was higher among infertile males. In addition to controversies about the real interference of seminal HPV infection on sperm parameters, a growing number of studies have demonstrated a correlation between unexplained infertility and seminal HPV infection. Semen HPV infection is also associated with lower rates of pregnancy and higher rates of miscarriage. Prevention measures such as HPV vaccination seem promising.

CONCLUSION

Further studies are required to confirm not only the association between HPV infection and reproductive outcomes but also the benefit of preventive measures.

Inequities in Screening and HPV Vaccination Programs and Their Impact on Cervical Cancer Statistics in Romania

(1) Introduction: A Romanian woman is diagnosed with cervical cancer every two hours; the country ranks second in Europe in terms of the mortality and incidence rate of this disease. This paper aims to identify the main reasons that have led to this situation, focusing on the measures taken by the Romanian Ministry of Health for the prevention of this type of cancer-national programs for cervical cancer screening and HPV vaccination. (2) Materials and methods: We performed a study based on the available secondary data from the National Statistics Institute, World Health Organization and Bucharest Institute of Oncology in order to assess the burden associated with cervical cancer and place it in the context of known global and European incidence and mortality rates, thus evaluating the importance of this health issue in Romania. The second component of our study was a cross-sectional study. Here, we used a 14-question questionnaire applied to the women participating in the National Screening Program for Cervical Cancer and aimed to evaluate the women's level of knowledge about screening and HPV vaccination and their access cervical-cancer-specific healthcare services. (3) Results: The results of this research show that a high percentage of women postpone routine checks due to a lack of time and financial resources and indicate that a low level of knowledge about the disease and the specific preventive methods determines the low participation in screening and HPV vaccination programs implemented in Romania, contributing to the country's cervical cancer situation. (4) Conclusions: The national programs have complicated procedures, are underfunded and do not motivate healthcare workers enough. This, combined with the lack of information for the eligible population, adds up to an extremely low number of women screened and vaccinated. Our conclusion is that the Romanian Ministry of Health must take immediate action by conducting major awareness campaigns, implementing measures to make the programs functional and ensuring coherent funding.

Viruses, bacteria and parasites: infection of the male genital tract and fertility

BACKGROUND

Infertility affects one couple out of six worldwide. Male infertilty can result from congenital or acquired factors, of which pathogens that reach the genital tract through sexual contact or blood dissemination. The impact of major viral, bacterial and parasitic infections on the male genital tract and fertility has been summarized.

RESULTS AND CONCLUSIONS

A systematic review of articles published in the Google Scholar and PubMed databases was conducted. It turns out that viruses, as well as bacteria and parasites are major inducers of male genital tract infections and ensuing infertility through damage to the organs and subsequent loss of function and/or through direct damage to the sperm cells. Moreover, not only male infertility results from such infections but these can also be transmitted to women and even to the offspring, thus highlighting the need to efficiently detect, treat and prevent them.

Are sexually transmitted infections associated with male infertility? A systematic review and in-depth evaluation of the evidence and mechanisms of action of 11 pathogens

Purpose

To systematically review the evidence on the association between sexually transmitted infections (STIs) and male infertility. We sought to answer two questions: Are STIs significantly associated with detrimental changes in semen parameters?; and, is the prevalence of STIs significantly higher in infertile than fertile men?

Materials and methods

PubMed, Scopus and Google Scholar databases were searched (inceptionMarch 2023) following the PRISMA guidelines. Identified original studies in English on the association between STIs and male infertility were included. Data was tabulated/described by pathogen, mechanisms of action, number of studies and their level of evidence.

Results

Seventy out of 903 originally retrieved articles were included in this review. For the detrimental changes in semen parameters (first question), the evidence seems equivocal based on the nearly equal number of studies and similar levels of evidence. The only exception was for Ureaplasma, where the number of studies and levels of evidence supported an association with male infertility. Pertaining to a significantly higher prevalence of STI among infertile compared to fertile men (second question), evidence was insufficient to support/deny a significant association. The two exceptions were Ureaplasma and Mycoplasma, where the number of studies and evidence levels were in favour of an association with male infertility.

Conclusions

Generally, the relationship between STIs and male infertility remains to be uncovered. Our appraisal of the overall state of this relationship shows that the evidence base leaves much to be desired. The exceptions are Ureaplasma and Mycoplasma, where the evidence convincingly suggests their associations with infertility in men.

Risk of decreased ovarian reserve in women with HPV infection and cervical lesions

Background

Human papillomavirus (HPV) infection has been considered an important involved factor for infertility. Since one of the causes of decreased ovarian reserve is oophoritis due to viral infections, this study aimed to evaluated the association between HPV infection and ovarian reserve.

Methods

This case-control study was performed on 219 women aged 25-35 years who were referred to the gynecologic oncology clinic during 2019-2020. The positive or negative HPV infection was confirmed by cervical biopsy and polymerase chain reaction (PCR) test. Cervical lesions or abnormalities in the cervix were assessed by colposcopy and histopathological analysis. Serum anti-Mullerian hormone (AMH) levels were measured for all participants to assess ovarian reserve.

Results

The results of this study showed that in patients who were HPV positive, decreased ovarian reserve was more common than in the HPV negative group (p = 0.0001). Also, there was a significant difference between Cervical intraepithelial neoplasia (CIN) I and CIN III sub-groups in AMH level (p = 0.0001).

Conclusions

Traces of HPV have been observed in various aspects of infertility, but no study has been performed on its association with ovarian reserve. According to the results of this study, decreased ovarian reserve was more common in patients who were HPV positive.

The impact of cryopreservation on both sperm HPV-negative and positive subtypes

It is well known that various human papillomavirus (HPV) genotypes are present in semen specimens. Also, it has been demonstrated that sperm parameters are negatively affected when HPV infection is present in the sperm sample. Besides all these, the effect of cryopreservation on HPV sensitivity and resistance is not known. The aim of the present study is to evaluate first the prevalence of HPV and secondly to elucidate whether cryopreservation of sperm HPV-positive samples has any effect on the viability of HPV. For this purpose, a cohort of 78 sperm specimens was used from a respective number of patients. After giving informed consent, semen analysis was performed. Each sperm sample was divided into four equal aliquots. The first one (fresh) was evaluated for the prevalence of HPV, while the other three aliquots were cryopreserved by adding an equal quantity of cryoprotectant and plunged into the LN. Each of the three aliquots was thawed 3, 6, and 12 months later, respectively, so as to evaluate whether there is a time-resistance period of HPV prevalence. HPV infection was found to be in eleven sperm samples, demonstrating a 14.1% (11/78) HPV prevalence. Among the HPV-positive samples, six of them were high-risk and the remaining were low-risk genotypes. Moreover, the high-risk fresh samples demonstrated higher motility values than the low-risk samples (60% ± 2.7 vs 45.6% ± 3.7, p < .05), while semen volume in the high-risk samples was significantly lower than the respective volume in the low-risk samples (2.26 ± 0.2ml vs 3.5 ± 0.6ml, p < .05). Interestingly, cryopreservation of the HPV-positive samples resulted in the sustainability and time-resistance of HPV in all high-risk HPV-positive samples, something that was not the case with the low-risk HPV-positive samples. Conclusively, sperm samples infected with high-risk HPV, demonstrate lower sperm parameters and time-resistance activity during cryopreservation.

Evaluation and management of male genital tract infections in the setting of male infertility: an updated review

PURPOSE OF REVIEW

Male infertility may be secondary to male genital tract infection (MGTI) in an estimated 15% of cases. In the absence of overt clinical signs, evaluation for MGTI beyond semen analysis is not well established. Therefore, we review the literature on the evaluation and management of MGTI in the setting of male infertility.

RECENT FINDINGS

A set of international guidelines recommends semen culture and PCR testing, but the significance of positive results remains unclear. Clinical trials evaluating anti-inflammatory or antibiotic treatment report improvements in sperm parameters and leukocytospermia, but data on the effect on conception rates are lacking. Human papillomavirus (HPV) and the novel coronavirus (SARS-CoV-2) have been associated with poor semen parameters and decreased conception rates.

SUMMARY

The finding of leukocytospermia on semen analysis prompts further evaluation for MGTI, including focused physical examination. The role of routine semen culture is controversial. Treatment options include anti-inflammatories; frequent ejaculation; and antibiotics, which should not be used in the absence of symptoms or microbiological infection. SARS-CoV-2 represents a subacute threat to fertility that should be screened for in the reproductive history along with HPV and other viruses.

Semen human papillomavirus (HPV) shedding in males: frequency, clinical significance, and reproductive outcomes—literature review

Background

The interest in the HPV status of the male has risen after the discovery of HPV shedding in the semen. To date, there is no consensus on the true prevalence of male HPV infection, yet there is a rising body of evidence suggesting that male HPV infection might negatively affect the sperm parameters.

Main body

The concern that HPV can lead to a couple’s infertility and affect reproductive outcomes had increased after the multiple publications of semen criteria perturbations specifically the asthenospermia associated with HPV infection. An extensive literature review was performed to define the actual frequency of male HPV infection as well as the true extent of sperm analysis perturbations related to the HPV illness. We also intended to define the impact of these infections on reproductive outcomes and to highlight any treatment plans for affected couples.

Conclusion

HPV is a prevalent disease with a rising concern among the male populations given the suggested impact on sperm motility as well as the pregnancy and miscarriage rates post-ART treatment. Vaccines are being studied now as a possible infertility adjunct treatment for males who are already infected.

Exploring the potential impact of human papillomavirus on infertility and assisted reproductive technology outcomes

Human papillomavirus (HPV) is a common sexually transmitted disease that has been linked to both cancer and reproductive health issues. While its impact on fertility and pregnancy success has been studied, there is still too little evidence about the influence of HPV on assisted reproductive technology (ART). Therefore, there exists a need for HPV testing in couples undergoing infertility treatments. Infertile men have been found to have a higher prevalence of seminal HPV infection, which can compromise sperm quality and reproductive function. As such, it could be important to investigate the correlation between HPV and ART outcomes in order to improve the quality of evidence. Understanding the potentially detrimental effects of HPV on ART outcomes may have promising important implications for the management of infertility. This minireview summarizes the so far limited developments in this area and highlights the major need for further well-designed studies to address this issue.

Sperm human papillomavirus infection and risk of idiopathic recurrent pregnancy loss: insights from a multicenter case-control study

OBJECTIVE

To test the hypothesis claiming an association between human papilloma virus (HPV) sperm infection and idiopathic recurrent pregnancy loss (RPL).

DESIGN

Multicenter retrospective case-control study.

SETTING

Three university hospitals.

PATIENT(S)

Cases included men belonging to couples affected by first trimester idiopathic RPL. Controls included men belonging to couples with proven fertility and no history of pregnancy loss; RPL was defined as the previous loss of 2 or more pregnancies. Couples were defined as "fertile" if they achieved a full-term pregnancy within the year before enrollment in the study. All participants conceived without assistance.

MAIN OUTCOME MEASURE(S)

The association between HPV DNA sperm infection, as identified using polymerase chain reaction, and RPL.

RESULTS

The HPV DNA sperm infection was detected in 23 of 117 cases (20%; 95% confidence interval [CI]: 13%, 28%) and in 3 of 84 controls (4%; 95% CI; 1%, 10%) (P<.001). A comparison across baseline characteristics and multiple regression analysis did not identify any potentially confounding factors. Multivariate regression models showed a significant association between HPV DNA sperm infection and RPL (adjusted odds ratio, 7.44; 95% CI: 2.08, 26.58; P=.002 [Model 1]; adjusted odds ratio, 8.96; 95% CI: 2.41, 33.44; P=.001 [Model 2]).

CONCLUSIONS

The prevalence of HPV sperm infection was significantly higher in couples affected by RPL than in their fertile counterparts. Notably, the semen sample was infected by HPV in approximately 1 out of 5 patients.

Review of the evidence of the effects of human papillomavirus infection and Gardnerella vaginalis, and their co-infection on infertility

A prevalent sexually transmitted infection, the human papillomavirus (HPV) is typically obtained just after the first sexual activity. The majority of HPV infections are asymptomatic and temporary. Cervical, anal, penile, vaginal, vulvar, and oropharyngeal cancers can occur due to recurrent infections with high-risk (hr)-HPV strains, generally decades later. Infections with HPV are significantly associated with reproductive function abnormalities. Per recent research, HPV infections may result in male infertility by reducing sperm motility. The hr-HPV infection was a risk factor for miscarriage, and the indiscriminate HPV genotype increased the probability of premature labor unexpectedly. Women's endometrial trophoblastic cell implantation is decreased by HPV. Gardnerella vaginalis (GV), an anaerobic bacterium that is a component of the natural vaginal flora, can be associated with bacterial vaginosis (BV) when it starts to overgrow and emerge as the dominant species. Reduced Lactobacillus species abundance and GV are linked to female infertility. Data from in vitro studies suggests that sialidase produced by GV may facilitate the entry and growth of papilloma and other sexually transmitted viruses. Also, based on some studies conducted in the past, it can be said that GV and BV are associated with the development of uterine cancer. However, there is still not enough information about the exact mechanism of GV and HPV in causing infertility, which requires more research.

Impact of seminal low-risk human papillomavirus infection on sperm parameters of adult men

Aim: We aimed to evaluate the impact of seminal low-risk human Papillomavirus (LR-HPV) infection on sperm conventional parameters.Material and methods: This was a retrospective case-control study including patients attending to our center for infertility. Patients with evidence for high risk (HR)-HPV infection previously or at the time of enrollment, and/or with severe oligozoospermia (sperm concentration <5 mil/ml) were ruled out. Twenty selected patients positive for a LR-HPV and 20 control subjects with no evidence of HPV DNA and with available results of sperm analysis were consecutively enrolled.Results: Patients positive for LR-HPV had a mean age of 31.0 + 11.0 years, while controls were 35.0 + 8.0-year-old (p > .05). Sperm concentration, total sperm count, sperm progressive motility, morphology, and leukocyte concentration did not differ between patients and controls. However, the prevalence of oligozoospermia was significantly higher in patients than controls (50% vs. 15%). No difference in the prevalence of astenozoospermia (30% vs. 40%) or teratozoospermia (15% vs. 15%) was found.Conclusion: We found no difference in sperm conventional parameters in LR-HPV infected patients than in controls. These data might prompt to research the impact on LR-HPV genotype on male fertility. Particularly, evidence on sperm DNA fragmentation (SDF) and pregnancy outcome is needed.

Human Papillomavirus (HPV) Infection and Its Impact on Male Infertility

Nowadays, the striking numbers of infertile couples that turn to assisted reproductive technologies (ART) drive the research toward a more comprehensive understanding of the underlying causes. Male factors contribute to the inability to conceive in half of the cases, and it has been suggested that sexually transmitted infections could have a role in the onset of spermatozoa impairments. Since the impact of HPV infection on sperm quality and sperm DNA integrity is debated, we wanted to analyze its impact on conventional seminal parameters and the sperm DNA fragmentation index (DFI). Therefore, 117 semen samples of patients undergoing IVF were evaluated for the following characteristics: HPV DNA detection and sperm DNA fragmentation, concentration, motility, and morphology. The results showed a higher rate of HPV-negative patients (59.8% vs. 40.2%) and no HPV-related effect on DFI, sperm concentration, total sperm number, and total motility. Only progressive motility and morphology were found as significantly influenced by HPV positivity. Moreover, we observed a statistically significant difference in DFI when comparing high-risk HPV (HR-HPV) and low-risk HPV (LR-HPV) genotypes. Our data suggest that the presence of any HPV type, whatever the exact localization of the virions, can impair some sperm parameters, while HR-HPVs specifically affect the integrity of spermatozoa DNA.

Management of male factor infertility: position statement from the Italian Society of Andrology and Sexual Medicine (SIAMS) : Endorsing Organization: Italian Society of Embryology, Reproduction, and Research (SIERR)

PURPOSE

Infertility affects 15-20% of couples and male factors are present in about half of the cases. For many aspects related to the diagnostic and therapeutic approach of male factor infertility, there is no general consensus, and the clinical approach is not uniform.

METHODS

In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), endorsed by the Italian Society of Embryology, Reproduction, and Research (SIERR), we propose evidence-based recommendations for the diagnosis, treatment, and management of male factor infertility to improve patient and couple care.

RESULTS

Components of the initial evaluation should include at minimum medical history, physical examination, and semen analysis. Semen microbiological examination, endocrine assessment, and imaging are suggested in most men and recommended when specific risk factors for infertility exist or first-step analyses showed abnormalities. Full examination including genetic tests, testicular cytology/histology, or additional tests on sperm is clinically oriented and based on the results of previous investigations. For treatment purposes, the identification of the specific cause and the pathogenetic mechanism is advisable. At least, distinguishing pre-testicular, testicular, and post-testicular forms is essential. Treatment should be couple-oriented, including lifestyle modifications, etiologic therapies, empirical treatments, and ART on the basis of best evidence and with a gradual approach.

CONCLUSION

These Guidelines are based on two principal aspects: they are couple-oriented and place high value in assessing, preventing, and treating risk factors for infertility. These Guidelines also highlighted that male infertility and in particular testicular function might be a mirror of general health of a man.

Human papillomavirus detected in sperm of Japanese infertile males affects reproductive parameters

OBJECTIVES

The effects of human papillomavirus (HPV) infection on male reproductive parameters are currently a matter of controversy. In order to clarify the issue in Japanese infertile men, the prevalence and localization of HPV in semen, sperm parameters, and superoxide dismutase (SOD) activity in seminal plasma were examined in 216 Japanese infertile men.

METHODS

DNA was extracted from liquid-based cytological semen samples. The β-globin gene was amplified by polymerase chain reaction (PCR), and HPV-DNA was amplified using nested PCR with MY09/MY11 as outer primers and GP5+/GP6+ as inner primers. HPV genotyping was performed in the HPV-positive samples. In addition, SOD levels in seminal plasma were analysed quantitatively. In-situ hybridization (ISH) was performed to localize HPV-DNA in sperm from HPV-positive samples.

RESULTS

Any-risk and high-risk prevalence rates of HPV in semen were 12.5% and 6.9%, respectively. No significant difference in the prevalence of HPV was observed between azoospermic and non-azoospermic subjects. Among non-azoospermic patients, those with HPV detected in semen had significantly lower sperm motility and concentration compared with subjects without HPV detected in semen. SOD levels in seminal plasma were significantly higher in HPV-positive patients compared with HPV-negative patients. ISH analysis of HPV-positive samples revealed that HPV-DNA was localized to the head and mid-piece of sperm. HPV-DNA was present in the sperm of young infertile men.

CONCLUSION

HPV infection of sperm was associated with reduced sperm motility and concentration, and resulted in an increase in seminal SOD activity.

European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility

CONTEXT

The European Association of Urology (EAU) has updated its guidelines on sexual and reproductive health for 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health, including advances and areas of controversy in male infertility.

EVIDENCE ACQUISITION

The panel performed a comprehensive literature review of novel data up to January 2021. The guidelines were updated and a strength rating for each recommendation was included that was based either on a systematic review of the literature or consensus opinion from the expert panel, where applicable.

EVIDENCE SYNTHESIS

The male partner in infertile couples should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors causing fertility impairment. Infertile men are at a higher risk of harbouring and developing other diseases including malignancy and cardiovascular disease and should be screened for potential modifiable risk factors, such as hypogonadism. Sperm DNA fragmentation testing has emerged as a novel biomarker that can identify infertile men and provide information on the outcomes from assisted reproductive techniques. The role of hormone stimulation therapy in hypergonadotropic hypogonadal or eugonadal patients is controversial and is not recommended outside of clinical trials. Furthermore, there is insufficient evidence to support the widespread use of other empirical treatments and surgical interventions in clinical practice (such as antioxidants and surgical sperm retrieval in men without azoospermia). There is low-quality evidence to support the routine use of testicular fine-needle mapping as an alternative diagnostic and predictive tool before testicular sperm extraction (TESE) in men with nonobstructive azoospermia (NOA), and either conventional or microdissection TESE remains the surgical modality of choice for men with NOA.

CONCLUSIONS

All infertile men should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors. Increasing data indicate that infertile men are at higher risk of cardiovascular mortality and of developing cancers and should be screened and counselled accordingly. There is low-quality evidence supporting the use of empirical treatments and interventions currently used in clinical practice; the efficacy of these therapies needs to be validated in large-scale randomised controlled trials.

PATIENT SUMMARY

Approximately 50% of infertility will be due to problems with the male partner. Therefore, all infertile men should be assessed by a specialist with the expertise to not only help optimise their fertility but also because they are at higher risk of developing cardiovascular disease and cancer long term and therefore require appropriate counselling and management. There are many treatments and interventions for male infertility that have not been validated in high-quality studies and caution should be applied to their use in routine clinical practice.

Association between human papillomavirus infection and sperm quality: A systematic review and a meta-analysis

Human papillomavirus (HPV) has a high incidence rate in both males and females. HPV infection in women has been shown to affect fertility and lead to foetal death and pregnancy loss. However, research on HPV infection in men is limited. The aim of this study was to study the effect of HPV infection in semen on sperm quality and present the findings of previous studies through a meta-analysis. Databases including PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library, WanFang data and China National Knowledge Infrastructure were searched for relevant studies. A systematic review and meta-analysis were performed, and 17 studies were included for analyses based on a set criterion. Meta-analyses indicated that HPV infection in semen significantly reduced sperm concentration (SMD = -0.12, 95% CI: -0.21 to -0.03, p = .009), sperm motility (SMD = -0.55, 95% CI: -0.780 to -0.33, p = .000), sperm viability (SMD = -0.55, 95% CI: -0.780 to -0.33, p = .000) and sperm morphology (SMD = -0.34, 95% CI: -0.61 to -0.07, p = .015). The high-risk HPV (HrHPV) infection could significantly reduce sperm count (SMD = -0.65, 95% CI: -1.11 to -0.18, p = .007) compared with high-risk HPV (LrHPV) infection. In conclusion, HPV infection in semen significantly reduced sperm quality, and the HrHPV infection could significantly reduce sperm count compared with LrHPV.

Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple

Capsule

This expert opinion summarizes current knowledge on risk factors for infertility and identifies a practical clinical and diagnostic approach for the male and female partners of an infertile couple aimed to improve the investigation and management of fertility problems.

Background

Infertility represents an important and growing health problem affecting up to 16% of couples worldwide. In most cases, male, female, or combined factor can be identified, and different causes or risk factors have been related to this condition. However, there are no standardized guidelines on the clinical-diagnostic approach of infertile couples and the recommendations concerning infertility are sometimes lacking, incomplete, or problematic to apply.

Objective

The aim of this work is to provide an appropriate clinical and diagnostic pathway for infertile couples designed by a multidisciplinary-team of experts. The rationale is based on the history and physical examination and then oriented on the basis of initial investigations. This approach could be applied in order to reduce variation in practice and to improve the investigation and management of fertility problems.

Methods

Prominent Italian experts of the main specialties committed in the ART procedures, including gynecologists, andrologists, embryologists, biologists, geneticists, oncologists, and microbiologists, called "InfertilItaly group", used available evidence to develop this expert position.

Outcomes

Starting from the individuation of the principal risk factors that may influence the fertility of females and males and both genders, the work group identified most appropriate procedures using a gradual approach to both partners aimed to obtain a precise diagnosis and the most effective therapeutic option, reducing invasive and occasionally redundant procedures.

Conclusions

This expert position provides current knowledge on risk factors and suggests a diagnostic workflow of infertile couples. By using this step-by-step approach, health care workers involved in ART, may individuate a practical clinical management of infertile couples shared by experts.

Hyaluronidase-based swim-up for semen selection in patients with human papillomavirus semen infection

Infection by human papillomavirus (HPV) represents one of the most common sexually transmitted diseases in both men and women worldwide. Recently, the detection of HPV virions in the semen of a large percentage of sexually active men has been associated with detrimental effects on both sperm parameters and on assisted reproductive technologies (ART) treatment outcomes. Conventional semen washing procedure used in ART have proved to be ineffective in removing HPV bound to sperm, requiring the identification of more effective and specific methods. In the present study, we assessed the possible use of hyaluronidase for the detachment of HPV from sperm cell surface. Semen samples from five normozoospermic control subjects (CTRL) were incubated with HPV virus-like particles (HPV-VLP) and treated with hyaluronidase by both a modified swim-up procedure (M-SU) and single-cell approach (SCA). The treatment with hyaluronidase was associated with the complete loss of HPV-VLP signal on sperms by both M-SU and SCA. In addition, semen samples from 12 HPV-positive infertile patients were treated with hyaluronidase 80 IU/mL by M-SU, resulting in the complete loss of HPV-DNA signal from sperm surface. Finally, the possible impact of hyaluronidase treatment on sperm parameters was assessed on both sperms from the five CTRL subjects and on further five oligo-astheno-terato-zoospermic (OAT) patients, both HPV negative. The treatment with hyaluronidase was equally associated with a slight reduction of sperm viability and progressive motility in both CTRL and OAT. In conclusion, the treatment with hyaluronidase removed efficiently and safely HPV virions bound to spermatozoa.

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.