Effects of valproate on reproductive endocrine function in male patients with epilepsy: A systematic review and meta-analysis

New valproate regulations, informed choice and seizure risk

Valproate is the most effective medication for generalised epilepsies, and several specific epilepsy syndromes. For some people, it will be the only medication to establish seizure remission, and withdrawing it carries risks of seizure recurrence and Sudden Unexpected Death in Epilepsy (SUDEP). It is also of proven efficacy for bipolar disorder and migraine prevention. Guidelines based on observational and epidemiological studies stress that maternal valproate related teratogenicity and neurodevelopmental effects are significantly higher than for other antiseizure medications (ASMs). It should, therefore, only be used if other medications are ineffective and after balancing the teratogenicity risk. Regulatory restrictions have changed prescribing practices and reduced valproate use. The number of other medications that must be trialled in the different conditions for which valproate has effectiveness and the consequences of the lack of efficacy of those drugs leading to significant harm including death remains unexplored. Risk minimisation measures (RMMs) for valproate, chiefly Pregnancy Prevention practices (PPP), consider foetal risk and not risk to people living with epilepsy. In the United Kingdom (UK), limitations relating to valproate use in all people < 55 years commenced in January 2024. While the evidence in child-bearing women is not disputed, the data in males are based on animal models, case reports, and one commissioned, unpublished, non-peer reviewed report unavailable to the UK public, stakeholder charities or professionals. Evidence suggests that 30-40% of people switching from valproate have breakthrough seizures. Thus, an estimated 21,000-28000 people in the UK will imminently be exposed to the potential hazards of breakthrough seizures, including death. There is little government investment in monitoring the effects of these changes to valproate prescribing on patient health and quality of life. This review summarises the history of valproate regulation, evidence underpinning it and argues how the latest regulations in the UK do not align with the country's medical regulatory bodies ethical principles nor with the Montgomery principles of informed patient choice and autonomy. It dissects how such regulations infringe Common Law principles, nor give due regard for patient outcomes beyond reproduction. The paper looks to provide recommendations to redress these concerns while appreciating the core need for such governance to emerge in the first place.

Antiepileptic drugs are endocrine disruptors for the human fetal testis ex vivo

Valproic acid (VPA) has long been the most widely used antiepileptic drug (AED) for the treatment of epilepsy, bipolar psychiatric disorders, and migraine. However, long-term VPA treatment has several adverse effects on the male reproductive system notably on endocrine functions and/or spermatic parameters. In utero exposure of the fetus to VPA is well known to be associated with a higher risk of several congenital malformations including those of male reproductive organs. Subsequent generations of AEDs, such as carbamazepine (CARB) and lamotrigine (LAM), are considered safer and are currently recommended for women of child-bearing age with epilepsy. Because anomalies of the male genital tract mostly result from endocrine imbalance during fetal life, we hypothesized that AEDs could directly impair testis differentiation. We thus aimed at identifying and characterizing the effects of VPA, CARB, and LAM on the differentiation and function of the different testicular cell types, and at understanding the mechanisms underlying these effects. By using ex vivo culture of first-trimester human fetal testes, we show that VPA induces multiple endocrine disruptive effects, compared with the milder ones caused by CARB and LAM. AED also subtly altered the germ cell lineage in distinct manners. Transcriptomic analysis of VPA-induced alterations highlighted a very broad range of effects on the fetal testis. Overall, our results show that AEDs can behave as endocrine disruptors for the human fetal testis ex vivo. This is consistent with, and likely underlies, the VPA-induced male genital tract masculinization abnormalities observed in patients.

SARS-CoV-2 Infection, Sex-Related Differences, and a Possible Personalized Treatment Approach with Valproic Acid: A Review

Sex differences identified in the COVID-19 pandemic are necessary to study. It is essential to investigate the efficacy of the drugs in clinical trials for the treatment of COVID-19, and to analyse the sex-related beneficial and adverse effects. The histone deacetylase inhibitor valproic acid (VPA) is a potential drug that could be adapted to prevent the progression and complications of SARS-CoV-2 infection. VPA has a history of research in the treatment of various viral infections. This article reviews the preclinical data, showing that the pharmacological impact of VPA may apply to COVID-19 pathogenetic mechanisms. VPA inhibits SARS-CoV-2 virus entry, suppresses the pro-inflammatory immune cell and cytokine response to infection, and reduces inflammatory tissue and organ damage by mechanisms that may appear to be sex-related. The antithrombotic, antiplatelet, anti-inflammatory, immunomodulatory, glucose- and testosterone-lowering in blood serum effects of VPA suggest that the drug could be promising for therapy of COVID-19. Sex-related differences in the efficacy of VPA treatment may be significant in developing a personalised treatment strategy for COVID-19.

Crosstalk between epigenetics and mTOR as a gateway to new insights in pathophysiology and treatment of Alzheimer's disease

Epigenetics in the current times has become a gateway to acquire answers to questions that were left unanswered by classical and modern genetics, be it resolving the complex mystery behind neurodegenerative disorders or understanding the complexity behind life-threatening cancers. It has presented to the world an entirely new dimension and has added a dynamic angle to an otherwise static field of genetics. Alzheimer's disease is one of the most prevalent neurodegenerative disorders is largely found to be a result of alterations in epigenetic pathways. These changes majorly comprise an imbalance in DNA methylation levels and altered acetylation and methylation of histones. They are often seen to cross-link with metabolic regulatory pathways such as that of mTOR, contributing significantly to the pathophysiology of AD. This review focusses on the study of the interplay of the mTOR regulatory pathway with that of epigenetic machinery that may elevate the rate of early diagnosis and prove to be a gateway to the development of an efficient and novel therapeutic strategy for the treatment of Alzheimer's disease at an early stage.

A Comparative Study of the Effects of Valproate and Oxcarbazepine on Sexual Function, Sperm Quality, and Sex Hormones in Males with Epilepsy

Aims

Although several studies have indicated that valproate (VPA) and oxcarbazepine (OXC) cause reproductive endocrine disorders and sexual dysfunction, there remains some controversy regarding these issues in males with epilepsy. This study is aimed at evaluating the effects of VPA and OXC on sexual function, sperm quality, and sex hormones in young males with epilepsy.

Methods

Males with newly diagnosed epilepsy treated with VPA and OXC were recruited, and sexual function questionnaires (International Index of Erectile Function-5 (IIEF-5)), sperm quality, and sex hormone levels were assessed before treatment and at 6 months after treatment with VPA or OXC monotherapy.

Results

Forty-four young males with epilepsy (23 treated with VPA, 21 treated with OXC) and 30 age-matched healthy individuals were recruited for our study. The sexual function, sperm quality, marriage rate, and fertility rate of these young males with epilepsy were lower than those of healthy controls. Sperm quality were significantly reduced in young male patients after 6 months of VPA administration. The level of follicle stimulating hormone (FSH) was increased in patients after OXC treatment. Meanwhile, sexual function and sperm quality were not affected.

Conclusion

Sexual function and sperm quality were reduced in young males with epilepsy. VPA may exert a negative effect on sperm quality, whereas OXC has no harmful effect on sexual function and sperm quality in young males with epilepsy.

Sexual dysfunction in clinically stable patients with bipolar disorder receiving valproate

AIM

This study evaluated the prevalence of sexual dysfunction in patients with bipolar disorder, while receiving valproate monotherapy.

MATERIALS AND METHODS

Sixty-three clinically stable patients with bipolar disorder were evaluated on the Arizona sexual experience scale (ASEX), Udvalg for Kliniske Undersogelser (UKU) other side effect subscale and brief adherence rating scale.

RESULTS

The mean age of the study sample was 38.84 (standard deviation: 12.49) years. About three-fourth of the participants were male (76.2%). About one-fourth (28.6%) were found to have sexual dysfunction as per the ASEX. In terms of dysfunction in specific domain of sexual functioning, depending on the cut-off used, problem with sexual desire varied from 13.33% to 35.41% among males and 6.66%-46.66% in females. Erectile dysfunction was seen in 13.33%-31.25% of males and difficulty in vaginal lubrication was reported by 13.33%-26.66% of females. When those with and without sexual dysfunction as per the ASEX were compared, it was seen that those with sexual dysfunction had significantly longer duration of illness, higher prevalence of abnormal blood pressure and higher mean scores on the UKU other side effect subscale. Both the groups did not differ on other clinical variables.

CONCLUSION

A significant proportion of patients receiving valproate experience sexual dysfunction. Higher prevalence of sexual dysfunction was associated with longer duration of illness, higher prevalence of abnormal blood pressure, and higher mean scores on UKU other side effect subscale.

Reproductive and Sexual Health Concerns in Transition-Age Adolescents and Young Adults With Epilepsy

A plethora of hormonal and physical changes occur as adolescents grow into adulthood. These changes pose additional challenges for youth with epilepsy. Providers, parents, and patients must be well educated about the hormonal influences, both intrinsic and pharmaceutical, on seizures and antiepileptics (AEDs). In addition, they must be made aware of safe/effective contraception, the importance of pregnancy planning, and potential menstrual and sexual health disturbances related to epilepsy and AEDS. Reproductive and sexual health should be an integral component of transition education and planning for all youth, but is especially important for the youth with epilepsy. While many clinicians will collaborate with adolescent gynecologists or pediatricians, it is important for all child neurologists to be aware of these issues.

An open study of valproate in subfertile men with epilepsy

OBJECTIVES

The aim of the study was to assess whether, male patients with epilepsy, switching from valproic acid (VPA) to levetiracetam (LEV) or lamotrigine (LMG) critically improves sperm counts and parameters, increasing chance of patients' female partners to spontaneously conceive.

MATERIALS AND METHODS

This is an observational prospective study recruiting all consecutive infertile male patients with epilepsy followed up at the outpatient Epilepsy Clinic of University Hospital of Ioannina, Northwest Greece. Infertile couples were referred to the Laboratory of Assisted Reproduction and Treatment of the University Hospital of Ioannina to conduct semen analysis. The first sample was collected while the patients were receiving VPA, and the second semen sample was collected after the patients were switched to LEV or LMG.

RESULTS

Seventeen infertile male patients were recruited in the study. Nine patients were switched to LEV, and eight patients were switched to LMG. The mean sperm count increased after VPA withdraw P = .06. Motility was improved with an increase of total motility and non-progressive motility (P = .02 and P = .03, accordingly), whether sperm defects were decreased, mainly head defects (P = .03). Differences between patients switched to LEV or LMG were minimal and showed no significant findings. Spontaneous pregnancies were reported in three of the patients' partners, without any other clinical intervention offered to the couple.

CONCLUSION

Switching from valproic acid to levetiracetam or lamotrigine improved sperm counts and other sperm parameters in subfertile male patients and increased the chance of spontaneously conceiving in subfertile couples.

Valproate, sexual health, and men: A narrative review

OBJECTIVE

This article explores current evidence about the effects of valproate (VPA) medicines on sexual health in men, how to monitor symptoms, communicate with patients, and improve clinical outcomes. There has been a lot of focus on VPA use in women of childbearing age following recent changes to prescribing regulations owing to the well-established and significant teratogenic risk. Concerns have been raised by patients and clinicians as to the risk of adverse sexual effects of VPA use in men.

RESULTS

The evidence base for the effect of VPA on sexual function compared with other antiepileptic drugs (AEDs) in men is limited with no randomized controlled trials. Sexual function in men with epilepsy is complex, and there is no direct relationship between objective measures of sexual function and sexual satisfaction. Epilepsy, comorbidities, psychosocial factors, and most AEDs including VPA may cause sexual dysfunction in men, including reduced sexual desire, erectile dysfunction, and fertility problems. Sexual and reproductive function should be discussed with men prior to treatment with AEDs including VPA.

CONCLUSION

Early and proactive discussion of sexual and reproductive functioning mitigates, rather than increases, the risk of sexual problems and potentially improves adherence. Sexual dysfunction in men with cognitive impairment [such as intellectual disability (ID) and dementia] may present with behavioral disturbance. Identification of sexual adverse effects of medication could significantly change treatment plans which is of particular importance for individuals with treatment resistance. We provide an information fact sheet for men to help guide prescribing discussions.

Glutamate and aspartate alleviate testicular/epididymal oxidative stress by supporting antioxidant enzymes and immune defense systems in boars

Several potential oxidative agents have damaging effects on mammalian reproductive systems. This study was conducted to investigate the effects of glutamate (Glu) and aspartate (Asp) supplementation on antioxidant enzymes and immune defense systems in the outer scrotum of boars injected with H₂O₂. A total of 24 healthy boars were randomly divided into 4 treatment groups: control (basal diet, saline-treated), H₂O₂ (basal diet, H₂O₂-challenged outer scrotum (1 mL kg^-1 BW)), Glu (basal diet +2% Glu, H₂O₂-challenged), and Asp (basal diet+2% Asp, H₂O₂-challenged). Our results showed that both Glu and Asp supplementation improved testicular morphology and decreased the genital index in the H₂O₂-treated boars. Glu and Asp administration increased the antioxidant enzyme activities and affected the testicular inflammatory cytokine secretion but had no effect on sex hormone levels. Furthermore, the mRNA expression of CAT, CuZnSOD, and GPx4 was altered in the testes and epididymis of boars treated with Asp and Glu. Glu and Asp supplementation also modulated the expression of TGF-β1, IL-10, TNF-α, IL-6 and IL-1β in the testis and epididymis. These results indicate that dietary Glu and Asp supplementation might enhance antioxidant capacity and regulate the secretion and expression of inflammatory cytokines to protect the testes and epididymis of boars against oxidative stress.

Retrospective evaluation of 99th percentile hCG results to adjust clinical decision points

While accurate measurement of chorionic gonadotropin (hCG) is necessary, so are appropriate clinical decision points (CDPs) for patients of all ages. The CDP for hCG is intended to identify early pregnancy in patients of child bearing age; non-pregnant patients who are older frequently yield hCG results > 5 IU/L, making the use of a low hCG CDP problematic for these patients. Using a retrospective review of all hCG results generated over a 32-month period, 8507 hCG results from non-pregnant females of all ages were analyzed. Patients < 40 years of age comprised 74% of hCG measurements, and produced hCG results ≥ 5 IU/L 1% of the time, but this frequency increased in patients 40-49 (17% of hCG results; 4% ≥5 IU/L) and ≥50 (9% of hCG results; 20% ≥ 5 IU/L). While only 3% of hCG results were ≥5 IU/L in the overall data set, all (24/24) of hCG results 10-14 IU/L came from patients ≥ 40 years of age and all (3/3) hCG results ≥ 15 IU/L came from patients ≥ 50 years of age. The 99th percentile hCG results in the population were 3 IU/L in patients < 40, 7 IU/L in patients 40-49, and 13 IU/L in patients ≥ 50 years of age. These findings demonstrate a progressive increase in measurable hCG correlating to patient age and demonstrate a proof-of-concept that institutions could assess 99th percentile hCG results to assign more appropriate method-dependent CDPs to different age groups.

Trends in valproate use in patients in Germany between 2009 and 2017

OBJECTIVE

The goal of this study was to analyze trends in valproate use in patients followed by neurologists and general practitioners in Germany between 2009 and 2017.

METHODS

This study included all patients aged ≥15 years followed in 2009, 2013, and 2017 in neurological (N = 99) and general (N = 499) practices in Germany. Trends in valproate use were estimated based on the mean number of patients per practice who were prescribed valproate and the proportion of physicians prescribing it. Covariables included gender, age, and physician. This cross-sectional study uses descriptive statistics only.

RESULTS

In total, 1,298,446 patients were followed in general and neurological practices in 2009, 1,358,160 in 2013, and 1,413,286 in 2017. The mean number of patients aged 15-45 years per practice with at least one valproate prescription decreased in neurological (men: 11.07 versus 9.92; women: 9.27 versus 5.88) and general practices (men: 0.82 versus 0.75; women: 0.60 versus 0.37) between 2009 and 2017. Moreover, the proportion of neurologists prescribing valproate in women between 15 and 45 years of age decreased over time (94% in 2009 versus 86% in 2017), and there was also a substantial decrease in the share of general practitioners prescribing valproate in men (47% versus 41%) and women between 15 and 45 years of age (37% versus 22%).

CONCLUSION

The proportion of men and women between 15 and 45 years of age receiving valproate decreased in neurological and general practices in Germany between 2009 and 2017.