Effect of sperm antibodies in females on human in vitro fertilization

Clinical associations and mechanisms of action of antisperm antibodies

OBJECTIVE

To review and critique the current English literature describing the effects of antisperm antibodies (ASA) on mammalian fertility.

DESIGN

A comprehensive English language literature was searched using Medline and by hand-searching. Emphasis was placed on clinically relevant articles.

RESULT(S)

Results from the studies were extrapolated and the effects of ASA on fertility described.

CONCLUSION(S)

Antisperm antibodies may interfere with fertility. Not all ASA cause infertility. Current tests cannot differentiate the infertility-related ASA from those that do not interfere with infertility, because the antigenic specificities of these ASA are not known. The antigens which the infertility-related ASA must be characterized to allow an accurate detection and proper treatment for couples with ASA.

The effect of sera antisperm antibodies in the female partner on in vivo and in vitro pregnancy and spontaneous abortion rates

PROBLEM

To determine the incidence of antisperm antibodies (ASA) in female sera from infertile couples or those suffering from recurrent abortions. Also to determine if the pregnancy and/or abortion rates are any higher in those positive versus those negative for ASA.

METHOD

All registered patients had sera drawn and ASA measured by indirect immunobead test on initial study. Pregnancy and abortion rates were determined for patients undergoing in vivo or in vitro therapy.

RESULTS

There was a low incidence of ASA in patients having in vivo or in vitro treatment. There was no decrease in pregnancy rates (PRs) or increase in spontaneous abortions (SAB) in those positive for ASA.

CONCLUSION

Antisperm antibodies in female sera do not seem to be etiologic in causing infertility or SAB. Future studies might consider changing the antigen source from donor sperm to husband's sperm.

High implantation rate and consequently high pregnancy rate by in vitro fertilization-embryo transfer treatment in infertile women with antisperm antibody

OBJECTIVE

To examine the effect of antisperm immunity on postfertilization steps, such as implantation of embryos and fetal growth in IVF-ET treatment of women with sperm-immobilizing antibodies.

DESIGN

Retrospective analysis of clinical laboratory data.

SETTING

The IVF-ET program of the Department of Obstetrics and Gynecology. The University of Tokushima, School of Medicine.

PATIENTS

Eighteen women with sperm-immobilizing antibodies and 122 infertile patients with nonimmune etiology as controls. Infertile couples due to a male factor and with unknown etiology were excluded.

INTERVENTIONS

All patients received the same IVF-ET program with GnRH agonist.

MAIN OUTCOME MEASURES

Rates of fertilization and cleavage, implantation rate per embryo transferred and pregnancy rate (PR) in both test and comparison groups.

RESULTS

The rate of fertilization in the antisperm group (61.3%) was significantly lower than that in the comparison group (76.8%). But the implantation rate per embryo transferred (23.5%) and consequently the modified PR per oocyte recovery procedure (34.4%) in immunologically infertile women were significantly higher than those in the comparison group (7.9% and 17.8%, respectively).

CONCLUSIONS

Although sperm-immobilizing antibodies prevent sperm-egg interaction, they do not seem to have any adverse effects on achievement of pregnancy. Moreover, the existence of antisperm immunity in woman with antisperm antibodies is suggested to be favorable for successful pregnancy by the IVF-ET procedure.

The effect of antisperm autoantibodies in male or female partners undergoing in vitro fertilization-embryo transfer

OBJECTIVE

To evaluate the effects of sperm bound autoantibodies on the outcome of IVF-ET.

DESIGN

Couples with positive antisperm autoantibodies as determined by the immunobead test were retrospectively classified into two groups: group A, consisting of 15 couples with positive antisperm antibodies in the female sera; and group B, consisting of 16 couples with sperm antibodies bound to motile spermatozoa from the male partner. Both groups were subclassified according to pregnancy outcome, i.e., pregnant and nonpregnant cycles.

PATIENTS

Thirty-one couples with positive antisperm autoantibodies were compared with 312 couples with tubal infertility undergoing IVF-ET.

RESULTS

No significant correlation could be shown between the mean percent binding of any specific immunoglobulin (Ig) class (G, A, and M) nor localization of sperm binding with regard to fertilization and embryonic development among pregnant and nonpregnant cycles within groups A and B. The mean fertilization rate was 59% in the control group, compared with 62% in group A and 52% in group B. Overall, the pregnancy rate (PR) in IVF-ET cycles with positive sperm autoantibodies did not demonstrate a decreasing trend compared with controls. The PR per cycle, per oocyte retrieval, and per ET was higher in group A (47%, 50%, and 53%, respectively) compared with group B (32%, 33%, and 37%) and to controls (27%, 31%, and 34%). The implantation rate was lowest in the control group (10%) compared with the study groups (group A, 20% and group B, 14%).

CONCLUSION

In vitro fertilization-embryo transfer is not significantly affected by the presence of sperm autoantibodies in female sera used to supplement the culture media or antibodies bound to inseminated sperm.

The frequency of antisperm antibodies in the cervical mucus of women with poor postcoital tests and their effect on pregnancy rates

PROBLEM

To determine the impact of the presence of antisperm antibodies (ASAs) in the cervical mucus of female partners in couples with unexplained poor postcoital tests (PCT). Furthermore, the efficacy of intrauterine insemination (IUI) in these same patients was determined by pregnancy rates (PRs).

METHOD

Pregnancy rates following IUI in patients with infertility and poor postcoital tests, whether the cervical mucus was positive or negative for ASAs, were evaluated.

RESULTS

The 6-month PRs were similar in the ASA negative (40.5%) versus the positive (42.4%) group.

CONCLUSIONS

It appears that the antifertility effect of ASA may be mainly the immobilization of sperm in the cervical mucus, and thus, performing IUI may effectively correct the problem.

The value of routine screening of female serum for antisperm antibodies in assisted reproductive technology cycles

OBJECTIVE

To determine the effect of antisperm antibodies in the female serum on fertilization and pregnancy rates (PRs) in assisted reproductive technology (ART) cycles.

DESIGN

Retrospective case control study.

SETTING

Assisted reproductive technology program at North Shore University Hospital.

PATIENTS, PARTICIPANTS

All patients undergoing an ART cycle in 1990 whose husbands did not have significant antisperm antibodies in the semen. Thirty-four female patients had significant antisperm antibodies level in the serum (antisperm antibodies-significant); 62 patients with no antibodies or nonsignificant levels constituted the control group (antisperm antibodies-negative). Incubation media were prepared with maternal serum in 37 of the antisperm antibodies-negative and in 10 of the antisperm antibodies-positive patients, whereas donor's serum (DS) was used for 25 and 24 patients, respectively.

MAIN OUTCOME MEASURES

Fertilization rate and clinical PR, defined as an intrauterine sac by transvaginal ultrasonography, were recorded for each group.

RESULTS

Analysis of variance showed a significant interaction between antisperm antibodies grouping and the type of media used, with fertilization rate in antisperm antibodies-significant patients significantly higher with maternal serum than with DS, whereas fertilization rate in antisperm antibodies-negative was quantitatively, though not statistically lower with maternal serum than with DS. When maternal serum was used, fertilization was higher in antisperm antibodies-significant than antisperm antibodies-negative. Of 29 clinical pregnancies, 11 were in antisperm antibodies-significant and 18 in antisperm antibodies-negative. In 10 of the pregnancies, maternal serum was used, whereas in 19 pregnancies DS was used. No variable was significantly predictive of pregnancy in the logistic regression analysis.

CONCLUSIONS

[1] Female patients with significant levels of antisperm antibodies in the serum had similar fertilization rates as patients with nonsignificant levels if DS was used. [2] The use of maternal serum in antisperm antibodies-significant patients did not result in inferior fertilization rates or the occurrence of pregnancy. [3] These findings suggest that a female antisperm antibodies may not hinder fertilization in vitro. [4] This study questions the value of routine screening of female serum for antisperm antibodies in ART.

Effect of anti-human sperm monoclonal antibodies on mouse in vitro fertilization

We employed anti-human sperm monoclonal antibodies to investigate how sperm membrane antigens are involved in gamete interactions. We have produced seven monoclonal antibodies specific for human sperm antigens, that showed reaction with mouse sperm by ELISA and by immunofluorescence. These antibodies did not react with zona pellucida or any other somatic human tissue. Some degree of toxicity was detected for oocytes at high antibody concentration and this was correlated with their inhibitory effect on fertilization. Unrelated to the degree of antigen expression or localization on sperm membrane, the antibodies showed several degrees of inhibition. The participation in sperm-zona pellucida interaction for every antigen could be evidenced by the impaired penetration of sperm caused by the presence of several concentrations of antibody. Thus, DAN-2, MOU-8 and VAC-4 inhibit mouse in vitro fertilization.

Relationship of sperm antibodies in women and men to human in vitro fertilization, cleavage, and pregnancy rate

PROBLEM

The presence of anti-sperm antibodies (ASA) in female serum has been correlated with decreased fertilization in the in vitro fertilization (IVF) program; however, the impact of each type of ASA (IgG, IgA, IgM) is not known.

METHOD

To clarify the role of each ASA subtype, the immunobead binding technique was used to identify IgG, IgA, and IgM ASA in the female sera and on the spermatozoa from 137 couples undergoing the IVF program.

RESULTS

Couples with ASA on spermatozoa had a lower fertilization rate and lower number of transferred embryos: and IgG was the major immunoglobin involved. Couples with ASA in female sera showed significant decreases in the rates of fertilization, cleavage, and number of transferred embryos only when IgM was detected, but not IgG or IgA. However, the presence of IgA ASA in female sera was only associated with a decrease in pregnancy rate, although the number of transferred embryos was not reduced.

CONCLUSION

These findings suggest that ASA can influence the results of IVF and that the specific effect is dependent upon the subtypes of ASA.

Antisperm antibodies and in vitro fertilization

The purpose of this study was to investigate the influence of antisperm antibodies in the male, the female, or both partners on the outcome of in vitro fertilization treatment. The results in terms of ongoing pregnancies in the male and female antibody-positive group were the same as in the antibody-negative group. In the double antibody-positive group two of the three patients became pregnant. When high levels of antisperm antibodies were present on the spermatozoa, the fertilization rate was significantly reduced. In the female positive group no clear relationship between the antibody titer and the fertilization percentage could be detected. Abnormal semen quality was responsible for a much lower fertilization rate than the presence of antibodies. The conclusion of this study is that in vitro fertilization provides an equal change of conception in couples with antisperm antibodies in comparison with couples with no antibodies if the other semen parameters are normal.

Male infertility: current concepts

The purpose of the article is to review the current concepts regarding the etiology and treatment of male-factor infertility. The following general conclusions can be drawn: (a) conventional parameters for sperm quality and male fertility are inadequate and any assessment should involve several different tests of sperm cell function to increase the fertility prognosis; (b) the causes of disturbed sperm quality are still poorly understood; (c) the role of the varicocele is still controversial but some of the discrepancies reported in the literature may be explained by the negative influence of other factors such as smoking, epididymal pathology or glandular infections operating either in conjunction or independent of the varicocele; (d) the role of chronic inflammatory processes in the reproductive organs, in particular the involvement of chronic chlamydial infections, has been underestimated, largely because it is often asymptomatic and difficult to demonstrate objectively; (e) partial androgen insensitivity may account for a significant number of cases of severe oligozoospermia; (f) no major advances have been made in the medical treatment of poor sperm quality; (g) assisted fertilization techniques such as IVF and GIFT offer encouraging possibilities for the treatment of male-factor infertility; and (h) recent advances in microsurgical techniques are increasing the treatment possibilities for certain forms of obstructive azoospermia and severe oligozoospermia.

Sperm antibodies

Anti-sperm antibodies (ASA) occur in 1% to 30% of infertile couples. Mechanisms by which ASA impair fertility include prevention of fertilization by decreasing acrosome reaction and/or zona pellucida binding, and postfertilization effects. Treatment for ASA involves assisted reproductive technologies.

Relation between antisperm antibodies and the rate of fertilization of human oocytes in vitro

To clarify further the role of antisperm antibodies in in vitro fertilization, the occurrence of antisperm antibodies on ejaculated sperm and in sera was determined by the immunobead binding assay in 67 couples after an unsuccessful in vitro fertilization cycle. Antisperm antibodies in maternal sera were associated with a failure of oocyte fertilization (P less than 0.02) or with fertilization of only 9-19% of the oocytes (P less than 0.01) in vitro. Antisperm antibodies were detected in sera from 13 of 24 women (54.2%) where no fertilization occurred, 9 of 14 women (64.3%) where less than 20% of the oocytes fertilized, and 3 of 19 women (15.8%) where greater than 40% of the oocytes fertilized. Antisperm antibodies in these sera were mostly IgG and directed against the sperm tail. Antibodies on the surface of ejaculated motile sperm were also associated with a low (9-19%) fertilization rate (P less than 0.01). Sperm-bound antibodies were detected in 2 of 24 men (8.3%) where no fertilization occurred, 5 of 14 men (35.7%) where less than 20% of the oocytes fertilized, and 0 of 19 men where fertilization was greater than 40%. Sperm-bound antibodies were mainly IgA and were tail-directed. Antisperm antibodies in sera of males were not related to the rate of fertilization.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunomagnetic separation of antibody-labelled from antibody-free human spermatozoa as a treatment for immunologic infertility. A preliminary report

A method is described where superparamagnetic polymer microspheres coated with monoclonal antibodies are used to isolate antibody-labelled from antibody-free spermatozoa in male autoimmune infertility. Autoimmune sperm samples or antibody-free spermatozoa adsorbed with antisperm-antibodies from sera were incubated with microspheres coated with a specific monoclonal antibody to murine immunoglobulins, after their preincubation with mouse anti-human IgG and IgA. Using a magnet, the microsphere-labelled spermatozoa were separated from the samples. Immunobead binding was performed before and after the treatment in order to detect changes in the percentage of antibody-bound spermatozoa. After the immunomagnetic separation, approximately 50% of the IgA-labelled spermatozoa was isolated while no difference was demonstrated when antisperm antibodies of IgG class were involved. The evaluation of sperm motility and membrane integrity after treatment seemed to indicate that the technique did not have any relevant effect on sperm characteristics. The fact that only a partial success in separation of IgA-bound spermatozoa and no success for IgG-labelled sperm was obtained indicates that the method needs to be improved before its clinical utilization might be postulated.

The effect of female antisperm antibodies on in vitro fertilization, early embryonic development, and pregnancy outcome

STUDY OBJECTIVE

To evaluate the extent to which human in vitro fertilization-embryo transfer (IVF-ET) alleviates immunological infertility.

DESIGN

Retrospective.

SETTING

In vitro fertilization program.

PATIENTS

Thirty-three patients with positive antisperm antibodies undergoing 50 cycles of IVF-ET in which maternal serum was replaced by 5 mg/mL of bovine serum albumin (BSA) comprised the study group. Seventy-one patients with tubal infertility served as controls. In 50 of these, medium was supplemented with 7.5% maternal serum, and 21 were assigned to BSA substitution.

RESULTS

Percentage of fertilization in the study group was significantly lower (41 +/- 31; mean +/- SD) than that of controls with maternal serum (77 +/- 15) and BSA (76 +/- 22). Early embryonic quality, as assessed by percentage of cleavage and morphological grading, was found to be inferior in patients with antisperm antibodies. The percentage of advanced embryos (greater than or equal to 4 blastomeres) at the time of transfer was 42 +/- 39 in the study group, compared with 65 +/- 23 and 75 +/- 35 for maternal serum and BSA controls, respectively. Percentage of morphologically favorable embryos (grades 1 and 2 in a 1 to 5 grading system) was 49 +/- 31 in the study group, compared with 78 +/- 35 and 74 +/- 23 for the controls. Percentage of clinical pregnancy was somewhat lower in the study group (12.5%) than in controls with either maternal serum (18%) or BSA (19%).

CONCLUSIONS

Antisperm antibodies may have an adverse effect on fertilization and early embryonic development. Female immunological infertility may not be completely alleviated by IVF-ET.

Micro-insemination: genetic aspects

Micro-insemination involves sperm deposition directly into oocytes. This can be by transfer of sperm (Micro-Insemination Sperm Transfer, or MIST) or by micro-injection into the ooplasm (Micro-Insemination Micro-Injection into Cytoplasm, or MIMIC). Micro-insemination is indicated in spermatozoa with no or very poor motility, very low density, multiple defects, or inability to penetrate oocyte vestments. There is a 10% incidence of chromosomal abnormalities in spermatozoa from fertile and normal men. However, there is no increase in sperm chromosomal abnormalities in men with normal peripheral karyotypes and highly abnormal sperm parameters. Preliminary results of karyotypes of human oocytes that failed to become fertilized after MIST and mouse morulae and blastocysts produced after MIST reveal that there was no significant increase in aneuploidy or polyploidy. There is evidence that MIMIC may result in increased abnormal sperm karyotypes. Polyspermy is low in the mouse and human after transfer of multiple spermatozoa into the perivitelline space, thus suggesting an oolemmal block. However, blastomere membranes do not fuse with spermatozoa, as observed in a study of MIST into human embryos. Zona drilling with acid is not advised because of disturbances to chromosomal kinetics. The conclusion of this review is that MIST does not result in an increased risk of chromosomal abnormalities, while caution must be exercised with MIMIC.

Does intraperitoneal insemination in the absence of prior sensitization carry with it a risk of subsequent immunity to sperm?

To evaluate the occurrence of antisperm antibodies in women, with no prior sensitization, 112 couples undergoing intraperitoneal insemination were tested for serum antisperm antibodies with the sperm immobilization test (SIT) and the immunobead test (IBT). A serum sample was taken from each of the 112 patients immediately before the first intraperitoneal insemination. Another sample was taken from 58 patients who underwent a second insemination procedure. In 16 of the 58 patients the IBT results were positive for one or more immunoglobulin classes. Five patients showed positive SITs. In 7 out of these 16 subjects (12%) the antibodies were bound to the head and to the shaft of the sperm tail. Five of the six patients submitted to a third intraperitoneal insemination procedure showed unchanged SIT values and IBT binding percentages. In one subject, SIT (6 months after the third insemination) became negative. Antibody production may be either a transient response to massive antigen stimulation or the first step toward systemic immunity.

Intrauterine insemination as treatment for antisperm antibodies in the female

Ninety-one women with long-standing infertility in the presence of humoral antisperm antibodies (ASA) underwent 473 cycles of intrauterine insemination of washed sperm (IUI), resulting in 26 pregnancies. Nine pregnancies were achieved in 67 women who underwent 285 IUI during unstimulated cycles (13% pregnancy rate; 3% pregnancy/cycles of treatment). Twenty women underwent 86 IUI after clomiphene citrate (CC) stimulation, resulting in 6 pregnancies (30%; 7% per cycle), while 28 underwent 102 cycles of IUI after human menopausal gonadotropins (hMG) stimulation, resulting in 11 pregnancies (39%; 11% per cycle). Twenty-one of the 26 pregnancies (81%) were achieved in the first 2 IUI cycles. During unstimulated and CC IUI cycles, all pregnancies occurred in the first two cycles of treatment, while with hMG stimulation pregnancies also occurred in the third, fourth, and fifth IUI cycles. Nine of these 91 women subsequently conceived spontaneously, and three others conceived through in vitro fertilization. Only 6 of the 38 pregnancies resulted in spontaneous abortion (16%). Thus, pregnancies achieved in women with ASA have no increased risk of abortion.

Sperm antibodies and human in vitro fertilization

In order to directly evaluate the effects of sperm antibodies in human in vitro fertilization (IVF), the authors preincubated donor sperm in female sera containing sperm antibodies and then inseminated supernumerary human oocytes from a gamete intrafallopian transfer (GIFT) program. The sperm were incubated for 30 minutes in medium containing 20% serum with antisperm activity (Test); or no antisperm activity (Control) as assessed by the immunobead test (IBT). Each oocyte was inseminated with 1 to 2 X 10(5)/ml of the preincubated motile sperm with Control or Test treatments allocated on a random basis. Six positive sera were tested in 17 experiments, resulting in a fertilization rate of 41% (25/61) versus 84% (36/43) for controls (P less than 0.001). When considered individually, three of six positive sera caused significant inhibition. The only serum that gave complete inhibition had the highest titer for IgG (10,000) and lower IgA (100). Absorption with protein A reduced the IgG titer to less than 10 and removed the fertilization inhibitory activity. These results confirm that sperm antibodies from female sera can inhibit human IVF.

Sperm antibodies and human fertilization

Previous investigations using zona-free hamster oocytes and salt-stored human zonae pellucidae, and retrospective analysis of routine human in vitro fertilization (IVF) results have suggested that sperm antibodies can impair the fertilizing capacity of human spermatozoa. The results of our investigations using viable human oocytes confirm that human antispermatozoal antibodies can inhibit fertilization by human spermatozoa. In the future we plan to examine the mechanism of fertilization inhibition, including characterization of the sperm antigens involved. These studies may facilitate the development of immunocontraceptive vaccines and of new treatments for immunological infertility.

Evaluation of the direct and indirect mixed antiglobulin reaction with latex particles for the diagnosis of immunological infertility

The direct Mixed Antiglobulin Reaction (MAR test) is a simple method for the detection of auto-antibodies attached to spermatozoa in fresh semen. The test was improved by using IgG-coated latex particles (SpermMAR) instead of coated red blood cells. A positive direct MAR test with adherence of latex particles to 40% or more of the motile spermatozoa was found in 16 out of 312 men (5%) consulting for infertility, but never in fertile controls. The percentage of motile spermatozoa reacting with the coated latex particles was correlated significantly with the serum titre of sperm agglutinins assessed by the tray agglutination test. The direct MAR test on semen was highly specific but rather insensitive, particularly if the serum titre of agglutinins was low. The same kit (SpermMAR) can be used to detect circulating sperm antibodies in serum of male or female patients with the indirect mixed antiglobulin reaction. The indirect MAR test discriminated clearly between serum with low (less than 1/32) or high (greater than 1/32) titres of circulating agglutinins assessed by the tray agglutination test. Considering their simplicity and accuracy, both the direct test on semen and the indirect spermMAR test on serum should be included in the routine evaluation of the infertile couple.

Involvement of fertilization antigen (FA-1) in involuntary immunoinfertility in humans

Sera from immunoinfertile patients (n = 32) and fertile controls (n = 20) were analyzed for cross-reaction with a purified and characterized sperm-specific glycoprotein, the fertilization antigen (FA-1), employing an enzyme-linked immunosorbent assay. The immunoinfertile sera demonstrated a strong reaction with FA-1 when compared with fertile control sera. There was no correlation between the reaction of sera with FA-1 and the titers obtained through the sperm agglutination technique and the sperm immobilization technique. Immunoinfertile sera showed binding with the protein bands in the regions corresponding to FA-1 on Western blots involving sodium deoxycholate-solubilized human sperm. Antigens isolated with immunoaffinity chromatography involving immunoinfertile sera also demonstrated antigen bands corresponding to FA-1 in sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Of the seven immunoinfertile couples, three that had antibodies to FA-1 in the male as well as female partners demonstrated a block of fertilization (IVF) due to antibodies bound on the sperm surface. The anti-FA-1 antibody activity was detected in serum as well as in follicular fluid and seminal plasma. Immunoinfertile sera that showed an inhibition of human sperm penetration of zona-free hamster ova showed a significant (P less than 0.001) increase in penetration rates after absorption with FA-1. These results indicate that sera from immunoinfertile patients had antibodies reacting with FA-1, and these antibodies are involved in the fertilization process.

How should sperm antibody tests be used clinically?

Immunoglobulin-specific assays are currently available for detection of patients with antibody-mediated infertility. Care must be taken in insuring that the correct immunoglobulin class is assayed, the assay is directed to the possible interaction of antibodies and sperm in the male or female genital tract, and the antigen employed will not detect antibodies against antigens not found on the plasma membrane of living sperm.