Inflammatory bowel disease and male infertility: effects of sulfasalazine and 5-aminosalicylic acid on sperm-fertilizing capacity and reactive oxygen species generation

The association of medications and supplements with human male reproductive health: a systematic review

Some medications used to treat comorbidities and conditions in reproductive-aged individuals could have a negative impact on fertility. This may occur through hormonal disruption, toxicity to germ cells and spermatozoa, functional impact on the sperm, teratogenicity potential, or ejaculatory abnormalities. Having knowledge of these potential interactions between medications and reproductive potential is important for clinicians to be aware of and guide the patient, along with their treating clinicians, to reproductively favorable alternatives when available. This review aims to summarize the state of the literature regarding medication interactions with human male reproduction using the Anatomical Therapeutic Chemical Classification System of medications.

The impact of autoimmune systemic inflammation and associated medications on male reproductive health in patients with chronic rheumatological, dermatological, and gastroenterological diseases: A systematic review

Autoimmune disorders currently affect 5%-8% of the global population, characterized by an aberrant chronic inflammatory response to self-antigens. The aim of this study was to systematically review the current available evidence investigating the impact of systemic autoimmune diseases and associated immunosuppressive treatment on fertility parameters of adult men. Clinical trials, observational studies, and case reports written in English and reporting semen analysis, evaluation of seminal oxidative stress, and/or sperm DNA fragmentation in patients affected by psoriasis and psoriatic arthritis, celiac disease, inflammatory bowel diseases, systemic lupus erythematosus, ankylosing spondylitis, hidradenitis suppurativa, uveitis, dermatomyositis, and rheumatoid arthritis were collected by searching on PubMed, EMBASE, OVID, Scopus, and Cochrane Library databases, with no limit of time. The study quality and the extent of bias in design, methods, and outcome assessment were evaluated by applying the Joanna Briggs Institute Critical Appraisal tools. Evidence suggested that various autoimmune diseases or relevant medications can adversely affect male fertility parameters and that patients may benefit of counseling and sperm cryopreservation. Clinical trials further investigating any adverse effect of autoimmunity and related thereby on male infertility are warranted, to develop appropriate guidelines for males diagnosed and treated for autoimmune disorders.

Immunosuppressants and Male Reproduction

Prolonged use of immunosuppressant medications is occasionally seen in infertile men with chronic inflammatory conditions; autoimmune disorders; or an organ or hematopoietic stem cell transplant. Chronic inflammation impacts negatively on male reproductive endpoints, so immunosuppressant therapy can produce improvements. Corticosteroids have been used to treat antisperm antibodies and even as an empirical treatment for male infertility in general. Trials of these methods have provided mixed results on semen quality and fertility, with improvement, no change and negative effects reported by different investigators. In a substantial number of observational studies, patients on long-term therapy with prednisone for chronic inflammatory disease, testosterone levels were lower compared to untreated controls, though randomized controlled trials have not been conducted. Similarly decreases in testosterone have been reported in men receiving corticosteroids to minimize transplant rejection; however, most were treated with multiple immunosuppressive medications that may have contributed to this effect. A large number of trials of healthy men treated with corticosteroids have shown some disruption in reproductive hormone levels, but other studies reported no effect. Studies in monkeys, rats (at human equivalent dose), cattle, sheep, and horses have shown endocrine disruption, including low testosterone with dexamethasone treatment. Of the cytostatic immunosuppressives, which have high potential for cellular damage, cyclophosphamide has received the most attention, sometimes lowering sperm counts significantly. Methotrexate may decrease sperm numbers in humans and has significant negative impacts in rodents. Other chemotherapeutic drugs used as immunosuppressants are likely to impact negatively on male fertility endpoints, but few data have been collected. The TNF-α Inhibitors have also received little experimental attention. There is some evidence that the immunophilin modulators: cyclosporine, sirolimus, and everolimus cause endocrine disruption and semen quality impairment. As we review in this chapter, results in experimental species are concerning, and well-designed studies are lacking for the effects of these medications on reproductive endpoints in men.

Review article: the safety of therapeutic drugs in male inflammatory bowel disease patients wishing to conceive

BACKGROUND

Many therapeutic drugs are used by patients with inflammatory bowel disease, often around the time of conception. The pregnancy outcomes of males and females exposed to these therapeutics needs to be examined and this information is necessary to counsel patients appropriately.

AIM

To review the literature describing male infertility and inflammatory bowel disease to educate practitioners of the impact of inflammatory bowel disease on male reproduction and the impact of therapeutics on pregnancy outcomes.

METHODS

We performed a PubMed search using the search terms 'male infertility,' 'Crohn's disease,' 'inflammatory bowel disease,' 'ulcerative colitis,' 'ciprofloxacin AND infertility,' 'metronidazole AND infertility,' 'sulfasalazine AND infertility,' 'azathioprine AND infertility,' 'methotrexate AND infertility,' 'ciclosporin AND infertility,' 'corticosteroids AND infertility,' 'infliximab AND male fertility,' 'infliximab AND infertility,' 'infliximab AND foetus,' 'infliximab AND paternal exposure' and 'infliximab AND sperm.' References from selected papers were reviewed and used if relevant.

RESULTS

Over half of male patients with IBD have some degree of infertility, compared to 8-17% of the general population. Semen parameters including total count, motility and morphology may be adversely affected by therapeutics. IBD medications in males do not increase foetal risk with the possible exception of azathioprine and mercaptopurine; however, increased foetal risk is seen in other drugs if taken by female patients.

CONCLUSIONS

It is recognised that male infertility is often impacted with therapeutic drugs used to treat inflammatory bowel disease; however, the effects of the paternal drug exposure at the time of conception and exposure in utero should be considered to counsel patients appropriately.

Urinary phthalate metabolite concentrations among men with inflammatory bowel disease on mesalamine therapy

BACKGROUND

Phthalates, a family of compounds used in a variety of consumer products, are reproductive and developmental toxicants in experimental animals. One of these phthalates, dibutyl phthalate (DBP), is an inactive ingredient in the coating of Asacol.

AIM

To determine if men with inflammatory bowel disease taking Asacol have higher urinary concentrations of monobutyl phthalate (MBP), a metabolite of DBP, compared to the general population in the United States.

METHODS

Five patients at the Massachusetts General Hospital Crohn's and Colitis Center, taking at least 800 mg of Asacol three times a day, provided one spot urine sample. Urinary MBP and other phthalate metabolite concentrations were measured by using online solid phase extraction coupled with isotope dilution high-performance liquid chromatography tandem mass spectrometry.

RESULTS

In four of the five men, the urinary concentrations of MBP (9888 ng/mL, 12,308 ng/mL, 10,124 ng/mL, and 41,590 ng/mL) and of a minor DBP metabolite, mono(3-carboxypropyl) phthalate (MCPP, 116.4 ng/mL, 163.4 ng/mL 72.6 ng/mL, 5604 ng/mL) were orders of magnitude higher than the background concentrations among the US general population. One subject missed his morning Asacol dose and had urinary MBP concentrations (17.5 ng/mL) similar to background levels.

CONCLUSION

We confirmed that men with inflammatory bowel disease taking Asacol have urinary concentrations of MBP and MCPP much higher than background levels.

The impact of commonly prescribed drugs on male fertility

To analyze the impact of commonly used drugs on male fertility, we assessed the clinical characteristics of patients with impaired semen quality while they were taking medication for chronic diseases and after switching therapies. Of 1768 infertile males, 201 patients were taking medications and had impaired semen quality without any seminal tract obstruction, spermatogenic abnormalities or hypogonadotropic hypogonadism. Of these 201 men, a total of 165 had no history of testicular diseases nor abnormalities in any examinations. Amongst them, H1 receptor antagonists were the most common medication taken, followed by antiepileptics and antibiotics. They were divided into two groups: an intervention group (73 patients), who could stop or switch their medications, and a control group (92 patients), who could not. In the intervention group, semen quality improvement rate and conception rate (93% and 85%, respectively) were much higher than those of the control group (12% and 10%, respectively). After switching therapies, the time interval before conception was 7.3 months, which was significantly shorter in asthenozoospermia than oligozoospermia. Our results confirm the potential fertility hazards of commonly used drugs and their reversibility. Moreover, after switching medication, drug-induced asthenozoospermia was cured more rapidly than oligozoospermia, suggesting that further delineation of such differences may help to elucidate mechanisms of spermatogenesis and might facilitate the development of non-hormonal male contraceptive agents.

Sulfasalazine induced oxidative stress: a possible mechanism of male infertility

The mechanism of action of sulfasalazine (SASP) in male infertility is not well elucidated. For it, an oxidative stress-like mechanism inductor of infertility was hypothesized. Adult male Sprague-Dawley rats (20/group) were orally administered 0, 300, and 600mg SASP/kg body weight for 14 days. One-half of animals in each group remained an additional period of 14 days without treatment. SASP induced a significant decrease of superoxide dismutase (SOD) and glutathione reductase (GR) at the highest dose in both testis and epididymis. GR remained altered in these tissues within the recovery period. However, an increase in SOD was noted in epididymis. An increase in thiobarbituric acid-reactive substances (TBARS) was noted in all SASP-treated groups. In epididymis, catalase (CAT) significantly increased at 600mg/(kgday). These results suggest that SASP induces oxidative stress, which in turn might act as a possible mechanism of male-induced infertility.

Mesalazine-induced reversible infertility in a young male

Mesalazine is a well-established treatment for ulcerative colitis. A young man treated with mesalazine for proctitis was found to have pathological semen with a count of only 3 x 10(6) sperm cells/ml. He failed to achieve conception with his wife. When mesalazine treatment was stopped, semen analysis returned to near normal and pregnancy ensued. Due to recurrent disease activity, mesalazine treatment was reinstituted. This was followed by deterioration of the patient's semen.

Subfertility and Gastrointestinal Disease: ???Unexplained??? Is Often Undiagnosed

Subfertility can be more reliably explained and effectively treated with an improved understanding of the contribution of chronic medical disease to reproductive dysfunction. This review addresses several common gastrointestinal disorders which are increasingly implicated in infertility and early pregnancy loss: celiac disease, inflammatory bowel disease (ulcerative colitis and Crohn's disease), and hemochromatosis. Appreciating the reproductive impact of these comorbidities and their treatments enables clinicians to accurately counsel patients and to modify medical and fertility treatments based on etiology. Because unexplained infertility can represent the initial presentation of undiagnosed medical disease, considering these often-subclinical gastrointestinal disorders in the differential diagnosis of subfertility provides an opportunity not only to increase the probability of conception and uncomplicated pregnancy, but also to improve overall maternal health.

Common medications and drugs: how they affect male fertility

Numerous drugs and medications have been shown to have adverse effects on male fertility, acting through diverse mechanisms. These drugs are summarized in Table 2. Mechanisms of impaired fertility include direct effects on germ cells or their supporting cells, effects on the delicately balanced HPG axis, effects on erectile or ejaculatory function, and effects on libido. In a thorough fertility evaluation of the male partner, the physician should determine what medication the patient is taking and his social habits involving alcohol consumption, tobacco, and recreational drug use. Most adverse effects from drugs and medications can be reversed by simply discontinuing the offending agents; however, in some instances, such as chemotherapeutic regimens, the medications cannot be discontinued, and pretreatment sperm cryopreservation remains critical. It is essential for urologists treating infertile men to be familiar with the more commonly encountered drugs and medications that may affect the potential for fertility.

Incidence of varicoceles in patients with ankylosing spondylitis evaluated by physical examination and color duplex sonography

OBJECTIVES

To assess the incidence of varicocele in ankylosing spondylitis (AS) in comparison to healthy age-matched controls.

METHODS

Twenty-one male patients with AS who were not taking disease-modifying antirheumatic drugs (eg, sulfasalazine, a well-known cause of drug-induced infertility) and age-matched healthy controls were evaluated with both physical examination and color duplex sonography for varicocele. The maximal vein diameters of pampiniform plexus and duration of reflux were recorded. Semen samples were also analyzed in both groups.

RESULTS

Patients with AS had a higher incidence of clinical varicoceles (52%) compared with the healthy age-matched controls (20%). On color Doppler examination, 12 patients (57%) had varicocele (3 bilateral and 9 on the left side) and 6 controls had varicocele on the left side. The patients with AS had significantly greater vein diameters of pampiniform plexus on the left and right side compared with the controls.

CONCLUSIONS

The incidence of varicocele is increased in patients with AS, and its clinical relevance needs to be evaluated.

The effect of Oren-gedoku-to on experimental colitis in rats

In Japan and China, Oren-gedoku-to (a complex mixture of ingredients derived from plants) has been used as a herbal medicine in the treatment of inflammatory and ulcerative diseases. In other countries salicylazosulfapyridine has been used to treat inflammatory bowel disease. In this study, we have compared the effect of Oren-gedoku-to with salicylazosulfapyridine on trinitrobenzene-sulphonic acid-induced colonic damage in rats, a model representative of ulcerative colitis and Crohn's disease in man. Oren-gedoku-to was administered orally for one or two weeks over a range of doses. Tissue damage scores, body weight, spleen weight, colon wet weight and colon wall thickness were measured, and colonic tissue levels of interleukin-8 (IL-8), leukotriene B4 (LTB4), prostaglandin E2 (PGE2), and myeloperoxidase activity were examined. The results indicated that Oren-gedoku-to was effective in the treatment of inflammatory bowel disease in the rat model. Histological observation showed a quicker healing process of the lesions, and a reduction of inflammatory cell infiltration following administration of Oren-gedoku-to. The precise mechanism of action for Oren-gedoku-to is still unclear; however, the reduction of IL-8, LTB4, and PGE2 observed suggests that the mechanism may be different from salicylazosulfapyridine (which has no effect on IL-8). There may be a potential benefit in offering combination therapy for the treatment of inflammatory bowel disease.

Short-term male reproductive toxicity study with sulfasalazine in the rat

Sulfasalazine (2-hydroxy-5-[[4-[(2-pyridinylamino) sulfonyl] phenyl]azo]benzoic acid; SASP) was administered to rats in a short-term male reproductive toxicity study to further examine the utility of this grouping of techniques and to generate reference data with a substance that is known to cause reversible infertility in men. Adult male CD rats (10/group) were orally administered 0, 150, 300, or 600 mg SASP/kg body weight in divided doses for 14 d followed by a 2-week period without treatment. Males were killed on test day (TD) 15 or 29. At each time point, the reproductive system was evaluated by comparing testicular and epididymal weights, DNA ploidy distributions of testicular cell suspensions, testicular and epididymal histopathology, and epididymal sperm concentrations, motion, morphology, and breakage. Adding time as a factor in the protocol aids in distinguishing testicular from posttesticular effects. Changes in sperm quality after 2 weeks of test article administration (TD 15) predominantly reflect effects that occurred after the sperm entered the epididymis, while testicular effects predominated on TD 29. Beginning on TD 14, males to be killed on TD 29 were cohabited with untreated females (1:2). Females were killed at midgestation and examined for pregnancy status. Body weight gain was depressed in all SASP groups during the first 3 d of test article administration. Food consumption was depressed at the 300- and 600-mg/kg dose levels. No changes were seen in testicular weight, but epididymal weight was depressed at the 600-mg/kg dose level. DNA ploidy distributions determined by flow cytometry did not indicate that the kinetics of spermatogenesis were disturbed. However, alterations in sperm release, which have not previously been reported, were seen at all SASP dose levels. On TD 29, the percentage of progressively motile sperm was depressed and beat/cross frequency was increased at the 600-mg/kg dose level. No changes were observed in sperm morphology or breakage. Fertility was slightly depressed at the 600-mg/kg dose level. In this study, testicular histopathology provided the most sensitive endpoint for reproductive toxicity. The impairment of fertility immediately after treatment was stopped, when no changes were apparent in sperm release or sperm motion, suggested that decreased sperm concentrations and altered motility, while contributory, may not be the primary causes of SASP-mediated infertility.

Reactive oxygen metabolites and colitis: a disturbed balance between damage and protection. A selective review

Enhanced local production of reactive oxygen metabolites has been found in association with colitis, both experimentally and in humans. Cellular and biochemical systems involved have been identified, and 5-aminosalicylic acid-containing drugs but, more effectively, specific scavengers have been found to reduce the intestinal inflammatory process. The multitude of reactions in which oxygen metabolites participate provides a new area of research in intestinal inflammation. These basic studies might bring related clinical studies in an era of new anti-inflammatory drugs for inflammatory bowel disease specifically designed to scavenge toxic oxygen metabolites.