Treatment of male sperm autoimmunity by using the gamete intrafallopian transfer procedure with washed spermatozoa

Diagnostic significance of sperm-zona pellucida interaction

Spermatozoa binding to the zona pellucida is an early, critical event leading to fertilization and early pre-embryo development. Fertilization involves a complex and orderly sequence of events that is completed at syngamy, which is defined as the union of the two sets of haploid chromosomes to form a new diploid fertilized ovum (zygote). In order to be able to fertilize an oocyte, spermatozoa need to undergo a process called ‘capacitation’, which is usually defined as a series of changes that renders the sperm cells capable of undergoing the acrosome reaction. This process that naturally occurs within the female genital tract is possible under in vitro conditions. However, capacitation is not the only process spermatozoa must undergo to fertilize the oocytes successfully. To fertilize an oocyte, spermatozoa must also be at least highly motile, as well as being capable of undergoing the acrosome reaction timely, penetrating through the oocyte investments and fusing with the oocyte plasma membrane properly.

Modalities for treatment of antisperm antibody mediated infertility: novel perspectives

Immunoinfertility because of antisperm antibodies (ASA) is an important cause of infertility in humans. The incidence of ASA in infertile couples is 9-36% depending on the reporting center. Early claims regarding the incidence and involvement of ASA in involuntary infertility were probably overemphasized, which has resulted in subsequent confusion, doubt, and underestimation of their clinical significance. No immunoglobulin that binds to sperm should be called an antisperm antibody in a strict sense unless it is directed against a sperm antigen that plays a role in fertilization and fertility. ASA directed against the fertilization-related antigens are more relevant to infertility than the immunoglobulins that bind to sperm associated antigens. Several methods have been reported for treatment of immunoinfertility. These include: immunosuppressive therapies using corticosteroids or cyclosporine; assisted reproductive technologies such as intrauterine insemination, gamete intrafallopian transfer, in vitro fertilization, and intracytoplasmic sperm injection; laboratory techniques such as sperm washing, immunomagnetic sperm separation, proteolytic enzyme treatment, and use of immunobeads. Most of the available techniques have side effects, are invasive and expensive, have low efficacy, or provide conflicting results. Recent findings using defined sperm antigens that have a role in fertilization/fertility have provided animal models and innovative novel perspectives for studying the mechanism of immunoinfertility and possible modalities for treatment. The better understanding of local immunity and latest advances in hybridoma and recombinant technologies, proteomics and genomics leading to characterization of sperm antigens relevant to fertility will help to clarify the controversy and to establish the significance of ASA in infertility.

Detection of antisperm antibodies in seminal plasma by flow cytometry: comparison with the indirect immunobead binding test

OBJECTIVE

To compare flow cytometry with the established indirect immunobead binding test (IBT) for the detection of antisperm antibodies in seminal plasma.

DESIGN

A prospective, comparative study.

SETTING

University-based andrology unit.

PATIENT(S)

One hundred and fifty-eight men with suspected male factor subfertility.

INTERVENTION(S)

Seminal plasma samples were incubated with antisperm antibody-negative donor sperm. Surface-bound antibody was detected with fluorescence-labeled antihuman antibody in the flow cytometry assay or with immunobead-labeled antihuman antibody in the IBT.

MAIN OUTCOME MEASURE(S)

The percentage of sperm that tested positive for surface-bound antibody was determined in the two assays. Seminal plasma was antisperm antibody-positive when > or = 20% of the sperm were antibody-bound, and clinically significant levels were present when > or = 50% of the sperm were antibody-bound.

RESULT(S)

Of 71 samples that were negative by the IMT, 66 (93%) also were negative by flow cytometry. Of 63 samples that had > or = 50% immunobead binding, 55 had equivalent results by flow cytometry. Overall statistical analysis showed a good correlation between the two assays.

CONCLUSION(S)

There is a good correlation between the indirect IBT and indirect flow cytometry for the detection of antisperm antibodies in seminal plasma.

Antisperm antibody detection: 1. Methods and standard protocol

PROBLEM

Today, antisperm antibody (ASA) detection is one of the most important steps in the evaluation of male infertility. This practice is generally accepted even though there is still some disagreement about the meaning of antisperm immunity and a good deal of controversy about the test regarded as the most suitable for the detection of antibodies directed against sperm antigens. International workshops have tried to standardize universally accepted protocols. A panel of three or four methods is generally advised to provide a correct and complete screening of patients with antisperm immunity.

METHOD OF STUDY

This paper reports on the results of a serum exchange workshop for the standardization of the ASA detection in the sera carried out under the auspices of the Italian Society of Endocrinology, which was used as reference laboratory. A careful description of the most widely used methods is reported and proposed as a standard protocol also on the basis of the results of the correlation studies carried out by our group is also reported.

CONCLUSIONS

If the proposed methods and procedures will be accepted by the members of the Alps-Adria Society for Immunology of Reproduction, a Study Group for Sperm Antibody Testing, could start its activity having the goal of reaching a consensus on methodology and carrying out a European serum exchange workshop.

Clinical significance of human sperm-zona pellucida binding

OBJECTIVE

To assess the relationship between sperm morphology and motion parameters and sperm-zona pellucida (ZP) binding capacity under hemizona assay (HZA) conditions and to determine the discriminatory power of the HZA for the prediction of in vitro sperm fertilizing ability.

DESIGN

Prospectively designed study.

SETTING

Academic tertiary centers.

PATIENT(S)

One hundred ninety-six couples undergoing IVF therapy participated in this study.

INTERVENTION(S)

Hemizona assay and IVF results were determined for each couple.

MAIN OUTCOME MEASURE(S)

Computerized sperm motion analysis, sperm morphology (strict) criteria), and HZA results were correlated with fertilization outcome.

RESULT(S)

Among sperm parameters from the original ejaculates, morphology was the best predictor of sperm-ZP binding ability; hyperactivated motility was the best predictor of HZA results after swim-up separation of the motile sperm fractions. The HZA index provided the highest discriminatory power for fertilization success/failure, with an overall accuracy of 86%.

CONCLUSION(S)

Sperm morphology and hyperactivated motility showed a high correlation with the capacity of sperm to achieve tight binding to the ZP. The excellent positive and negative predictive values of the HZA for fertilization outcome provide additional support for the use of this functional bioassay in the decision-making process within the assisted reproduction setting.

Binding of human spermatozoa to lectin-coated agarose microbeads

An inability or decreased ability of spermatozoa to bind to the zona pellucida (ZP) may be at the origin of many cases of poorly explained or idiopathic infertility. It would be clinically useful to be able to distinguish this condition from other causes of infertility. A major problem in testing the sperm-ZP binding ability is the paucity of biological ZP. Examination of whether sperm binding to PNA-, UEA-1-, WGA-, Con A-, or PSA-coated agarose microbeads reflected sperm binding to biological ZP and correlated with in vitro fertilization rates showed that only binding to WGA-coated microbeads showed significant positive and negative predictive values when compared to IVF rates in 2 x 2 contingency. Sperm binding to PNA, Con A, and PSA was indiscriminately high, irrespective of IVF rate. Human spermatozoa did not bind to UEA-1-coated agarose microbeads. Furthermore, sperm binding to WGA-coated microbeads correlated with sperm morphology ratings. These results implicate terminal N-acetyl-D-glucosamine and/or sialic acid (specific saccharides for WGA) in sperm-ZP interaction and also suggest that the use of lectin-coated microbeads may represent an initial step in the development of a synthetic sperm binding assay.

Effect of low dose continuous corticosteroid therapy in men with antisperm antibodies on spermatozoal quality and conception rate

The use of steroids for treating male immunological infertility is controversial. The effect of low dose prednisolone on sperm quality in men with antisperm antibodies and the conception rate, was evaluated in 40 men and their wives. Significant circulating antisperm antibodies were detected by immunofluorescence technique. Prednisolone (5 mg) was administered orally, daily for 3-6 months in men with significant antisperm antibodies. Another group of 37 men with significant antisperm antibodies, formed the control group. Both groups had initial pre- and post therapy semen analysis and hypoosmotic swelling (HOS) test. They were followed up for 12-18 months and the pregnancy outcome documented. There were significant improvement in sperm motility and hypoosmatic swelling test with therapy (P < 0.01, P > 0.05) of 13 and 15%, respectively. The pregnancy rate of 20% was much greater than 5% in the control group (P < 0.01). There were no side effects of prednisolone. Low dose prednisolone is useful in Antisperm antibody associated infertility, by improving the sperm quality and giving rise to pregnancies.

Corticosteroid treatment does not improve the results of intrauterine insemination in male subfertility caused by antisperm antibodies

AIM

To determine whether corticosteroid immunosuppression (CS) administered to the male partner together with intrauterine insemination (IUI) is preferable compared to IUI alone in treating male autoimmune subfertility.

MATERIALS AND METHODS

Thirty-six couples with proven male immunological subfertility were randomly assigned to begin CS + IUI (n = 18) or IUI (n = 18) treatment and progressed alternatively to receiving each treatment modality for three cycles unless pregnancy occurred. Each couple served as their own control. The administered corticosteroid was soluble prednisolone.

RESULTS

Five pregnancies were achieved with 77 cycles of CS + IUI and seven pregnancies with IUI alone. The pregnancy rates per cycle were 6.5% with CS + IUI and 9.21% with IUI, while the pregnancy rates per couple were 16.13% with CS + IUI and 21.2% with IUI alone. These rates do not differ to a statistically significant degree (P > 10%).

CONCLUSIONS

The addition of corticosteroid immunosuppression does not seem to significantly enhance the pregnancy rate in couples with male autoimmune subfertility treated with IUI as compared to the treatment with IUI alone. Considering the possible side-effects of corticosteroid intake, we conclude that IUI alone might be preferable to the combination of IUI with corticosteroid administration.

Study of antisperm antibodies bound to the sperm cell surface and their relationship to circulating ASA

PROBLEM

Direct and indirect tests for antisperm antibody (ASA) detection are commonly used in laboratories for the diagnosis of male immunological infertility. Even though the two kinds of tests study the same immunological phenomena, frequently no perfect correlation is found even on large series of patients and with precise statistical models. The aim of the present investigation was to try to establish whether biological models can explain the antibody test results and if a predictive threshold can be established for expected positivity/negativity.

METHOD

The data relate to 667 patients, who were screened using the Direct Immunobead test (d-IBT) for ASA bound to the sperm surface and with the gelatin and tray agglutination test (GAT and TAT) in sera for circulating ASA. Correlation were studied and cases of no correlation were further analyzed.

RESULTS

The number of patients with a clinically significant positivity to d-IBT (binding percentage > or = 20%) was 134 (20.1% of total patients). The analysis of the results of direct and indirect tests shows that the discordances are due to differences in the Ig class of immunization or to the site of epitopes involved. In fact, as far the Ig class is concerned, if d-IBT shows a prevalent or exclusive IgG or IgA positivity, this results in a poor correlation between binding percentage to d-IBT and GAT-TAT titers. If both the Ig classes are involved, the level of positivity of the two kinds of test are strictly related. As far as the site of Ag-Ab reaction on the sperm surface is concerned, the wide immunization involving all the surface sperm antigens (mixed), shown by d-IBT, is related to higher indirect test titers.

CONCLUSION

Local and systemic antisperm immunizations are strictly related and a predictive threshold of expectation can be established to explain even apparently discordant direct and indirect results.

Infertility due to antisperm antibodies

Immunoinfertility is an important problem, involving a significant number of infertile couples. Although the presence of antibodies on sperm has better prognostic value than those in serum or seminal plasma, it may not be the sole authentic evidence of immunoinfertility. Infertility from antisperm antibodies is likely only when they bind to a relevant sperm antigen involved in a specific fertility function. The variance in functional deficits seen in immunologic infertility is most likely related to antibodies directed at different sperm antigens or different class, subclass, or isotypes. Antibodies to FA-1 seem to be of significant importance in human immunoinfertility. In approaching couples with infertility, a high index of suspicion for antibodies is necessary to avoid misdiagnosis. In the optimal situation, all semen analyses should be screened for sperm-bound antibodies, but if this is impractical, testing should be performed on high-risk individuals (Table I). In couples in which the man has sperm-bound antibodies, and in whom there is no identifiable female factor, treatment should be instituted. Most treatments for immunoinfertility have been disappointing because of poor results, adverse effects, or high cost. Corticosteroid therapy has shown some promise in published reports (mostly poorly designed studies), but increase in pregnancy rate is modest and adverse effects may be significant. In our opinion, informed consent should be documented prior to institution of corticosteroid therapy, and subjects should be closely monitored. Advanced reproductive technologies offer a higher safety profile, and, with increasing technology, higher pregnancy rates. We recommend progressing from "low-tech" procedures, such as IUI and reserving the higher level procedures, such as IVF and ICSI, for those couples in whom pregnancy does not occur. The highest level reproductive technologies give the best current prospects for pregnancy in patients with this difficult problem but also are invasive and costly. It is hoped that further work in the laboratory will give rise to newer, safer, and less expensive effective treatments in the very near future.

Subfertility in the era of assisted reproduction: changes and consequences

OBJECTIVE

To review the major changes that have occurred during the last decade of assisted reproduction technology (ART) practice, looking at the various conditions that cause subfertility.

DESIGN

A short review describing the progress that has been made during the last decade of ART practice, analyzing the various conditions that cause subfertility, is presented. The efficacy of ART as a treatment of these conditions is discussed.

CONCLUSIONS

Assisted reproductive technology currently is used for a wide range of indications and has become an acceptable tool in the treatment of subfertile couples. Yet, there is an ongoing debate regarding the effectiveness of ART versus conventional treatment for the various conditions that cause subfertility. The effectiveness of IVF in terms of pregnancy rate (PR) was demonstrated only for patients with severe bilateral tubal disease and male subfertility. For couples with other causes of infertility the differences in PRs do not reach statistical significance, and the efficacy of IVF has not been demonstrated clearly to date. Moreover, much of the discussion about management of subfertility has centered on costs of ART and the cost-benefit of ART versus conventional therapy for subfertility. It has been shown that, in women with unexplained infertility, menotropin treatment is as successful, less expensive, and carries a smaller risk than the surgical approach used in ART. However, the exact role of ART in the management of polycystic ovarian syndrome, immunological infertility, and endometriosis still is to be determined. Yet, as embryo implantation after ART still is considerably lower than that of fertile couples who conceive naturally, we expect that the next major thrust improving the effectiveness of ART will occur after future elucidation of factors influencing embryonic implantation.

A comparison of intrauterine insemination in superovulated cycles to intercourse in couples where the male is receiving steroids for the treatment of autoimmune infertility

OBJECTIVE

To compare IUI with timed intercourse in men receiving oral steroid therapy for the treatment of infertility associated with antisperm antibodies.

DESIGN

A prospective, randomized, cross-over trial.

SETTING

All patients were managed and treated at the Andrology Unit, Churchill Hospital, Oxford, United Kingdom.

PATIENTS AND PARTICIPANTS

Thirty males who were found to have antisperm levels of > or = 50% [using the indirect immunobead test with isotypes immunoglobulin (Ig) G, IgA, and IgM (GAM) beads] in either seminal plasma or serum on routine testing were recruited with their partners into the study.

MAIN OUTCOME MEASURES

Antisperm antibody levels in seminal plasma and serum, sperm parameters, conception rates, and pregnancy outcome.

RESULTS

There was a statistically significant reduction in seminal plasma antisperm antibody levels associated with steroid therapy. There was a significant improvement in certain spermatozoan parameters during steroid therapy. The cumulative pregnancy rate over four cycles of IUI was 39.4%. The cumulative pregnancy rate over four cycles of natural intercourse was 4.8%. There was a significantly higher chance of achieving a pregnancy with IUI.

CONCLUSION

Intrauterine insemination significantly improves the chance of achieving a conception when used as an adjuvant therapy to cyclical intermediate dose steroid therapy. Antisperm antibody levels in seminal plasma are significantly reduced during treatment with cyclical intermediate dose steroid therapy, although levels in serum appear to be unaffected. Cyclical intermediate dose steroid therapy significantly improves certain sperm parameters but, when used in isolation, is associated with a low pregnancy rate.

Fluorescein isothiocyanate conjugate-wheat germ agglutinin staining of human spermatozoa and fertilization in vitro

OBJECTIVE

To determine the sensitivity and clinical significance of fluorescein isothiocyanate wheat germ agglutinin (FITC-WGA) staining of human spermatozoa.

DESIGN

Percentage FITC-WGA staining was assessed in the different morphological zones of human spermatozoa and compared with fertilization rates of metaphase II oocytes in vitro.

PATIENTS

Spermatozoa and oocytes were obtained from normospermic (n = 12) and male factor patients (n = 15) attending the Tygerberg Hospital's IVF clinic.

MAIN OUTCOME MEASURES

Aliquots of swim-up spermatozoa used in the IVF laboratory were examined for the presence and morphological localization of WGA receptors. Fertilization rates were expressed as the percentage of metaphase II oocytes with successful fertilization.

RESULTS

Human spermatozoa capacitated in vitro for use in an IVF program showed variations in the percent positive staining of the acrosomal region which correlated with IVF rates in both patient groups studied. Values of FITC-WGA acrosomal staining of < 35% corresponded with IVF rates of < 50% whereas > 35% WGA acrosomal staining corresponded with IVF rates > or = 50%. Significant differences between acrosomal and equatorial region staining from normozoospermic samples and male factor samples also were observed.

CONCLUSION

The results indicate the practical use of the WGA assay for molecular assessment of male fertilizing capacity in conjunction with an assisted reproductive program.

Appraisal of gamete intrafallopian transfer

OBJECTIVE

To collect results of gamete intrafallopian transfer on a large scale in order to compare treatment indications, results, and factors which influence the success rates; to evaluate whether gamete intrafallopian transfer is well-established and what the real place of this procedure is among other assisted reproduction techniques.

DESIGN

Data relating to gamete intrafallopian transfer were collected from World Reports, national registries of different countries and meta-analysis of medical publications during the years 1986-1991.

SUBJECT

Official registries reported 47,200 treatment cycles and 18,759 treatment cycles were analysed from ten medical publications.

RESULTS

The procedure accounts for 13.5% of all assisted reproduction techniques but its popularity varies significantly among countries. The same indications for gamete intrafallopian transfer are followed by all countries, but great differences exist with regard to the proportional share of each etiology. Also, the share has changed considerably over the years. TREATMENT OUTCOME: 10,667 clinical pregnancies were reported which represent 24% of treatment cycles and 29% of ovum pick-up. The live birth rate was 23.3%; abortion rate, 22%; and ectopic pregnancy rate, 5.5%. The stillbirth rate was 2.3% and the malformation rate was 2.8%, not confined to specific organs or systems. There were 19.5% twins, 4.6% triplets and 0.3% quadruplets or more. The number of transferred oocytes influenced pregnancy rates: 28% for transfer of four oocytes and only 10% following transfer of one oocyte. The cause of infertility might influence the results and the poorest results are obtained for male factor infertility. In most cases correlation of success rates reported by leading units through medical publications closely resembles the overall national registries results. Indications for this treatment were broadened over the years, but its role among other assisted reproduction technologies is not agreed upon, especially for male factor and unexplained infertility.

CONCLUSIONS

Gamete intrafallopian transfer carries an overall higher pregnancy rate than in vitro fertilization. Quality control by professional or public associations should be established and more research employed over indications for treatment and results in order to establish when GIFT is the treatment of choice and when other modes of treatment should be preferred.

Fertilization efficiency of morphologically abnormal spermatozoa in assisted reproduction is further impaired by antisperm antibodies on the male partner's sperm

OBJECTIVE

To investigate the influence of antisperm antibodies on the sperm surface on the outcome of IVF and GIFT.

DESIGN

Matched controlled retrospective review of two large series.

SETTING

Reproductive endocrine divisions of two level-three academic centers.

PATIENTS

Twenty-nine male factor patients (38 IVF cycles) showing positive antisperm antibodies on the sperm by immunobead test treated by IVF at the Norfolk program and 56 similar patients (57 cycles) treated by GIFT at the Tygerberg program. Twenty-nine male factor patients (29 IVF cycles) with negative antisperm antibodies screening matched by wife's stimulation protocol and baseline semen analysis characteristics were used as controls in Norfolk; 56 GIFT patients (56 GIFT cycles) matched similarly were the Tygerberg controls. Study and control groups were divided according to sperm morphology pattern in normal, good, and poor prognosis subgroups for comparison.

MAIN OUTCOME MEASURES

Fertilization rate of preovulatory oocytes used in IVF in Norfolk and of GIFT supernumerary preovulatory oocytes in Tygerberg; total and term pregnancy rates (PRs) and abortion rates.

RESULTS

Fertilization rate was significantly lower in the IVF (41.9% +/- 2.8%) as well as in the GIFT (26.8% +/- 3.8%) (mean +/- SE) study groups than in the respective control groups (73.1% +/- 3.9% and 61.8% +/- 3.9%). Total and term PRs in IVF per cycle (21.1% +/- 6.6%; 13.2% +/- 5.5%) and per transfer (23.5% +/- 7.4%; 14.7% +/- 6.1%), and in GIFT (25.0% +/- 5.8%; 19.6% +/- 5.3%) in the study groups were also lower when compared with their control counterparts (IVF per cycle: 62.1% +/- 6.2% and 41.4% +/- 6.0%; IVF per transfer: 41.9% +/- 2.0% and 27.9% +/- 1.9%; GIFT: 31.6% +/- 6.2% and 28.1% +/- 6.0%), but the difference did not reach statistical significance. Abortion rates were similar in the IVF study group (37.5% +/- 17.1%) and its control groups (39.9% +/- 11.5%). The abortion rate in the GIFT study group was 14.3% +/- 9.4%, and no abortions were recorded in the control group (not significant).

CONCLUSIONS

The presence of antisperm antibodies on the sperm surface per se impairs the outcome of assisted reproduction, mainly in terms of fertilization rate of preovulatory oocytes, and possibly in terms of total and term PRs. This holds true regardless of the impact of other semen parameters, particularly the morphology of the sperm within the semen sample.

Preparation of antibody free spermatozoa by in vitro immunodepletion using immunobeads

In the present study ejaculates from six infertile men with antisperm antibodies were processed on a six step discontinuous percoll gradient. This treatment yielded a sperm fraction with a different percentage of sperm with antisperm antibodies. The resultant sperm preparation was incubated with immunobeads. Sperm were recovered following incubation by swim-up. Sperm recovered at the end of processing showed reduced populations of antisperm antibodies. Even though sufficient numbers of sperm were obtained to consider assisted reproduction, reduced motility was recorded in four of the ejaculates when compared with routine processing. Following trial preparations of semen samples this technique may play a role in sperm selection for assisted conception.

The role of antisperm antibodies in infertility

OBJECTIVE

To discuss the role of antisperm antibodies (Ab) in infertility, including proposed mechanisms of antisperm Ab formation, assays for their detection, and treatments for immune-mediated infertility.

DESIGN

Major studies in the published literature and data from The University of Texas Southwestern Medical Center, Division of Reproductive Endocrinology. Reports were reviewed that investigated the development and impact of alloimmunity and autoimmunity to spermatozoa in men and alloimmunity in women and the current methods of treatment for resultant subfertility.

RESULTS

The exposure of spermatozoal antigens to the mucosal and systemic immune systems results in development of immunity to a multiplicity of spermatozoal epitopes. The evaluation of studies that examine the role of antisperm Ab in infertility is complicated by the lack of standardization of antisperm Ab assays and the difficulty in identifying those epitopes for antisperm Ab binding that are responsible for subfertility. Sperm-associated antisperm Ab and antisperm Ab in cervical mucus (CM) reduce sperm mobility and may also impair sperm-ovum interaction. The clinical significance of serum antisperm Ab in both men and women, however, is controversial. Current therapy for antisperm Ab associated infertility is empiric and largely unproven.

CONCLUSIONS

Antisperm Ab on the sperm surface and in CM are implicated in the pathogenesis of a subset of patients with infertility. Further studies that determine the clinically relevant sites of antisperm Ab interaction will aid in directing the treatment of subfertility mediated by antisperm Ab.

Treatment of antibody-associated sperm with media containing high serum content: a prospective trial of fertility involving men with high antisperm antibodies following intrauterine insemination

PROBLEM

Antisperm antibodies (ASAs) associated with the sperm surface can significantly influence oocyte fertilization. We initiated a prospective trial comparing the effect of serum-medium dilution on ASA binding and/or distribution following ejaculation and on subsequent pregnancy rates following intrauterine insemination (IUI).

METHOD

Infertile couples (N = 16) were entered into this prospective randomized protocol where the husband's sperm was at least 50% positive for both IgA and IgG ASAs using the immunobead assay. Couples underwent IUI with washed sperm collected during ejaculation into (a) 10 ml of serum medium made up of 50% maternal serum (antibody negative) in Hepes-buffered medium (SM) or (b) in a sterile cup (DRY). For the following cycle, each couple received the alternate sperm treatment. All patients underwent at least two DRY and two SM collections prior to beginning IUI. Sperm from these collections were analyzed by manual semen analysis, computer-aided semen analysis (CASA), and immunobead testing. All sperm preparations for IUI were analyzed by manual analysis and CASA before IUI. Outcome measures were changes in the distribution and amount of sperm antibody binding, sperm motion parameters, and pregnancy rates following IUI. Statistical analysis was performed using Fisher's exact test.

RESULTS

Collection of sperm into SM significantly reduces (P < 0.01) the percentage of antibody-bound sperm (54.8% IgA, 60.0% IgG) versus 83.5% IgA and 87.7% IgG with DRY collection. The distribution or pattern of antibody binding to the sperm also was altered by SM. There was no significant difference between the motility of the sperm following collection with SM or DRY sperm as determined by manual and CASA methods. More importantly, there was no statistically significant difference in the pregnancy rates/treatment cycle following SM (3.1% 32 cycles) or DRY (6.7%, 30 cycles).

CONCLUSION

Our data suggests that SM collection alters immunobead detectable ASA binding. Localization of ASA binding sites suggests that head-bound antibodies are influenced by SM treatment with little effect on tail-bound antibodies. In spite of the significant reduction of ASAs present on the sperm following SM treatment, there was no influence on pregnancy rates.

Effect of semen characteristics on pregnancy rate in a gamete intrafallopian transfer program

The aim of this study was to evaluate the influence of sperm morphology, swim-up concentration, and insemination volume on pregnancy outcome in patients undergoing gamete intrafallopian transfer (GIFT) treatment in whom the male partner had a morphology of less than 14%. Only patients who received four oocytes were entered into this study (n = 103). In all cases the swim-up procedure time was standardized to 1 h and the insemination concentration was standardized to 500,000 per oviduct. There was no significant difference in pregnancy rate when normal morphology, swim-up concentration, or insemination volume were used as predictors. In the P pattern group (< 4% normal forms) only four of the 28 (14%) patients had ongoing pregnancies, whereas in the G pattern group (5% to 14% normal forms) 16 out of 75 (21%) had ongoing pregnancies (P vs G, p > 0.05; not significant). The fertilization rate among excess oocytes in the P pattern group was 18% but was 39% (p < .0001) in the G pattern group. When an attempt was made to compensate for low morphology by increasing insemination concentration no significant difference in the pregnancy rate between the P and G pattern groups in the GIFT program was recorded. This was not the case when the in vitro fertilization rate was used as an endpoint. Insemination volume and swim-up concentration played no role in pregnancy rate.

Hemizona assay and its impact on the identification and treatment of human sperm dysfunctions

The HZA, a functional test for human gamete interaction, has become a useful and valuable experimental tool for physiological and cellular analysis of the early events leading to fertilization. The analysis of the conventional semen parameters with emphasis on sperm morphology (as judged by strict criteria) and motion characteristics (evaluated by computer assisted analysis) constitutes the first obligatory step for a critical evaluation of male-factor patients. Patients in whom fertilization disorders are suspected should be evaluated through bioassays of sperm function of established accuracy. The HZA, a bioassay of sperm-zona binding capacity is here proven to be highly predictive of IVF outcome. Ultimately, our increasing knowledge of sperm biology and dysfunction will provide a basis for a better diagnosis (membrane receptor defects and metabolic/biochemical abnormalities?) as well as better therapeutic interventions in patients with sperm disorders. It seems likely that the HZA may be eventually replaced by a standardized test kit in which recombinant human DNA-derived zona receptors mimic the natural function of the hemizonae currently used. This ZP3 reagent may also be a useful antigen for contraceptive development. The HZA therefore constitutes a useful adjuvant in the armentarium for the diagnosis and therapy of male-factor patients.

Immunological factors in infertility

Immune infertility can result from destruction of gametes by antisperm antibodies (ASA) or anti-ovary antibodies, by inhibition of sperm-zona pellucida binding by ASA, or by prevention of embryo cleavage and early development. Condoms, immunosuppressive therapy, sperm processing, and intrauterine insemination have been widely applied, but with controversial results.

In vitro sperm capacitation to treat antisperm antibodies bound to the sperm surface

Our objective was to study antisperm antibody bound to the acrosome region during in vitro capacitation and to determine whether acrosome-antibody free sperm can be obtained from previously acrosome-antibody-coated sperm. The spermatozoa from a selected series of 14 patients were tested for sperm antibodies bound to the sperm surface using d-IBT and focusing on the acrosome positivity. The tests were carried out before the incubation and after 3, 6, 9, and 12 h of incubation in Tyrode's solution with 0.5% human serum albumin as the capacitation medium. Tests to evaluate acrosome region, sperm motion parameters, and zonae binding ability were carried out. In this way we were able to evaluate sperm function during capacitation protocol. The patients were 14 subjects selected according to good seminal characteristics, good post-rise sperm parameters, and high percentage of ASA bound to the sperm surface. In all cases the results showed that antisperm antibodies bound to the acrosome region were shed prior to the acrosome reaction. During sperm capacitation in human a modification, migration, or shedding of plasma membrane molecules takes place. The presence of antibodies in such an important area of the sperm head could certainly interfere in the fertilization process. Our data indicate that in vitro capacitation could provide an in vitro therapy capable of eluting antibodies from the acrosome region.

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.