Best Practice Policies for Male Infertility

Comparison of sperm retrieval rate between superficial and deep dissection during microscopic testicular sperm extraction

Objective

The purpose of the study was to compare the outcome of microscopic testicular sperm extraction (micro-TESE) between superficial and deep dissection on the same testicle in terms of sperm retrieval rate (SRR).

Patients and Methods

In a retrospective study from June 2019 to October 2021, 44 patients with nonobstructive azoospermia who underwent micro-TESE with positive results (mature sperm identified) were included. Eight patients were excluded from the study due to deficient documentation on superficial and deep dissection. A total of 36 patients were included; 60 testicles were examined for superficial and deep biopsies. Testicular histopathology was performed in all patients, and a hormonal evaluation was obtained before the micro-TESE attempt.

Results

Thirty-six patients and 60 testicles were included in the study. Of them, 47 (78.3%) testicles had positive results. Superficial TESE was positive in 38 (63.3%) testicles, and deep TESE was successful in 45 (75.0%) testicles. An improvement of 13.9% in the SRR was observed, following deep dissection. However, there was no statistically significant difference (P = 0.166). Rates of positive sperm retrieval (from any side) did not differ significantly based on patients' age, microdissection testicular sperm extraction sides, and hormonal concentrations; these differences were not apparent after superficial or deep TESE.

Conclusion

The presented findings suggest that although successful SRRs of deep TESE were higher than that of its superficial counterpart, there was no significant statistical difference. A larger body of evidence is needed to provide a higher grade of recommendation.

Variation of the genes encoding antioxidant enzymes SOD2 (rs4880), GPX1 (rs1050450), and CAT (rs1001179) and susceptibility to male infertility: a genetic association study and in silico analysis

Enzymatic factors including superoxide dismutase (SOD), glutathione peroxidase (GPX), and catalase (CAT) are among the most important protective antioxidant systems in human semen. This study was conducted to investigate the association between the activities of the mentioned enzymes in semen and also the association between SOD2 rs4880, GPX1 rs1050450, and CAT rs1001179 polymorphisms with male infertility, which was followed by a bioinformatics approach. In a case-control study, 223 infertile men and 154 healthy fertile men were included in the study. After extracting genomic DNA from semen samples, the genotype of rs1001179, rs1050450, and rs4880 polymorphisms was determined using the PCR-RFLP. Next, the activities of SOD, CAT, and GPX enzymes were also measured in semen. Bioinformatics software was used to investigate the effect of polymorphisms on the function of genes. Data analysis indicated that rs1001179 polymorphisms were not associated with male infertility. But our data revealed that the rs1050450 polymorphism is associated with a reduced risk of male infertility as well as asthenozoospermia and teratozoospermia. In addition, rs4880 polymorphism was associated with an increased risk of male infertility as well as teratozoospermia. Further analysis showed that the activity of the CAT enzyme in the infertile group is significantly higher than in the fertile group, but the activity of GPX and SOD enzymes in the infertile group is significantly lower than in the fertile group. Bioinformatic analysis showed that rs1001179 polymorphism affects the transcription factors binding site upstream of the gene, while rs1050450 and rs4880 polymorphisms had an essential role in protein structure and function. On the other hand, rs1050450 (T allele) was exposed to a reduced risk of male infertility and may be a protective factor. And SOD2 rs4880 (C allele) is associated with an increased risk of male infertility, and it is considered a risk factor for male infertility. To reach accurate results, we recommend that the study of SOD2 rs4880 and GPX1 rs1050450 polymorphism effects in the different populations with a larger sample size and meta-analysis are needed.

Preoperative Predictors for the Presence of Motile Spermatozoa in the Epididymis and Patency of Anastomosis during Microsurgical Vasoepididymal Anastomosis in Patients with Obstructive Azoospermia

Background

Following microsurgical vaso-epididymal anastomosis (VEA), anastomotic patency with sperm returning to the ejaculate is not always present and may even be delayed. The presence of motile spermatozoa is highly suggestive of future patency following surgery.

Aims

We prospectively analyse the factors that could predict motile spermatozoa at the epididymis intraoperatively and predictors of patency in patients with obstructive azoospermia (OA) undergoing microsurgical VEA.

Settings and Design

Department of Urology of a tertiary care centre in Northern India. It is a prospective observational study.

Materials and Methods

Over a 2-year period (July 2019 to June 2021), 26 patients with idiopathic OA were enrolled in the study. Twenty patients underwent microsurgical VEA. Patients were divided into two groups based on the presence/absence of intraoperative motile spermatozoa.

Statistical Analysis Used

Analysis of preoperative and intraoperative factors was done using the Mann-Whitney U-test, Chi-squared test and Fischer exact test.

Results

Out of 20 patients, 5 (group 2) had intraoperative motile spermatozoa in the epididymal fluid and 15 (group 1) had nonmotile spermatozoa. Low luteinising hormone (LH) levels (P = 0.01) and high testosterone levels (P = 0.05) were the predictive of presence of motile spermatozoa in epididymal fluid. Mean follow-up was 9 months (6-18 months). Predictors of higher patency were grade 2 epididymis (firm, turgid and tense) (P = 0.003), low LH levels (P = 0.03), low sertoli cell index (P = 0.006), high sperm-Sertoli index (P = 0.002) and better surgeon satisfaction (P = 0.01).

Conclusion

Low LH levels and high testosterone levels may be predictive of the presence of motile spermatozoa in epididymal fluid. Firm, turgid and tense epididymis, low Sertoli cell index, high sperm-Sertoli index and surgeon satisfaction suggest a greater chance of success after VEA for idiopathic azoospermia.

Mitochondria-Targeted Compounds to Assess and Improve Human Sperm Function

Significance: Currently 10%-15% of couples in reproductive age face infertility issues. More importantly, male factor contributes to 50% of these cases (either alone or in combination with female causes). Among various reasons, impaired sperm function is the main cause for male infertility. Furthermore, mitochondrial dysfunction and oxidative stress due to increased reactive oxygen species (ROS) production, particularly of mitochondrial origin, are believed to be the main contributors. Recent Advances: Mitochondrial dysfunction, particularly due to increased ROS production, has often been linked to impaired sperm function/quality. For decades, different methods and approaches have been developed to assess mitochondrial features that might correlate with sperm functionality. This connection is now completely accepted, with mitochondrial functionality assessment used more commonly as a readout of sperm functionality. More recently, mitochondria-targeted compounds are on the frontline for both assessment and therapeutic approaches. Critical Issues: In this review, we summarize the current methods for assessing key mitochondrial parameters known to reflect sperm quality as well as therapeutic strategies using mitochondria-targeted antioxidants aiming to improve sperm function in various situations, particularly after sperm cryopreservation. Future Directions: Although more systematic research is needed, mitochondria-targeted compounds definitely represent a promising tool to assess as well as to protect and improve sperm function. Antioxid. Redox Signal. 37, 451-480.

Investigation of sub-chromosomal changes in males with idiopathic azoospermia by chromosomal microarray analysis

Azoospermia consists of a significant proportion of infertility aetiology in males. Although known genetic abnormalities may explain roughly the third of infertility cases, the exact aetiology is still unclear. Chromosomal microarrays are widely used to detect sub chromosomal abnormalities (e.g., microdeletions and microduplications). This study aimed to investigate aetiology in patients with idiopathic azoospermia by using the chromosomal microarray method to detect possible sub chromosomal changes. Twenty-eight patients (with a mean age of 30.4 ± 9 years) that had been diagnosed with idiopathic azoospermia between January 2019 and December 2020 were included in the study. Genomic DNA isolated from the blood of patients were amplified using polymerase chain reaction and was subjected to chromosomal microarray analysis. A total of six microdeletions were identified as clinically significant: one pathogenic copy number variation (CNV), four likely pathogenic CNVs, and one CNV of unknown clinical significance. However, clinical findings indicated that these microdeletions, with variable expression levels, may affect the spermatogenesis process and induce azoospermia. Future investigations regarding the functional effect of these deletions may contribute to our understanding of azoospermia aetiology.

Comprehensive Analysis of Global Research on Human Varicocele: A Scientometric Approach

Purpose

This study provides a comprehensive analysis of research trends on the etiology, mechanisms, potential risk factors, diagnosis, prognosis, surgical and non-surgical treatment of varicocele, and clinical outcomes before and after varicocele repair.

Materials and Methods

Varicocele studies published between 1988 and 2020 were retrieved from the Scopus database on April 5, 2021. Original studies on human varicocele were included, irrespective of language. Retrieved articles were manually screened for inclusion in various sub-categories. Bibliometric data was subjected to scientometric analysis using descriptive statistics. Network, heat and geographic mapping were generated using relevant software.

Results

In total, 1,943 original human studies on varicocele were published. These were predominantly from the northern hemisphere and developed countries, and published in journals from the United States and Germany. Network map analysis for countries showed several interconnected nodal points, with the USA being the largest, and Agarwal A. from Cleveland Clinic, USA, being a center point of worldwide varicocele research collaborations. Studies of adolescents were underrepresented compared with studies of adults. Studies on diagnostic and prognostic aspects of varicocele were more numerous than studies on varicocele prevalence, mechanistic studies and studies focusing on etiological and risk factors. Varicocele surgery was more investigated than non-surgical approaches. To evaluate the impact of varicocele and its treatment, researchers mainly analyzed basic semen parameters, although markers of seminal oxidative stress are being increasingly investigated in the last decade, while reproductive outcomes such as live birth rate were under-reported in the literature.

Conclusions

This study analyzes the publication trends in original research on human varicocele spanning over the last three decades. Our analysis emphasizes areas for further exploration to better understand varicocele’s impact on men’s health and male fertility.

The Potential Protective Effect and Possible Mechanism of Peptides from Oyster (Crassostrea hongkongensis) Hydrolysate on Triptolide-Induced Testis Injury in Male Mice

Peptides from oyster hydrolysate (OPs) have a variety of biological activities. However, its protective effect and exact mechanism on testicular injury remain poorly understood. This study aimed to evaluate the protective effect of OPs on triptolide (TP)-induced testis damage and spermatogenesis dysfunction and investigate its underlying mechanism. In this work, the TP-induced testis injury model was created while OPs were gavaged in mice for 4 weeks. The results showed that OPs significantly improved the sperm count and motility of mice, and alleviated the seminiferous tubule injury. Further study showed that OPs decreased malonaldehyde (MDA) level and increased antioxidant enzyme (SOD and GPH-Px) activities, attenuating oxidative stress and thereby reducing the number of apoptotic cells in the testis. In addition, OPs improved the activities of enzymes (LDH, ALP and ACP) related to energy metabolism in the testis and restored the serum hormone level of mice to normal. Furthermore, OPs promoted the expression of Nrf2 protein, and then increased the expression of antioxidant enzyme regulatory protein (HO-1 and NQO1) in the testis. OPs inhibited JNK phosphorylation and Bcl-2/Bax-mediated apoptosis. In conclusion, OPs have a protective effect on testicular injury and spermatogenesis disorders caused by TP, suggesting the potential protection of OPs on male reproduction.

Irisin alleviates obesity-related spermatogenesis dysfunction via the regulation of the AMPKα signalling pathway

BACKGROUND

Infertility is a common complication in obese men. Oxidative stress and testicular apoptosis play critical roles in obesity-induced spermatogenesis dysfunction. It has been reported that irisin, an exercise-induced myokine, may attenuate oxidative damage and testicular apoptosis in several diseases; however, its role in obesity-induced spermatogenesis dysfunction remains unclear. The purpose of this study was to investigate the role and underlying mechanism of irisin in obesity-induced dysfunction of spermatogenesis.

METHODS

Male mice were fed a high-fat diet (HFD) for 24 weeks to establish a model of obesity-induced spermatogenesis dysfunction. To explore the effects of irisin, mice were subcutaneously infused with recombinant irisin for 8 weeks beginning at 16 weeks after starting a HFD. To confirm the role of AMP-activated protein kinase α (AMPKα), AMPKα-deficient mice were used.

RESULTS

The data showed decreased serum irisin levels in obese patients, which was negatively correlated with sperm count and progressive motility. Irisin was downregulated in the plasma and testes of obese mice. Supplementation with irisin protected against HFD-induced spermatogenesis dysfunction and increased testosterone levels in mice. HFD-induced oxidative stress, endoplasmic reticulum (ER) stress and testicular apoptosis were largely attenuated by irisin treatment. Mechanistically, we identified that irisin activated the AMPKα signalling pathway. With AMPKα depletion, we found that the protective effects of irisin on spermatogenesis dysfunction were abolished in vivo and in vitro.

CONCLUSIONS

In conclusion, we found that irisin alleviated obesity-related spermatogenesis dysfunction via activation of the AMPKα signalling pathway. Based on these findings, we hypothesized that irisin is a potential therapeutic agent against obesity-related spermatogenesis dysfunction.

Multiple Lesions Contribute to Infertility in Males Lacking Autoimmune Regulator

Male factors, including those of autoimmune origin, contribute to approximately 50% of infertility cases in humans. However, the mechanisms underlying autoimmune male infertility are poorly understood. Deficiency in autoimmune regulator (AIRE) impairs central immune tolerance because of diminished expression of self-antigens in the thymus. Humans with AIRE mutations and mice with engineered ablation of Aire develop multiorgan autoimmunity and infertility. To determine the immune targets contributing to infertility in male Aire-deficient (-/-) mice, Aire-/- or wild-type (WT) males were paired with WT females. Aire-/- males exhibited dramatically reduced mating frequency and fertility, hypogonadism, and reduced serum testosterone. Approximately 15% of mice exhibited lymphocytic infiltration into the testis, accompanied by atrophy, azoospermia, and reduced numbers of mitotically active germ cells; the remaining mice showed normal testicular morphology, sperm counts, and motility. However, spermatozoa from all Aire-/- mice were defective in their ability to fertilize WT oocytes in vitro. Lymphocytic infiltration into the epididymis, seminal vesicle, and prostate gland was evident. Aire-/- male mice generated autoreactive antibodies in an age-dependent manner against sperm, testis, epididymis, prostate gland, and seminal vesicle. Finally, expression of Aire was evident in the seminiferous epithelium in an age-dependent manner, as well as in the prostate gland. These findings suggest that Aire-dependent central tolerance plays a critical role in maintaining male fertility by stemming autoimmunity against multiple reproductive targets.

The SEPT12 complex is required for the establishment of a functional sperm head-tail junction

The connecting pieces of the sperm neck link the flagellum and the sperm head, and they are important for initiating flagellar beating. The connecting pieces are important building blocks for the sperm neck; however, the mechanism of connecting piece assembly is poorly understood. In the present study, we explored the role of septins in sperm motility and found that Sept12D197N knock-in (KI) mice produce acephalic and immotile spermatozoa. Electron microscopy analysis showed defective connecting pieces in sperm from KI mice, indicating that SEPT12 is required for the establishment of connecting pieces. We also found that SEPT12 formed a complex with SEPT1, SEPT2, SEPT10 and SEPT11 at the sperm neck and that the D197N mutation disrupted the complex, suggesting that the SEPT12 complex is involved in the assembly of connecting pieces. Additionally, we found that SEPT12 interacted and colocalized with γ-tubulin in elongating spermatids, implying that SEPT12 and pericentriolar materials jointly contribute to the formation of connecting pieces. Collectively, our findings suggest that SEPT12 is required for the formation of striated columns, and the capitulum and for maintaining the stability of the sperm head-tail junction.

[Impact of bilateral varicocelectomy in infertile men]

BACKGROUND

Although the progress in diagnosis methods revealed a high incidence of infra-clinical varicocele, the clinical signification of this pathology is controversial. We compared left unilateral varicocelectomy to bilateral surgery in patients with left clinical varicocele associated to an infra-clinical right one.

PATIENTS AND METHODS

It is a retrospective study conducted between January 2007 and December 2015 concerning men followed for a varicocele related infertility (one-year or more primary infertility) with two altered sperm analysis (oligospermia and/or asthenospermia) and had a left clinical varicocele associated to right infra-clinical one detected at Doppler Ultrasound. Surgical techniques used were open surgery (sub-inguinal way), antegrade sclerotherapy and coelioscopy. All patients were reviewed with a 6 month post operatively spermogram and minimum follow up of 1 year.

RESULTS

Our study included 95 men. Thirty-five patients have had a unilateral left surgery (Group I) and 60 patients have had a bilateral surgical treatment (Group II). The pre-operative spermatic parameters (concentration and progressive mobility) were comparable for the 2 groups. After the surgical treatment, an improvement of these parameters was noted in all the patients without significant difference between the two groups regarding sperm concentration (24.07±9.36×10⁶/mL Vs 23.29±3.88×10⁶/mL) and their progressive mobility (30.47±9.04% Vs 32.39±9.54%). The spontaneous pregnancy rate was 22.8% for patients in group I and 26.6% for those in group II without any statistically difference (p=0.68).

CONCLUSION

Treatment of a right s infra-clinical varicocele, when combined with a left clinical varicocele, gave better results in terms of sperm parameters and spontaneous pregnancy than unilateral varicocelectomy but without statistically significant results.

LEVEL OF EVIDENCE

3.

Modulatory Role of Vitamin E on Proton Pump (ATPase) Activity of Cadmium Chloride-Induced Testicular Damage in Wistar Rats

Proton pumps are membrane-bound enzymes important in generating gradients that help in maintaining cellular ion homeostasis, cell membrane potential, water, and solute transport across the cell surface. This study investigated the modulatory role of vitamin E on proton pump activity and reproductive parameters in cadmium-induced testicular damage. Twenty (20) male Wistar rats weighing between 180 and 200 g were sorted into 4 groups of five rats each. Group I served as the control and was given normal saline orally, Group II rats were treated with a single dose of 2 mg/kg BW cadmium chloride (CdCl2) intraperitoneally, Group III rats were given 100 mg/kg BW of vitamin E orally, and Group IV rats were given 100 mg/kg BW of vitamin E orally for 30 days prior to intraperitoneal administration of single dose of 2 mg/kg BW of cadmium chloride. The rats were anaesthetized with diethyl ether, and blood samples were obtained for sex hormonal analysis; caudal epididymis was dissected for sperm count, motility, and viability, and the testis were homogenized for lipid peroxidation and proton pump (Na+/K+ ATPase, Ca2+ ATPase, and Mg2+ ATPase) activity. Proton pump activity was assayed spectrophotometrically using the Stewart method to determine the inorganic phosphate level. Histopathological changes of the testis were also studied. The group treated with CdCl2 showed a significant (p < 0.05) decrease in proton pump activity, sperm count, and motility and a significant (p < 0.05) increase in malondialdehyde level when compared with the control group. The CdCl2-treated group also showed decrease reproductive organ weights and hormonal levels and cause necrosis of spermatogonia lining the seminiferous tubules. Rats treated with vitamin E orally for 30 days prior to CdCl2 exposure showed improvement in proton pump activity, a significant (p < 0.05) increase in sperm parameters and luteinizing hormonal level, and a decrease in the lipid peroxidation level as compared with the CdCl2 group. This study showed that vitamin E ameliorated the toxic effect of CdCl2 on proton pump activity in the testes, hence improving testicular integrity, structures, and functions.

Effects of Cigarette Smoking on Preimplantation Embryo Development

In this chapter, we first gave a brief introduction to the detriments of cigarette smoking, with an emphasis on its adverse effects on female reproductive health. Then, we outlined recent advances about the impacts of cigarette smoke on preimplantation embryo development. Additionally, toxicities of cadmium and benzo(a)pyrene (BaP) at this specific developmental window were also discussed, to illustrate the potential mechanisms involved in cigarette smoke-associated embryotoxicity. Finally, we provide an overview of the issues to be solved in the future research. Further studies about the molecular mechanism of cigarette smoking-associated female infertility may provide vital insights into developing new interventions for the women smokers and thus improving their reproductive outcomes.

Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations

Although often asymptomatic and detected incidentally, varicocele is a relatively common problem in patients who seek medical attention for infertility problems. Ultrasound (US) is the imaging modality of choice for evaluation, but there is no consensus on the diagnostic criteria, classification, and examination technique. In view of this uncertainty, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) undertook a systematic review of the available literature on this topic, to use as the basis for evidence-based guidelines and recommendations. This paper provides the results of the systematic review on which guidelines were constructed.

Pulmonary Emphysema Impairs Male Reproductive Physiology Due To Testosterone and Oxidative Stress Imbalance in Mesocricetus auratus

This study evaluated whether pulmonary emphysema affects sperm quality, male reproductive organs, and testosterone levels in adult male hamsters. Mesocricetus auratus males (130-150 g) were subdivided into a control group (C group) and an emphysema group (E group). The C group received an intratracheal instillation of saline solution (0.3 mL/100 g of body weight), and the E group received papain (40 mg/100 g of body weight). After 60 days, the biometric, pulmonary, and reproductive parameters of each group were evaluated. The E group developed pulmonary emphysema, which decreased body weight and sperm quality compared to the C group. In oxidative stress-related assays, lipid peroxidation was increased in the testis and epididymis (caput and cauda) in the E group compared with the C group. However, only the caput epididymis showed a reduction in glutathione levels. Pulmonary emphysema also affected the testicle by inducing an increase in abnormal seminiferous tubules, accompanied by a decrease in seminiferous epithelium height. Spermatogenesis kinetics were also modified by pulmonary emphysema. The number of Leydig and Sertoli cells decreased in the E group, accompanied by an increase in the nuclear volume of Leydig cells. Testosterone concentration was increased in the E group. Similarly, pulmonary emphysema altered epididymal components in all regions. In conclusion, pulmonary emphysema affected the reproductive system in this experimental model, as shown by testicular and epididymal morphophysiology changes, hormonal alteration, and oxidative stress imbalance, inducing the loss of correct function in the male reproductive system.

Low-dose heavy metal mixture (lead, cadmium and mercury)-induced testicular injury and protective effect of zinc and Costus afer in wistar albino rats

The study evaluated the protective effect of Costus afer on low-dose heavy metal mixture (LDHMM)-mediated effects in the testis of albino rats. The weight-matched animals were divided into six groups: normal control, metal mixture of (PbCl₂  + CdCl₂ + HgCl₂ ), combination of metal mixture + Costus afer at 750 mg/kg, combination of metal mixture + Costus afer at 1,500 mg/kg, combination of metal mixture + Costus afer at 2,250 mg/kg and combination of metal mixture + (ZnCl₂ ). LDHMM reduced (p < .05) the antioxidant biomarkers (superoxide dismutase, SOD; catalase, CAT; and glutathione, GSH) and increased (p < .05) the lipid peroxidation marker (malondialdehyde, MDA) and lead, cadmium and mercury concentrations in the testis. Treatment with LDHMM increased (p < .05) abnormal sperm morphology and plasma prolactin (PRL) level and decreased epididymal sperm count, viability, follicle-stimulating hormone (FSH), luteinising hormone (LH) and testosterone. LDHMM exposure caused deleterious changes in the testis. Treatment of rats with Costus afer (750, 1,500 and 2,250 mg/kg) dose-dependently reduced (p < .05) the LDHMM-mediated toxicity. Treatment with Costus afer also reversed the testicular weight and LDHMM decrease in antioxidant biomarkers. Costus afer may be a defensive modulator of LDHMM-mediated testicular lesions.

Disruption of ubiquitin specific protease 26 gene causes male subfertility associated with spermatogenesis defects in mice†

Ubiquitin-specific protease 26 (USP26) is an X-linked gene exclusively expressed in the testis and codes for the USP26, a peptidase enzyme that belongs to the deubiquitinating enzyme family. Recent studies have indicated that mutations in USP26 affect spermatogenesis and are associated with male infertility in humans and mice. However, the exact role of USP26 in spermatogenesis and how it affects male reproduction remains unknown. In this study, we generated a conventional Usp26 knockout mouse model and found that deletion of Usp26 in male mice (Usp26-/Y) leads to significantly reduced pup numbers per litter and significantly increased intervals between two consecutive offspring. We also found that the serum follicle stimulating hormone and testosterone levels of adult Usp26-/Y mice were significantly decreased compared to those of Usp26+/Y mice. Histological examination results showed that Usp26-/Y mice had significantly increased percentage of abnormal seminiferous tubules at different ages. Flow cytometry results exhibited that Usp26-/Y mice had significantly reduced percentage of mature haploid cells in the testes compared to Usp26+/Y mice. Sperm counts in epididymis were also significantly declined in Usp26-/Y mice compared to those in Usp26+/Y mice. Immunohistochemistry and immunofluorescence staining and immunoprecipitation analysis results showed that USP26 and androgen receptor were co-localized in mouse testicular cells at different ages and they both had physiological interactions. All these results demonstrated that the loss of Usp26 affects spermatogenesis and hormone secretion and causes male subfertility. Our study also provides the evidence on the interactions between USP26 and androgen receptor in mouse testis, whereby pointing to a potential mechanism.

Conventional semen analysis and advanced sperm function tests in diagnosis and management of varicocele

Clinical varicoceles are a common cause of male infertility and affect sperm parameters as measured in a conventional semen analysis. Varicocelectomy has been shown in prospective studies to improve semen parameters in men with a clinical varicocele. Clinical varicoceles are also a well-known source of oxidative stress which may affect the quality of spermatozoa. Spermatozoa are particularly susceptible to oxidative stress due to a limited capacity for DNA repair. The susceptibility of spermatozoa to oxidative stress is modulated by a balance between ROS and antioxidants, which can be quantified by various laboratory assays. Varicocelectomy has been consistently shown to reduce both ROS and sperm DNA fragmentation, and various assays should be utilised in the diagnosis and treatment of infertile men with a clinical varicocele.

Association between polymorphisms in the XRCC1 gene and male infertility risk: A meta-analysis

BACKGROUND

X-ray repair cross-complementing group 1 (XRCC1) single nucleotide polymorphisms (SNPs) might correlate with male infertility susceptibility. This association has been described; however, the findings remain inconsistent. Consequently, this meta-analysis was conducted to characterize the relationship between XRCC1 SNPs and male infertility susceptibility.

METHODS/MAIN RESULTS

Studies were systematically searched in databases to evaluate the association between SNPs of XRCC1 and infertility in males. The effect measures chosen were the 95% confidence intervals (95% CIs) and odds ratios (ORs). A total of 7 studies, including 6 case-controlled studies on XRCC1 Arg399Gln and 3 case-controlled studies on XRCC1 Arg194Trp, were included. Ultimately, the results of this analysis revealed that XRCC1 Arg399Gln SNPs were significantly associated with infertility in males in homozygote comparisons (GG vs GA+AA: OR = 0.614, 95% CI: 0.40-0.937, P = .024). This meta-analysis did not demonstrate a relationship between XRCC1 Arg194Trp and male infertility risk.

CONCLUSIONS

Our study indicated that XRCC1 Arg399Gln polymorphism was associated with a significantly decreased male infertility risk, but not XRCC1 Arg194Trp.

A contiguous microdeletion syndrome at Xp23.13 with non-obstructive azoospermia and congenital cataracts

Non-obstructive azoospermia accounts for 10-15% of male infertility, resulting in 60% of all cases of azoospermia and affecting about 1% of the male population. About 30% of these cases are due to Y chromosome microdeletions, chromosome abnormalities, or hormonal disorders. Pathogenic variants in genes on the sex chromosomes have key roles in spermatogenic failure. The co-occurrence of azoospermia and congenital cataracts ranges between 1 in 165,000 and 1 in 500,000. Our 28-year-old patient with normal intelligence and abnormally shaped teeth presented with both disorders. A microarray revealed a microdeletion at Xp23.13 with a whole NHS gene deletion as well as a contiguous deletion of two other genes [SCML1 and RAI2]. This observation represents the first report of non-obstructive azoospermia with congenital cataracts and a contiguous deletion of the SCML1 gene, a transcript of which is exclusively expressed in the testis. SCML1 is the putative culprit gene, which requires functional study or animal experiments. Our analysis of 60 known spermatogenesis failure-related genes by whole-exome sequencing revealed no other candidate. The Nance-Horan syndrome due to pathogenic variants in the NHS gene at Xp23.13 including whole gene deletion does not have azoospermia as a feature. Our report adds to the completeness of genetic counseling for an individual with azoospermia and congenital cataracts.

Increased DNA methylation in the spermatogenesis-associated (SPATA) genes correlates with infertility

BACKGROUND

Spermatogenesis-associated (SPATA) family of genes plays important roles in spermatogenesis, sperm maturation or fertilization. The knockout studies in mice have demonstrated that SPATA genes are crucial for fertility. Gene expression and genetic polymorphism studies have further suggested their correlation with infertility; however, methylation analysis of SPATA genes in human male infertility has not yet been undertaken.

OBJECTIVES

To analyze the methylation status of SPATA4, SPATA5 and SPATA6 genes in oligozoospermic male infertility.

MATERIALS AND METHODS

In the present study, we have analyzed DNA methylation pattern in the promoter regions of SPATA4, SPATA5 and SPATA6 genes in oligozoospermic patients and compared it with normozoospermic fertile controls. Semen samples were obtained from 30 oligozoospermic infertile and 19 normozoospermic fertile controls, and DNA methylation levels of the target gene promoters were analyzed by amplicon based deep sequencing methylation analysis using MiSeq.

RESULTS

SPATA4 (P < 0.0008), SPATA5 (P = 0.009) and SPATA6 (Promoter, P < 0.0005; Exon 1, P = 0.0128) genes were significantly hypermethylated in oligozoospermic patients in comparison to controls. This is the first study reporting a higher methylation in the promoters of SPATA4, SPATA5 and SPATA6 in oligozoospermic infertile individuals in comparison to the normozoospermic fertile controls.

DISCUSSION

Altered methylation of SPATA genes would affect pathways involved in sperm production or affect various processes linked to sperm fertility.

CONCLUSION

In conclusion, hypermethylation in the SPATA4, SPATA5 and SPATA6 genes correlates with oligozoospermic infertility.

Automatic grading of human blastocysts from time-lapse imaging

BACKGROUND

Blastocyst morphology is a predictive marker for implantation success of in vitro fertilized human embryos. Morphology grading is therefore commonly used to select the embryo with the highest implantation potential. One of the challenges, however, is that morphology grading can be highly subjective when performed manually by embryologists. Grading systems generally discretize a continuous scale of low to high score, resulting in floating and unclear boundaries between grading categories. Manual annotations therefore suffer from large inter-and intra-observer variances.

METHOD

In this paper, we propose a method based on deep learning to automatically grade the morphological appearance of human blastocysts from time-lapse imaging. A convolutional neural network is trained to jointly predict inner cell mass (ICM) and trophectoderm (TE) grades from a single image frame, and a recurrent neural network is applied on top to incorporate temporal information of the expanding blastocysts from multiple frames.

RESULTS

Results showed that the method achieved above human-level accuracies when evaluated on majority votes from an independent test set labeled by multiple embryologists. Furthermore, when evaluating implantation rates for embryos grouped by morphology grades, human embryologists and our method had a similar correlation between predicted embryo quality and pregnancy outcome.

CONCLUSIONS

The proposed method has shown improved performance of predicting ICM and TE grades on human blastocysts when utilizing temporal information available with time-lapse imaging. The algorithm is considered at least on par with human embryologists on quality estimation, as it performed better than the average human embryologist at ICM and TE prediction and provided a slightly better correlation between predicted embryo quality and implantability than human embryologists.

Dietary Antioxidant Intake in Relation to Semen Quality Parameters in Infertile Men: a Cross-Sectional Study

The objective of this study was to assess the association between dietary antioxidant intake and semen quality parameters in infertile men. In this cross-sectional study, dietary antioxidant intake was evaluated in 175 infertile Iranian men by a validated dish-based 106-item semi-quantitative food frequency questionnaire. Men were asked to abstain from ejaculation for at least 72 hours before sample collection. Semen parameters were assessed by a sperm counting chamber and Terminal deoxynucleotidyl transferase dUTP nick end labeling assay methods. Linear quantile regression was used to determine the associations between antioxidant nutrient intake and semen quality parameters (including total sperm count, sperm density, total motility, DNA damage and DNA fragmentation). Mean age of study participants was 32.19 ± 2.34 years. Compared with the lowest quartile, men in the highest quartile of dietary β-carotene and vitamin C intake had lower sperm DNA fragmentation index (P_trend = 0.042 and P_trend = 0.03, respectively). Also, dietary intake of beta-cryptoxanthin had a positive association with sperm density (P_trend = 0.02), and dietary lutein was associated with total sperm count (P_trend = 0.045). Dietary intake of other antioxidants did not significantly correlate with the indicators related to the quantity and quality of sperm (p > 0.05). These data suggest that dietary intake of some of the antioxidants is associated with semen related parameters.

Step-by-step loupes-mTESE in non-obstructive azoospermic men, a retrospective study

Background

Men with non-obstructive azoospermia (NOA) may have sperm in their testes and a procedure of sperm retrieval and assisted reproduction is required in them to allow fertility. Standard procedures such as fine needle aspiration (FNA) and conventional testicular sperm extraction (cTESE) harvest random samples with a sperm retrieval rate (SRR) of 45%. Microdissection testicular sperm extraction (mTESE) is nowadays considered to be the most accurate technique to retrieve sperm in men with NOA. This procedure can identify dilated tubules that are more likely to contain viable sperm with a SRR of 60%.

Results

In our center, testicular biopsy was conducted in a standard fashion in 321 patients with NOA until March 2003. From then to December 2017, due to the lack of an operating microscope, we used 6 fold magnifying loupes to perform a step-by-step macro- mTESE in 1050 patients. Sperm was found in the first testis in 61% of the cases, leading to stop the procedure with less testicular damage. We increased our SRR from 43 to 51.8% in an acceptable operating time of 75mn for both sides.

Conclusions

In institutions where surgeons cannot afford an operating microscope, this modified mTESE technique using × 6 magnifying loupes is reliable, especially in patients with low testicular volumes and high FSH, in whom dilated tubules can be easily identified from the surrounding tissue.

Demographics, Usage Patterns, and Safety of Male Users of Clomiphene in the United States

PURPOSE

The aim of this study was to characterize the demographics, usage patterns and complication rates of clomiphene use in male patients.

MATERIALS AND METHODS

We retrospectively analyzed male patients from ages 20 to 55 years old who were prescribed clomiphene citrate from 2001 to 2014 using the Truven Health MarketScan, a US claims database. We collected data regarding associated medical diagnoses, diagnostic testing, duration of use, and reported side effects including thrombotic events, vision problems, gynecomastia, mental disorders, liver disease, nausea, or skin problems.

RESULTS

In total, 12,318 men took clomiphene and represented the primary study cohort, with a mean age of 37.8 years. The percentage of men prescribed clomiphene increased over the study period, as did the average age of clomiphene users. Associated diagnoses included male infertility (52.0%), testicular hypofunction (13.5%), erectile dysfunction (2.4%), and low libido (0.4%). Associated testing included semen analysis (43.7%), testosterone (23.5%), luteinizing hormone (19.3%), and follicle-stimulating hormone (21.1%) levels. The median time of clomiphene use was 3.6 months, with 63% of men stopping within 6 months. No increased risk of reported clomiphene side effects were apparent in men taking the medication.

CONCLUSIONS

There is a rising prevalence of clomiphene usage without associated adverse side effects in the US. The variability in associated diagnoses, diagnostic testing, and duration of use suggest a need for greater awareness of the proper evaluation and treatment of the men who are prescribed clomiphene.

Evaluation of Seminal Fructose and Citric Acid Levels in Men with Fertility Problem

CONTEXT

Male infertility is a medical problem, attributed to 50% of infertility. Seminal plasma can be an anticipating factor as it comprises secretions of accessory sex gland, thus offering novel and precise ways to understand potential roles of these biochemical markers in male infertility.

AIM

The objective of this study was to assess the correlation between biochemical markers and sperm parameters in envisaging male infertility.

SUBJECTS AND DESIGN

We enlisted 105 men with fertility issue as patients and 25 fertile men as controls to evaluate the sperm parameters and biochemical markers, namely fructose and citric acid in ascertaining male infertility.

MATERIALS AND METHODS

The semen samples from patients were collected properly and analyzed according to the World Health Organization-2010 manual. Later samples were centrifuged, seminal plasma was collected, and biochemical markers assessment was carried out by standard protocols.

STATISTICS

Descriptive statistics, independent t-test, one-way ANOVA, and Pearson correlation were used for statistical analysis of different variables using SPSS 20.0. The mean sperm count and motility by all infertile conditions displayed a significant difference when compared with the controls (P < 0.05).

RESULTS

The mean fructose levels of oligozoospermia showed a nonsignificance difference when compared with controls (P < 0.05). Asthenozoospermia, asthenoteratozoospermia, and azoospermia had a significance difference (P < 0.05) for citric acid levels. Pearson correlation coefficient showed significant negative correlation of sperm count (r = -0.564) and sperm motility (r = -0.574) with fructose levels. Whereas seminal citric acid concentration had a positive correlation with sperm count (r = 0.458) and sperm motility (r = 0.446).

CONCLUSION

Therefore, evaluation of certain biochemical markers of seminal fluid may benefit in understanding the functionality of accessory glands which subsidizes significantly to the seminal volume.

Genome-wide differential methylation analyses identifies methylation signatures of male infertility

STUDY QUESTION

Do methylation changes in sperm DNA correlate with infertility?

STUDY ANSWER

Loss of spermatogenesis and fertility was correlated with 1680 differentially-methylated CpGs (DMCs) across 1052 genes.

WHAT IS KNOWN ALREADY

Methylation changes in a number of genes have been correlated with reduced sperm count and motility.

STUDY DESIGN, SIZE, DURATION

This case-control study used spermatozoal DNA from 38 oligo-/oligoastheno-zoospermic infertile patients and 26 normozoospermic fertile men.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Genome-wide methylation analysis was undertaken using 450 K BeadChip on spermatozoal DNA from six infertile and six fertile men to identify DMCs. This was followed by deep sequencing of spermatozoal DNA from 32 infertile patients and 20 fertile controls.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1680 DMCs were identified, out of which 1436 were hypermethylated and 244 were hypomethylated. Classification of DMCs according to the genes identified BCAN, CTNNA3, DLGAP2, GATA3, MAGI2 and TP73 among imprinted genes, SPATA5, SPATA7, SPATA16 and SPATA22 among spermatogenesis-associated genes, KDM4C and JMJD1C, EZH2 and HDAC4 among genes which regulate methylation and gene expression, HLA-C, HLA-DRB6 and HLA-DQA1 among complementation and immune response genes, and CRISPLD1, LPHN3 and CPEB2 among other genes. Genes showing significant differential methylation in deep sequencing, i.e. HOXB1, GATA3, EBF3, BCAN and TCERG1L, are strong candidates for further investigations. The role of chance was ruled out by deep sequencing of select genes.

LARGE-SCALE DATA

N/A.

LIMITATIONS, REASON FOR CAUTION

Genome-wide analyses are fairly accurate, but may not be exactly validated in replication studies across all DMCs. We used the 't' test in the genome-wide methylation analysis, whereas other tests could provide a more robust and powerful analysis.

WIDER IMPLICATIONS OF THE FINDINGS

DMCs can serve as markers for inclusion in infertility screening panels, particularly those in the genes showing differential methylation consistent with previous studies. The genes validated by deep sequencing are strong candidates for investigations of their roles in spermatogenesis.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Council of Scientific and Industrial Research (CSIR), Govt. of India with grant number BSC0101 awarded to Rajender Singh. None of the authors has any competing interest to declare.

Brain Cortical and Hippocampal Dopamine: A New Mechanistic Approach for Eurycoma longifolia Well-Known Aphrodisiac Activity and Its Chemical Characterization

Eurycoma longifolia Jack (Fam.: Simaroubaceae), known as Tongkat Ali (TA), has been known as a symbol of virility and sexual power for men. Metabolic profiling of the aqueous extract of E. longifolia (AEEL) using UPLC-MS/MS in both positive and negative modes allowed the identification of seventeen metabolites. The identified compounds were classified into four groups: quassinoids, alkaloids, triterpenes, and biphenylneolignans. AEEL is considered safe with oral LD₅₀ cut-off >5000 mg/kg. Oral administration of 50, 100, 200, 400, or 800 mg/kg of AEEL for 10 consecutive days to Sprague-Dawley male rats caused significant reductions in mounting, intromission, and ejaculation latencies and increased penile erection index. AEEL increased total body weight and relative weights of seminal vesicles and prostate. Total and free serum testosterone and brain cortical and hippocampal dopamine content was significantly elevated in treated groups with no significant effects on serotonin or noradrenaline content.

Reactive oxygen species-induced alterations in H19-Igf2 methylation patterns, seminal plasma metabolites, and semen quality

PURPOSE

This study was conducted in order to investigate the effects of reactive oxygen species (ROS) levels on the seminal plasma (SP) metabolite milieu and sperm dysfunction.

METHODS

Semen specimens of 151 normozoospermic men were analyzed for ROS by chemiluminescence and classified according to seminal ROS levels [in relative light units (RLU)/s/106 sperm]: group 1 (n = 39): low (ROS < 20), group 2 (n = 38): mild (20 ≤ ROS < 40), group 3 (n = 31): moderate (40 ≤ ROS < 60), and group 4 (n = 43): high (ROS ≥ 60). A comprehensive analysis of SP and semen parameters, including conventional semen characteristics, measurement of total antioxidant capacity (TAC), sperm DNA fragmentation index (DFI), chromatin maturation index (CMI), H19-Igf2 methylation status, and untargeted seminal metabolic profiling using nuclear magnetic resonance spectroscopy (1H-NMR), was carried out.

RESULT(S)

The methylation status of H19 and Igf2 was significantly different in specimens with high ROS (P < 0.005). Metabolic fingerprinting of these SP samples showed upregulation of trimethylamine N-oxide (P < 0.001) and downregulations of tryptophan (P < 0.05) and tyrosine/tyrosol (P < 0.01). High ROS significantly reduced total sperm motility (P < 0.05), sperm concentration (P < 0.001), and seminal TAC (P < 0.001) but increased CMI and DFI (P < 0.005). ROS levels have a positive correlation with Igf2 methylation (r = 0.19, P < 0.05), DFI (r = 0.40, P < 0.001), CMI (r = 0.39, P < 0.001), and trimethylamine N-oxide (r = 0.45, P < 0.05) and a negative correlation with H19 methylation (r = - 0.20, P < 0.05), tryptophan (r = - 0.45, P < 0.05), sperm motility (r = - 0.20, P < 0.05), sperm viability (r = - 0.23, P < 0.01), and sperm concentration (r = - 0.30, P < 0.001).

CONCLUSION(S)

Results showed significant correlation between ROS levels and H19-Igf2 gene methylation as well as semen parameters. These findings are critical to identify idiopathic male infertility and its management through assisted reproduction technology (ART).

Declining Sperm Counts… or Rather Not? A Mini Review

Importance

Temporal global trends of sperm quality remain a matter of debate.

Objective

The aim of this study was to present a comprehensive review of studies reporting on sperm quality counts, summarize the main end points, and assess the main reasons for potential discrepancies.

Evidence Acquisition

An evidence-based review of PubMed and Scopus databases was performed regarding studies reporting on modification of sperm quality counts, independently of study character, study language, or date.

Results

Since the meta-analysis of Carlsen et al in 1992 (Br Med J 1992;305:609-613) that suggested an annual decline in sperm count of 1%, several reports confirmed the decline in sperm quality, whereas others disproved them, suggesting a slight increase or absence of change in sperm count. Such controversies may be attributed to geographical and time-related variability in sperm values and also to several confounding factors that influence the semen parameters. Intrinsic weaknesses of the studies include heterogeneity of subjects recruited, lack of adjustment for confounding factors, and samples that do not always represent the general population.

Conclusions

No consensus exists on whether sperm counts actually decrease because studies' results are often controversial or inconclusive with methodological deficiencies. More prospective, large-scale, population based studies are needed in order to provide sound evidence of possible global trends in sperm count.

Protective effect of MOTILIPERM in varicocele-induced oxidative injury in rat testis by activating phosphorylated inositol requiring kinase 1α (p-IRE1α) and phosphorylated c-Jun N-terminal kinase (p-JNK) pathways

CONTEXT

MOTILIPERM was prepared as a mixture of extracts of three medicinal herbs [roots of Morinda officinalis How (Rubiaceae), outer scales of Allium cepa L. (Liliaceae) and seeds of Cuscuta chinensis Lamark (Convolvulaceae)].

OBJECTIVE

To investigate the role of reactive oxygen species (ROS)-based endoplasmic reticulum (ER) stress in a rat model of varicocele and the therapeutic efficacy of MOTILIPERM in this model.

MATERIALS AND METHODS

Sixty male rats were divided into five experimental groups: a normal control group (CTR + vehicle), a control group administered MOTILIPERM 200 mg/kg (CTR + M 200), a varicocele-induced control group (VC + vehicle) and two varicocele-induced groups administered MOTILIPERM 100 (VC + M 100) or 200 (VC + M 200) mg/kg for 4 weeks. Testis weights were recorded and serums were assayed for hormone concentrations. Tissues were subjected to semen analysis, histopathology, analyses of ER response protein expression levels and oxidative stress were assessed by measuring ROS, reactive nitrogen species (RNS), malondialdehyde (MDA) level and ratios of total glutathione (GSH)/oxidized GSH (GSSG).

RESULTS

MOTILIPERM treatment of varicocele-induced groups significantly increased left testis weight, testosterone level, sperm motility, count and spermatogenic cell density. ER-response protein expression levels were dose-dependently decreased in VC + M 200 group compared with VC + vehicle group. MOTILIPERM treatment also decreased MDA and ROS/RNS level but increased GSH/GSSG ratio.

DISCUSSION AND CONCLUSIONS

This study suggests that ROS-related ER stress may play a major role in varicocele-induced infertility and MOTILIPERM, a novel compound targeting ROS-based ER stress, may be therapeutically useful in treatment of varicocele, or as a supplement for the treatment of infertility.

Fine mapping the MHC region identified rs4997052 as a new variant associated with nonobstructive azoospermia in Han Chinese males

OBJECTIVE

To investigate the association between genetic variants in the major histocompatibility complex (MHC) region and nonobstructive azoospermia (NOA) susceptibility.

DESIGN

MHC region fine-mapping analysis based on previous NOA genome-wide association study (GWAS) data.

SETTING

Medical university.

PATIENT(S)

Nine hundred and eighty-one men with NOA and 1,657 normal fertile male controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The MHC region imputation assessed with SNP2HLA software, taking the specific Han-MHC database as a reference panel; statistical significance of the MHC variants calculated using logistic regression models; functional annotation based on online public databases; and phenotypic variances explained by specific groups of genetic variants estimated using the fixed effects model from individual associations.

RESULT(S)

Two independent risk loci, rs7194 (odds ratio [OR] 1.37) at MHC class II molecules and rs4997052 (OR 1.30) at MHC class I molecules, were identified. Functional annotation showed rs7194 may tag the effect of multiple amino acid residues and the expression of HLA-DQB1 and HLA-DRB1; while rs4997052 showed the effect of amino acid changes of HLA-B at position 116 as well as the expression of HLA-B and CCHCR1, which coexpressed with genes enriched in pathways of spermatogenesis and male gamete generation. The novel variant rs4997052 identified in our study can explain another approximately 0.66% of the phenotypic variances of NOA.

CONCLUSION(S)

We fine-mapped the MHC region and identified two loci that independently drove NOA susceptibility. These results provide a deeper understanding of the association mechanisms of MHC and NOA risk.

Idiopathic male infertility is strongly associated with aberrant DNA methylation of imprinted loci in sperm: a case-control study

BACKGROUND

Male infertility is a complex disease caused by a combination of genetic, environmental, and lifestyle factors. Abnormal epigenetic programming has been proposed as a possible mechanism compromising male fertility. Recent studies suggest that aberrant imprinting in spermatozoa in a subset of infertile men is a risk factor for congenital diseases in children conceived via assisted reproduction techniques. In this study, we examined the DNA methylation status of CpG sites within the differentially methylated regions (DMRs) of three imprinted genes, H19, GNAS, and DIRAS3, using combined bisulfite PCR restriction analysis and bisulfite sequencing in sperm obtained from 135 men with idiopathic male infertility, including normozoospermia (n = 39), moderate oligozoospermia (n = 45), and severe oligozoospermia (n = 51), and fertile controls (n = 59). The percentage of global methylation was compared between fertile controls and infertile patients displaying abnormal DNA methylation status of imprinted loci. Moreover, we also analyzed whether the DNA methyltransferases (DNMTs) polymorphisms impact upon the methylation patterns of imprinted genes in idiopathic infertile males.

RESULTS

Aberrant methylation patterns of imprinted genes were more prevalent in idiopathic infertile males, especially in patients with oligozoospermia. Infertile males with aberrant methylation patterns of imprinted genes displayed a tendency of lower global methylation levels, although not reaching statistical significance (P = 0.13). In the genotype-epigenotype correlation analysis, no significant association was observed between aberrant methylation patterns of the three imprinted genes and genotypes of the four DNA methyltransferase (DNMT) genes.

CONCLUSION

We conclude that abnormalities of DMR within imprinted genes may be associated with idiopathic male infertility. Disruption in methylation pattern of the three imprinted genes does not occur in high-risk genotypes of DNMTs.

The Impact of Microsurgical Repair of Subclinical and Clinical Varicoceles on Total Motile Sperm Count: Is There a Difference?

OBJECTIVE

To determine if subclinical varicocele repair produces similar results to palpable varicocele repair.

METHODS

Retrospective review was performed on 190 infertile men who underwent a microsurgical varicocele repair by two surgeons from 2009 to 2017. Improvement in total motile sperm count (TMC) that enables men limited to in vitro fertilization (IVF) or intrauterine insemination (IUI) to undergo IUI or natural conception (upgrade) is clinically meaningful. Using TMC, men were grouped into three pre- and postoperative categories: IVF, (TMC < 5 million), IUI (TMC 5-9 million), or natural pregnancy (TMC > 9 million). Changes in category after varicocele repair were assessed. We compared the proportion of men in each category with clinical varicoceles to those with subclinical varicoceles.

RESULTS

Men with clinical and subclinical varicoceles had improvements in TMC after surgery (change in TMC of 9.3 ± 19.5, 7.7 ± 22.6 million, P < 0.001 for both, respectively). There was no difference in TMC improvement between men with clinical and subclinical varicoceles (P = 0.66). Of men initially limited to IVF, 11% improved to IUI, and 38% to natural pregnancy. Of patients starting in IUI category, 22% transitioned to natural pregnancy category. No difference exists in the proportion of men who "upgraded" between palpable or subclinical varicoceles.

CONCLUSION

Men with subclinical varicoceles have similar, clinically meaningful improvement in TMC after varicocele repair compared with men with palpable varicoceles.

High-quality human and rat spermatozoal RNA isolation for functional genomic studies

Sperm RNA is a sensitive monitoring endpoint for male reproductive toxicants, and a potential biomarker to assess male infertility and sperm quality. However, isolation of sperm RNA is a challenging procedure due to the heterogeneous population of cells present in the ejaculate, the low yield of RNA per spermatozoon, and the absence of 18S and 28S ribosomal RNA subunits. The unique biology of spermatozoa has created some uncertainty in the field about RNA isolation methods, indicating the need for rigorous quality control checks to ensure reproducibility of data generated from sperm RNA. Therefore, we developed a reliable and effective protocol for RNA isolation from rat and human spermatozoa that delivers highly purified and intact RNA, verified using RNA-specific electrophoretic chips and molecular biology approaches such as RT-PCR and Western blot analysis. The sperm RNA isolation technique was optimized using rat spermatozoa and then adapted to human spermatozoa. Three steps in the sperm isolation procedure, epididymal fluid collection, sperm purification, and spermatozoon RNA extraction, were evaluated and assessed. The sperm RNA extraction methodology consists of collection of rat epididymal fluid with repeated needle punctures of the epididymis, somatic cell elimination using detergent-based somatic cell lysis buffer (SCLB) and the use of RNA isolation Kit. Rat sperm heads are more resistant to disruption than human spermatozoa, necessitating the addition of mechanical lysis with microbeads and heat in the rat protocol, whereas the human sperm protocol only required lysis buffer. In conclusion, this methodology results in reliable and consistent isolation of high-quality sperm RNA. Using this technique will aid in translation of data collected from animal models, and reproducibility of clinical assessment of male factor fertility using RNA molecular biomarkers.

Microscopic subinguinal varicocelectomy in 100 consecutive cases: Spermatic cord vascular anatomy, recurrence and hydrocele outcome analysis

Objective

To evaluate the detailed vascular anatomy of the spermatic cord during subinguinal microscopic varicocelectomy and to assess the outcome of the cases with regard to varicocele recurrence and hydrocele formation.

Patients and methods

In all, 100 varicocele cases including 74 left-sided and 26 bilateral, comprising 126 spermatic cord units with clinically palpable varicoceles underwent microscopic subinguinal varicocelectomy. Detailed description of vascular anatomy of the spermatic cords was reported. The number of spermatic, cremasteric, and inguinal veins was recorded. A record of testicular arteries and lymphatics was noted. Testicular delivery was done in all the cases and assessment of the gubernacular veins was reported. The patients underwent clinical evaluation, as well as scrotal Doppler ultrasonography, to detect varicocele recurrence and hydrocele formation. The mean (range) postoperative evaluation period was 6 (3–12) months.

Results

The mean number of spermatic veins was 14 on both sides. The mean number of spermatic arteries on both sides was 1.3. For lymphatics, the mean number was around three on both sides. The gubernacular veins were noted in 75% of the cases on the left side (mean number of 1.2) and in 85% on the right-side, (mean number of 1). The mean number of cremasteric veins on the left and right sides was 1.4 and 1.2, respectively. Finally, inguinal floor vessels were noted in 9% on the left-side and were not seen in the right-side cases. The incidence of varicocele recurrence was 2% and for hydrocele that was not clinically significant was 0.07%.

Conclusion

Microscopic subinguinal varicocelectomy accurately evaluated the detailed vascular anatomy of the spermatic cord, achieving excellent surgical outcome with minimal varicocele recurrence and hydrocele formation. Microscopic subinguinal varicocelectomy should be the ‘gold standard’ for varicocelectomy.

Role of reactive oxygen species in male infertility: An updated review of literature

Objectives

To review the literature and provide an updated summary on the role of reactive oxygen species (ROS) in male infertility.

Methods

A review of PubMed, Cochrane review, and Web of Science databases for full-text English-language articles published between 1943 and 2017 was performed, focusing on the aetiology of ROS, physiological role of ROS on spermatic function, pathological role of ROS in infertility, evaluation of ROS, and role of antioxidants in oxidative stress.

Results

ROS play a role in spermatic function and fertilisation. The literature describes both a physiological and a pathological role of ROS in fertility. A delicate balance between ROS necessary for physiological activity and antioxidants to protect from cellular oxidative injury is essential for fertility.

Conclusion

Although elevated levels of ROS are implicated as a cause of infertility, there is no consensus on selecting patients to test for ROS, which test to perform, or if treatment for ROS can have a positive impact on infertility rates and pregnancy.

Protective Effect of Selenium on Aflatoxin B1-Induced Testicular Toxicity in Mice

Aflatoxins have been considered as one of the major risk factors of male infertility, and aflatoxin B1 (AFB1) is the most highly toxic and prevalent member of the aflatoxins family. Selenium (Se), an essential nutritional trace mineral for normal testicular development and male fertility, has received extensive intensive on protective effects of male reproductive system due to its potential antioxidant and activating testosterone synthesis. To investigate the protective effect of Se on AFB1-induced testicular toxicity, the mice were orally administered with AFB1 (0.75 mg/kg) and Se (0.2 mg/kg or 0.4 mg/kg) for 45 days. We found that that Se elevated testes index, sperm functional parameters (concentration, malformation, and motility), and the level of serum testosterone in AFB1-exposed mice. Moreover, our results showed that Se attenuated the AFB1-induced oxidative stress and the reduction of testicular testosterone synthesis enzyme protein expression such as steroidogenic acute regulatory protein (StAR), P450 side-chain cleavage (P450scc), and 17β-hydroxysteroid dehydrogenase (17β-HSD) in AFB1-exposed mice. These results demonstrated that Se conferred protection against AFB1-induced testicular toxicity and can be attributed to its antioxidant and increased testosterone level by stimulating protein expression of StAR and testosterone synthetic enzymes.

Perspectives in Pediatric Pathology, Chapter 20. Adolescent Varicocele

Varicocele is characterized by elongation, dilatation, and tortuosity of the veins draining the testis and its covers, causing circulatory reflux along the inner spermatic vein [ 1 ]. Varicocele results in progressive testicular lesions and, if untreated, can lead to testicular atrophy [ 2 ]. Varicocele is considered the most frequently identified cause of male infertility [ 3 ]. The mechanisms involved in varicocele formation are not well known and probably are multiple, differing from one patient to another.

Relationship of DNA integrity to HRG C633T SNP and ART outcome in infertile couples

The status of sperm DNA fragmentation, protamine deficiency, free thiols and disulphide bonds in colloid-selected samples and its relationship to ART outcome or HRG C633T SNP is not known. The objective of this study was to determine these relationships in spermatozoa from men with male factor or unknown factor infertility (n = 118) undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). Sperm DNA integrity was analysed by flow cytometry using three fluorescent probes (acridine orange, monobromobimane and chromomycin A3). Principal component analysis (PCA) was used to identify the parameters that most influenced fertility. The relationships of sperm DNA integrity with seminal parameters, HRG C633T SNP and ART outcome were established using ANOVA and t-test. Sperm concentration and yield after preparation accounted for 27% of the total variance; sperm DNA integrity (%DFI and disulphide bonds) accounted for 16% of the variance in men from infertile couples. Sperm %DFI was significantly higher (P < 0.05) in older men than in younger men. A significant difference (P < 0.01) was observed in %DFI between smokers and non-smokers. Sperm %DFI was significantly higher (P < 0.01) in male factor infertility compared to either female factor or unknown factor infertility while free thiols were significantly higher (P < 0.01) in unknown infertility factor. No significant difference was observed between IVF success/failure in any of the seminal parameters studied. There was a tendency for protamine deficiency to be higher and disulphide concentration to be lower in men with HRG 633T. Such assessments may provide additional useful information about the prognosis for ART outcome, although more research is needed before clinical guidelines can be provided.

Are oxidative stress markers associated with unexplained male infertility?

Male infertility can be responsible for up to 20% of the cases attending fertility consultation facilities; nonetheless, the underlying molecular mechanisms that could explain it are still elusive. Therefore, we aimed to evaluate conventional and functional parameters of semen samples from patients who presented with male infertility of unknown origin. Conventional semen parameters and functional parameters (i.e. intracellular reactive oxygen species production, mitochondrial membrane potential, sperm chromatin structure assay, sperm membrane lipid peroxidation and antioxidant capacity of seminal plasma) were evaluated on semen samples from 54 healthy donors, 23 patients with idiopathic infertility and 34 fertile controls. No significant differences were observed in the conventional seminal parameters between the fertile and infertile men. However, increased intracellular reactive oxygen species (ROS) production and DNA fragmentation were observed in the infertile patients compared to the fertile group. Alterations in intracellular ROS production and DNA fragmentation could be associated with male idiopathic infertility. These parameters could eventually distinguish both groups more accurately than the conventional parameters. Our current results are encouraging, and the efficacy of these parameters in the clinical settings needs to be further assessed to establish their predictive potential as a marker of unexplained male infertility.

Altered micro-ribonucleic acid expression profiles of extracellular microvesicles in the seminal plasma of patients with oligoasthenozoospermia

OBJECTIVE

To determine whether microRNA (miRNA) expression profile is different in extracellular microvesicles collected from seminal plasma of men with oligoasthenozoospermia, to gain further insight into molecular mechanisms underlying male infertility.

DESIGN

Microarray with quantitative real-time polymerase chain reaction validation and Western blot analysis confirmation.

SETTING

University research and clinical institutes.

PATIENT(S)

A total of 24 men, including 12 oligoasthenozoospermic subfertile men and 12 normozoospermic men.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Statistically significant altered miRNA expression profiles in oligoasthenozoospermic subfertile men compared with normozoospermic fertile men.

RESULT(S)

Extracellular microvesicles including exosomes were isolated from seminal plasma by ultracentrifugation. Presence of exosome-specific proteins was confirmed by Western blotting. In the extracellular microvesicles, we analyzed 1,205 miRNAs by microarray and identified 36 miRNAs with altered expression levels in oligoasthenozoospermic compared with normozoospermic fertile men. Seven miRNAs were overexpressed and 29 miRNAs were underexpressed in oligoasthenozoospermic men. Using quantitative real-time polymerase chain reaction as an independent method, we confirmed the significantly higher expression levels of miR-765 and miR-1275 and the significantly lower expression level of miR-15a in oligoasthenozoospermic subfertile men as compared with the normozoospermic men.

CONCLUSION(S)

We identified altered expression levels of miRNAs in extracellular microvesicles from seminal plasma as part of the molecular events in the male genital tract. These miRNAs may help to understand the molecular mechanisms underlying male infertility.