Male contraception

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

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

A cell-based high-content screen identifies isocotoin as a small molecule inhibitor of the meiosis-specific MEIOB-SPATA22 complex†

MEIOB and SPATA22 are meiosis-specific proteins, interact with each other, and are essential for meiotic recombination and fertility. Aspartic acid 383 (D383) in MEIOB is critical for its interaction with SPATA22 in biochemical studies. Here we report that genetic studies validate the requirement of D383 for the function of MEIOB in mice. The Meiob^D383A/D383A mice display meiotic arrest due to depletion of both MEIOB and SPATA22 proteins in the testes. We developed a cell-based bimolecular fluorescence complementation (BiFC) assay, in which MEIOB and SPATA22 are fused to split YFP moieties and their co-expression in cultured cells leads to the MEIOB–SPATA22 dimerization and reconstitution of the fluorophore. As expected, the interaction-disrupting D383A substitution results in the absence of YFP fluorescence in the BiFC assay. A high-throughput screen of small molecule libraries identified candidate hit compounds at a rate of 0.7%. Isocotoin, a hit compound from the natural product library, inhibits the MEIOB–SPATA22 interaction and promotes their degradation in HEK293 cells in a dose-dependent manner. Therefore, the BiFC assay can be employed to screen for small molecule inhibitors that disrupt protein–protein interactions or promote degradation of meiosis-specific proteins.

The Function of Pre-mRNA Alternative Splicing in Mammal Spermatogenesis

Alternative pre-mRNA splicing plays important roles in co-transcriptional and post-transcriptional regulation of gene expression functioned during many developmental processes, such as spermatogenesis. The studies focusing on alternative splicing on spermatogenesis supported the notion that the development of testis is regulated by a higher level of alternative splicing than other tissues. Here, we aim to review the mechanisms underlying alternative splicing, particularly the splicing variants functioned in the process of spermatogenesis and the male infertility. There are five points regarding the alternative splicing including ⅰ) a brief introduction of alternative pre-mRNA splicing; ⅱ) the alternative splicing events in spermatogenesis-associated genes enriched in different stages of spermatogenesis; ⅲ) the mechanisms of alternative splicing regulation, such as splicing factors and m⁶A demethylation; ⅳ) the splice site recognition and alternative splicing, including the production and degradation of abnormal transcripts caused by gene variations and nonsense-mediated mRNA decay, respectively; ⅴ) abnormal alternative splicing correlated with male infertility. Taking together, this review highlights the impacts of alternative splicing and splicing variants in mammal spermatogenesis and provides new insights of the potential application of the alternative splicing into the therapy of male infertility.

Epididymal approaches to male contraception

Today, a vast arsenal of contraceptive methods interfering at different levels of the female reproductive axis is available. This is not the case for men for whom, until now, there is no reliable male reversible method and for whom vasectomy, condom and withdrawal are the only options available. Despite this limited supply, more than one third of all contraceptive methods used worldwide rely on the cooperation of the male partner. Besides developing hormonal approaches to stop sperm production, there may be attractive approaches that will interfere with sperm functions rather than production. Sperm functions are primarily established during post-testicular maturation, with the epididymis accounting for the majority. The purpose of this review is to present some of the promising and/or already abandoned leads that emerge from research efforts targeting the epididymis and its activities as potential means to achieve male post-meiotic contraception.

A Comparison of Secondary Polycythemia in Hypogonadal Men Treated with Clomiphene Citrate versus Testosterone Replacement: A Multi-Institutional Study

PURPOSE

We evaluated the relative prevalence of secondary polycythemia in hypogonadal men treated with clomiphene citrate or testosterone replacement therapy.

MATERIALS AND METHODS

In this retrospective, multi-institutional study, we included 188 men who received clomiphene citrate and 175 who received testosterone replacement therapy with symptomatic hypogonadism. The overall prevalence and ORs of secondary polycythemia for clomiphene citrate treatment vs testosterone replacement were primarily measured, as were baseline characteristics. Subset analysis included polycythemia rates for different types of testosterone replacement therapy.

RESULTS

Overall, men on testosterone replacement therapy were older than clomiphene citrate treated men (age 51.5 vs 38 years). Men on testosterone replacement had longer treatment duration than clomiphene citrate treated men (19.6 vs 9.2 months). For testosterone replacement therapy and clomiphene citrate the mean change in hematocrit was 3.0% and 0.6%, and the mean change in serum testosterone was 333.1 and 367.6 ng/dl, respectively. The prevalence of polycythemia in men on testosterone replacement was 11.2% vs 1.7% in men on clomiphene citrate (p = 0.0003). This significance remained on logistic regression after correcting for age, site, smoking history and pretreatment hematocrit.

CONCLUSIONS

The prevalence of polycythemia in men treated with clomiphene citrate was markedly lower than that in men on testosterone replacement therapy. The improvement in absolute serum testosterone levels was similar to that in men on testosterone replacement. There is no significant risk of polycythemia in men treated with clomiphene citrate for hypogonadism.

Expression of the SET protein in testes of mice at different developmental stages

SET is a multifunctional protein involved in regulating many biological processes of the cell cycle. It is also a regulator of steroidogenesis in the ovary. However, the expression of SET protein in testis, and its function, still remains ambiguous. In this study, we observed the expression of SET in the testes of mice at different developmental stages, and have discussed its potential function in regulating spermatogenesis and androgen production. Forty-eight male mice at different developmental stages (1 week old as the infancy group; 4 weeks old as the prepubertal group; 12 weeks old as the adult group; over 12 months old as the ageing group) were used. Cellular location of SET protein in the testes was observed by immuno-histochemistry. Expression levels of Set mRNA and SET protein were analyzed by quantitative polymerase chain reaction and Western blotting. SET protein was expressed in spermatogonial cells and spermatocytes; the highest level was mainly in haploid and tetraploid cells of the prepubertal and adult groups, and Leydig cells of the adult and ageing groups. There was a low expression in Sertoli cells. Expression of Set mRNA in the prepubertal group was significantly higher than that in the adult group (P < 0.05), while expression of SET protein was at the highest level in the adult group (P < 0.05). SET protein is mainly expressed in spermatogonial cells and spermatocytes, and poorly expressed in Sertoli cells, suggesting that it is involved in spermatogenesis. Expression of SET protein in Leydig cells suggests a possible role in steroidogenesis.

Enclomiphene citrate stimulates testosterone production while preventing oligospermia: a randomized phase II clinical trial comparing topical testosterone

OBJECTIVE

To determine the effect of enclomiphene citrate in men with secondary hypogonadism.

DESIGN

Phase II clinical trial.

SETTING

Community dwelling men making visits to physician offices.

PATIENT(S)

Men with secondary hypogonadism.

INTERVENTION(S)

Oral administration of enclomiphene citrate or 1% topical T gel.

MAIN OUTCOME MEASURE(S)

Luteinizing hormone, FSH, T, and semen analysis.

RESULT(S)

Treatment with enclomiphene citrate resulted in increased morning serum T, E2, and LH levels similar to those obtained with a topical T gel in men with secondary hypogonadism. Follicle-stimulating hormone and LH were increased with enclomiphene, and sperm counts were conserved.

CONCLUSION(S)

Enclomiphene citrate reverses the two hallmarks of secondary hypogonadism, namely, low serum total T and low or inappropriately normal LH while preserving sperm production.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01270841 (ClinicalTrials.gov Identifier NCT01270841).

Les approches épididymaires de la contraception masculine

L’offre en matière de moyens contraceptifs masculins est limitée et, en particulier, à ce jour il n’existe pas de contraception hormonale masculine sur le marché. L’épididyme, dans lequel les spermatozoïdes acquièrent leurs capacités fécondantes et où ils sont stockés, s’avère être un site intéressant à cibler. Cette revue vise à présenter de façon synthétique les quelques pistes prometteuses qui ont émergé ces dernières années.

transient scrotal hyperthermia and levonorgestrel enhance testosterone-induced spermatogenesis suppression in men through increased germ cell apoptosis

CONTEXT

In rodents and monkeys, a combination of hormonal and physical agents accelerates germ cell death.

OBJECTIVE

A "proof of concept" study was performed to investigate whether addition of heat exposure or a progestin to an androgen induces germ cell death and more complete and rapid spermatogenesis suppression.

DESIGN AND SETTINGS

A randomized clinical trial was performed at academic medical centers.

PARTICIPANTS

We treated four groups of healthy male volunteers (18 per group) for 18 wk: 1) testosterone undecanoate (TU) 1000 mg im (first dose), followed by 500 mg im every 6 wk; 2) submersion of scrota at 43 C in water for 30 min/d for 6 consecutive days; 3) TU plus heat; and 4) TU plus oral levonorgestrel (LNG) 250 microg/d.

MAIN OUTCOME MEASURES

Semen parameters, testicular histology, and germ cell apoptosis were the main outcome measures.

RESULTS

Heat alone and TU plus heat suppressed sperm counts more than TU alone by wk 6. By wk 9, recovery began in the heat only group, whereas spermatogenesis remained suppressed in the TU plus heat group. Oral LNG plus TU suppressed spermatogenesis earlier and more severely than TU alone. At wk 2, significantly greater germ cell apoptosis occurred in heat and heat plus TU subjects, but not in subjects without heat treatment, compared with pretreatment subjects. By 9 wk, markedly smaller seminiferous tubule diameters and fewer spermatocytes and spermatids were noted in all 12 biopsies from men receiving TU, TU plus LNG, with most dramatic differences for the TU plus heat group, whereas no differences from pretreatment biopsies were observed in men who received heat treatment only.

CONCLUSIONS

Heat causes a rapid and transient suppression of spermatogenesis. TU plus heat resulted in low-sperm output that was maintained by continuous treatment with TU. Addition of an oral progestin accelerated spermatogenesis suppression by TU alone. Increased germ cell apoptosis contributed to suppression of spermatogenesis.

Advances in male hormonal contraception

There is a need to develop new contraceptives, particularly for men whose current choices are suboptimal in terms of effectiveness and ease of reversibility. Recent surveys indicate that men and their partners would be willing to rely on male hormonal contraceptives. Male hormonal contraception works by reversibly suppressing sperm production. Testosterone in combination with progestins or gonadotropin-releasing hormone antagonists induces profound and consistent sperm suppression. Asian men are more susceptible to the suppressive effects of testosterone given alone, even if they may benefit from the addition of an adjunctive agent to obtain optimal contraceptive protection. The aim of this review is to comment on the recent relevant achievements in the field.

Acceptability of an injectable male contraceptive regimen of norethisterone enanthate and testosterone undecanoate for men

BACKGROUND

We assessed attitudes towards and acceptability of male hormonal contraception among volunteers participating in a clinical trial of a prototype regimen, consisting of progestin and testosterone injections.

METHODS

After completing screening, eligible men were randomly assigned to the no-treatment group (n = 40) or to receive injections of norethisterone enanthate and testosterone undecanoate or placebo at different intervals (n = 50) according to a blocked randomization list. They underwent self-administered questionnaires.

RESULTS

The average age of the participants was approximately 28 years; most were involved in a stable relationship and had no children. Ninety-two percentage of the respondents thought that men and women should share responsibility for contraception and 75% said they would try a hormonal contraceptive if available. At the end of the treatment phase, 66% of the participants said that they would use such a method, and most rated its acceptability very highly; none reported it to be unacceptable. The injections themselves were indicated as the biggest disadvantage. No significant changes in sexual function or mood states were detected among the men who underwent hormone injections.

CONCLUSIONS

The contraceptive tested in this study was well accepted by the participants over the course of 1 year.

Transient testicular warming enhances the suppressive effect of testosterone on spermatogenesis in adult cynomolgus monkeys (Macaca fascicularis)

CONTEXT

The context of the study was to examine whether combined testosterone (T) and heat (H) treatment have additive or synergistic effects on suppression of spermatogenesis.

OBJECTIVE

The objective of the study was to determine whether T+H induces a greater suppression of spermatogenesis than either treatment alone in monkeys.

DESIGN

The study was a randomized, placebo-controlled study.

SETTING

The study was conducted at a primate center in China.

PARTICIPANTS

The study population was comprised of 32 adult cynomolgus monkeys.

INTERVENTIONS

Groups of eight adult monkeys were treated for 12 wk with: 1) two empty implants (C); 2) two T implants (T); 3) daily testicular heat exposure (43 C for 30 min) for 2 consecutive days (H); or 4) two T implants plus testicular heat exposure (T+H). Treatment was followed by an 8-wk recovery period.

MAIN OUTCOME MEASURES

Measures included sperm counts and germ cell apoptosis.

RESULTS

Serum T levels were elevated in both the T and T+H groups during treatment but not in the C or H group. Sperm counts were transiently suppressed after heat to 16.4% of baseline at 4 wk and then returned to pretreatment levels. Sperm counts were suppressed slowly after T treatment to nadir of 6.4% of pretreatment levels at 12 wk. T+H rapidly suppressed sperm output as early as 4 wk to 3.9% of pretreatment levels that was maintained throughout treatment. The decreased sperm counts were due to increased germ cell apoptosis in all treatment groups. Sperm counts recovered to the pretreatment levels in all groups by 8 wk after treatment.

CONCLUSION

This proof-of-concept study demonstrates that transient testicular warming enhances and hastens the effect of T implant on the suppression of spermatogenesis in monkeys.

Control of spermatogenesis in primate and prospect of male contraception

The present review is a summary of mechanisms of spermatogenesis in primates with emphasis on anti-spermatogenesis of testosterone (T), gossypol, and "testicular heat stress" for development of male contraception, Both FSH and testosterone stimulate all phases of spermatogenesis. FSH is capable of amplifying the population of the differential spermatogonia (B1, B2, B3 and B4) and controls the spermatogonia production rate, and, in synergy with testosterone, regulating spermatogenesis in adult monkeys. Pituitary FSH beta gene expression is governed by a feedback of Beta inhibin, which is a major component of the testicular negative feedback signals. Beta inhibin secreted by Sertoli cells is in turn inhibited by testosterone from Leydig cells under the control of LH. Disturbance of the normal interaction of pituitary FSH with Sertoli cell Beta inhibin is responsible for azoospermia or oligozoospermia induced by exogenous T. Three possible regimens of T, gossypol and "heat stress" have been suggested for male contraception. They act on different sites and stages of spermatogenesis in testis or sperm activity in epididymis. Apoptosis induced by testosterone occurs mainly at staged VII-VIII of spermatogenesis while that by testicular "heat stress" mostly occurs at stages I-IV and X-XII. Low dose of gossypol mainly influences the sperm activity in the epididymis although it also acts on testicular spermatids.

Progesterone: the forgotten hormone in men?

'Classical' genomic progesterone receptors appear relatively late in phylogenesis, i.e. it is only in birds and mammals that they are detectable. In the different species, they mediate manifold effects regarding the differentiation of target organ functions, mainly in the reproductive system. Surprisingly, we know little about the physiology, endocrinology, and pharmacology of progesterone and progestins in male gender or men respectively, despite the fact that, as to progesterone secretion and serum progesterone levels, there are no great quantitative differences between men and women (at least outside the luteal phase). In a prospective cohort study of 1026 men with and without cardiovascular disease, we were not able to demonstrate any age-dependent change in serum progesterone concentrations. Progesterone influences spermiogenesis, sperm capacitation/acrosome reaction and testosterone biosynthesis in the Leydig cells. Other progesterone effects in men include those on the central nervous system (CNS) (mainly mediated by 5alpha-reduced progesterone metabolites as so-called neurosteroids), including blocking of gonadotropin secretion, sleep improvement, and effects on tumors in the CNS (meningioma, fibroma), as well as effects on the immune system, cardiovascular system, kidney function, adipose tissue, behavior, and respiratory system. A progestin may stimulate weight gain and appetite in men as well as in women. The detection of progesterone receptor isoforms would have a highly diagnostic value in prostate pathology (benign prostatic hypertrophy and prostate cancer). The modulation of progesterone effects on typical male targets is connected with a great pharmacodynamic variability. The reason for this is that, in men, some important effects of progesterone are mediated non-genomically through different molecular biological modes of action. Therefore, the precise therapeutic manipulation of progesterone actions in the male requires completely new endocrine-pharmacological approaches.

Steroid hormones for contraception in men

BACKGROUND

Male hormonal contraception has been an elusive goal. Administration of sex steroids to men can shut off sperm production through effects on the pituitary and hypothalamus. However, this approach also decreases production of testosterone, so "add-back" therapy is needed.

OBJECTIVES

To summarize all randomized controlled trials of male hormonal contraception.

SEARCH STRATEGY

We searched the computerized databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Popline, and LILACS (each from inception to February, 2003) for randomized controlled trials of hormonal contraception in men. We wrote to authors of identified trials to seek unpublished or published trials that we might have missed.

SELECTION CRITERIA

We included all randomized controlled trials in any language that compared a steroid hormone with another contraceptive. We excluded non-steroidal male contraceptives, such as gossypol. We included both placebo and active-regimen control groups. All trials identified included only healthy men with normal semen analyses.

DATA COLLECTION AND ANALYSIS

Azoospermia (absence of spermatozoa on semen examination) was the primary outcome measure. Data were insufficient to examine pregnancy rates and side effects.

MAIN RESULTS

The proportion of men who achieved azoospermia varied widely in reports to date. Few significant differences emerged from these trials. Levonorgestrel implants combined with injectable testosterone enanthate (100 mg IM) was significantly more effective than was levonorgestrel 125 mcg by mouth daily combined with testosterone patches (10 mg/d) (OR for azoospermia with the oral levonorgestrel regimen 0.03; 95%CI 0.00-0.29). The addition of levonorgestrel 500 mcg by mouth daily improved the effectiveness of testosterone enanthate 100 mg IM weekly by itself (OR for azoospermia with the combined regimen 4.0; 95%CI 1.00-15.99). Several regimens, including testosterone alone and GnRH agonists and antagonists, had disappointing results.

REVIEWERS' CONCLUSIONS

No male hormonal contraceptive is ready for clinical use. All trials published to date have been small exploratory studies. As a result, their power to detect important differences has been limited and their results imprecise. In addition, the definition of oligospermia has been imprecise or inconsistent in many reports. To avoid bias, future trials need more attention to the methodological requirements for randomized controlled trials. Trials with adequate power would also be helpful.

Testosterone undecanoate maintains spermatogenic suppression induced by cyproterone acetate plus testosterone undecanoate in normal men

In this study we evaluated whether testosterone undecanoate (TU), alone or combined with low dose cyproterone acetate (CPA), can maintain spermatogenic suppression induced by higher doses of CPA plus TU. Twenty-four men received for 12 wk 20 mg/d CPA plus 1000 mg/6 wk TU and then 1000 mg/8 wk TU plus 20 mg/d CPA (n = 8), 2 mg/d CPA (n = 8), or plus placebo (n = 8) for 32 wk. Blood samples, physical examinations, hormones, chemistry, hematology, semen analysis, and sexual/behavioral assessments were performed throughout the study. Sperm counts decreased to less than 1 million/ml in all subjects by wk 12, and 54% of them achieved azoospermia. Suppression of sperm counts was maintained until wk 44. Serum LH and FSH levels were suppressed by wk 12 of hormone administration and remained suppressed until wk 44. No significant changes in any biochemical parameters were detected at wk 44 in any group. There was a slight increase in total prostate volume to within the normal range at wk 44 that returned to baseline 1 yr after stopping hormone administration. In conclusion, TU alone or combined with lower doses of CPA maintains sperm suppression induced by higher dose CPA plus TU for 32 wk. This prototype regimen represents a promising male contraceptive regimen.

Effects of the chronic use of dehydroepiandrosterone (DHEA) on testicular weight and spermatogenesis: experimental study in rats

AIM

The complete biological effects of chronic use of dehydroepiandrosterone (DHEA), reported as a weak androgen, are not completely understood. The aim of the present study is to evaluate the effects of chronic administration of DHEA on the spermatogenesis in rats.

METHODS

Male Wistar rats, 4 months old, were selected for the study. The animals were divided into two groups. Group 1 (n = 9) received placebo (saline solution) 0.5 ml/day and Group 2 (n = 15) received DHEA 5 mg/kg/day. Both the groups received the respective treatments 5 days a week during 10 months. At the end of the exposure, the rats were sacrificed and the testes removed, weighed and processed for histologic analysis. Spermatogenesis was evaluated as the mean number of seminiferous tubules with and without spermatids in maturation phase in their lumen, in five random fields on the same slide.

RESULTS

The median levels of serum total testosterone and dehydroepiandrosterone sulfate was measured in the two groups. Significant higher concentrations in total testosterone (2.06 +/- 0.4 vs. 0.80 +/- 0.2; p < 0.05) and DHEAS (222.1 +/- 41.5 vs. 2.0 +/- 0.3) were observed in the group treated with DHEA as compared to the control group. The mean weights of the right testes were 1.59 +/- 0.3 in group 1 and 1.58 +/- 0.2 g in group 2 (p > 0.05). These values for the left testes were 1.57 +/- 0.3 and 1.55 +/- 0.3 g, respectively (p > 0.05). The histologic analysis showed a mean of 13.5 +/- 1.5 and 12.8 +/- 1.8 seminiferous tubules per field in the groups 1 and 2, respectively (p > 0.05). The same analysis demonstrated that in the control group 0.06 +/- 0.1 of the tubules presented without spermatids in maturation phase and in the DHEA group this was observed in 0.22 +/- 1.2 of the tubules (p > 0.05).

CONCLUSION

Chronic administration of DHEA in the present dose did not show any detectable effect on the quantitative and qualitative analyses of spermatogenesis in rats.

Reversible infertility in male mice after oral administration of alkylated imino sugars: a nonhormonal approach to male contraception

During mammalian spermatogenesis, male germ cells undergo a dramatic transformation, which includes a change of shape, nuclear condensation, and development of specialised structures, such as an acrosome, and a flagellum with a mitochondrial sheath. We have found a previously undescribed pharmacological approach to intervene in these events. After oral administration of the alkylated imino sugar N-butyldeoxynojirimycin (NB-DNJ) to mice, epididymal spermatozoa displayed a spectrum of abnormal head shapes, and acrosomal antigens were mostly absent or displayed irregular patterns. In addition, the mitochondria of these cells often had an aberrant morphology, and were arranged in relatively short and wide mitochondrial sheaths. The motility of the affected spermatozoa was severely impaired. After 3 weeks of administration of NB-DNJ, male mice became sterile, and regained their fertility during the fourth week off drug. The NB-DNJ-induced infertility was not associated with a reduction in the serum testosterone level. Biochemically, the capacity of imino sugars to impair spermatogenesis was associated with their potential to attenuate the biosynthesis of glucosylceramide-based sphingolipids. Our study reveals that male fertility is affected by partial glycosphingolipid depletion, or, alternatively, by a distinct as yet unidentified property that is shared by alkylated imino sugars that inhibit glucosylceramide biosynthesis. These compounds therefore may be new leads in the development of a male contraceptive, especially because NB-DNJ has already been through extensive evaluation in various mammals, including man.