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Takeshima T, Mihara T, Tomita M, Kuroda S, Yumura Y, Ueno H, Yamamoto M, Murase M. Add-on effects of oral tocopherol supplementation to surgical varicocelectomy on the outcome of assisted reproductive technology: a single-center pilot study report. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 5:1325566. [PMID: 38318605 PMCID: PMC10839009 DOI: 10.3389/frph.2023.1325566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/18/2023] [Indexed: 02/07/2024] Open
Abstract
Introduction Varicocelectomy is well known to improve the pregnancy outcome of patients with clinical varicoceles in assisted reproductive technologies as well as spontaneous conception. Therefore, this study aimed to evaluate the additional effects of oral antioxidant therapy after varicocelectomy on the pregnancy outcome in the assisted reproductive technology setting. Methods This study was a retrospective cohort study. The subjects were couples among whom the male partner had undergone varicocelectomy and was scheduled for subsequent assisted reproductive technology. Pregnancy outcomes were followed retrospectively in 62 couples with male partners who received tocopherol (antioxidant group) and 37 couples who did not (control group). The tocopherol and control groups were assigned dependent on the decision of the physician in charge and the patient's request. The clinical pregnancy rates per couple and embryo transfer, time to pregnancy, and the number of cycles during transfer to pregnancy were evaluated. Results No significant differences were observed in the pregnancy rate per couple (antioxidant group 70.9% vs. control group 64.9%, P = 0.55) and per embryo transfer (50.4% vs. 39.6%, P = 0.22). Regarding the time to event analyzed by adjusted restricted mean survival time, the mean time to pregnancy was significantly shorter in the antioxidant (tocopherol) group (14.2 vs. 17.4 months, P = 0.025). No significant difference was observed in the embryo transfer cycle to pregnancy (mean embryo transfer cycles: 2.6 vs. 3.0, P = 0.238). Conclusions Additional oral tocopherol nicotinate as antioxidant therapy after varicocelectomy was shown to shorten the time to pregnancy. It is recommended that add-on effects be tested in more well-designed randomized controlled trials to examine whether it improves assisted reproductive outcomes.
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Affiliation(s)
- Teppei Takeshima
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Kanagawa, Japan
- Department of Urology, Reproduction Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Kanagawa, Japan
| | - Makoto Tomita
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Kanagawa, Japan
| | - Shinnosuke Kuroda
- Department of Urology, Reproduction Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Yasushi Yumura
- Department of Urology, Reproduction Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Hiroe Ueno
- Department of Gynecology, Reproduction Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Mizuki Yamamoto
- Department of Gynecology, Reproduction Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Mariko Murase
- Department of Gynecology, Reproduction Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
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2
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Banihani SA, Aljabali SM. Men with oligozoospermia had lower level of seminal plasma pyridoxine compared to normozoospermic men. Heliyon 2022; 8:e11983. [DOI: 10.1016/j.heliyon.2022.e11983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 09/22/2021] [Accepted: 11/22/2022] [Indexed: 12/03/2022] Open
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3
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Wang K, Gao Y, Wang C, Liang M, Liao Y, Hu K. Role of Oxidative Stress in Varicocele. Front Genet 2022; 13:850114. [PMID: 35401656 PMCID: PMC8984266 DOI: 10.3389/fgene.2022.850114] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/08/2022] [Indexed: 01/29/2023] Open
Abstract
According to the official statistics of the World Health Organization, at least 48 million couples and 186 million people suffer from infertility. Varicocele has been recognized as the leading cause of male infertility and can affect spermatogenesis and cause testicular and epididymal disorders through multiple diverse pathophysiological processes. Reactive oxygen species (ROS) produced by oxidative stress have been reconciled as an important pathogenic factor throughout the course of varicocele. Testis respond to heat stress, hypoxia, and inflammation at the cost of producing excessive ROS. High levels of ROS can lead to infertility not only through lipid peroxidation or DNA damage, but also by inactivating enzymes and proteins in spermatogenesis. This review studies the oxidative stress and its role in the pathophysiology and molecular biology of varicocele in the context of a decline in fertility.
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Affiliation(s)
| | | | | | | | | | - Ke Hu
- *Correspondence: Ke Hu, ; Yaping Liao,
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4
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Finelli R, Leisegang K, Kandil H, Agarwal A. Oxidative Stress: A Comprehensive Review of Biochemical, Molecular, and Genetic Aspects in the Pathogenesis and Management of Varicocele. World J Mens Health 2021; 40:87-103. [PMID: 34666421 PMCID: PMC8761243 DOI: 10.5534/wjmh.210153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/02/2021] [Accepted: 08/12/2021] [Indexed: 12/02/2022] Open
Abstract
Oxidative stress is a condition due to an imbalance between the concentrations of oxidants and antioxidants, and it is a well-recognized contributor in several male infertility conditions. Varicocele, a common vascular condition, may cause male infertility due to hyperthermia, hypoxia and/or exposure to toxic adrenal and renal metabolites. In this review, the mechanisms by which oxidative stress can affect cellular integrity and functions are described, along with molecular markers of cellular oxidative damage, and the most commonly performed techniques for their detection in seminal fluid. Moreover, we focus on the role of oxidative stress in the pathophysiology of varicocele based on recently published evidence from omics based studies, such as proteomics and genomics. Finally, we discuss strategies for the management of oxidative stress and the clinical guidelines for testing oxidative stress-related sperm DNA fragmentation in this group of patients.
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Affiliation(s)
- Renata Finelli
- Department of Urology, American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Kristian Leisegang
- School of Natural Medicine, University of the Western Cape, Bellville, Cape Town, South Africa
| | - Hussein Kandil
- Fakih IVF Fertility Center, Abu Dhabi, United Arab Emirates
| | - Ashok Agarwal
- Department of Urology, American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA.
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5
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Tsampoukas G, Gkeka K, Dellis A, Brown D, Katsouri A, Alneshawy A, Moussa M, Papatsoris A, Buchholz N. Vitamins as primary or adjunctive treatment in infertile men with varicocele: A systematic review. Arab J Urol 2021; 19:264-273. [PMID: 34552778 PMCID: PMC8451598 DOI: 10.1080/2090598x.2021.1932124] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/08/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To investigate the usage and the efficacy of vitamins as primary or adjuvant treatment in infertile men with varicocele. METHODS A systematic search in PubMed, the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cochrane Library with the terms (varicocele) AND (vitamins) was performed. We searched for studies: a) reporting the administration of vitamins (individually or as part of a complex) in men with varicocele and infertility, b) primarily or adjuvant to invasive treatment, and c) reporting the impact on semen parameters and/or pregnancy rates. Exclusion criteria were animal, adolescent and non-English studies, grey literature and trials reporting abstracts only. RESULTS Seven studies were identified eligible for qualitative analysis. All studies were randomised except one (case series). Vitamins were administered dominantly as part of antioxidant complex and only two studies used vitamins (C and E, respectively) as sole agent. In two studies, vitamin monotherapy resulted in improvement in semen quality, but the effect on pregnancy rates is unknown. One study reported no efficacy of adjuvant multivitamin treatment after embolisation in terms of both semen quality and pregnancy rates. Finally, four studies reported a positive effect of vitamins on semen parameters after varicocelectomy, but the effect on pregnancy rates is conflicting; one study reported improved pregnancy rates with adjuvant treatment, two studies did not evaluate the pregnancy rates, and in one study the outcome was unclear due to missing data. CONCLUSIONS Vitamins have been used mostly as part of an antioxidant panel for the management of infertile men with varicocele. Most studies have found a positive impact on semen parameters in selected men with varicocele and infertility, as primary or adjuvant treatment. However, the clinical benefit of vitamins administration on pregnancy rate is under-evaluated and should be the target of future research.
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Affiliation(s)
- Georgios Tsampoukas
- U-merge Ltd. (Urology for Emerging Countries), London, UK
- Department of Urology, Princess Alexandra Hospital, Harlow, UK
| | - Kristiana Gkeka
- Department of Urology, General Hospital of Patras, Patras, Greece
| | - Athanasios Dellis
- U-merge Ltd. (Urology for Emerging Countries), London, UK
- Department of Urology, Aretaieion Academic Hospital, Athens, Greece
| | - Dominic Brown
- Department of Urology, Princess Alexandra Hospital, Harlow, UK
| | | | - Ahmed Alneshawy
- U-merge Ltd. (Urology for Emerging Countries), London, UK
- Department of Urology, Princess Alexandra Hospital, Harlow, UK
| | - Mohamad Moussa
- Al Zahraa Hospital, University Medical Center, Lebanese University, Beirut, Lebanon
| | - Athanasios Papatsoris
- U-merge Ltd. (Urology for Emerging Countries), London, UK
- Second Department of Urology, University Hospital of Athens, Athens, Greece
| | - Noor Buchholz
- U-merge Ltd. (Urology for Emerging Countries), London, UK
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Bustani GS, Baiee FH. Semen extenders: An evaluative overview of preservative mechanisms of semen and semen extenders. Vet World 2021; 14:1220-1233. [PMID: 34220124 PMCID: PMC8243668 DOI: 10.14202/vetworld.2021.1220-1233] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 03/25/2021] [Indexed: 11/30/2022] Open
Abstract
Reproduction is fundamental for all living things as it ensures the continued existence of a species and an improved economy in animal husbandry. Reproduction has developed since history, and diverse processes, such as artificial insemination and in vitro fertilization, have been developed. Semen extenders were discovered and developed to protect sperm from harmful factors, such as freeze and osmotic shock, oxidative stress, and cell injury by ice crystals. Semen extenders preserve sperm by stabilizing its properties, including sperm morphology, motility, and viability and membrane, acrosomal, and DNA integrity. Therefore, semen extenders must provide a favorable pH, adenosine triphosphate, anti-cooling and anti-freeze shock, and antioxidant activity to improve semen quality for fertilization. Hence, this review provides precise data on different semen extenders, preservative mechanisms, and essential additives for semen extenders in different animals.
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Affiliation(s)
| | - Falah Hasan Baiee
- Department of Clinical Science, Faculty of Veterinary Medicine, University of Kufa, Kufa 54003, Najaf, Iraq
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7
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Bahmyari R, Ariafar A, Sayadi M, Hossieni S, Azima S. The Effect of Daily Intake of Selenium, Vitamin E and Folic Acid on Sperm Parameters in Males with Idiopathic Infertility: A Single-Blind Randomized Controlled Clinical Trial. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2021; 15:8-14. [PMID: 33497041 PMCID: PMC7838762 DOI: 10.22074/ijfs.2021.6236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/07/2020] [Indexed: 11/04/2022]
Abstract
Background Male infertility may originate from a wide spectrum of conditions while in 30-40 percent of cases, no significant reason can be identified. Thereby, it is recognized as male idiopathic infertility. This study was undertaken to investigate the effect of daily intake of selenium, vitamin E and folic acid on sperm parameters in males with idiopathic infertility. Materials and Methods Seventy infertile men were selected to participate in this single-blind, randomized controlled clinical trial using convenience sampling. They were equally divided into two groups via permuted block randomization method. The intervention group received selenium tablet (200 μg per day, oral), vitamin E capsule (400 IU per day, oral) and folic acid tablet (5 mg per day, oral).The placebo group received matching placebo for three months. Semen volume, total sperm motility, sperm concentration, progressive sperm motility, normal sperm morphology, sperm motility index (SMI) and functional sperm concentration (FSC) were assessed by sperm quality analyzer-v (SQAV) before and after the intervention. Paired t test, and independent t test were used to compare the results within and between the groups, respectively. The IBM SPSS V.16.005 was used for data analysis. A P<0.05 was considered statistically significant. Results After three months, according to within-group analysis, a significant difference was found in mean SMI (P=0.007) and FSC (P=0.001) in the intervention group. According to between-group analysis, no significant difference was found in mean semen volume (P=0.610), sperm concentration (P=0.126), total sperm motility (P=0.765), progressive sperm motility (P=0.767), normal sperm morph (P=0.403), SMI (P=0.556) or FSC (P=0.706) between the groups. Conclusion Consumption of selenium, vitamin E and folic acid in infertile men with asthenozoospermia was not effective (Registration number: IRCT2017012432153N1).
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Affiliation(s)
- Rezvan Bahmyari
- Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Ariafar
- Department of Urology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrab Sayadi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shirzad Hossieni
- Department of Anatomy, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Azima
- Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.
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8
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Arab D, Doustmohammadi H, Ardestani Zadeh A. Dietary supplements in the management of varicocele-induced infertility: A review of potential mechanisms. Andrologia 2020; 53:e13879. [PMID: 33108825 DOI: 10.1111/and.13879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/10/2020] [Accepted: 09/16/2020] [Indexed: 12/30/2022] Open
Abstract
Varicocele is a main cause of lower production of spermatozoon and infertility with multiple pathophysiological mechanisms. In the past decades, the use of dietary supplements has significantly increased due to both the modern lifestyle and the food shortages of the industrialised countries. The purpose of this review paper is to collect scientific evidences from basic and clinical studies which support the use of dietary supplements to define the clinical framework for patients with varicocele. In the present review, we used keywords such as dietary supplements, varicocele, male infertility, oxidative stress, DNA fragmentation, sperm parameters to find the proper articles. The standard search biomedical engines were used for seeking the papers. The use of dietary supplements such as minerals, vitamins and antioxidants has an essential role in the prevention and treatment of varicocele by increasing the levels of antioxidant enzymes (e.g. peroxidase, superoxide dismutase and catalase) and decreasing the levels of inflammatory markers (e.g. tumour necrosis factor-α, interleukin-6 and interleukin-1) in testis. According to the results, the dietary supplements may alleviate the spermatogenesis in varicocele patients through different mechanisms such as suppression of stress oxidative and inflammation in testicular tissue.
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Affiliation(s)
- Davood Arab
- Clinical Research Development Center, Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran.,Department of Surgery, Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran
| | - Hoda Doustmohammadi
- Department of Anatomy, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Arash Ardestani Zadeh
- Clinical Research Development Center, Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran.,Department of Surgery, Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran
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9
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Hosseini M, Tavalaee M, Rahmani M, Eskandari A, Shaygannia E, Kiani-Esfahani A, Zohrabi D, Nasr-Esfahani MH. Capsaicin improves sperm quality in rats with experimental varicocele. Andrologia 2020; 52:e13762. [PMID: 32816332 DOI: 10.1111/and.13762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/08/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Capsaicin is the main capsaicinoid in chilli peppers that have numerous biological and pharmaceutical roles in the body such as antioxidant, anti-inflammatory, anticarcinogenic, analgesic, counterirritant and antiarthritic properties. Numerous studies have shown increased oxidative stress in men with varicocele that is caused by dilation of the spermatic vein and increase of testicular temperature. Therefore, we aimed to assess the effect of Capsaicin on sperm parameters in rats with experimental varicocele. At first, we induced varicocele in 30 Wistar rats and, verify varicocele model only in 10 rats by assessment of sperm parameters, oxidative stress, DNA damage and persistent histone after 2 months. Of the remaining 20 varicocelised rats, half of them were treated with 2.5 mg/kg Capsaicin for two months and the other half served as control. Then, sperm tests were assessed, and the results showed that Capsaicin can restore the mean of sperm oxidative stress (38.78 ± 3.75 versus 58.37 ± 4.34; p < .05), sperm concentration (60.14 ± 7.66 versus 34.87 ± 5.78; p < .05) and motility (62.43 ± 3.10 versus 41.22 ± 5.11; p < .05) in varicocelised rats treated with Capsaicin compared to varicocelised rats that were not treat. Therefore, Capsaicin possibly with reduction of oxidative stress level could improve mean of sperm concentration and motility in varicocele condition.
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Affiliation(s)
- Mahshid Hosseini
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran.,Department of Biology, Faculty of Science, NourDanesh Institute of Higher Education, Isfahan, Iran
| | - Marziyeh Tavalaee
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Mohsen Rahmani
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Anahita Eskandari
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Erfaneh Shaygannia
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Abbas Kiani-Esfahani
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Dina Zohrabi
- Department of Biology, Faculty of Science, NourDanesh Institute of Higher Education, Isfahan, Iran
| | - Mohammad Hossein Nasr-Esfahani
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
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10
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Su JS, Farber NJ, Vij SC. Pathophysiology and treatment options of varicocele: An overview. Andrologia 2020; 53:e13576. [PMID: 32271477 DOI: 10.1111/and.13576] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
Varicocele is the most common correctable cause for male infertility, but not all men with varicocele are affected equally by this condition. The pathophysiology of varicocele-induced fertility remains ill-defined. While evidence suggests that oxidative stress remains a central factor, other mechanisms likely include scrotal hyperthermia, reflux of metabolites, hypoxia and cadmium accumulation. Microsurgical varicocelectomy remains the gold standard treatment option for infertile men with a clinically palpable varicocele and abnormal semen parameters. Newer evidence suggests a potential role for antioxidant supplementation and a meaningful role of varicocelectomy for patients destined for ART to improve pregnancy outcomes.
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Affiliation(s)
- Johnny S Su
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas J Farber
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sarah C Vij
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Banihani SA, Aljabali SM. Seminal plasma vitamin B 6 levels in men with asthenozoospermia and men with normal sperm motility, a measurement using liquid chromatography with tandem mass spectrometry. Andrologia 2020; 52:e13556. [PMID: 32129519 DOI: 10.1111/and.13556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/06/2020] [Accepted: 02/11/2020] [Indexed: 12/16/2022] Open
Abstract
There is growing evidence that vitamin B6 has a valuable contribution in maintaining normal sperm parameters; however, this contribution has not yet well-identified. Here, we aimed to measure the level of seminal plasma vitamin B6 in men with asthenozoospermia compared to men with normal sperm motility. Ninety-seven human males with asthenozoospermia and eighty-eight human males with normal sperm motility (control) were recruited in this study. Collected semen samples were assessed for sperm motility, sperm count and semen volume. Liquid chromatography with tandem mass spectrometry was used to measure seminal plasma vitamin B6 concentrations. A highly significant difference (p < .0001) in concentrations of seminal plasma vitamin B6 was found between asthenozoospermic and control groups. Besides, no statistical correlations were found between seminal plasma vitamin B6 level and sperm motility, sperm count, semen volume and men age in both tested groups. In conclusion, men with asthenozoospermia have lower seminal plasma vitamin B6 level compared to men with normal sperm motility. Also, seminal plasma vitamin B6 was found not to be correlated with sperm motility and count, semen volume and men age in both tested groups. These results may provide new contribution in the management of male infertility.
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Affiliation(s)
- Saleem Ali Banihani
- Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Shefa' Muneer Aljabali
- Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid, Jordan
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