1
|
Kuang M, Yu Y, He S. Association between the age-adjusted visceral adiposity index (AVAI) and female infertility status: a cross-sectional analysis of the NHANES 2013-2018. Lipids Health Dis 2024; 23:314. [PMID: 39334174 PMCID: PMC11438287 DOI: 10.1186/s12944-024-02295-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Obesity stands as an essential factor contributing to infertility in women. Early identification of obese individuals leads to favorable results for female infertility. The objective of this research is to assess the association between the age-adjusted visceral adiposity index (AVAI) and female infertility. METHODS This study was conducted using NHANES data from 2013 to 2018, in which 1,231 women aged 20-45 were selected. Infertility was defined by survey questions. AVAI was calculated using anthropometric and serum data. Covariates included demographics and lifestyle factors. Statistical analysis with R, adjusting for covariates, and assessing nonlinearity and cutoff effects. RESULTS The study of 1,231 women from the NHANES database revealed that 11.94% were diagnosed with infertility. Individuals with higher AVAI scores showed increased age, WC, BMI, and reduced HDL levels, with a positive correlation between AVAI and female infertility (OR = 1.42, 95%CI: 1.26-1.60). AVAI quartiles showed a pronounced relationship with female infertility risk, with the highest quartile showing the greatest risk(OR = 9.35,95% CI: 2.96-29.55). Nonlinear and threshold effects in the relationship between AVAI and female infertility were identified, with an inflection point at -9.70. Subgroup analyses indicated significant interactions between AVAI and educational status and BMI, particularly in women with a BMI below 25 kg/m2, where a high AVAI level was closely related to increased infertility risk(OR = 1.92, 95%CI: 1.44-2.58). CONCLUSION The study identifies a strong association between elevated AVAI scores and female infertility risk, especially in women with a BMI under 25 kg/m2. This suggests that AVAI could be a valuable predictor in female fertility assessments.
Collapse
Affiliation(s)
- Mingqin Kuang
- Guangdong Cardiovascular Institute, Guangzhou, Guangdong, 510080, People's Republic of China
- Gynecology and Oncology Department of Ganzhou Cancer Hospital, Ganzhou, Jiangxi, 341000, People's Republic of China
| | - Ying Yu
- Gynecology and Oncology Department of Ganzhou Cancer Hospital, Ganzhou, Jiangxi, 341000, People's Republic of China
| | - Shanyang He
- Department of Gynecology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China.
| |
Collapse
|
2
|
Donatti LM, Martello CL, Andrade GM, Oliveira NP, Frantz N. Advanced Paternal Age Affects the Sperm DNA Fragmentation Index and May Lead to Lower Good-quality Blastocysts. Reprod Sci 2023:10.1007/s43032-023-01209-9. [PMID: 36897559 DOI: 10.1007/s43032-023-01209-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
Several studies show reductions in some seminal parameters in aged men and describe them as a consequence of many age-dependent changes in male organisms. This study aims to evaluate the impact of age on seminal parameters, particularly the DNA fragmentation index (DFI), and outcomes after in vitro fertilization (IVF) cycles. This is a retrospective study that includes 367 patients who underwent sperm chromatin structure assay testing between 2016 and 2021. The participants were split into three groups according to age: < 35 years (younger group, n = 63), 35-45 years (intermediate group, n = 227), and ≥ 45 years (older group, n = 77). The mean DFI (%) was compared. Among all patients, 255 received IVF cycles after DFI evaluation. For these patients, the sperm concentration, motility, and volume, as well as the fertilization rate, mean oocyte age, and good-quality blastocyst formation rate, were analyzed. One-way ANOVA was applied. The older group showed a significantly higher sperm than did the younger group (28.6% vs. 20.8% p = 0.0135). Despite not presenting a significant difference, the DFI level tends to be inversely related to good-quality blastocyst formation since the oocyte age was similar between the groups (32.0 v.s 33.6 vs. 32.3 years, respectively, p = 0.1183). Among aged men, the sperm DFI level is increased but other seminal parameters are not modified. Considering that men with a high sperm DFI can present some degree of infertility due to high sperm chromatin damage, male age should also be considered a limiting factor of IVF.
Collapse
Affiliation(s)
- Luiza M Donatti
- Nilo Frantz Reproductive Medicine, Porto Alegre, Rio Grande Do Sul, Brazil.
| | | | | | - Norma P Oliveira
- Nilo Frantz Reproductive Medicine, Porto Alegre, Rio Grande Do Sul, Brazil
| | - Nilo Frantz
- Nilo Frantz Reproductive Medicine, Porto Alegre, Rio Grande Do Sul, Brazil
| |
Collapse
|
3
|
Jimbo M, Kunisaki J, Ghaed M, Yu V, Flores HA, Hotaling JM. Fertility in the aging male: a systematic review. Fertil Steril 2022; 118:1022-1034. [PMID: 36509505 PMCID: PMC10914128 DOI: 10.1016/j.fertnstert.2022.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 12/14/2022]
Abstract
The negative effect of advanced female age on fertility and offspring health is well understood. In comparison, much less is known about the implications of male age on fertility, with many studies showing conflicting results. Nevertheless, increasing evidence suggests that advanced paternal age has negative effects on sperm parameters, reproductive success, and offspring health. Herein, we summarize the current body of knowledge on this controversial topic, with the belief that this review will serve as a resource for the clinicians providing fertility counseling to couples with older male partners.
Collapse
Affiliation(s)
- Masaya Jimbo
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jason Kunisaki
- Department of Human Genetics, University of Utah, Salt Lake City, Utah
| | - Mohammadali Ghaed
- Urology Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Victor Yu
- University of Nevada Reno School of Medicine, Reno, Nevada
| | - Hunter A Flores
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas
| | - James M Hotaling
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
| |
Collapse
|
4
|
Luo Y, Wu S, Zhang M, Zhou H, Yuan J, Yang Y, Zhong Y, Li Q, Sun X, Xu X, Zhu D. Sperm DNA integrity is critically impacted by male age but does not influence outcomes of artificial insemination by husband in the Chinese infertile couples. Aging (Albany NY) 2022; 14:4326-4335. [PMID: 35580171 PMCID: PMC9186781 DOI: 10.18632/aging.204058] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Abstract
The sperm chromatin structure assay (SCSA) is crucial for assessing male fertility. However, the predictive value of the SCSA parameters, including the DNA fragment indices (DFI) and the percentages of high DNA stainability (HDS), for outcomes of artificial insemination by husband (AIH) remains controversial. This study aims to evaluate the correlations between SCSA parameters and male aging as well as other routine semen parameters, and explore their prognostic powers on AIH outcomes of the Chinese infertile couples. A total of 809 AIH cycles were retrospectively analyzed. The results showed that DFI in the age groups < 35 years were significantly lower than that in the age groups ≥ 35 years (P < 0.001). Meanwhile, there was no statistical difference in HDS between the age groups (P = 0.063). DFI and HDS are negatively correlated with most routine semen parameters (all P < 0.05). The chi-square and generalized linear model tests indicated that neither DFI nor HDS influenced the clinical pregnancy rate of AIH. In summary, this study found that aging is a critical factor leading to increased sperm DFI but not HDS. DFI and HDS are negatively correlated with most semen parameters but do not significantly influence AIH outcomes.
Collapse
Affiliation(s)
- Yumei Luo
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
| | - Shunhong Wu
- Guangzhou Key Laboratory for Clinical Rapid Diagnosis and Early Warning of Infectious Diseases, Kingmed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou 510182, China
| | - Mimi Zhang
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
| | - Hua Zhou
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
| | - Jingru Yuan
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
| | - Yiying Yang
- Department of Clinical Laboratory, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
| | - Yufang Zhong
- Guangzhou Key Laboratory for Clinical Rapid Diagnosis and Early Warning of Infectious Diseases, Kingmed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou 510182, China
| | - Qing Li
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
| | - Xiaofang Sun
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
| | - Xia Xu
- Guangzhou Key Laboratory for Clinical Rapid Diagnosis and Early Warning of Infectious Diseases, Kingmed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou 510182, China
| | - Detu Zhu
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
| |
Collapse
|
5
|
Gao J, Yuan R, Yang S, Wang Y, Huang Y, Yan L, Jiang H, Qiao J. Age-related changes in human conventional semen parameters and sperm chromatin structure assay-defined sperm DNA/chromatin integrity. Reprod Biomed Online 2021; 42:973-982. [PMID: 33785305 DOI: 10.1016/j.rbmo.2021.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
RESEARCH QUESTION What are the correlations between male age, traditional semen parameters, sperm DNA fragmentation index (DFI) and high DNA stainability (HDS) in a sufficiently large sample size? DESIGN Retrospective cohort study of 18,441 semen samples, with data divided into seven age groups according to male age: ≤25, 26-30, 31-35, 36-40, 41-45, 46-50 and ≥51 years. RESULTS Age was negatively correlated with semen volume, total sperm count, motility and HDS, and positively correlated with sperm concentration and DFI (P < 0.001). After 35 years of age, semen volume and total sperm count began to decline. After 30 years of age, motility and HDS decreased consistently. Sperm concentration and DFI increased from 26-30 years of age. DFI was negatively correlated with sperm concentration, total sperm count, motility and normal morphology (P < 0.001) and positively correlated with semen volume and HDS (P < 0.001). HDS was negatively correlated with all parameters (P < 0.001) except semen volume (r = -0.013, P = 0.074) and DFI (r = 0.124, P < 0.001). Patients aged ≥40 years had higher DFI than those aged <40 years in the entire cohort, in the abnormal semen parameters cohort, and in the normal semen parameters cohort (OR 2.145, 2.042, 1.948, respectively, P < 0.001). The ≥40 years age group had a lower HDS than the <40 years age group in the entire cohort and abnormal semen parameters cohort (OR 0.719, 0.677, respectively, P < 0.001). CONCLUSIONS Ageing is a negative effector of sperm quantity and quality, and routine sperm parameters have weak but significant correlations with sperm DNA/chromatin integrity.
Collapse
Affiliation(s)
- Jiangman Gao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; Key Laboratory of Assisted Reproduction, Peking University, Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing 100191, China
| | - Renpei Yuan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
| | - Siwei Yang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
| | - Yuanyuan Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; Key Laboratory of Assisted Reproduction, Peking University, Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing 100191, China
| | - Ying Huang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
| | - Liying Yan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; Key Laboratory of Assisted Reproduction, Peking University, Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing 100191, China
| | - Hui Jiang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China.
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; Key Laboratory of Assisted Reproduction, Peking University, Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing 100191, China.
| |
Collapse
|
6
|
Martinez M, Majzoub A. Best laboratory practices and therapeutic interventions to reduce sperm DNA damage. Andrologia 2020; 53:e13736. [PMID: 32662555 DOI: 10.1111/and.13736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/25/2020] [Accepted: 05/31/2020] [Indexed: 12/20/2022] Open
Abstract
Conventional semen analysis is considered the cornerstone investigation for infertile men. Nonetheless, this routine test does not provide information on important sperm functions like sperm DNA fragmentation (SDF). Abnormalities of human spermatozoal nucleus and chromatin have a detrimental impact on both natural and assisted reproductive outcomes. In vivo, SDF results from abnormalities in chromatin compaction, abortive apoptosis and oxidative stress, while in vitro, a number of factors may be implicated. Various SDF testing methods are available, and the most commonly utilised assays include terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL), sperm chromatin dispersion (SCD) test, sperm chromatin structure assay (SCSA) and Comet assay. SDF testing has shown beneficial effects on treatment decision-making; however, its routine use in the initial evaluation of infertile men is still not recommended. One of the treatment options to reduce sperm DNA damage is the use of antioxidants. Despite the documented improvement in semen parameters and sperm DNA integrity following antioxidant therapy, no definitive recommendation is reached due to lack of large, well-designed, randomised, placebo-controlled trials assessing their exact role in male factor infertility. The objectives of this review article are to illustrate the aetiologies of SDF, to describe the effects of SDF on male factor fertility, to explore the common techniques utilised in SDF testing, to review the clinical indications for SDF testing and to review the effect of antioxidant therapy as a method to alleviate SDF.
Collapse
Affiliation(s)
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar.,Department of Clinical Urology, Weill Cornel Medicine -Qatar, Doha, Qatar
| |
Collapse
|
7
|
Abstract
With the increasing incidence of male infertility, routine detection of semen is insufficient to accurately assess male fertility. Infertile men, who have lower odds of conceiving naturally, exhibit high levels of sperm DNA fragmentation (SDF). The mechanisms driving SDF include abnormal spermatogenesis, oxidative stress damage, and abnormal sperm apoptosis. As these factors can induce SDF and subsequent radical changes leading to male infertility, detection of the extent of SDF has become an efficient routine method for semen analysis. Although it is still debated, SDF detection has become a research hotspot in the field of reproductive medicine as a more accurate indicator for assessing sperm quality and male fertility. SDF may be involved in male infertility, reproductive assisted outcomes, and growth and development of offspring. The effective detection methods of SDF are sperm chromatin structure analysis (SCSA), terminal transferase-mediated dUTP end labeling (TUNEL) assay, single-cell gel electrophoresis (SCGE) assay, and sperm chromatin dispersion (SCD) test, and all of these methods are valuable for assisted reproductive techniques. Currently, the preferred method for detecting sperm DNA integrity is SCSA. However, the regulation network of SDF is very complex because the sperm DNA differs from the somatic cell DNA with its unique structure. A multitude of molecular factors, including coding genes, non-coding genes, or methylated DNA, participate in the complex physiological regulation activities associated with SDF. Studying SDF occurrence and the underlying mechanisms may effectively improve its clinical treatments. This review aimed to outline the research status of SDF mechanism and detection technology-related issues, as well as the effect of increased SDF rate, aiming to provide a basis for clinical male infertility diagnosis and treatment.
Collapse
Affiliation(s)
- Ying Qiu
- The Reproductive Medical Center, Nanning Second People's Hospital, Nanning, Guangxi, China (mainland)
| | - Hua Yang
- The Reproductive Medical Center, Nanning Second People's Hospital, Nanning, Guangxi, China (mainland)
| | - Chunyuan Li
- The Reproductive Medical Center, Nanning Second People's Hospital, Nanning, Guangxi, China (mainland)
| | - Changlong Xu
- The Reproductive Medical Center, Nanning Second People's Hospital, Nanning, Guangxi, China (mainland)
| |
Collapse
|
8
|
Condorelli RA, La Vignera S, Barbagallo F, Alamo A, Mongioì LM, Cannarella R, Aversa A, Calogero AE. Bio-Functional Sperm Parameters: Does Age Matter? Front Endocrinol (Lausanne) 2020; 11:558374. [PMID: 33362711 PMCID: PMC7761869 DOI: 10.3389/fendo.2020.558374] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 11/04/2020] [Indexed: 12/19/2022] Open
Abstract
The evaluation of biofunctional sperm parameters can explain some cases of idiopathic male infertility. Among these, sperm DNA fragmentation (fDNA) is the most studied biofunctional sperm parameter. Mitochondrial membrane potential (MMP) correlates positively with sperm motility, the evaluation of sperm apoptosis by flow cytometry allows us to identify a population of spermatozoa not recognizable at the optical microscopy and finally, lipid peroxidation (LP) and mitochondrial superoxide levels measurements are rational oxidative stress indices. Male age seems to affect sperm concentration and sperm fDNA. For these reasons, this study was undertaken to evaluate the correlation, if any, between male age and biofunctional sperm parameters evaluating their possible impact on fDNA. To accomplish this, MMP, degree of chromatin compactness, sperm apoptosis/vitality, fDNA, LP, and mitochondrial superoxide levels were evaluated by flow cytometry in a cohort of 874 men. A significant negative correlation was found between age and the percentage of alive spermatozoa (r = -0.75, p < 0.05). The percentage of spermatozoa with low MMP (L-MMP) correlated positively with the percentage of spermatozoa with abnormal chromatin compactness (r = 0.24, p < 0.05). Spermatozoa with abnormal chromatin compactness and L-MMP correlated negatively with the percentage of alive spermatozoa (r = 0.83, p < 0.05) and positively with spermatozoa with PS externalization (r = 0.13, p < 0.01). The percentage of alive spermatozoa correlated negatively with both the percentage of spermatozoa with PS externalization (r = 0.24, p < 0.01) and of the spermatozoa with fDNA (r = 0.10, p < 0.05). Spermatozoa with PS externalization correlated positively with the percentage of spermatozoa with fDNA (r = 0.09, p < 0.05). Spermatozoa with LP correlated positively with the percentage of spermatozoa with increased mitochondrial superoxide (r = 0.11, p < 0.01) In conclusion, these findings in a large number of men suggest that age, mitochondrial damage, and alteration of chromatin compactness could activate the apoptotic cascade which could result in an increased fDNA rate.
Collapse
Affiliation(s)
- Rosita A. Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- *Correspondence: Sandro La Vignera,
| | - Federica Barbagallo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Angela Alamo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Laura M. Mongioì
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Antonio Aversa
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Aldo E. Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| |
Collapse
|