Care for the infertile male

Similar prevalence of expanded CGG repeat lengths in the fragile X mental retardation I gene among infertile women and among women with proven fertility: a prospective study

PURPOSE

We sought to determine the usefulness of fragile X mental retardation 1 (FMR1) carrier testing among young infertile women with or without signs of ovarian insufficiency as compared with fertile women.

METHODS

Three cohorts of women were recruited to determine the cytosine-guanine-guanine (CGG) repeats trinucleotide repeat length in the 5'-untranslated region of the FMR1 gene in lymphocyte DNA. A total of 199 fertile women, who were reported to have conceived within 3 months, were recruited together with 372 infertile women with ongoing menstrual cycles and 48 infertile women with primary ovarian insufficiency. The various ranges of FMR1 CGG repeat lengths among infertile women were compared with those of fertile controls. In infertile women with ongoing menstrual cycles, the serum concentrations of follicle-stimulating hormone, anti-Muellerian hormone, and inhibin B were measured during the early follicular phase.

RESULTS

None of the three categories of FMR1 CGG repeat length expansions (premutation, intermediate range, and high normal range) were more prevalent among infertile women than among fertile women. The CGG repeat length was not correlated with any of the ovarian reserve parameters.

CONCLUSION

In comparison with a generalized preconception screening strategy, infertility as a criterion, even together with reduced ovarian reserve, is not suitable for identifying a higher proportion of women with expanded FMR1 CGG repeat length.

Correlation between testicular sperm extraction outcomes and clinical, endocrine and testicular histology parameters in 120 azoospermic men with normal serum FSH levels

We retrospectively evaluated the clinical and hormonal profiles, sperm extraction outcomes and testicular histology parameters in 120 azoospermic men with normal serum follicle-stimulating hormone (FSH) level. Microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) were performed in 33 and 87 cases, respectively. Sperm were successfully retrieved in all the MESA procedures and in 65 of the TESE procedures. The mean serum FSH and inhibin B levels and the testicular volume differed significantly according to whether or not sperm were retrieved. The threshold serum inhibin B value for predicting successful TESE was 123.5pg/mL (sensitivity: 69.7%; specificity: 66.7%). The 13 patients with Sertoli cell only syndrome (SCOS) had a higher mean serum FSH level and a lower mean serum inhibin B level than the other phenotypes. TESE was negative for 11 of the 13 SCOS men. The mean±SD inhibin B level was significantly lower in patients with 5-10IU/L of FSH than those with 2-5IU/L of FSH (108.30±53.86 vs. 175.23±70.17pg/mL, respectively). The sperm retrieval rates were 71.42% for the group with 5-10IU/L of FSH and 87.32% for the group with 2-5IU/L of FSH. Ten of the 13 SCOS men had a FSH level between 5 and 10IU/L. The clinical pregnancy rate was significantly lower (p=0.04) in the group with 5-10IU/L (50%) of FSH than in the group with 2-5IU/L (77.5%) of FSH. In conclusion, there is no FSH value below which spermatogenesis is always found. Inhibin B assays and clinical assessments are thus of particular value in men with normal serum FSH levels.

FSH in therapy: physiological basis, new preparations and clinical use

Follicle stimulating hormone (FSH) is a glycoprotein hormone secreted by the pituitary gland that, together with luteinizing hormone (LH), controls development, maturation and function of the gonad. Like the related hormones, LH, thyroid stimulating hormone (TSH) and human chorionic gonadotropin (hCG), FSH consists of two polypeptide chains, α and β, bearing carbohydrate moietiesN-linked to asparagine (Asn) residues. The α subunit is common to all members of the glycoprotein hormone family, whereas the β subunit, although structurally very similar, differs in each hormone and confers specificity of action.

Use of carnitine therapy in selected cases of male factor infertility: a double-blind crossover trial

OBJECTIVE

To determine the efficacy of L-carnitine therapy in selected cases of male factor infertility.

DESIGN

Placebo-controlled, double-blind, crossover trial.

SETTING

University tertiary referral center.

PATIENT(S)

One hundred infertile patients (ages 20-40 years) with the following baseline sperm selection criteria: concentration, 10-20 x 10(6)/mL; total motility, 10%-30%; forward motility, <15%; atypical forms, <70%; velocity, 10-30 micro/s; linearity, <4. Eighty-six patients completed the study.

INTERVENTION(S)

Patients underwent L-carnitine therapy 2 g/day or placebo; the study design was 2 months of washout, 2 months of therapy/placebo, 2 months of washout, and 2 months placebo/therapy.

MAIN OUTCOME MEASURE(S)

Variation in sperm parameters used in the patients selection criteria, in particular, sperm motility. Excluding outliers, a statistically significant improvement in semen quality, greater than after the placebo cycle, was seen after the L-carnitine therapy for sperm concentration and total and forward sperm motility. The increase in forward sperm motility was more significant in those patients with lower initial values, i.e., <5 x 10(6) or <2 x 10(6) of forward motile sperm/ejaculate or sperm/mL.

CONCLUSION(S)

Based on a controlled study of efficacy, L-carnitine therapy was effective in increasing semen quality, especially in groups with lower baseline levels. However, these results need to be confirmed by larger clinical trials and in vitro studies.

Serum inhibin B may be a reliable marker of the presence of testicular spermatozoa in patients with nonobstructive azoospermia

OBJECTIVE

To establish the predictive value of serum inhibin B levels as an indicator of the presence of testicular spermatozoa in nonobstructive azoospermia, compared with the traditional serum FSH marker.

DESIGN

Prospective study.

SETTING

Private high-complexity reproductive center with university affiliation.

PATIENT(S)

Seventy-eight patients with nonobstructive azoospermia, 15 patients with obstructive azoospermia, and 10 fertile volunteers.

INTERVENTION(S)

Blood samples, testicular sperm extraction, percutaneous epididymal sperm aspiration, and semen collection.

MAIN OUTCOME MEASURE(S)

Serum levels of inhibin B and FSH and presence of spermatozoa on TESE, PESA, or regular semen analysis.

RESULT(S)

Patients with nonobstructive azoospermia has significantly higher levels of serum FSH and significantly lower levels of inhibin B. Mean inhibin B serum levels were significantly higher in patients with nonobstructive azoospermia who had spermatozoa on TESE than in those in whom no spermatozoa were found (89.31 +/- 73.24 pg/mL vs. 19.23 +/- 22.34 pg/mL), but mean FSH serum levels did not have similar predictive power (21.37 +/- 12.92 IU/mL vs. 19.27 +/- 10.28 IU/mL). The cut-off level of inhibin B separating both groups, as determined by the receiver-operating characteristic curves, was >53 pg/mL.

CONCLUSION(S)

Serum inhibin B level seems to be more accurate than serum FSH level in prediction of the presence of testicular spermatozoa in patients with nonobstructive azoospermia.

Increased testicular steroid concentrations in patients with idiopathic infertility and normal FSH levels

In 10 men with idiopathic infertility, the authors evaluate hypophyso-gonadal axis by measuring the intratesticular concentrations of several steroids in relation with the serum hormonal status. The data are compared with those from men (n = 20) after cerebral death (stage IV coma), taken as a control group. There was no difference between the two groups. The histological studies of the testes revealed no significant differences between control and infertile men both in the development of the interstitial tissue and in the spermatogenic score. Conversely, the testicular concentrations of pregnenolone, dehydroepiandrosterone, progesterone, androstenedione, testosterone, and estradiol were higher in infertile men compared to control. Therefore, it is difficult to evoke a specific parameter involved in that peculiar pathology, but the large amounts of endogenous estradiol may account for the impairment of fertility.

Seminal plasma nitrite/nitrate and intratesticular Doppler flow in fertile and infertile subjects

The objective of the present study was prospectively to evaluate the role of nitric oxide (NO) in modulating intratesticular blood flow and sperm function. A total of 56 males, undergoing assisted reproduction, were divided into three groups according to semen analysis: (i) normozoospermic (n = 16); (ii) oligozoospermic (n = 21); and (iii) azoospermic (n = 19). All the subjects were submitted to hormone analysis [luteinizing hormone, follicle stimulating hormone (FSH), growth hormone, testosterone, androstenedione, insulin], and to ultrasonographic (testicular volume) and Doppler (transmediastinal artery) evaluations. Plasma and seminal plasma nitrite/nitrate concentrations, and plasma insulin-like growth factor-I were assayed. All 56 patients completed the study. In normozoospermic patients, significantly greater testicular volume, lower transmediastinal resistances, and higher seminal plasma nitrite/nitrate concentrations were observed in comparison with both oligo- and azoospermic subjects. Testicular volume was inversely correlated with plasma FSH (r = -0.589; P = 0.005) and pulsatility index of transmediastinal artery (r = -0.402; P = 0.049). Furthermore, the seminal plasma nitrite/nitrate concentrations were inversely correlated with pulsatility index of transmediastinal artery (r = -0.511; P = 0.015). It was concluded that NO is involved in vascular modulation of testicular vessels and ultimately in sperm output.

Effects of long-term treatment with human pure follicle-stimulating hormone on semen parameters and sperm-cell ultrastructure in idiopathic oligoteratoasthenozoospermia

Ten subfertile men affected by idiopathic oligoteratoasthenozoospermia and exhibiting normal serum hormone levels received a long-term treatment with human pure follicle-stimulating hormone (hp-FSH) (150 IU, intramuscularly, three times per week for 6 months). Semen parameters and ultrastructural features of spermatozoa were evaluated before and after therapy. The results showed an increase in sperm cell concentration and, more interestingly, motility. Electron microscopic examination revealed an improved fine architectural pattern, mainly involving acrosome, head and chromatin and middle-piece, in accordance with the positive changes of functional data. No significant changes of hp-FSH treatment on serum hormone levels were observed, since the latter were found to be substantially unchanged after 6 months of therapy. The present data suggest: (i) the benefit of hp-FSH administration in idiopathic oligoteratoasthenozoospermia, when hormone parameters support a substantial integrity of spermatogenetic microenvironment and (ii) an optimal effect after long-term (6 months) therapy.

FSH treatment improves sperm function in patients after varicocelectomy

One-hundred and eighty-three patients affected with idiopathic left varicocele, aged between 18 and 45 years, surgically treated have been studied. They were divided in 3 subsets according to sperm count: group A: <10 x 10(6)/ml, group B: 10-20 x 10(6)/ml, group C: >20 x 10(6)/ml. Six months after surgery 115 patients were treated for 3 months with pure human FSH: 75 IU i.m. every other day, while 68 patients treated with placebo served as control group. After therapy, group A showed a significant clear-cut improvement of sperm parameters: count, forward progression, swollen tails and cervical mucus penetration test (CMPT). In group B a significant improvement of sperm motility, viability, DNA integrity and CMPT was observed, while in group C only a significant improvement of CMPT was observed. In conclusion, it can be suggested that FSH treatment in patients after varicocelectomy could improve spermatogenesis, particularly in those who previously have more compromised sperm quality. On the contrary, no significant difference of sperm patterns was recorded in the control group before and after placebo.

Relationship between hormone levels and testicular biopsies of azoospermic men

This study was conducted to evaluate the testicular biopsies and the sera levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), testosterone (T), and prolactin (PRL) in 96 azoospermic men attending the Andrology Clinic. Plasma levels of FSH were the most common hormone abnormality in the evaluation of azoospermia. Plasma levels of LH and T were useful only in azoospermic men with hypogonadism, whereas plasma PRL levels rarely occurred in azoospermia.

Clinical review 100: Evaluation and treatment of the infertile couple

Infertility by itself does not threaten physical health but has a strong impact on the psychological and social well-being of couples. In the last two decades, progress in caring for the infertile couple, in particular progress in the field of assisted reproduction and micromanipulation, has provided significant hope for many couples for whom hope could not have been offered in the past. This is especially true for bilateral tubal disease and for male factor infertility, as nearly all couples with male factor infertility can now undergo either one (or more) IVF or ICSI attempt(s). For couples with other causes of infertility, however, the differences in pregnancy rates often do not reach statistical significance. We must also remember that the total cost incurred for successful delivery for couples with a better chance of successful IVF (i.e. those with tubal disease) increases from approximately $55,000 in American dollars for the first cycle to $73,000 by the sixth cycle. Because of these high costs, many insurers in the United States and many public health systems in Europe do not cover or only partially cover these procedures. Consequently, the availability of IVF and related therapies frequently depends on the couple's ability to pay. Therefore, after having established the correct diagnosis, appropriate treatment should be counseled to the infertile couple keeping in mind the following points: 1) in subfertile couples expectant management should be reasonably counselled if the age of the woman is less than 30 yr and the duration of infertility is less than 36 months, even if oligozoospermia is present; 2) superovulation and timed intercourse seems also to be a reasonable approach in couples with anovulatory, mild/moderate endometriosis, and unexplained infertility; 3) in unexplained infertility, ovarian stimulation (with clomiphene or gonadotropin) and IUI seem to offer some advantage over ovarian stimulation and timed intercourse; 4) IVF can be a firstline approach in tubal sterility and when IUI or IPI cannot be performed because the number of motile sperm is insufficient, but is usually also the final treatment attempt when other methods have failed. The outcome of IVF is negatively influenced mainly by the woman's age; however, the number of deliveries is also generally lower in couples with male factor; 5) ICSI is a further option, which should be limited to couples: a) with very poor semen parameters; b) previous failed fertilization; c) presence of obstructive or nonobstructive azoospermia in which ICSI is combined with sperm extraction from the epididymis or the testis; 6) international register studies demonstrate that the risk of malformation after conventional IVF is not increased; 7) some reports suggest that incidence of congenital major and minor malformations is not increased in children born after ICSI. However, the rate of sex chromosome anomalies in ICSI fetuses has been reported to be approximately 1% in 585 prenatal diagnoses, a frequency increased by a factor of 4 if compared with naturally conceived live-born babies. ICSI bypasses the physiological selection of spermatozoa that occurs at the level of the testis and epididymis, and in the female reproductive tract as well as at the sperm-oocyte interface. As genetic abnormalities are present in a significant percentage of infertile males with impaired spermatogenesis, karyotyping and analysis of the Y chromosome for microdeletions should be carried out in all potential ICSI fathers. Screening for cystic fibrosis gene mutations should also be performed in azoospermia caused by congenital absence of the vas deferens and seminal vesicles. Appropriate genetic counseling should be made available to all ICSI couples whenever a gene or chromosomal anomaly has been identified. With most ARTs the average delivery rate per cycle is approximately 15% and the cumulative delivery rate after several cycles is about 50%. (ABSTRACT TRUNCATED)

Effects of pure human follicle-stimulating hormone (pFSH) on sperm quality correlate with the hypophyseal response to gonadotrophin-releasing hormone (GnRH)

In 41 men with idiopathic infertility, the effect of pure follicle-stimulating hormone (pFSH) therapy on semen parameters was evaluated in relation to the results of the gonadotrophin-releasing hormone (GnRH) stimulation test in an open study. The patients showed a mean (+/-standard error) sperm concentration of 15.84 (+/-2.87) Mill. ml-1, 41.02 (+/-4.19)% of the spermatozoa were motile and 46.16 (+/-2.36)% normomorph before treatment. All patients were administered 150 IU pFSH subcutaneously three times weekly for 10 weeks. After therapy with pFSH, no significant differences compared with the pre-treatment sperm characteristics were observed (P > 0.05) except for the velocity average path, VAP (P = 0.029). However, the stimulation factors of FSH in the GnRH test showed a significantly negative correlation with the pFSH mediated improvement of sperm concentration (r = -0.662, P = 0.000002), of percentage of normomorph spermatozoa (r = -0.480, P = 0.0015) and total count of motile spermatozoa per ejaculate (r = -0.567, P = 0.00014). In consequence, the patients were divided into two groups depending on the stimulation factor of hypophyseal FSH secretion, FSH-SF. The cut-off point of the FSH-SF was set at 1.7 because the correlation analyses detected a 1.5-fold improvement of sperm parameters at this hypophyseal response on average. Pure FSH treatment increased the concentration of spermatozoa (P = 0.0007), the total count of motile spermatozoa in the ejaculate (P = 0.015) as well as the computer-aided sperm motion parameters VAP (P = 0.029) and velocity curve linear, VCL (P = 0.049) in patients with FSH-SF < 1.7, whereas in the patient group with FSH-SF > 1.7 no improvement of semen parameters was found. Insufficient stimulation of hypophyseal FSH secretion may be a prerequisite but not a guarantee for responsiveness to pFSH treatment. The results of the present investigation suggest that FSH stimulation in the GnRH test should be taken into account in idiopathic infertile men before pFSH therapy.

Severe impairment of spermatogenesis in mice lacking the CREM gene

Spermatogenesis is a complex developmental process that occurs in several phases. A large number of genes have been identified that are expressed during spermatogenesis, but the biological significance of many of these is not yet known. We have used gene targeting to selectively eliminate the transcription factor CREM (cyclic AMP- responsive element modulator), which is thought to be important for mammalian spermatogenesis. Male mice deficient for all CREM proteins are sterile, as their developing spermatids fail to differentiate into sperm, and postmeiotic gene expression in the testis declines dramatically. The cessation of sperm development is not accompanied by decreases in the levels of follicle-stimulating hormone or testosterone. Our findings indicate that the CREM gene is essential for spermatogenesis, and mice deficient for this transcription factor could serve as a model system for the study of idiopathic infertility in men.

Gonadotrophin control of testicular germ cell development

Successful and complete male germ cell development is dependent on the balanced, endocrine interplay of the hypothalamus, the pituitary and the testis. The hypothalamus secretes gonadotrophin-releasing hormone in a pulsatile manner which, in turn, elicits the pulsatile release of the gonadotrophins LH and FSH from the pituitary. Luteinizing hormone stimulates spermatogenesis indirectly via testosterone, whereas FSH acts directly on the seminiferous tubules. The synthesis and release of gonadotrophic hormones is under the feedback control of testosterone. Whether other testicular peptides such as inhibin and activin are also involved is not yet clear. Luteinizing hormone/testosterone and FSH are the prime regulators of germ cell development. On their own, these hormones are capable of exerting clear-cut stimulatory effects on the spermatogenic process. However, the quantitative production of spermatozoa generally requires the presence of both LH/testosterone and FSH. Since receptors for androgens and FSH are confined to the somatic cells of the testis, the trophic effects of these hormones on germ cells must be indirect. However, it is not known as yet precisely which genes/factors mediate the beneficial effects of androgens and FSH on spermatogenesis. The gonadotrophic hormones have been found in a number of isoforms and multiple transcripts of the LH and FSH receptor have been detected. Therefore, the possibility must be considered that certain forms of male infertility could be due to dysfunctional hormones and/or mutated receptors.

Serum FSH and testicular morphology in male infertility

OBJECTIVE

In patients with azoospermia serum FSH helps to differentiate between obstruction or spermatogenetic dysfunction as the possible cause of this condition. The role of FSH in the diagnosis of infertile men with oligoasthenoteratozoospermia is less clearly defined. In order to evaluate the diagnostic significance of serum FSH in the management of male infertility, serum FSH levels were related to testicular morphology from bilateral biopsies of infertile men.

DESIGN AND PATIENTS

Testicular biopsies were obtained from 213 infertile men and evaluated in semi-thin sections. Biopsies were performed either in order to distinguish between obstructive and non-obstructive azoospermia or because of subnormal semen variables when history, clinical investigation and hormone levels failed to explain infertility. Serum FSH was measured by fluoroimmunoassay.

RESULTS

Patients were divided into five groups on the basis of morphological criteria. The mean serum FSH value of patients with obstructive azoospermia and normal histology (group 1, n = 14) was normal (3.0 (2.2-4.1) IU/l) (mean (95% confidence limits)). Serum levels of FSH in non-obstructive oligo or azoospermia were as follows: group 2: mixed atrophy of tubular tissue without focal Sertoli cell only syndrome (SCO) (n = 104) (4.5 (4.0-5.1) IU/l), group 3: mixed atrophy with unilateral focal Sertoli cell only (n = 39) (7.4 (6.1-9.0) IU/l), group 4: mixed atrophy with bilateral focal SCO (n = 36) (10.7 (8.7-13.0) IU/l). Group 5: bilateral or unilateral total Sertoli cell only (n = 20) (16.0 (12.1-20.9) IU/l). Mean serum FSH levels were significantly different between all groups (P < 0.05).

CONCLUSIONS

Elevation of serum FSH correlates with the appearance of Sertoli cell only tubules. Elevated FSH serum levels make testicular biopsies superfluous for diagnostic purposes, but normal FSH does not exclude severe derangement of spermatogenesis in individual cases.

Primary amenorrhoea and infertility due to a mutation in the beta-subunit of follicle-stimulating hormone

We report a woman with primary amenorrhoea and infertility associated with an isolated deficiency of pituitary follicle-stimulating hormone (FSH), but normal luteinizing hormone (LH) secretion. Ovulation was induced by administration of exogenous FSH and resulted in a successful pregnancy. Sequence analysis of the FSH beta-subunit gene indicated that she is homozygous for a two nucleotide frameshift deletion in the coding sequence. Her mother and son are heterozygous for this mutation. This deletion results in an alteration of amino acid codons 61-86 followed by a premature termination codon. The predicted truncated beta-subunit peptide lacks regions which are important for association with the alpha subunit and for binding to and activation of the FSH receptor. Abnormalities of FSH structure or function might be an under recognised but treatable cause of infertility.