A controlled trial of the use of erythromycin for men with asthenospermia

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.

[Infections and male infertility]

BACKGROUND

The role of urogenital infections in male infertility has long been the subject of debate.

METHODS

A bibliographic search limited to English-language literature on human subjects published before 5/2023 resulted in the selection of 189 articles.

RESULTS

Male infertility is often of multifactorial aetiology, and to optimise the prognosis it is important to manage all the factors that can be corrected, including infectious causes, which represent one of the most frequent aetiologies. The infectious agents involved in urogenital infections are most often bacterial or viral, and more rarely parasitic. They can infect the seminal tract, male accessory glands and/or testicles, and usually result in inflammation and increased oxidative stress. These infections reduce male fertility, in particular by altering spermogram parameters and increasing sperm DNA fragmentation. For these reasons, the search for a urogenital infection should be systematic, involving a careful history and clinical examination, ultrasound and systematic bacteriological tests guided by clinical findings. Aetiological treatment may be proposed depending on the picture and the germ involved.

CONCLUSION

This review should help the urologist to establish an accurate diagnosis of the form and extent of the infection, and enable him to define an appropriate therapeutic strategy, tailored to the patient, in order to obtain the best chances of improving male fertility.

Effectiveness of Pharmacological Intervention Among Men with Infertility: A Systematic Review and Network Meta-Analysis

Background. Infertility is an emerging health issue for men. Comparative efficacy of different pharmacological interventions on male infertility is not clear. The aim of this review is to investigate the efficacy of various pharmacological interventions among men with idiopathic male infertility. All randomized control trials evaluating the effectuality of interventions on male infertility were included for network meta-analysis (NMA) from inception to 31 April 2020, systematically performed using STATA through the random effect model. The protocol was registered at PROSPERO (CRD42020152891). Results. The outcomes of interest were semen and hormonal parameters. Treatment effects (p < 0.05) were estimated through WMD at the confidence interval of 95%. Upon applying exclusion criteria, n=28 RCTs were found eligible for NMA. Results from NMA indicated that consumption of supplements increases sperm concentration levels [6.26, 95% CI 3.32, 9.21] in comparison to SERMs [4.97, 95% CI 1.61, 8.32], hormones [4.14, 95% CI 1.83, 6.46], and vitamins [0.15, 95% CI -20.86, 21.15)] with placebo, whereas the use of SERMs increased percentage sperm motility [6.69, 95% CI 2.38, 10.99] in comparison to supplements [6.46, 95% CI 2.57, 10.06], hormones [3.47, 95% CI 0.40, 6.54], and vitamins [-1.24, 95% CI -11.84, 9.43] with placebo. Consumption of hormones increased the sperm morphology [3.71, 95% CI, 1.34, 6.07] in contrast to supplements [2.22, 95% CI 0.12, 4.55], SERMs [2.21, 95% CI -0.78, 5.20], and vitamins [0.51, 95% CI -3.60, 4.62] with placebo. Supplements boosted the total testosterone levels [2.70, 95% CI 1.34, 4.07] in comparison to SERMs [1.83, 95% CI 1.16, 2.50], hormones [0.40, 95% CI -0.49, 1.29], and vitamins [-0.70, 95% CI -6.71, 5.31] with placebo. SERMs increase the serum FSH levels [3.63, 95% CI 1.48, 5.79] better than hormones [1.29, 95% CI -0.79, 3.36], vitamins [0.03, 95% CI -2.69, 2.76], and supplements [-4.45, 95% CI -7.15, -1.76] in comparison with placebo. Conclusion. This review establishes that all interventions had a significantly positive effect on male infertility. Statistically significant increased sperm parameters were noted in combinations of zinc sulfate (220 mg BID), clomiphene citrate (50 mg BID), and testosterone undecanoate and CoQ10; tamoxifen citrate and FSH were shown to improve the hormonal profile in infertile males.

The current status and future of andrology: A consensus report from the Cairo workshop group

BACKGROUND

In attempting to formulate potential WHO guidelines for the diagnosis of male infertility, the Evidence Synthesis Group noted a paucity of high-quality data on which to base key recommendations. As a result, a number of authors suggested that key areas of research/evidence gaps should be identified, so that appropriate funding and policy actions could be undertaken to help address key questions.

OBJECTIVES

The overall objective of this Consensus workshop was to clarify current knowledge and deficits in clinical laboratory andrology, so that clear paths for future development could be navigated.

MATERIALS AND METHODS

Following a detailed literature review, each author, prior to the face-to-face meeting, prepared a summary of their topic and submitted a PowerPoint presentation. The topics covered were (a) Diagnostic testing in male fertility and infertility, (b) Male fertility/infertility in the modern world, (c) Clinical management of male infertility, and (d) The overuse of ICSI. At the meeting in Cairo on February 18, 2019, the evidence was presented and discussed and a series of consensus points agreed.

RESULTS

The paper presents a background and summary of the evidence relating to these four topics and addresses key points of significance. Following discussion of the evidence, a total of 36 consensus points were agreed.

DISCUSSION

The Discussion section presents areas where there was further debate and key areas that were highlighted during the day.

CONCLUSION

The consensus points provide clear statements of evidence gaps and/or potential future research areas/topics. Appropriate funding streams addressing these can be prioritized and consequently, in the short and medium term, answers provided. By using this strategic approach, andrology can make the rapid progress necessary to address key scientific, clinical, and societal challenges that face our discipline now and in the near future.

New changes in pregnancy and lactation labelling: Review of dermatologic drugs

Background

The U.S. Food and Drug Administration has published new pregnancy and lactation labelling rules that set standards on the presentation of information with regard to drug usage during pregnancy and breastfeeding, as well as the effects on fertility. These guidelines became effective June 30, 2015, and classified the risks of using prescription drugs during pregnancy in three detailed subsections: Pregnancy, Lactation, and Females and Males of Reproductive Potential. These sections describe the risks within a real-world context of caring for these patients.

Objective

In this study, we reclassified and categorized drugs and treatments commonly used in dermatology according to these new guidelines.

Methods

We performed a search of the medical literature about the use of relevant prescription drugs during pregnancy and breastfeeding and their effect on fertility. The search included prospective and retrospective studies, review articles from PubMed-indexed journals (from inception to November 2018), U.S. Food and Drug Administration records, pregnancy exposure registries, relevant information and studies provided in drug labeling by companies, and updated pharmacologic texts and guidelines up to 2018.

Results

Topical immunomodulators, systemic immunomodulators (including biologics), systemic antipruritic agents, antimicrobials, as well as acne, hair, and cosmetic agents were included. We have made best attempts to review and consolidate existing and new data and include them in our guide.

Conclusion

This new narrative format facilitates prescribing by considering a variety of factors. One previously overlooked aspect was the impact on the reproductive potential of both male and female patients. Rather than depending on overly simplistic letter risk categories, dermatologists will now need to make prescribing decisions based on each patient and the information provided, which will allow for better decision making and patient care.

The varicocele argument resurfaces

A recent series of articles and reviews published in Fertility and Sterility have rekindled the more than half century debate on varicocelectomy. Every one of these articles favored strongly the repair of varicocele for male infertility. Since my review paper on this issue in 2001, published in Human Reproduction Update, and since advent of ICSI in 1993, I had thought that most reproductive physicians felt negatively about the benefit of varicocelectomy. However, more recent urological papers are causing this negative view to be re-evaluated. It is now advocated by some urologists that varicocelectomy improves sperm count and testosterone levels, and even improves the results with ICSI. Thus, it may be appropriate to revisit older studies again and review the newer ones in this never ending controversy. Newer studies are re-opening the door to review and possibly re-instate varicocelectomy. This dilemma may never be fully resolved, but it is important to keep an open mind.

Treatment of Leukocytospermia in Male Infertility: A Systematic Review

Male factors account for 20% to 50% of infertility cases, and infection in the genitourinary tract may play a contributing role in up to 15% of male infertility. Leukocytospermia is a well-known indicator of infection or inflammation in the male sex glands and the urogenital tract. Although great deal of effort has been expended to elucidate definite management strategies in infertile men with leukocytospermia, the gold standard of treatment remains unclear. Until recently, broad spectrum antibiotics and antioxidants have been used in the treatment of leukocytospermia for male infertility to eliminate infection and reduce reactive oxygen free radicals produced inside cellular mitochondria as a result of inflammation. The present review reveals that antibiotics might improve sperm parameters, the rate of resolution of leukocytospermia, the bacteriologic cure rate, and even the pregnancy rate, although some reports conflict. Antioxidants might also have clinical benefits for sperm function as shown by in vitro studies. However, the data are insufficient to conclude whether antibiotics and antioxidants for the treatment of infertile men with leukocytospermia are effective or not. Better designed investigations into leukocytospermia are needed.

Age-related disease pattern in infertile men: increasing incidence of infections in older patients

In a cross-sectional retrospective study, the age-dependency of semen parameters of men with specific andrological diseases was investigated in 3,698 men (mean age 33 years; range 19-63 years) attending a tertiary referral clinic for couple infertility. In all, 1,853 patients suffered from idiopathic infertility (mean age 33.2 years; range 19-60 years), 388 from infections of the accessory glands (34.2; 20-61), 363 had a history of maldescended testes (32.0; 20-51) and 833 a varicocele (33.6; 20-63). In 172 patients, a varicocele and an infection (34.3; 24-54) and in 94 a varicocele and a history of maldecended testes (32.5; 21-53) were found. Semen analysis was performed according to WHO criteria. An age-related decrease in testicular volume was not observed in any group. Total sperm count decreased significantly with advancing age only in patients with an infection of the accessory glands. We found no evidence for age-dependent progressive deterioration of semen variables in the other groups. It may be concluded that the causes for the spermatogenetic defects in men with idiopathic infertility, a history of maldescended testes or varicocele are acquired before adolescence and do not progress during adulthood. In contrast, infections of the accessory glands may lead to decreased sperm counts by functional impairment or partial occlusion of the seminal ducts. Thus, if in the general population declining sperm counts are observed, genital tract infections may be suspected as a contributing factor.

New concepts in operative andrology: a review

Several recently published, or about to be published, controversial issues in operative andrology are clarified and reviewed in this paper. The microsurgical technique for sperm retrieval for nonobstructive azoospermia, the round spermatid controversy and the varicocoele dilemma (why does everybody keep doing varicocoelectomy for male factor infertility?) are presented with salient points that have recently been presented elsewhere and referenced. Finally, at the end, we review briefly what is known about the likelihood of genetic transmission of infertility from male factor patients to their offspring as a result of the new ICSI technology.

Medical treatment for idiopathic male infertility: is it curative or palliative?

Medical treatment of disorders of sperm production and function remains an important goal despite major advances in assisted reproductive technology. Effective treatments exist for genital tract obstruction, gonadotrophin deficiency, sperm autoimmunity, coital disorders and some impairments caused by toxins or illness. However, the majority of men seen for reduced sperm production or function do not have these conditions and the empirical treatments used in the past are probably ineffective. New therapeutic approaches derived from research on the causes and mechanisms of testicular dysfunction are needed and their curative effects must be established by well-designed controlled clinical trials.

Nonsperm cells in human semen: with special reference to seminal leukocytes and their possible influence on fertility

Nonspermatozoal cells (NSC) in semen, including immature germ cells, leukocytes (WBC) and epithelial cells, are normally found in a concentration less than 15% of the sperm concentration. Cytological staining methods and immunoenzymatic assays for characterization of seminal WBC and methods for detection of various enzymes from WBC are evaluated. Criteria for abnormally high levels of WBC in semen, caused by exogenic factors (e.g., infection) and possibly by endogenic factors (e.g., abnormal sperm), are discussed. Leukocytospermia is associated with reduced in vitro fertilization rate, and experimentally-measured sperm functions (e.g., motility) are inhibited by high concentrations of certain WBC products (e.g., reactive oxygen species and interferon-gamma). At the present stage, the following procedures could be used to evaluate WBC in ejaculates from infertile patients: (1) count the number of NSC using a hemocytometer. (2) Determine the number of WBC in percentage of NSC in smears using the Papanicolaou staining technique, or an immuno-enzymatic assay using monoclonal antibodies to the different kinds of WBC. (3) If, abnormally high levels of WBC (according to the WHO criteria or based on a percentile determined from examination of normal, fertile men) is detected, a second ejaculate should be examined 3 months later. (4) Persistent leukocytospermia should indicate physical and microbiological examinations, after which antibiotic treatment may be indicated.

Infection and male infertility: effect of different antibiotic regimens on semen quality

Objective criteria of semen quality were evaluated in 60 men with positive culture of semen after treatment with two different antibiotics and compared with placebo. Group I received 160 mg trimethoprim and 800 mg sulfamethoxazole twice a day, group II received 250 mg ciprofloxacin twice a day, and group III received a placebo. No difference was recorded between antibiotic treatment and placebo in sperm quality but accessory gland function was modified.

Infertility treatment: from cookery to science. The epidemiology of randomised controlled trials

OBJECTIVES

To review the epidemiology of published randomised controlled trials in infertility treatment over the last 25 years, with special emphasis on the number and quality of trials.

DESIGN

Computer literature review by MEDLINE backed up by a manual search of 41 journals. Each trial was classified according to the methodology described and quality criteria. The results were recorded in a computer database. Odds ratios (OR) and confidence intervals (CI) were calculated where the data were sufficient.

SUBJECTS

Couples suffering from primary or secondary infertility. The trials studied 33,761 patients overall.

SETTING

Institute of Epidemiology and Health Services Research, Leeds.

RESULTS

Five hundred and one randomised trials in male and female infertility treatment were identified between 1966 and 1990. Pregnancy was an outcome in 291 (58%) and these were the subject of detailed analysis. Two hundred and twenty-four (77%) and 67 (23%) 'pregnancy trials' were concerned, respectively, with female and male infertility. Four per cent of the trials were preceded by a sample size calculation, and the average sample size was 96 patients (range 5-933); 700 patients per group would be required to demonstrate plausible success rates for most treatments. The method of randomisation was unstated or pseudo-randomised in 206 (71%) of trials where pregnancy was an outcome. Only 29 (5.8%) of studies were multicentre. The method of confirmation of pregnancy was omitted for 70% of papers. Cross-over design was used in 103 (21%) of cases. Meta-analysis is possible for selected topics such as the use of anti-oestrogens in idiopathic oligospermia and unexplained female infertility. Eight cases of double reporting were identified.

CONCLUSIONS

Trials using randomised methodology were relatively few in comparison with other branches of medicine, although their use is important in the evaluation of treatment for infertility as treatment-independent pregnancy is common. It was encouraging to note that an exponential increase in the use of this methodology occurred during the last three years, especially in association with assisted conception techniques, and meta-analysis has become possible for selected topics. However, many trials suffer from an unrealistically small sample size, inappropriate use of cross-over design or pseudo-randomisation. The trend towards properly controlled studies should be encouraged but these studies should be of improved quality and organised on a multicentre or even international basis.

Use of a novel non-steroidal anti-inflammatory drug, nimesulide, in the treatment of abacterial prostatovesiculitis

Nimesulide, a novel non-steroidal anti-inflammatory drug, was used in cases of abacterial prostato-vesiculitis. Thirty patients with a mean age of 33.7 years (range 18-58) were studied. Nimesulide was administered orally 100 mg b.i.d. for three cycles of 10 d each. Dysuric symptoms, semen analysis, and transrectal ultrasound were examined during the study. The concentration-time curves of nimesulide (NIM) and its metabolite, hydroxynimesulide (OH-NIM) in seminal fluid were also evaluated after single oral administration (100 mg) using an HPLC technique. Following administration of the drug, the Cmax was reached in seminal fluid at the second hour for NIM (with a mean value +/- SD of 0.58 +/- 0.13 micrograms ml-1) and at the fourth hour for OH-NIM (2.98 +/- 0.38 micrograms ml-1). Maximal seminal fluid concentrations compared to blood plasma levels were observed at the fourth hour for both substances (31.73 +/- 2.34% for NIM; 31.87 +/- 8.66% for OH-NIM. Dysuric symptoms were relieved in 20 (66%) patients. A clear amelioration of inflammatory signs were observed at transrectal ultrasound evaluation in 16 (54%) patients. No statistically significant changes of sperm count and motility in the whole sample were observed, while a significant reduction in the number of abnormal forms occurred. From these results, nimesulide appears to be an effective anti-inflammatory drug with a good diffusion into the genital apparatus and low side-effects.

Infection in the male reproductive tract. Impact, diagnosis and treatment in relation to male infertility

The following are the conclusions that can be derived from a review of the literature regarding the role of infection in the aetiology of male infertility. (i) Temporary inflammatory episodes in the male reproductive tract which are self-limiting are probably common. (ii) Caution should be exercised in the use of leukospermia or bacteriospermia as parameters for glandular infection. (iii) There is a need for alternative techniques for detecting non-symptomatic deep pelvic infections in the male; one technique of great promise is rectal ultrasound. (iv) Rectal ultrasound indicates that a large number of men with poor sperm quality have a non-symptomatic, chronic prostatovesiculitis. (v) Increasing evidence implicates Chlamydia trachomatis as being a major cause of chronic non-bacterial prostatitis. (vi) An important aspect of chlamydial infections in men may be that the male accessory sex glands may function as reservoirs for the organism, increasing the probability of infection in the female. (vii) Ureaplasma urealyticum may also play an important aetiological role in male infertility but its significance is confounded by its acknowledged function as a commensal in the reproductive tract. (viii) One of the manifestations of male reproductive tract infection is the induction of sperm autoantibodies. (ix) There is a need for more systematic controlled studies of the effects of antibiotic treatment on sperm quality with different preparations for extended periods using patient groups in which a glandular infection has been verified, e.g. by rectal ultrasonography.

Variation of semen quality in normal men

To examine the amount of variability in semen analysis results and whether there is any effect of season, 673 specimens provided by seven normal, healthy men (61-205 specimens/subject) over 72-324 weeks were assessed for sperm concentration, ejaculate volume, motility and motility index. Noticeable sample to sample variations were found. The largest proportion of the overall variance was due to within-subject differences, e.g., sperm concentration (54%), ejaculate volume (59%), percentage motility (96%) and motility index (74%). Although changes in semen-analysis results occurred over the year, no consistent trend was seen. No evidence was found to suggest that the differences were due to modifications of the methods employed by the laboratory, or to the change of season.

Duration of involuntary infertility and subsequent pregnancy

During 1978-1983, 1,040 couples had been evaluated at our infertility clinic and subsequently followed up for an average of two years. The length of time the couple had been trying for a pregnancy (trying time) is shown to be strongly related to the subsequent chances of pregnancy. There are few effective treatments for male infertility and, therefore, these data may represent the spontaneous fertility rates from an untreated population. This background pregnancy rate should be useful to any physician planning a trial of treatment for the infertile couple when pregnancy is the success criterion, and allowance needs to be made for this spontaneous pregnancy rate when analyzing the results of treatments. Review of the literature suggests that some reported results could be misleading because of failure to allow for this background pregnancy rate.

The effect of doxycycline in infertile couples with male accessory gland infection: a double blind prospective study

Male accessory gland infection (MAGI, epididymo-prostato-vesiculitis) with abnormal semen quality was rarely the only abnormality in infertile couples since it occurred in no more than 1.6% of 2871 couples evaluated in 7 centres during a 3-year period. Both partners of 33 infertile couples with no other demonstrable abnormality than abnormal semen and MAGI consented to participate in a double blind trial and were treated with either doxycycline, 100 mg/day for 1 month (20 couples) or placebo (13 couples). Follow-up during a total of 175 couple-months included semen analysis and the recording of pregnancy. Pregnancy occurred in 2 of the doxycycline-treated couples (10%) and in 1 of the placebo treated couples (8%), corresponding with conception rates per month of 1.9% and 1.5%, respectively. Sperm motility and, to a lesser extent, morphology showed improvement in both groups. Evidence of infection, namely increased numbers of white blood cells and positive sperm culture, disappeared in both the doxycycline-treated and placebo group. It is concluded that features of MAGI in semen may regress spontaneously and are not influenced by the doxycycline treatment. The concomitant improvement of sperm motility and morphology still does not seem to enhance the probability of conception.

Testicular vein ligation and fertility in men with varicoceles

Pregnancy rates in 651 subfertile couples in which the man had a varicocele were analysed by life table methods and were not found to be significantly different before and after testicular vein ligation performed in 283 patients. Estimated proportions of couples conceiving were roughly 30% by one year and 45% by two years in both groups. The operation was also not associated with improvement in results of semen analysis. These findings suggest that testicular vein ligation for varicoceles does not improve fertility.

Spontaneous improvement in semen quality: regression towards the mean

Regression towards the mean was demonstrated in semen analyses from 216 donors for artificial insemination by selecting those with low sperm concentration (less than 40 X 10(6)/ml), low motility (less than 50%) or low motility index (less than 120) in the first test. For each characteristic, the result was significantly higher in the second test, the means for first and second tests being, for sperm concentration 28 and 56 million per ml (n = 14, P less than 0.01), for motility 42 and 55% (n = 14, P less than 0.01) and for the motility index 95 and 131 (n = 24, P less than 0.001). Regression towards the mean occurs whenever extremes of the range of a variable and selected for re-measurement. Many of the current treatments for oligospermia and asthenospermia have been promoted because semen quality improved during uncontrolled studies in which this phenomenon may have been operative. Using means of multiple samples before and following therapeutic intervention will not prevent regression towards the mean, only reduce its magnitude. Thus, placebos are essential in the evaluation of treatments for male infertility.