Assessment of sperm motion characteristics in infertile renal transplant recipients using computerized analysis

The effect of paternal exposure to immunosuppressive drugs on sexual function, reproductive hormones, fertility, pregnancy and offspring outcomes: a systematic review

BACKGROUND

Information regarding the possible influence of immunosuppressive drugs on male sexual function and reproductive outcomes is scarce. Men diagnosed with immune-mediated diseases and a wish to become a father represent an important neglected population since they lack vital information to make balanced decisions about their treatment.

OBJECTIVE AND RATIONALE

The aim of this research was to systematically review the literature for the influence of paternal immunosuppressive drug use on many aspects of male sexual health, such as sexual function, fertility, pregnancy outcomes and offspring health outcomes.

SEARCH METHODS

A systematic literature search was performed in the bibliographic databases: Embase (via Elsevier embase.com), MEDLINE ALL via Ovid, Cochrane Central Register of Trials (via Wiley) and Web of Science Core Collection. Additionally, Google Scholar and the Clinical trial registries of Europe and the USA were searched. The databases were searched from inception until 31 August 2019. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes and offspring health with a list of immunosuppressive drugs. Studies were included if they were published in English and if they included original data on male human exposure to immunosuppressive drugs. A meta-analysis was not possible to perform due to the heterogeneity of the data.

OUTCOMES

A total of 5867 references were identified, amongst which we identified 161 articles fulfilling the eligibility criteria. Amongst these articles, 50 included pregnancy and offspring outcomes and 130 included sexual health outcomes. Except for large Scandinavian cohorts, most of the identified articles included a small number of participants. While a clear negative effect on sperm quality was evident for sulfasalazine and cyclophosphamide, a dubious effect was identified for colchicine, methotrexate and sirolimus. In three articles, exposure to tumour necrosis factor-α inhibitors in patients diagnosed with ankylosing spondylitis resulted in improved sperm quality. The information regarding pregnancy and offspring outcomes was scant but no large negative effect associated with paternal immunosuppressive drug exposure was reported.

WIDER IMPLICATIONS

Evidence regarding the safety of immunosuppressive drugs in men with a wish to become a father is inconclusive. The lack of standardisation on how to evaluate and report male sexual function, fertility and reproduction as study outcomes in men exposed to immunosuppressive drugs is an important contributor to this result. Future research on this topic is needed and should be preferably done using standardised methods.

Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update

Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.

Male infertility in renal failure and transplantation

The global disease burden of end stage renal disease (ESRD) is growing rapidly, and organ transplantation remains the gold standard for improving both the quality and quantity of life particularly in young adults. It is therefore critical to understand the effect of ESRD and renal transplantation on male fertility. Many men in renal failure exhibit subfertility or infertility due to several factors including hypogonadism, erectile dysfunction (ED), and direct impairment of spermatogenesis with spermatotoxicity and late stage maturational arrest causing oligospermia or azoospermia. Kidney transplantation has been shown to rescue some-but not all-of these defects, with normalization of reproductive hormonal parameters, improvement in semen parameters (sperm count, motility, morphology), and partial restoration of erectile function. This improvement in fertility is sufficient for a subset to father children either naturally or with assisted reproduction. In this review, we summarize the literature regarding fertility in men with chronic kidney disease (CKD) and on dialysis, and we describe the changes associated with renal transplantation.

The Treatment of Male Infertility After Allograft Renal Transplantation: A Case Series

Background:

Renal transplantation is a useful option for allowing female renal failure patients of childbearing age to achieve pregnancy. However, there have been a few reports on the effects of renal transplantation on infertility treatment in male renal failure patients. We herein report two cases in which male patients underwent infertility treatment after renal transplantation.

Case Presentation:

Case 1: A 51-year-old Asian (Japanese) man underwent transplantation (the donor was his wife) for renal failure due to Autosomal Dominant Polycystic Kidney Disease (ADPKD). At two years after transplantation, he visited the reproduction center in our institute due to infertility. A semen analysis revealed oligoasthenozoospermia. He ultimately failed to achieve pregnancy and gave up on infertility treatment.

Case 2: A 47-year-old Asian (Japanese) man underwent renal transplantation (the donor was his sister) due to renal failure caused by diabetes mellitus. At three years after renal transplantation, he visited the reproduction center in our institute for infertility. Due to ejaculation disability and the absence of sperm in the patient’s urine after masturbation, he was diagnosed with anejaculation. Thus, testicular sperm extraction (TESE) was performed. Twenty-three motile spermatozoa were successfully retrieved by microdissection TESE (micro-TESE). ICSI was subsequently performed and a good embryo was transferred. His wife achieved pregnancy and is expected to deliver this October.

Conclusion:

We report two cases of male infertility treatment after renal transplantation.

Protective effects of new Wenshen Shengjing Decoction on cyclosporine-induced impairment of testosterone synthesis and spermatogenic apoptosis

The aim of the present study was to investigate the potential protective effects of new Wenshen Shengjing Decoction (new WSSJD; including Cornu Cervi Nippon Parvum, Panax ginseng, Cynomorium songaricum, Cistanche deserticola, Radix Astragali, Epimedium brevicornum and Angelica sinensis) on cyclosporine-induced impairment of testosterone synthesis and spermatogenic apoptosis in mice. A total of 90 adult male Kunming mice were divided into the following 6 groups: Control (no intervention), dimethylsulfoxide (DMSO; received only DMSO), cyclosporine A (CsA), clomifene citrate (CC; CsA + CC, 15 mg/kg/day), WSSJD (CsA + WSSJD, crude drug 12 g/kg/day) and new WSSJD (CsA + new WSSJD, crude drug 12 g/kg/day). All mice were treated for 30 days via oral gavage. The testes were subsequently fixed and stained with hematoxylin & eosin to assess the development of seminiferous epithelia. Immunohistochemical techniques were used to detect the expression of luteinizing hormone receptor (LHR) and P450 side chain cleavage (P450scc) in testicular Leydig cells. In addition, the apoptosis of spermatogenic cells in the testes was detected using a terminal dexynucleotidyl transferase-mediated dUTP nick-end labeling assay, and flow cytometry was used to analyze the survival rate and early apoptosis of sperm in the epididymis. Compared with the CsA and CC groups, new WSSJD administration significantly increased levels of serum testosterone and the expressions of LHR and P450scc in testicular Leydig cells (P<0.05), while the apoptosis of spermatogenic cells in the seminiferous tubules and early apoptosis of mature sperm were significantly decreased (P<0.05). These results suggest that new WSSJD may ameliorate CsA-induced spermatogenic damage in male mice by enhancing testosterone synthesis and the secretion of testicular Leydig cells, and by reducing the apoptosis of spermatogenic cells.

Immunosuppressants and Male Reproduction

Prolonged use of immunosuppressant medications is occasionally seen in infertile men with chronic inflammatory conditions; autoimmune disorders; or an organ or hematopoietic stem cell transplant. Chronic inflammation impacts negatively on male reproductive endpoints, so immunosuppressant therapy can produce improvements. Corticosteroids have been used to treat antisperm antibodies and even as an empirical treatment for male infertility in general. Trials of these methods have provided mixed results on semen quality and fertility, with improvement, no change and negative effects reported by different investigators. In a substantial number of observational studies, patients on long-term therapy with prednisone for chronic inflammatory disease, testosterone levels were lower compared to untreated controls, though randomized controlled trials have not been conducted. Similarly decreases in testosterone have been reported in men receiving corticosteroids to minimize transplant rejection; however, most were treated with multiple immunosuppressive medications that may have contributed to this effect. A large number of trials of healthy men treated with corticosteroids have shown some disruption in reproductive hormone levels, but other studies reported no effect. Studies in monkeys, rats (at human equivalent dose), cattle, sheep, and horses have shown endocrine disruption, including low testosterone with dexamethasone treatment. Of the cytostatic immunosuppressives, which have high potential for cellular damage, cyclophosphamide has received the most attention, sometimes lowering sperm counts significantly. Methotrexate may decrease sperm numbers in humans and has significant negative impacts in rodents. Other chemotherapeutic drugs used as immunosuppressants are likely to impact negatively on male fertility endpoints, but few data have been collected. The TNF-α Inhibitors have also received little experimental attention. There is some evidence that the immunophilin modulators: cyclosporine, sirolimus, and everolimus cause endocrine disruption and semen quality impairment. As we review in this chapter, results in experimental species are concerning, and well-designed studies are lacking for the effects of these medications on reproductive endpoints in men.

Long-term impact of immunosuppressants at therapeutic doses on male reproductive system in unilateral nephrectomized rats: a comparative study

Cyclosporine, tacrolimus, and sirolimus are commonly used in renal transplant recipients to prevent rejection. However, information for comparative effects of these agents on the male productive system is extremely limited and controversial. In a physiologically and clinically relevant rat model of unilateral nephrectomy, we demonstrated that long-term oral administration of both cyclosporine and sirolimus at doses equivalent to the therapeutic levels used for postrenal transplant patients significantly affects testicular development and the hypothalamic-pituitary-gonadal axis accompanied by profound histological changes of testicular structures on both light and electron microscopic examinations. Spermatogenesis was also severely impaired as indicated by low total sperm counts along with reduction of sperm motility and increase in sperm abnormality after treatment with these agents, which may lead to male infertility. On the other hand, treatment with therapeutic dose of tacrolimus only induced mild reduction of sperm count without histological evidence of testicular injury. The current study clearly demonstrates that commonly used immunosuppressants have various impacts on male reproductive system even at therapeutic levels. Our data provide useful information for the assessment of male infertility in renal transplant recipients who wish to father children. Clinical trials to address these issues should be urged.

The decline of fertility in male uremic patients is correlated with low expression of the cystic fibrosis transmembrane conductance regulator protein (CFTR) in human sperm

BACKGROUND

The present study was designed to investigate the possible association between infertility of male uremic patients and expression of the cystic fibrosis transmembrane conductance regulator (CFTR) protein in their sperm.

METHODS

Semen was collected and analyzed. Serum levels of FSH, LH and testosterone were measured by radioimmunoassay. The sperm CFTR expressions of 21 uremic patients and 15 renal transplant patients were measured and compared with those of 32 healthy and 33 infertile men.

RESULTS

Only 9 ± 5.9% of sperm from uremic patients expressed CFTR, significantly less than those of the renal transplant patients (29 ± 14.3%, P< 0.001), the infertile men (42 ± 20.7%, P< 0.001) and the healthy men (51 ± 20.5%, P< 0.001). Furthermore, significantly fewer sperm from renal transplant patients expressed CFTR than those of the infertile men (P< 0.05) and the healthy men (P< 0.01). LH levels in uremic patients were significantly higher than in all other groups, whereas FSH levels in uremic patients were only significantly higher than in infertile and healthy men. There was no significant difference in testosterone level among the four categories.

CONCLUSIONS

Sperm CFTR expression is depressed in uremic patients but recovers to some degree after renal transplant along with some improvement in fertility, indicating a 'reversible' change. These results suggest that the CFTR expression rate in sperm is correlated with the decline of uremic patients' fertility, and may be considered as a potential marker to assess the fertility of male uremic patients.

Analyse du statut spermatique, érectile et hormonal chez des patients hémodialysés

But

Le but de notre travail était d’établir le profil hormonal, érectile et spermatique chez les patients hémodialysés et de rechercher l’impact des perturbations hormonales sur la fonction érectile (FE) et les paramètres spermatiques.

Patients et méthodes

Nous avons réalisé une étude transversale chez 30 sujets hémodialysés chez qui un spermogramme a été réalisé parallèlement à un bilan hormonal qui incluait le dosage sérique de FSH (follicle-stimulating hormone) et la testostérone totale. La FE a été évaluée par l’étude de l’indice international de la FE dans sa version française (IIEF-5). Le dosage des hormones sexuelles a été fait par la technique radio-immunologique, et la pratique du spermogramme a été faite selon les recommandations de l’OMS.

Résultats

Deux patients seulement avaient un spermogramme et un bilan hormonal normaux, l’IIEF était normal chez un seul patient.

Les patients azoospermiques (16 %) présentaient un eugonadisme hypergonadotrophique. Quarante pour cent des patients avaient une hypospermie. Un tiers des patients présentait une oligozoospermie sévère associée à un taux élevé de FSH dans 77 % des cas.

La mobilité et la morphologie spermatique étaient altérées dans respectivement 96 et 50 % des cas. Le bilan hormonal montrait une élévation de la FSH (> 8,5 mUI/ml) chez 40 % des patients, et la testostéronémie était diminuée (< 3,2 ng/ml) chez 25 % des patients. Deux patients présentaient un hypogonadisme franc (testostérone < 2 ng /ml).

Discussion

Le volume de sperme était diminué de façon significative chez les patients de plus de 30 ans. La FE était perturbée dans 73 % des cas avec un IIEF moyen de 15 (IIEF normal > 20). Plusieurs auteurs ont mis en évidence une corrélation entre le dysfonctionnement gonadique et les taux élevés de gonadotrophines chez l’homme présentant une insuffisance rénale chronique, avec ou sans atrophie testiculaire. Dans notre série, la testostéronémie était normale chez nos patients malgré l’absence de prise d’androgène. Les séances d’hémodialyses permettent-elles de préserver la fonction endocrine des testicules ?

Conclusion

Les patients au stade d’hémodialyse chronique d’une durée supérieure à un an présentaient un eugonadisme hypergonadotrophique ainsi qu’une insuffisance érectile. L’ancienneté de l’hémodialyse n’altère pas de manière significative les paramètres spermatiques ni la FE. Les patients d’un âge supérieur à 30 ans présentaient une diminution significative du volume spermatique qui pourrait être un marqueur déterminant de l’atteinte de la FE et de la fonction reproductive.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Examination of the semen quality of patients with uraemia and renal transplant recipients in comparison with a control group

To examine the semen quality of patients with uraemia and renal transplant recipients, 40 patients with uraemia and 40 renal transplant recipients were included. According to their interval of post-transplantation, renal transplant recipients were subdivided into group A (22) < or =2 years and group B (18) >2 years. A total of 40 healthy men with normal fertility were included as the controls. Semen samples from all subjects were collected and analysed. The fertility index (FI) value was calculated. The FI value of the normal fertility men was 13.02 (14.26), that of the renal transplant recipient groups A and B were 5.53 (8.30) and 9.27 (22.49) respectively, while the FI of the patients with uraemia was 0.23 (0.76). Compared with the uraemia group, the FI values of renal transplant recipient group either group A or group B were significantly better (P < 0.01). However, compared with the normal control group, the FI values of renal transplant recipient group A were lower (P < 0.01), while there was no significant difference between group B and the control group (P > 0.05). In conclusion, the FI of renal transplant recipients was recovered close to the level of healthy men with normal fertility 2 years after transplantation.

Sirolimus may reduce fertility in male renal transplant recipients

Assessment of sex hormones in organ transplant recipients suggests that sirolimus may impair testicular function. The aim of this study was to evaluate the frequency and severity of sirolimus-associated alterations in sperm parameters and their impact on fathered pregnancy rate. An observational study was carried out in male patients aged 20-40 years who received a kidney transplant during 1995-2005. Patients were sent a questionnaire by post, and sperm analysis was proposed. The fathered pregnancy rates according to the immunosuppressive regimen were estimated and compared using the Poisson model. Complete information was obtained from 95 out of 116 recipients. Patients treated with sirolimus throughout the post-transplant period had a significantly reduced total sperm count compared to patients who did not receive sirolimus (28.6 +/- 31.2 x 10(6) and 292.2 +/- 271.2 x 10(6), respectively; p = 0.006), and a decreased proportion of motile spermatozoa (22.2 +/- 12.3% and 41.0 +/- 14.5%, p = 0.01). Moreover, the fathered pregnancy rate (pregnancies/1000 patient years) was 5.9 (95% CI, 0.8-42.1) and 92.9 (95% CI, 66.4-130.0) in patients receiving sirolimus-based and sirolimus-free regimens, respectively (p = 0.007). Of six patients in whom sirolimus treatment was interrupted, only three showed a significant improvement in sperm parameters. Sirolimus is associated with impaired spermatogenesis and, as a corollary, may reduce male fertility.

Male hypogonadism in cirrhosis and after liver transplantation

Liver is deeply involved in the metabolism of proteins, hormones, enzymes, cytokines, as well as in sex hormones catabolism. Gonadal function requires a normal liver function, and it is well known that clinical signs of hypogonadism are common in patients with liver cirrhosis. Few studies have focused on hypothalamic- pituitary-gonadal alterations in male cirrhotic patients or after orthotopic liver transplantation (OLT). The pathogenesis of hypogonadism in cirrhotic patients is complex and not well explained. It involves both a gonadal and a hypothalamic- pituitary dysfunction. After OLT the hypothalamic-pituitary-gonadal function partially improves, showing that the hepatic dysfunction before OLT is deeply involved in its pathogenesis. After OLT some alterations persist in some patients, both because of pre-existing gonadal alterations (toxic-metabolic damage) and immunosuppressive pharmacological side effects. Further studies will explain the relationship between hypogonadism and OLT outcome, and the role of androgen therapy in hypogonadism after OLT, in the early months and in the long term.

Sexual and reproductive function in end-stage renal disease and effect of kidney transplantation

Advanced chronic kidney disease is associated with impaired spermatogenesis and testicular damage. Semen analysis typically shows a decreased volume of ejaculate, oligo- or complete azoospermia, and a low percentage of motile sperm. Erectile dysfunction (ED) is also common in patients with chronic renal failure (CRF) and is observed in excess of 50% of these patients. There have been ongoing improvements in survival and quality of life after renal transplantation. One of the most impressive aspects of successful renal transplantation in the young people is the ability of the male patient to father a child. In this article we first review pathophysiology of reproductive failure in end-stage renal disease (ESRD), then ED in ESRD and its management are discussed, finally sexual function in renal transplant patients and management of ED in these patients are reviewed.

Cryptozoospermia with normal testicular function after allogeneic stem cell transplantation: a case report

One of the most frequent consequences of allogeneic haemopoietic stem cell transplantation (allo-SCT) in both males and females is gonadal insufficiency. We report the case of a 27-year-old myelodysplastic male who developed azoospermia after allogeneic transplantation of haemopoietic stem cells from his HLA-identical sister. Post-transplant azoospermia was alternated with intermittent severe oligospermia. The patient had a normal endocrine pattern and evidence of mild chronic graft-versus-host disease (cGVHD). Normal intratesticular spermatogenesis was revealed by bilateral fine needle aspiration (FNA) cytology. Inflammation was evident at semen analysis, but no infection was detected by microbiological examination and sperm culture. These findings, together with the re-appearance of sperm cells at semen analysis after a low-dose immunosuppressive treatment, suggested the presence of cGVHD of the urogenital tract, causing a reversible obstruction of the spermatic tract and cryptozoospermia. This is the first case report documenting a severe impairment of sperm count because of a reversible obstruction of the seminal tract, likely caused by cGVHD, in a long-term survivor of allo-SCT with normal endocrine pattern. An important practical consequence of this case report is the fact that azoospermia was cured using low-dose immunosuppressive therapy, and this allowed us to avoid expensive stimulatory treatments with gonadotrophins, which remain, however, ineffective if the obstruction of spermatic tracts is not removed. A spontaneous uncomplicated pregnancy occurred in the partner of the patient 3 months after the corticosteroid treatment withdrawal.

Male infertility after renal transplantation: achievement of pregnancy after intracytoplasmic sperm injection

Chronic renal failure, dialysis, and immunosuppression after transplantation may cause reproductive failure. Although transplantation may reverse most sperm functions in the male, there is sufficient evidence in the literature that sperm motility may not be restored. Herein we present three cases with male factor infertility who underwent intracytoplasmic sperm injection (ICSI). There is a lack of evidence for use of ICSI for couples in whom the infertile husband had undergone renal transplantation. Case 1, a 25-year-old woman with a 7-year history of infertility had a 33-year-old husband, with asthenoteratospermia status-post renal transplantation 1 year prior. The wife delivered healthy twins at 36 weeks of gestation after three embryos were transferred. Case 2, a 34-year-old woman with infertility of 6 years, had a 34-year-old husband transplanted 2 years prior and hospitalized for chronic rejection during ICSI treatment. He had severe oligoasthenoteratozoospermia. She is currently 20 weeks pregnant with a singleton after transfer of two embryos. Case 3, a 31-year-old woman with a previous spontaneous abortion and 3 years of failure to conceive, had a 41-year-old husband status-post renal transplantation 16 years ago, currently in chronic renal failure treated with continuous ambulatory peritoneal dialysis. His sperm analysis showed oligoasthenoteratozoospermia. However, pregnancy did not occur after transfer of two embryos. Health status after renal transplantation influences sperm function. Because healthy sperm is required for fertilization and embryonic development, ICSI candidates after renal transplantation must be in optimum health.

Fertilization of sea urchin eggs and sperm motility are negatively impacted under low hypergravitational forces significant to space flight

Sperm and other flagellates swim faster in microgravity (microG) than in 1 G, raising the question of whether fertilization is altered under conditions of space travel. Such alterations have implications for reproduction of plant and animal food and for long-term space habitation by man. We previously demonstrated that microG accelerates protein phosphorylation during initiation of sperm motility but delays the sperm response to the egg chemotactic factor, speract. Thus sperm are sensitive to changes in gravitational force. New experiments using the NiZeMi centrifugal microscope examined whether low hypergravity (hyperG) causes effects opposite to microG on sperm motility, signal transduction, and fertilization. Sperm % motility and straight-line velocity were significantly inhibited by as little as 1.3 G. The phosphorylation states of FP130, an axonemal phosphoprotein, and FP160, a cAMP-dependent salt-extractable flagellar protein, both coupled to motility activation, showed a more rapid decline in hyperG. Most critically, hyperG caused an approximately 50% reduction in both the rate of sperm-egg binding and fertilization. The similar extent of inhibition of both fertilization parameters in hyperG suggests that the primary effect is on sperm rather than eggs. These results not only support our earlier microG data demonstrating that sperm are sensitive to small changes in gravitational forces but more importantly now show that this sensitivity affects the ability of sperm to fertilize eggs. Thus, more detailed studies on the impact of space flight on development should include studies of sperm function and fertilization.