Effect of antisperm antibodies on postcoital results and effect of intrauterine insemination on pregnancy outcome

Anti-sperm Antibodies as an Increasing Threat to Male Fertility: Immunological Insights, Diagnostic and Therapeutic Strategies

It is a fact that sperm possess antigenic properties. Substantial scientific research suggests that specific antibodies that attach to sperm antigens can induce infertility in both humans and other species. Antisperm antibodies (ASA) represent a significant etiology of infertility in humans, leading to immunoinfertility. The association between ASA and infertility is multifaceted. The observation of sperm agglutination, although not conclusive for the diagnosis of immunological infertility, may suggest the presence of ASA. Nevertheless, ASA may also manifest in the lack of any sperm agglutination. Managing ASA from an andrological perspective depends on the underlying cause and the specific approaches healthcare professionals adopt. The precise etiology of male infertility resulting from ASA remains unclear. Current research has examined the impact of ASA and its prevalence among infertile males to understand the relationship between ASA and changes in semen parameters. However, the findings have been inconclusive. Numerous techniques have been documented for the management of immunoinfertility. This review examines the importance of ASA in the context of infertility, encompassing the postulated mechanisms underlying the development of ASA, the various assays employed for detecting them, and the available treatments.

Anti-sperm antibodies detection by a modified MAR test: Towards a better definition of its indications

RESEARCH QUESTION

Anti-sperm antibodies (ASA) have been shown to reduce male fertility but consensus about the precise situations in which tests should be carried out are lacking. In infertility investigations, should the mixed antiglobulin reaction (MAR) test be a first-line test? Should it be carried out systematically before assisted reproductive technology (ART)? What are the risk factors for ASA?

DESIGN

All infertile patients (n = 1364) were tested with SpermMar (modified MAR test) between July 2013 and June 2017. Intra-patient variability of the MAR test was also assesed by comparing two tests within the same year in selected patients (n = 101).

RESULTS

The main factor that influenced the percentage of ASA was the presence or absence of sperm agglutination. In the presence of agglutinations, 27 out of 72 (37.5%) patients were positive for ASA compared with 33 out of 1292 (2.6%) in the absence of agglutinations (P < 0.0001). When one risk factor was present (spontaneous sperm agglutination, history of scrotal trauma or inguinal surgery), 33 out of 179 (18.44%) tests were positive for ASA (≥50% coated spermatozoa), whereas only 27 out of 1242 (2.2%) were positive when no risk factor was present (P < 0.0001).

CONCLUSIONS

ASA detection should not be systematically recommended in investigations of fertility status and before ART but reserved for when sperm agglutination is found during conventional sperm examination, or if the patient has a history of scrotal trauma or has undergone inguinal surgery.

Effect of an abnormal sperm chromatin structural assay (SCSA) on pregnancy outcome following (IVF) with ICSI in previous IVF failures

A high DNA fragmentation index (DFI) when performing the sperm chromatin structural (SCSA) assay was claimed to be so specific for male subfertility that even IVF and ICSI did not result in live pregnancies. The present study was designed to corroborate or refute these findings. The SCSA test was performed on the male partner from couples failing to have a successful pregnancy despite at least 2 previous IVF attempts. In contrast to the aforementioned studies, ongoing pregnancies were found despite working with a group of recalcitrant patients. Nevertheless, a high DFI score was associated with a trend for lower ongoing pregnancy rates especially related to a high miscarriage rate. Other more recent studies seem to support our conclusions. A high DFI score should influence a patient to choose IVF as a therapeutic modality sooner, especially with ICSI.

Modalities for treatment of antisperm antibody mediated infertility: novel perspectives

Immunoinfertility because of antisperm antibodies (ASA) is an important cause of infertility in humans. The incidence of ASA in infertile couples is 9-36% depending on the reporting center. Early claims regarding the incidence and involvement of ASA in involuntary infertility were probably overemphasized, which has resulted in subsequent confusion, doubt, and underestimation of their clinical significance. No immunoglobulin that binds to sperm should be called an antisperm antibody in a strict sense unless it is directed against a sperm antigen that plays a role in fertilization and fertility. ASA directed against the fertilization-related antigens are more relevant to infertility than the immunoglobulins that bind to sperm associated antigens. Several methods have been reported for treatment of immunoinfertility. These include: immunosuppressive therapies using corticosteroids or cyclosporine; assisted reproductive technologies such as intrauterine insemination, gamete intrafallopian transfer, in vitro fertilization, and intracytoplasmic sperm injection; laboratory techniques such as sperm washing, immunomagnetic sperm separation, proteolytic enzyme treatment, and use of immunobeads. Most of the available techniques have side effects, are invasive and expensive, have low efficacy, or provide conflicting results. Recent findings using defined sperm antigens that have a role in fertilization/fertility have provided animal models and innovative novel perspectives for studying the mechanism of immunoinfertility and possible modalities for treatment. The better understanding of local immunity and latest advances in hybridoma and recombinant technologies, proteomics and genomics leading to characterization of sperm antigens relevant to fertility will help to clarify the controversy and to establish the significance of ASA in infertility.

Prognosis for sperm fertilizability: analysis of different variables in men

An overview of various sperm tests is presented. The standard semen analysis obtained by most clinicians evaluating infertility usually consists of sperm concentration, percent motility, quality of motility, and sperm morphology. Unfortunately, unless the motile density is extremely low, the count and motility are not good prognosticators of fertility potential. Values above the norm for normal fertile couples unfortunately cannot reliably predict normal fertility potential. It is important to find sperm tests that are easy to perform, are relatively inexpensive, and provide an accurate prognosis. Strict morphology was hoped to be such a tool with initial optimism that it was far superior to standard morphology. Unfortunately, this test also failed to be the ideal inexpensive prognostic test after further evaluation. One test that is inexpensive and highly correlates with fertilizability is the presence of antisperm antibodies since their presence frequently does not alter count, motility, or morphology. This test should be performed as part of the routine semen analysis. Other tests highly correlate with the achievement of pregnancy and are simple and inexpensive to perform, but, interestingly, do not correlate with fertilizability. These include the hypoosmotic swelling test (HOST) and the sperm stress test. Abnormalities in these tests imply a different abnormality of sperm that leads to conception failure and that is the transfer of a toxic factor from the sperm to oocyte to embryo that prevents the embryo from implanting. Certainly, the simple, inexpensive HOST should be performed routinely. Other tests of sperm function, e.g., sperm penetration assay, sperm zona pellucida binding assay, and acrosome reaction, have their definite place in the evaluation of the infertile male. However, because they are expensive and difficulty to perform they lend themselves to certain specific circumstances but not to routine testing.

ICSI as an effective therapy for male factor with antisperm antibodies

This study was conducted to evaluate if in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) is an effective treatment for infertility complicated by the presence in the male partner of sperm autoantibodies. Over a 1-year study period comparisons of fertilization, pregnancy, and implantation rates were made in couples where the male partner was negative or weakly positive for sperm autoantibodies (<50%) (gr 1); autoantibodies were strongly positive (>80%) (gr 2); or autoantibodies were moderately positive (50-80%) (gr 3). Only patients having oocytes fertilized by ICSI were included. The fertilization, clinical pregnancy, implantation, and miscarriage rate for group 1 (n = 67) was 56, 43, 21, and 14%. Comparable values for group 2 (n = 20) were 55, 40, 23, and 25%, and for group 3 (n = 6) were 63, 33, 23, and 0%. IVF with ICSI demonstrates comparable fertilization, pregnancy, implantation, and miscarriage rates in female partners of males with and without sperm autoantibodies.

Infertility due to antisperm antibodies

Immunoinfertility is an important problem, involving a significant number of infertile couples. Although the presence of antibodies on sperm has better prognostic value than those in serum or seminal plasma, it may not be the sole authentic evidence of immunoinfertility. Infertility from antisperm antibodies is likely only when they bind to a relevant sperm antigen involved in a specific fertility function. The variance in functional deficits seen in immunologic infertility is most likely related to antibodies directed at different sperm antigens or different class, subclass, or isotypes. Antibodies to FA-1 seem to be of significant importance in human immunoinfertility. In approaching couples with infertility, a high index of suspicion for antibodies is necessary to avoid misdiagnosis. In the optimal situation, all semen analyses should be screened for sperm-bound antibodies, but if this is impractical, testing should be performed on high-risk individuals (Table I). In couples in which the man has sperm-bound antibodies, and in whom there is no identifiable female factor, treatment should be instituted. Most treatments for immunoinfertility have been disappointing because of poor results, adverse effects, or high cost. Corticosteroid therapy has shown some promise in published reports (mostly poorly designed studies), but increase in pregnancy rate is modest and adverse effects may be significant. In our opinion, informed consent should be documented prior to institution of corticosteroid therapy, and subjects should be closely monitored. Advanced reproductive technologies offer a higher safety profile, and, with increasing technology, higher pregnancy rates. We recommend progressing from "low-tech" procedures, such as IUI and reserving the higher level procedures, such as IVF and ICSI, for those couples in whom pregnancy does not occur. The highest level reproductive technologies give the best current prospects for pregnancy in patients with this difficult problem but also are invasive and costly. It is hoped that further work in the laboratory will give rise to newer, safer, and less expensive effective treatments in the very near future.

A comparison of intrauterine insemination in superovulated cycles to intercourse in couples where the male is receiving steroids for the treatment of autoimmune infertility

OBJECTIVE

To compare IUI with timed intercourse in men receiving oral steroid therapy for the treatment of infertility associated with antisperm antibodies.

DESIGN

A prospective, randomized, cross-over trial.

SETTING

All patients were managed and treated at the Andrology Unit, Churchill Hospital, Oxford, United Kingdom.

PATIENTS AND PARTICIPANTS

Thirty males who were found to have antisperm levels of > or = 50% [using the indirect immunobead test with isotypes immunoglobulin (Ig) G, IgA, and IgM (GAM) beads] in either seminal plasma or serum on routine testing were recruited with their partners into the study.

MAIN OUTCOME MEASURES

Antisperm antibody levels in seminal plasma and serum, sperm parameters, conception rates, and pregnancy outcome.

RESULTS

There was a statistically significant reduction in seminal plasma antisperm antibody levels associated with steroid therapy. There was a significant improvement in certain spermatozoan parameters during steroid therapy. The cumulative pregnancy rate over four cycles of IUI was 39.4%. The cumulative pregnancy rate over four cycles of natural intercourse was 4.8%. There was a significantly higher chance of achieving a pregnancy with IUI.

CONCLUSION

Intrauterine insemination significantly improves the chance of achieving a conception when used as an adjuvant therapy to cyclical intermediate dose steroid therapy. Antisperm antibody levels in seminal plasma are significantly reduced during treatment with cyclical intermediate dose steroid therapy, although levels in serum appear to be unaffected. Cyclical intermediate dose steroid therapy significantly improves certain sperm parameters but, when used in isolation, is associated with a low pregnancy rate.

Chymotrypsin-galactose treatment of sperm with antisperm antibodies results in improved pregnancy rates following in vitro fertilization

PROBLEM

To determine if chymotrypsin-galactose (CG) treatment of sperm bound with antisperm antibodies (ASA) improves pregnancy rates (PRs) following in vitro fertilization (IVF).

METHOD

Patients with > 50% ASA who failed to conceive despite six intrauterine insemination (IUI) cycles were included. Initially the sperm treatments were randomized with CG vs culture medium; subsequently only CG treatment was used.

RESULTS

There was a significantly lower fertilization rate in those patients inseminated with sperm incubated in culture medium vs CG (27% vs 47%, P < .05 t-test). Similarly, a higher percentage of patients receiving culture medium treatment of sperm had failed fertilization (45%) compared to CG (11%). Though the clinical PRs were higher with CG (21%) tham medium (9.5%), there was no statistical difference.

CONCLUSIONS

Though the percentage of sperm bound with antibodies are not reduced, we hypothesize that the CG treatment improves fertility by possibly mitigating the antagonistic action of these antibodies.