The effect of systemic isotretinoin on male fertility

Exploring the association between isotretinoin and sexual dysfunction: a comprehensive scoping review

BACKGROUND

A potential link between isotretinoin and sexual dysfunction has been reported in various studies. However, such an association has not been explored within the context of a literature review until now.

OBJECTIVES

To evaluate the methodology and quality of studies investigating this association, and to examine the definitions of sexual dysfunction used.

METHODS

A scoping review approach was used to identify peer-reviewed research articles. The search terms used were 'isotretinoin', 'sexual dysfunction', 'erectile dysfunction', 'ejaculatory disorders', 'decreased libido', 'female sexual interest', 'female arousal disorder', 'libido', 'pelvic pain', 'dyspareunia', 'orgasmic disorder', 'impotence', 'ovaries', 'fertility' and 'menstrual irregularity'.

RESULTS

In total, 55 peer-reviewed manuscripts were included, consisting of 8 animal studies and 46 human studies with 2420 patients. Of the studies in humans, there were 18 case reports or case series, 2 case-control studies, 4 cross-sectional studies, 6 longitudinal studies, 3 pharmacovigilance reports and 13 cohort studies. The most frequently observed dose range of isotretinoin was 0.5-1.0 mg kg-1 per day, usually for a duration of 1-6 months. More than half of the studies (54%, n = 25) reported a beneficial or neutral effect of isotretinoin on sexual function. The majority of studies (89%, n = 41) were categorized as Oxford Evidenced-Based Medicine level 4.

CONCLUSIONS

This scoping review revealed very weak evidence supporting a link between isotretinoin and sexual dysfunction. Notably, the diverse definitions of sexual dysfunction pose a significant challenge for comparative analysis. The authors advocate for a standardized definition of sexual dysfunction and a framework for determining causality in order to contribute to a more comprehensive understanding of the relationship between isotretinoin and sexual dysfunction.

Development and Validation of the Isotretinoin Hesitancy Scale for Acne Vulgaris: A Preliminary Study

BACKGROUND

Oral isotretinoin is the most effective systemic treatment for acne patients who fail to respond to other forms of therapies. However, hesitations and concerns regarding its side effect profile may detain the patients from treatment. This study aimed to develop and validate the Isotretinoin Hesitancy Scale (IHS) among acne patients.

METHODS

A cross-sectional study was conducted with 100 acne patients who had not used isotretinoin previously. A 22-item scale was created based on the related literature and expert opinions. The items of the scale related to beliefs and worries about isotretinoin were formatted with response options: agree, indecisive, and disagree. In this study, construct validity was tested with exploratory factor analysis, and reliability was tested with internal consistency and split-half reliability.

RESULTS

The results of exploratory factor analysis indicated a three-factor solution with a total of 14 items, explaining 57% of the total variance. The first factor (Hesitancy Related to Reversible Adverse Effects: 6 items) accounted for 30% of the variance, the second factor (Hesitancy Related to Irreversible Adverse Effects: 4 items) accounted for 16% of the variance and the third factor (Isotretinoin-related Anxiety: 4 items) accounted 11% of the variance. The internal consistency of the three factors was calculated as 0.79, 0.78, and 0.72, respectively. The Cronbach's alpha score of the total scale was found to be 0.81, and split-half reliability was found to be 0.87.

CONCLUSIONS

The IHS is the first scale that provides a valid and reliable assessment of isotretinoin hesitancy in acne patients. Eliminating isotretinoin hesitancy may reduce acne-related clinical and psychosocial consequences.

A clinical guide to rare male sexual disorders

Conditions referred to as 'male sexual dysfunctions' usually include erectile dysfunction, ejaculatory disorders and male hypogonadism. However, some less common male sexual disorders exist, which are under-recognized and under-treated, leading to considerable morbidity, with adverse effects on individuals' sexual health and relationships. Such conditions include post-finasteride syndrome, restless genital syndrome, post-orgasmic illness syndrome, post-selective serotonin reuptake inhibitor (SSRI) sexual dysfunction, hard-flaccid syndrome, sleep-related painful erections and post-retinoid sexual dysfunction. Information about these disorders usually originates from case-control trials or small case series; thus, the published literature is scarce. As the aetiology of these diseases has not been fully elucidated, the optimal investigational work-up and therapy are not well defined, and the available options cannot, therefore, adequately address patients' sexual problems and implement appropriate treatment. Thus, larger-scale studies - including prospective trials and comprehensive case registries - are crucial to better understand the aetiology, prevalence and clinical characteristics of these conditions. Furthermore, collaborative efforts among researchers, health-care professionals and patient advocacy groups will be essential in order to develop evidence-based guidelines and novel therapeutic approaches that can effectively address these disorders. By advancing our understanding and refining treatment strategies, we can strive towards improving the quality of life and fostering healthier sexual relationships for individuals suffering from these rare sexual disorders.

Assessment of the In Vivo Reprotoxicity of Isotretinoin in Sprague-Dawley Male Rat

BACKGROUND

Isotretinoin (ISO) belongs to a family of drugs called retinoids. It is the most effective drug prescribed by dermatologists for the treatment of the inflammatory disease, acne vulgaris. A significant barrier to the use of ISO has worries regarding its adverse effect profile. Despite the well-recognized reproductive toxicity and teratogenicity in females, there is no warning related to the use by male patients in the medication prospectus. Current data on the effects on human male fertility is contradictory and inconclusive.

OBJECTIVES

This study was undertaken to investigate the potential effects of ISO oral doses in the Sprague-Dawley male rat germ cells using the sperm morphology assay. Also, the serum levels of the follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone were measured.

METHODS

The rat groups were given varying ISO doses via gastric gavage for seven consecutive days. The epididymis sperm specimens were microscopically examined for the following reproductive toxicity parameters: sperm concentration, examined viability, motility, and morphology. The serum FSH, LH, and testosterone levels were measured by using the corresponding enzyme-linked immunosorbent assay (ELISA) kit. The data were analyzed statistically by one-way analysis of variance (ANOVA) followed by the Tukey test at P ≤ 0.05 significance level.

RESULTS

The results indicated that the drug did not significantly increase the sex hormone levels but notably affected both the sperm quantity and quality.

CONCLUSION

These observations suggest that ISO was reprotoxic, and future therapies should be further reassessed.

Effect of systemic isotretinoin therapy on semen parameters

PURPOSE

Vitamin A has multiple functions in the human body, being involved in growth, epithelial differentiation, vision, immune function and reproduction. While normal spermatogenesis is influenced by several factors, it requires vitamin A. Systemic isotretinoin is a vitamin A derivative that is used in the treatment of many dermatological diseases, especially acne vulgaris (AV). There is limited research on the changes in semen parameters after systemic isotretinoin therapy in humans. Our study investigates the presence of varicoceles in patients undergoing systemic isotretinoin therapy for AV and examines whether there were any changes in the semen parameters before and after treatment.

METHODS

Included in the study were 46 men patients who were scheduled for systemic isotretinoin therapy for AV. Before treatment, the patients underwent a physical examination and ultrasonography for varicoceles assessment. The patients underwent spermiogram before treatment and after 6 months of treatment. The spermiogram assessments included semen volume, sperm concentration, total sperm count, progressive motility, viability and sperm morphology.

RESULTS

After treatment, there was an increase in semen volume, sperm concentration, total sperm count, progressive motility and vitality from the pre-treatment values, but a deterioration in the sperm morphology (p < .05). Comparing patients with and without varicoceles revealed more changes in semen parameters after treatment in those with varicoceles. There was a statistically significant difference in sperm concentration (p < .001).

CONCLUSIONS

Systemic isotretinoin therapy negatively affects sperm morphology, but has positive effect on other semen parameters, and these changes in semen parameters occur more frequently in patients with varicoceles.KEY MESSAGESAcne vulgaris is a very common disease and systemic isotretinoin is used as the most effective agent in its treatment.Systemic isotretinoin positively affects semen parameters except sperm morphology.Changes in semen parameters are more common in patients with varicocele.

Does isotretinoin affect spermatogenesis in the long term? A rat model

OBJECTIVES

Spermatogenesis, in which cell regeneration continues, can be affected by environmental, chemical, psychological factors or various diseases. There is conflicting information in the literature about the effect of isotretinoin, which is widely used in acne treatment, on testes and spermatogenesis. Therefore, we planned a rat study to evaluate the long-term efficacy of oral isotretinoin on testicular tissues and spermatogenesis.

MATERIALS AND METHODS

The Group 1 (n = 6) 7.5 mg/kg/day and the Group 2 (n = 6) received isotretinoin at a dose of 30 mg/kg/day dissolved in sunflower oil, the Sham Group (n = 6) received only sunflower oil by gavage, and the control group (n = 6) received standard feed and water for four weeks. After the 4th week, all animals were fed with standard feed and water and followed for the next four weeks. At the end of the 8th week, all animals were sacrificed under deep anesthesia. Seminiferous tubule diameters, epithelial thickness, apoptotic index, sperm number and motility recorded Results: Sperm count, motility, vitality, diameter of seminiferous tubule and germinal epithelium thickness were decreased and apoptotic index increased in the groups received isotretinoin. There was no significant difference between the groups in terms of testosterone levels.

CONCLUSIONS

We consider that further comprehensive studies, including human clinical trials, should be conducted to examine the negative effects of isotretinoin on spermatogenesis in the long term especially when there is a need using isotretinoin in men for various reasons and to eliminate the contradictions in the literature in this regard.

Effect of isotretinoin (Netlook) on the testis of adult male albino rats and the role of omega 3 supplementation: A histological and biochemical study

Isotretinoin is an oral retinoid which used across the world in the treatment of patients especially adolescents complaining of acne. In spite of the prevalent clinical use of isotretinoin, the generation of oxidative stress with the affection of several organs leads to the limitation and restriction of its use. Omega-3 (N-3) is an essential polyunsaturated fatty acid (PUFAs) with powerful antioxidant properties. The aim of this study was to investigate the histological and biochemical changes occurring in the rat testis following isotretinoin intake and to evaluate the role of omega 3 supplementation in ameliorating testicular damage. Thirty adult male albino rats were divided equally into three groups. Group I is the control group, group II received isotretinoin (1.0 mg/kg/day) dissolved in distilled water and group III received isotretinoin (1.0 mg/kg/day) and omega 3 (400 mg/kg/day). Testis samples were collected and processed for light and electron microscopic examination. The blood samples were collected for biochemical assessments. Results indicated that isotretinoin caused histological changes in all stages of spermatogenesis and alterations of the hormonal assay. These changes in the rat testis which were corrected by omega 3 use.

A systematic review of retinoic acid in the journey of spermatogonium to spermatozoa: From basic to clinical application

Background: Retinoic acid plays an essential role in testicular development and functions, especially spermatogenesis. We have reviewed the role of retinoic acid from basic (molecular) to clinical application.

Methods: A search was conducted in the online database including PubMed, Google Scholar, and Scopus for English studies published in the last eight years about this issue. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in assessing the studies we are going to investigate.

Results: Studies indicated that retinoic acid plays an essential role during pluripotent stem cell migration and lineage commitment, cell differentiation, apoptosis, stem cell number regulation, and maturation arrest in spermatogenic cells. Retinoic acid can also affect related protein expression and signaling pathways at different stages of spermatogenesis. Four studies have applied retinoic acid to humans, all of them in the single-arm observational study. The results look promising but need further research with more controlled study methods, randomization, and large samples.

Conclusions: This current systematic review emphasizes a novel retinoic acid mechanism that has not been well described in the literature previously on its functions during the first seven days of spermatogenesis, leading to new directions or explanations of male infertility cause and treatments as a part of reproductive health care.

Review of Dermatologic Medications and Impact on Male Fertility, Sexual Dysfunction and Teratogenicity

BACKGROUND

Dermatologic medications have been linked to issues with safety during pregnancy and lactation. Despite this, limited research, often with conflicting findings, has been published on the association between dermatologic medications, male infertility, sexual dysfunction, and teratogenicity following paternal exposure.

OBJECTIVE

This review seeks to provide evidence-based guidance for physicians who are prescribing dermatologic medications to male patients who are trying to conceive.

METHODS

Common medications used in the largest outpatient specialist dermatologic centre in Singapore were the focus of this review. A PubMed search using MeSH terms from inception to April 22, 2021, was conducted. A secondary search was conducted to include common non-dermatologic medications. Drug information from various online clinical resources and the Tenth Edition of Drugs in Pregnancy and Lactation were also used as a reference.

RESULTS

In this review of 234 studies, 131 medications were covered. A total of 34 medications were associated with male infertility and sexual dysfunction, while 16 medications were implicated with concerns of teratogenicity.

DISCUSSION AND CONCLUSION

Physicians are advised to discuss the potential impact on male fertility and teratogenicity with males who are trying to conceive, while taking into consideration the clinical efficacy and tolerability of these medications and alternative treatments. This article is protected by copyright. All rights reserved.

Adverse Events in Isotretinoin Therapy: A Single-Arm Meta-Analysis

Isotretinoin (ISO) is an oral prescription-only retinoid, well known for its acne-treating effect. However, it affects a substantial number of human cell types, causing a broad spectrum of adverse effects. The purpose of this study is to establish the isotretinoin therapy adverse events among human clinical trials and their prevalence. Two authors (J.K., J.L.) systematically performed the literature review and assessment from December 2021-February 2022. Three databases (PubMed, ClinicalTrials, and Cochrane Library) were searched using the following terms: "isotretinoin acne vulgaris" for published studies in English from 1980-2021. Finally, 25 randomized controlled clinical trials (RCTs) and five open-label clinical trials provided 3274 acne vulgaris suffering patients. Isotretinoin therapy affects almost all of the systems in the human body, causing numerous adverse events. However, they mainly concern mild mucocutaneous conditions (severe cases are rare) and represent individual responses to a drug. In addition, all adverse events are reversible and can be avoided by specific preparations.

Isotretinoin for acne vulgaris - an update on adverse effects and laboratory monitoring

A significant barrier to the usage of isotretinoin has been concerns regarding its adverse effect profile. The dose-dependent mucocutaneous side effects of isotretinoin are well recognised and easily managed, particularly if a lower dose is used. A possible association with depression has gained widespread media attention and is a source of concern for many patients and their carers, but data from prospective studies and recent meta-analyses has been reassuring. Furthermore, there has been much confusion amongst both patients and physicians regarding a possible association with inflammatory bowel disease, as well the ocular and rheumatological adverse effects of isotretinoin. We provide an update on the evidence surrounding the adverse effects of isotretinoin, and discuss practical strategies to prevent and manage these adverse effects. We also discuss appropriate laboratory monitoring for patients taking isotretinoin.

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.

Low dose of isotretinoin: A comprehensive review

Isotretinoin is a first-generation retinoid initially approved for the treatment of severe cases of acne vulgaris (nodulocystic acne). Because of its broad anti-inflammatory and immunomodulatory properties, it has been used beyond its initial approval in a myriad of other indications. Adverse effects of isotretinoin vary from xerosis to teratogenicity. Herein, we reviewed the literature, through date-unlimited PubMed search, from inception till December 2019, using the following search terms: "low-dose isotretinoin" and "dermatology," "isotretinoin and safety," "isotretinoin, off-label uses," "isotretinoin and male fertility," "isotretinoin, iPLEDGE system," aiming to deliver a therapeutic update relevant to clinical practice. All English-language articles were considered with no limitation based on the articles' type. Low-dose isotretinoin is not limited to old and novel dermatological conditions, but also showed promising results in the field of infertility and safety in the field of gastroenterology. We also highlight on the safety profile of the drug and experts' recommendations to enhance safety measures to decrease fetal risk while on isotretinoin.

Perceptions about oral isotretinoin treatment

There are some studies on the knowledge, beliefs, and perceptions of patients about acne vulgaris, however, there is no sufficient data on patients' beliefs about oral isotretinoin treatment (OIT). The aim of this study was to assess the knowledge, beliefs, and perceptions of the patients with acne vulgaris about the therapy of OIT and its side effects. A total of 214 patients with acne vulgaris in our outpatient clinic were included. Patients who were planned to treat with OIT were asked whether they had information about the treatment and its side effects. It was noted whether the patients accepted treatment after being informed both verbally and written about the OIT details. The study consisted of 133 female and 81 male aged 12-57 years. Most of the patients (78%) stated that they had heard of OIT. The most common source of the information on isotretinoin therapy was friends (57.6%). The dryness was the best-known side effect. While 86.4% of patients (n: 185) accepted OIT, the group (14.4%) stated that "I have knowledge about side effects." And refused to use the treatment. Most of the patients agreed to the treatment after explanation of dermatologist. Patients may be educated and informed via reliable medical sources to prevent bias and improve compliance to the treatment.

Infertility and teratogenicity after paternal exposure to systemic dermatologic medications: A systematic review

BACKGROUND

This systematic review assesses effects of paternal exposure to dermatologic medications by using the former US Food and Drug Administration (FDA) pregnancy categories as a benchmark.

OBJECTIVE

To assess whether systemic dermatologic medications can cause infertility and teratogenicity when taken by men.

METHODS

Categories D and X dermatologic medications were identified; a systematic review of the literature and reviews of the FDA Adverse Events Reporting System and prescribing information were performed to identify the effects of these medications on male fertility and teratogenicity. A secondary search was performed to assess for other systemic dermatologic medications causing teratogenicity or infertility following paternal exposure.

RESULTS

A total of 13 medications met the inclusion criteria. Of 1,032 studies identified, 19 were included after a systematic review of the literature. Studies evaluating medication effects with paternal exposure were identified for 10 of the 13 evaluated medications, and evidence of a negative effect was identified for 6 medications.

LIMITATIONS

We did not encounter any studies for 3 medications that met the inclusion criteria. Information submitted to the FDA Adverse Events Reporting System may not reflect the incidence of side effects.

CONCLUSIONS

Many former pregnancy category D and X systemic dermatologic medications also have effects on male fertility. More research and better-quality studies are required in this area, particularly studies assessing potential teratogenicity.

Isotretinoin administration improves sperm production in men with infertility from oligoasthenozoospermia: a pilot study

There is currently no effective medical therapy for men with infertility due to oligoasthenozoospermia. As men with abnormal sperm production have lower concentrations of 13-cis-retinoic acid in their testes, we hypothesized that men with infertility from oligoasthenozoospermia might have improved sperm counts when treated with isotretinoin (13-cis-retinoic acid). We conducted a single-site, single-arm, pilot study to determine the effect of therapy with isotretinoin on sperm indices in 19 infertile men with oligoasthenozoospermia. Subjects were men between 21 and 60 years of age with infertility for longer than 12 months associated with sperm concentrations below 15 million sperm/mL. All men received isotretinoin 20 mg by mouth twice daily for 20 weeks. Subjects had semen analyses, physical examinations, and laboratory tests every 4 weeks during treatment. Nineteen men enrolled in the study. Median (25th, 75th) sperm concentration increased from 2.5 (0.1, 5.9) million/mL at baseline to 3.8 (2.1, 13.0) million/mL at the end of treatment (p = 0.006). No significant changes in sperm motility were observed. There was a trend toward improved sperm morphology (p = 0.056). Six pregnancies (three spontaneous and three from intracytoplasmic sperm injection) and five births occurred during the study. Four of the births, including all three of the spontaneous pregnancies, were observed in men with improvements in sperm counts with isotretinoin therapy. Treatment was well tolerated. Isotretinoin therapy improves sperm production in some men with oligoasthenozoospermia. Additional studies of isotretinoin in men with infertility from oligoasthenozoospermia are warranted.