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Mottola F, Santonastaso M, Ronga V, Finelli R, Rocco L. Polymorphic Rearrangements of Human Chromosome 9 and Male Infertility: New Evidence and Impact on Spermatogenesis. Biomolecules 2023; 13:biom13050729. [PMID: 37238599 DOI: 10.3390/biom13050729] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/07/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
Chromosomal polymorphisms are structural variations in chromosomes that define the genomic variance of a species. These alterations are recurrent in the general population, and some of them appear to be more recurrent in the infertile population. Human chromosome 9 is highly heteromorphic, and how its rearrangement affects male fertility remains to be fully investigated. In this study, we aimed to investigate the association between the polymorphic rearrangements of chromosome 9 and male infertility via an Italian cohort of male infertile patients. Cytogenetic analysis was carried out, along with Y microdeletion screening, semen analysis, fluorescence in situ hybridization, and TUNEL assays using spermatic cells. Chromosome 9 rearrangements were observed in six patients: three of them showed a pericentric inversion, while the others showed a polymorphic heterochromatin variant 9qh. Of these, four patients exhibited oligozoospermia associated with teratozoospermia, along with a percentage of aneuploidy in the sperm of above 9%, in particular, an increase in XY disomy. Additionally, high values for sperm DNA fragmentation (≥30%) were observed in two patients. None of them had microdeletions to the AZF loci on chromosome Y. Our results suggest that polymorphic rearrangements of chromosome 9 might be associated with abnormalities in sperm quality due to incorrect spermatogenesis regulation.
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Affiliation(s)
- Filomena Mottola
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, University of Campania "Luigi Vanvitelli", 81100 Caserta, Italy
| | - Marianna Santonastaso
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", 80138 Napoli, Italy
| | - Valentina Ronga
- Prenatal Diagnosis Unit, Varelli Diagnostic Institute, 80126 Napoli, Italy
| | | | - Lucia Rocco
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, University of Campania "Luigi Vanvitelli", 81100 Caserta, Italy
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Sangild J, Faldborg A, Schousboe C, Fedder MDK, Christensen LP, Lausdahl AK, Arnspang EC, Gregersen S, Jakobsen HB, Knudsen UB, Fedder J. Effects of Chokeberries ( Aronia spp.) on Cytoprotective and Cardiometabolic Markers and Semen Quality in 109 Mildly Hypercholesterolemic Danish Men: A Prospective, Double-Blinded, Randomized, Crossover Trial. J Clin Med 2023; 12:jcm12010373. [PMID: 36615174 PMCID: PMC9821700 DOI: 10.3390/jcm12010373] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023] Open
Abstract
Background: Chokeberries (Aronia spp.) are known to exhibit both direct and indirect antioxidant properties and have been associated with beneficial effects on human health, including cardiovascular risk factors (inflammation, serum lipids, sugars, blood pressure), oxidative stress, and semen quality. This prospective, double-blinded, randomized, crossover clinical trial was conducted to elucidate the effects of Aronia supplementation on these health targets in mildly hypercholesterolemic men. Methods: The standardized Aronia supplementation comprised three wild Aronia spp. (A. arbutifolia, A prunifolia and A. melanocarpa) and the Aronia hybrid × Sorbaronia mitschurinii (standardized to 150 mg anthocyanins daily). Participants (n = 109) were healthy men with respect to all outcome targets except for the total cholesterol level (5.0−7.0 mM). Participants were randomized to supplementation with either Aronia or placebo for 90 days, followed by a wash-out period and lastly the complementary supplementation. Effects on the health parameters were compared among both the whole group of men and in subgroups according to age, body mass index (BMI), lifestyle, dietary habits, and serum glutathione levels at baseline. The study is registered in ClinicalTrials.gov.: NCT03405753. Results: Glutathione levels were significantly improved after 90 days intake of Aronia supplementation compared to placebo in the subgroup of men with a low level of glutathione at baseline (p = 0.038) and a high coffee intake (p = 0.045). A significant decrease in levels of sperm DNA fragmentation and an increase in the percentage of motile sperm were observed in men aged >40 and in men with BMI > 25. Further, these parameters were significantly improved in the dietary subgroup defined by a high level of coffee intake. Total cholesterol and low-density lipoprotein-cholesterol levels decreased significantly in men <40 years after Aronia supplementation. No statistically significant effects were observed regarding blood pressure, markers of blood sugar regulation, hemoglobin A1c, superoxide dismutase, catalase, isoprostane levels, high sensitivity C reactive protein, or other semen parameters. Conclusions: This study demonstrated a significant increase in glutathione levels and improvement of cytoprotective targets following Aronia supplementation in specific subgroups of men >40 years of age and BMI > 25 but did not demonstrate a significant effect in the overall analysis. The observed concurrent increase in glutathione levels and improvement of cytoprotective targets following Aronia supplementation in subgroups of men, suggests that the endogenous phase II antioxidant glutathione is involved in the modulation of the observed cytoprotective effects. This study is a good foundation for further investigation of these cytoprotective effects in groups with oxidative stress in a dose−response study.
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Affiliation(s)
- Julie Sangild
- Department of Clinical Medicine, Aarhus University, DK-8200 Aarhus, Denmark
| | - Anne Faldborg
- Department of Clinical Medicine, Aarhus University, DK-8200 Aarhus, Denmark
| | - Cecilie Schousboe
- Department of Clinical Medicine, Aarhus University, DK-8200 Aarhus, Denmark
| | | | - Lars Porskjær Christensen
- Department of Physics, Chemistry and Pharmacy, Faculty of Science, University of Southern Denmark, DK-5230 Odense, Denmark
| | - Astrid Komal Lausdahl
- Department of Green Technology, Faculty of Engineering, University of Southern Denmark, DK-5230 Odense, Denmark
| | - Eva Christensen Arnspang
- Department of Green Technology, Faculty of Engineering, University of Southern Denmark, DK-5230 Odense, Denmark
| | - Søren Gregersen
- Department of Clinical Medicine, Aarhus University, DK-8200 Aarhus, Denmark
- Steno Diabetes Center Aarhus, DK-8200 Aarhus, Denmark
| | | | - Ulla Breth Knudsen
- Department of Clinical Medicine, Aarhus University, DK-8200 Aarhus, Denmark
- Department of Obstetrics and Gynecology, Fertility Clinic, Horsens Regional Hospital, DK-8700 Horsens, Denmark
| | - Jens Fedder
- Centre of Andrology, Fertility Clinic, Department D, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Medicine, University of Southern Denmark, DK-5000 Odense, Denmark
- Correspondence:
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Liu X, Shi S, Sun J, He Y, Zhang Z, Xing J, Chong T. The influence of male and female overweight/obesity on IVF outcomes: a cohort study based on registration in Western China. Reprod Health 2023; 20:3. [PMID: 36593463 PMCID: PMC9806889 DOI: 10.1186/s12978-022-01558-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 12/22/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Overweight/obesity can affect fertility, increase the risk of pregnancy complications, and affect the outcome of assisted reproductive technology (ART). However, due to confounding factors, the accuracy and uniformity of published findings on IVF outcomes have been disputed. This study aimed to assess the effects of both male and female body mass index (BMI), individually and in combination, on IVF outcomes. METHODS This retrospective cohort study included 11,191 couples undergoing IVF. Per the Chinese BMI standard, the couples were divided into four groups: normal; female overweight/obesity; male overweight/obesity; and combined male and female overweight/obesity. The IVF outcomes of the four groups were compared and analysed. RESULTS Regarding the 6569 first fresh IVF-ET cycles, compared with the normal weight group, the female overweight/obesity and combined male/female overweight/obesity groups had much lower numbers of available embryos and high-quality embryos (p < 0.05); additionally, the fertilization (p < 0.001) and normal fertilization rates (p < 0.001) were significantly decreased in the female overweight/obesity group. The combined male/female overweight/obesity group had significant reductions in the available embryo (p = 0.002), high-quality embryo (p = 0.010), fertilization (p = 0.001) and normal fertilization rates (p < 0.001); however, neither male or female overweight/obesity nor their combination significantly affected the clinical pregnancy rate (CPR), live birth rate (LBR) or abortion rate (p > 0.05). CONCLUSION Our findings support the notion that overweight/obesity does not influence pregnancy success; however, we found that overweight/obesity affects the fertilization rate and embryo number and that there are sex differences.
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Affiliation(s)
- Xiang Liu
- grid.43169.390000 0001 0599 1243The Second Affiliated Hospital of Xi’an Jiao Tong University, Xi’an, 710004 Shaanxi China ,grid.440257.00000 0004 1758 3118Reproductive Center of Northwest Women’s and Children’s Hospital, Xi’an, 710061 Shaanxi China
| | - Shengjia Shi
- grid.440257.00000 0004 1758 3118Reproductive Center of Northwest Women’s and Children’s Hospital, Xi’an, 710061 Shaanxi China
| | - Jianhua Sun
- grid.440257.00000 0004 1758 3118Reproductive Center of Northwest Women’s and Children’s Hospital, Xi’an, 710061 Shaanxi China
| | - Yuan He
- grid.440257.00000 0004 1758 3118Reproductive Center of Northwest Women’s and Children’s Hospital, Xi’an, 710061 Shaanxi China
| | - Zhou Zhang
- grid.440257.00000 0004 1758 3118Reproductive Center of Northwest Women’s and Children’s Hospital, Xi’an, 710061 Shaanxi China
| | - Junping Xing
- grid.43169.390000 0001 0599 1243The First Affiliated Hospital of Xi’an Jiao Tong University, Xi’an, 710061 Shaanxi China
| | - Tie Chong
- grid.43169.390000 0001 0599 1243The Second Affiliated Hospital of Xi’an Jiao Tong University, Xi’an, 710004 Shaanxi China
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Is There a Relationship between Sperm DNA Fragmentation and Intra-Uterine Insemination Outcome in Couples with Unexplained or Mild Male Infertility? Results from the ID-Trial. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010011. [PMID: 36675960 PMCID: PMC9863271 DOI: 10.3390/life13010011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/06/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Sperm DNA fragmentation has been proposed as a candidate test for the assessment of sperm function on the premise that damage to the sperm chromatin is associated with a detrimental reproductive outcome. The objective of our study was to investigate whether sperm DNA fragmentation testing has a prognostic value, and thus can play a pivotal role in selecting future patients for intra-uterine insemination (IUI) therapy. METHODS This was a prospective cohort study conducted in a University Hospital setting. SDF was measured through TUNEL assay on the fresh semen sample presented at diagnosis and at insemination in couples with idiopathic/mild male infertility undergoing natural cycle IUI treatment. The generalized estimating equation (GEE)-model and multivariable model were used to analyze the probability of live birth and clinical pregnancy, respectively. ROC analysis was carried out to determine an SDF cut-off. RESULTS There was an inverse relationship between SDF in the ejaculate of the diagnostic semen sample and CP (p = 0.02; OR 0.94 95% CI (0.90, 0.989)) as well as LB (p = 0.04; OR 0.95 95% CI (0.90, 0.9985)). No significant association was found between SDF after gradient and IUI outcome in the diagnostic sample nor between SDF (ejaculate/after gradient) in the IUI samples. The ROC analysis proposed a cutoff of 17.5% as the best compromise between sensitivity and specificity in the diagnostic SDF for live birth; however, the test diagnostics are low, with an AUC of 0.576. CONCLUSIONS Overall, this study strengthens the hypothesis of an inverse relationship between SDF and CP/LB. Furthermore, SDF taken together with other clinical characteristics might provide more insight into male reproductive potential and predicting IUI outcome. Couples with SDF ≥ 17.5% in the diagnostic semen sample did not reach live birth. Further research is necessary to establish the diagnostic and prognostic potential of SDF as an add-on test.
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In Vitro Combination of Ascorbic and Ellagic Acids in Sperm Oxidative Damage Inhibition. Int J Mol Sci 2022; 23:ijms232314751. [PMID: 36499078 PMCID: PMC9740292 DOI: 10.3390/ijms232314751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
It is known that an altered redox balance interferes with normal spermatic functions. Exposure to genotoxic substances capable of producing oxidative stress (OS) can cause infertility in humans. The use of antioxidants to reduce oxidative stress contributes to the improvement in reproductive function. This study focused on an antigenotoxic evaluation of ellagic acid (EA) and ascorbic acid (AA) in combination against benzene genotoxic action on human spermatozoa in vitro. In addition to the evaluation of sperm parameters, damage in sperm genetic material and intracellular ROS quantification were assessed after AA, EA and benzene co-exposure using the TUNEL technique and DCF assay. The results showed that the combination of the two antioxidants generates a greater time-dependent antigenotoxic action, reducing both the sperm DNA fragmentation index and the oxidative stress. The genoprotective effect of AA and EA association in sperm cells lays the foundations for a more in-depth clinical study on the use of antioxidants as a therapy for male infertility.
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Grosen A, Bellaguarda E, Nersting J, Hvas CL, Liljeqvist-Soltic I, Stein A, Christensen LA, Ruderman EM, Brown CR, Schmiegelow K, Zhang JX, Kelsen J, Hanauer SB. Low-dose Methotrexate Therapy Does Not Affect Semen Parameters and Sperm DNA. Inflamm Bowel Dis 2022; 28:1012-1018. [PMID: 34463329 DOI: 10.1093/ibd/izab205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Methotrexate is widely used in inflammatory diseases during the patients' reproductive years. The effect on male fertility and sperm DNA integrity is largely unknown. We evaluated sperm DNA integrity and basic semen parameters according to the World Health Organization (WHO) in male patients with inflammatory diseases treated with methotrexate. METHODS Semen samples from 14 patients on low-dose maintenance methotrexate were compared with samples from 40 healthy volunteers. Further, 5 patients delivered samples on and off methotrexate therapy for paired comparison. Sperm DNA fragmentation index (DFI), concentration, motility, and morphology were evaluated. Blood sex hormones and methotrexate levels were measured in blood and semen. RESULTS DNA fragmentation index in methotrexate-treated patients was comparable with that in healthy volunteers (DFI, 11.5 vs 15.0; P = .06), and DFI did not change significantly on and off methotrexate in the paired samples (DFI, 12.0 vs 14.0; P = 0.35). Sperm concentration, motility, and morphology did not differ between men treated with methotrexate and healthy volunteers. Sperm progressive motility increased off therapy compared with on therapy (65.0% vs 45.0%, P = .04), but all fluctuations in progressive motility were within the WHO reference interval. All methotrexate polyglutamates1-5 were detected in blood, but only methotrexate polyglutamate1 in semen. Serum testosterone was unaffected by methotrexate therapy. CONCLUSIONS Patients treated with low-dose methotrexate have a sperm quality comparable with that of healthy volunteers, and methotrexate treatment does not increase sperm DNA fragmentation. This study does not support cryopreservation of semen before treatment initiation nor a 3-month methotrexate-free interval prior to conception.
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Affiliation(s)
- Anne Grosen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Emanuelle Bellaguarda
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacob Nersting
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Adam Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lisbet Ambrosius Christensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Eric M Ruderman
- Division of Rheumatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Calvin R Brown
- Division of Rheumatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - John X Zhang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jens Kelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Stephen B Hanauer
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Minhas S, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, Cocci A, Corona G, Dimitropoulos K, Gül M, Hatzichristodoulou G, Jones TH, Kadioglu A, Martínez Salamanca JI, Milenkovic U, Modgil V, Russo GI, Serefoglu EC, Tharakan T, Verze P, Salonia A. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility. Eur Urol 2021; 80:603-620. [PMID: 34511305 DOI: 10.1016/j.eururo.2021.08.014] [Citation(s) in RCA: 229] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/20/2021] [Indexed: 12/19/2022]
Abstract
CONTEXT The European Association of Urology (EAU) has updated its guidelines on sexual and reproductive health for 2021. OBJECTIVE To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health, including advances and areas of controversy in male infertility. EVIDENCE ACQUISITION The panel performed a comprehensive literature review of novel data up to January 2021. The guidelines were updated and a strength rating for each recommendation was included that was based either on a systematic review of the literature or consensus opinion from the expert panel, where applicable. EVIDENCE SYNTHESIS The male partner in infertile couples should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors causing fertility impairment. Infertile men are at a higher risk of harbouring and developing other diseases including malignancy and cardiovascular disease and should be screened for potential modifiable risk factors, such as hypogonadism. Sperm DNA fragmentation testing has emerged as a novel biomarker that can identify infertile men and provide information on the outcomes from assisted reproductive techniques. The role of hormone stimulation therapy in hypergonadotropic hypogonadal or eugonadal patients is controversial and is not recommended outside of clinical trials. Furthermore, there is insufficient evidence to support the widespread use of other empirical treatments and surgical interventions in clinical practice (such as antioxidants and surgical sperm retrieval in men without azoospermia). There is low-quality evidence to support the routine use of testicular fine-needle mapping as an alternative diagnostic and predictive tool before testicular sperm extraction (TESE) in men with nonobstructive azoospermia (NOA), and either conventional or microdissection TESE remains the surgical modality of choice for men with NOA. CONCLUSIONS All infertile men should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors. Increasing data indicate that infertile men are at higher risk of cardiovascular mortality and of developing cancers and should be screened and counselled accordingly. There is low-quality evidence supporting the use of empirical treatments and interventions currently used in clinical practice; the efficacy of these therapies needs to be validated in large-scale randomised controlled trials. PATIENT SUMMARY Approximately 50% of infertility will be due to problems with the male partner. Therefore, all infertile men should be assessed by a specialist with the expertise to not only help optimise their fertility but also because they are at higher risk of developing cardiovascular disease and cancer long term and therefore require appropriate counselling and management. There are many treatments and interventions for male infertility that have not been validated in high-quality studies and caution should be applied to their use in routine clinical practice.
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Affiliation(s)
- Suks Minhas
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK.
| | | | - Luca Boeri
- Department of Urology, Foundation IRCCS Ca' Granda - Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Paolo Capogrosso
- Department of Urology and Andrology, Ospedale di Circolo and Macchi Foundation, Varese, Italy
| | - Joana Carvalho
- CPUP: Center for Psychology of Porto University, Faculty of Psychology and Educational Sciences, Porto University, Porto, Portugal
| | - Nusret Can Cilesiz
- Department of Urology, Taksim Training & Research Hospital, Istanbul, Turkey
| | - Andrea Cocci
- Department of Minimally Invasive and Robotic Urologic Surgery and Kidney Transplantation, University of Florence, Florence, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Konstantinos Dimitropoulos
- Academic Urology Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Murat Gül
- School of Medicine, Department of Urology, Selcuk University, Konya, Turkey
| | | | - Thomas Hugh Jones
- Centre for Diabetes and Endocrinology, Barnsley Hospital NHS Trust, Barnsley, UK
| | - Ates Kadioglu
- Department of Urology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | | | - Uros Milenkovic
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Vaibhav Modgil
- Manchester Andrology Centre, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, UK
| | - Giorgio Ivan Russo
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Ege Can Serefoglu
- Department of Urology, Biruni University School of Medicine, Istanbul, Turkey
| | - Tharu Tharakan
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Paolo Verze
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Fisciano, Italy
| | - Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
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