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Lira Neto FT, Roque M, Esteves SC. Effect of varicocele and varicocelectomy on sperm deoxyribonucleic acid fragmentation rates in infertile men with clinical varicocele. Minerva Obstet Gynecol 2024; 76:49-69. [PMID: 36222786 DOI: 10.23736/s2724-606x.22.05169-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Varicocele is the leading cause of male infertility. It can affect sperm quantity and quality through various non-mutually exclusive pathophysiological mechanisms, mainly oxidative stress. Excessive production of reactive oxygen species may overwhelm the sperm's defenses against oxidative stress and harm the sperm's DNA. Excessive sperm DNA breaks, so-called sperm DNA fragmentation, result from the oxidative stress cascade and are commonly found in the ejaculates of men with varicocele and fertility-related issues. Measuring sperm DNA fragmentation can provide valuable information on the extent of harm and might help select candidates for surgical treatment. Varicocelectomy is beneficial for alleviating oxidative stress-associated infertility and improving sperm DNA integrity. However, reproductive outcomes of infertile men with elevated sperm DNA fragmentation rates and surgically treated varicoceles remain poorly studied, and there is a need for well-designed trials to determine the impact of sperm DNA fragmentation reduction on natural and medically assisted reproduction.
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Affiliation(s)
- Filipe T Lira Neto
- AndrosRecife, Andrology Clinic, Recife, Brazil
- Department of Urology, Prof. Fernando Figueira Institute of Integrative Medicine, Recife, Brazil
| | - Matheus Roque
- Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, Brazil -
- Division of Urology, Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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2
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Munoz-Lopez C, Wong A, Lewis K, Bole R, Vij SC, Lundy SD. The Evolving Landscape of Male Varicocele Pathophysiology in the Era of Multi-Omics: A Narrative Review of the Current Literature. BIOLOGY 2024; 13:80. [PMID: 38392299 PMCID: PMC10886418 DOI: 10.3390/biology13020080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/24/2024]
Abstract
Male-factor infertility is implicated in over half of the millions of cases of infertility worldwide, and varicoceles are the most common correctable cause of male-factor infertility. The pathophysiologic mechanism for varicoceles is complex and next-generation technologies offer promising insights into the molecular underpinnings of this condition. In this narrative review, we highlight historical and contemporary paradigms associated with varicoceles, with an emphasis on the biological underpinnings of this disease. Specifically, we review the literature describing the underlying causes of varicoceles, discuss the molecular and cellular mechanisms causing pathological changes in some (but not all) men, and highlight key articles regarding the next-generation analyses (e.g., transcriptome, epigenome, proteome, and microbiome) being applied to better understand the condition and its treatment. These data demonstrate an ongoing evolution of the knowledge of varicoceles and the potential for improved personalized care in the future for men with this condition.
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Affiliation(s)
- Carlos Munoz-Lopez
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH 44195, USA
| | - Anne Wong
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH 44195, USA
| | - Kieran Lewis
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH 44195, USA
| | - Raevti Bole
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Sarah C Vij
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Scott D Lundy
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Alahmar AT. The Effect of Selenium Therapy on Semen Parameters, Antioxidant Capacity, and Sperm DNA Fragmentation in Men with Idiopathic Oligoasthenoteratospermia. Biol Trace Elem Res 2023; 201:5671-5676. [PMID: 36959435 DOI: 10.1007/s12011-023-03638-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/16/2023] [Indexed: 03/25/2023]
Abstract
Idiopathic male infertility (IMI) remains challenging as the etiology of semen abnormalities is still unidentified. Sperm DNA fragmentation (SDF) has been suggested as a potential mechanism. Oral antioxidants including selenium have been tried for IMI with variable results. This study was undertaken to explore the effect of selenium therapy on semen parameters, antioxidant capacity, and SDF in infertile patients with idiopathic oligoasthenoteratospermia (OAT). Sixty-five infertile men with idiopathic OAT and fifty fertile controls were included in this prospective clinical study. Patients received selenium (200 μg/day) orally for 6 months. Seminal fluid parameters (WHO 5th criteria), total antioxidant capacity (TAC), catalase (CAT), and seminal SDF levels were assessed for all participants at the start of the study and after 6 months. Sperm concentration (P < 0.001), progressive motility (P < 0.001), and total motility (P < 0.01) significantly increased in patients after selenium therapy. Seminal TAC and CAT increased in patients post-therapy as compared to baseline values (P < 0.01). SDF levels significantly decreased (P < 0.001) in patients following selenium treatment in comparison to baseline values. SDF levels also correlated negatively with sperm progressive motility (r = - 0.44, P = 0.003) and total motility (r = - 0.48, P = 0.001). In conclusion, selenium therapy (200 μg/day) for 6 months increases sperm concentration, motility, seminal antioxidant capacity, and reduces SDF in patients with idiopathic OAT. Thus, selenium could be a promising therapy for men with IMI and may boost their fertility and fertility treatment outcomes.
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Affiliation(s)
- Ahmed T Alahmar
- Department of Medical Physiology, College of Medicine, University of Babylon, Hillah, Iraq.
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Hervás I, Rivera-Egea R, Pacheco A, Gil Julia M, Navarro-Gomezlechon A, Mossetti L, Garrido N. Elevated Sperm DNA Damage in IVF-ICSI Treatments Is Not Related to Pregnancy Complications and Adverse Neonatal Outcomes. J Clin Med 2023; 12:6802. [PMID: 37959265 PMCID: PMC10649005 DOI: 10.3390/jcm12216802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
This multicenter retrospective cohort study assesses the effect of high paternal DNA fragmentation on the well-being of the woman during pregnancy and the health of the newborn delivered. It was performed with clinical data from 488 couples who had a delivery of at least one newborn between January 2000 and March 2019 (243 used autologous oocytes and 245 utilized donated oocytes). Couples were categorized according to sperm DNA fragmentation (SDF) level as ≤15% or >15%, measured by TUNEL assay. Pregnancy, delivery, and neonatal outcomes were assessed. In singleton pregnancies from autologous cycles, a higher but non-significant incidence of pre-eclampsia, threatened preterm labor, and premature rupture of membranes was found in pregnant women from the >15%SDF group. Additionally, a higher proportion of children were born with low birth weight, although the difference was not statistically significant. After adjusting for potential confounders, these couples had lower odds of having a female neonate (AOR = 0.35 (0.1-0.9), p = 0.04). Regarding couples using donor's oocytes, pregnancy and neonatal outcomes were comparable between groups, although the incidence of induced vaginal labor was significantly higher in the >15% SDF group (OR = 7.4 (1.2-46.7), p = 0.02). Adjusted analysis revealed no significant association of elevated SDF with adverse events. In multiple deliveries from cycles using both types of oocytes, the obstetric and neonatal outcomes were found to be similar between groups. In conclusion, the presence of an elevated SDF does not contribute to the occurrence of clinically relevant adverse maternal events during pregnancies, nor does it increase the risk of worse neonatal outcomes in newborns. Nevertheless, a higher SDF seems to be related to a higher ratio of male livebirths.
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Affiliation(s)
- Irene Hervás
- IVIRMA Global Research Alliance, IVIRMA Rome, Via Federico Calabresi, 11, 00169 Rome, Italy; (I.H.); (L.M.)
| | - Rocio Rivera-Egea
- IVIRMA Global Research Alliance, IVIRMA Valencia, Andrology Laboratory and Sperm Bank, Plaza de la Policía Local 3, 46015 Valencia, Spain;
| | - Alberto Pacheco
- IVIRMA Global Research Alliance, IVIRMA Madrid, Andrology Laboratory and Sperm Bank, Av. del Talgo 68-70, 28023 Madrid, Spain;
- Faculty of Health Sciences, Alfonso X el Sabio University, Avda. de la Universidad, 1, Villanueva de la Cañada, 28691 Madrid, Spain
| | - Maria Gil Julia
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106—Torre A, Planta 1ª, 46026 Valencia, Spain; (M.G.J.); (A.N.-G.)
| | - Ana Navarro-Gomezlechon
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106—Torre A, Planta 1ª, 46026 Valencia, Spain; (M.G.J.); (A.N.-G.)
| | - Laura Mossetti
- IVIRMA Global Research Alliance, IVIRMA Rome, Via Federico Calabresi, 11, 00169 Rome, Italy; (I.H.); (L.M.)
| | - Nicolás Garrido
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106—Torre A, Planta 1ª, 46026 Valencia, Spain; (M.G.J.); (A.N.-G.)
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Andretta RR, de Castro LS, de Carvalho RC, Moura JACD, Fraietta R, Okada FK, Bertolla RP. Understanding the impact of varicocele on sperm capacitation. F&S SCIENCE 2023; 4:229-238. [PMID: 37169221 DOI: 10.1016/j.xfss.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To study the relationship between the seminal sample quality of men with varicocele and sperm capacitation. DESIGN Cross-sectional observational study. SETTING Academic hospital. PATIENT(S) Seventy-six men (19 control and 57 with varicocele) were analyzed. INTERVENTION(S) Semen samples were submitted to a discontinuous density gradient for sperm selection. Sperm capacitation was induced using a human tubal fluid medium supplemented with bovine serum albumin. MAIN OUTCOME MEASURE(S) After capacitation induction, the sperm were assessed by capacitation state, computer-assisted sperm motility, mitochondrial activity, membrane integrity, acrosome reaction, and intracellular oxidative stress. RESULT(S) The capacitation period increased sperm motility, showing an increase in the average path velocity and a decrease in the straightness compared with sperm before capacitation (paired analysis). After capacitation, the rate of capacitated sperm, motility, and mitochondrial activity showed differences between groups (control and varicocele). The varicocele group showed lower mitochondrial activity and capacitation than the control group. On the other hand, no significant differences were observed in the other variables evaluated. CONCLUSION(S) Varicocele men showed less viable sperm and mitochondrial activity than control men after capacitation sperm. The induction of capacitation altered motility by increasing path velocity and decreasing straightness in all of the studied groups, evidencing the occurrence of hyperactivation.
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Affiliation(s)
- Rhayza Roberta Andretta
- Human Reproduction Section, Division of Urology, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Letícia Signori de Castro
- Laboratory of Spermatozoa Biology, Department of Animal Reproduction, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Renata Cristina de Carvalho
- Human Reproduction Section, Division of Urology, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Renato Fraietta
- Human Reproduction Section, Division of Urology, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fatima Kazue Okada
- Human Reproduction Section, Division of Urology, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil; Laboratory of Developmental Biology, Department of Morphology and Genetics, Federal University of Sao Paulo, Sao Paulo, Brazil.
| | - Ricardo Pimenta Bertolla
- Human Reproduction Section, Division of Urology, Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
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Male infertility and gonadotropin treatment: What can we learn from real-world data? Best Pract Res Clin Obstet Gynaecol 2023; 86:102310. [PMID: 36682942 DOI: 10.1016/j.bpobgyn.2022.102310] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022]
Abstract
Gonadotropin therapy to treat specific male infertility disorders associated with hypogonadotropic hypogonadism is evidence-based and effective in restoring spermatogenesis and fertility. In contrast, its use to improve fertility in men with idiopathic oligozoospermia or nonobstructive azoospermia remains controversial, despite being widely practiced. The existence of two major inter-related pathways for spermatogenesis, including FSH and intratesticular testosterone, provides a rationale for empiric hormone stimulation therapy in both eugonadal and hypogonadal males with idiopathic oligozoospermia or nonobstructive azoospermia. Real-world data (RWD) on gonadotropin stimulating for these patient subsets, mainly using human chorionic gonadotropin and follicle-stimulating hormone, accumulated gradually, showing a positive therapeutic effect in some patients, translated by increased sperm production, sperm quality, and sperm retrieval rates. Although more evidence is needed, current insights from RWD research indicate that selected male infertility patients might be managed more effectively using gonadotropin therapy, with potential gains for all parties involved.
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Mahdi M, Majzoub A, Khalafalla K, To J, Aviles‐Sandoval M, Elbardisi H, AlSaid S, Agarwal A, Henkel R, Arafa M. Effect of redo varicocelectomy on semen parameters and pregnancy outcome: An original report and meta‐analysis. Andrologia 2022; 54:e14525. [DOI: 10.1111/and.14525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/23/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mohamed Mahdi
- Department of Urology Hamad Medical Corporation Doha Qatar
| | - Ahmad Majzoub
- Department of Urology Hamad Medical Corporation Doha Qatar
- Clinical Urology Weill Cornell Medicine –Qatar Doha Qatar
| | - Kareim Khalafalla
- Department of Urology Hamad Medical Corporation Doha Qatar
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Jason To
- College of Alameda Alameda California USA
| | | | - Haitham Elbardisi
- Department of Urology Hamad Medical Corporation Doha Qatar
- Clinical Urology Weill Cornell Medicine –Qatar Doha Qatar
- College of Medicine Qatar University Doha Qatar
| | - Sami AlSaid
- Department of Urology Hamad Medical Corporation Doha Qatar
- Clinical Urology Weill Cornell Medicine –Qatar Doha Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine Cleveland Clinic Cleveland Ohio USA
| | - Ralf Henkel
- Department of Metabolism Digestion and Reproduction at Imperial College London London UK
| | - Mohamed Arafa
- Department of Urology Hamad Medical Corporation Doha Qatar
- Clinical Urology Weill Cornell Medicine –Qatar Doha Qatar
- Andrology Department Cairo University Cairo Egypt
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Sciorio R, Esteves SC. Contemporary Use of ICSI and Epigenetic Risks to Future Generations. J Clin Med 2022; 11:jcm11082135. [PMID: 35456226 PMCID: PMC9031244 DOI: 10.3390/jcm11082135] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/30/2022] [Accepted: 04/07/2022] [Indexed: 12/19/2022] Open
Abstract
Since the birth of Louise Brown in 1978 via IVF, reproductive specialists have acquired enormous knowledge and refined several procedures, which are nowadays applied in assisted reproductive technology (ART). One of the most critical steps in this practice is the fertilization process. In the early days of IVF, a remarkable concern was the unpleasant outcomes of failed fertilization, overtaken by introducing intracytoplasmic sperm injection (ICSI), delineating a real breakthrough in modern ART. ICSI became standard practice and was soon used as the most common method to fertilize oocytes. It has been used for severe male factor infertility and non-male factors, such as unexplained infertility or advanced maternal age, without robust scientific evidence. However, applying ICSI blindly is not free of potential detrimental consequences since novel studies report possible health consequences to offspring. DNA methylation and epigenetic alterations in sperm cells of infertile men might help explain some of the adverse effects reported in ICSI studies on reproductive health in future generations. Collected data concerning the health of ICSI children over the past thirty years seems to support the notion that there might be an increased risk of epigenetic disorders, congenital malformations, chromosomal alterations, and subfertility in babies born following ICSI compared to naturally conceived children. However, it is still to be elucidated to what level these data are associated with the cause of infertility or the ICSI technique. This review provides an overview of epigenetic mechanisms and possible imprinting alterations following the use of ART, in particular ICSI. It also highlights the sperm contribution to embryo epigenetic regulation and the risks of in vitro culture conditions on epigenetic dysregulation. Lastly, it summarizes the literature concerning the possible epigenetic disorders in children born after ART.
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Affiliation(s)
- Romualdo Sciorio
- Edinburgh Assisted Conception Programme, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
- Correspondence:
| | - Sandro C. Esteves
- Androfert, Andrology and Human Reproduction Clinic, Campinas 13075-460, Brazil;
- Department of Surgery, Division of Urology, University of Campinas, Campinas 13083-970, Brazil
- Faculty of Health, Aarhus University, 8000 Aarhus, Denmark
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9
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Sperm DNA fragmentation measured by TUNEL assay is not related to reduced cumulative live birth rates per consumed oocyte after IVF/ICSI from unselected males. Reprod Biomed Online 2022; 44:1079-1089. [DOI: 10.1016/j.rbmo.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/24/2022] [Accepted: 02/15/2022] [Indexed: 11/20/2022]
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10
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Yamasaki K, Uchida M, Watanabe N, Ihana T, Ishiguro Y, Kuroda S, Takeshima T, Yumura Y, Mieno M, Yoshida K, Iwamoto T, Nishiyama H. Effects of antioxidant co-supplementation therapy on spermatogenesis dysfunction in relation to the basal oxidation-reduction potential levels in spermatozoa: A pilot study. Reprod Med Biol 2022; 21:e12450. [PMID: 35386378 PMCID: PMC8967282 DOI: 10.1002/rmb2.12450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose In this pilot study, the authors compared the effects of antioxidant co-supplementation therapy and methylcobalamin therapy in patients with impaired semen quality. Methods Eighty-four subjects who visited male infertility clinics and showed abnormal semen test results were randomly subjected to one of the two therapies: antioxidant co-supplementation therapy with vitamin C, vitamin E, coenzyme Q10, and flaxseed oil or methylcobalamin therapy. The oxidation-reduction potential (ORP) and 8-hydroxy-2'-deoxyguanosine levels were used as indicators of oxidative stress levels in semen. Semen analysis was also performed. Results The authors obtained results from 67 patients who had completed 3 months of treatment. Neither antioxidant co-supplementation therapy nor methylcobalamin therapy changed the semen parameters significantly (except for the sperm concentration, which was increased by the latter therapy). When the pre-treatment ORP value in semen was higher than the cutoff value, both therapies significantly increased the sperm concentration. The 8-hydroxy-2'-deoxyguanosine level did not yield any meaningful predictive value with regard to increased sperm concentrations. Conclusions Both antioxidant co-supplementation therapy and methylcobalamin therapy increased the sperm concentration in patients with impaired semen quality when the basal ORP levels in their semen were elevated.
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Affiliation(s)
- Kazumitsu Yamasaki
- Department of Urology Tsukuba Gakuen Hospital Tsukuba Japan
- Male Infertility Center for Human Reproduction Sanno Hospital Minato-ku Japan
| | | | - Noriko Watanabe
- Oak Clinic Ginza Chuo-ku Japan
- Center for Human Reproduction and Gynecologic Endoscopy Sanno Hospital Minato-ku Japan
| | - Tatsuji Ihana
- Center for Human Reproduction and Gynecologic Endoscopy Sanno Hospital Minato-ku Japan
| | - Yukari Ishiguro
- Department of Urology, Reproduction Center Yokohama City University Medical Center Yokohama Japan
| | - Shinnosuke Kuroda
- Department of Urology, Reproduction Center Yokohama City University Medical Center Yokohama Japan
| | - Teppei Takeshima
- Department of Urology, Reproduction Center Yokohama City University Medical Center Yokohama Japan
| | - Yasushi Yumura
- Department of Urology, Reproduction Center Yokohama City University Medical Center Yokohama Japan
| | - Makiko Mieno
- Department of Medical Informatics Center for Information Jichi Medical University Shimotsuke Japan
| | - Kaoru Yoshida
- Faculty of Biomedical Engineering Toin University of Yokohama Yokohama Japan
| | - Teruaki Iwamoto
- Male Infertility Center for Human Reproduction Sanno Hospital Minato-ku Japan
| | - Hiroyuki Nishiyama
- Department of Urology Faculty of Medicine University of Tsukuba Tsukuba Japan
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11
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Alahmar A, Singh R, Palani A. Sperm DNA fragmentation in reproductive medicine: A review. J Hum Reprod Sci 2022; 15:206-218. [PMID: 36341018 PMCID: PMC9635374 DOI: 10.4103/jhrs.jhrs_82_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/08/2022] [Accepted: 08/28/2022] [Indexed: 11/17/2022] Open
Abstract
Approximately 15% of the world's couples suffer from infertility during their reproductive period of which the male factor is responsible for 50% of cases. Male factor infertility is multifactorial in origin, and sperm DNA fragmentation (SDF) has also been linked to male infertility including idiopathic male infertility. Some degree of controlled DNA nicking is essential for adequate DNA compaction, but excessive SDF is usually associated with reduced male fertility potential, reduced fertilisation, poor embryo quality, recurrent pregnancy loss and poor assisted reproductive techniques (ARTs) outcomes. Although semen analysis remains the gold standard for diagnosis of male factor infertility worldwide, its limitations motivated the search and the development of complementary tests of sperm function and integrity. SDF assay is an emerging diagnostic tool in infertile men, and several indications for SDF testing in infertile couples have also been proposed. The use of SDF in routine male infertility assessment is, however, still controversial. Furthermore, both direct and indirect SDF tests are now available. Hence, the present review was conducted to summarise the recent evidence of SDF, underlying mechanisms, clinical indications, diagnostic tests, as well as the role of SDF in male factor infertility, pregnancy and ART outcomes.
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12
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Chereshnev VA, Pichugova SV, Beikin YB, Chereshneva MV, Iukhta AI, Stroev YI, Churilov LP. Pathogenesis of Autoimmune Male Infertility: Juxtacrine, Paracrine, and Endocrine Dysregulation. PATHOPHYSIOLOGY 2021; 28:471-488. [PMID: 35366245 PMCID: PMC8830464 DOI: 10.3390/pathophysiology28040030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/24/2022] Open
Abstract
According to global data, there is a male reproductive potential decrease. Pathogenesis of male infertility is often associated with autoimmunity towards sperm antigens essential for fertilization. Antisperm autoantibodies (ASAs) have immobilizing and cytotoxic properties, impairing spermatogenesis, causing sperm agglutination, altering spermatozoa motility and acrosomal reaction, and thus preventing ovum fertilization. Infertility diagnosis requires a mandatory check for the ASAs. The concept of the blood–testis barrier is currently re-formulated, with an emphasis on informational paracrine and juxtacrine effects, rather than simple anatomical separation. The etiology of male infertility includes both autoimmune and non-autoimmune diseases but equally develops through autoimmune links of pathogenesis. Varicocele commonly leads to infertility due to testicular ischemic damage, venous stasis, local hyperthermia, and hypoandrogenism. However, varicocelectomy can alter the blood–testis barrier, facilitating ASAs production as well. There are contradictory data on the role of ASAs in the pathogenesis of varicocele-related infertility. Infection and inflammation both promote ASAs production due to “danger concept” mechanisms and because of antigen mimicry. Systemic pro-autoimmune influences like hyperprolactinemia, hypoandrogenism, and hypothyroidism also facilitate ASAs production. The diagnostic value of various ASAs has not yet been clearly attributed, and their cut-levels have not been determined in sera nor in ejaculate. The assessment of the autoimmunity role in the pathogenesis of male infertility is ambiguous, so the purpose of this review is to show the effects of ASAs on the pathogenesis of male infertility.
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Affiliation(s)
- Valeriy A. Chereshnev
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, 620049 Yekaterinburg, Russia; (V.A.C.); (S.V.P.); (M.V.C.)
| | - Svetlana V. Pichugova
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, 620049 Yekaterinburg, Russia; (V.A.C.); (S.V.P.); (M.V.C.)
- State Autonomous Healthcare Institution of the Sverdlovsk Region “Clinical and Diagnostic Center” (GAUZ SO “CDC” Clinical Diagnostic Center), 620144 Yekaterinburg, Russia;
| | - Yakov B. Beikin
- State Autonomous Healthcare Institution of the Sverdlovsk Region “Clinical and Diagnostic Center” (GAUZ SO “CDC” Clinical Diagnostic Center), 620144 Yekaterinburg, Russia;
| | - Margarita V. Chereshneva
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, 620049 Yekaterinburg, Russia; (V.A.C.); (S.V.P.); (M.V.C.)
| | - Angelina I. Iukhta
- Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, 199304 Saint Petersburg, Russia; (Y.I.S.); (L.P.C.)
- Correspondence:
| | - Yuri I. Stroev
- Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, 199304 Saint Petersburg, Russia; (Y.I.S.); (L.P.C.)
| | - Leonid P. Churilov
- Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, 199304 Saint Petersburg, Russia; (Y.I.S.); (L.P.C.)
- Saint Petersburg Research Institute of Phthisiopulmonology, 191036 Saint Petersburg, Russia
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13
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Using Data Mining to Assist in Predicting Reproductive Outcomes Following Varicocele Embolization. J Clin Med 2021; 10:jcm10163503. [PMID: 34441799 PMCID: PMC8397051 DOI: 10.3390/jcm10163503] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/26/2022] Open
Abstract
We carried out a retrospective analysis of infertile couple data using several methodologies and data analysis techniques, including the application of a novel data mining approach for analyzing varicocele treatment outcomes. The aim of this work was to characterize embolized varicocele patients by ascertaining the improvement of some of their clinical features, predicting the success of treatment via pregnancy outcomes, and identifying data patterns that can contribute to both ongoing varicocele research and the more effective management of patients treated for varicocele. We retrospectively surveyed the data of 293 consenting couples undergoing infertility treatment with male varicocele embolization over a 10-year period, and sperm samples were collected before and at 3, 6, and 12 months after varicocele embolization treatment and analyzed with World Health Organization parameters—varicocele severity grades were assessed with medical assessment and scrotal ultrasound, patient personal information (e.g., age, lifestyle, and embolization complications) was collected with clinical inquiries, and varicocele embolization success was measured through pregnancy outcomes. Varicocele embolization significantly improved sperm concentration, motility, and morphology mean values, as well as sperm chromatin integrity. Following this study, we can predict that a male patient without a high varicocele severity grade (with grade I or II) has a 70.83% chance of conceiving after embolization treatment if his partners’ age is between 24 and 33 with an accuracy of 70.59%. Furthermore, male patients successful in achieving pregnancy following embolization are mostly characterized by having a normal sperm progressive motility before treatment, a normal sperm concentration after treatment, a moderate to low varicocele severity grade, and not working in a putatively hazardous environment.
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14
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Majzoub A, Arafa M, El Ansari W, Mahdi M, Agarwal A, Al-Said S, Elbardisi H. Correlation of oxidation reduction potential and total motile sperm count: its utility in the evaluation of male fertility potential. Asian J Androl 2021; 22:317-322. [PMID: 31339113 PMCID: PMC7275803 DOI: 10.4103/aja.aja_75_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Oxidative stress (OS) is detrimental to sperm functions, and the oxidation reduction potential (ORP) is a good measure of OS as it considers the balance between oxidants and reductants. Total motile sperm count (TMSC) is viewed as the single most important semen analysis parameter that can predict male infertility severity, and its correlation with ORP has never been undertaken. The objectives of this study were to assess the correlation between ORP and TMSC, to identify the ORP cutoff value based on the TMSC result, and to compare this cutoff value with previously reported ORP cutoff values in literature. One thousand one hundred and sixty-eight infertile patients and 100 fertile controls were enrolled. Demographic and semen data of the participants were retrieved and analyzed. Wilcoxon's rank-sum test compared variables between infertile men and fertile controls; Spearman's correlation assessed the static ORP (sORP)-TMSC relationship for the whole sample and among each group individually. Using a 20×106 TMSC threshold, receiver operator characteristic (ROC) analysis determined the sORP cutoff associated with the highest predictive values. TMSC was significantly negatively correlated with sORP across all participants (r = 0.86, P < 0.001), among infertile patients (r = 0.729, P < 0.001), and among fertile controls (r = 0.53, P < 0.001). A 20-million TMSC threshold determined an sORP cutoff value of 2.34 mV/106 sperm/ml to be associated with 82.9% sensitivity, 82.8% specificity, 91.5% positive predictive value (PPV), 68.5% negative predictive value (NPV), and 82.9% overall accuracy. Compared with previously reported cutoff values in searched literature, the 2.34 mV/106 sperm/ml cutoff value identified in our study yielded the highest overall diagnostic accuracy in the evaluation of infertile men.
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Affiliation(s)
- Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha 00974, Qatar.,Department of Urology, Weill Cornell Medicine-Qatar, Doha 00974, Qatar
| | - Mohamed Arafa
- Department of Urology, Hamad Medical Corporation, Doha 00974, Qatar.,Department of Urology, Weill Cornell Medicine-Qatar, Doha 00974, Qatar.,Department of Andrology, Cairo University, Cairo 12613, Egypt
| | - Walid El Ansari
- Department of Surgery, Hamad Medical Corporation, Doha 00974, Qatar.,College of Medicine, Qatar University, Doha 00974, Qatar.,School of Health and Education, University of Skövde, Skövde 54128, Sweden
| | - Mohammed Mahdi
- Department of Urology, Hamad Medical Corporation, Doha 00974, Qatar
| | - Ashok Agarwal
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland Clinic Foundation, OH 44195, USA
| | - Sami Al-Said
- Department of Urology, Hamad Medical Corporation, Doha 00974, Qatar.,Department of Urology, Weill Cornell Medicine-Qatar, Doha 00974, Qatar
| | - Haitham Elbardisi
- Department of Urology, Hamad Medical Corporation, Doha 00974, Qatar.,Department of Urology, Weill Cornell Medicine-Qatar, Doha 00974, Qatar
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15
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Jeremias JT, Belardin LB, Okada FK, Antoniassi MP, Fraietta R, Bertolla RP, Intasqui P. Oxidative origin of sperm DNA fragmentation in the adult varicocele. Int Braz J Urol 2021; 47:275-283. [PMID: 33146981 PMCID: PMC7857753 DOI: 10.1590/s1677-5538.ibju.2019.0827] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/02/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Sperm DNA fragmentation is a major cellular mechanism underlying varicocele-related male infertility. However, the type of DNA fragmentation - whether oxidative or of another nature - remains unknown. Thus, the aim of this study was to evaluate single- and double-stranded sperm DNA fragmentation, and oxidative-induced sperm DNA damage in men with varicocele. MATERIALS AND METHODS A cross-sectional study was performed, including 94 normozoospermic adults, of which 39 men without varicocele (controls) and 55 men with varicocele grades II or III, uni- or bilaterally. All men collected semen by masturbation. After semen analysis, the remaining volume was used for evaluation of three types of sperm DNA damage: (i) total DNA fragmentation, using an alkaline comet assay, (ii) double-stranded DNA fragmentation, using a neutral comet assay, and (iii) oxidative DNA damage, using an alkaline comet assay associated with the DNA glycosylase formamidopyrimidine enzyme. In each assay, percentage of sperm with any degree of DNA fragmentation, and with high DNA fragmentation were compared between the groups using an unpaired Student's t test or a Mann-Whitney test. RESULTS The varicocele group presented a higher rate of sperm with fragmented DNA (both any and high DNA fragmentation), considering single-stranded DNA fragmentation, double-stranded DNA fragmentation, or a combination of both, as well as oxidative-induced DNA fragmentation. CONCLUSIONS Patients with varicocele have an increase in sperm DNA fragmentation levels, particularly in oxidative stress-induced sperm DNA damage.
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Affiliation(s)
- Jessica Timóteo Jeremias
- Universidade Federal de São Paulo - UnifespDivisão de UrologiaDepartamento de CirurgiaSão PauloSPBrasilDepartamento de Cirurgia, Divisão de Urologia, Seção de Reprodução Humana, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil
| | - Larissa Berloffa Belardin
- Universidade Federal de São Paulo - UnifespDivisão de UrologiaDepartamento de CirurgiaSão PauloSPBrasilDepartamento de Cirurgia, Divisão de Urologia, Seção de Reprodução Humana, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil
| | - Fatima Kazue Okada
- Universidade Federal de São Paulo - UnifespDivisão de UrologiaDepartamento de CirurgiaSão PauloSPBrasilDepartamento de Cirurgia, Divisão de Urologia, Seção de Reprodução Humana, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil
| | - Mariana P. Antoniassi
- Universidade Federal de São Paulo - UnifespDivisão de UrologiaDepartamento de CirurgiaSão PauloSPBrasilDepartamento de Cirurgia, Divisão de Urologia, Seção de Reprodução Humana, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil,Correspondence address: Mariana Pereira Antoniassi, MD, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 – 2° andar, São Paulo, SP, 04024-002, Brasil. Telephone: +55 11 5576-4848 R. 4086. E-mail:
| | - Renato Fraietta
- Universidade Federal de São Paulo - UnifespDivisão de UrologiaDepartamento de CirurgiaSão PauloSPBrasilDepartamento de Cirurgia, Divisão de Urologia, Seção de Reprodução Humana, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil
| | - Ricardo Pimenta Bertolla
- Universidade Federal de São Paulo - UnifespDivisão de UrologiaDepartamento de CirurgiaSão PauloSPBrasilDepartamento de Cirurgia, Divisão de Urologia, Seção de Reprodução Humana, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil
| | - Paula Intasqui
- Universidade Federal de São Paulo - UnifespDivisão de UrologiaDepartamento de CirurgiaSão PauloSPBrasilDepartamento de Cirurgia, Divisão de Urologia, Seção de Reprodução Humana, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil
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16
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Miller D, Vukina J. Recent advances in clinical diagnosis and treatment of male factor infertility. Postgrad Med 2020; 132:28-34. [PMID: 32990123 DOI: 10.1080/00325481.2020.1830589] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Infertility is a significant global health issue affecting around 8-12% of couples worldwide with male factor infertility accounting for a substantial proportion of these cases. Despite significant advances within the past few decades, an etiology for male factor infertility cannot be identified in up to 80% of patients and thus, this continues to be an area of active study. This review aims to provide an update on recent advances in the field of male infertility including semen analysis and at-home semen testing, genetics, DNA fragmentation, surgical approaches, and the rise of telemedicine in the era of COVID19.
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Affiliation(s)
- David Miller
- Department of Urology, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania, USA
| | - Josip Vukina
- Department of Urology, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania, USA
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17
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Hosseini M, Tavalaee M, Rahmani M, Eskandari A, Shaygannia E, Kiani-Esfahani A, Zohrabi D, Nasr-Esfahani MH. Capsaicin improves sperm quality in rats with experimental varicocele. Andrologia 2020; 52:e13762. [PMID: 32816332 DOI: 10.1111/and.13762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/08/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Capsaicin is the main capsaicinoid in chilli peppers that have numerous biological and pharmaceutical roles in the body such as antioxidant, anti-inflammatory, anticarcinogenic, analgesic, counterirritant and antiarthritic properties. Numerous studies have shown increased oxidative stress in men with varicocele that is caused by dilation of the spermatic vein and increase of testicular temperature. Therefore, we aimed to assess the effect of Capsaicin on sperm parameters in rats with experimental varicocele. At first, we induced varicocele in 30 Wistar rats and, verify varicocele model only in 10 rats by assessment of sperm parameters, oxidative stress, DNA damage and persistent histone after 2 months. Of the remaining 20 varicocelised rats, half of them were treated with 2.5 mg/kg Capsaicin for two months and the other half served as control. Then, sperm tests were assessed, and the results showed that Capsaicin can restore the mean of sperm oxidative stress (38.78 ± 3.75 versus 58.37 ± 4.34; p < .05), sperm concentration (60.14 ± 7.66 versus 34.87 ± 5.78; p < .05) and motility (62.43 ± 3.10 versus 41.22 ± 5.11; p < .05) in varicocelised rats treated with Capsaicin compared to varicocelised rats that were not treat. Therefore, Capsaicin possibly with reduction of oxidative stress level could improve mean of sperm concentration and motility in varicocele condition.
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Affiliation(s)
- Mahshid Hosseini
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran.,Department of Biology, Faculty of Science, NourDanesh Institute of Higher Education, Isfahan, Iran
| | - Marziyeh Tavalaee
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Mohsen Rahmani
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Anahita Eskandari
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Erfaneh Shaygannia
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Abbas Kiani-Esfahani
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
| | - Dina Zohrabi
- Department of Biology, Faculty of Science, NourDanesh Institute of Higher Education, Isfahan, Iran
| | - Mohammad Hossein Nasr-Esfahani
- Department of Reproductive Biotechnology, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
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18
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Dutta S, Henkel R, Agarwal A. Comparative analysis of tests used to assess sperm chromatin integrity and DNA fragmentation. Andrologia 2020; 53:e13718. [PMID: 32628294 DOI: 10.1111/and.13718] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/23/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
Male infertility has a complex etiology, and many times, the cause is unknown. While routine semen analysis provides an overview of basic semen parameters, such as sperm concentration, motility, viability and morphology, a significant overlap of these parameters has been reported in fertile and infertile men. Moreover, conventional semen parameters do not reveal the cellular or molecular mechanisms of sperm dysfunctions leading to infertility. Therefore, sperm functional parameters, including sperm chromatin integrity, are evaluated to provide information on subtle sperm defects that are not routinely identified. Incomplete or defective sperm chromatin condensation increases the susceptibility of the sperm DNA to oxidative damage or other factors. To evaluate sperm chromatin integrity, different methods with varying degrees of diagnostic and prognostic capabilities are available. Among these assays, SCSA, TUNEL and SCD assays are most commonly used. While these assays rather evaluate the DNA directly for damages, the aniline blue and chromomycin A3 stains test for the quality of chromatin condensation. Thus, this review discusses and compares different methods used to evaluate sperm chromatin integrity and condensation, and their inclusion in the routine evaluation of the male infertility.
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Affiliation(s)
- Sulagna Dutta
- Department of Oral Biology and Biomedical Sciences, Faculty of Dentistry, MAHSA University, Selangor, Malaysia
| | - Ralf Henkel
- Department of Medical Bioscience, University of the Western Cape, Bellville, South Africa.,American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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19
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Panner Selvam MK, Ambar RF, Agarwal A, Henkel R. Etiologies of sperm DNA damage and its impact on male infertility. Andrologia 2020; 53:e13706. [PMID: 32559347 DOI: 10.1111/and.13706] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 12/12/2022] Open
Abstract
Male factor is responsible for up to 50% of infertility cases in the world. Semen analysis is considered the cornerstone of laboratory evaluation of male infertility, but it has its own drawbacks and fails to predict the male fertility potential with high sensitivity and specificity. Different etiologies have been linked with male infertility, of which sperm DNA damage has gained significant attention with extensive research on sperm function tests. The associations between sperm DNA damage and a variety of disorders such as varicocele, obesity, cancer, radiation and lifestyle factors are explored in this review. Furthermore, we discuss the mechanisms of DNA damage as well as its impact in different scenarios of male infertility, associated with spontaneous and assisted reproduction. Finally, we review the clinical applicability of sperm DNA fragmentation testing in the management of male infertility.
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Affiliation(s)
| | - Rafael F Ambar
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA.,Sexual and Reproductive Medicine - Department of Urology, Faculdade de Medicina do ABC, Santo André, Brazil
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ralf Henkel
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA.,Department of Medical Bioscience, University of the Western Cape, Bellville, South Africa
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20
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Panner Selvam MK, Baskaran S, Agarwal A, Henkel R. Protein profiling in unlocking the basis of varicocele-associated infertility. Andrologia 2020; 53:e13645. [PMID: 32453911 DOI: 10.1111/and.13645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/21/2020] [Accepted: 04/24/2020] [Indexed: 12/21/2022] Open
Abstract
Varicocele is one of the major causes of male infertility and has a negative impact on spermatogenesis. The conventional semen analysis does not reveal the underlying subcellular mechanisms associated with defects in spermatozoa. Proteomics and bioinformatics analysis can be used to identify the molecular aetiologies associated with poor semen quality in varicocele patients. Mitochondrial dysfunction has been identified as the main factor affecting normal physiological functions of spermatozoa. This article discusses the proteomic studies of spermatozoa and seminal plasma in varicocele patients. Proteomics can identify potential spermatozoa and seminal plasma biomarkers in varicocele-mediated male infertility. In future, these protein biomarkers can be useful in the development of noninvasive diagnostic and therapeutic strategies for varicocele patients.
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Affiliation(s)
| | - Saradha Baskaran
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ralf Henkel
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA.,Department of Medical Bioscience, University of the Western Cape, Bellville, South Africa
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21
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Dave P, Farber N, Vij S. Conventional semen analysis and advanced sperm function tests in diagnosis and management of varicocele. Andrologia 2020; 53:e13629. [PMID: 32369238 DOI: 10.1111/and.13629] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/06/2020] [Accepted: 04/10/2020] [Indexed: 12/17/2022] Open
Abstract
Clinical varicoceles are a common cause of male infertility and affect sperm parameters as measured in a conventional semen analysis. Varicocelectomy has been shown in prospective studies to improve semen parameters in men with a clinical varicocele. Clinical varicoceles are also a well-known source of oxidative stress which may affect the quality of spermatozoa. Spermatozoa are particularly susceptible to oxidative stress due to a limited capacity for DNA repair. The susceptibility of spermatozoa to oxidative stress is modulated by a balance between ROS and antioxidants, which can be quantified by various laboratory assays. Varicocelectomy has been consistently shown to reduce both ROS and sperm DNA fragmentation, and various assays should be utilised in the diagnosis and treatment of infertile men with a clinical varicocele.
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Affiliation(s)
- Priya Dave
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Nicholas Farber
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological & Kidney Institute, Cleveland, OH, USA
| | - Sarah Vij
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological & Kidney Institute, Cleveland, OH, USA
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22
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Douglas C, Parekh N, Kahn LG, Henkel R, Agarwal A. A Novel Approach to Improving the Reliability of Manual Semen Analysis: A Paradigm Shift in the Workup of Infertile Men. World J Mens Health 2019; 39:172-185. [PMID: 31749341 PMCID: PMC7994658 DOI: 10.5534/wjmh.190088] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/08/2019] [Accepted: 10/28/2019] [Indexed: 12/13/2022] Open
Abstract
Conventional semen analysis (SA) is an essential component of the male infertility workup, but requires laboratories to rigorously train and monitor technicians as well as regularly perform quality assurance assessments. Without such measures there is room for error and, consequently, unreliable results. Furthermore, clinicians often rely heavily on SA results when making diagnostic and treatment decisions, however conventional SA is only a surrogate marker of male fecundity and does not guarantee fertility. Considering these challenges, the last several decades have seen the development of many advances in SA methodology, including tests for sperm DNA fragmentation, acrosome reaction, and capacitation. While these new diagnostic tests have improved the scope of information available to clinicians, they are expensive, time-consuming, and require specialized training. The latest advance in laboratory diagnostics is the measurement of seminal oxidation-reduction potential (ORP). The measurement of ORP in an easy, reproducible manner using a new tool called the Male Infertility Oxidative Stress System (MiOXSYS) has demonstrated ORP's potential as a feasible adjunct test to conventional SA. Additionally, the measurement of ORP by this device has been shown to be predictive of both poor semen quality and male infertility. Assessing ORP is a novel approach to both validating manual SA results and identifying patients who may benefit from treatment of male oxidative stress infertility.
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Affiliation(s)
- Christopher Douglas
- American Center for Reproductive Medicine, Cleveland Clinic, OH, USA.,Texas College of Osteopathic Medicine, Fort Worth, TX, USA
| | - Neel Parekh
- American Center for Reproductive Medicine, Cleveland Clinic, OH, USA.,Department of Urology, Cleveland Clinic, Cleveland, OH, USA
| | - Linda G Kahn
- American Center for Reproductive Medicine, Cleveland Clinic, OH, USA.,Department of Pediatrics, New York University School of Medicine, New York City, NY, USA
| | - Ralf Henkel
- American Center for Reproductive Medicine, Cleveland Clinic, OH, USA.,Department of Medical Bioscience, University of the Western Cape, Bellville, South Africa
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, OH, USA.
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23
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Esteves SC. Interventions to Prevent Sperm DNA Damage Effects on Reproduction. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1166:119-148. [PMID: 31301050 DOI: 10.1007/978-3-030-21664-1_8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Excessive oxidation and antioxidant imbalance resulting from several conditions may cause sperm DNA damage, which, in turn, affect male fertility, both natural and assisted. Sperm DNA damage transferred to the embryo might also affect the health of offspring. Several conditions associated with excessive oxidative stress are modifiable by the use of specific treatments, lifestyle changes, and averting exposure to environmental/occupational toxicants. Here, we discuss the strategies to reduce sperm DNA damage with a focus on clinical and surgical interventions.
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Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil. .,Department of Surgery (Division of Urology), University of Campinas (UNICAMP), Campinas, SP, Brazil. .,Faculty of Health, Aarhus University, Aarhus, Denmark.
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24
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Esteves SC, Roque M, Bedoschi G, Haahr T, Humaidan P. Intracytoplasmic sperm injection for male infertility and consequences for offspring. Nat Rev Urol 2019; 15:535-562. [PMID: 29967387 DOI: 10.1038/s41585-018-0051-8] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Intracytoplasmic sperm injection (ICSI) has become the most commonly used method of fertilization in assisted reproductive technology. The primary reasons for its popularity stem from its effectiveness, the standardization of the procedure, which means that it can easily be incorporated into the routine practice of fertility centres worldwide, and the fact that it can be used to treat virtually all forms of infertility. ICSI is the clear method of choice for overcoming untreatable severe male factor infertility, but its (over)use in other male and non-male factor infertility scenarios is not evidence-based. Despite all efforts to increase ICSI efficacy and safety through the application of advanced sperm retrieval and cryopreservation techniques, as well as methods for selecting sperm with better chromatin integrity, the overall pregnancy rates from infertile men remain suboptimal. Treating the underlying male infertility factor before ICSI seems to be a promising way to improve ICSI outcomes, but data remain limited. Information regarding the health of ICSI offspring has accumulated over the past 25 years, and there are reasons for concern as risks of congenital malformations, epigenetic disorders, chromosomal abnormalities, subfertility, cancer, delayed psychological and neurological development, and impaired cardiometabolic profile have been observed to be greater in infants born as a result of ICSI than in naturally conceived children. However, as subfertility probably influences the risk estimates, it remains to be determined to what extent the observed adverse outcomes are related to parental factors or associated with ICSI.
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Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil. .,Department of Surgery (Division of Urology), Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil. .,Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Matheus Roque
- ORIGEN, Center for Reproductive Medicine, Rio de Janeiro, Brazil
| | - Giuliano Bedoschi
- Division of Reproductive Medicine, Department of Gynecology and Obstetrics, University of São Paulo (USP), São Paulo, Brazil
| | - Thor Haahr
- Faculty of Health, Aarhus University, Aarhus, Denmark.,Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - Peter Humaidan
- Faculty of Health, Aarhus University, Aarhus, Denmark.,Fertility Clinic, Skive Regional Hospital, Skive, Denmark
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25
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Hassanen E, Elqusi K, Zaki H, Henkel R, Agarwal A. TUNEL assay: Establishing a sperm DNA fragmentation cut-off value for Egyptian infertile men. Andrologia 2019; 51:e13375. [PMID: 31347719 DOI: 10.1111/and.13375] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/15/2019] [Accepted: 06/20/2019] [Indexed: 12/31/2022] Open
Abstract
Male factor infertility is responsible for half of all infertility cases. Conventional semen analysis is inadequate to evaluate male fertility. Sperm DNA fragmentation (SDF) test can be done by: direct methods such as Terminal deoxynucleotidyl transferase dUTP Nick-End Labeling (TUNEL) and Comet assay, or indirect like Sperm Chromatin Structure Assay (SCSA) and Sperm Chromatin Dispersion (SCD). TUNEL assay measures both single- and double-strand breaks and is technically less demanding, while SCSA tests for the susceptibility for nuclear DNA denaturation and samples should be sent to the reference lab. Studies showed that a single cut-off value does not fit all. Therefore, this study aimed at establishing a cut-off value to discriminate between fertile and infertile Egyptian men. We enrolled 354 infertile men and 40 proven fertile volunteers.TUNEL assay was performed using Apo-Direct kit and bench top flow cytometer.The calculated SDF cut-off value was 20.3% with a sensitivity of 96.6% and specificity of 87.5%, and the overall accuracy of the test was 95.7%. Sperm DNA fragmentation Test using TUNEL assay is valuable tool for male infertility evaluation, and it assists in offering the best treatment options based on it's results.
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Affiliation(s)
| | | | | | - Ralf Henkel
- University of the Western Cape, Cape Town, South Africa.,American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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26
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Panner Selvam MK, Agarwal A, Dias TR, Martins AD, Baskaran S, Samanta L. Round cells do not contaminate or mask human sperm proteome in proteomic studies using cryopreserved samples. Andrologia 2019; 51:e13325. [PMID: 31168855 DOI: 10.1111/and.13325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/21/2019] [Accepted: 05/05/2019] [Indexed: 12/14/2022] Open
Abstract
Semen contains leucocytes and round cells, besides spermatozoa. The objective of this study was to identify whether the proteins from round cells and leucocytes affect the proteomic analysis of spermatozoa. Cryopreserved human sperm samples were divided into four groups: (1) samples with ≥1 × 106 /ml leucocytes unprocessed; (2) samples with ≥1 × 106 /ml leucocytes processed by 65% density centrifugation; (3) samples with round cells <1 × 106 /ml unprocessed; and (4) samples with round cells <1 × 106 /ml processed by 65% density centrifugation. Samples from each group (1, 2, 3 and 4) were pooled (n = 5) for quantitative proteomic analysis using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Comparative analysis revealed nine differentially expressed proteins (DEPs) groups 1 and 2. Moreover, five DEPs were identified between groups 3 and 4. We observed that cylicin-1, Atlastin-1 and vesicle transport protein SFT2B are specific to spermatozoa, and none of them were associated with leucocytes. The number of DEPs in spermatozoa of processed and unprocessed cryopreserved semen samples was negligible. Our results indicate that the presence of round cells (<1 × 106 /ml) in the seminal ejaculation does not interfere in the accurate detection of spermatozoa proteome by LC-MS/MS.
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Affiliation(s)
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Tânia R Dias
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, Ohio.,Universidade da Beira Interior, Covilhã, Portugal.,Department of Microscopy, Laboratory of Cell Biology, Institute of Biomedical Sciences Abel Salazar and Unit for Multidisciplinary Research in Biomedicine, University of Porto, Porto, Portugal
| | - Ana D Martins
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, Ohio.,Department of Microscopy, Laboratory of Cell Biology, Institute of Biomedical Sciences Abel Salazar and Unit for Multidisciplinary Research in Biomedicine, University of Porto, Porto, Portugal
| | - Saradha Baskaran
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Luna Samanta
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, Ohio.,Redox biology Laboratory, Department of Zoology, Ravenshaw University, Cuttack, India
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27
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Esteves SC, Roque M, Garrido N. Use of testicular sperm for intracytoplasmic sperm injection in men with high sperm DNA fragmentation: a SWOT analysis. Asian J Androl 2019; 20:1-8. [PMID: 28440264 PMCID: PMC5753543 DOI: 10.4103/aja.aja_7_17] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Spermatozoa retrieved from the testis of men with high levels of sperm DNA fragmentation (SDF) in the neat semen tend to have better DNA quality. Given the negative impact of SDF on the outcomes of Assisted Reproductive Technology (ART), an increased interest has emerged about the use of testicular sperm for intracytoplasmic sperm injection (Testi-ICSI). In this article, we used a SWOT (strengths, weaknesses, opportunities, and threats) analysis to summarize the advantages and drawbacks of this intervention. The rationale of Testi-ICSI is bypass posttesticular DNA fragmentation caused by oxidative stress during sperm transit through the epididymis. Hence, oocyte fertilization by genomically intact testicular spermatozoa may be optimized, thus increasing the chances of creating a normal embryonic genome and the likelihood of achieving a live birth, as recently demonstrated in men with high SDF. However, there is still limited evidence as regards the clinical efficacy of Testi-ICSI, thus creating opportunities for further confirmatory clinical research as well as investigation of Testi-ICSI in clinical scenarios other than high SDF. Furthermore, Testi-ICSI can be compared to other laboratory preparation methods for deselecting sperm with damaged DNA. At present, the available literature supports the use of testicular sperm when performing ICSI in infertile couples whose male partners have posttesticular SDF. Due to inherent risks of sperm retrieval, Testi-ICSI should be offered when less invasive treatments for alleviating DNA damage have failed. A call for continuous monitoring is nonetheless required concerning the health of generated offspring and the potential complications of sperm retrieval.
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Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Av. Dr. Heitor Penteado 1464, Campinas, SP, 13075-460 Brazil
| | - Matheus Roque
- ORIGEN, Center for Reproductive Medicine, Rio de Janeiro, Brazil
| | - Nicolás Garrido
- Andrology Laboratory and Sperm Bank, IVI Foundation, Valencia, Spain
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Panner Selvam MK, Agarwal A, Dias TR, Martins AD, Samanta L. Presence of Round Cells Proteins do not Interfere with Identification of Human Sperm Proteins from Frozen Semen Samples by LC-MS/MS. Int J Mol Sci 2019; 20:ijms20020314. [PMID: 30646561 PMCID: PMC6359632 DOI: 10.3390/ijms20020314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 12/22/2022] Open
Abstract
In sperm proteomic experiments round cells and leukocyte proteins are profiled along with sperm proteome. The influence of round cell and leukocyte proteins on the sperm proteome has not been investigated. The objective of this study was to identify if the proteins from round cells, including leukocytes, interfere with the proteomic analysis of spermatozoa in frozen semen samples. Proteomic profiling of sperm was performed using liquid chromatography-tandem mass spectrometry in four groups: Group 1 contained neat semen with round cells and leukocytes ≥ 1 × 106/mL, group 2 contained neat semen with round cells ≥ 1 × 106/mL that was processed by 65% density gradient to remove the round cells and leukocytes, group 3 contained neat semen with round cells < 1 × 106/mL, and group 4 contained neat semen with round cells < 1 × 106/mL that was processed by 65% density gradient to remove the round cells. Pure leukocyte culture was used as control group. A total of 1638, 1393, 1755, and 1404 proteins were identified in groups 1, 2, 3, and 4, respectively. Comparative analysis of group 1 vs. 3 revealed 26 (1.18%) differentially expressed proteins (DEPs). On the other hand, only 6 (0.31%) DEPs were observed with group 2 vs. 4. Expression of these DEPs were either absent or very low in the control group. The results of our proteomics analysis failed to show any influence of non-spermatogenic round cell proteins on sperm proteome identification. These results validate the use of neat semen samples for sperm proteomic studies.
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Affiliation(s)
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - Tânia R Dias
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH 44195, USA.
- Universidade da Beira Interior, 6201-001 Covilhã, Portugal.
- Department of Microscopy, Laboratory of Cell Biology, Institute of Biomedical Sciences Abel Salazar and Unit for Multidisciplinary Research in Biomedicine, University of Porto, 4050-313 Porto, Portugal.
| | - Ana D Martins
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH 44195, USA.
- Department of Microscopy, Laboratory of Cell Biology, Institute of Biomedical Sciences Abel Salazar and Unit for Multidisciplinary Research in Biomedicine, University of Porto, 4050-313 Porto, Portugal.
| | - Luna Samanta
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH 44195, USA.
- Redox Biology Laboratory, Department of Zoology, School of Life Sciences, Ravenshaw University, Cuttack 753003, India.
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Zavattaro M, Ceruti C, Motta G, Allasia S, Marinelli L, Di Bisceglie C, Tagliabue MP, Sibona M, Rolle L, Lanfranco F. Treating varicocele in 2018: current knowledge and treatment options. J Endocrinol Invest 2018; 41:1365-1375. [PMID: 30284221 DOI: 10.1007/s40618-018-0952-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 09/11/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE Varicocele is defined as a state of varicosity and tortuosity of the pampiniform plexus around the testis caused by retrograde blood flow through the internal spermatic vein. The prevalence of clinically relevant varicocele ranges from 5 to 20% in the male population and is often associated with infertility and reduction of sperm quality. In this review, the pathophysiology and clinical aspects of varicocele are reviewed along with therapeutic options and treatment effects on sperm parameters and fertility both in adult and in pediatric/adolescent subjects. METHODS We conducted a Medline and a PubMed search from 1965 to 2018 to identify publications related to varicocele clinical aspects, treatment procedures and treatment outcomes. Keywords used for the search were: "varicocele", "varicocelectomy", "sclerotherapy", "male infertility", "subfertility", and "semen abnormalities". RESULTS Data from a large number of studies in adolescent and adult males indicate that varicocele correction improves semen parameters in the majority of patients, reducing oxidative stress and improving sperm nuclear DNA integrity either with surgical or percutaneous approach. CONCLUSIONS Varicocele repair seems to represent a cost-effective therapeutic option for all males (both adolescent and adults) with a clinical varicocele in the presence of testicular hypotrophy, worsening sperm alterations or infertility. On the other hand, some investigators questioned the role of varicocelectomy in the era of assisted reproduction. Thus, a better understanding of the pathophysiology of varicocele-associated male subfertility is of paramount importance to elucidating the deleterious effects of varicocele on spermatogenesis and possibly formulating new treatment strategies.
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Affiliation(s)
- M Zavattaro
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - C Ceruti
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - G Motta
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - S Allasia
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - L Marinelli
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - C Di Bisceglie
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - M P Tagliabue
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Sibona
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - L Rolle
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - F Lanfranco
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
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Cho CL, Agarwal A. Role of sperm DNA fragmentation in male factor infertility: A systematic review. Arab J Urol 2018; 16:21-34. [PMID: 29713533 PMCID: PMC5922225 DOI: 10.1016/j.aju.2017.11.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 11/07/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To summarise the latest evidence on the role of sperm DNA fragmentation (SDF) in male factor infertility, as SDF has been emerging as a valuable tool for male infertility evaluation. METHODS A search of PubMed was conducted using the keywords 'sperm DNA fragmentation' and 'male infertility'. Studies in languages other than English were excluded. All identified studies were screened and clinical studies in humans were included. RESULTS In all, 150 articles were included for analysis. Current evidence supports the association between high SDF and poor reproductive outcomes for natural conception and intrauterine insemination. Although the relationship between high SDF and in vitro fertilisation and intracytoplasmic sperm injection is less clear, the negative implication of high SDF on pregnancy loss is evident. Various treatment strategies have been attempted with varying success. The predictive value of SDF testing on outcomes of natural pregnancy and assisted reproduction illustrates its value in clinical practice. CONCLUSION The significant role of SDF in male factor infertility is supported by current evidence. The beneficial role of SDF testing in selection of varicocelectomy candidates, evaluation of patients with unexplained infertility and recurrent pregnancy loss, selection of the most appropriate assisted reproductive technique with highest success rate for infertile couples, and assessment of infertile men with modifiable lifestyle factors or gonadotoxin exposure has been recently proposed.
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Key Words
- ART, assisted reproductive technology
- ASRM, American Society for Reproductive Medicine
- Assisted reproductive technology (ART)
- Comet, single cell gel electrophoresis assay
- EAU, European Association of Urology
- ICSI, intracytoplasmic sperm injection
- IMSI, intracytoplasmic morphologically selected sperm injection
- IUI, intrauterine insemination
- IVF, in vitro fertilisation
- MACS, magnetic cell sorting
- Male infertility
- OR, odds ratio
- PICSI, physiological ICSI with hyaluronic acid binding assay
- ROS, reactive oxygen species
- RR, relative risk
- SCD, sperm chromatin dispersion
- SCSA, sperm chromatin structure assay
- SDF, sperm DNA fragmentation
- Sperm DNA fragmentation (SDF)
- TUNEL, terminal deoxynucleotidyl transferase dUTP nick end labelling
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Affiliation(s)
- Chak-Lam Cho
- Division of Urology, Department of Surgery, Kwong Wah Hospital, Yaumatei, Hong Kong
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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Reproductive outcomes of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with high levels of DNA fragmentation in semen: systematic review and meta-analysis. Fertil Steril 2017; 108:456-467.e1. [PMID: 28865546 DOI: 10.1016/j.fertnstert.2017.06.018] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/10/2017] [Accepted: 06/12/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To compare sperm DNA fragmentation (SDF) levels between testicular and ejaculated sperm and to evaluate outcomes of intracytoplasmic sperm injection (ICSI) with the use of testicular (Testi-ICSI) versus ejaculated (Ejac-ICSI) sperm in nonazoospermic men with high SDF. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Normo- and oligozoospermic men with high levels of SDF in semen subjected to Testi-ICSI or Ejac-ICSI. INTERVENTION(S) Summary mean difference (MD) and odds ratio (OR) were calculated with the use of an inverse variance model and fixed- or random-effects models, respectively. MAIN OUTCOME MEASURE(S) Primary outcomes were SDF levels, clinical pregnancy rates (CPRs), and live birth rates (LBRs). Secondary outcomes were fertilization and miscarriage rates. RESULT(S) Five studies involving 143 patients provided paired SDF rates for testicular and ejaculated sperm, revealing lower SDF in testicular sperm (MD -24.58%). Four studies involving 507 cycles and 3,840 oocytes reported clinical outcomes of Testi-ICSI and Ejac-ICSI. Fertilization rates were not different between sperm sources, but a trend to lower rates was observed with Testi-ICSI. CPRs were higher for Testi-ICSI than for Ejac-ICSI, as were LBRs, whereas miscarriage rates were reduced with Testi-ICSI. CONCLUSION(S) Testicular sperm have lower levels of SDF than ejaculated sperm, with Testi-ICSI for high post-testicular SDF men improving reproductive outcomes compared with Ejac-ICSI. Infertile couples may benefit from Testi-ICSI if male partners have confirmed high SDF in the ejaculate.
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Tadros NN, Sabanegh E. Commentary on clinical utility of sperm DNA fragmentation testing: Practice Recommendations of Sperm DNA Fragmentation Testing: Expert Commentaries by Invited Authors and Replies by Guest Editors Contributors from North America. Transl Androl Urol 2017; 6:S374-S376. [PMID: 29082147 PMCID: PMC5643698 DOI: 10.21037/tau.2017.01.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
| | - Edmund Sabanegh
- Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA
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35
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Majzoub A, Agarwal A, Esteves SC. Elucidating the clinical indications of sperm DNA fragmentation in male infertility. Transl Androl Urol 2017; 6:S658-S660. [PMID: 29082950 PMCID: PMC5643654 DOI: 10.21037/tau.2017.03.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, Brazil
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36
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Majzoub A, Agarwal A, Esteves SC. Antioxidants for elevated sperm DNA fragmentation: a mini review. Transl Androl Urol 2017; 6:S649-S653. [PMID: 29082954 PMCID: PMC5643651 DOI: 10.21037/tau.2017.07.09] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil
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37
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Majzoub A, Agarwal A, Esteves SC. Sperm DNA fragmentation testing in patients with subclinical varicocele: is there any evidence? Transl Androl Urol 2017; 6:S459-S461. [PMID: 29082973 PMCID: PMC5643679 DOI: 10.21037/tau.2017.03.88] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil
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Cho CL, Agarwal A, Majzoub A, Esteves SC. Clinical utility of sperm DNA fragmentation testing: concise practice recommendations. Transl Androl Urol 2017; 6:S366-S373. [PMID: 29082146 PMCID: PMC5643614 DOI: 10.21037/tau.2017.07.28] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Sperm DNA integrity is generally acknowledged as an essential component for human reproduction. While the negative impact of high sperm DNA fragmentation (SDF) on outcomes of natural pregnancy and assisted reproductive technology (ART) is well known, the clinical indication of SDF testing is less well defined. A recent review on clinical utility of SDF testing highlighted the different SDF assays and clinical indications of SDF testing. This concise practice recommendations aim at summarizing the evidence and presenting to the readers the essence of the clinical utility of SDF testing based on the currently existing evidence. The potential role of SDF testing in varicocelectomy candidates, couples with recurrent pregnancy loss, patients with unexplained infertility, couples with failed assisted reproduction, and infertile men with exposure to modifiable lifestyle risk factors is illustrated. Recommendations from an expert panel on each clinical condition is presented, with levels of evidence.
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Affiliation(s)
- Chak-Lam Cho
- Division of Urology, Department of Surgery, Kwong Wah Hospital, Hong Kong, China
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, University of Campinas (UNICAMP), Campinas, SP, Brazil.,Division of Urology, University of Campinas (UNICAMP), Campinas, SP, Brazil.,Faculty of Health, Department of Clinical Medicine, Aarhus University, Denmark
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39
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Esteves SC, Majzoub A, Agarwal A. Expanding our understanding of clinical laboratory testing in male infertility patients. Transl Androl Urol 2017; 6:S440-S442. [PMID: 29082926 PMCID: PMC5643612 DOI: 10.21037/tau.2017.05.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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40
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Esteves SC, Majzoub A, Agarwal A. Integrating surgical and clinical andrology is essential to improve the quality of care delivered to infertile couples. Transl Androl Urol 2017; 6:S629-S631. [PMID: 29082976 PMCID: PMC5643673 DOI: 10.21037/tau.2017.05.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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41
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Esteves SC, Agarwal A, Majzoub A. An evidence-based perspective on the role of sperm chromatin integrity and sperm DNA fragmentation testing in male infertility. Transl Androl Urol 2017; 6:S665-S672. [PMID: 29082963 PMCID: PMC5643668 DOI: 10.21037/tau.2017.05.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil.,Division of Urology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
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42
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Basar MM, Kahraman S. Clinical utility of sperm DNA fragmentation testing: practice recommendations based on clinical scenarios. Transl Androl Urol 2017; 6:S574-S576. [PMID: 29082180 PMCID: PMC5643703 DOI: 10.21037/tau.2017.04.40] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Murad M Basar
- Department of Urology & Andrology, Memorial Sisli Hospital, Istanbul, Turkey
| | - Semra Kahraman
- Department of IVF and Reproductive Genetics, Memorial Sisli Hospital, Istanbul, Turkey
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43
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Esteves SC, Majzoub A, Agarwal A. The importance of quality control and quality assurance in SDF testing. Transl Androl Urol 2017; 6:S604-S606. [PMID: 29082943 PMCID: PMC5643611 DOI: 10.21037/tau.2017.05.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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44
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Majzoub A, Agarwal A, Esteves SC. Sperm DNA fragmentation for the evaluation of male infertility: clinical algorithms. Transl Androl Urol 2017; 6:S405-S408. [PMID: 29082942 PMCID: PMC5643626 DOI: 10.21037/tau.2017.03.93] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil
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45
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Agarwal A, Cho CL, Majzoub A, Esteves S. Expanding treatment paradigm of high sperm DNA fragmentation. Transl Androl Urol 2017; 6:S450-S452. [PMID: 29082929 PMCID: PMC5643622 DOI: 10.21037/tau.2017.03.72] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Chak-Lam Cho
- Division of Urology, Department of Surgery, Kwong Wah Hospital, Hong Kong, China
| | - Ahmad Majzoub
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, Brazil
| | - Sandro Esteves
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
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46
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Majzoub A, Agarwal A, Esteves SC. Understanding sperm DNA fragmentation. Transl Androl Urol 2017; 6:S535-S538. [PMID: 29082959 PMCID: PMC5643687 DOI: 10.21037/tau.2017.04.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil
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Esteves SC, Majzoub A, Agarwal A. Technical aspects of sperm DNA fragmentation testing, methods to select sperm with low DNA fragmentation, and usefulness of redox potential measurement in male infertility. Transl Androl Urol 2017; 6:S636-S639. [PMID: 29082972 PMCID: PMC5643696 DOI: 10.21037/tau.2017.05.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction.,Division of Urology, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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Tavalaee M, Kiani-Esfahani A, Nasr-Esfahani MH. Relationship between phospholipase C-zeta, semen parameters, and chromatin status. Syst Biol Reprod Med 2017; 63:259-268. [PMID: 28345968 DOI: 10.1080/19396368.2017.1298006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The need for additional tests to complement basic sperm analysis in clinics is well appreciated. In this regard, a number of tests such as sperm DNA integrity test as a tool in diagnosis and treatment of infertility are suggested. But recent studies have focused on main sperm factors involved in oocyte activation such as phospholipase C-zeta (PLCζ) that initiate intracellular Ca2+ signaling and embryogenesis. Therefore, this study aimed to investigate the relationship between PLCζ, basic semen parameters, sperm DNA fragmentation (SDF), and protamine deficiency in men with normal (n=32) and abnormal (n=23) semen parameters. Unlike SDF and protamine deficiency, as negative factors related to fertility, the mean value of PLCζ as positive factor related to infertility was significantly lower in men with abnormal semen parameters compared to men with normal semen parameters. Significant correlations were also observed between sperm concentration, motility, and abnormal morphology with the percentage of PLCζ positive spermatozoa. In addition, logistic regression analysis revealed that sperm morphology is more predictive than sperm motility and concentration for PLCζ presence. In addition, a statistically significant negative relationship was observed between the percentage of PLCζ positive spermatozoa and SDF. These findings suggested during ICSI, selection of sperm based on morphology has a profound effect on its ability to induce oocyte activation based on the likelihood of PLCζ expression. Therefore, assessment of PLCζ as an index for fertilization potential of a semen sample in men with severe teratozoospermia may define individuals who are candidates for artificial oocyte activation (AOA) and may avoid failed fertilization post ICSI.
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Affiliation(s)
- Marziyeh Tavalaee
- a Department of Reproductive Biotechnology , Reproductive Biomedicine Research Center, Royan Institute for Biotechnology , ACECR , Isfahan , Iran
| | - Abbas Kiani-Esfahani
- a Department of Reproductive Biotechnology , Reproductive Biomedicine Research Center, Royan Institute for Biotechnology , ACECR , Isfahan , Iran
| | - Mohammad H Nasr-Esfahani
- a Department of Reproductive Biotechnology , Reproductive Biomedicine Research Center, Royan Institute for Biotechnology , ACECR , Isfahan , Iran.,b Isfahan Fertility and Infertility Center , Isfahan , Iran
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Dumont A, Barbotin AL, Lefebvre-Khalil V, Mitchell V, Rigot JM, Boitrelle F, Robin G. [Necrozoospermia: From etiologic diagnosis to therapeutic management]. ACTA ACUST UNITED AC 2017; 45:238-248. [PMID: 28697346 DOI: 10.1016/j.gofs.2017.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/19/2017] [Indexed: 12/11/2022]
Abstract
This review describes necrospermia, its diagnosis, causes and management. Sperm vitality is commonly assessed in the laboratory of reproductive biology, with the eosin test or with the hypo-osmotic swelling test. Necrospermia is defined by a percentage of living spermatozoa inferior to 58%, and can be related to male infertility. Several pathological mechanisms may be involved and can be classified either in testicular causes (hyperthyroidism, local hyperthermia, varicocele), or post-testicular causes (epididymal necrospermia, dysregulation of seminal plasma, adult polycystic kidney disease, vasectomy reversal, anti-sperm antibodies) or both (infection, toxic, age, spinal cord injury). The first treatment is to correct the underlying cause, if possible. Repetitive ejaculation has demonstrated to be effective as well. Many drugs would also improve the sperm vitality (antioxidants, non-and-steroidal anti-inflammatory drugs) but there is currently no guideline to recommend their use. With necrospermia, fertilization rates are lower but in vitro fertilization (IVF) with Intracytoplasmic sperm injection (ICSI) improves the chances of conception.
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Affiliation(s)
- A Dumont
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional universitaire, 2, avenue Oscar-Lambret, 59000 Lille, France.
| | - A-L Barbotin
- Service de biologie de la reproduction-spermiologie-CECOS, hôpital Jeanne-de-Flandre, centre hospitalier régional universitaire, 59000 Lille, France; EA 4308 gamétogenèse et qualité du gamète, institut de biologie de la reproduction-spermiologie-CECOS, hôpital Albert-Calmette, centre hospitalier régional universitaire, 59000 Lille, France
| | - V Lefebvre-Khalil
- Service de biologie de la reproduction-spermiologie-CECOS, hôpital Jeanne-de-Flandre, centre hospitalier régional universitaire, 59000 Lille, France
| | - V Mitchell
- Service de biologie de la reproduction-spermiologie-CECOS, hôpital Jeanne-de-Flandre, centre hospitalier régional universitaire, 59000 Lille, France; EA 4308 gamétogenèse et qualité du gamète, institut de biologie de la reproduction-spermiologie-CECOS, hôpital Albert-Calmette, centre hospitalier régional universitaire, 59000 Lille, France
| | - J-M Rigot
- EA 4308 gamétogenèse et qualité du gamète, institut de biologie de la reproduction-spermiologie-CECOS, hôpital Albert-Calmette, centre hospitalier régional universitaire, 59000 Lille, France; Service d'andrologie, hôpital Albert-Calmette, centre hospitalier régional universitaire, 59000 Lille, France
| | - F Boitrelle
- Service de biologie de la reproduction et de cytogénétique, centre hospitalier Poissy-Saint-Germain-en-Laye, 78303 Poissy, France
| | - G Robin
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional universitaire, 2, avenue Oscar-Lambret, 59000 Lille, France; EA 4308 gamétogenèse et qualité du gamète, institut de biologie de la reproduction-spermiologie-CECOS, hôpital Albert-Calmette, centre hospitalier régional universitaire, 59000 Lille, France; Service d'andrologie, hôpital Albert-Calmette, centre hospitalier régional universitaire, 59000 Lille, France
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Affiliation(s)
- Ashok Agarwal
- Department of Urology, American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Chak-Lam Cho
- Division of Urology, Department of Surgery, Kwong Wah Hospital, Hong Kong
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