HIV Immunocapture Reveals Particles Expressed in Semen under INSTI-based Therapy are Largely Myeloid Cell-Derived and Disparate from Circulating Provirus

As use of HIV integrase strand transfer inhibitors (INSTI) increases and formulations are being developed for maintenance therapies and chemoprophylaxis, assessing virus suppression under INSTI-based regimens in prevention-relevant biologic compartments, such as the male genital tract, is timely. We used cell-source marker virion immunocapture to examine amplification of particle RNA then assessed the phylogenetic relatedness of seminal and blood viral sequences from men with HIV who were prescribed INSTI-based regimens. Seminal plasma immunocaptures yielded amplifiable virion RNA from 13/24 (54%) men, and the sequences were primarily associated with markers indicative of macrophage and resident dendritic cell sources. Genetic distances were greatest (>2%) between seminal virions and circulating proviruses, pointing to ongoing low-level expression from tissue-resident cells. While the low levels in semen predict an improbable likelihood of transmission, viruses with large genetic distances are expressed under potent INSTI therapy and have implications for determining epidemiologic linkages if adherence is suboptimal.

Innovations in monoclonal antibody-based multipurpose prevention technology (MPT) for the prevention of sexually transmitted infections and unintended pregnancy

Monoclonal antibodies (mAbs) are currently being produced for a number of clinical applications including contraception and the prevention of sexually transmitted infections (STIs). Combinations of contraceptive and anti-STI mAbs, including antibodies against HIV-1 and HSV-2, provide a powerful and flexible approach for highly potent and specific multipurpose prevention technology (MPT) products with desirable efficacy, safety and pharmacokinetic profiles. MAbs can be administered systemically by injection, or mucosally via topical products (e.g., films, gels, rings) which can be tailored for vaginal, penile or rectal administration to address the needs of different populations. The MPT field has faced challenges with safety, efficacy, production and cost. Here, we review the state-of-the-art of mAb MPTs that tackle these challenges with innovative strategies in mAb engineering, manufacturing, and delivery that could usher in a new generation of safe, efficacious, cost-effective, and scalable mAb MPTs.

A Brief History and Advancement of Contraceptive Multipurpose Prevention Technology (cMPT) Products

The high incidence of HIV and other sexually transmitted infections (STIs), and an unmet need for modern contraception resulting in a high unintended pregnancy rate, are major problems in reproductive health. The concept of multipurpose prevention technology (MPT) was introduced following the failure of several leading microbicide candidates to prevent human immunodeficiency virus type 1 (HIV-1) transmission in large clinical trials in the early 2000s. MPTs are defined as products designed to simultaneously prevent at least two of the following conditions: unintended pregnancy, HIV-1, or other major STIs. The goal of contraceptive MPT products (cMPTs) is to provide contraception and protection against one or more major STI pathogen (eg, HIV-1, herpes simplex virus (HSV) type 2, Neisseria gonorrhoeae (gonorrhea), Treponema pallidum (syphilis), Trichomonas vaginalis, Chlamydia trachomatis (Chlamydia). This new field has great potential and will benefit from lessons learned from the early microbicide trials. The cMPT field includes candidates representing various categories with different mechanisms of action including pH modifiers, polyions, microbicidal peptides, monoclonal antibodies, and other peptides that target specific reproductive and infectious processes. More preclinical research is being conducted to ensure minimal side effects and maximum efficacy in vivo. Effective proven and novel candidates are being combined to maximize efficacy, minimize side effects, and avoid drug resistance. More attention is being paid to acceptability and new delivery systems. cMPTs have a very promising future if adequate resources can be mobilized to sustain the effort from preclinical research to clinical trials to bring effective, acceptable, and affordable products to market.

ZB-06, a vaginal film containing an engineered human contraceptive antibody (HC4-N), demonstrates safety and efficacy in a phase 1 postcoital test and safety study

BACKGROUND

With an unplanned pregnancy rate of 50% or more in many countries, there is an urgent need for contraceptives that are more accessible and acceptable. To meet the growing demand for new contraceptives, ZabBio developed ZB-06, a vaginal film containing HC4-N, a human contraceptive antibody (HCA) that inactivates sperm.

OBJECTIVES

To assess the potential contraceptive activity of the ZB-06 film using a surrogate assessment for contraceptive efficacy, the postcoital test (PCT). We also assessed clinical safety of film use among healthy heterosexual couples. Serum, cervical mucus (CM) and vaginal fluid HC4-N antibody concentrations and sperm agglutination potency were determined after single film use. Changes in the concentration of soluble pro-inflammatory cytokines and vaginal Nugent score after film use were measured as sub-clinical safety endpoints.

STUDY DESIGN

Phase I first-in-woman, open-label, proof-of-concept, PCT and safety study.

RESULTS

Twenty healthy women were enrolled in the study and 8 heterosexual couples completed all study visits. The product was safe for both female participants and their male sexual partners. The PCT performed on ovulatory CM at baseline (no product use), revealed a mean of 25.9 (± 30.6) progressively motile sperm (PMS) per high power field (hpf). After use of a single ZB-06 film prior to intercourse, this number dropped to 0.04 (± 0.06) PMS/hpf (p<0.0001). At the follow up PCT visit approximately one month later (no product use), a mean of 47.4 (± 37.4) PMS/hpf was observed, indicating contraceptive reversibility.

CONCLUSIONS

A single dose of the ZB-06 film applied prior to intercourse was safe and met efficacy surrogate benchmarks of excluding progressively motile sperm from ovulatory CM. These data indicate that ZB-06 is a viable contraceptive candidate warranting further development and testing.

LALAPG variant of the Human Contraception Antibody (HCA) reduces Fc-mediated effector functions while maintaining sperm agglutination activity

High rates of unintended pregnancies worldwide indicate a need for more accessible and acceptable methods of contraception. We have developed a monoclonal antibody, the Human Contraception Antibody (HCA), for use by women in vaginal films and rings for contraception. The divalent F(ab')2 region of HCA binds to an abundant male reproductive tract-specific antigen, CD52g, and potently agglutinates sperm. Certain other antibody activities mediated by the Fc region such as mucus trapping, complement-dependent cytotoxicity (CDC) and antibody-dependent cellular phagocytosis (ADCP) could have beneficial or negative effects. The purpose of this study was to document HCA Fc effector functions and determine whether an engineered variant of HCA with a modified Fc region, HCA-LALAPG, retains desirable contraceptive activity while minimizing Fc-mediated effects. Fab and Fc functions were compared between HCA and HCA-LALAPG. Fab activity was assessed using sperm agglutination and modified swim-up ("sperm escape") assays. Fc functions were assessed by CDC (sperm immobilization), ADCP, and cervical mucus penetration assays. HCA and HCA-LALAPG showed equivalent activity in assays of Fab function. In the assays of Fc function, HCA supported strong CDC, ADCP, and sperm trapping in cervical mucus whereas HCA-LALAPG demonstrated little to no activity. HCA and the HCA-LALAPG variant were both highly effective in the sperm agglutination assays but differed in Fc mediated functions. Use of the HCA-LALAPG variant for contraception in women could reduce antibody-mediated inflammation and antigen presentation but may have reduced contraceptive efficacy due to much weaker sperm trapping in mucus and complement-dependent sperm immobilization activity.

Impact of race versus ethnicity on infertility diagnosis between Black American, Haitian, African, and White American women seeking infertility care: a retrospective review

Objective

To determine whether infertility diagnoses differ between Black ethnic subgroups.

Design

Retrospective review.

Setting

an urban safety-net hospital.

Patient(s)

Women seeking infertility care between 2005 and 2015.

Intervention(s)

Charts of women with infertility and polycystic ovary syndrome (International Classification of Diseases, Ninth Revision diagnoses) were reviewed to confirm diagnoses. Data were stratified by race and subsequently by ethnicity to evaluate the differences in infertility diagnoses between Black American, Black Haitian, and Black African women. White American women were used as the comparison group.

Main Outcome Measure(s)

Infertility diagnoses between Black ethnic subgroups and White women.

Result(s)

A total of 358 women met the inclusion criteria, including 99 Black American, 110 Black Haitian, 61 Black African, and 88 White American women. Anovulation/polycystic ovary syndrome was the most common diagnosis in each ethnic group, accounting for 40% of infertility among White American, 57% among Black American, 25% among Black Haitian, and 21% among Black African women. There were no significant differences in the individual infertility diagnoses between Black and White women. Between ethnic subgroups, multivariate analysis showed significantly higher odds of infertility because of anovulation/polycystic ovary syndrome in Black American women compared with Black African women (odds ratio [OR], 4.9; 95% confidence interval [CI], 1.4–17.0). Compared with Black African women, higher odds of tubal factor infertility were observed in Black American (OR, 4.7; 95% CI, 1.16–18.7) and Black Haitian women (OR, 4.0; 95% CI, 1.1–14.0).

Conclusion(s)

Infertility diagnoses were not homogeneous across Black ethnic groups. Studies examining infertility should specify the ethnic subgroups within a race because this may affect results.

Production and characterization of a human antisperm monoclonal antibody against CD52g for topical contraception in women

BACKGROUND

Approximately 40% of human pregnancies are unintended, indicating a need for more acceptable effective contraception methods. New antibody production systems make it possible to manufacture reagent-grade human monoclonal antibodies (mAbs) for clinical use. We used the Nicotiana platform to produce a human antisperm mAb and tested its efficacy for on-demand topical contraception.

METHODS

Heavy and light chain variable region DNA sequences of a human IgM antisperm antibody derived from an infertile woman were inserted with human IgG₁ constant region sequences into an agrobacterium and transfected into Nicotiana benthamiana. The product, an IgG₁ mAb ["Human Contraception Antibody" (HCA)], was purified on Protein A columns, and QC was performed using the LabChip GXII Touch protein characterization system and SEC-HPLC. HCA was tested for antigen specificity by immunofluorescence and western blot assays, antisperm activity by sperm agglutination and complement dependent sperm immobilization assays, and safety in a human vaginal tissue (EpiVaginal™) model.

FINDINGS

HCA was obtained at concentrations ranging from 0.4 to 4 mg/ml and consisted of > 90% IgG monomers. The mAb specifically reacted with a glycan epitope on CD52g, a glycoprotein produced in the male reproductive tract and found in abundance on sperm. HCA potently agglutinated sperm under a variety of relevant physiological conditions at concentrations ≥ 6.25 µg/ml, and mediated complement-dependent sperm immobilization at concentrations ≥ 1 µg/ml. HCA and its immune complexes did not induce inflammation in EpiVaginal™ tissue.

INTERPRETATION

HCA, an IgG1 mAb with potent sperm agglutination and immobilization activity and a good safety profile, is a promising candidate for female contraception.

FUNDING

This research was supported by grants R01 HD095630 and P50HD096957 from the National Institutes of Health.

Safety, acceptability, and pharmacokinetics of a monoclonal antibody-based vaginal multipurpose prevention film (MB66): A Phase I randomized trial

BACKGROUND

MB66 film is a multipurpose prevention technology (MPT) product with monoclonal antibodies (mAbs) against HIV-1 (VRC01-N) and HSV-1 and 2 (HSV8-N). The mAbs were produced by transient expression in Nicotiana benthamiana (N). We conducted a Phase I clinical trial to assess the safety, pharmacokinetics (PK), and ex vivo efficacy of single and repeated doses of MB66 when used intravaginally.

METHODS AND FINDINGS

The clinical trial enrolled healthy reproductive-aged, sexually abstinent women. In Segment A, 9 women received a single MB66 film which was inserted into the vaginal posterior fornix by a clinician. In Segment B, 29 women were randomly assigned to MB66 (Active) or Placebo film groups and were instructed to insert 1 film vaginally for 7 consecutive days. Visits and clinical sampling occurred predose and at various time points after single and repeated film doses. The primary endpoint was number of adverse events (AEs) Grade 2 or higher related to product use. Secondary endpoints included film dissolution rate, Nugent score (a Gram stain scoring system to diagnose bacterial vaginosis), vaginal pH, post-use survey results, cytokine concentrations in cervicovaginal lavage (CVL) specimens (assessed by Luminex assay), mAb concentrations in vaginal fluid collected from 4 sites (assessed by ELISA), and HIV and HSV neutralization activity of CVL samples ex vivo (assessed by TZM-bl and plaque reduction assay, respectively). The product was generally safe and well tolerated, with no serious AEs recorded in either segment. The AEs in this study were primarily genitourinary in nature with the most commonly reported AE being asymptomatic microscopic hematuria. There were no differences in vaginal pH or Nugent scores or significant increases in levels of proinflammatory cytokines for up to 7 days after film insertion in either segment or between Active and Placebo groups. Acceptability and willingness to use the product were judged to be high by post-use surveys. Concentrations of VRC01-N and HSV8-N in vaginal secretions were assessed over time to generate pharmacokinetic curves. Antibody levels peaked 1 hour postdosing with Active film (median: 35 μg/mL) and remained significantly elevated at 24 hours post first and seventh film (median: 1.8 μg/mL). Correcting for sample dilution (1:20), VRC01-N concentrations ranged from 36 to 700 μg/mL at the 24-hour time point, greater than 100-fold the IC50 for VRC01 (0.32 μg/mL); HSV8-N concentrations ranged from 80 to 601 μg/mL, well above the IC50 of 0.1 μg/m. CVL samples collected 24 hours after MB66 insertion significantly neutralized both HIV-1 and HSV-2 ex vivo. Study limitations include the small size of the study cohort, and the fact that no samples were collected between 24 hours and 7 days for pharmacokinetic evaluation.

CONCLUSIONS

Single and repeated intravaginal applications of MB66 film were safe, well tolerated, and acceptable. Concentrations and ex vivo bioactivity of both mAbs in vaginal secretions were significantly elevated and thus could provide protection for at least 24 hours postdose. However, further research is needed to evaluate the efficacy of MB66 film in women at risk for HIV and HSV infection. Additional antibodies could be added to this platform to provide protection against other sexually transmitted infections (STIs) and contraception.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02579083.

Engineering monoclonal antibody-based contraception and multipurpose prevention technologies†

Sexually transmitted infections are highly prevalent, and over 40% of pregnancies are unplanned. We are producing new antibody-based multipurpose prevention technology products to address these problems and fill an unmet need in female reproductive health. We used a Nicotiana platform to manufacture monoclonal antibodies against two prevalent sexually transmitted pathogens, HIV-1 and HSV-2, and incorporated them into a vaginal film (MB66) for preclinical and Phase 1 clinical testing. These tests are now complete and indicate that MB66 is effective and safe in women. We are now developing an antisperm monoclonal antibody to add contraceptive efficacy to this product. The antisperm antibody, H6-3C4, originally isolated by Shinzo Isojima from the blood of an infertile woman, recognizes a carbohydrate epitope on CD52g, a glycosylphosphatidylinositol-anchored glycoprotein found in abundance on the surface of human sperm. We engineered the antibody for production in Nicotiana; the new antibody which we call "human contraception antibody," effectively agglutinates sperm at concentrations >10 μg/ml and maintains activity under a variety of physiological conditions. We are currently seeking regulatory approval for a Phase 1 clinical trial, which will include safety and "proof of principle" efficacy endpoints. Concurrently, we are working with new antibody production platforms to bring the costs down, innovative antibody designs that may produce more effective second-generation antibodies, and delivery systems to provide extended protection.

Condylomata Acuminata (Anogenital Warts) Contain Accumulations of HIV-1 Target Cells That May Provide Portals for HIV Transmission

Background

Condylomata acuminata (anogenital warts [AGWs]) are prevalent in human immunodeficiency virus (HIV)-infected individuals and sexually active populations at risk for HIV acquisition and have been associated with HIV transmission. We compared AGW specimens to control tissue specimens for abundance, types, and location of HIV target cells and for susceptibility to HIV infection in vitro, to provide biologic evidence that AGWs facilitate HIV transmission.

Methods

We used immunohistologic staining to identify HIV target cells in AGW and control specimens. We also inoculated HIV in vitro into AGW and control specimens from HIV-negative men and assessed infection by means of TZM-bl and p24 assays.

Results

CD1a+ dendritic cells, CD4+ T cells, and macrophages were significantly more abundant in the epidermis of AGW specimens than control specimens. These HIV target cells also often appeared in large focal accumulations in the dermis of AGW specimens. Two of 8 AGW specimens versus 0 of 8 control specimens showed robust infection with HIV in vitro.

Conclusions

Compared with normal skin, AGWs contain significantly higher concentrations of HIV target cells that may be susceptible to HIV infection. Condylomata may thus promote HIV transmission, especially in the setting of typical lesion vascularity and friability. Prevention or treatment of AGWs may decrease the sexual transmission of HIV.

Systemic and topical use of monoclonal antibodies to prevent the sexual transmission of HIV

: Passive immunization, the transfer of antibodies to a nonimmune individual to provide immunological protection, has been used for over 100 years to prevent and treat human infectious diseases. The introduction of techniques to produce human mAbs has revolutionized the field, and a large number of human mAbs have been licensed for the treatment of cancer, autoimmune and inflammatory diseases. With the recent discovery and production of highly potent broadly neutralizing and other multifunctional antibodies to HIV, mAbs are now being considered for HIV therapy and prophylaxis. In this review, we briefly present recent advances in the anti-HIV mAb field and outline strategies for the selection, engineering and production of human mAbs, including the modification of their structure for optimized stability and function. We also describe results from nonhuman primate studies and phase 1 clinical trials that have tested the safety, tolerability, pharmacokinetics, and efficacy of mAb-based HIV prevention strategies, and discuss the future of parenteral and topical mAb administration for the prevention of HIV transmission.

Physician-scientists in obstetrics and gynecology: predictors of success in obtaining independent research funding

BACKGROUND

Obstetrics and gynecology departments receive the smallest amount of National Institutes of Health research funding and have significantly lower application success rates compared to pediatric, internal medicine, and surgery departments. The development of mentored early career development training grants (K awards) has been one strategy implemented by the National Institutes of Health to help aspiring physician-scientists establish independent research careers.

OBJECTIVE

The purpose of this study is to describe the cohort of obstetrics and gynecology physician-scientists who were K08, K12, and K23 recipients from 1988 through 2015 and to identify predictors of success in obtaining independent federal funding, as defined by acquisition of an R01, R21, R34, U01, U54, P01, or P50 award. We hypothesized that sex, subspecialty, type of K award, and dual MD/PhD would impact success rates.

STUDY DESIGN

K08, K12, and K23 recipients from 1988 through 2015 were identified from the National Institutes of Health Research Portfolio Online Reporting Tools, the office of the National Institutes of Health Freedom of Information Act, and the website of the Reproductive Scientist Development Program. Data were stratified by sex, educational degree, subspecialty, and type of K award. Data were analyzed using the Pearson χ² and Fisher exact tests. The Kaplan-Meier estimator was used to determine rates of conversion to independent funding over time.

RESULTS

A total of 388 K recipients were identified. Women accounted for 66% of K awards while men accounted for 34%. Among K recipients, 82% were MDs, while 18% were MD/PhDs. K12 awards accounted for 82% of all K awards, while K08 and K23 awards accounted for 10% and 8%, respectively. Subspecialists in maternal-fetal medicine and reproductive endocrinology and infertility received the highest proportion of K awards, followed by generalists and gynecologic oncologists. Altogether, the 3 subspecialty groups accounted for 68% of all K awards. R01 awards made up the bulk of independent funding. Among recipients who received their first K award between 1988 and 2009, 63 of 288 (22%) were successful at obtaining an R01. Rates of R21 (n = 22), U01 (n = 15), U54 (n = 12), P01 (n = 5), R34 (n = 1), and P50 (n = 1) acquisition ranged from 0.35-7.6%. In all, 118 K scholars (41%) were successful at achieving independent funding of any type compared to 1219 of 7535 (16.2%) obstetrics and gynecology non-K scholars. K08 recipients received the largest proportion of R01 awards compared to K12 and K23 recipients (32% vs 20%; P = .12), while 21% of K12 recipients and 17% of K23 recipients achieved an R01. There were no differences in the rates of independent funding success among K12 programs. K23 recipients were more likely to obtain an R21 (22% vs 6%, P = .008) compared to K12 and K08 recipients. The mean time to R01 acquisition was 6.8 years, while the mean time to independent funding of any type was 6.4 years. There were no significant differences in independent funding success rates by sex, educational degree, or subspecialty, although generalists received the highest proportion of R01 awards (29%).

CONCLUSION

Mentored early career development K programs enable aspiring obstetrics and gynecology physician-scientists to achieve higher rates of National Institutes of Health-based independent research funding compared to non-K recipients.

Impact of daylight savings time on spontaneous pregnancy loss in in vitro fertilization patients

Transition into daylight savings time (DST) has studied negative impacts on health, but little is known regarding impact on fertility. This retrospective cohort study evaluates DST impact on pregnancy and pregnancy loss rates in 1,654 autologous in vitro fertilization cycles (2009 to 2012). Study groups were identified based on the relationship of DST to embryo transfer. Pregnancy rates were similar in Spring and Fall (41.4%, 42.2%). Pregnancy loss rates were also comparable between Spring and Fall (15.5%, 17.1%), but rates of loss were significantly higher in Spring when DST occurred after embryo transfer (24.3%). Loss was marked in patients with a history of prior spontaneous pregnancy loss (60.5%).

Characteristics and quantities of HIV host cells in human genital tract secretions

Human immunodeficiency virus (HIV)-infected leukocytes have been detected in genital secretions from HIV-infected men and women and may play an important role in the sexual transmission of HIV. However, they have been largely overlooked in studies on mechanisms of HIV transmission and in the design and testing of HIV vaccine and microbicide candidates. This article describes the characteristics and quantities of leukocytes in male and female genital secretions under various conditions and also reviews evidence for the involvement of HIV-infected cells in both horizontal and vertical cell-associated HIV transmission. Additional research is needed in this area to better target HIV prevention strategies.

Role of Seminal Plasma in Human Female Reproductive Failure: Immunomodulation, Inflammation, and Infections

Human seminal plasma contains factors that can regulate the female immune system and potentially promote reproductive fitness. Adverse effects on fertility and pregnancy may occur when seminal plasma provides insufficient, excessive, or altered signals or when the female partner is incapable of receiving these signals.

HIV infection and immune defense of the penis

Recent evidence that circumcision decreases HIV infection in heterosexual men by 50-60% has focused research on the foreskin as a target of HIV infection. In this review article, we discuss potential mechanisms underlying the circumcision effect and re-examine the assumption that the foreskin is the principle penile HIV infection site. HIV target cells are present in the foreskin epithelium, but are also found in the epithelia of the penile shaft, glans/corona, meatus and urethral introitus. Sexually transmitted infections (STIs) can affect any of these sites and increase susceptibility to HIV acquisition by eroding the protective epithelial layer and by attracting and activating HIV target cells in the epithelium. The moist subpreputial cavity, which encompasses the entire penile tip in most uncircumcised men including the glans, meatus and urethral introitus, plays an important role in STI acquisition. Circumcised men have a lower rate of STIs that infect not only the foreskin but also other distal penile sites, especially the urethra. Likewise, the foreskin may trap HIV and HIV-infected cells after intercourse thereby increasing the risk of HIV acquisition not only through the inner foreskin but also other sites covered by the foreskin. The subpreputial cavity also hosts a unique microbiome that may also play a role in HIV infection. We hypothesize that the penile urethra may be the primary HIV acquisition site in circumcised men and possibly also in non-circumcised men because of the presence of superficial HIV target cells and a high incidence of STIs at this site. Both innate and adaptive immune defense mechanisms are operative in the lower male genital region. The penile urethral mucosa contains accumulations of IgA(+) plasma cells and T lymphocytes and may provide a responsive target for future mucosal vaccines to prevent HIV sexual transmission.

A giant oocyte in a cohort of retrieved oocytes: does it have any effect on the in vitro fertilization cycle outcome?

OBJECTIVE

To investigate an association between the presence of a giant oocyte and outcome for the cohort in in vitro fertilization (IVF).

DESIGN

Retrospective study.

SETTING

Hospital-based academic medical center.

PATIENT(S)

IVF and IVF/intracytoplasmic sperm injection (ICSI) cycles having at least one giant oocyte (study group; n = 105), matched with cycles without a giant oocyte (external control group). A further subanalysis compared giant oocyte cycles with the next closest cycles within patients (internal control group; n = 65).

INTERVENTION(S)

Standard IVF protocols.

MAIN OUTCOME MEASURE(S)

Incidence of giant oocytes, fertilization rate, quality of cohort embryos, and pregnancy outcome.

RESULT(S)

Out of 97,556 oocytes, 117 (0.12%) were giant. Compared with the external control group, cleavage in the study group was abnormal (increased percentage of 1-cell and 10-cell embryos and decreased percentage of 6-cell and 7-cell embryos), although there was no difference for percentage of embryos with perfect symmetry, fragmentation, or implantation, clinical pregnancy, or ongoing/delivered rate. The study group had two cases of pregnancy termination due to chromosomal abnormalities (4.4%) versus none in external controls. No striking differences in embryo quality existed between the study and internal control groups.

CONCLUSION(S)

A giant oocyte is associated with abnormal cleavage in cohort embryos, but not with implantation or pregnancy rates. Giant oocytes occur sporadically and appear not to reflect quality of remaining oocytes in the ovary.

Safety analysis of the diaphragm in combination with lubricant or acidifying microbicide gels: effects on markers of inflammation and innate immunity in cervicovaginal fluid

OBJECTIVE

Diaphragms are being considered for use with vaginal microbicide gels to provide enhanced protection against sexually transmitted pathogens. The purpose of this study was to determine whether use of a diaphragm with microbicide or placebo gel causes cervicovaginal inflammation or perturbations in cervicovaginal immune defense.

METHOD OF STUDY

Eighty-one non-pregnant women were randomized into three groups and instructed to use Milex (CooperSurgical, Inc., Trumbull, CT, USA)diaphragms overnight for 14 days in combination with one of the two acid-buffering microbicide gels [ACIDFORM (Instead Inc., La Jolla, CA, USA) or BufferGel(trade mark) (BG; ReProtect Inc., Baltimore, Maryland)] or placebo gel (K-Y Jelly); Personal Products Inc., Raritan, NJ, USA). Cervicovaginal lavages (CVLs) were performed prior to study entry and on days 8 and 16. Nine soluble mediators of vaginal inflammation or immune defense were measured in CVLs by Bio-Plex or ELISA.

RESULTS

Use of diaphragms with placebo or microbicide gel was not associated with increased levels of inflammation markers. Concentrations of secretory leukocyte protease inhibitor (SLPI) were markedly reduced in the BG group.

CONCLUSION

Daily use of a diaphragm with placebo or acidifying microbicide gel did not cause cervicovaginal inflammation. However, diaphragm/BG use was associated with markedly reduced levels of SLPI, an important mediator of innate immune defense. Further studies are warranted to establish the safety of diaphragm/microbicide gel combinations.

Concentrations and significance of cytokines and other immunologic factors in semen of healthy fertile men

BACKGROUND

The purpose of this study was to establish normal reference values for several immunologic factors in semen to provide a foundation for understanding their physiologic significance in health and disease.

METHODS

Semen from 83 healthy, fertile men was assessed by Bio-Plex or enzyme-linked immunosorbent assay to determine quantities of immunoglobulin (Ig) isotypes, chemokines, cytokines and growth factors. We also enumerated polymorphonuclear granulocytes (PMN) by peroxidase staining to examine the association of inflammation with levels of these factors.

RESULTS

High concentrations of IgG and IgA were detected in all samples. IgG concentrations were significantly higher than IgA concentrations (P < 0.0001). Likewise, two multifunctional growth factors, transforming growth factor-beta1 and interleukin (IL)-7, and three chemokines, stromal cell-derived factor-1alpha, monocyte chemotactic/chemoattractant protein-1 and IL-8, were present in high concentrations in all samples (medians >1000 pg/ml). Other soluble factors were detectable in low concentration (medians <150 pg/ml), either in a majority of samples [IL-1alpha and beta, IL-5, IL-6, IL-13, IL-17, regulated on activation normal T cell expressed and secreted (RANTES), macrophage inflammatory protein (MIP)-1beta, interferon (IFN)-alpha and granulocyte colony-stimulating factor (CSF)], or in a minority of samples (MIP-1alpha, IL-2, IL-10, IL-12, TNF-alpha, IFN-gamma and granulocyte-macrophage-CSF). PMN counts significantly correlated with IL-1beta, IL-6, TNF-alpha, MIP-1alpha, MIP-1beta, IL-13 and IgA concentrations.

CONCLUSIONS

The semen of healthy, fertile men contains a broad array of immunologic factors. These normative values can serve as a foundation for future studies on the role of these factors in infertility, genital tract infections and other pathologic conditions.

Prevalence of sexually transmissible pathogens in semen from asymptomatic male infertility patients with and without leukocytospermia

OBJECTIVE

To determine the prevalence of pathogens that cause sexually transmitted infections (STIs) in semen from asymptomatic male infertility patients with and without leukocytospermia (LCS), and associations between STIs, inflammatory markers, and other semen variables.

DESIGN

Retrospective, controlled study.

SETTING

Academic Medical Center.

PATIENT(S)

Two hundred and forty-one male infertility patients undergoing routine semen analysis: 132 with LCS, and 109 without LCS.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The DNA from STI pathogens (human papillomavirus [HPV], cytomegalovirus [CMV], herpes simplex virus [HSV], human herpesvirus type 6 [HHV-6], Epstein-Barr virus [EBV], hepatitis B virus [HBV], and Chlamydia trachomatis [CT]), routine semen parameters, and markers of accessory gland and epididymal function and inflammation.

RESULT(S)

The DNA from STI pathogens was detected in 45/241 (18.7%) of the samples (CMV, 8.7%; HPV, 4.5%; HHV-6, 3.7%; HSV, 3.7%; CT, 2.5%; EBV, 0.4%; and HBV, 0%), with no difference in prevalence between the LCS and non-LCS groups. The DNA of STI pathogens in semen was associated with a decrease in sperm concentration, motile sperm concentration, total sperm count, and neutral alpha-glucosidase concentration, whereas LCS was associated with a decrease in total sperm count, percent normal forms, and fructose concentration.

CONCLUSION(S)

The DNA of STI pathogens was detected in semen from a high percentage of asymptomatic male infertility patients, and was associated with poor semen quality. Efforts to diagnose and treat subclinical genital-tract infections should be intensified.

T-Lymphocyte Profile and Total and Virus-Specific Immunoglobulin Concentrations in the Cervix of HIV-1-Infected Women

BACKGROUND

The mucosal lymphocyte population is the largest in the body, and the gastrointestinal compartment has been well characterized in HIV infection. Much less is known about the effects of HIV on the genital tract.

OBJECTIVE

: To examine the T-lymphocyte phenotype and receptor repertoire as well as total and virus-specific immunoglobulin concentrations in the endocervix of HIV-infected women at different stages of infection as compared with uninfected women.

PATIENTS AND METHODS

Participants were 12 seronegative women, 10 HIV-infected "slow progressors" not taking antiretroviral therapy, and 9 HIV-infected women whose antiretroviral therapy was failing. We used multiparameter flow cytometry to enumerate T-cell populations on cytobrush-obtained cervical specimens, the immunoscope technique to determine the T-cell receptor (TCR) repertoire, and quantitative enzyme-linked immunosorbent assays for antibody determinations on cervical secretions absorbed onto ophthalmic sponges. Nonparametric statistical analyses were performed.

RESULTS

We found marked depletion of leukocytes and CD4 T lymphocytes in the endocervix of HIV-infected women as compared with uninfected women; this was significant at more advanced disease stages. Naive T cells were rare in the endocervix of all groups. Activation marker expression was higher in endocervical T lymphocytes than in peripheral blood among control and slow-progressing HIV-infected women but not in women failing therapy. Endocervical T lymphocytes showed highly restricted utilization of Vbeta TCR families. Unlike other mucosal sites, the cervix contained IgG as the predominant immunoglobulin isotype. HIV-IgG was detected in the cervix of most HIV-infected women and in blood of all infected women.

CONCLUSIONS

HIV infection induces substantial changes in the immune profile of the female genital tract. Further study of the implications of these findings for HIV acquisition and transmission is needed.

Human immunodeficiency virus type-1 episomal cDNA in semen

BACKGROUND

Episomal 2-long terminal repeat (LTR) HIV-1 cDNA, a by-product of HIV-1 infection, is used in clinical trials as a marker for ongoing viral replication. It would be useful to employ 2-LTR cDNA to monitor cryptic HIV-1 infection in the genital tract of men on antiretroviral therapy (ART) to predict the evolution of sexually transmissible drug-resistant HIV-1, but studies thus far have failed to detect this marker in semen. The objectives of this study were: 1) to use a technique that maximizes DNA recovery from HIV-1 infected white blood cells in semen to determine if episomal 2-LTR cDNA is detectable in semen of ART-naïve men with other evidence of genital tract HIV-1 infection, and 2) to compare levels of HIV-1 2-LTR cDNA, RNA, and proviral DNA in semen from HIV-1+ men on ART.

RESULTS

Using a somatic cell DNA extraction technique, 2-LTR cDNA was detected by PCR/ELISA in 4 out of 8 semen samples from ART-naïve men selected for other signs of seminal HIV-1 infection (positive controls). Southern blot and DNA sequencing confirmed that the amplified sequences were HIV-1 2-LTR cDNA; copy numbers ranged from 55 to 504 copies/sample. Two semen samples from a cohort of 22 HIV-1-infected men on dual nucleoside therapy, one with and one without detectable seminal HIV-1 RNA, were 2-LTR cDNA positive (336 and 8,560 copies/sample). Following addition of indinavir to the therapy regimen, no semen samples from 21 men with controlled peripheral and seminal viral loads were 2-LTR cDNA positive at 1 and 6 month time points, despite the persistence of HIV-1 proviral DNA+ semen cells and seminal cytomegalovirus (CMV) shedding in some cases. However, one individual who failed indinavir therapy and later developed distinct protease inhibitor (PI) drug resistance mutations in semen, maintained elevated levels of HIV-1 RNA and 2-LTR cDNA in semen.

CONCLUSION

2-LTR HIV-1 cDNA is detectable in semen of HIV-1-infected men. Two men on ART had 2-LTR HIV-1 cDNA in semen, suggesting that this marker may prove to be useful to monitor HIV-1 infection in the genital tract of men on ART to predict the evolution of drug resistance mutations in semen.

T-Helper 2 and 3 type immunity to trophoblast in successful in vitro fertilization-embryo transfer

OBJECTIVE

To determine whether peripheral blood mononuclear cell (PBMC) secretion of T-helper (Th)-1 type cytokines and Th-2 and Th-3 type cytokines in women undergoing in vitro fertilization-embryo transfer (IVF-ET) is associated with therapeutic failure and success, respectively.

DESIGN

Cohort study.

SETTING

Academic medical center.

PATIENT(S)

One hundred one women undergoing IVF-ET and 19 fertile controls.

INTERVENTION(S)

Peripheral blood was obtained from women undergoing IVF-ET before oocyte retrieval and from 19 nonpregnant fertile controls. The PBMCs were cultured in the presence or absence of a protein extract from either a trophoblast cell line or sperm membrane.

MAIN OUTCOME MEASURE(S)

Supernatants from PBMC cultures were tested by enzyme-linked immunoabsorbent assay (ELISA) for the Th-1 type cytokines tumor necrosis factor-alpha (TNF)-alpha) and interferon-gamma (IFN)-gamma), the Th-2 type cytokines interleukin (IL)-6 and IL-10, and the Th-3 type cytokine transforming growth factor (TGF)-beta1.

RESULT(S)

Levels of IL-6 and IL-10 were significantly higher in controls than in infertile women with endometriosis, and levels of IL-10 were higher in controls than in women with unexplained infertility. No differences were found in unstimulated levels of TNF-alpha, IFN-gamma, or TGF-beta1 between infertile patients and controls. In trophoblast-stimulated PBMC cultures, levels of TGF-beta1 were significantly lower in subjects who experienced failed compared with ongoing pregnancies.

CONCLUSION(S)

Baseline PBMC secretion of IL-6 and IL-10 is higher in fertile controls than in women with endometriosis, and IL-10 secretion is also higher than in women with unexplained infertility. Trophoblast-stimulated PBMC secretion of TGF-beta1 is positively associated with the establishment of successful pregnancy in women undergoing IVF-ET. Our study provides novel evidence to support a faciliatory role of Th-2 and Th-3 type responses to trophoblast in early pregnancy.

Detection of implantation-related cytokines in cervicovaginal secretions and peripheral blood of fertile women during ovulatory menstrual cycles

OBJECTIVE

To determine whether cytokines implicated in uterine receptivity are detectable in cervicovaginal secretions and/or serum of fertile women, and whether their concentrations undergo hormonal regulation during the menstrual cycle.

DESIGN

Prospective, observational study.

SETTING

Academic medical center.

PATIENT(S)

Six fertile volunteers studied over two menstrual cycles.

INTERVENTION(S)

Cervicovaginal lavages (CVLs) and peripheral blood specimens were obtained during the menstrual, proliferative, periovulatory, and midsecretory phases of the cycle. Endometrial biopsies were obtained during the midsecretory phase.

MAIN OUTCOME MEASURE(S)

Concentrations of leukemia inhibitory factor (LIF), macrophage-colony stimulating factor (M-CSF), interleukin-1beta (IL-1beta), transforming growth factor-beta1 (TGF-beta1), TGF-beta2, and epidermal growth factor (EGF) in CVL and peripheral blood of fertile women; endometrial cytokine messenger (m)RNA levels in midsecretory phase; and serum E(2) and P levels throughout the menstrual cycle.

RESULT(S)

Macrophage-colony stimulating factor and EGF were detectable in all CVL samples. Macrophage-colony stimulating factor concentrations were positively correlated with serum E2 levels and the E2/P ratio. Whereas EGF concentrations in serum and CVL samples remained constant throughout the menstrual cycle, individual concentrations during the secretory phase of the menstrual cycle were positively correlated with endometrial EGF mRNA levels. Interleukin-1beta, TGF-beta1, and TGF-beta2 were detected in most CVL samples. Interleukin-1beta concentrations in CVL were significantly higher at menses than at the periovulatory stage of the menstrual cycle; TGF-beta2 levels were higher at menses than at the periovulatory and secretory stages. Leukemia inhibitory factor was undetectable in CVL except at menses. In serum, TGF-beta1, TGF-beta2, M-CSF, and EGF were detectable, but there was no menstrual cycle effect. There were no correlations between cytokine levels in CVL and serum.

CONCLUSION(S)

This study demonstrates that several endometrial cytokines that have been implicated in uterine receptivity are detectable in cervicovaginal secretions and peripheral blood of reproductive-aged women, and it provides normal concentration ranges of these cytokines in CVL and serum of fertile women at four stages of the menstrual cycle. Macrophage-colony stimulating factor and EGF warrant further study in CVLs of fertile and infertile women to determine their predictive value as minimally invasive markers of uterine receptivity.

Implications of blood contamination for assessment of local cellular immunity in the endocervix

Cervical cytobrushes provide a tool to sample endocervical T cells for assessment of local immunity. However, most previous studies in HIV-seropositive women have excluded samples containing blood and hence have analyzed selected populations of patients. As determined by multiple-parameter flow cytometric analysis of T lymphocytes from two sequential cytobrushes and concurrently collected blood samples, this study found a minimal effect of blood contamination on cervical T cell phenotypic parameters in normal women. The consequences of blood in endocervical samples will ultimately depend on the design and objective of each study, but these data suggest studies could be more inclusive and should not automatically discard samples that contain red blood cells.

Separation of human immunodeficiency virus type 1 from motile sperm by the double tube gradient method versus other methods

OBJECTIVE

To compare a new sperm-processing device, utilizing a double tube and gradient, with other commonly used sperm-processing methods for their abilities to exclude human immunodeficiency virus type 1 (HIV-1) from the motile sperm fraction while retaining maximum sperm yield.

DESIGN

Laboratory experiments.

SETTING

Academic research environment.

PATIENT(S)

Healthy HIV-1 seronegative men between the ages of 25 and 55.

INTERVENTION(S)

Semen samples were spiked with HIV-1 (MN HIV-1 strain; range of concentrations: 10(-1)-10(6) TCID(50)) and subjected to one of the following sperm-processing methods: double sperm tube with discontinuous gradient of sperm separation medium formed inside (double tube gradient), conventional single tube gradient, swim-up or single tube gradient followed by swim-up (gradient/swim-up), which is the method currently used to minimize HIV-1 in semen used for assisted reproductive technology (ART) procedures. For the gradient techniques, Percoll, ISolate, and PureSperm sperm separation media were compared for efficacy of HIV-1 removal. The amount of HIV-1 remaining in the motile sperm pellet after processing was measured by reverse transcription-polymerase chain reaction (RT-PCR), NucliSens assay, or quantitative HIV-1 culture. A hemacytometer was used to microscopically assess motile sperm count.

MAIN OUTCOME MEASURE(S)

HIV-1 RNA copy number, decrease in HIV-1 TCID(50), motile sperm yield.

RESULT(S)

The double tube gradient technique was significantly better than all other methods in the removal of HIV-1 from the motile sperm fraction, and produced significantly higher sperm yields in comparison with the gradient/swim-up method.

CONCLUSION(S)

The double tube gradient technique is a relatively simple and effective method that reduces the risk of infection by HIV-1 while producing good sperm recovery.

Immunotherapy of human cervical high-grade cervical intraepithelial neoplasia with microparticle-delivered human papillomavirus 16 E7 plasmid DNA

OBJECTIVE

The purpose of this study was to evaluate the safety of the administration of a bacterial expression plasmid encoding a 13 amino acid sequence that is highly homologous with human papillomavirus E7 within poly (lactide-co-glycolide) microparticles (ZYC101) in women with HLA A2+ antigen and persistent cervical intraepithelial neoplasia grade 2/3 and human papillomavirus 16.

STUDY DESIGN

Fifteen women entered an institutional review board-approved dose-escalating phase I study with the use of three levels of blood monitoring and urine studies, Papanicolaou tests, and colposcopy. Escalation required no serious adverse events. Immunologic responses were evaluated in peripheral blood with the use of human papillomavirus peptide-stimulated interferon gamma enzyme-linked immunosorbent assay for T-cell reactivity. In cervical secretions, immunoglobulin A anti-human papillomavirus 16 E2 concentrations were measured. Three doses every 3 weeks were followed 4 weeks later by surgical excision.

RESULTS

No serious adverse events occurred. Five women had complete histologic responses; 11 women had human papillomavirus-specific T-cell responses. Four of five complete histologic responses developed immunoglobulin A anti-E2-specific antibody.

CONCLUSION

ZYC101 warrants further investigation because of a 33% complete histologic responses, a 73% immunologic response, and no serious adverse events.

Conversion of high-response gonadotropin intrauterine insemination cycles to in vitro fertilization results in excellent ongoing pregnancy rates

OBJECTIVE

To determine whether conversion of gonadotropin/IUI cycles at high risk of high-order multiple pregnancies to IVF yields a pregnancy rate high enough to warrant the added intervention.

DESIGN

Case-control study.

SETTING

Brigham and Women's Hospital assisted reproductive technology program.

PATIENT(S)

Seventy-seven patients converted from gonadotropin/IUI to IVF, 77 consecutive age and attempt number-matched controls (sequential controls [SCs]), and 77 consecutive age-, attempt-, and E(2)-matched controls (E(2) controls [ECs]).

INTERVENTION(S)

Gonadotropin/IUI cycles with exuberant responses were converted to IVF (cases) to avoid cycle cancellation and high-order multiple pregnancies.

MAIN OUTCOME MEASURE(S)

Pregnancy rates, delivery rates, E(2) levels, follicle and oocyte number, and fertilization and implantation rates.

RESULT(S)

Compared with SCs and ECs, cases had more follicles (16.3 +/- 0.6 vs. 13.3 +/- 0.9 and 14.4 +/- 0.9) and higher E(2) at hCG administration (1,951 +/- 93 vs. 1,568 +/- 96 and 1,939 +/- 89 pg/mL). Delivery rates among the three groups (45.5% vs. 32.5% and 39.0%) did not differ significantly. Despite the transfer of fewer embryos in cases than in controls (2.5 +/- 0.1 vs. 3.1 +/- 0.1 and 2.9 +/- 0.1), three triplet pregnancies occurred in cases and three in controls.

CONCLUSION(S)

Conversion of high responder gonadotropin/IUI patients to IVF is an effective alternative to cycle cancellation and offers a delivery rate as high or higher per cycle than that of planned IVF. Sample size limited the statistical power of the study.

Factors associated with the formation of triploid zygotes after intracytoplasmic sperm injection

OBJECTIVE

To determine whether clinical or laboratory factors influence development of triploid (3PN) zygotes after ICSI.

DESIGN

Retrospective review.

SETTING

The assisted reproductive technology program of Brigham and Women's Hospital.

PATIENT(S)

Patients undergoing ICSI.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Cycles were divided into two groups: group A, cycles with one or more 3PN zygotes after ICSI, and group B, cycles with no 3PN zygotes. Age, amount of gonadotropin administered, peak estradiol levels, number of follicles, number of oocytes retrieved and injected, time between retrieval and injection, oocyte abnormalities, sperm type and motile count, percentage of diploid zygotes, and ongoing pregnancy rates were compared between groups.

RESULT(S)

Compared with patients in group B, those in group A received fewer ampoules of gonadotropins, had higher estradiol levels, and had more follicles on the day of hCG administration, oocytes, immature oocytes and oocytes injected and lower percentages of diploid zygotes. However, ongoing pregnancy rates did not differ between groups.

CONCLUSION(S)

Patients who produce 3PN zygotes after ICSI are high responders to ovarian stimulation. The appearance of such embryos is not associated with lower ongoing pregnancy rates and should not necessarily dictate alterations in ovarian stimulation protocols.

Factors associated with increased levels of human immunodeficiency virus type 1 DNA in semen

Human immunodeficiency virus type 1 (HIV-1)-infected cells have been isolated from semen and may be a major source of transmissible virus. Quantitative polymerase chain reaction (PCR) assay was used to determine HIV proviral DNA load in cellular fractions of semen from 74 antiviral therapy-naive HIV-1-seropositive men and 53 paired blood samples. HIV-1 DNA was detected in 65% of semen (range: <10-5000 copies/mL) and 100% of blood samples (range: 20-2500 copies/mL). HIV-1 DNA copy numbers in semen correlated significantly with those in blood, but for most cases, the concentration of blood HIV-1 DNA was higher (mean blood-to-semen ratio = 2.9). Factors associated with elevated HIV-1 provirus levels in semen included reduced peripheral CD4 cell count and asymptomatic genital tract inflammation (>10(6) white blood cells/mL of semen). These data provide evidence that genital tract inflammation and reduced peripheral CD4 cell count may be associated with enhanced sexual transmission of HIV-1 because of increased numbers of HIV-1-infected cells in semen.

Optimized assay for antisperm cell-mediated immunity

Previous studies on antisperm cell-mediated immunity (CMI) have been confounded by the presence of immunogenic leukocytes in sperm antigen preparations. In this study we isolated pure populations of viable spermatozoa on discontinuous Percoll gradients, and utilized sonicated and cavitated extracts, as well as live motile spermatozoa, to measure cellular immunity to spermatozoa in vasectomized men, men with proven fertility, infertile women, fertile women and umbilical cord blood. Using a thymidine incorporation assay to assess lymphocyte proliferation, nine out of 13 (69%) vasectomized men and five out of 10 (50%) fertile men responded to sperm extracts. Lymphocyte proliferation to sperm extracts was also observed in both infertile and fertile women (27 and 50% respectively). In addition, viable sperm preparations promoted lymphocyte responses in five out of eight (63%) fertile women, seven out of 11 (63%) healthy men and four out of 11 (45%) cord blood specimens. Furthermore, four out of 11 (36%) healthy normal men responded to autologous spermatozoa. No relationship between serum antisperm antibodies, as measured with the Immunobead test, and sperm CMI was observed in any group. This study provides evidence that lymphocytes from fertile as well as infertile men and women and sperm-naive newborn infants proliferate when exposed to viable spermatozoa or sperm extracts. Thus the lymphocyte proliferation assay does not appear to be useful in the diagnosis of immunological infertility, but immunological recognition of spermatozoa may be a common feature that could have a role in fertility.

Is leukocytospermia clinically relevant?

OBJECTIVE

To evaluate the relationship between seminal leukocytes and abnormal semen parameters in a large population of infertility patients.

DESIGN

Prospective clinical study.

SETTING

Center for Reproductive Medicine at Brigham and Women's Hospital, Boston, Massachusetts.

PATIENT(S)

One thousand seven hundred ten male partners in infertile couples attending the Center for Reproductive Medicine.

MAIN OUTCOME MEASURE(S)

Seminal leukocyte concentrations, sperm count, motility and morphology, and the prevalence of samples with < 10 x 10(6) motile sperm per ejaculate (a parameter defined by IVF as the most clinically significant predictor of male infertility).

RESULT(S)

There was a strong relationship between increasing leukocyte concentrations in semen and abnormal semen parameters. Statistically significant differences in sperm concentrations and morphology were observed at leukocytospermia thresholds of 5 x 10(5) and 2 x 10(6) granulocytes/mL, respectively. The percentage of suboptimal semen specimens as defined by IVF criteria (< 10(7) total motile sperm per ejaculate) significantly increased with increasing seminal granulocyte concentrations. A twofold increased prevalence in such suboptimal semen specimens was observed at the leukocytospermia threshold of 2 x 10(6) granulocytes/mL.

CONCLUSION(S)

There is a relationship between increasing seminal granulocyte concentrations and poor semen parameters. At seminal granulocyte concentrations > 2 x 10(6)/mL, semen parameter abnormalities were observed that were both statistically and clinically significant.

Antibiotic therapy and leukocytospermia: a prospective, randomized, controlled study

OBJECTIVE

To determine the efficacy of common antibiotic therapies for treatment of leukocytospermia of unknown etiology.

DESIGN

Prospective, randomized, controlled clinical study.

SETTING

Fertility and Endocrinology Unit at Brigham and Women's Hospital, Boston, Massachusetts.

PATIENTS

One thousand seven hundred ten male partners in infertile couples attending the Fertility and Endocrinology Unit.

INTERVENTIONS

Concentrations of seminal peroxidase-positive granulocytes were determined during all routine semen analyses performed over a 30-month period. Of 119 men found to have leukocytospermia (> 10(6) granulocytes/mL semen) on first visit, 54 agreed to be randomized into one of three groups, and 41 patients completed the study. Group I (n = 13) and their wives received a 14-day course of oral doxycycline, 100 mg twice per day. Group II (n = 11) and their wives received a 14-day course of oral trimethoprim 160 mg-sulfamethoxazole 800 mg twice per day. Group III (n = 17) and their wives received no therapy. Four weeks after randomization, repeat semen analyses and granulocyte quantitations were done.

RESULTS

Neither of the antibiotic regimens resulted in a significantly higher rate of resolution of leukocytospermia over that seen in the control group.

CONCLUSIONS

There is a high rate of spontaneous resolution of leukocytospermia after one positive test. Antibiotics are no more beneficial than no therapy for treatment of this condition.

Seminal white blood cells and recurrent abortion

The incidence of leukocytospermia (> 1 million white blood cells/ml semen) and concentrations of white blood cell populations in semen from men whose partners experience unexplained recurrent spontaneous abortion by conventional testing criteria are described and compared to those of men whose partners have normal reproductive histories. Comparable seminal granulocyte and total white blood cell concentrations between groups suggest that couples with unexplained recurrent abortion do not have an abnormally high incidence of subclinical genital tract infections for which leukocytospermia could serve as a marker. However, a significantly higher prevalence of elevated CD4+ and CD8+ T lymphocyte concentrations in semen from men whose partners have cellular immunity to sperm antigens (i.e. produce embryotoxic factors in response to sperm antigen stimulation) warrants further investigation.

The effects of disease progression and zidovudine therapy on semen quality in human immunodeficiency virus type 1 seropositive men

OBJECTIVE

To investigate the effects of disease progression and zidovudine antiretroviral therapy on semen parameters in human immunodeficiency virus type 1 (HIV-1) seropositive men.

DESIGN

Cross-sectional analysis of semen parameters of 166 HIV-1 seropositive men in various stages of disease progression as defined by peripheral CD4+ cell count. Clinical symptoms and zidovudine therapy status were obtained from medical records and clinical interviews.

PATIENTS

Human immunodeficiency virus type 1 seropositive men participating in clinical studies at the Fenway Community Health Center (Boston, MA), the University of San Francisco (San Francisco, CA), and Brown University (Providence, RI).

MAIN OUTCOME MEASURES

Ejaculate volume; sperm concentration, motility, forward progression, morphology, total sperm count; seminal immature germ cell; and white blood cell (WBC) concentrations.

RESULTS

Human immunodeficiency virus type 1 seropositive men that were not on zidovudine therapy and were in early disease stage (> 200 CD4+ cells/mm3) had normal semen parameters as defined by World Health Organization criteria. In contrast untreated men in advanced disease stage (< or = 200 CD4+ cells/mm3) had significant reductions in sperm concentration and total sperm count and an increased percentage of abnormal sperm forms. Men receiving zidovudine antiretroviral therapy, regardless of disease stage, had normal semen parameters similar to those of untreated early disease stage patients. Seminal WBC concentrations were not affected significantly by disease progression but were reduced in patients receiving zidovudine.

CONCLUSION

Most HIV-1-infected men in this study had semen parameters consistent with fertility. Disease progression was associated with reduced semen quality, but this effect appeared to be abrogated by zidovudine therapy. Zidovudine was also associated with a significant reduction of WBC numbers in semen. As seminal WBC are principal HIV-1 host cells in ejaculates of HIV-1-infected men, this effect could explain recent laboratory and epidemiological evidence that zidovudine therapy is associated with a reduced prevalence of HIV-1 in semen and a lower rate of sexual transmission.

Sperm morphology and recurrent abortion

In 98 men whose partners experienced three or more spontaneous abortions, there were no significant differences in ejaculate volume, concentration of sperm, the percentage of total abnormal sperm, or the percentage of individual sperm defects as compared with normal WHO standards and 17 men fathering successful pregnancies. These data indicate that neither abnormal sperm concentration nor abnormal sperm morphology are significantly associated with recurrent spontaneous abortion.

Comparison of methods to enumerate white blood cells in semen

Seminal WBC counts obtained by an mAb-based immunohistologic method correlated well with seminal granulocyte counts obtained with a simple peroxidase method (rho = +0.70; P < 0.0001). However, total WBC counts were significantly higher than granulocyte counts for most samples. With the immunohistologic method, 17 of 112 samples (15.2%) contained > 10(6) WBC/mL semen, whereas the peroxidase method resulted in only 10 samples (8.9%) with > 10(6) WBC/mL. When the threshold defining leukocytospermia was set at 1 x 10(6) positive cells/mL for both methods, the specificity of the peroxidase test compared with the immunohistology technique was 100% (10/10), but the sensitivity was only 58.8% (10/17). When the threshold for leukocytospermia in the peroxidase test was lowered to 5 x 10(5) positive cells/mL semen, the sensitivity relative to the immunohistology technique increased to 94.1% (16/17), and specificity remained 100% (16/16). Likewise, good interassay sensitivity and specificity values were obtained with thresholds of 10(6) WBC/mL for the peroxidase assay and 2 x 10(6) WBC/mL for the immunohistology assay. We conclude that either peroxidase or immunohistology assays can be used to screen for leukocytospermia, but that more research is needed to establish thresholds for pathological levels of WBC in semen using these two approaches. Total round cell counts are of no value for enumerating WBC in semen.