Vaccination coverage during pregnancy and factors associated with refusal of recommended vaccinations: An Italian cross sectional study

Background

The vaccines recommended during pregnancy are the Tdap, the influenza vaccine, and, during the SARS-CoV-2 pandemic, the vaccine against COVID-19. This survey aimed at determining vaccination coverage among pregnant women and adverse events, reasons for vaccine refusal, and factors associated with vaccine uptake.

Methods

A single-center cross-sectional study was conducted on women who delivered between March and April 2022 at Careggi University Hospital in Florence, Italy. Information on the vaccinations (Tdap, influenza and COVID-19) received during pregnancy were collected through in-person interviews.

Results

Among 307 enrolled women (response rate 99 % on a study population of 310 eligible women), 74 % of patients were vaccinated with Tdap, 82 % against COVID-19, and only 33 % against influenza. Vaccination coverage for Tdap and COVID-19 was significantly higher among Italian than foreign patients (80 % vs 51 %, p < 0.001 and 86 % vs 69 %, p = 0.002, respectively), and for Tdap was higher among patients followed in the private vs public care setting. The main reasons behind refusal of vaccinations were low risk perception of influenza (41 %), insufficient information received from the prenatal care provider regarding the Tdap (35 %), and, for the COVID-19, fear of vaccine side effects (64 %), and concerns about effects on the fetus (70 %).

Conclusions

Adherence to the influenza vaccine was low because of reduced perception of the disease risks. The difference in vaccination coverage between Italians and foreigners is an example of healthcare disparity. Better information provided to patients about vaccines' efficacy and safety is advisable to increase acceptance of recommended vaccines.

Testicular and Haematological Cancer Induce Very High Levels of Sperm Oxidative Stress

Cancer impairs spermatogenesis, whereas results on sperm DNA integrity are controversial and no data are available about sperm oxidative stress. In cancer patients, we detected sperm DNA fragmentation (sDF) and both viable (ROS production in viable sperm fraction/viable spermatozoa) and total (ROS production in viable sperm fraction/total spermatozoa) oxidative stress. We found that cancer (22.50 (17.00-26.75)%, n = 85) increased sDF with respect to the control groups in both normozoospermic subfertile patients (NSP) (12.75 (8.63-14.88)%, n = 52, p < 0.001) and in healthy donors (HD) (8.50 (7.00-14.00)%, n = 19, p < 0.001). The induction of viable oxidative stress (n = 96) with cancer was even higher: 36.60 (24.05-58.65)% versus 11.10 (8.63-14.90)% in NSP (p < 0.001) and 9.60 (8.00-14.03)% in HD (p < 0.001). Similar, albeit lower, differences were found for total oxidative stress. SDF sharply correlated to viable oxidative stress when we considered all subjects (cancer patients and controls) (r = 0.591, p < 0.001, n = 134), but no correlation was found when only cancer patients were studied (r = 0.200; p > 0.05, n = 63). In conclusion, cancer significantly increases sDF and sperm oxidative stress levels. Additional mechanisms to oxidative attack might be responsible for increased sDF in cancer patients. Because sperm oxidative stress might affect the outcomes of sperm cryopreservation, of cancer treatments and of sperm epigenoma, the detection of oxidative stress could be of help in managing the reproductive issues of cancer patients.

Decrease of air pollution during lockdown in Tuscany (Italy): An effect on sperm DNA fragmentation?

In March 2020, the Italian government imposed a national lockdown which was almost completely removed in June 2020. Due to the abrupt stop of human activities, emissions of air pollutants decreased. Air pollution is an environmental risk factor for noncommunicable disease and mortality. Emerging evidence also suggests a role in male infertility. In this study, we compared sperm DNA fragmentation (sDF) levels and conventional semen parameters between subjects undergoing sDF determination and routine semen analysis in a single Italian centre, during about 6 months before (N = 119) and after lockdown (N = 105). After lockdown, we found an improvement of sperm progressive motility (48.00[38.50-58.00]% vs. 42.00[33.00-53.00]%) and sDF levels (as total: 24.79[18.33-33.97]% vs. 35.02[25.04-45.73]%, p < .001; brighter: 14.02[10.69-17.93]% vs 18.54[13.58-25.82]%, p < .001 and dimmer sDF: 9.24[5.64-15.78]% vs. 12.24[8.08-19.10]%, p < .01), mirrored by a decrease of leukocyte semen concentration (p < .01). The improvement of sperm motility and DNA quality was maintained after adjusting for leukocyte concentration and several conditions known to affect sperm motility and/or sDF levels. With a significant decrease in air pollution observed in Tuscany during and after lockdown, associated improvement in sperm motility and DNA quality in patients referred to the infertility clinic is suggestive of the potential role of air pollution in male infertility.

P-058 Risk factors associated with sperm DNA fragmentation in Tunisian subfertile men

Study question

The aim of the study was to investigate risk factors for sperm DNA fragmentation to determine which factors influence significantly the sperm DNA fragmentation.

Summary answer

Obesity seems to lead to higher risk of sperm DNA damage in Tunisian subfertile men.

What is known already

A positive association between lifestyle conditions, varicocele, advanced age and exposure to toxicants and DNA fragmentation has been documented.

Study design, size, duration

It’s a retrospective case control study. 61 Patients registered from October 2018 to December 2021 were divided into two groups: group “C” with good quality sperm DNA (n = 20) and group “F” with fragmented sperm DNA (n = 41).

Participants/materials, setting, methods

DNA fragmentation was measured using terminal deoxynucleotidyltransferase dUTP nick and labeling assay. The Odds Ratio (OR) and their 95% CI were calculated using univariate logistic regression in order to quantify the association between the variable of interest “Sperm DNA fragmentation” and the various risk factors: lifestyle conditions (e.g. tobacco smoking, alcohol consumption, and obesity), age, professional exposure to high temperature and toxic products and urological history (e.g. varicocele, testicular hypotrophy or hypertrophy).

Main results and the role of chance

Our results showed that tobacco, professional exposure to high temperature and toxic products and urological history are risk factors that may alter sperm DNA with an odds ratio (OR) of 2.1, 1.9 and 1.5, respectively. Interestingly, we demonstrated that obesity seems to be the most significant risk factor of DNA fragmentation with an OR of 4.2 (p = 0.002).

Limitations, reasons for caution

Further studies are needed to investigate the mechanism by which obesity occur sperm DNA damage.

Wider implications of the findings

Our finding are in accordance with several retrospective studies demonstrating that obesity is liable to sperm DNA damage

Trial registration number

not applicable

P-741 The COVID-19 pandemic: is there any impact on male fertility?

Study question

Is there any impact of the pandemic period on semen parameters?

Summary answer

Both total and progressive sperm motility as well as sperm morphology were impaired during COVID-19 pandemic.

What is known already

Male fertility could be affected by many environmental conditions. The COVID-19 pandemic has led to many dramatic consequences on human lives (psychological, financial level…). However, little information is available on the impact of the emergent COVID-19 on male fertility.

Study design, size, duration

This was a cohort study comparing semen parameters before and during the two first COVID-19 waves in infertile Tunisian patients.

Participants/materials, setting, methods

Were included in the current study 90 patients followed in the consultation of the department of Cytogenetics and Reproductive Biology (Monastir, Tunisia) for hypofertility. Each of the included patients has already a spermogram before the COVID-19 pandemic and a spermogram during the COVID-19 pandemic allowing the comparison of semen parameters for each patient so that he was considered as his own control. Patients who received medication (antibiotics, antioxidants…) were excluded from the current study.

Main results and the role of chance

Among standard semen parameters, we have shown a significant decrease in both total and progressive sperm motility during COVID-19 pandemic (p < 0.0001 and p = 0.001 respectively). The observed decrease 30 min after ejaculation was maintained 2 hours and 4 hours after ejaculation. Furthermore, we observed an impairment in sperm morphology. Indeed, the percentage of morphologically abnormal spermatozoa raises from 90.99±7.37% to 93.67±4.54% (p < 0.0001). The remaining semen parameters was similar between the two compared timepoints except a slight decrease in sperm count during the pandemic (p = 0.079).

Multivariate analysis didn’t show among clinical and epidemiological characteristics any associated factor with the observed decrease in semen quality.

Limitations, reasons for caution

The included patients didn’t have any COVID-19 symptoms on the day of sperm collection. However, as we have no proof of negative PCR test, the observed impairment in semen quality could be not only the consequence of psychological stress but may be also induced by a latent infection.

Wider implications of the findings

Even in patients with no proof of COVID-19 infection, the pandemic seems to have a real impact on hypofertile men as sperm motility and morphology were significantly impaired. It would be preffered to control semen parameters away from such period before referring patients to assisted reproduction.

Trial registration number

Not Applicable

P-068 Oxidative stress and DNA fragmentation of spermatozoa in patients with cancer

Study question

Does cancer increase sperm DNA fragmentation (sDF) level by increasing oxidative stress in human spermatozoa?

Summary answer

Cancer increases both sDF and oxidative stress, but further studies are necessary to understand whether higher levels of ROS are responsible for sperm DNA damage.

What is known already

In recent years, it has been emerging that not only oncological therapies but also cancer itself can induce abnormal spermatogenesis. In addition, several Authors reported that occurrence of malignancy provokes also increases of sperm DNA damage, although such finding was not confirmed by others and the possible mechanisms responsible for such damage are presently unknown

Study design, size, duration

This was a prospective observational study conducted from 2018 to today, conducted in 102 patients affected by cancer and in 66 control subjects.

Participants/materials, setting, methods

We recruited 102 patients affected by cancer and 66 male partners of infertile couples as control subjects, in the Andrology Clinic of University of Florence. Control subjects were normozoospermic with absence of leukocytospermia, semen viscosity, smoking habit and recent antibiotic therapies. In the recruited men, we evaluated standard semen parameters, sperm DNA Fragmentation with SCD (Sperm Chromatin Dispersion) Test and oxidative stress as percentage of viable spermatozoa with MitoSOX™ Red labeling on total viable spermatozoa.

Main results and the role of chance

We found poorer standard semen parameters (sperm motility, concentration and number) in cancer patients (both testicular and hematological ones) with respect to control group, whereas no differences were observed between the two types of cancer. Testicular, but not hematological patients, were younger than control subjects. No difference was seen in the other tested characteristics (sperm morphology, abstinence, semen volume and pH, BMI). Regarding sDF, we found higher median values [IQR] in cancer patients (total: 22.25[17.00-25.95], n = 68; hematological: 23.00[20.13-26.38], n = 28; testicular: 21.13[16.13-25.73], n = 40) vs control subjects (12.50[8.25-14.75], n = 53); p &lt; 0.05, test U di Mann-Whitney. In addition, the amount of sperm oxidative stress was dramatically higher in patients with cancer (total:38.92[24.90-58.87], n = 79; hematological: 38.85[24.98-50.77], n = 34; testicular: 38.92[20.59-63.59], n = 45) vs control subjects (11.50[8.38-17.20], n = 62); p &lt; 0.05, test U di Mann-Whitney. We also studied the occurrence of a correlation between levels of sDF and oxidative stress. We found a sharp correlation when both cancer patients and control subjects were analysed (Spearman coefficient = 0.62, p &lt; 0.001, n = 103), but such correlation was completely lost when only cancer patients were considered (Spearman coefficient = 0.10, p &gt; 0.05, n = 50). This finding suggests that mechanisms different from ROS attack to DNA could explain the increase of sDF levels in cancer patients.

Limitations, reasons for caution

The study did not investigate, because of scarce availability of semen samples from cancer patients, other possible mechanisms (i.e apoptosis, defects in sperm chromatin maturation, failure in DNA system repair) which could cause the observed increase of sperm DNA damage in such patients.

Wider implications of the findings

Cancer patients show high levels of both sDF and oxidative stress. This finding rises concern, as cancer patients cryopreserve semen for using it with Assisted Reproductive Tecnhologies and both parameters represent a threat for natural and assisted reproduction. In addition, emerging evidence suggest that oxidative stress may alter sperm epigenome.

Trial registration number

not applicable

Vapour fast freezing with low semen volumes can highly improve motility and viability or DNA quality of cryopreserved human spermatozoa

Objectives

To challenge a vapour fast freezing (VFF) cryopreservation procedure (conventional VFF) with several vitrification protocols and VFF conducted with small semen volumes (10 μl, microVFF), in order to implement a procedure for sperm banking in subjects with small sperm number.

Materials and methods

Conventional VFF was conducted with test yolk buffer (TYB) as freezing medium and 500 μl straws as carriers. MicroVFF was conducted with TYB and using tips or cell sleepers as carriers. Vitrification was performed with TYB or SpermFreeze as freezing medium and with microspheres and tips as carriers. The effect of different procedures on progressive and total motility, viability, oxidative stress and DNA fragmentation of spermatozoa (sDF) was determined. Fresh and thawed samples, the latter after adequate washing/centrifuging, were evaluated. In some experiments, motility and viability recovery was determined in thawed samples, omitting the washing/centrifuging step.

Results

All the cryopreservation procedures blunted sperm motility and viability and induced increase of oxidative stress and sDF. However, VFF better preserved sperm motility and viability and less induced oxidative stress and sDF than vitrification, independently from the freezing medium and the carriers used in the latter. MicroVFF with cell sleepers resulted in a percentage increase of 57.58 ± 63.63%, 48.82 ± 74.96% and 24.55 ± 39.20% of, respectively, progressive and total motility and viability compared to the conventional VFF. Further, when tips were used, microVFF resulted in a percentage decrease of 15.77 ± 20.77% of sDF with respect to conventional VFF. Finally, omission of washing/centrifuging in post thawed samples, resulted in a much lower negative effect on motility and viability.

Discussion and conclusion

VFF, and in particular microVFF, better prevents sperm cryodamage than vitrification. Washing/centrifuging step after sample thawing seems to be responsible for a relevant fraction of damage to sperm motility and viability. Overall, our results are promising for developing a novel strategy of sperm banking in subjects with small sperm number, where low semen volumes are mandatory.

Novel methods to detect ROS in viable spermatozoa of native semen samples

A crucial issue in male infertility work-up is to have reliable methods to detect oxidative stress in native semen samples. Here, we explored flow cytometric detection of Reactive Oxygen Species (ROS) in viable spermatozoa using native semen samples. To this aim, we challenged three fluorescent probes: CM-H2DCFDA, CellROX Green and MitoSOX Red. After excluding all non-sperm cells, each probe was coupled to a suitable stain to eliminate also semen apoptotic bodies and non-viable spermatozoa: Merocyanine 540 (M540) for CM-H2DCFDA and CellROX Green, and LIVE/DEAD Fixable Green Dead Cell Stain (LD-G) for MitoSOX Red. We found that CM-H2DCFDA was confined in the sperm midpiece, whereas CellROX Green and MitoSOX Red were localized in the head of spermatozoa. Treatment with H₂O₂ highly increased MitoSOX Red fluorescence (36.20 ± 5.24 vs 18.02 ± 2.25, %, p < 0.01), but not, or only slightly, the labelling with CMH2DCFDA (2.57 ± 1.70 vs 2.77 ± 1.43, p > 0.05) and CellROX Green (5.34 ± 3.18 vs 3.76 ± 2.04, p < 0.05), respectively. Menadione treatment highly increased CellROX Green (10.13 ± 5.85 vs 3.82 ± 2.70, p < 0.01) and MitoSOX Red (69.20 ± 27.14 vs 21.18 ± 7.96, %, p < 0.05), but not CM-H2DCFDA fluorescence (8.30 ± 11.56 vs 7.30 ± 9.19, p > 0.05). Further, only MitoSOX Red was able to detect spontaneous ROS generation during in vitro sperm incubation. We also detected DNA fragmentation by Comet and SCD Assay after sorting MitoSOX Red positive and negative sperm viable fractions. Results indicated that MitoSOX labelling in viable spermatozoa was strictly associated to sperm DNA fragmentation. In conclusion, MitoSOX Red/LD-G appears to be a promising method to detect oxidative stress in human semen for male infertility work-up.

P–086 High level of sperm DNA breaks in infertile men with varicocele: its association with sperm cells death, seminal oxidative stress, and spermatic parameters

Study question

Our objectives were to determine the extent of nuclear sperm injury in varicocele patients with and without altered spermatic parameters and to investigate its relationship with apoptosis and oxidative stress.

Summary answer

Oxidative stress (OS) in the varicocele patients may play a role in the etiology of nuclear sperm DNA damage associated with apoptosis.

What is known already

Varicocele is associated with high level of DNA Breaks.

Study design, size, duration

Ejaculated sperm samples from 51 patients diagnosed with varicocele and 29 fertile men were examined. According to the guidelines, the patient’s sperm samples were classified into varicocele with normal semen parameters (n = 11) and varicocele with abnormal semen parameters (n = 40).

Participants/materials, setting, methods

Sperm DNA breaks was assessed using terminal deoxynucleotidyl transferase dUTP nick end labeling assay. The proportion of both viable and dead spermatozoa with externalized phosphatidylserine was detected by the bivariate annexin V cy3/6-CFDA staining method. Seminal malondialdehyde (MDA) amounts and antioxidant enzymes activities of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) were measured spectrophotometrically.

Main results and the role of chance

Sperm DNA Breaks, viable spermatozoa with externalized PS, and MDA levels were significantly higher in studied subgroups of patients with varicocele, either with normal or with abnormal semen parameters than controls. The seminal antioxidant enzymes activities were significantly reduced in both subgroups of patients with varicocele compared to the controls. The percentage of spermatozoa with fragmented DNA was positively correlated to the MDA level as well as the proportion of viable spermatozoa with externalized PS. However, the decreased seminal antioxidant status was negatively correlated with the increased proportion of sperm DNA fragmentation and apoptotic spermatozoa.

Limitations, reasons for caution

We suggest further comparative studies connecting the varicocele patients with and without altered spermatic parameters representing high level of DNA fragmentation with more apoptotic and oxidative stress markers.

Wider implications of the findings: This study reveals that impaired seminal antioxidant profile and increased seminal level of lipid peroxidation may be involved in the pathophysiological mechanisms of cell death-mediated DNA breaks in patients with varicocele.

Trial registration number

Not applicable

Evaluation of teamwork in operating rooms in a Tunisian university hospital

Background

Teamwork is fundamental to ensuring the quality of care and patient safety in operating rooms. It has been shown that the occurrence of adverse events is closely linked to a poor quality of teamwork in these settings. Thus, this study aimed to assess teamwork in different operating rooms of the university hospital of Sahloul Sousse (Tunisia).

Methods

It is a descriptive cross-sectional study with convenience sampling, conducted in operating rooms of the university hospital of Sahloul Sousse (Tunisia) between February and April 2018. The measuring instrument was the validated observation grid 'Communication and Teamwork Skills Assessment Tool (CATS) '. Teamwork is assessed through 4 domains (Situation awareness, Coordination, Communication, Cooperation). Behaviors are marked in rows each time they occur and are rated for quality in columns labeled “Observed and Good,” “Variation in Quality” (meaning incomplete or of variable quality), and “Expected but not Observed.”

Results

A total of 51 interventions were observed. Good coordination between the team members was noted, as well as good cooperation within the teams. A variation of quality level of communication with the patient was noted in 31.4% of cases, also communication about the context, the situation and recommendation among caregivers is not quite good with a percentage of 39.2%. Moreover, the work environment was rated as good in 84.3% of cases.

Conclusions

Some failures in teamwork were noted, hence it is important to take corrective measures for better practice and better patient management in such a complex environment, the operating rooms, where there is a strong need for team coordination.

Key messages

There is a direct relationship between the quality of care and the effectiveness of teamwork. It is necessary to eliminate the barriers to communication, in order to prevent adverse events.

Novel association between apoptotic sperm biomarkers with seminal biochemical parameters and acetylcholinesterase activity in patients with teratozoospermia

OBJECTIVE

We aimed to determine whether the dysfunction of physiological apoptosis and specific seminal biochemical parameters could be associated with male infertility and sperm morphological defects.

STUDY DESIGN

Ejaculated sperm samples from sixty patients with isolated teratozoospermia and thirty fertile donors were analyzed. The proportion of both viable and dead spermatozoa expressing activated caspases was detected by fluorescence microscopy through the use of different specific carboxyfluorescein-labeled caspase inhibitors FLICA. The different stages of apoptosis in human were qualitatively and quantitatively determined by using the AO/EB fluorescent staining method. The levels of the seminal biochemical parameters (acetylcholinesterase (AChE), lactate dehydrogenase (LDH), creatine phosphokinase (CK), iron (Fe), calcium (Ca), and phosphorus (P)) were evaluated spectrophotometrically.

RESULTS

Patients with teratozoospermia showed significantly higher proportions of dead and live spermatozoa with activated caspases and spermatozoa in the late stage of apoptosis when compared to controls. Among the different studied biochemical seminal parameters, the rates of acetylcholinesterase activity, creatine phosphokinase, iron, and calcium were significantly increased in the patient group. However, the rate of phosphorus was significantly decreased. Interestingly, significant relationships were found between the studied biochemical and apoptotic biomarkers and the rates of atypical sperm forms with the incidences of head, mid-piece, and tail abnormalities. Furthermore, positive correlations were found between P, AChE, Fe, CK, and LDH with apoptotic markers.

CONCLUSIONS

These results emphasize the impact of apoptosis in the pathophysiology of teratozoospermia and suggest that seminal biochemical disturbance may arise such damage.

Oxidative stress, genotoxicity, biochemical and histopathological modifications induced by epoxiconazole in liver and kidney of Wistar rats

Epoxiconazole (EPX) is a triazole fungicide commonly used in agriculture and for domestic purposes around the world. The excessive application of this pesticide may result in a variety of adverse effects on non-target organisms, including humans. Since, the liver and kidneys are the target organs of this fungicide, potential hepatotoxic and nephrotoxic effects are of high relevance. Thus, our study aimed to investigate the toxic effects of EPX on the liver and kidney of Wistar rats. The exposure of rats to EPX at these concentrations (8, 24, 40, 56 mg/kg bw representing, respectively, NOEL (no observed effect level), NOEL × 3, NOEL × 5, and NOEL × 7) for 28 days significantly enhances hepatic and renal lipid peroxidation which is accompanied by an increase in the level of protein oxidation. Furthermore, the results of the present study clearly indicated that EPX administration induces an increase in the levels of DNA damage in a dose-dependent manner. In addition, the activities of liver and kidney antioxidant enzymes such as superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and glutathione S-transferase (GST) are increased significantly in EPX-treated rats at concentrations of 8, 24, and 40 mg/kg bw. However, with the dose NOEL × 7 (56 mg/kg bw of EPX), the activities of CAT, GPx, and GST are decreased. Indeed, EPX-intoxicated rats revealed a significant reduction in acetylcholinesterase (AChE) activity in both liver and kidney compared with the control group. Also, our results demonstrated that the EPX administration leads to a disruption of the hepatic (aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH)) and renal (uric acid and creatinine) functions. The biochemical perturbations obtained in the present study are corroborated with the histopathological modifications. Since EPX treatment caused severe damage in the overall histo-architecture of liver and kidney tissues, these results suggest that administration of EPX induced a marked deregulation of liver and kidney functions. Graphical abstract.

The association between iron, calcium, and oxidative stress in seminal plasma and sperm quality

The present study aimed to determine the level of iron and calcium in the seminal plasma of men with different fertility potentials and to examine its relationship with oxidative stress. Seventy-nine sub-fertile patients with asthenoteratozoospermia (AT), n 27; teratoleucozoospermia (TL), n 20; teratozoospermia (Terato), n 32; and 29 healthy donors were included. The ability of spermatozoa to produce reactive oxygen species (ROS) was evaluated by using nitroblue tetrazolium (NBT) staining. The lipid peroxidation end product, malondialdehyde (MDA), and the trace element levels (iron and calcium) were measured spectrophotometrically. Iron and calcium concentrations in seminal plasma of the patient groups were significantly more elevated than the normal group. Nevertheless, both calcium and iron showed strong negative correlations with the total sperm motility and normal sperm morphology, but only iron was positively and significantly associated with multiple anomalies index and seminal leucocyte concentration. On the other hand, the rates of MDA and ROS production in semen were significantly higher in the three abnormal groups than in controls. These two oxidative stress biomarkers were significantly associated with the percentage of atypical forms in semen. However, only semen ROS level was significantly associated with the decreased sperm motility and the sperm leucocytes concentration. Meanwhile, there are positive correlations between seminal iron and calcium content and the studied oxidative stress biomarkers. Oxidative stress and trace element excess are implicated in low sperm quality. Iron and calcium might be the mediators of the effects of oxidative damage and induces lipid peroxidation.