Introduction: Access to fertility care

Given that only an estimated 24% of infertile couples in the United States can fully engage in the medical care required to successfully conceive, the American Society for Reproductive Medicine (ASRM) has incorporated improved access to the full gamut of fertility therapies as an integral component of the Society's strategic plan that was launched in 2014. Toward this end, the ASRM hosted a two-day summit held in Washington D.C. in September 2015 that attracted thought leaders, both speakers and attendees, from around the world. This issue's Views and Reviews focuses on several key areas integral to this effort: an appreciation of the economic challenges to access, as well as the impact and interplay of racial, ethnic, emotional and gender-specific issues in the treatment of infertility. The potential to broaden access to care through modification of existing assisted reproductive techniques is also explored.

It's not all about the testes: medical issues in Klinefelter patients

Important medical conditions associated with Klinefelter syndrome (KS) are categorized as: 1) motor, cognitive, and behavioral dysfunction; 2) tumors; 3) vascular disease; and 4) endocrine/metabolic and autoimmune diseases. Earlier diagnosis of KS may lead to earlier intervention with effective treatment.

Endocrinology of male infertility: evaluation and treatment

A normal functioning reproductive endocrine system is a prerequisite for normal male fertility. Any disruption of the delicately coordinated interaction between the components of the hypothalamic-pituitary-testicular axis may lead to hypogonadism and/or infertility. The goal of the clinical evaluation is to determine if the patient has an abnormality of testosterone production or action, the etiology of the abnormality, and if hormone therapy will correct the infertility. Based on a careful history, physical examination, and evaluation of the hormones of the reproductive axis, the physician will ascertain if the patient's hypogonadism is (1) prepubertal or postpubertal in onset; (2) the result of an abnormality in the hypothalamic-pituitary axis, the testes, or the androgen receptor; or (3) associated with another underlying medical condition. This information will place the patient into one of four diagnostic categories: hypogonadotropic hypogonadism, testicular failure, 5alpha-reductase deficiency, or androgen resistance. Within each category are disorders with identifiable pathogenic mechanisms. Recent studies have added to these lists and have provided insights into the molecular basis and inheritance patterns of several of these endocrinopathies.

Widespread epigenetic abnormalities suggest a broad DNA methylation erasure defect in abnormal human sperm

BACKGROUND

Male-factor infertility is a common condition, and etiology is unknown for a high proportion of cases. Abnormal epigenetic programming of the germline is proposed as a possible mechanism compromising spermatogenesis of some men currently diagnosed with idiopathic infertility. During germ cell maturation and gametogenesis, cells of the germ line undergo extensive epigenetic reprogramming. This process involves widespread erasure of somatic-like patterns of DNA methylation followed by establishment of sex-specific patterns by de novo DNA methylation. Incomplete reprogramming of the male germ line could, in theory, result in both altered sperm DNA methylation and compromised spermatogenesis.

METHODOLOGY/PRINCIPAL FINDING

We determined concentration, motility and morphology of sperm in semen samples collected by male members of couples attending an infertility clinic. Using MethyLight and Illumina assays we measured methylation of DNA isolated from purified sperm from the same samples. Methylation at numerous sequences was elevated in DNA from poor quality sperm.

CONCLUSIONS

This is the first report of a broad epigenetic defect associated with abnormal semen parameters. Our results suggest that the underlying mechanism for these epigenetic changes may be improper erasure of DNA methylation during epigenetic reprogramming of the male germ line.

Male infertility and variation in CAG repeat length in the androgen receptor gene: a meta-analysis

CONTEXT

Many studies have investigated the association between male infertility and trinucleotide repeat polymorphisms in the androgen receptor (AR) gene, but no comprehensive meta-analysis of all published studies has been conducted.

OBJECTIVE

Our goals were to summarize published data on associations between AR CAG and GGC repeat lengths and male infertility and investigate sources of variation between study results.

DATA SOURCES

We searched for reports published before October 2006 using Medline, PubMed, and Web of Science.

STUDY SELECTION

All selected studies included the following: a case group with infertility as measured by semen parameters, a control group of known or presumed fertile men, and measurement of CAG and/or GGC repeat lengths among cases and controls. Thirty-nine reports were selected based on these criteria, and 33 were ultimately included in the meta-analysis.

DATA EXTRACTION

One investigator extracted data on sample size, mean and sd of trinucleotide repeat length, and study characteristics.

DATA SYNTHESIS

Estimates of the standardized mean difference (95% confidence interval) were 0.19 (0.09-0.29) for the 33 studies and 0.31 (0.14-0.47) for a subset of 13 studies that used more stringent case and control selection criteria. Thus, in both groups, cases had statistically significantly longer CAG repeat length than controls. Publication date appeared to be a significant source of variation between studies.

CONCLUSIONS

This meta-analysis provides support for an association between increased androgen receptor CAG length and idiopathic male infertility, suggesting that even subtle disruptions in the androgen axis may compromise male fertility.

Voltage-dependent calcium channels in mammalian spermatozoa revisited

The last few years have seen an explosion in the number of voltage-dependent ion channel sequences detected in sperm and testes. The complex structural paradigm of these channels is now known to include a pore-forming alpha1 subunit(s) whose electrophysiological properties are modulated by an intracellular beta subunit, a disulfide-linked complex of a membrane-spanning delta subunit with an extracellular alpha2 subunit, and a transmembrane gamma subunit. Many of these are alternatively spliced. Furthermore, the known number of genes coding each subtype has expanded significantly (10 alpha1, 4 beta, 4 alpha2delta, 8 gamma). Recently, the CatSper gene family has been characterized based on similarity to the voltage-dependent calcium channel alpha1 subunit. From among this multiplicity, a wide cross-section is active in sperm, including many splice variants. For example, expression of the various alpha1 subunits appears strictly localized in discrete domains of mature sperm, and seems to control distinct physiological roles such as cellular signaling pathways. These include alpha1 alternative splicing variants that are regulated by ions passed by channels in developing sperm. Various combinations of ion channel sequence variants have been studies in research models and in a variety of human diseases, including male infertility. For example, rats that are genetically resistant to testes damage by lead seem to respond to lead ions by increasing alpha1 alternative splicing. In contrast, in varicocele-associated male infertility, the outcome from surgical correction correlates with suppression of alpha1 alternative splicing, Ion channel blockers remain attractive model contraceptive drugs because of their ability to modulate cholesterol levels. However, the large number of sperm ion channel variants shared with other cell types make ion channels less attractive targets for male contraceptive development than a few years ago. In this review, the genetics, structure and function of voltage-dependent calcium channels and related CatSper molecules will be discussed, and several practical clinical applications associated with these channels will be reported.

Etiology of azoospermia in a large nonreferral inner-city population

A higher proportion of nonobstructive than obstructive azoospermia, as well as an increased prevalence of hypogonadotropic hypogonadism were documented in a retrospective study characterizing azoospermia in a population of predominantly Latino, inner-city male partners of infertile couples, as compared to previous reports from relatively affluent socioeconomic status male populations.

Exposure to environmental ozone alters semen quality

Idiopathic male infertility may be due to exposure to environmental toxicants that alter spermatogenesis or sperm function. We studied the relationship between air pollutant levels and semen quality over a 2-year period in Los Angeles, California, by analyzing repeated semen samples collected by sperm donors. Semen analysis data derived from 5,134 semen samples from a sperm donor bank were correlated with air pollutant levels (ozone, nitrogen dioxide, carbon monoxide, and particulate matter < 10 microm in aerodynamic diameter) measured 0-9, 10-14, and 70-90 days before semen collection dates in Los Angeles between January 1996 and December 1998. A linear mixed-effects model was used to model average sperm concentration and total motile sperm count for the donation from each subject. Changes were analyzed in relationship to biologically relevant time points during spermatogenesis, 0-9, 10-14, and 70-90 days before the day of semen collection. We estimated temperature and seasonality effects after adjusting for a base model, which included donor's date of birth and age at donation. Forty-eight donors from Los Angeles were included as subjects. Donors were included if they collected repeated semen samples over a 12-month period between January 1996 and December 1998. There was a significant negative correlation between ozone levels at 0-9, 10-14, and 70-90 days before donation and average sperm concentration, which was maintained after correction for donor's birth date, age at donation, temperature, and seasonality (p < 0.01). No other pollutant measures were significantly associated with sperm quality outcomes. Exposure to ambient ozone levels adversely affects semen quality.

Pituitary imaging is indicated for the evaluation of hyperprolactinemia

OBJECTIVE

To evaluate the signs and symptoms associated with hyperprolactinemia and establish guidelines for a minimal serum PRL level for which pituitary imaging is indicated.

DESIGN

Retrospective study.

SETTING

Reproductive endocrinology clinic in a university hospital.

PATIENT(S)

One hundred four consecutive patients with hyperprolactinemia, mean age 30 +/- 6.5 (range 19-44) years.

INTERVENTION(S)

Classification of clinical symptoms, serum hormone measurements, and pituitary magnetic resonance imaging (MRI).

MAIN OUTCOME MEASURE(S)

Incidence of presenting symptoms, serum PRL levels, and pituitary tumor size.

RESULT(S)

Median (range) PRL value was 82.6 ng/mL (25-1,342). Reported symptoms from most to least common were infertility (48%), headaches (39%), oligoamenorrhea (29%), galactorrhea (24%), and visual changes (13%). Hypothyroidism was diagnosed in 2 of 104 (1.9%) patients. Of 86 patients who had pituitary imaging, 23 (26%) had normal findings and 63 (74%) had pituitary tumor; of these, 47 (55% of total imaged) had microadenomas and 16 (19% of total imaged) had macroadenomas. There was a statistically significant association between the tumor size and the PRL level. However, 11% of the patients with microadenomas had PRL levels >200 ng/mL, and 44% of the patients with macroadenomas had PRL levels between 25 and 200 ng/mL.

CONCLUSION(S)

The most common symptoms in the population studied were infertility and headaches. Coexisting thyroid disease was an uncommon finding. Most patients had a pituitary tumor on MRI. Although tumor size correlated with the serum PRL level, some macroadenomas were detected in women with only moderately elevated PRL values. On the basis of these findings, pituitary imaging should be obtained to identify pituitary tumors in all patients with persistently elevated PRL levels.

Diagnosis of pituitary gonadotroph adenomas in reproductive-aged women

OBJECTIVE

To describe the clinical symptoms associated with the diagnosis of pituitary gonadotroph adenoma in premenopausal women.

DESIGN

Report of three separate cases.

SETTING

University medical center.

PATIENT(S)

Three patients: a 31-year-old woman with primary infertility, recurrent adnexal masses, and highly elevated estradiol level; a 30-year-old woman with recurrent multicystic ovaries following multiple cystectomies and transvaginal cyst aspirations, and elevated estradiol level; a 43-year-old woman with bilateral complex cystic adnexal masses and an elevated estradiol level, who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a suspected granulosa cell tumor.

INTERVENTION(S)

Transsphenoidal resection of a pituitary mass.

MAIN OUTCOME MEASURE(S)

Serum estradiol, FSH, and LH levels; transvaginal ultrasonography of the ovaries; histologic examination of pituitary tumors.

RESULT(S)

Transsphenoidal resection of pituitary adenomas resulted in normalization of serum estradiol and FSH levels and resolution of adnexal masses in two of the women.

CONCLUSION(S)

Pituitary gonadotroph adenoma must be considered in the differential diagnosis in reproductive-aged women presenting with the clinical symptom triad of new onset oligomenorrhea, bilateral cystic adnexal masses, and elevated estradiol and FSH levels with suppressed levels of LH; timely diagnosis may prevent unnecessary and potentially damaging surgical procedures.

Pharmacokinetics of dehydroepiandrosterone and its metabolites after long-term daily oral administration to healthy young men

OBJECTIVE

To determine the effects of dehydroepiandrosterone (DHEA) supplementation on the pharmacokinetics of DHEA and its metabolites and the reproductive axis of healthy young men.

DESIGN

A prospective, randomized, double-blind, placebo-controlled pharmacokinetic study.

SETTING

General Clinical Research Center and laboratories at the Keck School of Medicine of the University of Southern California, Los Angeles, California.

PATIENT(S)

Fourteen healthy men, ages 18-42 years.

INTERVENTION(S)

Daily oral administration of placebo (n = 5), 50 mg DHEA (n = 4), or 200 mg DHEA (n = 5) for 6 months. Blood samples were collected at frequent intervals on day 1 and at months 3 and 6 of treatment.

MAIN OUTCOME MEASURE(S)

Quantification of DHEA, DHEA sulfate (DHEAS), androstenedione, T, E(2), dihydrotestosterone (DHT), and 5alpha-androstane-3alpha-17beta-diol glucuronide (ADG). Physical examination, semen analysis, serum LH, FSH, prostate-specific antigen, and general chemistries were carried out.

RESULT(S)

Baseline DHEA, DHEAS, and ADG levels increased significantly from day 1 to months 3 and 6 in the DHEA treatment groups but not in the placebo group. No significant changes were observed in pharmacokinetic values. Clinical parameters were not affected.

CONCLUSION(S)

DHEA, DHEAS, and ADG increased significantly during 6 months of daily DHEA supplementation. Although the pharmacokinetics of DHEA and its metabolites are not altered, sustained baseline elevation of ADG, a distal DHT metabolite, raises concerns about the potential negative impact of DHEA supplementation on the prostate gland.

Spontaneous twin gestation after vaginal dilation in a woman with uterus didelphys and bladder exstrophy

BACKGROUND

Bladder exstrophy is an uncommon anomaly rarely associated with uterus didelphys. Fertility is limited by associated vaginal malformations, which have traditionally required surgical reconstruction.

CASE

A woman with a history of bladder exstrophy and hypoplastic vagina presented complaining of painful intercourse. The patient underwent vaginal dilator treatment after corrective surgery for the bladder defect. Without any further fertility therapy she subsequently conceived twins, with one implantation in each horn of a didelphic uterus.

CONCLUSION

Bladder exstrophy, uterus didelphys, and vaginal hypoplasia share a common embryological devel-opment, and the finding of one anomaly can alert to the presence of another. Vaginal dilators may be used in place of surgical reconstruction to allow conception.

Long-term, low-dose lead exposure alters the gonadotropin-releasing hormone system in the male rat

Lead is a male reproductive toxicant. Data suggest that rats dosed with relatively high levels of lead acetate for short periods of time induced changes in the hypothalamic gonadotropin-releasing hormone (GnRH) at the molecular level, but these changes were attenuated with increased concentration of exposure. The current study evaluated whether exposure to low levels of lead acetate over longer periods of time would produce a similar pattern of adaptation to toxicity at the molecular and biologic levels. Adult 100-day-old Sprague-Dawley male rats were dosed with 0, 0.025, 0.05, 0.1, and 0.3% lead acetate in water. Animals were killed after 1, 4, 8, and 16 weeks of treatment. Luteinzing hormone (LH) and GnRH levels were measured in serum, and lead levels were quantified in whole blood. Hypothalamic GnRH mRNA levels were also quantified. We found no significant differences in serum LH and GnRH among the groups of animals treated within each time period. A significant dose-related increase of GnRH mRNA concentrations with lead dosing occurred in animals treated for 1 week. Animals treated for more than 1 week also exhibited a significant increase in GnRH mRNA, but with an attenuation of the increase at the higher concentrations of lead with increased duration of exposure. We conclude that the signals within and between the hypothalamus and pituitary gland appear to be disrupted by long-term, low-dose lead exposure.

Infertility in men with cystic fibrosis

The majority of men with cystic fibrosis (CF) have associated congenital bilateral absence of the vas deferens (CBVAD). This congenital defect results in the absence of the anatomic ducts through which spermatozoa pass from the testes to the urethra. No spermatozoa are found in the semen, a condition referred to as obstructive azoospermia. This abnormality of the genital-urinary system is associated with the same genetic mutation in the cystic fibrosis transmembrane conductance regulator gene (CFTR ), which leads to the classic presentation of a patient with CF. However, patients may have CBVAD and CFTR mutations without symptoms of CF. Screening for the common mutations may miss a milder rare gene alteration: a DNA variant in the 5T allele. With the advent of assisted reproductive technologies, fertility is now possible for these men. The National Institutes of Health recommend genetic counseling for any couple attempting assisted reproductive techniques when the man has CF or presents with obstructive azoospermia and is positive for a CF mutation.

The lack of influence of age on male fertility

OBJECTIVE

This study was undertaken to determine the effect of male aging on sperm quality as determined by semen analysis, the fertilization rate of human oocytes in vitro, and live birth rates.

STUDY DESIGN

Retrospective analysis correlating outcome measures with male age was performed for 558 oocyte donation cycles in 441 couples. The oocyte donation model was chosen because it controls for oocyte quality and endometrial receptivity, which allows variations in sperm quality as a function of male age to be the only dependent variable. Outcome measures analyzed were semen analysis, fertilization rates in vitro, pregnancy rates, live birth rates, and cumulative live birth rates by life-table analysis.

RESULTS

There was a negative correlation between male age and total sperm count, but there was no correlation between male age and any of the other parameters in the semen analysis. There was no association between male age and the fertilization rate of donated oocytes in vitro, pregnancy rates, or live birth rates. Recipient couples were grouped by quartiles of male age, and cumulative live birth rates were the same in the 4 groups.

CONCLUSION

Whereas male aging is associated with a significant decline in total sperm count, this change is not reflected in a decreased fertilization rate or a decreased live birth rate in the oocyte donation model.

Serum inhibin B levels in males with gonadal dysfunction

OBJECTIVE

To determine whether inhibin B levels are reflective of the etiology of gonadal dysfunction.

DESIGN

Institutional study.

SETTING

A tertiary care university-affiliated infertility clinic.

PATIENT(S)

Forty-four men: 16 with primary testicular failure, 10 with partial idiopathic hypogonadotropic hypogonadism (IHH), 8 with primary germ cell failure, one with iatrogenic hypogonadotropic hypogonadism, one with untreated Kallmann's syndrome, and 8 healthy fertile controls.

INTERVENTION(S)

Three individuals (one each with IHH, hypogonadotropic hypogonadism [HH], and Kallmann's syndrome) underwent treatment with human chorionic gonadotropin.

MAIN OUTCOME MEASURE(S)

Baseline serum inhibin B, FSH, LH, total testosterone and estradiol levels, and sperm concentrations were measured.

RESULT(S)

Serum inhibin B concentrations were significantly higher in fertile controls (255 +/- 59 pg/mL) than in men presenting with primary testicular failure (75 +/- 46 pg/mL, P<.0001) or in those presenting with primary germ cell failure (73 +/- 31 pg/mL, P<.0001). Inhibin B levels were also lower in males with partial IHH (187 +/- 112 pg/mL, P<.05). The patient with iatrogenic HH had a level of 184 pg/mL, whereas the patient with Kallmann's syndrome had nondetectable levels (<10 pg/mL). Serum inhibin B levels correlated positively with sperm concentration (P=.0001), and negatively with FSH levels (P=.01) and LH levels (P<.05). Human chorionic gonadotropin therapy altered inhibin B levels.

CONCLUSION(S)

Inhibin B plays an important role as an endocrine regulator of FSH secretion, whereas gonadotropins are involved in the regulation of inhibin B secretion.

Comparison of two methods for the measurement of sperm concentration

OBJECTIVE

To determine the accuracy of both the hemocytometer and the MicroCell, to evaluate which method is the most reliable, and to confirm the accuracy of latex beads as an internal standard.

DESIGN

Prospective procedural assessment.

SETTING

University-based infertility clinic.

PATIENT(S)

One hundred sixty-five male sexual partners of women undergoing screening for infertility.

INTERVENTION(S)

Semen analysis.

MAIN OUTCOME MEASUREMENT(S)

Sperm and latex bead concentrations.

RESULT(S)

Sperm concentration values obtained with the hemocytometer were highly correlated with those obtained from the MicroCell (r = 0.88). The mean value of the latex beads concentration was closer to the standard value using the hemocytometer than the MicroCell.

CONCLUSION(S)

Both the hemocytometer and the MicroCell are suitable as screening techniques to measure sperm concentration. Fixed suspensions of latex beads serve as reliable internal quality control standards.

Evaluation of a large cohort of men presenting for a screening semen analysis

OBJECTIVE

To determine: [1] what percentage of men in an infertile relationship will have a semen abnormality, [2] the average value for each semen parameter in this group of men, [3] the distribution of abnormal semen parameters in this group, and [4] if our data support the hypothesis that sperm concentration is declining.

DESIGN

Retrospective cohort study.

SETTING

County hospital university-based infertility clinic.

PATIENT(S)

Male partners of women presenting for an infertility evaluation.

INTERVENTION(S)

Semen specimens were collected after 2-5 days of abstinence.

MAIN OUTCOME MEASURE(S)

Sperm concentration, motility, and morphology.

RESULT(S)

Fifty-two percent of samples had at least one sperm abnormality based on World Health Organization criteria. Fifty-one percent had an abnormality in sperm motility, 18% in sperm concentration, and 14% in sperm morphology. Four percent of the patients were azoospermic.

CONCLUSION(S)

No decline in sperm density was revealed in semen collected by men presenting for an initial screening semen analysis.

Normative reproductive indices for male and female adult Sprague-Dawley rats

The Sprague-Dawley rat is traditionally used as the experimental model for the study of contraceptive agents and reproductive toxicants. Until recently, the normative values used to compare hormone levels after drug exposure were based on the values generated by radioimmunoassay methods developed 30 years ago. To ascertain normative reproductive indices for adult female and male Sprague-Dawley rats over a 6-month age period, we measured luteinizing hormone, testosterone, and estradiol using commercially available kits that employ updated assay techniques. In addition, sperm indices were correlated with reproductive hormones over the same time period. Animals were killed at 107, 128, 156, 212, and 268 days of age irrespective (for females) of cycle stage. Serum LH levels did not change with increasing age; however, the female rats had significantly higher LH values than did the males at comparable ages (p < 0.001). Testosterone levels and sperm parameters did not significantly change with increasing age. Estradiol levels were significantly higher in 107-day-old female rats than they were in female rats in all older age groups (p < 0.01). The values reported can be used in designing and interpreting data generated in ongoing, long term toxicological and contraceptive studies using the rat animal model.

Effects of lead exposure on GnRH and LH secretion in male rats: response to castration and alpha-methyl-p-tyrosine (AMPT) challenge

Animal and clinical studies suggest that lead exposure disrupts the hypothalamic-pituitary axis. To define more precisely the toxic action of lead on the hypothalamic-pituitary unit, a series of in vivo and in vitro experiments were performed. The first experiment was designed to determine whether lead exposure exerts an inhibitory effect on GnRH secretion as reflected by an enhanced inhibition of luteinizing hormone (LH) secretion in response to the tyrosine hydroxylase inhibitor methyl-p-tyrosine (AMPT). In the control animals, the AMPT dose had no significant effect on LH secretion, whereas LH fell significantly in the lead-treated animals. In experiments designed to evaluate the effects of lead exposure on the pattern of pulsatile release of gonadotropins castrated control and lead-dosed animals were cannulated, and serial blood sampling was performed. Baseline LH and follicle-stimulating hormone values were not statistically different between the control and lead-treated group. There were no significant differences noted in pulsatile patterns when the data were analyzed as groups. Pituitary cells harvested from lead-treated animals released significantly more LH that did the control animals. These data are consistent with the hypothesis that the signals between the hypothalamus and pituitary gland are disrupted by lead exposure in the intact animal. However, the lead-exposed castrated rat's hypothalamic-pituitary unit is able to adapt to the toxic effects of lead.

Factors influencing sperm-zona pellucida binding in vitro using the intact zona model

The zona pellucida binding assay assesses the ability of spermatozoa to bind to the zona pellucida. The present study investigated the influence of: (i) prior oocyte exposure to spermatozoa on subsequent sperm-zona pellucida binding in vitro; and (ii) cryopreservation of oocytes. Only oocytes obtained from fertile donors were used and the binding capacity of non-inseminated, cryopreserved oocytes was compared with both inseminated/unfertilized, cryopreserved oocytes and inseminated/unfertilized, non-cryopreserved oocytes recovered from in-vitro fertilization cultures on sperm-zona pellucida binding using an intact zona model. There was no statistically significant difference in sperm-zona binding between non-inseminated, cryopreserved oocytes (range 9.6-23.2), inseminated/unfertilized, cryopreserved oocytes (range 15.0-16.0) and inseminated/ unfertilized, non-cryopreserved oocytes (range 3.3-23.0). The coefficient of variation for sperm binding to all oocyte groups was very large (range 37-121%). We conclude that neither prior exposure of human oocytes to human spermatozoa nor cryopreservation of human oocytes influences the subsequent binding of a different population of spermatozoa to the zona pellucida. However, large oocyte-to-oocyte variation of sperm-zona binding may diminish the usefulness of this assay in clinical practice and as a research tool.

The diagnosis and treatment of male infertility

Male factor infertility is a heterogeneous disorder, a factor that precludes the development of either a single laboratory test to predict sperm fertility potential or a single therapy to improve fertility. A better understanding of the pathophysiology of the disorder will ultimately lead to more clearly defined diagnostic categories and specific treatment regimens.

A method for quantification and correction of proteins after transfer to immobilization membranes

A method is described for quantification of specific proteins after electrophoresis and transfer to immobilization membranes for Western blots. This method is analogous to methods used to correct the amounts of specific transcripts detected on Northern blots. Ponceau S staining of proteins bound to immobilization membranes is efficient and accurate compared to antibody binding in terms of time, effort and cost. Comparison of Ponceau S to other detection and staining methods for quantifying proteins and the basic chemistry of Ponceau S are summarized.

Effects of toxic levels of lead on gene regulation in the male axis: increase in messenger ribonucleic acids and intracellular stores of gonadotrophs within the central nervous system

Lead is a male reproductive toxicant. Lead exposure results in a general suppression of the hypothalamic-pituitary-testicular (HPT) axis in male rats. The mechanism(s) for this disruption by lead is unknown. Toxic lead levels seem to disrupt central nervous system (CNS) control of the HPT system, resulting in a decrease in serum testosterone levels and sperm concentrations. A study designed to elucidate the mechanisms accounting for the disruption of the normal function of the male axis by toxic lead levels at the molecular level demonstrated a 2-3-fold enhancement of mRNA levels of GnRH and the tropic hormone LH. A 3-fold increase of intracellular stores of LH was also found. Because mRNA levels of LH and GnRH and pituitary levels of stored LH are proportional to blood levels of lead, we hypothesize that lead interferes with the normal release of tropic hormones and disrupts hormonal feedback mechanisms. The observed pleiotropic effects of lead upon the male axis and other systems may be explained by simple and unique competition by lead with normal metal ion binding sites that govern genetic control of specific genes.

Lead exposure in vivo alters the fertility potential of sperm in vitro

Lead is a male reproductive toxicant. We previously reported that in vivo lead exposure results in a suppression of the hypothalamic-pituitary-testicular axis in male rats. This study was designed to assess if lead exposure in vivo alters (1) the ability of sperm to fertilize ova in vitro, (2) the morphology of the spermatozoa, and (3) the relationship of cell types in the testes as evaluated by DNA flow cytometry. Male Sprague-Dawley rats were given access to either lead-free (0.0%) or 0.3% lead acetate-containing water for 14, 30, or 60 days starting at 100 days of age. On the day of termination, sperm harvested from the caudae epididymis were incubated with eggs harvested from superovulated non-lead-treated females and were scored for stages of penetration. Sperm were also studied by electron microscopy. The testes of animals treated for 60 days were processed for DNA flow cytometry. The overall distribution of the stages of fertilization was significantly different between control and lead-treated animals. The lead-treated groups fertilized significantly fewer eggs than did sperm from the control group. Increased duration of exposure to lead acetate did not result in a more significant percentage of eggs not fertilized. No ultrastructural changes were noted in the spermatozoa of animals treated with lead compared to control animals. There were no differences in the histogram patterns of testicular cells collected from lead-treated animals and control animals. We conclude that lead alters sperm function by altering the hormonal control of spermatogenesis rather than by direct toxic action on spermatozoa.

Inclusion of synthetic DNA templates of similar length and base composition to PCR-amplified products in restriction enzyme digestions: an efficient aid in characterization of point mutations

Because of a subtle anomaly we encountered upon an analytical gel while characterizing a point mutation in an exon of a patient, we decided to perform expensive and time-consuming procedures to characterize the anomaly. Although initial and subsequent Southern blots and PCR analyses of this patient's mutation suggested that his mutation lay directly within a TaqI recognition site, further characterization revealed that the mutation actually lay in a base immediately outside the recognition site. Had we included an appropriate double-stranded DNA control in the restriction enzyme digestion of this patient's PCR-amplified exon, we could have arrived at the correct conclusion as to the location of the mutation without incurring high costs and time loss. This brief report depicts the use of DNA controls of appropriate length and base composition as a means of avoiding erroneous conclusions and expense in routine mutational analyses in the clinical setting.

Comparison of two weeks versus one week of prenatal ethanol exposure in the rat on gonadal organ weights, sperm count, and onset of puberty

Sprague-Dawley dams from Harlan Ind. (Indianapolis, IN) were administered a fortified ethanol liquid diet containing 35% ethanol derived calories for two weeks (E-2) beginning on day 7 or one week (E-1) beginning on day 13 of gestation and continuing through parturition. Control dams were pair-fed an isocaloric liquid diet containing no ethanol during these periods or remained on lab chow and water. E-2 dams consumed an average of 13.52 g ethanol/kg bwt during the first week of exposure (days 8-14) and 12.50 g ethanol/kg bwt the second week (days 14-20). E-1 dams consumed significantly less than E-2 dams during the second week (9.75 g/kg; p < 0.0001). Although the lower consumption in E-1 dams led to a significant decrease in maternal weight gained during the few days of pregnancy compared to E-2 dams, birthweights of E-1 offspring were significantly heavier than those of E-2 offspring (p < 0.05). No effect of ethanol was detected on anogenital distance at birth in either sex. Puberty was delayed in female offspring of both E-1 and E-2 dams (p < 0.01) as measured by age of vaginal opening. These data suggest that the primary teratogenic actions of ethanol in the rat on fetal growth, as well as delayed puberty in females, occur in the last week of gestation. In adult E-2 males, testis weight was significantly heavier than all other groups when indexed to body weight. No effect of prenatal ethanol exposure was observed on the indexed weights of prostate, epididymis, or seminal vesicles.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of azoospermia in normal men with combined Nal-Glu gonadotropin-releasing hormone antagonist and testosterone enanthate

The effects of a combined GnRH antagonist and testosterone (T) replacement regimen on gonadotropins and spermatogenesis were examined to assess its potential as a male contraceptive regimen. The potent Nal-Glu GnRH antagonist ([Ac-D2-Nal1,D4-Cl-Phe2,D3-Pal3,Arg5, D4-p-methoxybenzoyl-2-amino butyric acid6,D-Ala10]GnRH) was administered daily (7.5 mg, sc) to eight normal men for 16 weeks. T enanthate was given im starting at week 2 and every 2 weeks thereafter through week 14 of the treatment phase. Serum LH, FSH, T, and estradiol concentrations were measured frequently during the 5-week control period, the 16-week treatment phase, and the 14-week recovery phase. Semen analyses were performed every week during the control phase and every 2 weeks during the treatment and recovery phases. Seven of eight subjects became azoospermic by 6-10 weeks of treatment; the eighth subject, who failed to achieve azoospermia, suppressed his sperm count to 7 million/mL by week 14 (from a mean baseline of 42 million/mL) before treatment was prematurely terminated because of localized swelling at each of his injection sites. Sperm counts returned to baseline 10-14 weeks after the end of Nal-Glu administration. Seven of the eight subjects showed suppression of LH to the limit of assay detection (less than 0.2 U/L), whereas the eighth subject showed incomplete suppression. Serum bioactive and immunoreactive LH concentrations showed concordant responses. Mean serum FSH concentrations were also markedly suppressed. Serum T and estradiol concentrations declined dramatically during the first 2 weeks of Nal-Glu GnRH treatment, but returned to the normal physiological range after T enanthate replacement was initiated. Libido and sexual potency were maintained. No systemic side-effects, other than erythema and induration at injection sites, were observed. These data demonstrate that combined GnRH antagonist plus T treatment can predictably and reversibly induce azoospermia in most men and has potential as a male contraceptive regimen.

Prenatal lead exposure in the rat during the third week of gestation: long-term behavioral, physiological, and anatomical effects associated with reproduction

Sprague-Dawley dams were administered lead acetate (0.1%) in their drinking water from Day 14 of gestation to parturition to determine whether exposure of the fetus to elevated lead (Pb) levels during a period of rapid differentiation of the hypothalamic-pituitary-gonadal (HPG) axis would disrupt HPG function in adulthood. At birth, offspring from 20 Pb-treated and 10 control dams were weighed and 2 litter representatives from each sex were fostered to untreated dams. Animals were weaned at 26 days of age and subsequently group housed by sex and treatment. Blood Pb levels in prenatally exposed pups were below the limits of detectability at weaning. Female offspring from Pb-treated dams were found to have a significant delay in the day of vaginal opening. In a sample of lead exposed females, 50% were found to exhibit prolonged and irregular periods of diestrous which was accompanied by an absence of observable corpora lutea when they were euthanized at 83 days of age. Male offspring from these dams were found to have decreased sperm counts at 70 and 160 days of age and to exhibit significantly less territorial scent marking and masculine sex behavior in adulthood compared to controls. Azoospermia was observed in 1 lead exposed animal at 70 days of age and 2 animals at 160 days. Enlarged prostates were observed in Pb-exposed males measured at 160 days, but other sex organ weights were normal. Volume of the sexually dimorphic nucleus of the preoptic area of the hypothalamus in adulthood was significantly reduced by approximately 35% in Pb-exposed males. Pulsatile release of gonadotropins, measured in castrated adult animals of both sexes, revealed irregular release patterns of both FSH and LH in some Pb animals which were not observed in controls. The overall pattern of results suggests that multiple levels of the HPG axis can be affected by exposure to Pb during a period of gestation when structures related to the HPG axis are undergoing rapid proliferation. These data indicate that lead exposure during this period places the exposed animal at significant risk for reduced reproductive capacity in adulthood.

The effect of age of exposure on lead-induced testicular toxicity

The present study was designed to assess the significance of age of exposure on the expression of lead toxicity on the male gonad. Male Wistar rats, age 42 days, 52 days and 70 days were treated with lead acetate in their water for 30 days prior to sacrifice. The lead treated groups in all cases had blood lead values significantly greater than control animals. Blood lead levels in control animal groups were less than 7 micrograms/dl. Serum testosterone and sperm concentration and production rate were significantly suppressed in those animals that were exposed to lead acetate starting at age 52 days and 70 days, but not 42 days. These data indicate that prepubertal rats may be less sensitive to the toxic effects of lead than are rats whose exposure begins after puberty has been initiated.

The effect of duration of exposure on the expression of lead toxicity on the male reproductive axis

This study assesses the significance of duration of exposure on the expression of lead toxicity on the male reproductive system. Male Wistar rats, 52 days old, were treated with 0.0% or 0.6% lead acetate in their water for 7, 14, 30, or 60 days prior to sacrifice. In all cases, the lead-treated groups had blood lead and free erythrocyte protoporphyrin (FEP) levels significantly higher than control animals (P less than 0.0001). Serum testosterone levels and spermatogenesis were suppressed in all lead-treated groups compared to the corresponding controls (P less than 0.05 and P less than 0.001, respectively), except for the group treated for 7 days. The data presented verify that exposure to lead acetate is toxic to the reproductive axis in male rats, but that increased duration of exposure after 14 days does not further suppress serum testosterone levels or spermatogenesis.

Prenatal exposure to a low-frequency electromagnetic field demasculinizes adult scent marking behavior and increases accessory sex organ weights in rats

Pregnant Sprague-Dawley dams were exposed to a low-level, low-frequency pulsed electromagnetic (EM) field (15 Hz, 0.3 msec duration, peak intensity 8 gauss) for 15 min twice a day from day 15 through day 20 of gestation, a period in development that is critical for sexual differentiation of the male rat brain. No differences in litter size, number of stillborns, or body weight were observed in offspring from field-exposed dams. At 120 days of age, field-exposed male offspring exhibited significantly less scent marking behavior than controls. Accessory sex organ weights, including epididymis, seminal vesicles, and prostate, were significantly higher in field-exposed subjects at this age. However, circulating levels of testosterone, luteinizing hormone, and follicle-stimulating hormone, as well as epididymal sperm counts, were normal. These data indicate that brief, intermittent exposure to low-frequency EM fields during the critical prenatal period for neurobehavioral sex differentiation can demasculinize male scent marking behavior and increase accessory sex organ weights in adulthood.

Immunohistochemical localization of relaxin in human prostate

We identified relaxin in human male prostate by use of an anti-human relaxin analogue polyclonal antibody and the avidin-biotin-immunoperoxidase method. The antibody was obtained by immunizing a rabbit with a synthetic human relaxin analogue which has 95% sequence homology with native human relaxin. Human prostate tissues incubated with the anti-human relaxin analogue exhibited positive immunostaining up to an antibody dilution of 1:3200. Inhibition of immunostaining with this antibody by excess relaxin analogue demonstrated specificity of the antibody. The exact role of relaxin in human male reproductive physiology remains to be fully elucidated.

Reversibility of the toxic effect of lead on the male reproductive axis

The present study investigates the reversibility of the toxic effects of lead on the hypothalamic-pituitary-testicular axis in prepubertal and pubertal male rats. Male Wistar rats, 27 days and 52 days old, were given ad libitum access to 0.0% or 0.6% lead acetate containing water. Groups of animals were sacrificed at the end of 30 days of exposure or after a 30-day recovery period. Blood lead and free erythrocyte porphyrin (FEP) levels in the lead-treated groups were significantly higher than in the control animals (P less than 0.001). The animals in the recovery groups had lower, albeit not normal, blood lead and FEP levels 30 days after discontinuing treatment. Serum testosterone, intratesticular sperm counts, and sperm production rates were suppressed in the lead-treated groups (P less than 0.001). Serum testosterone and sperm parameters normalized at the end of the recovery period in the prepubertal animals but not in the pubertal animals.

A controlled comparison of the efficacy of clomiphene citrate in male infertility

To determine whether clomiphene citrate (CC) improves fertility in oligospermic men, 23 men with sperm concentrations between 0.5 and 20 million sperm per milliliter; normal serum gonadotropins and testosterone; and a presumptively fertile partner were enrolled in the study. After a 3-month control period, patients were randomly prescribed CC, 25 mg/day; or placebo, 1 tablet/day, for 12 months. The pregnancy rates for the CC group and the placebo group were 9.09% and 44.44%, respectively (not significant). During the treatment phase, the CC group had significantly higher levels of luteinizing hormone (LH) serum, follicle-stimulating hormone (FSH), testosterone (T), and estradiol than the placebo group. CC treatment also resulted in greater LH, FSH, and T responses to gonadotropin-releasing hormone (GnRH). There were no differences between the placebo and CC groups for the sperm penetration assay or semen parameters. The authors conclude that CC is not a useful drug in the treatment of male infertility.

Effect of abstinence on sperm motility in normal men

We investigated the effect of varying the length of ejaculatory abstinence on sperm motility by a method of automated videomicrography. Ten fertile donors to an artificial insemination clinic provided semen samples at randomly assigned intervals of 12, 24, 72, and 120 hours. All specimens were produced on site, immediately incubated at 37 degrees C, and processed in triplicate. In comparing ejaculates obtained after 12 hours' abstinence with those after 120 hours, semen volume and sperm concentration demonstrated a significant increase with increasing abstinence time (p = 0.03). However, no correlation between abstinence time and percentage of motility, lateral head amplitude, cross-beat frequency, mean velocity, and mean linearity was found. We conclude that motility does not change with ejaculatory frequency and that in normal men prescribed abstinence before analysis of semen for motility characterization may not be necessary.

Endocrine evaluation in the assessment of male reproductive hazards

Male reproductive function requires the integrated functioning of the hypothalamus, pituitary, and testis. The disturbance of endocrine function at any of these levels may result in hypogonadism and infertility. The clinical and laboratory evaluation of these disorders is reviewed here.

Hormonal effects of lead acetate in the male rat: mechanism of action

Environmental exposure to toxic levels of lead occurs in a number of industries with potential adverse effects on the reproductive capacity of exposed men. Using a rat model, we previously reported that dietary exposure to lead resulted in suppressed spermatogenesis and testosterone levels without significant changes in luteinizing hormone (LH). In this study, to identify more specifically the site of lead's toxic actions on the hypothalamic-pituitary-testicular axis, the response of lead-treated male rats as compared to control animals to naloxone, gonadotropin-releasing hormone (GnRH), and LH stimulation was studied. Three groups of 52-day-old Wistar rats were allowed access to either deionized distilled water containing no lead acetate or a 0.3% lead acetate solution for 30 days. In each study group, 10 control and 10 lead-treated animals were anesthetized prior to cardiac puncture and collection of serum for the measurement of lead level and baseline LH (Groups I and II) or testosterone levels (Group III). In Group I, 20 min after an i.p. injection of naloxone (1.5 mg/kg/BW), the animals were killed by decapitation, and serum was collected for LH measurement. Thirty minutes after an i.p. injection of GnRH (100 ng/100 gm BW), Group II animals were killed by decapitation, and serum was collected for LH. Sixty minutes after an injection of LH (100 mg/100 mg BW), serum was collected from Group III animals for testosterone measurement. All control animals and lead-treated animals consumed similar volumes of water. Control animals had undetectable levels of lead in their blood. Lead-treated animals had mean blood lead values of 30 micrograms/dl +/- 5 micrograms/dl.(ABSTRACT TRUNCATED AT 250 WORDS)

Demonstrated paternity in spite of severe idiopathic oligospermia

In this study we report on a successful pregnancy in the spouse of a man who, on repeated occasions, spaced over 3 years, presented with a mean sperm concentration of less than 200,000 sperm/ml. Serum was drawn from the father, mother, and daughter for polymorphic gene marker analysis. The calculation of relative probability of paternity with the use of gene frequencies for whites gave a figure of 99.9% that our patient is the father of the child.

The split ejaculate: assessment of fertility potential using two in vitro test systems

Semen samples (split & whole ejaculates) were obtained from 12 normal men (group A) and 8 oligospermic infertile men with sperm concentrations of less than 20 x 10(6) sperm/ml (group B). All samples were evaluated by standard semen analysis, bovine cervical mucus penetration assay (CMPT), and, in all cases with sufficient sperm, in the human spermatozoa zona-free hamster in vitro penetration assay (SPA). In group A the motile sperm concentration was significantly higher in the ejaculated material of the first two contractions (fraction I or FI) than in the remainder of the ejaculate (fraction II or FII) (p less than 0.02). No significant differences were observed in sperm penetration into zona-free hamster ova or bovine cervical mucus by sperm from FI, FII or the whole ejaculate. Motile sperm concentration was significantly correlated with sperm penetration into bovine cervical mucus (r = 0.65, p less than 0.01), but not into zona-free hamster ova (r = 0.01 NS). In the samples collected by group B, the mean sperm concentration and motile sperm concentration were higher in the first (FI) than in the second (FII) fractions of the split ejaculate or the whole ejaculate (p less than 0.05). No significant differences were found among the FI, FII and the whole ejaculate semen samples for penetration of sperm into bovine cervical mucus. Sperm concentration and motile sperm concentration were significantly correlated with sperm penetration into bovine cervical mucus (r = 0.58, p less than 0.01 and r = 0.57, p less than 0.01, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Serum and semen zinc levels in normozoospermic and oligozoospermic men

Zinc is necessary for growth, sexual maturation and reproduction. Because high concentrations of zinc are found in the male reproductive system, a relationship between zinc and male infertility has been suggested. We studied 11 unselected men who presented to a Reproductive Endocrinology Clinic with histories of infertility and low sperm counts. Reproductive hormones and semen and serum zinc levels were measured. All men had semen analyses performed on at least three separate occasions. A similar set of laboratory evaluations were performed on 11 other men who had normal semen analyses and no history of infertility. No abnormalities of reproductive hormones were found in either group. Mean serum zinc levels were significantly lower in the infertile men (p less than 0.05). Mean semen zinc levels were not significantly different. There was no correlation between serum and semen zinc levels in either group. A significant correlation was found between sperm count and semen zinc (r = 0.66, p less than 0.05) in the volunteers with normal counts, but not in the oligozoospermic men. The results obtained in this study suggest that lowered serum zinc is more common than formerly appreciated in unselected patients with infertility. The high level of zinc found in semen is due primarily to the secretions of the prostate gland and reflects prostatic stores. Serum zinc is thought to be a reasonable indicator of zinc status. The lack of correlation between serum zinc and semen zinc found in our study suggests that mild zinc deficiency may lower serum zinc while the larger prostatic zinc stores remain unaffected.(ABSTRACT TRUNCATED AT 250 WORDS)

UCLA conference. Infertility in the male

Male infertility is a common and distressing problem in which reproductive abnormalities frequently play an important role. Assessment requires an understanding of the control of spermatogenesis and factors responsible for normal sperm function. Standard tests for assessment of semen quality frequently fail to detect impaired function, but newer tests are now available to measure sperm movement and their ability to penetrate the ovum. Algorithmic approaches based on laboratory data can be used to characterize subgroups of infertile men, but many patients have subtle abnormalities. Treatment of male infertility is ideally directed to a specific pathogenic mechanism; nonspecific therapies have produced disappointing results. Surgery is indicated for certain types of ductal obstruction, but whether internal spermatic vein ligation should be used to treat varicocele remains uncertain.

Lead toxicity and the hypothalamic-pituitary-testicular axis

Environmental exposure to toxic levels of lead occurs in a number of industries with potential adverse effects on the reproductive capacity of exposed men. Clinical and animal studies indicate that abnormalities of spermatogenesis result from toxic lead exposure, but the pathogenetic mechanisms involved have not been identified. In order to ascertain what reproductive abnormalities occur in experimental animals when exposed to low levels of lead, 52-day-old animals were treated with water containing 0.0% (control), 0.1%, or 0.3% lead acetate for 30 days prior to killing. Whole blood serum lead levels were below detection (less than 7 micrograms/dl) in the control animals, 34 +/- 3 micrograms/dl in the 0.1% group, and 60 +/- 4 micrograms/dl in the 0.3% group (P less than 0.001). Significant negative correlations between whole blood lead levels and serum and intratesticular testosterone values were found (r = 0.64, P less than 0.001 and r = 0.6, P less than 0.001, respectively). As the level of lead exposure increased, intratesticular sperm counts significantly decreased (r = 0.81, P less than 0.001). No significant changes in serum luteinizing hormone (LH) values were found, but sperm follicle-stimulating hormone (FSH) values were significantly suppressed (P less than 0.05) after lead treatment. There was a significant decrease in ventral prostate weight (P less than 0.05), but no differences in testicular or seminal vesicle weights. Our data indicate that dietary exposure to lead resulting in whole blood serum lead values considered acceptable in the workplace (less than or equal to 40 micrograms/dl) causes inhibition of testicular function.(ABSTRACT TRUNCATED AT 250 WORDS)

Identification and partial characterization of gonadotropin-releasing hormone-like factors in human seminal plasma

Gonadotropin-releasing hormone (GnRH)-like material was measured by radioimmunoassay in acid-ethanol-extracted human seminal plasma using radiolabeled D-[Leu6] GnRH ethylamide as labeled ligand, authentic GnRH as standard, and antibody raised against D-[Lys6] GnRH analog. The mean amount of GnRH-like material measured in the seminal plasma of semen samples with sperm counts greater than 20 X 10(6)/ml was 229.0 +/- 66 pg/ml, with sperm counts less than 20 X 10(6)/ml was 213 +/- 42 pg/ml, and from vasectomized samples was 252 +/- 36 pg/ml. There was no significant difference among the three groups. Scatchard analysis of radioreceptor binding data demonstrated significant displacement of GnRH agonist ligand from castrated male rat pituitary membrane preparations. Ultrafiltration and gel column chromatography of pooled extracted seminal plasma identified two compounds with apparent molecular weights of 2600 and 5000 that differ chemically and immunologically from native GnRH. Further characterization using affinity column chromatography suggests that at least one of these GnRH-like factors is a glycosylated protein.