Infection and pyospermia in male infertility

Round Cells in Diagnostic Semen Analysis: A Guide for Laboratories and Clinicians

Round cells in seminal fluid are defined as either leucocytes or immature germ cells. Laboratories undertaking semen analysis often report these combined as a concentration, with no further review, comment or direction for clinician action or review. Although numerous publications discuss the possible clinical relevance of these cells (particularly leucocytes) in infertility, the methods employed to differentiate them are often beyond the scope of most diagnostic laboratories. This paper aims to support healthcare scientists in understanding the clinical significance of round cells and aid their identification, differentiation and interpretation. This will support the quality of care the patient receives and direct clinicians to further considerations that may be appropriate for their patient and should consequently reduce indiscriminate and unnecessary use of antibiotics.

Epididymal contribution to male infertility: An overlooked problem

The diagnosis and treatment of male infertility, excluding assisted conception, are limited because of, but not limited to, poor understanding of sperm post-testicular development and storage. Many may think that sperm dysfunction is only self-contained in the sperm cell itself as a result of defective spermatogenesis. However, it can also be a consequence of inadequate epididymal maturation following disorders of the epididymis. Improper epididymal functions can disturb semen parameters and sperm DNA integrity, result in high leucocyte concentrations and high numbers of immature germ cells and debris or even cause idiopathic infertility. To date, the data are limited regarding critical markers of sperm maturation and studies that can identify such markers for diagnosis and managing epididymal dysfunction are scarce. Therefore, this article aims to draw attention to recognise a disturbed epididymal environment as a potential cause of male infertility.

The role of infections and leukocytes in male infertility

Declining birth rates are one of the problems facing society today. Male counterparts are responsible for about half of the infertility cases, and genitourinary tract infections may play a contributing role in approximately 15% of male infertility cases. Leukocytospermia is an established indicator of infection in the male urogenital tract, although other microorganisms such as bacteria and virus may also be contributors to the etiology of male infertility. The pathophysiology of these infectious agents may be initiated by a local inflammatory reaction resulting in an increase in reactive oxygen species (ROS). This results in testicular injury, thereby affecting sperm morphology, sperm motility, sperm viability and elevation of the seminal leukocyte as a result of the genital tract infection. The infectious and inflammatory changes can result in male infertility. It is proposed that high concentrations of seminal leukocyte and infectious agents may affect sperm function resulting in clumping of motile spermatozoa, decreasing acrosomal functionality and also causing alterations in sperm morphology. However, the literature has poorly clarified the role of infection in male infertility, provoking further debate and research on this topic.

Time trends for bacterial species and resistance patterns in semen in patients undergoing evaluation for male infertility

Semen from asymptomatic men who are being evaluated as male partners in interfile couples have been reported to contain a variety of bacteria. Longitudinal studies of the variation of these bacteria over time and their resistance patterns have not been commonly reported. At our institution, residues from semen samples are routinely evaluated for bacteria, including antibiotic sensitivity profiles. We set out to profile the changes in semen bacteria and antibiotic resistance at our institution over time. A total of 72 semen isolates were examined for type of bacteria and sensitivity to a panel of antibiotics. The results were divided into two separate 5-year intervals (the first beginning in 2006, the second in 2011) and compared. The majority of bacteria were skin flora, with Streptococcus and Staphylococcus being the most prevalent. The resistance data for these two pathogens showed minimal statistically significant difference between the two time periods, although the Staphylococcus species did show a trend toward increasing resistance, suggesting that antibiotics currently used in sperm cell preparations may need to be varied.

Comparison of Sperm Parameters in Patients with Infertility Induced by Genital Infection versus Varicocele

BACKGROUND

Male infertility is a common and complex problem and, despite much research in this field, the major cause of infertility unfortunately remains unknown. Genital infection and varicocele are important causes of infertility.

AIMS

To compare the influence of genital infection and varicocele individually on male infertility based on semen analysis.

STUDY DESIGN

Cross-sectional study.

METHODS

The study included 120 infertile patients divided into two groups according to the presence of genital infection or varicocele. The first group included 60 examinees with proven genital infection, but without varicocele formation. The second included 60 patients with varicocele, regardless of the varicocele grade, but without genital infection. The fertile parameters were compared and an assessment was performed on the impact on quality of spermatogenesis due to infection and varicocele.

RESULTS

There is a statistically significant difference regarding abnormal forms of spermatozoids (45.94±9.79 vs. 25.27±6.54) and progressive motility (8.15±1.24 vs. 24.95±7.2), between two groups of patients. However, acidity of ejaculates, minimum sperm concentration, total spermatozoid motility and ejaculate volume showed no statistically significant difference.

CONCLUSION

The study showed a stronger negative influence of genital infection on fertile parameters over varicocele. The significance of our study is the lack of contemporary researches comparing varicocele and genital infection influence on male infertility individually.

Efficacy of two sperm preparation techniques in reducing non-specific bacterial species from human semen

CONTEXT

Artificial reproductive techniques using seminal preparations with bacteria may cause pelvic inflammatory disease and its sequalae.

AIMS

To assess efficacy of two sperm preparation techniques to clear bacteria and the effect of bacteriospermia on sperm recovery rates.

SETTINGS AND DESIGN

A descriptive cross-sectional study was carried out among males of subfertile couples.

SUBJECTS AND METHODS

Semen samples were randomly allocated into swim-up method (group S, n = 68) and density gradient method (group D, n = 50) for sperm preparation. Seminal fluid analysis and bacterial cultures were performed in each sample before and after sperm preparation.

STATISTICAL ANALYSIS

McNemar's chi-squared test and independent samples t-test in SPSS version 16.0 were used.

RESULTS

Organisms were found in 86 (72.88%) out of 118 samples, before sperm preparation; Streptococcus species (n = 40, 46.51% of which 14 were Group D Streptococcus species), Coagulase negative Staphylococcus species (n = 17, 19.76%), Staphylococcus aureus (n = 13, 15.11%), Coliform species (n = 11, 12.79% of which 09 were Escherichia coli) and Corynebacterium species (n = 5, 5.81%). There was a statistically significant reduction of culture positive samples in raw vs. processed samples; in group S, 49 (72.05%) vs. 16 (23.52%) and in group D, 37 (74%) vs. 18 (36%). In group S and D, mean (SD) recovery rates of culture positive vs. culture negative samples were 39.44% (SD-14.02) vs. 44.22% (SD-22.38), P = 0.39 and 52.50% (SD-37.16) vs. 49.58% (SD-40.32), P = 0.82 respectively.

CONCLUSIONS

Both sperm preparation methods significantly reduced bacteria in semen, but total clearance was not achieved. Sperm recovery rate was not affected by bacteriospermia.

Superoxide anion production by human neutrophils activated by Trichomonas vaginalis

Neutrophils are the predominant inflammatory cells found in vaginal discharges of patients infected with Trichomonas vaginalis. In this study, we examined superoxide anion (O₂^.-) production by neutrophils activated by T. vaginalis. Human neutrophils produced superoxide anions when stimulated with either a lysate of T. vaginalis, its membrane component (MC), or excretory-secretory product (ESP). To assess the role of trichomonad protease in production of superoxide anions by neutrophils, T. vaginalis lysate, ESP, and MC were each pretreated with a protease inhibitor cocktail before incubation with neutrophils. Superoxide anion production was significantly decreased by this treatment. Trichomonad growth was inhibited by preincubation with supernatants of neutrophils incubated for 3 hr with T. vaginalis lysate. Furthermore, myeloperoxidase (MPO) production by neutrophils was stimulated by live trichomonads. These results indicate that the production of superoxide anions and MPO by neutrophils stimulated with T. vaginalis may be a part of defense mechanisms of neutrophils in trichomoniasis.

Asymptomatic seminal infection of herpes simplex virus: impact on male infertility

In more than half of infertile men, the cause of their infertility is unknown. Several studies revealed the role of viral infections in male infertility. The aim of the present study was to determine the prevalence of herpes simplex virus-1 (HSV-1) and HSV-2 in semen from asymptomatic infertile male patients, and its association with altered semen parameters. A total of 70 semen samples were collected from infertile men who attended the Research and Clinical Center for Infertility in Yazd, Iran. Semen analysis and diagnostic real-time PCR using specific primers and probes for HSV-1 and HSV-2 DNA were performed. Comparison of semen parameters between virally infected and non-infected samples were performed with independent t-test and Mann-Whitney test. Semen analysis showed that infertile men fell into two groups, the male factor group and the unexplained group. HSV-1 and HSV-2 DNA was detected in 16 (22.9%) and 10 (14.3%) of 70 semen samples, respectively. All HSV-positive samples had abnormal semen parameters (the male factor group). Although HSV infection was not associated with sperm motility and morphological defects, it was correlated with lower sperm count in the seminal fluid. The findings suggest that asymptomatic seminal infection of HSV plays an important role in male infertility by adversely affecting sperm count.

An update on the clinical assessment of the infertile male. [corrected]

Male infertility is directly or indirectly responsible for 60% of cases involving reproductive-age couples with fertility-related issues. Nevertheless, the evaluation of male infertility is often underestimated or postponed. A coordinated evaluation of the infertile male using standardized procedures improves both diagnostic precision and the results of subsequent management in terms of effectiveness, risk and costs. Recent advances in assisted reproductive techniques (ART) have made it possible to identify and overcome previously untreatable causes of male infertility. To properly utilize the available techniques and improve clinical results, it is of the utmost importance that patients are adequately diagnosed and evaluated. Ideally, this initial assessment should also be affordable and accessible. We describe the main aspects of male infertility evaluation in a practical manner to provide information on the judicious use of available diagnostic tools and to better determine the etiology of the most adequate treatment for the existing condition.

Antisperm Antibodies in Semen, Sera and Follicular Fluids of Infertile Patients: Relation to Reproductive Outcome afterIn VitroFertilization

PROBLEM

Data given in the literature, regarding the influence of antisperm antibodies (ASA) in the semen and/or sera on in vitro fertilization (IVF) procedure outcome are controversial. The aim of this study was to compare the prevalence of ASA in semen, peripheral blood and follicular fluid as well as to determine total immunoglobulin concentration in the serum and follicular fluid. Selected parameters were analyzed with regard to IVF outcome.

METHOD OF STUDY

The study enrolled 52 married couples. ASA in the semen was determined by direct immunobead mixed antiglobulin reaction (MAR Screen test), while in the peripheral blood and follicular fluid was determined by indirect immunobead MAR Screen test. Immunoglobulin (IgG, IgM and IgA) concentration in the follicular fluid and serum was determined by a liquid-phase immunoprecipitation assay with nephelometric end-point detection and analyzed with regard to IVF outcome.

RESULTS

Semen MAR test IgG was < 20% in 38 couples, and > 20% in 14 couples. Fertilization (73.2% versus 71.5%) and pregnancy rates (28.9% versus 28.57%) in both groups of patients were not significantly different. The results of direct and indirect MAR test were not associated with fertilization and pregnancy rates. Total serum IgG, IgM and IgA in infertile women were within normal ranges. Follicular fluid IgG was within normal values for serum samples, while IgA and IgM were decreased.

CONCLUSION

The presence of ASA on sperm or in the serum and follicular fluid was not associated with IVF outcome in the couples with good quality semen characteristic.

Effect of blood admixture on in vitro survival of chilled and frozen–thawed canine spermatozoa

Hematospermia in the dog usually occurs secondary to benign prostatic hypertrophy or trauma of the penis or prepuce during semen collection. Regarding the difficulty of removing blood cells from a hematospermic sample, the present study was performed to determine whether blood contaminated ejaculates can still be chilled (4 degrees C) or frozen (-196 degrees C) without an additional decrease in sperm quality. In the first experiment, blood additions of up to 10% exerted no negative effects on the functional characteristics of canine spermatozoa cooled (4 degrees C) and stored for 4 days in an egg-yolk-Tris extender. In contrast, in experiment 2, blood admixtures of 4% or more clearly caused negative effects on cryopreserved (-196 degrees C) spermatozoa, mainly on the motility parameters, on the membrane integrity and on the acrosomal status of the spermatozoa. In experiment 3, we showed that these negative effects of blood admixture on cryopreserved spermatozoa were mainly associated with the red blood cells (RBCs) whereas the addition of plasma, serum or inactivated serum exerted little or no negative effect. Moreover, in experiment 4, we showed that 58.3+/-11.6% of the RBCs hemolysed after a freeze-thaw process. In experiment 5, a clear and negative effect of hemoglobin on cryopreserved canine spermatozoa was observed. We conclude that the presence of up to 10% blood is not detrimental for the storage of chilled canine spermatozoa and that the detrimental effects of blood on cryopreserved spermatozoa are at least partly attributable to the high amount of hemoglobin originating from the RBC hemolysis observed after freezing and thawing.

Effect of whole blood and serum on bovine sperm quality and in vitro fertilization capacity

Under physiologic conditions, low concentrations of blood may be present in the uterine fluid of the estrous cow at the moment of insemination. To decrease the insemination dose and to obtain good insemination results with less fertile semen, more invasive insemination methods such as utero tubal junction (UTJ) insemination can be used. More invasive insemination methods increase the risk of damaging the hyperemic endometrium, with blood in the uterine fluid as result. In this study, the effect of 0, 0.15 and 1.5% whole blood and serum on bovine sperm quality and in vitro fertilizing capacity was evaluated. Sperm quality as assessed by total motility, progressive motility, membrane integrity and acrosomal status was not affected by the presence of blood or serum (P > 0.05). However, the in vitro fertilizing capacity decreased with increasing concentrations of blood and serum (P < 0.01). The rate of polyspermy increased with increasing concentrations of serum (P < 0.01), but not with increasing concentrations of blood (P = 0.30). In conclusion, no immediate effect of blood and serum was visible on several sperm quality parameters, except for an increased prevalence of head to head agglutination (HHA). However, blood and serum did have a negative effect on in vitro fertilizing capacity.

Leukocytospermia in spinal cord injured patients is not related to histological inflammatory changes in the prostate

PURPOSE

Patients with spinal cord injuries have abnormal seminal plasma, which contributes to impaired sperm motility and viability. A common finding in these patients is an elevated leukocyte count in semen. We examined the prostatic tissue of spinal cord injured patients vs young healthy controls to determine whether a pathological process related to the prostate gland is a possible source of leukocytospermia.

MATERIALS AND METHODS

Seven men with a mean age of 26.1 years with spinal cord injury and 4 controls with a mean age of 35.0 years underwent standard transrectal ultrasound guided prostate biopsy. Semen analyses were performed prior to biopsies. At least 3 biopsy cores were obtained from each prostate and all underwent routine hematoxylin and eosin staining.

RESULTS

No significant abnormalities were found in any prostate biopsy cores. Two spinal cord injured patients had minor evidence of prostatic inflammation in 1 core. No inflammation was seen in any control specimens. None of the specimens showed signs of malignancy.

CONCLUSIONS

Prostate biopsies obtained in this study did not show any signs of a chronic or acute significant inflammatory process that could explain increased leukocytospermia seen in patients with spinal cord injury.

Indirect immunofluorescence using monoclonal antibodies for the detection of leukocytospermia: comparison with peroxidase staining

The presence of increased number of leukocytes in semen is indicative of inflammation in the male genital tract. Inflammatory processes at this level may lead to marked impairment of sperm function, and finally to a reduction in their fertilizing capability. An immunocytological technique for the detection of seminal leukocytes was evaluated in this study. As part of the standardization technique, different fixation methods were tested to ascertain whether samples could be stored and examined later. It was found that fixation with cold acetone at freezing temperatures retained immunoreactivity until day 11 of storage. All other methods showed a significant loss of immunoreactivity, from as little as day 2 of storage. In 46 specimens with elevated numbers of round cells, number of peroxidase-positive cells and number and type of leukocytes were evaluated by means of indirect immunofluorescence. Determination of peroxidase-positive cells to detect leukocytospermia, the standard procedure recommended by the WHO, was compared with the indirect immunofluorescence technique using monoclonal antibodies. While 19 of 46 patients showed high numbers of leukocytes in the ejaculate, as determined by the immunocytological method, only 9 of these were identified to be leukocytospermic, according to the WHO (standard) procedure. This difference was statistically significant (P < 0.01) and indicates that the standard method of detection of seminal leukocytes may be inaccurate.

Effectiveness and limits of antimicrobial treatment on seminal leukocyte concentration and related reactive oxygen species production in patients with male accessory gland infection

To evaluate whether bacteriological cure, sperm outcome, spontaneous pregnancy rate and white blood cell (WBC)-related reactive oxygen species (ROS) production were related to the extent of the infection and to an intermittent and repetitive antimicrobial treatment, 122 patients with bacterial [>10(5) colony-forming units (CFU)/ml] male accessory gland infections (MAGI) were studied. According to ultrasound criteria, patients had prostatitis (PR, n = 52), prostatovesiculitis (PV, n = 32) or prostatovesiculoepididymitis (PVE, n = 38). Each group was further subdivided into two subsets: one subset (PR, n = 40; PV, n = 20; PVE, n = 25) was given ofloxacin or doxycycline for 14 consecutive days per month for 3 months; the other subset (PR, n = 12; PV, n = 12; PVE, n = 13) received no treatment. The female partners were also treated. All patients were evaluated before, during (1 and 3 months) and after (3 months) treatment. The bacteriological cure rate was the highest (92.5%) after the third antibiotic course in PR, followed by PV (70.4%), and the lowest in PVE (52.0%). At 3 months after therapy discontinuation, some sperm parameters, seminal WBC concentration and ROS generation (assessed in the 45% Percoll fraction) were ameliorated in PR and PV, whereas no improvement occurred in patients with PVE, except for the percentage of coiled tails. Antibiotic treatment in PR and PV patients led to positive effects on sperm output and spontaneous pregnancy rate (40%) by removing pro-oxidant noxae (microbial and/or WBC-related ROS production). The persistent infertility, dyspermia and sperm-derived ROS overproduction in PVE may relate to a significant percentage of antibiotic-independent re-infection and/or to low antioxidative epididymal properties, which persisted following antimicrobial treatment.

Immature germ cells in semen and their correlations with other semen parameters

PURPOSE

The significance of the presence of leukocytes and immature germ cells in semen and other parameters of semen is currently a subject of controversy.

MATERIALS AND METHODS

Semen from 572 subfertile patients was analyzed according to WHO criteria and leukocytes as well as immature germ cells were assessed by identifying the round cells in semen by peroxidase staining. Microbiological investigation was carried out in cases with leukocyte counts of >1,000,000/ml.

RESULTS

It was found that as the concentration of spermatozoa decreased the rate of immature germ cells increased and this increase was accompanied by a decrease in motility and in the number of spermatozoa with normal morphology. As the sperm count increased, motility, number of spermatozoa with normal morphology and of immature germ cells also increased whereas an increase in sperm motility was accompanied by an increase in the percentage of spermatozoa with normal morphology. Microbiological investigations were negative in patients with semen leukocyte counts of >l,000,000/ml.

CONCLUSIONS

Although it is possible to establish that the leukocyte and immature germ cell counts correlate with other parameters of semen, these correlations are not statistically significant. The most significant finding is that as the number of sperms decreases, the ratio of immature germ cells to total germ cells increases. While assessing immature germ cells instead of giving special attention to the number of immature germ cells in semen, the ratio of immature germ cells to total germ cells should be considered. The increase of leukocyte count in the semen of oligospermic patients may not always mean leukospermia.

Accurate detection of male subclinical genital tract infection via cervical culture and DNA hybridization assay of the female partner

The accuracy of the PACE2 DNA hybridization assay of the cervix and cervical culture in female partners for the diagnosis of male subclinical genital tract infection were assessed in a male infertility population. A total of 184 men were screened for the presence of Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma hominis. Seventy-one men were identified with a positive test for one or more of the above mentioned micro-organisms. The overall prevalence of bacterial infection was 39%. Female partners of all men were tested with the PACE2 DNA hybridization assay to detect a C. trachomatis infection. Sensitivity was 100% and specificity was 100%. In 67 female partners (94%) of men who tested positive for U. urealyticum and/or M. hominis, a cervical swab culture was performed. The sensitivity of the cervical swab culture was 100%. In view of the high prevalence of U. urealyticum and M. hominis in the male genital tract and the role these sexually transmitted pathogens may play in infertility, one might question whether all couples should be screened for the presence of these pathogens. Transurethral swab culture after digital prostatic massage is disincentive to men. The cervical culture in their female partner, performed as part of the routine fertility work-up, is a suitable alternative to detect the presence of these micro-organisms in the male genital tract.

Seminal immune response in infertile men with leukocytospermia: effect on antioxidant activity

OBJECTIVE

To investigate the incidence of leukocytospermia and relation to T helper cytokines, tumor necrosis factor alpha (TNFalpha) and interleukin-4 (IL-4), antisperm antibodies and antioxidant activity.

DESIGN

Semen samples from 176 infertile men and 24 fertile controls were investigated.

METHODOLOGY

The protocol included tubal patency test, hysterosalpingography and laparoscopy and dye test and ovulation through mid-luteal phase progesterone for the wives. The husbands had semen analysis, cytomorphology evaluation and semen culture. Seminal TNFalpha and IL-4, antisperm antibodies, total antioxidant activity, superoxide dismutase and zinc were determined.

RESULTS

Leukocytospermia occurred in 44.3% of the infertile men compared to 12.5% of the fertile men (P<0.01). Thirty-six (20.5%) men had pathogenic bacterial organisms which constituted 46.2% of those with leukocytospermia. Sperm parameters were worse with leukocytospermia in terms of sperm count (P<0.01), total motility progressive motility (P<0.01), morphology, asthenozoospermia, sperm membrane integrity and antisperm antibodies. TNFalpha and IL-4 had an inverse relationship; the expression of TNFalpha was higher with leukocytospermia and bacteriospermia (P<0.001), while IL-4 was higher in fertile controls (P<0.005). Incidence of antisperm antibodies was higher with leukocytospermia. Total antioxidant activity, superoxide dismutase and zinc were lower with leukocytospermia.

CONCLUSION

Leukocytospermia impairs sperm function through reduced antioxidant activity and enhanced T helper 1 modulation.

Evaluation of seminal plasma parameters in patients with chronic prostatitis or leukocytospermia

Though detailed cytological and microbiological diagnostic procedures are routinely carried out in male genital tract infection, the correct diagnosis and localization of inflammation or infection is often difficult. In this prospective study, the relevance of the seminal plasma markers PMN elastase, complement C3, CRP, fructose, PSP 94, PSA, and alpha-glucosidase was investigated in 13 patients with chronic prostatitis, 31 patients with significant leukocytospermia, and 58 patients with non-inflammatory diseases (controls). Statistically relevant results were obtained for PMN elastase when comparing chronic prostatitis with controls, leukocytospermia with controls (P < 0.001) and chronic prostatitis with leukocytospermia (P < 0.05); for complement C3 chronic prostatitis and leukocytospermia vs. controls (P < 0.05) and for fructose/ejaculate leukocytospermia vs. controls (P < 0.05). No statistically relevant differences were found for C-reactive protein, alpha-glucosidase, PSA and prostatic secretory protein (PSP 94). To delimit genital tract inflammation from non-inflammatory patients, cutpoint levels for PMN elastase of 230 ng ml-1 and for C3c of 0.01 g l-1 were suggested. PMN elastase was shown to possess the strongest discriminating power. The assessment of a cutpoint for fructose to indicate seminal vesicle dysfunction is not possible as the significance level is weak (P < 0.05).

Chlamydial infections and male infertility

Chlamydial infections may be difficult to diagnose due to the silent symptoms and difficulty in culturing. An infectious process may impair fertility by adversely affecting sperm functions, resulting in testicular damage or causing obstruction of the genital tract. In our study, we tried to find Chlamydial antigen by using EIA (Enzyme Immune Assay) and to compare the Ag(+) and Ag(-) groups according to semen parameters. Except for semen volume, we found significant differences in density, morphology, motility and viability (intervolume p > 0.05, interdensity p < 0.01, intermorphology p < 0.001, intermotility p < 0.001 and interviability p < 0.001).

Generation of reactive oxygen species by leukocytes and sperm following exposure to urogenital tract infection

The association between male urogenital tract infection (UTI) and infertility is still controversial. Oxidative stress caused by reactive oxygen species (ROS) in semen has been suggested to be an important factor in the etiology of poor sperm function through peroxidative damage to the cell membrane. This study explored the potential association between the ROS generation and UTIs by examining ROS production by sperm and seminal leukocytes in response to various infectious and cytokine stimulating factors. Semen and blood samples were obtained from 17 normal donors. Highly motile pure sperm, poorly motile sperm, and polymorphonuclear leukocytes (PMN) were isolated and exposed to various infectious and stimulating factors, including lipopolysaccharide (LPS), gamma interferon (gamma-IFN), tumor necrosis factor-alpha (TNF-alpha), granulocyte, macrophage-colony stimulating factor (GM-CSF), and phorbol myristate acetate (PMA). ROS generation was determined by measuring luminescence in a luminometer. In this study, purified PMNs produced high levels of ROS, and this production was markedly enhanced in the presence of cytokines, LPS, as well as PMA. Pure motile sperm produced low levels of ROS, and ROS production was not enhanced by addition of bacterial products or cytokines. In conclusion, PMNs in semen are the major source of ROS, and ROS production by these cells is enhanced by bacterial products and cytokines. Detection of activation markers and/or soluble factors produced by activated leukocytes in the urogenital tract or semen could enhance the diagnosis and lead to improved therapy of male infertility due to subclinical genital tract infections.