A systematic review of recent clinical practice guidelines and best practice statements for the evaluation of the infertile male

IAS-FET: An intelligent assistant system and an online platform for enhancing successful rate of in-vitro fertilization embryo transfer technology based on clinical features

BACKGROUND

Among all of the assisted reproductive technology (ART) methods, in vitro fertilization-embryo transfer (IVF-ET) holds a prominent position as a key solution for overcoming infertility. However, its success rate hovers at a modest 30% to 70%. Adding to the challenge is the absence of effective models and clinical tools capable of predicting the outcome of IVF-ET before embryo formation. Our study is dedicated to filling this critical gap by aiming to predict IVF-ET outcomes and ultimately enhance the success rate of this transformative procedure.

METHODS

In this retrospective study, infertile patients who received artificial assisted pregnancy treatment at Gansu Provincial Maternity and Child-care Hospital in China were enrolled from 2016 to 2020. Individual's clinical information were studied by cascade XGBoost method to build an intelligent assisted system for predicting the outcome of IVF-ET, called IAS-FET. The cascade XGBoost model was trained using clinical information from 2292 couples and externally tested using clinical information from 573 couples. In addition, several schemes which will be of help for patients to adjust their physical condition to improve their success rate on ART were suggested by IAS-FET.

RESULTS

The outcome of IVF-ET can be predicted by the built IAS-FET method with the area under curve (AUC) value of 0.8759 on the external test set. Besides, this IAS-FET method can provide several schemes to improve the successful rate of IVF-ET outcomes. The built tool for IAS-FET is addressed as a free platform online at http://www.cppdd.cn/ART for the convenient usage of users.

CONCLUSIONS

It suggested the significant influence of personal clinical features for the success of ART. The proposed system IAS-FET based on the top 27 factors could be a promising tool to predict the outcome of ART and propose a plan for the patient's physical adjustment. With the help of IAS-FET, patients can take informed steps towards increasing their chances of a successful outcome on their journey to parenthood.

Filling the Gaps in Oncofertility Care by Addressing Challenges Faced by Patients and Providers

With enhanced technology and upcoming treatment strategies in the cancer field, the survival rates of patients have increased. We have now reached a stage in the treatment of cancer where we not only address the disease but also address complications that arise due to the disease and the side effects that present in the post-survival population due to its treatment. One of the primary consequences after oncotherapy is infertility, which is a major reason for distress for patients' post-survival, as they are afraid they may be deemed as less desirable, be rejected by their existing partner, or cannot grapple with the fact that they cannot have children of their own. This can be avoided by the implementation of proper oncofertility practices. The subject of oncofertility involves interactions between experts in the domains of cancer diagnosis, therapy, fertility preservation, and reproductive health. It attempts to investigate and broaden the possibilities for cancer survivors' reproductive future in order to suit their needs according to their ethical religious and sociocultural beliefs. However, these practices are often not implemented effectively due to ineffective doctor-patient communication, lack of knowledge, or partial knowledge of clinicians themselves regarding fertility care. This leads to a feeling of insecurity among clinicians hence resulting in them not referring patients. Lack of awareness among doctors of different oncofertility procedures available especially for patient groups like women and younger patients, hence leading to reduced referral in these groups. Improper coordination across health departments, patient ignorance regarding procedures, financial instability especially in a country with a lower sociodemographic index like India, and neglect or less importance given to the related ethical, social, and legal issues. In this article, we cover the effects of cancer and cancer treatment on fertility, the options available to adult and pediatric cancer patients to preserve their fertility like oocyte/ovarian tissue cryopreservation in females and sperm cryopreservation in males, techniques undergoing experimental studies that could be implemented in the future like spermatogonial stem culture and transplantation of testicular tissue, the obstacles that we face that hinder the proper implementation of such practices and what measures can we take to overcome these obstacles to improve patient care and be better healthcare providers.

Seminal biomarkers and their correlations to semen parameters in subfertile men

Research question

To assess the levels of seminal biomarkers fructose, zinc and citrate and their correlations to semen parameters in infertile men.

Design

200 infertile male participants undergoing fertility assessment at Singapore General Hospital (SGH), Singapore were recruited prospectively, from June 2020 to August 2021. Their semen samples were assessed for seminal parameters, biomarker levels of fructose, citrate and zinc, leukocyte concentrations and aerobic cultures. They were also assessed for their smoking habits.

Results

Sperm concentrations were negatively correlated to seminal fructose levels, r = -0.262, P < 0.001. Progressive motility were positively correlated to seminal citrate levels, r = 0.181, P = 0.014. Sperm morphology and total motile sperm count (TMSC) were positively correlated to seminal zinc and citrate levels, P < 0.05. Zinc and citrate levels were significantly reduced in teratozoospermia, asthenoteratozoospermia and oligoasthenoteratozoospermia groups compared to normozoospermia, P < 0.05. The presence of infection was associated with elevated leukocyte concentrations, lower sperm concentration (12.5 vs 55.8 million/mL, P = 0.024) and fructose levels (35.5 vs 49.2 µmol/ejaculate). Heavy smokers compared to light smokers, had lower sperm concentrations (35.3 vs 49.4 million/mL), TMSC (30.9 vs 47.5 million) and zinc levels (4.9 vs 6.7 µmol/ejaculate) and significantly lower citrate levels (52.6 vs 79.2 µmol/ejaculate, P = 0.029).

Conclusions

Higher zinc and citrate levels correlated with better progressive motility, sperm morphology and TMSC. Smoking negatively impacted zinc and citrate levels, thereby affecting sperm quality. In conclusion, the inclusion of biomarkers in basic male work-up assessment would assist in identifying common deficiencies and aid in adequate replacement therapy.

Ureaplasma urealyticum and Mycoplasma hominis urogenital infections associate with semen inflammation and decreased sperm quality

Ureaplasma urealyticum and Mycoplasma hominis are among the most prevalent sexually transmitted infections proposed to induce urogenital inflammation and impair sperm quality. However, the topic remains controversial since contradictory findings have been reported. Herein, we performed a comprehensive analysis of U. urealyticum and M. hominis urogenital infections and their association with urogenital inflammation (i.e., leukocyte subsets and inflammatory cytokines in semen,) and sperm quality parameters in a cohort of men with couple's primary infertility undergoing initial infertility evaluation or with lower urinary tract symptoms and no infertility-related complaints. Overall, U. urealyticum and M. hominis infection was detected in 17.0% and 23.6% of patients, respectively, whereas the coinfection was detected in 3.8% of patients only. Remarkably, similar infection frequencies were found in the different patient subpopulations analyzed. Moreover, infections were associated with elevated semen levels of TNF, IL-1β, and IL-6 and/or increased counts of total leukocytes and their subsets, including CD4 and CD8 T lymphocytes and neutrophils. In addition, M. hominis infection and the coinfection with U. urealyticum were associated with impairments in sperm quality variables. Our results indicate that U. urealyticum and M. hominis male urogenital infections induce urogenital inflammation and decrease sperm quality, thus impairing male fertility potential. Screening for U. urealyticum and M. hominis infections and performing a comprehensive analysis of different leukocyte subsets and inflammatory cytokines in semen may be clinically helpful in the diagnosis and follow-up of male urogenital infection.

Geniposide attenuates spermatogenic dysfunction via inhibiting endoplasmic reticulum stress in male mice

BACKGROUND

Spermatogenesis dysfunction is common in clinically infertile patients. Geniposide (GP) is one of the important active ingredients extracted from Eucommia ulmoides. However, the protective effect and mechanism of GP in the treatment of spermatogenic dysfunction is not known yet.

METHODS

After cyclophosphamide-induced spermatogenic dysfunction was established in male mice, we gavaged GP for 4 weeks to evaluate spermatogenic function and anti-apoptotic effects by fertility, testicular weight, sperm quality, endoplasmic reticulum stress (ER stress), comet assay and serum testosterone level.

RESULTS

GP can improve the damage of fertility and reproductive organs induced by cyclophosphamide and increase the number and activity of sperm. In comet assay, it was found that GP administration could alleviate sperm DNA damage induced by cyclophosphamide. In addition, GP treatment can significantly reduce ThT fluorescence intensity and improve endoplasmic reticulum stress induced by cyclophosphamide. Besides, TUNEL staining and WB showed that GP could inhibit the excessive apoptosis of cells and protect testis. (p < 0.05, p < 0.01, p < 0.001).

CONCLUSION

The protective effect of Geniposide on cyclophosphamide-induced spermatogenic dysfunction in mice is related to the inhibition of endoplasmic reticulum stress.

Association between virulence factors and biofilm formation in Enterococcus faecalis isolated from semen of infertile men

PROBLEM

Enterococcus faecalis is a common microbial semen contaminant. Although virulence factors and biofilm formation have often been analyzed in Enterococcus spp., there is little information about these features in isolates obtained from the genitourinary tract. This study was intended to characterize and determine the relationship between biofilm-forming ability and the presence of E. faecalis virulence factors isolated from human semen.

METHOD OF STUDY

A total of 32 patients diagnosed with primary infertility and 28 healthy men were included in the study. Semen analyses were performed according to the WHO guidelines. PCR reactions were applied for the detection of ace, esp, efeA, gelE, asa1, and cylA genes. Microtiter plate assay, via measurement of OD_560, was used to measure the biofilm-forming ability of the isolates.

RESULTS

Sixty E. faecalis isolates from semen of infertile and fertile men were characterized by phenotypic and genotypic methods. The prevalence of ace, esp, efeA, gelE, asa1 and cylA were reported to be 81.3%/100.0%, 81.3%/89.3%, 81.3%/85.7%, 71.9%/53.6%, 8.8%/75.0%, and 62.5%/67.9% in infertile/fertile groups; respectively. Strong, weak, and non-biofilm reactions were reported to be 50.0%/21.4%, 40.6%/64.3%, and 9.4%/14.3% in infertile and fertile groups; respectively.

CONCLUSIONS

There was a significant relationship between fertility and weak biofilm reaction and also between biofilm formation and possession of the esp gene (P < .05). It could be speculated that colonization with E. faecalis with a strong ability for biofilm formation could become a potential threat to men's fertility.

Management of male factor infertility: position statement from the Italian Society of Andrology and Sexual Medicine (SIAMS) : Endorsing Organization: Italian Society of Embryology, Reproduction, and Research (SIERR)

PURPOSE

Infertility affects 15-20% of couples and male factors are present in about half of the cases. For many aspects related to the diagnostic and therapeutic approach of male factor infertility, there is no general consensus, and the clinical approach is not uniform.

METHODS

In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), endorsed by the Italian Society of Embryology, Reproduction, and Research (SIERR), we propose evidence-based recommendations for the diagnosis, treatment, and management of male factor infertility to improve patient and couple care.

RESULTS

Components of the initial evaluation should include at minimum medical history, physical examination, and semen analysis. Semen microbiological examination, endocrine assessment, and imaging are suggested in most men and recommended when specific risk factors for infertility exist or first-step analyses showed abnormalities. Full examination including genetic tests, testicular cytology/histology, or additional tests on sperm is clinically oriented and based on the results of previous investigations. For treatment purposes, the identification of the specific cause and the pathogenetic mechanism is advisable. At least, distinguishing pre-testicular, testicular, and post-testicular forms is essential. Treatment should be couple-oriented, including lifestyle modifications, etiologic therapies, empirical treatments, and ART on the basis of best evidence and with a gradual approach.

CONCLUSION

These Guidelines are based on two principal aspects: they are couple-oriented and place high value in assessing, preventing, and treating risk factors for infertility. These Guidelines also highlighted that male infertility and in particular testicular function might be a mirror of general health of a man.

Exome sequencing reveals variants in known and novel candidate genes for severe sperm motility disorders

STUDY QUESTION

What are the causative genetic variants in patients with male infertility due to severe sperm motility disorders?

SUMMARY ANSWER

We identified high confidence disease-causing variants in multiple genes previously associated with severe sperm motility disorders in 10 out of 21 patients (48%) and variants in novel candidate genes in seven additional patients (33%).

WHAT IS KNOWN ALREADY

Severe sperm motility disorders are a form of male infertility characterised by immotile sperm often in combination with a spectrum of structural abnormalities of the sperm flagellum that do not affect viability. Currently, depending on the clinical sub-categorisation, up to 50% of causality in patients with severe sperm motility disorders can be explained by pathogenic variants in at least 22 genes.

STUDY DESIGN, SIZE, DURATION

We performed exome sequencing in 21 patients with severe sperm motility disorders from two different clinics.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Two groups of infertile men, one from Argentina (n = 9) and one from Australia (n = 12), with clinically defined severe sperm motility disorders (motility <5%) and normal morphology values of 0-4%, were included. All patients in the Argentine cohort were diagnosed with DFS-MMAF, based on light and transmission electron microscopy. Sperm ultrastructural information was not available for the Australian cohort. Exome sequencing was performed in all 21 patients and variants with an allele frequency of <1% in the gnomAD population were prioritised and interpreted.

MAIN RESULTS AND ROLE OF CHANCE

In 10 of 21 patients (48%), we identified pathogenic variants in known sperm assembly genes: CFAP43 (3 patients); CFAP44 (2 patients), CFAP58 (1 patient), QRICH2 (2 patients), DNAH1 (1 patient) and DNAH6 (1 patient). The diagnostic rate did not differ markedly between the Argentinian and the Australian cohort (55% and 42%, respectively). Furthermore, we identified patients with variants in the novel human candidate sperm motility genes: DNAH12, DRC1, MDC1, PACRG, SSPL2C and TPTE2. One patient presented with variants in four candidate genes and it remains unclear which variants were responsible for the severe sperm motility defect in this patient.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

In this study, we described patients with either a homozygous or two heterozygous candidate pathogenic variants in genes linked to sperm motility disorders. Due to unavailability of parental DNA, we have not assessed the frequency of de novo or maternally inherited dominant variants and could not determine the parental origin of the mutations to establish in all cases that the mutations are present on both alleles.

WIDER IMPLICATIONS OF THE FINDINGS

Our results confirm the likely causal role of variants in six known genes for sperm motility and we demonstrate that exome sequencing is an effective method to diagnose patients with severe sperm motility disorders (10/21 diagnosed; 48%). Furthermore, our analysis revealed six novel candidate genes for severe sperm motility disorders. Genome-wide sequencing of additional patient cohorts and re-analysis of exome data of currently unsolved cases may reveal additional variants in these novel candidate genes.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported in part by funding from the Australian National Health and Medical Research Council (APP1120356) to M.K.O.B., J.A.V. and R.I.M.L., The Netherlands Organisation for Scientific Research (918-15-667) to J.A.V., the Royal Society and Wolfson Foundation (WM160091) to J.A.V., as well as an Investigator Award in Science from the Wellcome Trust (209451) to J.A.V. and Grants from the National Research Council of Argentina (PIP 0900 and 4584) and ANPCyT (PICT 9591) to H.E.C. and a UUKi Rutherford Fund Fellowship awarded to B.J.H.

Evaluation of immune status in testis and macrophage polarization associated with testicular damage in patients with nonobstructive azoospermia

OBJECTIVE

Immune cells residing in the testicular interstitial space form the immunological microenvironment of the testis. They are assumed to play a role in maintaining testicular homeostasis and immune privilege. However, the immune status and related cell polarization in patients with nonobstructive azoospermia (NOA) remains poorly characterized. System evaluation of the testis immunological microenvironment in NOA patients may help to reveal the mechanisms of idiopathic azoospermia.

STUDY DESIGN

The gene expression patterns of immune cells in normal human testes were systematically analyzed by single-cell RNA sequencing (scRNA-seq) and preliminarily verification by the human protein atlas (HPA) online database. The immune cell infiltration profiles and immune status of patients with NOA was analyzed by single-sample gene set enrichment analysis (ssGSEA) and gene set variation analysis (GSVA) based on four independent public microarray datasets (GSE45885, GSE45887, GSE9210, and GSE145467), obtained from Gene Expression Omnibus (GEO) online database. The relationship between immune cells and spermatogenesis score was further analyzed by Spearman correlation analysis. Finally, immunohistochemistry (IHC) staining was performed to identify the main immune cell types and their polarization status in patients with NOA.

RESULTS

Both scRNA-seq and HPA analysis showed that testicular macrophages represent the largest pool of immune cells in the normal testis, and also exhibit an attenuated inflammatory response by expressing high levels of tolerance proteins (CD163, IL-10, TGF-β, and VEGF) and reduced expression of TLR signaling pathway-related genes. Correlation analysis revealed that the testicular immune score and macrophages including M1 and M2 macrophages were significantly negatively correlated with spermatogenesis score in patients with NOA (GSE45885 and GSE45887). In addition, the number of M1 and M2 macrophages was significantly higher in patients with NOA (GSE9210 and GSE145467) than in normal testis. GSVA analysis indicated that the immunological microenvironment in NOA tissues was manifested by activated immune system and pro-inflammatory status. IHC staining results showed that the number of M1 and M2 macrophages was significantly higher in NOA tissues than in normal testis and negatively correlated with the Johnson score.

CONCLUSION

Testicular macrophage polarization may play a vital role in NOA development and is a promising potential therapeutic target.

Impact of Moriamin Forte on Testicular and Epididymal Damage in Rats with Oligoasthenospermia

To investigate the effect and mechanism of action of Moriamin Forte (MF) on oligoasthenospermia (OA) in rats exposed to multiglycosides of Tripterygium wilfordii (GTW), forty male Sprague Dawley rats were randomly divided into four groups. Rats in the control group were treated with 0.5% sodium carboxymethyl cellulose. The remaining rats were administered GTW (30 mg/kg/d) for 40 d to establish an OA model. Concurrently, the groups were treated with normal saline and low-dose (100 mg/kg/d) and high-dose (200 mg/kg/d) MF, respectively. After treatment, the number and motility of sperm cells were examined. Testicular and epididymal histomorphology changes were observed. Antioxidant indicators (SOD, CAT, MDA, TAC, and Nrf2) in testicular and epididymal tissues were detected. Apoptotic and antiapoptotic indicators (Bax and Bcl2 expression) in the testicular tissue were measured by immunohistochemistry. GTW decreased sperm count and motility, damaged testicular and epididymis tissues, impaired antioxidase activity, and increased tissue MDA levels. Meanwhile, GTW upregulated the expression of Bax and downregulated the expression of Bcl2. Western blot analysis demonstrated a decrease in the Nrf2 expression in the model group. Treatment with MF improved sperm count and motility, as well as inhibited the rate of apoptosis in the rat reproductive system. Moreover, MF improved the activity of antioxidants and increased the relative expression of the antioxidant pathway-related protein Nrf2. In conclusion, MF may reverse the GTW-induced OA by modulating the expression of apoptotic and antioxidant pathway-related proteins. This study may provide a pharmacological foundation for the use of MF in OA treatment.

Loss of CEP70 function affects acrosome biogenesis and flagella formation during spermiogenesis

The spermatogenesis process is complex and delicate, and any error in a step may cause spermatogenesis arrest and even male infertility. According to our previous transcriptomic data, CEP70 is highly expressed throughout various stages of human spermatogenesis, especially during the meiosis and deformation stages. CEP70 is present in sperm tails and that it exists in centrosomes as revealed by human centrosome proteomics. However, the specific mechanism of this protein in spermatogenesis is still unknown. In this study, we found a heterozygous site of the same mutation on CEP70 through mutation screening of patients with clinical azoospermia. To further verify, we deleted CEP70 in mice and found that it caused abnormal spermatogenesis, leading to male sterility. We found that the knockout of CEP70 did not affect the prophase of meiosis I, but led to male germ-cell apoptosis and abnormal spermiogenesis. By transmission electron microscopy (TEM) and scanning electron microscopy (SEM) analysis, we found that the deletion of CEP70 resulted in the abnormal formation of flagella and acrosomes during spermiogenesis. Tandem mass tag (TMT)-labeled quantitative proteomic analysis revealed that the absence of CEP70 led to a significant decrease in the proteins associated with the formation of the flagella, head, and acrosome of sperm, and the microtubule cytoskeleton. Taken together, our results show that CEP70 is essential for acrosome biogenesis and flagella formation during spermiogenesis.

Sperm DNA fragmentation testing: Summary evidence and clinical practice recommendations

We herein summarise the evidence concerning the impact of sperm DNA fragmentation in various clinical infertility scenarios and the advances on sperm DNA fragmentation tests. The collected evidence was used to formulate 41 recommendations. Of these, 13 recommendations concern technical aspects of sperm DNA fragmentation testing, including pre-analytical information, clinical thresholds and interpretation of results. The remaining 28 recommendations relate to indications for sperm DNA fragmentation testing and clinical management. Clinical scenarios like varicocele, unexplained infertility, idiopathic infertility, recurrent pregnancy loss, intrauterine insemination, in vitro fertilisation/intracytoplasmic sperm injection, fertility counselling for men with infertility risk factors and sperm cryopreservation have been contemplated. The bulk evidence supporting the recommendations has increased in recent years, but it is still of moderate to low quality. This guideline provides clinicians with advice on best practices in sperm DNA fragmentation testing. Also, recommendations are provided on possible management strategies to overcome infertility related to sperm DNA fragmentation, based on the best available evidence. Lastly, we identified gaps in knowledge and opportunities for research and elaborated a list of recommendations to stimulate further investigation.

The effect of seminal plasma cadmium and lead levels on semen parameters in male subjects of infertile couples: a prospective cohort study

The aim of this prospective study was to investigate whether there is a relationship between seminal plasma cadmium (Cd) and lead (Pb) levels and semen parameters in male partners of infertile couples. Two hundred fifty one (251) men recruited with no history of occupational exposure to toxic metals. After semen analysis, seminal Cd and Pb levels were measured using atomic absorption spectrometry. Cadmium levels in men with hypospermia was significantly higher than men with normal semen volume (p = .049). In contrast, there was no statistically significant difference in median seminal Pb levels between men with hypospermia and men with normal semen volume (p = .13). There was no statistically significant association between seminal plasma Cd and Pb levels sperm concentration, motility, morphology and total progressively motile sperm count. These findings suggest that environmental Cd exposure may contribute to low semen volume in male partners of infertile couples.IMPACT STATEMENTWhat is already known on this subject? Toxic metals may adversely affect both male and female reproductive system.What the results of this study add? Seminal plasma cadmium levels in men with hypospermia were statistically significantly higher than men with normal semen volume.What the implications are of these findings for clinical practice and/or further research? Patients should be informed about possible adverse effects of toxic metals.

Increased Sperm DNA Fragmentation in Infertile Men with Varicocele: Relationship with Apoptosis, Seminal Oxidative Stress, and Spermatic Parameters

This study intends to determine the extent of nuclear sperm injury in patients with varicocele and to investigate its relationship with apoptosis and oxidative stress (OS). 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). Sperm DNA fragmentation was assessed using terminal deoxynucleotidyl transferase dUTP nick end labeling assay. The proportion of both viable and dead spermatozoa with externalized phosphatidylserine (PS) was detected by the bivariate annexin V/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. Sperm DNA fragmentation, 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. 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.

Bacterial infection of the male reproductive system causing infertility

Bacterial infections play a disruptive and hidden role in male reproductive failure. Different kinds of bacteria are often able to interfere with reproductive function in both sexes and lead to infertility. In this study, to further evaluate the role of bacterial infections in male reproduction we provided an extensive overview of so far researches investigating the effects of bacterial infections on male fertility. We searched Medline, PubMed, Scopus and Google scholar databases to identify the potentially relevant studies on bacterial infections and their implications in male infertility. All the bacteria included in this article have negative effects on the male reproductive function; however, there is ample evidence to blame bacteria such as Escherichia coli, Chlamydia trachomatis, Ureaplasma, Mycoplasma and Staphylococcus aureus for reduced fertility and deterioration of sperm parameters. More studies are needed to clarify the molecular mechanisms by which different bacteria exert their detrimental effects on male reproductive system. Getting more insight into probable mechanisms, would significantly facilitate the production of new, advanced, and effective remedies in the future. In view of all evidence, we strongly suggest increasing awareness among people and considering screening programs for patients seeking fertility both to avoid transmission and to improve fertility outcomes among them.

Establishing the lower limits of total serum testosterone among Chinese proven fertile men who received treatment of assisted reproductive technology

Testosterone (T) plays a crucial role in spermatogenesis because extremely low levels of intratesticular T lead to correspondingly low serum levels of total T (tT), severe disorders of spermatogenesis, and male sterility. However, there is little consensus on the lower limits of serum tT in proven fertile men undergoing assisted reproductive technology treatments in Chinese or other Asian populations. We aimed to establish the reference range of serum tT based on a population of 868 fertile Chinese men undergoing in vitro fertilization or intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) treatments. We defined a fertile man as having had a live baby with his partner as recorded in our IVF registration system. The lower limits of serum tT were established using a Siemens IMMULITE 2000 chemiluminescent system. The 1st, 2.5th, and 5th percentiles and their 95% confidence intervals (CIs) were 3.6 (95% CI: 2.7-4.1) nmol l-1, 4.3 (95% CI: 4.1-5.0) nmol l-1, and 5.6 (95% CI: 4.8-5.8) nmol l-1, respectively. Using the linear correlation of serum tT between the Siemens platform and a liquid chromatography-tandem mass spectrometry platform, the calculated lower limits of serum tT were also established for fertile Chinese men undergoing IVF/ICSI-ET treatments, which will benefit the clinical diagnosis and treatment of male infertility during such procedures.

Infertility: Practical Clinical Issues for Routine Investigation of the Male Partner

About one-fifth of couples has fertility problems in Western countries. Male factors are present in about half of them, either alone or in combination with female causes. Therefore, both partners should be evaluated simultaneously. The fertility status and/or specific conditions of each partner influence the clinical and treatment approach. This article summarizes in a practical way when, how, and why the male partner of an infertile couple should be investigated. The available evidence and international guidelines were used, interpreting, discussing, and expanding them from personal decades-long experience in this field. The aim is to delineate the most appropriate clinical approach for the male partner of infertile couples, considering traditional and emerging technologies and laboratory analyses in the context of their clinical significance. Components of the initial evaluation in men without known risk factors for infertility should include at minimum medical history, physical examination, and semen analysis. Semen microbiological examination, endocrine assessment, scrotal ultrasound, and transrectal ultrasound are suggested in most men and are mandatory when specific risk factors for male infertility are known to be present or when the initial screening demonstrated abnormalities. Full examination, including genetic tests, testicular histology, or additional tests on sperm, is clinically oriented and/or suggested after the results of initial investigations.

Oncofertility in adult and pediatric populations: options and barriers

Cancer and its treatments can affect fertility in a variety of ways, and recent advances in cancer detection and treatment have led to an increasing number of cancer survivors for whom future fertility is a primary concern. Oncofertility is the study of interactions between cancer, anti-cancer therapy, fertility, and reproductive health. Fertility preservation aims to optimize fertility potential before initiation of gonadotoxic therapies. Sperm cryopreservation from an ejaculated sample is the gold standard for adults and post-pubertal adolescents, though added maneuvers such as medical therapy, penile vibratory stimulation, and electroejaculation can be employed when appropriate. When all these approaches fail, testicular sperm extraction can be used to obtain and cryopreserve testicular sperm from the azoospermic patient. Fertility preservation in the pre-pubertal pediatric patient is still experimental, but recent scientific breakthroughs with use of spermatogonial stem cells and testicular tissue transplantation offer great promise for the future. While there may be several practical, cultural, religious, and other barriers to fertility preservation, the establishment of a dedicated fertility preservation team can help to overcome these obstacles and optimize the utilization of fertility preservation in cancer patients of all ages.

Semen quality pattern and age threshold: a retrospective cross-sectional study of 71,623 infertile men in China, between 2011 and 2017

BACKGROUND

The aim of this study was to provide information on the semen quality pattern of infertile men and age thresholds for semen parameters in China.

METHODS

This was a retrospective cross-sectional study investigating 71,623 infertile men from the Reproductive and Genetic Hospital of CITIC Xiangya in Hunan, China, from 2011 to 2017. The Kruskal-Wallis test, Mann-Kendall test, linear regression model and joinpoint regression were used.

RESULTS

Although erratic changes were observed in the median semen parameters (sperm concentration 40.1-52.1 × 10⁶/ml, total sperm count 117.8-153.1 × 10⁶, sperm progressive motility 33.4-38.1%) during the 7 years of observation, no significant decrease in semen quality was found, and 47.88% of infertile men showed normal semen parameters according to the World Health Organization (WHO) criteria. According to the joinpoint regression analysis, sperm progressive motility appeared to decrease earlier than the sperm concentration and total sperm count (at 28, 58, and 42 years of age, respectively).

CONCLUSIONS

There is no evidence of a deterioration in semen quality among infertile men in Hunan, China. Semen parameters decreased with increasing age, with turning points noted at different ages. Semen parameters are not absolute evidence for the assessment of male fertility potential. Therefore, we believe that, among semen parameters, the sperm concentration is the best predictor of fertility for ART, followed by motility. Decreased sperm motility may affect natural pregnancy, but it is not necessary for successful IVF.

Fertility management of Klinefelter syndrome

Introduction: Klinefelter syndrome (KS) represents the most common chromosomal abnormality in the general population, and one of the most common genetic etiologies of nonobstructive azoospermia (NOA) and in severe oligospermia. Once considered untreatable, men with KS and NOA now have a variety of treatment options to obtain paternity.Areas covered: The cornerstone of treatment for both KS and NOA patients remains the surgical retrieval of viable sperm, which can be used for intracytoplasmic sperm injection to obtain pregnancy. Although the field has advanced significantly since the early 1990s, approximately half of men with KS will ultimately fail fertility treatments. Presented is a critical review of the available evidence that has attempted to identify predictive factors for successful sperm recovery. To optimize surgical success, a variety of treatment modalities have also been suggested and evaluated, including hormonal manipulation and timing of retrieval.Expert opinion: Individuals with KS have a relatively good prognosis for sperm recovery compared to other men with idiopathic NOA. Surgical success is heavily dependent upon surgical technique and the experience of the andrology/embryology team tasked with the identification and use of testicular sperm.

Evaluation of the Standardization in Semen Analysis Performance According to the WHO Protocols Among Laboratories in Tehran, Iran

Background and Objective:

Infertility refers to the failure in achieving pregnancy of a couple after one year of regular sexual intercourse without using a protection method. The purpose of this research work was to evaluate the current status of the test and quality control performance in semen analysis in selected laboratories.

Material and Methods:

The semen analysis was performed in the Laboratory of Andrology in terms of macroscopic examination which include volume, color, viscosity, pH and acidity, and in terms of microscopy: the rate of sperm movement, the exact number of sperms per ml of semen, the percentage of sperm viability and movement, the presence of germ cells and white blood cells. Several questions for each part of the test were selected and answered by the director of the laboratories or andrology section supervisor.

Results:

There was a wide range in the performance of selected medical laboratories in Tehran regarding the standards of semen analysis according to the World Health Organization (WHO) Laboratory Manual for the examination and processing of human semen, fifth edition in 2010. They followed the instructions related to the sample collection in about 70% of the evaluated parameters, initial macroscopic examination in about 87% of the selected subjects, and the microscopic evaluation of sperm in about 65% of the test parameters.

Conclusion:

some laboratories do not follow the instructions of the WHO in performing semen analysis, and most of them do not follow the suggested methods in all parts of the test.

Female subfertility

Subfertility is common and affects one in six couples, half of whom lack an explanation for their delay in conceiving. Developments in the diagnosis and treatment of subfertility over the past 50 years have been truly remarkable. Indeed, current generations of couples with subfertility are more fortunate than previous generations, as they have many more opportunities to become parents. The timely access to effective treatment for subfertility is important as many couples have a narrow window of opportunity before the age-related effects of subfertility limit the likelihood of success. Assisted reproduction can overcome the barriers to fertility caused by tubal disease and low sperm count, but little progress has been made in reducing the effect of increasing age on ovarian function. The next 5-10 years will likely see further increases in birth rates in women with subfertility, a greater awareness of lifestyle factors and a possible refinement of current assisted reproduction techniques and the development of new ones. Such progress will bring challenging questions regarding the potential benefits and harms of treatments involving germ cell manipulation, artificial gametes, genetic screening of embryos and gene editing of embryos. We hope to see a major increase in fertility awareness, access to safe and cost-effective fertility care in low-income countries and a reduction in the current disparity of access to fertility care.

Microsurgery Versus Laparoscopic Surgery for Varicocele: A Meta-Analysis and Systematic Review of Randomized Controlled Trials

Background: The goal of this meta-analysis and systematic review is to evaluate the overall effect and safety of microsurgery versus laparoscopic surgery in the treatment of varicocele according to qualified randomized controlled trials (RCTs). Methods: The following electronic databases were searched including PubMed, Cochrane, Embase to identify the qualified studies and publications that were associated with this meta-analysis updated to February 2018 based on index words. The qualified studies only included RCTs. We analyzed the main outcomes through mean difference (MD) and relative risk (RR) along with 95% confidence interval (95% CI). Results: Totally, the current meta-analysis included 23 studies with 1178 patients in the group with microsurgery and 1069 patients in the group with laparoscopic surgery. The results indicated that compared with the laparoscopic surgery group, the microsurgery group could significantly decrease the complication rate (RR: 0.40, 95% CI: 0.21-0.75), as well as the hospital stay (WMD: -0.53, 95% CI: -0.85 to -0.21), increase the sperm concentration after the surgery (WMD: 3.00, 95% CI: 1.23-4.76), and decrease the recurrence rate (RR: 0.35, 95% CI: 0.22-0.55). Besides, there was no significant difference of operation time (SMD: 1.61, 95% CI: 0.71-2.51) and sperm motility (WMD: 2.38, 95% CI: 0.39-4.37) between the two groups. Conclusion: The results demonstrated microsurgery would significantly decrease the complication, hospital stay, and recurrence rate and increase the sperm concentration when compared with laparoscopic surgery. In conclusion, microsurgery is prone to be a better alternative therapy for the treatment of varicocele than laparoscopic surgery.

Proteomic profile of human spermatozoa in healthy and asthenozoospermic individuals

Asthenozoospermia is considered as a common cause of male infertility and characterized by reduced sperm motility. However, the molecular mechanism that impairs sperm motility remains unknown in most cases. In the present review, we briefly reviewed the proteome of spermatozoa and seminal plasma in asthenozoospermia and considered post-translational modifications in spermatozoa of asthenozoospermia. The reduction of sperm motility in asthenozoospermic patients had been attributed to factors, for instance, energy metabolism dysfunction or structural defects in the sperm-tail protein components and the differential proteins potentially involved in sperm motility such as COX6B, ODF, TUBB2B were described. Comparative proteomic analysis open a window to discover the potential pathogenic mechanisms of asthenozoospermia and the biomarkers with clinical significance.

A Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis on the clinical utility of sperm DNA fragmentation testing in specific male infertility scenarios

Background

Sperm DNA fragmentation (SDF) is recognized as a leading cause of male infertility because it can impair the paternal genome through distinct pathophysiological mechanisms. Current evidence supports SDF as a major factor in the pathophysiology of several conditions, including varicocele, unexplained infertility, assisted reproductive technology failure, and environmental lifestyle factors, although the mechanisms involved have not been fully described yet. Measurement of the levels of DNA fragmentation in semen provides valuable information on the integrity of paternal chromatin and may guide therapeutic strategies. A recently published clinical practice guideline (CPG) highlighted how to use the information provided by SDF testing in daily practice, which triggered a series of commentaries by leading infertility experts. These commentaries contained an abundance of information and conflicting views about the clinical utility of SDF testing, which underline the complex nature of SDF.

Methods

A search of papers published in response to the CPG entitled “Clinical utility of sperm DNA fragmentation testing: practice recommendations based on clinical scenarios” was performed within the Translational Andrology and Urology (TAU) website (http://tau.amegroups.com/). The start and end dates for the search were May 2017 and August 2017, respectively. Each commentary meeting our inclusion criteria was rated as “supportive without reservation”, “supportive with reservation”, “not supportive” or “neutral”. We recorded whether articles discussed either SDF characteristics as a laboratory test method or clinical scenarios, or both. Subsequently, we extracted the particulars from each commentary and utilized the ‘Strengths-Weaknesses-Opportunities-Threats’ (SWOT) analysis to understand the perceived advantages and drawbacks of SDF as a specialized sperm function method in clinical practice.

Results

Fifty-eight fertility experts from six continents and twenty-two countries contributed commentaries. Overall, participants (87.9%; n=51) were supportive of the recommendations provided by the CPG on the utility of SDF testing based on clinical scenarios. The majority of participants made explicit remarks about both the clinical scenarios and SDF assays’ characteristics. Among ‘not supportive’ and ‘supportive with reservation’ participants, 75% (n=30/40) and 77.5% (n=31/40) expressed concerns related to technical limitations of SDF testing methods and clinical utility of the test in one or more clinical scenarios discussed in the CPG, respectively. The SWOT analysis revealed that the CPG provides a reasonable evidence-based proposal for integration of SDF testing in the routine daily practice. It also uncovered gaps of knowledge and threats limiting the widespread application of SDF in everyday practice, thus allowing the identification of opportunities to further refine SDF testing and its clinical utility.

Conclusions

The understanding of the role of SDF in male infertility requires an in-depth analysis of the multifactorial pathophysiological processes and the theories involved. The SWOT analysis allowed an objective evaluation of CPG on the clinical utility of SDF testing based on clinical scenarios and its accompanying commentaries written by global experts in all possible angles. Implementation of SDF testing in the clinic may not only increase the outcome of ART but more importantly improve the health of both fathers to be and resulting offspring.

Adjuvant Treatment with Qilin Pill for Men with Oligoasthenospermia: A Meta-Analysis of Randomized Controlled Trials

Qilin pill has been used in the management of oligoasthenospermia. This meta-analysis aimed to evaluate the effects of Qilin pill as an adjunctive therapy on semen parameters in oligoasthenospermic men. A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, Wanfang, CNKI, and VIP databases until June 2016. Randomized controlled trials (RCTs) that evaluated Qilin pill as an adjunctive therapy in oligoasthenospermic were included. Dichotomous data and continuous data were calculated as the risk ratio (RR) and mean difference (MD) with their 95% confidence interval (CI), respectively. Eight RCTs involving 778 patients were identified. Adjunctive treatment with Qilin pill significantly improved the semen volume (MD 0.50 mL; 95% CI 0.42-0.59), sperm concentration (MD 5.01 × 10⁶ /mL; 95% CI 3.28-6.75), sperm motility (MD 7.54%; 95% CI 5.64-9.45), grade A sperm (MD 9.75%; 95% CI 4.05-15.45), serum testosterone level (MD 1.66 nM; 95% CI 0.40-2.92), and pregnancy rate (RR 1.46; 95% CI 1.08-1.99) during follow-up. However, differences in the serum follicle-stimulating and luteinizing hormone levels were not significant. Adjunctive treatment with Qilin pill significantly improves the sperm quality in patients with oligoasthenospermia. However, further trials are necessary to investigate the efficacy of Qilin pill on oligoasthenospermia-induced male infertility. Copyright © 2017 John Wiley & Sons, Ltd.

Burned-Out Testis Tumors in Asymptomatic Infertile Men: Multiparametric Sonography and MRI Findings

Multiparametric testicular ultrasound and magnetic resonance imaging (MRI) findings were analyzed in a series of 10 infertile asymptomatic men presenting with pathologically confirmed burned-out testicular tumors. Color/power Doppler ultrasound (CDUS), shear wave elastography (SWE), contrast-enhanced ultrasonography (CEUS), and MRI were performed on 10, 5, 6, and 7 patients, respectively. All lesions appeared as a hypoechoic and hypovascular nodular area at CDUS, SWE, CEUS CDUS, and CEUS (if performed). Shear wave elastography showed a stiffer nodular area compared with the surrounding/contralateral tissues (13 versus 2 kPa); MRI revealed a well-delineated nodular area in hypointense signal on T2, a high apparent diffusion coefficient value, and a lack of enhancement.

Use of electroacupuncture and transcutaneous electrical acupoint stimulation in reproductive medicine: a group consensus

With the rapid development of assisted reproductive technology, various reproductive disorders have been effectively addressed. Acupuncture-like therapies, including electroacupuncture (EA) and transcutaneous electrical acupoint stimulation (TEAS), become more popular world-wide. Increasing evidence has demonstrated that EA and TEAS are effective in treating gynecological disorders, especially infertility. This present paper describes how to select acupoints for the treatment of infertility from the view of theories of traditional Chinese medicine and how to determine critical parameters of electric pulses of EA/TEAS based on results from animal and clinical studies. It summarizes the principles of clinical application of EA/TEAS in treating various kinds of reproductive disorders, such as polycystic ovary syndrome (PCOS), pain induced by oocyte retrieval, diminished ovarian reserve, embryo transfer, and oligospermia/ asthenospermia. The possible underlying mechanisms mediating the therapeutic effects of EA/TEAS in reproductive medicine are also examined.

Outcome of varicocele repair in men with nonobstructive azoospermia: systematic review and meta-analysis

The objective of this systemic review was to evaluate the benefit of repairing clinical varicocele in infertile men with nonobstructive azoospermia (NOA). The surgically obtained sperm retrieval rate (SRR) and pregnancy rates following assisted reproductive technology (ART) with the use of retrieved testicular sperm were the primary outcomes. The secondary outcomes included the presence of viable sperm in postoperative ejaculate to avoid the testicular sperm retrieval and pregnancy rates (both assisted and unassisted) using postoperative ejaculated sperm. An electronic search to collect the data was performed using the MEDLINE and EMBASE databases until April 2015. Eighteen studies were included in this systematic review and accounted for 468 patients who were diagnosed with NOA and varicocele. These patients were subjected to either surgical varicocele repair or percutaneous embolization. Three controlled studies evaluating sperm retrieval outcomes indicated that in patients who underwent varicocelectomy, SRR increased compared to those without varicocele repair (OR: 2.65; 95% CI: 1.69–4.14; P < 0.001). Although pregnancy rates with the use of testicular sperm favored the varicocelectomy group, results were not statistically significant (clinical pregnancy rate OR: 2.07; 95% CI: 0.92–4.65; P = 0.08; live birth rate OR: 2.19; 95% CI: 0.99–4.83; P = 0.05). The remaining fifteen studies reported postoperative semen analysis results. In 43.9% of the patients (range: 20.8%–55.0%), sperm were found in postoperative ejaculates. Pregnancy rates for unassisted and assisted (after IVF/ICSI) were 13.6% and 18.9% in the group of men with sperm in postoperative ejaculates, respectively. Our findings indicate that varicocelectomy in patients with NOA and clinical varicocele is associated with improved SRR. In addition, approximately 44% of the treated men will have enough sperm in the ejaculate to avoid sperm retrieval. Limited data on pregnancy outcomes with both postoperative ejaculated sperm and harvested testicular sperm preclude any firm conclusion with regard to the possible increased fertility potential in treated individuals. In conclusion, the results of our study indicate that infertile men with NOA and clinical varicocele benefit from varicocelectomy. Given the low/moderate quality of evidence available, it is advisable that doctors discuss with their patients with NOA the risks and benefits of varicocele repair.

The significance of clinical practice guidelines on adult varicocele detection and management

Varicoceles are the most common correctable etiology of male factor infertility. However, the detection and management of varicoceles have not been standardized. This has led to decades of debate regarding the effect of varicocele on male infertility and subsequently whether repair leads to an improved fertility status. The current body of evidence investigating the role of varicocele and varicocelectomy is weak and conflicting. The stance taken by the AUA and ASRM suggests that there is insufficient outcomes data to support evidenced-based guidelines, citing evidence used to provide current recommendations are generally of a low quality level. On the other hand, the EAU Guidelines give a level 1a of evidence for management of varicoceles that are clinically palpable, associated with subnormal semen analyses and having otherwise unexplained fertility. Besides aiding with clinical varicocele detection and management, clinical practice opinion statements and guidelines aim to direct and strengthen the infrastructure of future studies. We review the current status of opinion statements and guidelines in varicocele and management detection with focus on their application in practice.

Novel concepts in male factor infertility: clinical and laboratory perspectives

In recent years, the management of male factor infertility has undergone important changes with the introduction of novel concepts, advanced testing, and therapeutic interventions. This review highlights some of these changes and discusses their impact to routine clinical practice. First, we discuss the recent changes in the World Health Organization (WHO) laboratory methods and reference values for the examination of human semen. Second, we examine the role of sperm chromatin integrity tests in light of increasing evidence of the detrimental effect of sperm DNA fragmentation on reproductive outcomes. Third, we summarize the main findings of varicocele-related infertility and the outcomes of microsurgical varicocele repair to different case scenarios. Lastly, we critically discuss the current management of men with nonobstructive azoospermia seeking fertility and the new opportunities that emerged to help these men achieve biological fatherhood.

Zinc levels in seminal plasma and their correlation with male infertility: A systematic review and meta-analysis

Zinc is an essential trace mineral for the normal functioning of the male reproductive system. Current studies have investigated the relationship between seminal plasma zinc and male infertility but have shown inconsistent results. Hence, we systematically searched PubMed, EMBASE, Science Direct/Elsevier, CNKI and the Cochrane Library for studies that examined the relationship between seminal plasma zinc and male infertility, as well as the effects of zinc supplementation on sperm parameters. Twenty studies were identified, including 2,600 cases and 867 controls. Our meta-analysis results indicated that the seminal plasma zinc concentrations from infertile males were significantly lower than those from normal controls (SMD (standard mean differences) [95% CI] −0.64 [−1.01, −0.28]). Zinc supplementation was found to significantly increase the semen volume, sperm motility and the percentage of normal sperm morphology (SMD [95% CI]: −0.99 [−1.60, −0.38], −1.82 [−2.63, −1.01], and −0.75 [−1.37, −0.14], respectively). The present study showed that the zinc level in the seminal plasma of infertile males was significantly lower than that of normal males. Zinc supplementation could significantly increase the sperm quality of infertile males. However, further studies are needed to better elucidate the correlation between seminal plasma zinc and male infertility.