Immunological status of patients before and after vasovasostomy as determined by the immunobead antisperm antibody test

Seminal Factor VIII and von Willebrand Factor: a possible role of the conventional clotting system in human semen?

Factor (F) VIII circulates in blood complexed with von Willebrand Factor (vWF). Deficiency or defect accounts for haemophilia A and vWF disease. In blood, FVIII functions as a co-factor for FIXa in the activation of FX. Human semen coagulates and liquefies in a process that resembles and has some links with the conventional haemostatic process. A study elsewhere has detected traces, but not measurable levels, of FVIII coagulant activity (FVIII:C). In the present study we have assessed FVIII antigen (FVIII:Ag), FVIII:C and vWF antigen (vWF:Ag) levels in 159 semen specimens obtained from sub-fertile (n = 21), normally fertile (n = 38), fertile donors (n = 32), and vasectomized men (n = 57). Seminal FVIII:Ag levels were also measured in a group defined by several parameters derived from the World Health Organization (WHO) fertility criteria, termed "pooled normal semen parameters" (PNSP). Factor VIII:Ag levels were compared with conventional fertility parameters. In addition, both FVIII:C and vWF:Ag were assessed in a separate group of normal individuals (n = 11). Factor VIII:Ag, FVIII:C and vWF were present and quantifiable in human semen. Factor VIII:Ag levels were significantly lower in vasectomy subjects compared with donors (p = 0.01) or PNSP group (p = 0.01). Several trends taken together suggest an associations between FVIII:Ag and semen quality. Parallel investigations demonstrate FV, FVII, FVIIa, FIX, FIXa, FXa, FXI, FXII, tissue factor (TF) and tissue factor pathway inhibitor (TFPI) in semen. The present report therefore provides further evidence for the presence of a functioning clotting system in human semen.

Comprehensive office evaluation in the new millennium

The success of a comprehensive office-based evaluation of male-factor infertility depends on the physician's thorough understanding of risk assessment in the history, identification of pertinent physical examination findings, and correct assessment of laboratory data. Office-based ultrasonographic techniques have already increased the urologist's ability to visualize suspected anatomic abnormalities, and the use of functional tests of sperm has given greater depth to the limited, but essential, prognostic capabilities of the routine semen analysis.

Contemporary approach to the male infertility evaluation

Evaluation of infertile couples has revealed that male factor infertility contributes to the problem in up to 50% of cases. Evaluation of the male infertility patient may include endocrine studies, sophisticated semen testing, and select radiographic studies. Reversible and life-threatening causes of male infertility should be identified before proceeding directly to assisted reproductive technology. For cases with irreversible causes, a proper evaluation can identify patients who may be treated with the breakthrough method of intracytoplasmic sperm injection. Many men who were previously thought to be infertile may now initiate their own biologic pregnancies. This article emphasizes the essentials of the contemporary approach to evaluating the male factor in an infertile couple.

Infertility due to antisperm antibodies

Immunoinfertility is an important problem, involving a significant number of infertile couples. Although the presence of antibodies on sperm has better prognostic value than those in serum or seminal plasma, it may not be the sole authentic evidence of immunoinfertility. Infertility from antisperm antibodies is likely only when they bind to a relevant sperm antigen involved in a specific fertility function. The variance in functional deficits seen in immunologic infertility is most likely related to antibodies directed at different sperm antigens or different class, subclass, or isotypes. Antibodies to FA-1 seem to be of significant importance in human immunoinfertility. In approaching couples with infertility, a high index of suspicion for antibodies is necessary to avoid misdiagnosis. In the optimal situation, all semen analyses should be screened for sperm-bound antibodies, but if this is impractical, testing should be performed on high-risk individuals (Table I). In couples in which the man has sperm-bound antibodies, and in whom there is no identifiable female factor, treatment should be instituted. Most treatments for immunoinfertility have been disappointing because of poor results, adverse effects, or high cost. Corticosteroid therapy has shown some promise in published reports (mostly poorly designed studies), but increase in pregnancy rate is modest and adverse effects may be significant. In our opinion, informed consent should be documented prior to institution of corticosteroid therapy, and subjects should be closely monitored. Advanced reproductive technologies offer a higher safety profile, and, with increasing technology, higher pregnancy rates. We recommend progressing from "low-tech" procedures, such as IUI and reserving the higher level procedures, such as IVF and ICSI, for those couples in whom pregnancy does not occur. The highest level reproductive technologies give the best current prospects for pregnancy in patients with this difficult problem but also are invasive and costly. It is hoped that further work in the laboratory will give rise to newer, safer, and less expensive effective treatments in the very near future.