Steroid treatment of male subfertility caused by antisperm antibodies

The association of medications and supplements with human male reproductive health: a systematic review

Some medications used to treat comorbidities and conditions in reproductive-aged individuals could have a negative impact on fertility. This may occur through hormonal disruption, toxicity to germ cells and spermatozoa, functional impact on the sperm, teratogenicity potential, or ejaculatory abnormalities. Having knowledge of these potential interactions between medications and reproductive potential is important for clinicians to be aware of and guide the patient, along with their treating clinicians, to reproductively favorable alternatives when available. This review aims to summarize the state of the literature regarding medication interactions with human male reproduction using the Anatomical Therapeutic Chemical Classification System of medications.

Antisperm Antibody Testing: A Comprehensive Review of Its Role in the Management of Immunological Male Infertility and Results of a Global Survey of Clinical Practices

Antisperm antibodies (ASA), as a cause of male infertility, have been detected in infertile males as early as 1954. Multiple causes of ASA production have been identified, and they are due to an abnormal exposure of mature germ cells to the immune system. ASA testing (with mixed anti-globulin reaction, and immunobead binding test) was described in the WHO manual 5th edition and is most recently listed among the extended semen tests in the WHO manual 6th edition. The relationship between ASA and infertility is somewhat complex. The presence of sperm agglutination, while insufficient to diagnose immunological infertility, may indicate the presence of ASA. However, ASA can also be present in the absence of any sperm agglutination. The andrological management of ASA depends on the etiology and individual practices of clinicians. In this article, we provide a comprehensive review of the causes of ASA production, its role in immunological male infertility, clinical indications of ASA testing, and the available therapeutic options. We also provide the details of laboratory procedures for assessment of ASA together with important measures for quality control. Additionally, laboratory and clinical scenarios are presented to guide the reader in the management of ASA and immunological male infertility. Furthermore, we report the results of a recent worldwide survey, conducted to gather information about clinical practices in the management of immunological 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.

Immunosuppressants and Male Reproduction

Prolonged use of immunosuppressant medications is occasionally seen in infertile men with chronic inflammatory conditions; autoimmune disorders; or an organ or hematopoietic stem cell transplant. Chronic inflammation impacts negatively on male reproductive endpoints, so immunosuppressant therapy can produce improvements. Corticosteroids have been used to treat antisperm antibodies and even as an empirical treatment for male infertility in general. Trials of these methods have provided mixed results on semen quality and fertility, with improvement, no change and negative effects reported by different investigators. In a substantial number of observational studies, patients on long-term therapy with prednisone for chronic inflammatory disease, testosterone levels were lower compared to untreated controls, though randomized controlled trials have not been conducted. Similarly decreases in testosterone have been reported in men receiving corticosteroids to minimize transplant rejection; however, most were treated with multiple immunosuppressive medications that may have contributed to this effect. A large number of trials of healthy men treated with corticosteroids have shown some disruption in reproductive hormone levels, but other studies reported no effect. Studies in monkeys, rats (at human equivalent dose), cattle, sheep, and horses have shown endocrine disruption, including low testosterone with dexamethasone treatment. Of the cytostatic immunosuppressives, which have high potential for cellular damage, cyclophosphamide has received the most attention, sometimes lowering sperm counts significantly. Methotrexate may decrease sperm numbers in humans and has significant negative impacts in rodents. Other chemotherapeutic drugs used as immunosuppressants are likely to impact negatively on male fertility endpoints, but few data have been collected. The TNF-α Inhibitors have also received little experimental attention. There is some evidence that the immunophilin modulators: cyclosporine, sirolimus, and everolimus cause endocrine disruption and semen quality impairment. As we review in this chapter, results in experimental species are concerning, and well-designed studies are lacking for the effects of these medications on reproductive endpoints in men.

Diversity of antisperm antibodies bound to sperm surface in male immunological infertility

PROBLEM

The presence of antisperm antibodies (ASA) in males can reduce fecundity, however, relationship between the two is disputed. This study was performed to investigate if there is diversity of ASA bound to sperm surface using immunobead test (IBT) combined with complement dependent sperm immobilization test (SIT).

METHODS

The ASA bound to sperm surface were detected using the direct IBT (D-IBT) in 275 semen samples. In some cases with ASA detected by D-IBT, sperm immobilizing antibodies bound to sperm surface were also evaluated using direct SIT (D-SIT).

RESULTS

The incidence of the immunoglobulin G (IgG), IgA, and IgM classes of ASA detected by D-IBT were 2.5, 1.8, and 0.4%, respectively. Totally, nine (3.3%) infertile men had ASA on the sperm surface. D-SIT was tested positive in four (66.7%) of six cases with ASA assessed by D-IBT.

CONCLUSIONS

Some of the sperm-bound antibodies are associated with complement dependent sperm immobilizing antibodies, indicating that there exists a heterogeneity of sperm-bound antibodies. This result might be one of the reasons for the controversy about the relationship between ASA and immunological infertility in men.

cDNA cloning and characterization of a human sperm antigen (SPAG6) with homology to the product of the Chlamydomonas PF16 locus

Serum from an infertile male with high-titer anti-sperm antibodies was used to identify a novel human sperm antigen by screening of a testis expression library. The clone, initially designated Repro-SA-1 (HUGO-approved symbol SPAG6), was found to encode a sequence highly enriched in testis. The deduced amino acid sequence of the full-length cDNA revealed striking homology to the product of the Chlamydomonas reinhardtii PF16 locus, which encodes a protein localized to the central pair of the flagellar axoneme. The human gene encodes 1.8- and 2.8-kb mRNAs highly expressed in testis but not in prostate, ovary, spleen, thymus, small intestine, colon, peripheral blood leukocytes, heart, brain, placenta, liver, muscle, kidney, and pancreas. The gene was mapped to chromosome 10p11.2-p12. Antibodies raised against SPAG6 sequences localized the protein to the tails of permeabilized human sperm. Both the Chlamydomonas protein and SPAG6 contain eight contiguous armadillo repeats, which place them in a family of proteins known to mediate protein-protein interactions. The cloning of the human homologue of the Chlamydomonas PF16 locus provides a new avenue to explore the role of the axoneme central pair in human sperm function.

Male fertility disorders

Effective treatments for extreme oligozoospermia include in vitro fertilization, recovery of sperm through epididymal sperm aspiration or testicular sperm aspiration, and direct injection of sperm through intracytoplasmic sperm injection. The clinical evaluation of and treatment options for male patients with fertility disorders are detailed in this article.

Intracytoplasmic sperm injection for treating infertility associated with sperm autoimmunity

OBJECTIVE

To determine whether intracytoplasmic sperm injection (ICSI) can be used to achieve normal fertilization, embryo cleavage, and pregnancies in cases of sperm autoimmunity.

DESIGN

A retrospective analysis of ICSI results in sperm antibody-positive and randomly selected antibody-negative groups.

SETTING

University- and hospital-based reproductive research laboratory and tertiary referral IVF program.

PATIENT(S)

Thirty-nine couples selected on the basis of a strongly positive result for sperm antibodies of immunoglobulin (Ig) G and/or IgA immunoglobulin class in the male partner and a control group of 140 antibody-negative couples.

INTERVENTION(S)

Human menopausal gonadotropin, hCG and Lucrin (Abbott Australasia, Kurnell, NSW, Australia) were given by injection. Oocyte collection was by transvaginal ovarian puncture. Blood was collected for beta-hCG measurement.

MAIN OUTCOME MEASURE(S)

Normal fertilization, embryo cleavage, establishment of clinical pregnancy, and delivery.

RESULT(S)

There were no significant differences in fertilization rates (62% versus 58%) or clinical pregnancy rates (19% versus 12%) between sperm antibody-positive and sperm antibody-negative patient groups.

CONCLUSION

Intracytoplasmic sperm injection is an effective treatment for patients with severe sperm autoimmunity.

Identification of human sperm antigen recognized by serum of an immunoinfertile woman: a candidate for immunocontraception

PROBLEM

It has been well documented that antisperm antibodies can be causative factors of infertility. In this study we have identified an antigen on human sperm surface using serum of an immunoinfertile woman; it is thus a candidate for immunocontraception.

METHOD

Thirty-three women of reproductive age who were infertile were screened for presence of antisperm antibodies by indirect immunofluorescence and agglutination assay. The serum of one such woman, SU-4, reacted with her husband's as well as normal donor sperm and recognized a band of apparent molecular weight of 71-kDa on Western blot. Anti-71-kDa antiserum was raised in rabbit by eluting 71-kDa protein and was characterized by agglutination test, immunofluorescence assay, transmission electron microscopy, flow cytometry, and sperm-egg interaction in mouse system.

RESULTS

Interestingly, sera raised in rabbit against 71-kDa antigen, was identified by immunoinfertile serum of SU-4, revealed similar results of localization of human acrosome. Anti-71-kDa antibodies showed cross-reactivity with other species of sperm, demonstrated inhibition of sperm attachment to oocytes in an in vitro mouse system, and revealed surface binding of human live sperm by flow cytometry. Transmission electron microscopy documented the presence of 71-kDa antigen in the acrosomal compartment.

CONCLUSION

This study has put in evidence an antigen of apparent molecular weight of 71-kDa in all donor sperm tested in this study. The presence of this antigen on the sperm of several species will enable us to determine the efficacy of this antigen in controlling fertility in vivo in both rodents and primates. This antigen may be a candidate for immunocontraception.

Effect of low dose continuous corticosteroid therapy in men with antisperm antibodies on spermatozoal quality and conception rate

The use of steroids for treating male immunological infertility is controversial. The effect of low dose prednisolone on sperm quality in men with antisperm antibodies and the conception rate, was evaluated in 40 men and their wives. Significant circulating antisperm antibodies were detected by immunofluorescence technique. Prednisolone (5 mg) was administered orally, daily for 3-6 months in men with significant antisperm antibodies. Another group of 37 men with significant antisperm antibodies, formed the control group. Both groups had initial pre- and post therapy semen analysis and hypoosmotic swelling (HOS) test. They were followed up for 12-18 months and the pregnancy outcome documented. There were significant improvement in sperm motility and hypoosmatic swelling test with therapy (P < 0.01, P > 0.05) of 13 and 15%, respectively. The pregnancy rate of 20% was much greater than 5% in the control group (P < 0.01). There were no side effects of prednisolone. Low dose prednisolone is useful in Antisperm antibody associated infertility, by improving the sperm quality and giving rise to pregnancies.

The effective cumulative pregnancy rate of different modes of treatment of male infertility

The clinical efficacy of conventional and advanced methods of treatment was assessed in 814 couples with infertility due to a male factor. The monthly and effective cumulative rate of ongoing or term pregnancies was calculated during 4712 couple-months. Treatment of varicocele by transcatheter embolization, resulting in 3.9% pregnancies per cycle and an effective cumulative pregnancy rate of 41% after 1 year, is more effective than counselling and timed intercourse (9% pregnancies after 12 months). Intrauterine insemination (IUI) of washed spermatozoa produced 17% pregnancies in the initial 4 months, but the success rate of the subsequent cycles (1.7% per cycle) was not different from that of the controls. In vitro fertilization (IVF) resulted in 16% pregnancies per attempt, but the effective cumulative pregnancy rate was only 31% in 12 months due to the long interval between treatment attempts and the high drop-out rate. With subzonal microinjection of sperm, the fertilization rate was higher (71%) than with regular IVF (29%) but both the pregnancy rate per attempt (9%) and the effective cumulative pregnancy rate (17% after 12 months) were low. The 10th percentile of sperm characteristics (cut-off values) of successful cases showed intrauterine insemination to be advantageous in cases with a lower percentage of spermatozoa with progressive motility (9%) than in the controls (15%). The cut-off value of sperm morphology in IVF (4%) is lower than that of IUI (8%) and of the controls (9%), but higher than that of subzonal insemination (1%). Treatment strategy must be defined selecting or combining conventional and assisted reproductive technology for each individual couple with male factor infertility.

Effect of low-dose prednisolone on sperm fertilizing capacity in subfertile men with circulating antisperm antibodies

To assess if low-dose prednisolone reduced circulating antisperm antibodies and improved sperm fertilizing capacity, the hamster oocyte penetration test (HOPT) was used to evaluate treatment in 36 males with significant serum antisperm antibodies, measured by the tray agglutination test (TAT). Prednisolone 5 mg three times a day for 3 months was used. Only couples in whom all tests in the female partner were normal were entered into the study. A significant increase in sperm density, normal morphology, and HOPT were noted after therapy (p < .001). A significant decrease in antisperm antibody titer was noted (p < .0001) and correlated with improvement of HOPT (p < .05). There were no significant side effects. Six pregnancies (17%) occurred. Three pregnancies (18%) occurred in partners of an untreated group of 17 men. Prednisolone therapy in this regime does not significantly improve pregnancy rates. The HOPT does not offer any additional information for predicting patients who will show an improvement in antibody titers or achieve pregnancy after steroids.

The role of antisperm antibodies in infertility

OBJECTIVE

To discuss the role of antisperm antibodies (Ab) in infertility, including proposed mechanisms of antisperm Ab formation, assays for their detection, and treatments for immune-mediated infertility.

DESIGN

Major studies in the published literature and data from The University of Texas Southwestern Medical Center, Division of Reproductive Endocrinology. Reports were reviewed that investigated the development and impact of alloimmunity and autoimmunity to spermatozoa in men and alloimmunity in women and the current methods of treatment for resultant subfertility.

RESULTS

The exposure of spermatozoal antigens to the mucosal and systemic immune systems results in development of immunity to a multiplicity of spermatozoal epitopes. The evaluation of studies that examine the role of antisperm Ab in infertility is complicated by the lack of standardization of antisperm Ab assays and the difficulty in identifying those epitopes for antisperm Ab binding that are responsible for subfertility. Sperm-associated antisperm Ab and antisperm Ab in cervical mucus (CM) reduce sperm mobility and may also impair sperm-ovum interaction. The clinical significance of serum antisperm Ab in both men and women, however, is controversial. Current therapy for antisperm Ab associated infertility is empiric and largely unproven.

CONCLUSIONS

Antisperm Ab on the sperm surface and in CM are implicated in the pathogenesis of a subset of patients with infertility. Further studies that determine the clinically relevant sites of antisperm Ab interaction will aid in directing the treatment of subfertility mediated by antisperm Ab.

Complement in human reproduction: activation and control

The behaviour of the complement system during human reproduction is now the focus of much scientific attention. The presence of antisperm antibodies in the reproductive tracts of some infertile individuals, and of complement in cervical and ovarian follicular fluid, suggests that complement-mediated damage of spermatozoa is involved in some cases of infertility. Further, deposition of maternal IgG and of complement in the extrafetal tissues indicates that complement activation occurs within the fetoplacental unit. Recently, three complement-regulatory proteins--decay-accelerating factor, membrane cofactor protein and CD59--have been detected on spermatozoa and in the extrafetal tissues. It is likely that these inhibitors are essential for normal reproductive function. This article reviews current understanding of the interaction of the complement system with cells and tissues involved in reproduction, with emphasis on the nature and function of the controlling proteins.

An approach to the management of male infertility

Male factors are present in nearly half the couples consulting for infertility. The correct approach to the management of male infertility follows a logical and scientifically sound sequence of procedures. These include history taking, systematic physical examination for general and local causes of abnormal semen quality, complemented by contact-thermoscopy, echography and hormone assays if available. Conventional semen analysis can be replaced by more accurate advanced methods measuring sperm motility characteristics. Several tests of sperm functional capacity are also available. It is mandatory to detect and treat known and accepted causes of impaired sperm quality using adequate and reliable methods. Complementary methods to stimulate spermatogenesis, or to assist reproduction should be offered in well-defined cases. The overall success rate of male infertility treatment remains lower than that of female treatment, though recent technology has improved results remarkably.

Antisperm antibodies in the polyglandular autoimmune (PGA) syndrome type I: response to cyclical steroid therapy

OBJECTIVE

To determine if cyclical intermediate dose steroid therapy could improve semen parameters in an infertile man with sperm autoimmunity associated with the polyglandular autoimmune (PGA) syndrome.

DESIGN

Sperm agglutination studies performed before, during and after three courses of cyclical intermediate dose prednisolone therapy.

PATIENT

A twenty-six-year old man with polyglandular autoimmune syndrome, consisting of Addison's disease, hypoparathyroidism, chronic mucocutaneous candidiasis and alopecia totalis, presented with infertility. He had normal endocrine testicular function but severe exocrine failure evidenced by a low sperm count (4.5 x 10(6)/ml), zero motility and universal sperm agglutination.

MEASUREMENTS

Sperm agglutination tests.

RESULTS

At presentation the gelatin agglutination test (GAT) was strongly positive in serum (1/1204) and seminal plasma (1/64) as was the tray agglutination test (TAT) (1/32). The patient's wife had a regular menstrual cycle with normal luteal phase progesterone levels. Following three courses of cyclical prednisolone (20 mg twice daily on days 1-10 of wife's cycle, and 5 mg on days 11 and 12), sperm quantity and motility improved considerably (12 x 10(6)/ml, 40% respectively) and sperm agglutination tests became negative. After a fourth course of therapy the patient's wife became pregnant. Three months post-treatment sperm motility was very low again and agglutinating activity in serum and seminal plasma increased.

CONCLUSIONS

This is the first case of male infertility due to sperm autoimmunity in association with the PGA syndrome type 1. The immunosuppressive action of cyclical intermediate dose steroid therapy led to a significant quantitative and qualitative improvement in semen parameters.

Characterisation of 24-kD proteins from rat testes using polyclonal sera reactive to human sperm antigens

A group of antigens of 24-kD Mr from rat testes were characterised biochemically. These antigens were part of a larger molecule of approximately 200 kD. On treatment with disulfide bond reducing agent, the 200-kD molecule was reduced to subunits. Immunoreactivity was confined to a doublet of approximately 24 kD and a single band of approximately 50 kD Mr after the reduction. Glycoprotein in nature, this antigen shared immunoreactive epitopes with a 40-kD antigen on human spermatozoa. Antiserum raised in rabbits against the 24-kD antigen from rat testes reacted with antigens on the acrosome of human spermatozoa. Agglutination of sperm could be induced by the antiserum. The carbohydrate residue could be removed by mannosidase digestion. Chemical deglycosylation studies showed a slight decrease in molecular weight. Immunoreactivity was however not completely lost after chemical deglycosylation. Isoelectric focusing of the antigen identified nine isoelectric species. Two relatively minor species showed immunoreactivity. Acrosome-reacted spermatozoa showed loss of antigens from acrosome.

Effect of therapy on infertile couples with antisperm antibodies

One hundred seventy-eight couples with positive antisperm antibody titers in serum and genital secretions were offered treatment with prednisone. Of 60 couples who received prednisone only, 43% conceived. Of 25 who had no therapy, 48% conceived. Fifty-four patients treated with prednisone received additional therapy and 31% conceived. Ten of 39 patients not treated with prednisone but receiving other therapies conceived. Cytotoxic antibodies were reduced in 30% to 42% of serum samples and in 24% to 33% of genital secretion samples. In those couples with decreased cytotoxic antibodies pregnancy rates were 40% to 60% compared with 0% to 23% in those with decreased hemagglutinating antibody titers. Our data suggest that prednisone did not improve overall pregnancy rates; pregnancy rates were comparable in both groups treated with other therapies; donor insemination was the most successful of the alternative therapies; reduction of cytotoxic antibody titers after prednisone treatment was associated with increased pregnancy rates.

Analysis of the action of corticosteroid treatment in immunologic infertility: a preliminary report and an alternative hypothesis

The presence of sperm antibodies can be demonstrated in 8-10% of the male partners of infertile couples. The therapeutic schedule with which the highest pregnancy rate has been obtained in these cases is that proposed by Shulman, which uses methylprednisolone (MP). If treatment with corticosteroids (CS) is effective, the way in which it acts is not entirely clear. In this study we report the results of 16 treatment cycles with CS administered to eight male patients having sperm antibodies in their serum, in which several parameters of humoral immunity were evaluated. The results are conflicting: several parameters (such as IgG concentration) underwent only slight variations after 7 days of therapy, whereas in 12 cycles out of 16, the Tray agglutination test (TAT) indicated that a reduction or disappearance of the antibodies had been obtained. This confirms the usefulness of CS in immunological infertility, and allows us to hypothesize that the beneficial effect may be found in a reduction of inflammation rather than in a suppression of the immunological response, since CS are well known to have these two kinds of effect.

Immunocompetent cells in human testis in health and disease

The authors have investigated lymphocyte subpopulations and macrophages in normal human testes and the testes of patients under investigation and treatment for subfertility. Specific monoclonal antibodies were used in an indirect immunoperoxidase technique. In normal tissues, T lymphocytes (Leu 4-positive cells) were present in the rete testis with a preponderance of cells of the suppressor/cytotoxic phenotype. In contrast, no lymphocytes were detected within the peripheral portions of the testis. Cells reacting with the anti-Leu M3 monoclonal antibody, which defines monocytes/macrophages, were detected in appreciable numbers in peripheral testis with a specific location around the seminiferous tubules. HLA-DR-positive cells (human leukocyte antigens--class II [DR] determinants of the major histocompatibility complex) also were identified and showed a similar pattern of distribution to that of the Leu-M3 positive cells. While no lymphocytes were seen in the normal peripheral testis, T lymphocytes were detected in testicular biopsies from subfertile patients. Suppressor/cytotoxic T cells (Leu 2a-positive) predominated in patients with oligozoospermia and obstructive azoospermia while T cells of the helper/inducer phenotype predominated in patients with unilateral testicular obstruction and in postvasectomy patients. Sperm antibody measurements correlated with these findings.

The SCMC test: a accurate indicator for spermatozoal antibodies

Eighteen couples (12.9%) were selected from a group of 138 infertile couples for a special study about the reliability of the SCMC test, when compared with spermantibody titres in the cervical mucus and or seminal plasma and corticosteroides as treatment for immunologic infertility. It can be demonstrated that there exists a reliability of the SCMC test as an immunologic assay for sperm antibody activity in the semen and the cervical mucus.

Male infertility. 1. Patient evaluation

Although the cause of male infertility is often obscure, proper evaluation can reveal physiologic abnormalities on which a concept of management can be based. Evaluation includes history taking, physical examination, laboratory studies, semen analysis, radiographic studies, and occasionally, testicular biopsy and other studies. The history and physical examination are the foundation of evaluation and may provide clues to diagnosis. However, semen analysis is the most informative test in evaluation of male infertility. For optimum results, proper collection techniques must be followed and data must be carefully interpreted.

Clinical significance of unilateral testicular obstruction in subfertile males

Unilateral testicular obstruction has been defined by exploratory scrototomy in 80 spontaneously infertile males. The most common sites of obstruction were either in the tail of the epididymis after previous infection (40 cases) or in the vas deferens due to congenital absence or after previous infection or surgery (24 cases). Half of the patients had severe oligozoospermia (less than 5 million/ml) and three-quarters had developed antisperm antibodies, often in high titres. Spermatogenesis was shown by testicular biopsy to be normal (Johnsen score-count greater than 8.0) in almost all of the obstructed testes, and serum FSH levels were normal. Following surgical reconstruction, with prednisolone therapy if indicated by high antisperm antibody titres, 19 (32%) of 60 patients with adequate follow-up successfully impregnated their female partners, with the best results occurring in 30 men who started with sperm counts less than 5 million/ml, 12 of whom (40%) were successful. Removal of irreparably blocked testes in 10 men led to profound falls in high antisperm antibody titres, with production of two pregnancies. Unilateral testicular obstruction appears to be a correctable cause of infertility in some human males.

Effect of cyclosporin A in male autoimmune infertility

Nine infertile men (mean duration of infertility, 8.3 years) with antisperm antibodies were treated with the immunosuppressive drug cyclosporin A for 6 months with a dose of 5 to 10 mg/kg/day. Seminal plasma and serum antisperm antibodies fell in three subjects on treatment, and sperm count and motility increased substantially in one. Three successful pregnancies occurred in the study group: one on treatment, one in the first cycle of artificial insemination with the husband's sperm after treatment (twin infants), and one 3 months after cessation of treatment (twin infants). Successful conceptions with cyclosporin were unrelated to falls in antisperm antibody titer.

Cyclic prednisolone therapy for male infertility associated with autoantibodies to spermatozoa

Seventy-six subfertile men with significant titers of antisperm antibodies were treated with a new corticosteroid regimen, consisting of prednisolone, 40 mg daily, rising to 80 mg daily if antibody titers did not fall, given from days 1 to 10 of the partner's menstrual cycle, for up to nine cycles. Twenty-five (33%) of the partners became pregnant during a treatment cycle, more than twice the expected incidence without treatment. No serious complications occurred, although one half of the patients had transient minor side effects. This regimen appears to be encouraging and suitable for further assessment in a prospective controlled trial.

Steroid therapy for male infertility associated with antisperm antibodies. Results of a small randomized clinical trial

Ten infertile men with significant titres of antisperm antibodies were entered into a randomized double-blind study to test the efficacy of corticosteroid therapy compared to a placebo. Prednisolone was given orally at a dose of 1 mg/kg/day for 9 days repeated over 3 cycles (their wives' menstrual cycles). This treatment had no significant effect, when compared to placebo, on fertility, serum antibody levels or semen characteristics. A slight decrease in the titre of seminal antibodies was, however, observed in patients receiving prednisolone. In individuals, there were important fluctuations in antibody levels which were independent of drug administration.

Immunological screening of a male population with infertile marriages

Four hundred not preselected male partners of infertile marriages were screened for the presence of anti-sperm antibodies. Serum and seminal plasma specimens from each patient were tested by the modified slide agglutination test (MSAT) and by the sperm-immobilization test. In addition, the IgG MAR test was performed on fresh ejaculates. Thirteen per cent of patients showed sperm agglutinating activity in serum and 5.7% also in seminal plasma. Sperm-immobilizing activity was found in 4.7% of serum and 1% of seminal plasma specimens, always associated with a high titre of sperm agglutinating activity. A highly significant linear correlation was found between the results of the MAR test and serum sperm-agglutinating activity; the presence of sperm-agglutinating activity in seminal plasma was always associated with MAR test positivity greater than 50%. The incidence of anti-sperm antibodies was not significantly different in patients with normo-, oligo- and azoospermia. The effectiveness and the easiness of both the MAR test and the MSAT do not justify, in our opinion, the utilization of more complex and expensive techniques for the detection of anti-sperm antibodies.

An immunosorption assay for antibodies to spermatozoa: comparison with agglutination and immobilization tests

We have developed an enzyme-linked immunosorption assay (ELISA) with an antigen extract made by treatment of freeze-thawed sperm pools with 0.3 M lithium 3,5-diiodosalicylate (LIS). This procedure is quick, safe, and simple to perform in a clinical laboratory. When the LIS antigen preparation was compared by ELISA with whole sperm and several other antigen extracts, it was found to be superior in detecting human antisperm antibodies related to infertility; it gave less variability, better precision, and fewer false-positive reactions than whole sperm fixed to the wells as antigen. The antigen was stable when stored at -20 degrees C. In one experimental series, serum samples from 18 normal control subjects and 159 infertility patients with positive sperm-immobilizing titers, positive sperm-agglutinating titers, or both, were tested by ELISA with LIS antigen; the correlation yielded a P less than or equal to 0.0001. Based on another series of 156 samples from patients with positive antibody titers by the sperm agglutination test and 30 sera from normal humans, the predictive value of the test was 96%. In a third series of 162 serum samples obtained from 82 women and 80 men, we found no difference in the test results based on sex. The assay is specific for the antibody binding portion of the immunoglobulin. Absorption of positive sera with sperm but not red blood cells markedly reduces the response. In addition to being more efficient and precise than standard methods, the ELISA eliminates the need for fresh sperm and provides data that can be objectively interpreted.

Exploratory scrototomy in 168 azoospermic males

In 168 azoospermic males with normal or only slightly raised serum FSH levels, serum antisperm antibodies were measured, and the site of obstruction or the nature of the failure of spermatogenesis was defined by exploratory scrototomy with inspection of epididymes, vasography and testicular biopsy. When possible, surgical reconstruction was done by side-to-side epididymovasostomy, with vasovasostomy when necessary using 6/0 Prolene and no splints. Acquired blocks of cauda epididymis (34 cases) and vas (23 cases) were significantly more commonly associated with serum antisperm antibodies than congenital bilateral absence of vasa (29 cases) or blocks at the caput epididymis (48 cases), most of which were associated with sinusitis, bronchitis or bronchiectasis (Young's syndrome). Many of the former patients came from abroad, whereas most of the latter came from the British Isles. Sperm counts of 10 million per ml or more were produced by 23 (45%) of 51 adequately followed up patients with acquired blocks following surgical reconstruction, and 11 pregnancies (21.5%) were produced. Amongst those with spermatozoa in the ejaculate after surgery, serum antisperm antibodies were found significantly less often in those whose wives became pregnant compared with those who failed to produce pregnancies. It is concluded that failure of surgical treatment in some of these cases may have an immunological basis. No success was achieved with other groups.

Successful treatment of male infertility caused by antispermatozoal antibodies

Spermatozoa in the ejaculate of a man with antispermatozoal antibodies in the serum (gelatin agglutination technique (GAT) titre, 640) and the seminal plasma (GAT titre, 80) were shown to have IgG and IgA bound to them. In preparation for intrauterine artificial insemination, the ejaculate was collected in Tyrode's medium. Then spermatozoa were washed, resuspended in Tyrode's medium, and 0.2 mL of the suspension was injected in the uterus. A successful pregnancy resulted. Reasons are given for considering that the successful pregnancy resulted from the manipulation of the semen.

Methylprednisolone treatment of immunologic infertility in male

Over a 5-year period, 98 men (101 "cases") with immunologic infertility, as diagnosed by Kibrick and F-D sperm agglutination testing, were treated with one or more regimens of methylprednisolone (96 mg/day for 7 days). Among the 71 patients for whom complete follow-up data were obtained, 31 (44%) succeeded in achieving pregnancy in their partners within 12 months of the start of treatment. The pregnancy-achievers and nonachievers were compared with respect to their semen quality, Kibrick titers, and F-D agglutination before and after therapy. No single, clear-cut factor could be identified to explain, or predict, a successful outcome. However, some men did have improved semen quality; of these, 69% achieved a pregnancy in the partner. Furthermore, pregnancy was somewhat more likely to occur if the man had a decrease in Kibrick titer; a decrease in titer was more likely in men whose titers were higher initially. No correlation with F-D agglutination activity was found. side effects were of limited incidence; only 16% of the men had any discomfort at all, and only 2% of them had severe problems. However, all discomfort and problems were transient.