Testicular function in a birth cohort of young men

Single and multi-dose pharmacology of recombinant and urinary human chorionic gonadotrophin in men

OBJECTIVE

Human choriogonadotrophin (hCG) treatment of gonadotrophin-deficient infertile men uses hCG of urinary (uhCG) or recombinant (rhCG) origin, but these treatments have not been compared nor are there studies defining rhCG dosing in men.

DESIGN

hCG products were studied in randomized cross-over single-dose studies of standard (Study 1, 1500 IU and 62.5 µg, respectively) or high (Study 2, 5000 IU and 250 µg) dose and a multi-dose population pharmacology study of hCG use.

PARTICIPANTS

Eight (Study 1) and seven (Study 2) volunteers in cross-over and 52 gonadotrophin-deficient men in the multi-dose study MEASUREMENTS: In cross-over studies, serum testosterone (T), dihydrotestosterone (DHT) and estradiol by liquid chromatography-mass spectrometry (LCMS) and serum hCG, LH, FSH, SHBG and T (observational study) by immunoassays.

RESULTS

After standard and high-dose injection, serum hCG and testosterone responses had similar timing and peak concentrations except for a mildly lower early (<48 h) serum testosterone with uhCG. In the multi-dosing study, both hCGs had similar pharmacokinetics (pooled half-life 5.8 days, p < .001), while serum testosterone concentrations were stable after injection and did not differ between hCG products. Bench testing verified that 20% of pens from 4/10 individuals were used inappropriately.

CONCLUSIONS

Although hCG pharmacokinetics are not formally bioequivalent, the similar pharmacodynamic effects on serum testosterone indicate that at the doses tested both hCGs provide comparable clinical effects. The starting dose of rhCG for treating gonadotrophin-deficient men should be 62.5 µg (6 clicks) of the rhCG pen.

MEHP activates JNK to inhibit the migration of human foreskin fibroblasts

This study aimed to investigate the impact of mono(2-ethylhexyl) phthalate (MEHP) on the proliferation, apoptosis, and migration of human foreskin fibroblast cells (HFF-1) and the role of the JNK signaling pathway in cell migration. HFF-1 cells were randomly assigned to the control group with 0 MEHP exposure (M0) or the experimental groups with 25, 50, 100, 200, and 400 μmol/L MEHP exposure (M25, M50, M100, M200, and M400, respectively). After 24 and 48 h of MEHP exposure, the proliferation of HFF-1 cells in any group had no significant change. However, compared with the M0 group, the M200 and M400 groups presented substantially increased apoptosis of HFF-1 cells. Moreover, cell migration ability significantly decreased in all groups (p < 0.05). Additionally, the transcription and phosphorylated protein activation of JNK kinase in HFF-1 cells were substantially upregulated with the increase in MEHP exposure. Subsequently, HFF-1 cells were randomly divided into three groups: the DMSO blank control group, the 100 μM MEHP experimental group (M100), and the 100 μM MEHP plus 10 μM SP600125 (specific JNK inhibitor) experimental group (S10). The activation of JNK protein in HFF-1 cells was substantially downregulated in the S10 group. HFF-1 cells were also divided into the blank control group (M0). They were treated with 100 μM MEHP and varying concentrations of SP600125 (5, 10, and 15 μM for S5, S10, and S15, respectively). As the concentration of the antagonist increased, the migration ability of HFF-1 cells was returned to normal. Finally, the ROS in HFF-1 cells increased under MEHP exposure. This finding indicates that the regulation of cell migration by the JNK signaling pathway may be important in the occurrence of hypospadias.

Sleep duration and biomarkers of fecundity in young men: a cross-sectional study from a population-based cohort

BACKGROUND

Poor male fecundity is of concern and warrants the identification of potential modifiable risk factors. Short and long sleep duration might be risk factors for poor male fecundity although evidence in this research field is inconsistent.

OBJECTIVES

To investigate the association between sleep duration and biomarkers of male fecundity in young men.

MATERIALS AND METHODS

We conducted a cross-sectional study of 1,055 young men from the Fetal Programming of Semen Quality (FEPOS) cohort, Denmark, 2017-2019. Sleep duration was obtained from an online survey answered by the participants prior to the clinical visit, where semen and blood samples were obtained, and testis volume was self-assessed using an Orchidometer. Percentage differences in semen characteristics, testes volume, and reproductive hormone levels were analysed according to sleep duration using multivariable negative binomial regression models. Sleep duration was dichotomised (recommended (6-9 h/night) versus deviant sleep) and visualised continuously as restricted cubic spline plots.

RESULTS

Deviation from recommended sleep duration was associated with higher high DNA stainability (HDS) of 5% (95% CI: -1%; 13%), higher testosterone of 3% (95% CI: 0%; 7%) and higher free androgen index (FAI) of 6% (95% CI: 0%; 13%). The spline plots overall supported these results, suggesting u-shaped associations between sleep duration and HDS, testosterone and FAI, a linear association between sleep duration and semen volume and sex hormone binding globulin (SHBG) and an inverse u-shaped association with normal morphology.

DISCUSSION

Information on sleep duration was obtained by self-report in broad categories with at least 3 h intervals. We were not able to investigate short or long sleep duration separately, since only few participants reported this.

CONCLUSION

Sleep duration was associated with some biomarkers of fecundity in young men. Maintaining a recommended sleep duration may thus be beneficial for young men with regard to reproductive health.

Parental age at birth and biomarkers of fecundity in young Danish men

BACKGROUND

High parental age is associated with adverse birth and genetic outcomes, but little is known about fecundity in male offspring.

OBJECTIVES

We investigated if high parental age at birth was associated with biomarkers of male fecundity in a large population-based sample of young men.

MATERIALS AND METHODS

We conducted a study of 1057 men from the Fetal Programming of Semen Quality (FEPOS) cohort, a sub-cohort of sons born 1998-2000 into the Danish National Birth Cohort. Semen characteristics and reproductive hormone concentrations were measured in samples provided by the men 2017-2019. Testis volume was determined by self-measurement. Data on the parental age was drawn from registers. Adjusted relative difference in percentage with 95% confidence intervals were estimated for each outcome according to pre-specified maternal and paternal age groups (< 30 (reference), 30-34 and ≥ 35) as well as for combinations of parental age groups, using multivariable negative binomial regression models.

RESULTS

We did not observe consistent associations between parental age and biomarkers of fecundity, although sons of mothers ≥ 35 years had lower sperm concentration (-15% (95% CI: -30, 3)) and total sperm count (-10% (95% CI: -25, 9)). The analysis with parental age combinations showed lower sperm concentration with high age of the parents (both ≥ 35 years: -27%, 95% CI: -40, -19) when compared to the reference where both parents were below 30 years.

DISCUSSION AND CONCLUSION

We found no strong association between higher parental age and biomarkers of fecundity in young men. However, we cannot exclude poorer semen characteristics in sons born by older mothers or with high age of both parents.

Maternal vitamin D levels and male reproductive health: a population-based follow-up study

Maternal vitamin D levels during pregnancy may be important for reproductive health in male offspring by regulating cell proliferation and differentiation during development. We conducted a follow-up study of 827 young men from the Fetal Programming of Semen Quality (FEPOS) cohort, nested in the Danish National Birth Cohort to investigate if maternal vitamin D levels were associated with measures of reproductive health in adult sons. These included semen characteristics, testes volume, and reproductive hormone levels and were analysed according to maternal vitamin D (25(OH)D3) levels during pregnancy. In addition, an instrumental variable analysis using seasonality in sun exposure as an instrument for maternal vitamin D levels was conducted. We found that sons of mothers with vitamin D levels < 25 nmol/L had 11% (95% CI - 19 to - 2) lower testes volume and a 1.4 (95% CI 1.0 to 1.9) times higher risk of having low testes volume (< 15 mL), in addition to 20% (95% CI - 40 to 9) lower total sperm count and a 1.6 (95% CI 0.9 to 2.9) times higher risk of having a low total sperm count (< 39 million) compared with sons of mothers with vitamin D levels > 75 nmol/L. Continuous models, spline plots and an instrumental variable analysis supported these findings. Low maternal vitamin D levels were associated with lower testes volume and lower total sperm count with indications of dose-dependency. Maternal vitamin D level above 75 nmol/L during pregnancy may be beneficial for testes function in adult sons.

Maternal intake of folate and folic acid during pregnancy and markers of male fecundity: A population-based cohort study

BACKGROUND

Poor male fecundity is of concern, and a prenatal origin has been proposed. Folate, a methyl donor involved in DNA methylation, is essential for normal fetal development by regulating gene expression during different periods of fetal development. Thus, prenatal exposure to low maternal folate intake might have a programing function of the developing reproductive organs.

OBJECTIVES

To examine the association between maternal intake of folate from diet and folic acid from supplements during pregnancy and markers of fecundity in young men.

MATERIALS AND METHODS

We conducted a follow-up study using a Danish mother-son cohort of 787 young men born 1998-2000. Percentage differences in semen characteristics, testes volume, and reproductive hormone levels were analyzed according to total folate calculated as dietary folate equivalents from diet and supplements in midpregnancy, using multivariable negative binomial regression models. Total folate was analyzed in quintiles, continuous per standard deviation decrease (SD: 318 μg/day) and as restricted cubic splines.

RESULTS

Low maternal intake of total folate was associated with lower total sperm count (-5% (95% confidence intervals [CI]: -11%; 2%)), a lower proportion of non-progressive and immotile spermatozoa (-5% [95% CI: -8%; -3%]), and lower testes volume (-4% [95% CI: -6%; -2%]) per SD decrease in total folate intake. Spline plots supported these findings.

DISCUSSION

The finding of a lower proportion of non-progressive and immotile spermatozoa, and hence a higher proportion of motile spermatozoa, in men of mothers with a lower intake of total folate in midpregnancy was surprising and may be a chance finding.

CONCLUSION

Lower maternal intake of total folate in midpregnancy was associated with lower sperm count and lower testes volume, however, also with a lower proportion of non-progressive and immotile spermatozoa in adult men. Whether this actually affects the ability to obtain a pregnancy warrants further investigation.

Maternal fever during pregnancy and male offspring reproductive health: A longitudinal cohort study in young Danish males

BACKGROUND

Maternal fever during pregnancy has been associated with an increased risk of genital malformations, but the implication for long-term reproductive health in the offspring is unknown.

OBJECTIVES

To investigate associations between timing, duration, and temperature of fetal exposure to maternal fever and sons' semen quality, testicular volume, and levels of reproductive hormones in early adulthood. Further, to examine whether concurrent use of antipyretics and/or antibiotics modified the effect.

MATERIALS AND METHODS

We used the Fetal Programming of Semen Quality cohort consisting of men born to women enrolled in the Danish National Birth Cohort. Self-reported information on maternal fever was collected twice during pregnancy (median 16 and 31 pregnancy weeks) and categorized as any fever during pregnancy, fever during early pregnancy (weeks 1-15), and fever exclusively during late pregnancy (weeks 16-42). Semen quality and concentrations of reproductive hormones were measured at a clinical examination at the age of 18.9 years. We used negative binomial regression to examine the associations, adjusting for maternal age at birth, maternal smoking, family occupational status, and precision variables related to semen quality and hormonal levels, for example, abstinence time.

RESULTS

986 men were included in the study, of which 23% had mothers reporting at least one episode of fever. We found no strong indications of associations between maternal fever during pregnancy and male reproductive health in young men. Concurrent use of antipyretics and antibiotics did not modify the association.

DISCUSSION

Strengths include the large sample size, prospectively collected data, and the adjustment for maternal factors during pregnancy and important precision variables. A limitation is the crude self-reported information on maternal fever.

CONCLUSION

We found no evidence to support that timing, duration, or temperature of maternal fever during pregnancy has a long-term impact on semen characteristics, testicular volume, or level of reproductive hormones in male offspring.

Marijuana Is Associated With a Hormonal Imbalance Among Several Habits Related to Male Infertility: A Retrospective Study

Marijuana is one of the most consumed drugs worldwide. There is increasing evidence of an association between marijuana and male infertility. This study intends to assess the repercussion of marijuana smoking and other habits (sedentary lifestyle, alcohol, and tobacco use) in the testicular function of infertile men seeking andrological evaluation. A retrospective study was performed using medical records data of men aged 18-59 years from 2009 to 2017. Complete semen analyses, sperm functional tests, SHBG, and hormonal levels, testosterone-to-estradiol ratio (T/E2), and testis volume were evaluated. Exclusion criteria included cryptorchidism, infertility caused by genetic or infectious diseases, and cancer. A multiple linear regression analysis was performed to investigate which habit could predict certain parameters using the software SPSS 23.0 (P < 0.05). In a sample of 153 men, semen parameters, testosterone levels, and testis volume were not significantly influenced. Marijuana use had the broader hormonal changes since it influences estradiol (P = 0.000; B = -11.616), prolactin (P = 0.000; B = 3.211), SHBG levels (P = 0.017; B = 7.489), and T/E2 (P = 0.004; B = 14.030). Sedentary lifestyle (P = 0.028; B = 1.279) and tobacco smoking (P = 0.031; B = -2.401) influenced the prolactin levels. Marijuana is associated with hormonal imbalance in this infertile cohort by lowering estradiol levels and inhibiting aromatase function.

Parental Separation and Semen Quality in Young Men: A Population-Based Cohort Study

Purpose

Parental separation may be a stressful life event with the potential to influence hormonal regulation of offspring reproductive health and thereby affect semen quality in young men. We aimed to study the association between parental separation in pregnancy or in childhood and semen quality in young men and to study whether the timing of parental separation in childhood was important.

Patients and Methods

We conducted a follow-up study of 1058 young men born 1998–2000 from the Fetal Programming of Semen Quality (FEPOS) cohort nested within the Danish National Birth Cohort. Data on parental separation were obtained longitudinal by self-report. Parental separation in pregnancy was dichotomized, and parental separation in childhood was both dichotomized and categorized according to the timing of parental separation (from birth, from early childhood (0–5 years), and from late childhood (6–10 years)). Semen volume, concentration, total sperm count, motility, morphology, and testes volume were analysed using multivariable negative binomial regression models.

Results

Parental separation in pregnancy was not associated with semen quality. The association between parental separation in childhood and semen quality differed with the timing of parental separation. Parental separation from birth was associated with higher semen volume of 25%, 95% CI (−5; 64); higher total sperm count of 62%, 95% CI (−6; 179); and higher proportion of morphologically normal spermatozoa of 59%, 95% CI (20; 111). Parental separation in early childhood was associated with lower semen volume of −14%, 95% CI (−24; −3); lower concentration of −15%, 95% CI (−28; 1); lower total sperm count of −17%, 95% CI (−32; 2) and lower testes volume of −11%, 95% CI (−18; −3).

Conclusion

The timing of parental separation was important, and parental separation from birth was associated with higher semen quality, and parental separation in early childhood was associated with lower semen quality.

Association of diabetes and obesity with sperm parameters and testosterone levels: a meta-analysis

BACKGROUND

The present study performed two distinct meta-analyses with common outcomes (sperm parameters); one was performed in obese individuals (and non-obese controls) and the other in diabetic individuals (and non-diabetic controls).

METHODS

PubMed, Embase, The Cochrane library, Web of Science, Scopus databases were searched to collect clinical studies related to the effects of obesity and diabetes on male sperm from inception to on 1st February 2021. Statistical meta-analyses were performed using the RevMan 5.4 software. Stata16 software was used to detect publication bias. The methodological quality of the included studies was assessed with the Ottawa-Newcastle scale using a star-based system.

RESULTS

A total of 44 studies were finally included in the present study, which enrolled 20,367 obese patients and 1386 patients with diabetes. The meta-analysis results showed that both obesity and diabetes were associated with reduced semen volume (obese versus non-obese controls: mean difference (MD) = - 0.25, 95% CI = (- 0.33, - 0.16), p < 0.001; diabetes versus non-diabetic controls: MD = - 0.45, 95% CI = (- 0.63, - 0.27), p < 0.001), reduced sperm count (obese versus non-obese controls: MD = - 23.84, 95% CI = (- 30.36, - 17.33), p < 0.001; diabetes versus non-diabetic controls: MD = - 13.12, 95% CI = (- 18.43, - 7.82), p < 0.001), reduced sperm concentration (obese versus non-obese controls: MD = - 7.26, 95% CI = (- 10.07, - 4.46), p < 0.001; diabetes versus non-diabetic controls: MD = - 11.73, 95% CI = (- 21.44, - 2.01), p = 0.02), reduced progressive motility (obese versus non-obese controls: MD = - 5.68, 95% CI = (- 8.79, - 2.56), p < 0.001; diabetes versus non-diabetic controls: MD = - 14.37, 95% CI = (- 21.79, - 6.96), p = 0.001), and decreased testosterone levels (obese versus non-obese controls: MD = - 1.11, 95% CI = (- 1.92, - 0.30), p = 0.007; diabetes versus non-diabetic controls: MD = - 0.37, 95% CI = (- 0.63, - 0.12), p = 0.004).

CONCLUSIONS

Current evidence suggests that obesity and diabetes negatively affect sperm parameters in men and are associated with low testosterone levels. Due to the limitation of the number and quality of included studies, the above conclusions need to be verified by more high-quality studies.

Impaired semen quality in trans women: prevalence and determinants

STUDY QUESTION

What is the semen quality in trans women at time of fertility preservation, prior to the start of gender-affirming hormone treatment?

SUMMARY ANSWER

Before the start of gender-affirming hormone treatment, semen quality in trans women was already strongly decreased compared to the general population.

WHAT IS KNOWN ALREADY

Hormone treatment for -trans women (birth-assigned males, female gender identity) consists of anti-androgens combined with estrogens in order to achieve feminization and it is accompanied by a loss of reproductive capability. Trans women can opt for semen cryopreservation prior to their medical transition to retain the possibility to parent genetically related offspring. Post-thaw semen parameters determine which ART can be used. Knowledge of semen quality and the factors negatively influencing semen parameters in trans women are important to improve semen quality before fertility preservation.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study was performed between 1972 and 2017. In total, 260 trans women were included for this study. Due to the study design, there was no loss to follow-up or attrition.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied the quality of the preserved semen in trans women, prior to their medical transition, who visited our gender clinic. Semen parameters were collected, as well as data on age, alcohol consumption, smoking, cannabis use, BMI, previous use of estrogens or anti-androgens and endocrine laboratory results. Semen parameters were categorized using reference values for human semen of the World Health Organization (WHO) and compared with data from the general population. Logistic regression analyses were performed to analyze the extent to which factors known to have a negative impact on semen quality in the general population explained the impaired semen quality in the cohort.

MAIN RESULTS AND THE ROLE OF CHANCE

The cohort consisted of 260 trans women between the age of 16 and 52 years. Semen quality in trans women was significantly decreased compared to WHO data from the general population. In total, 21 trans women had an azoospermia and median semen parameters for the remaining trans women and the general population, respectively, were as follows: volume 2.7 and 3.2 ml (P < 0.05), sperm concentration 40 and 64 million/ml (P < 0.05), total sperm number 103 and 196 million (P < 0.05) and progressive motility 41% and 57% (P < 0.05). Smoking (odds ratio (OR) 2.35 (95% CI 1.06–5.21)) and a higher age at time of fertility preservation (OR 1.04 (95% CI 1.00–1.08)) were found to correlate with an impaired progressive motility. Twelve trans women reported to have used anti-androgens and estrogens, and all had discontinued for at least 3 months prior to the first attempt for semen cryopreservation. No correlation was found between previous gender-affirming hormone use and decreased semen parameters. The median post-thaw total motile sperm count was 1.0 million per vial (interquartile range 0.1–3.1) and in only 26.4% of thawed semen samples was the quality adequate for a minimally invasive IUI.

LIMITATIONS, REASONS FOR CAUTION

Limitations include the retrospective design and insufficient data on transgender-specific factors, such as bringing the testes into the inguinal position (tucking), wearing tight underwear and low masturbation frequency.

WIDER IMPLICATIONS OF THE FINDINGS

Semen quality in trans women was decreased compared to the general population, which could not be explained by known risk factors, such as BMI, alcohol consumption, cannabis use, gender-affirming hormone use or abnormal endocrine laboratory results. Although a negative impact of smoking was observed, it was insufficient to explain the overall decreased semen quality in this cohort. Since low pre-freeze semen quality results in an even lower post-thaw semen quality, the majority of trans women and their female partner or surrogate may need an invasive and burdensome treatment to establish a pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

For this study, no external funding was obtained and there were no competing interests.

TRIAL REGISTRATION NUMBER

NA.

Male infertility due to testicular disorders

CONTEXT

Male infertility is defined as the inability to conceive following 1 year of regular unprotected intercourse. It is the causative factor in 50% of couples and a leading indication for assisted reproductive techniques (ART). Testicular failure is the most common cause of male infertility, yet the least studied to date.

EVIDENCE ACQUISITION

The review is an evidence-based summary of male infertility due to testicular failure with a focus on etiology, clinical assessment, and current management approaches. PubMed-searched articles and relevant clinical guidelines were reviewed in detail.

EVIDENCE SYNTHESIS/RESULTS

Spermatogenesis is under multiple levels of regulation and novel molecular diagnostic tests of sperm function (reactive oxidative species and DNA fragmentation) have since been developed, and albeit currently remain as research tools. Several genetic, environmental, and lifestyle factors provoking testicular failure have been elucidated during the last decade; nevertheless, 40% of cases are idiopathic, with novel monogenic genes linked in the etiopathogenesis. Microsurgical testicular sperm extraction (micro-TESE) and hormonal stimulation with gonadotropins, selective estrogen receptor modulators, and aromatase inhibitors are recently developed therapeutic approaches for men with the most severe form of testicular failure, nonobstructive azoospermia. However, high-quality clinical trials data is currently lacking.

CONCLUSIONS

Male infertility due to testicular failure has traditionally been viewed as unmodifiable. In the absence of effective pharmacological therapies, delivery of lifestyle advice is a potentially important treatment option. Future research efforts are needed to determine unidentified factors causative in "idiopathic" male infertility and long-term follow-up studies of babies conceived through ART.

Low Testosterone and Semen Parameters in Male Partners of Infertile Couples Undergoing IVF with a Total Sperm Count Greater than 5 Million

Low serum testosterone is found in approximately 15% of subfertile men. Although testosterone is essential in spermatogenesis, it is unclear whether low testosterone levels may have a negative impact on the semen parameters of men belonging to infertile couples with a total sperm count greater than 5 million. Furthermore, it is debatable whether the initial evaluation of the subfertile male should include an endocrine assessment. This was a retrospective, single-center cohort study conducted at a tertiary fertility clinic. Male partners of infertile couples undergoing in vitro fertilization (IVF), with a total sperm count greater than 5 million, were included. All men provided morning blood samples, and none had been on exogenous testosterone or other relevant medications. Low total testosterone (TT) was defined as <264 ng/dL. Free T was calculated using TT and sex hormone-binding globulin (SHBG) levels (nmol/L) by a constant albumin concentration of 43 g/L. In total, 853 patients were included: 116 had low TT (<264 ng/dL) and 737 had normal TT (≥264 ng/dL). Semen volume, sperm cell count, progressive (A + B) motility and morphology (≥4% strict Kruger) were lower in the low TT group but not significantly different between low and normal TT groups (3.2 ± 1.79 vs. 3.23 ± 1.64, p = 0.87; 76.82 ± 83.18 vs. 67.55 ± 57.70, p = 0.7; 54.89 ± 19.45 vs. 56.25 ± 19.03, p = 0.6; 5.77 ± 3.23 vs. 6.89 ± 3.94, p = 0.23). The percentage of patients with below-reference sperm volume (<1.5 mL), cell count (<15 × 106/mL), motility (A + B) (<32%) and morphology (<4%) was higher in the low TT group but not statistically different compared to the normal TT group. Multivariable regression analysis revealed that low TT and free T levels had no significant effect on the aforementioned semen parameters (coefficient: 3.94, 0.88, 1.37, 0.39; p = 0.53, 0.8, 0.3, 0.2; coefficient: 0.001, 0.06, 0.007, 0.0002; p = 0.73, 0.52, 0.85, 0.98). Despite our robust methodological approach, the presence of biases related to retrospective design cannot be excluded. Our findings highlighted the lack of association between low TT levels and semen parameter alterations in male partners of infertile couples undergoing IVF, with a total sperm count greater than 5 million. However, it is important to emphasize that more patients in the low TT group had subnormal semen parameters, albeit the difference was not statistically significant. Larger, prospective studies are warranted in order to validate these findings, as well as to investigate the existence of a TT threshold below which semen parameters might be negatively affected.

Regional difference in semen quality of young men: a review on the implication of environmental and lifestyle factors during fetal life and adulthood

The prevalence of low semen quality and the incidence of testicular cancer have been steadily increasing over the past decades in different parts of the World. Although these conditions may have a genetic or epigenetic origin, there is growing evidence that multiple environmental and lifestyle factors can act alone or in combination to induce adverse effects. Exposure to these factors may occur as early as during fetal life, via the mother, and directly throughout adulthood after full spermatogenic capacity is reached. This review aims at providing an overview of past and current trends in semen quality and its relevance to fertility as well as a barometer of men’s general health. The focus will be on recent epidemiological studies of young men from the general population highlighting geographic variations in Europe. The impact of some lifestyle and environmental factors will be discussed with their role in both fetal life and adulthood. These factors include smoking, alcohol consumption, psychological stress, exposure to electromagnetic radiation, and Endocrine Disrupting Chemicals (EDCs). Finally, the challenges in investigating the influence of environmental factors on semen quality in a fast changing world are presented.

Health and fertility of ICSI-conceived young men: study protocol

STUDY QUESTIONS

What are the long-term health and reproductive outcomes for young men conceived using ICSI whose fathers had spermatogenic failure (STF)? Are there epigenetic consequences of ICSI conception?

WHAT IS KNOWN ALREADY

Currently, little is known about the health of ICSI-conceived adults, and in particular the health and reproductive potential of ICSI-conceived men whose fathers had STF. Only one group to date has assessed semen parameters and reproductive hormones in ICSI-conceived men and suggested higher rates of impaired semen quality compared to spontaneously conceived (SC) peers. Metabolic parameters in this same cohort of men were mostly comparable. No study has yet evaluated other aspects of adult health.

STUDY DESIGN SIZE DURATION

This cohort study aims to evaluate the general health and development (aim 1), fertility and metabolic parameters (aim 2) and epigenetic signatures (aim 3) of ICSI-conceived sons whose fathers had STF (ICSI study group). There are three age-matched control groups: ICSI-conceived sons whose fathers had obstructive azoospermia (OAZ) and who will be recruited in this study, as well as IVF sons and SC sons, recruited from other studies. Of 1112 ICSI parents including fathers with STF and OAZ, 78% (n = 867) of mothers and 74% (n = 823) of fathers were traced and contacted. Recruitment of ICSI sons started in March 2017 and will finish in July 2020. Based on preliminary participation rates, we estimate the following sample size will be achieved for the ICSI study group: mothers n = 275, fathers n = 225, sons n = 115. Per aim, the sample sizes of OAZ-ICSI (estimated), IVF and SC controls are: Aim 1-OAZ-ICSI: 28 (maternal surveys)/12 (son surveys), IVF: 352 (maternal surveys)/244 (son surveys), SC: 428 (maternal surveys)/255 (son surveys); Aim 2-OAZ-ICSI: 12, IVF: 72 (metabolic data), SC: 391 (metabolic data)/365 (reproductive data); Aim 3-OAZ-ICSI: 12, IVF: 71, SC: 292.

PARTICIPANTS/MATERIALS SETTING METHODS

Eligible parents are those who underwent ICSI at one of two major infertility treatment centres in Victoria, Australia and gave birth to one or more males between January 1994 and January 2000. Eligible sons are those aged 18 years or older, whose fathers had STF or OAZ, and whose parents allow researchers to approach sons. IVF and SC controls are age-matched men derived from previous studies, some from the same source population. Participating ICSI parents and sons complete a questionnaire, the latter also undergoing a clinical assessment. Outcome measures include validated survey questions, physical examination (testicular volumes, BMI and resting blood pressure), reproductive hormones (testosterone, sex hormone-binding globulin, FSH, LH), serum metabolic parameters (fasting glucose, insulin, lipid profile, highly sensitive C-reactive protein) and semen analysis. For epigenetic and future genetic analyses, ICSI sons provide specimens of blood, saliva, sperm and seminal fluid while their parents provide a saliva sample. The primary outcomes of interest are the number of mother-reported hospitalisations of the son; son-reported quality of life; prevalence of moderate-severe oligozoospermia (sperm concentration <5 million/ml) and DNA methylation profile. For each outcome, differences between the ICSI study group and each control group will be investigated using multivariable linear and logistic regression for continuous and binary outcomes, respectively. Results will be presented as adjusted odds ratios and 95% CIs.

STUDY FUNDING/COMPETING INTERESTS

This study is funded by an Australian National Health and Medical Research Council Partnership Grant (NHMRC APP1140706) and was partially funded by the Monash IVF Research and Education Foundation. L.R. is a minority shareholder and the Group Medical Director for Monash IVF Group, and reports personal fees from Monash IVF group and Ferring Australia, honoraria from Ferring Australia, and travel fees from Merck Serono, MSD and Guerbet; R.J.H. is the Medical Director of Fertility Specialists of Western Australia and has equity in Western IVF; R.I.M. is a consultant for and a shareholder of Monash IVF Group and S.R.C. reports personal fees from Besins Healthcare and non-financial support from Merck outside of the submitted work. The remaining authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

TRIAL REGISTRATION DATE

Not applicable.

DATE OF FIRST PATIENT’S ENROLMENT

Not applicable.

Palmitic Acid Targets Human Testicular Peritubular Cells and Causes a Pro-Inflammatory Response

Palmitic acid (PA) is a major fatty acid, derived from diet and endogenous production, which is being linked to inflammation. While such actions of PA at the level of the testis remain difficult to examine, we reasoned that studies in human testicular cells may be instructive. Human testicular peritubular cells (HTPCs) can be isolated from men and cultured. They have contractile properties but also produce Interleukin 6 (IL6), express the inflammasome member NLRP3, and via glia cell line derived neurotrophic factor (GDNF), they contribute to the spermatogonial stem cell niche. We found that PA at 100 µM significantly increased the levels of IL6, while NLRP3 or the related Interleukin 1 beta (IL1beta) were not affected. The contractility marker calponin (CNN1) and the growth factor GDNF were likewise not affected. ELISA studies confirmed the stimulatory PA actions on IL6. Hence, PA derived from diet and/or endogenous sources may be able to foster a pro-inflammatory milieu in the testis. A possible link of these results to diet and high fat intake and obesity is indicated by the about 12-fold elevated testicular levels of IL6 in testes of obese rhesus monkeys (n = 3), fed with a Western Style diet. They had elevated 2–5-fold increased body fat and increased circulating triglyceride levels. Further consequences of PA and obesity for testicular functions remain to be evaluated.

Fetal Programming of Semen Quality (FEPOS) Cohort - A DNBC Male-Offspring Cohort

BACKGROUND

Prenatal exposures may contribute to male infertility in adult life, but large-scale epidemiological evidence is still lacking. The Fetal Programming of Semen quality (FEPOS) cohort was founded to provide means to examine if fetal exposures can interfere with fetal reproductive development and ultimately lead to reduced semen quality and reproductive hormone imbalances in young adult men.

METHODS

Young adult men at least 18 years and 9 months of age born to women in the Danish National Birth Cohort living in relative proximity to Copenhagen or Aarhus and for whom a maternal blood sample and two maternal interviews during pregnancy were available were invited to FEPOS. Recruitment began in March 2017 and ended in December 2019. The participants answered a comprehensive questionnaire and underwent a physical examination where they delivered a semen, urine, and hair sample, measured their own testicular volume, and had blood drawn.

RESULTS

In total 21,623 sons fulfilled eligibility criteria of whom 5697 were invited and 1058 participated making the response rate 19%. Semen characteristics did not differ between sons from the Copenhagen and Aarhus clinics. When comparing the FEPOS semen parameters to similar cohorts, the median across all semen characteristics was slightly lower for FEPOS participants, although with smaller variation.

CONCLUSION

With its 1058 young adult men, the FEPOS cohort is the largest population-based male-offspring cohort worldwide specifically designed to investigate prenatal determinants of semen quality. Wide-ranging information on maternal health, lifestyle, socioeconomic status, occupation, and serum concentrations of potential reproductive toxicants during pregnancy combined with biological markers of fertility in their sons collected after puberty allow for in-depth investigations of the 'fetal origins of adult disease hypothesis'.

Semen quality of young men in Switzerland: a nationwide cross-sectional population-based study

BACKGROUND

Sperm counts have been steadily decreasing over the past five decades with regional differences in the Western world. The reasons behind these trends are complex, but numerous insights indicate that environmental and lifestyle factors are important players.

OBJECTIVE

To evaluate semen quality and male reproductive health in Switzerland.

MATERIALS AND METHODS

A nationwide cross-sectional study was conducted on 2523 young men coming from all regions of Switzerland, recruited during military conscription. Semen volume, sperm concentration, motility, and morphology were analyzed. Anatomy of the genital area and testicular volume was recorded. Testicular cancer incidence rates in the general population were retrieved from Swiss regional registries.

RESULTS

Median sperm concentration adjusted for period of sexual abstinence was 48 million/mL. Comparing with the 5th percentile of the WHO reference values for fertile men, 17% of men had sperm concentration below 15 million/mL, 25% had less than 40% motile spermatozoa, and 43% had less than 4% normal forms. Disparities in semen quality among geographic regions, urbanization rates, and linguistic areas were limited. A larger proportion of men with poor semen quality had been exposed in utero to maternal smoking. Furthermore, testicular cancer incidence rates in the Swiss general population increased significantly between 1980 and 2014.

DISCUSSION

For the first time, a systematic sampling among young men has confirmed that semen quality is affected on a national level. The median sperm concentration measured is among the lowest observed in Europe. No specific geographical differences could be identified. Further studies are needed to determine to what extent the fertility of Swiss men is compromised and to evaluate the impact of environmental and lifestyle factors.

CONCLUSION

A significant proportion of Swiss young men display suboptimal semen quality with only 38% having sperm concentration, motility, and morphology values that met WHO semen reference criteria.

Pharmacokinetics and Acceptability of Subcutaneous Injection of Testosterone Undecanoate

Context

Can injectable testosterone undecanoate (TU) be administered effectively and acceptably by the subcutaneous (SC) route?

Objective

To investigate the acceptability and pharmacokinetics (PK) of SC injection of TU.

Design

Randomized sequence, crossover clinical study of SC vs IM TU injections.

Setting

Ambulatory clinic of an academic andrology center.

Participants

Twenty men (11 hypogonadal, 9 transgender men) who were long-term users of TU. injections. Intervention: Injection of 1000 mg TU (in 4 mL castor oil vehicle) by SC or IM route. Main Outcome Measures: Patient-reported pain, acceptability, and preference scales. PK by measurement of serum testosterone, dihydrotestosterone (DHT), and estradiol (E₂) concentrations with application of population PK methods and dried blood spot (DBS) sampling.

Results

Pain was greater after SC compared with IM injection 24 hours (but not immediately) after injection but both routes were equally acceptable. Ultimately 11 preferred IM, 6 preferred SC, and 3 had no preference. The DBS-based PK analysis of serum testosterone revealed a later time of peak testosterone concentration after SC vs IM injection (8.0 vs 3.3 days) but no significant route differences in model-predicted peak testosterone concentration (8.4 vs 9.6 ng/mL) or mean resident time (183 vs 110 days). The PK of venous serum testosterone, DHT, and E₂ did not differ according to route of injection.

Conclusions

We conclude that SC TU injection is acceptable but produces greater pain 24 hours after injection that may contribute to the overall majority preference for the IM injection. The PK of testosterone, DHT, or E₂ did not differ substantially between SC and IM routes. Hence whereas further studies are required, the SC route represents an alternative to IM injections without a need to change dose for men for whom IM injection is not desired or recommended.

Low total motile sperm in transgender women seeking hormone therapy

PURPOSE

This study was undertaken to compare semen quality, hormonal status, and social factors in transgender women seeking fertility preservation with those of fertile cisgender men. Long-range goals are to establish standard practice measures ensuring optimum semen quality for cryopreservation and fertility preservation in transgender women.

METHODS

This is a case-control study carried out at an academic medical center. Cases are transgender women seeking fertility preservation prior to initiation of hormone therapy. Controls are cisgender men recently fathering a child. All participants completed the Depression Anxiety Stress Scales 21 survey and additional survey questions related to personal behaviors. Complete semen analysis was carried out in a clinical andrology laboratory according to WHO guidelines, 5th edition. Serum follicle stimulating hormone, estradiol, and testosterone were measured at the time of semen analysis.

RESULTS

Sperm concentration, total sperm per ejaculate, total motile sperm, volume, and normal sperm morphology were significantly lower in transgender females compared with fertile cisgender men. Other measures of semen parameters and hormone concentrations were not different between groups. Survey results indicated transgender women were more likely to have symptoms of depression, anxiety, and stress and utilize tucking and tight undergarments, compared with controls; however, both groups reported similar numbers of ejaculations per week.

CONCLUSIONS

Although semen parameters were low, cryopreservation of sperm prior to hormone therapy is a viable fertility preservation option for most transgender women. The etiology of the differences in semen parameters is not known. Enhanced education related to personal behaviors or treatment to reduce effects of stressors prior to cryopreservation may improve future fertility potential.

Risk factors affecting post-pubertal high serum follicle-stimulating hormone in patients with hypospadias

Purpose

The factors affecting spermatogenesis in adulthood in patients with hypospadias (HS) are not clearly understood. In the present study, risk factors affecting post-pubertal high serum follicle-stimulating hormone (FSH) were evaluated in patients with HS.

Materials and methods

Among those with a history of HS surgery, patients in whom endocrinological evaluation regarding pituitary–gonadal axis was performed at 15 years of age or older between March 2004 and April 2018 were enrolled in the present study. High serum FSH was defined as greater than 10 mIU/ml. The severity of HS was divided into mild and severe. Factors affecting the post-pubertal high serum FSH were estimated.

Results

Seventy-nine patients were included in the present study. The severity of HS was mild in 35 and severe in 44. History of undescended testis (UDT) was confirmed in 12. High serum FSH was detected in nine. On logistic regression model analysis, a history of UDT was the only significant factor for high serum FSH. The incidence of high serum FSH in patients with UDT was significantly higher than that in those without UDT (58.3% vs 7.5%, p < 0.01). When stratified by severity of HS and the presence of UDT, high serum FSH was detected in 70% in patients with severe HS and UDT, whereas less than 10% in other groups.

Conclusions

A history of UDT was a significant factor for post-pubertal high serum FSH in patients with HS. Accordingly, the presence of UDT may be a marker for impaired spermatogenesis in patients with HS, especially in severe cases.

Sleep Duration Is Associated With Testis Size in Healthy Young Men

STUDY OBJECTIVES

Sleep is increasingly recognized to influence a growing array of physiological processes. The relationship between sleep duration and testis size, a marker of male reproductive potential, has not been studied.

METHODS

This was a preliminary cross-sectional analysis of the baseline data from 92 healthy men (mean ± standard deviation, age 33 ± 6 years, body mass index [BMI] 24.7 ± 6.1 kg/m2), of whom 66 underwent at-home actigraphy and 47 underwent in-laboratory polysomnography. Sleep duration and architecture were measured by actigraphy and polysomnography, testicular volume by Prader orchidometer, total testosterone by liquid chromatography tandem mass spectrometry, free testosterone by equilibrium dialysis, and luteinizing hormone and follicle-stimulating hormone (FSH) by immunochemiluminometric assay.

RESULTS

Sleep duration was correlated with testicular volume (r = .31, P = .046) and with FSH (r = -.30, P = .035), and rapid eye movement sleep was correlated with FSH (r = .44, P = .006). The significance of these findings did not change after adjustment for age and BMI, and were confirmed nonparametrically by resampling. A putative inverse U-shaped relationship between testicular volume and sleep duration was observed by polynomial regression (P = .049), but not with resampling (P = .068).

CONCLUSIONS

There is a positive linear and a possible inverse U-shaped relationship between sleep duration and testis volume. Longitudinal or interventional studies manipulating sleep are required to better define causality, and ultimately to establish how much sleep is needed to maximize male reproductive potential.

CLINICAL TRIAL REGISTRATION

Title: Hormonal Mechanisms of Sleep Restriction, Registry: ClinicalTrials.gov, Identifier: NCT02256865, URL: https://clinicaltrials.gov/ct2/show/NCT02256865.

Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance

Elite athletic competitions have separate male and female events due to men's physical advantages in strength, speed, and endurance so that a protected female category with objective entry criteria is required. Prior to puberty, there is no sex difference in circulating testosterone concentrations or athletic performance, but from puberty onward a clear sex difference in athletic performance emerges as circulating testosterone concentrations rise in men because testes produce 30 times more testosterone than before puberty with circulating testosterone exceeding 15-fold that of women at any age. There is a wide sex difference in circulating testosterone concentrations and a reproducible dose-response relationship between circulating testosterone and muscle mass and strength as well as circulating hemoglobin in both men and women. These dichotomies largely account for the sex differences in muscle mass and strength and circulating hemoglobin levels that result in at least an 8% to 12% ergogenic advantage in men. Suppression of elevated circulating testosterone of hyperandrogenic athletes results in negative effects on performance, which are reversed when suppression ceases. Based on the nonoverlapping, bimodal distribution of circulating testosterone concentration (measured by liquid chromatography-mass spectrometry)-and making an allowance for women with mild hyperandrogenism, notably women with polycystic ovary syndrome (who are overrepresented in elite athletics)-the appropriate eligibility criterion for female athletic events should be a circulating testosterone of <5.0 nmol/L. This would include all women other than those with untreated hyperandrogenic disorders of sexual development and noncompliant male-to-female transgender as well as testosterone-treated female-to-male transgender or androgen dopers.

Early pubertal timing is associated with lower sperm concentration in college students

To study the associations between pubertal timing and semen quality and reproductive hormones, 680 volunteers were recruited from universities in Chongqing, China. Pubertal timing was obtained using a questionnaire. The main measurements were five routine semen parameters and six reproductive hormones. After adjusting for potential confounders, we found that early pubertal timing was associated with lower sperm concentration. An one-year increase in age of peak height velocity was associated with a 4.7% (95% confidence interval [CI] = 1.0 to 8.6) increase in sperm concentration. An one-year increase in age of first spermatorrhea was associated with a 6.4% increase in sperm concentration and a 2.9% decrease in semen volume (95% CI = 1.7 to 11.3, -5.5 to -0.3; respectively). Regarding reproductive hormones, an one-year increase in age of height spurt and peak height velocity was associated with a 6.5% and a 6.7% decrease in estrogen (95% CI = -9.8 to -3.0, -10.4 to -2.8; respectively). While an one-year increase in age of height spurt was associated with higher follicle-stimulating hormone (% change = 2.6, 95% CI = 0.2 to 4.7). This was the first report that has suggested that early pubertal timing is associated with lower sperm concentration. However, further study is still needed to validate this association and fully elucidate the mechanism behind it.

The Possible Impact of Antenatal Exposure to Ubiquitous Phthalates Upon Male Reproductive Function at 20 Years of Age

Phthalates are ubiquitous environmental endocrine-disrupting chemicals suspected to interfere with developmental androgen action leading to adverse effects on male reproductive function. Prenatal exposure studies in rodents show cryptorchidism, hypospadias and reduced testicular volume (TV), testosterone and anogenital distance in males. It is postulated that there is a developmental window in utero when phthalate exposure has the most potent adverse effects. Some human studies show associations between prenatal phthalate exposure and reduced calculated "free" serum testosterone in infant boys and shorter anogenital distance. However, there are no data available yet which link antenatal exposure to long-term effects in men. We aimed to correlate antenatal phthalate exposure with adult TV, semen parameters and serum reproductive hormone concentrations. 913 men from the Western Australian (Raine) Pregnancy Cohort were contacted aged 20-22 years. 423 (56%) agreed to participate; 404 underwent testicular ultrasound examination; 365 provided semen samples, and reproductive hormones were measured in 384. Maternal antenatal serum phthalate metabolite measurements were available for 185 and 111 men, who provided serum and semen, respectively. Maternal serum collected at 18 and 34 weeks gestation, stored at -80°C, was pooled and analyzed for 32 phthalate metabolites by liquid chromatography-tandem mass spectrometry. TV was calculated, semen analysis performed by WHO approved methods, and serum concentrations of gonadotrophins, inhibin B, and testosterone measured. Eleven phthalate metabolites were detected. Primary and secondary metabolites of di-(2-ethyl-hexyl) phthalate (DEHP) and di-iso-nonyl phthalate (DiNP) were positively correlated. After correction for adult height, BMI, presence of a varicocele and exposure to maternal smoking mono-iso-nonyl phthalate (MiNP) (r = -0.22) and sums of DEHP and DiNP metabolites (r = -0.24) and the sum of the metabolites of the high molecular weight phthalates (r = -0.21) were negatively correlated with TV (all p < 0.05). After adjustment for BMI adult serum total testosterone was positively associated with exposure to the following antenatal serum phthalate metabolites: mono-(2-ethylhexyl) phthalate (r = 0.26), MiNP (r = 0.18), the sum of metabolites for DEHP (r = 0.21) and DiNP (r = 0.18), and the sum of high molecular phthalates (r = 0.20) (p = 0.0005 to p = 0.02). Given sample size, storage duration and confounding through postnatal exposures, further studies are required.

The difference in expression of long noncoding RNAs in rat semen induced by high-fat diet was associated with metabolic pathways

Background

Obesity, a common metabolic disease, is a known cause of male infertility due to its associated health risk. Long noncoding RNAs (lncRNAs) have also been reported to be associated with male reproductive diseases; however, their role in the association between high-fat diet-induced obesity (DIO) and male reproduction remains unclear.

Methods

We used microarray analysis to compare the expression levels of lncRNAs and mRNAs in the spermatozoa of rats with DIO and normal rats. We selected a few lncRNAs that were obviously up-regulated or down-regulated, and then used RT-PCR to verify the accuracy of their expression. We then performed a functional enrichment analysis of the differentially expressed mRNAs using gene ontology and pathway analysis. Finally, target gene predictive analysis was used to explore the relationship between lncRNAs and mRNAs.

Results

The results revealed a statistically significant difference in the fasting blood glucose level in rats with DIO and control rats. We found that 973 lncRNAs and 2,994 mRNAs were differentially expressed in the sperm samples of the DIO rats, compared to the controls. GO enrichment analysis revealed 263 biological process terms, 39 cellular component terms, and 40 molecular function terms (p < 0.01) in the differentially expressed mRNAs. The pathway analysis showed that metabolic pathways were most enriched in protein-coding genes.

Discussion

To the best of our knowledge, this is the first report to show differences in the expression levels of lncRNAs and mRNAs in the sperms of rats with DIO and normal rats, and to determine the expression profile of lncRNAs in the sperm of rats with DIO. Our results have revealed a number of lncRNAs and pathways associated with obesity-induced infertility, including metabolic pathways. These pathways could be new candidates that help cope with and investigate the mechanisms behind the progression of obesity-induced male infertility.

Reproductive hormones of ICSI-conceived young adult men: the first results

STUDY QUESTION

Are reproductive hormone levels (FSH, LH, inhibin B and testosterone) in male offspring conceived by ICSI because of male infertility comparable with those from peers born after spontaneous conception?

SUMMARY ANSWER

In this cohort of 54 young men conceived by ICSI because of male-factor infertility, mean and median reproductive hormone levels were found to be comparable with results from spontaneously conceived peers, but ICSI-conceived men were more likely to have low inhibin B (<10th percentile) and high FSH (>90th percentile) levels.

WHAT IS KNOWN ALREADY

Since the worldwide oldest ICSI offspring have recently reached young adulthood, their reproductive health can now be investigated. This typically involves semen analysis and a hormonal profiling including the measurement of FSH, LH, inhibin B and testosterone. Circulating levels of FSH and inhibin B are generally known as markers of the exocrine function of the testis, i.e. spermatogenesis, while LH and testosterone reflect its endocrine function. We have previously observed a normal pubertal development and comparable levels of inhibin B and testosterone among pubertal ICSI boys when compared to spontaneously conceived peers. However, at present, information on the gonadal function of ICSI offspring in adulthood is still lacking.

STUDY DESIGN, SIZE, DURATION

This study, conducted between March 2013 and April 2016 at the UZ Brussel, is part of a larger follow-up project focusing on reproductive and metabolic health of young adults between 18 and 22 years and conceived after ICSI because of male infertility. The ICSI men are part of a longitudinally followed cohort while the spontaneously conceived controls were recruited cross-sectionally.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Results of a single fasting blood sample from 54 young adult ICSI men were compared to that of 57 spontaneously conceived peers. Reproductive hormone analysis involved FSH, LH, testosterone and inhibin B measurement. Furthermore, the association between their reproductive hormones and their sperm parameters was examined. Data were analyzed by multiple linear and logistic regression adjusted for covariates.

MAIN RESULTS AND THE ROLE OF CHANCE

ICSI men had comparable mean levels of FSH, LH, testosterone and inhibin B in comparison to spontaneously conceived counterparts, even after adjustment for confounders, such as age, BMI and season. Young ICSI-conceived men were more likely to have inhibin B levels below the 10th percentile (<125.2 ng/l; Adjusted Odds Ratio (AOR) 4.0; 95% CI: 0.9-18.4; P = 0.07) compared with spontaneously conceived peers and were more likely to have FSH levels above the 90th percentile (>5.5 IU/L; AOR 3.3; 95% CI: 0.9-11.9; P = 0.06) compared with spontaneously conceived peers, but neither difference reached statistical significance. FSH, LH and inhibin B, but not testosterone, levels were significantly associated with sperm concentration and total sperm count.

LIMITATIONS, REASONS FOR CAUTION

The main limitation is the small study population. Furthermore, the results of this study should be interpreted according to the background of the participants: all subjects in our study group were conceived by ICSI because of severe male infertility and hence the results cannot be generalized to all ICSI offspring because the indications for performing ICSI have since been widened.

WIDER IMPLICATIONS OF THE FINDINGS

These first results in a small group of ICSI men show reassuring reproductive hormonal levels. However, larger studies are required to confirm our results. Since inhibin B and FSH are consistently correlated with semen characteristics, we would suggest that the reproductive status of young adults conceived by ICSI is explored with a hormonal assessment given its easier acceptance compared to semen sampling.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by Methusalem grants and by grants from Wetenschappelijk Fonds Willy Gepts, all issued by the Vrije Universiteit Brussel (VUB). A grant from the Belgian Society for Pediatric Endocrinology and Diabetology was received for this project. All co-authors, except M.B. and H.T., declare no conflict of interest. M.B. has received consultancy fees from MSD, Serono Symposia and Merck. The Universitair Ziekenhuis Brussel (UZ Brussel) and the Centre for Medical Genetics have received several educational grants from IBSA, Ferring, Organon, Shering-Plough, Merck for establishing the database for follow-up research and organizing the data collection. The institution of HT receives research grants from the 'Research Fund of Flanders' (FWO), an unconditional grant from Ferring for research on testicular stem cells and research grants from Ferring, Merck, MSD, Roche, Besins, Goodlife and Cook for several research projects in female infertility. H.T. has received consultancy fees from Finox, Abbott and ObsEva for research projects in female infertility.

TRIAL REGISTRATION NUMBER

N/A.

Semen quality of young adult ICSI offspring: the first results

STUDY QUESTION

What is the semen quality of young adult men who were conceived 18-22 years ago by ICSI for male infertility?

SUMMARY ANSWER

In this cohort of 54 young adult ICSI men, median sperm concentration, total sperm count and total motile sperm count were significantly lower than in spontaneously conceived peers.

WHAT IS KNOWN ALREADY

The oldest ICSI offspring cohort worldwide has recently reached adulthood. Hence, their reproductive health can now be investigated. Since these children were conceived by ICSI because of severe male-factor infertility, there is reasonable concern that male offspring have inherited the deficient spermatogenesis from their fathers. Previously normal pubertal development and adequate Sertoli and Leydig cell function have been described in pubertal ICSI boys; however, no information on their sperm quality is currently available.

STUDY DESIGN, SIZE, DURATION

This study was conducted at UZ Brussel between March 2013 and April 2016 and is part of a large follow-up project focussing on reproductive and metabolic health of young adults, between 18 and 22 years and conceived after ICSI with ejaculated sperm. Results of both a physical examination and semen analysis were compared between young ICSI men being part of a longitudinally followed cohort and spontaneously conceived controls who were recruited cross-sectionally.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Results of a single semen sample in 54 young adult ICSI men and 57 spontaneously conceived men are reported. All young adults were individually assessed, and the results of their physical examination were completed by questionnaires. Data were analysed by multiple linear and logistic regression, adjusted for covariates. In addition, semen parameters of the ICSI fathers dating back from their ICSI treatment application were analysed for correlations.

MAIN RESULTS AND THE ROLE OF CHANCE

Young ICSI adults had a lower median sperm concentration (17.7 million/ml), lower median total sperm count (31.9 million) and lower median total motile sperm count (12.7 million) in comparison to spontaneously conceived peers (37.0 million/ml; 86.8 million; 38.6 million, respectively). The median percentage progressive and total motility, median percentage normal morphology and median semen volume were not significantly different between these groups. After adjustment for confounders (age, BMI, genital malformations, time from ejaculation to analysis, abstinence period), the statistically significant differences between ICSI men and spontaneously conceived peers remained: an almost doubled sperm concentration in spontaneously conceived peers in comparison to ICSI men (ratio 1.9, 95% CI 1.1-3.2) and a two-fold lower total sperm count (ratio 2.3, 95% CI 1.3-4.1) and total motile count (ratio 2.1, 95% CI 1.2-3.6) in ICSI men compared to controls were found. Furthermore, compared to men born after spontaneous conception, ICSI men were nearly three times more likely to have sperm concentrations below the WHO reference value of 15 million/ml (adjusted odds ratio (AOR) 2.7; 95% CI 1.1-6.7) and four times more likely to have total sperm counts below 39 million (AOR 4.3; 95% CI 1.7-11.3). In this small group of 54 father-son pairs, a weak negative correlation between total sperm count in fathers and their sons was found.

LIMITATIONS, REASONS FOR CAUTION

The main limitation is the small study population. Also, the results of this study where ICSI was performed with ejaculated sperm and for male-factor infertility cannot be generalized to all ICSI offspring because the indications for ICSI have nowadays been extended and ICSI is also being performed with non-ejaculated sperm and reported differences may thus either decrease or increase.

WIDER IMPLICATIONS OF THE FINDINGS

These first results in a small group of ICSI men indicate a lower semen quantity and quality in young adults born after ICSI for male infertility in their fathers.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by Methusalem grants and by grants from Wetenschappelijk Fonds Willy Gepts, all issued by the Vrije Universiteit Brussel (VUB). All co-authors except M.B. and H.T. declared no conflict of interest. M.B. has received consultancy fees from MSD, Serono Symposia and Merck. The Universitair Ziekenhuis Brussel (UZ Brussel) and the Centre for Medical Genetics have received several educational grants from IBSA, Ferring, Organon, Shering-Plough and Merck for establishing the database for follow-up research and organizing the data collection. The institution of H.T. has received research grants from the Research Fund of Flanders (FWO), an unconditional grant from Ferring for research on testicular stem cells and research grants from Ferring, Merck, MSD, Roche, Besins, Goodlife and Cook for several research projects in female infertility. H.T. has received consultancy fees from Finox, Abbott and ObsEva for research projects in female infertility.

Former Abusers of Anabolic Androgenic Steroids Exhibit Decreased Testosterone Levels and Hypogonadal Symptoms Years after Cessation: A Case-Control Study

Aims

Abuse of anabolic androgenic steroids (AAS) is highly prevalent among male recreational athletes. The objective of this study was to investigate the impact of AAS abuse on reproductive hormone levels and symptoms suggestive of hypogonadism in current and former AAS abusers.

Methods

This study had a cross-sectional case-control design and involved 37 current AAS abusers, 33 former AAS abusers (mean (95%CI) elapsed duration since AAS cessation: 2.5 (1.7; 3.7) years) and 30 healthy control participants. All participants were aged 18–50 years and were involved in recreational strength training. Reproductive hormones (FSH, LH, testosterone, inhibin B and anti-Müllerian hormone (AMH)) were measured using morning blood samples. Symptoms of hypogonadism (depressive symptoms, fatigue, decreased libido and erectile dysfunction) were recorded systematically.

Results

Former AAS abusers exhibited significantly lower median (25^th –75^th percentiles) total and free testosterone levels than control participants (total testosterone: 14.4 (11.9–17.7) nmol/l vs. 18.8 (16.6–22.0) nmol/l) (P < 0.01). Overall, 27.2% (13.3; 45.5) of former AAS abusers exhibited plasma total testosterone levels below the lower reference limit (12.1 nmol/l) whereas no control participants exhibited testosterone below this limit (P < 0.01). Gonadotropins were significantly suppressed, and inhibin B and AMH were significantly decreased in current AAS abusers compared with former AAS abusers and control participants (P < 0.01). The group of former AAS abusers had higher proportions of participants with depressive symptoms ((24.2%) (11.1; 42.2)), erectile dysfunction ((27.3%) (13.3; 45.6)) and decreased libido ((40.1%) (23.2; 57.0)) than the other two groups (trend analyses: P < 0.05).

Conclusions

Former AAS abusers exhibited significantly lower plasma testosterone levels and higher frequencies of symptoms suggestive of hypogonadism than healthy control participants years after AAS cessation. Current AAS abusers exhibited severely decreased AMH and inhibin B indicative of impaired spermatogenesis.

Transitional Urology for Male Adolescents: What Adult Urologists Should Know

In recent years, there has been increasing interest in transitional urology, or how to best prepare patients with major congenital urologic diseases, such as bladder exstrophy and neuropathic bladder, to manage their own health care with adult urologists. However, common pediatric urologic conditions may be encountered by the adult urologist with more regularity. This review focuses on three relatively common conditions which may be identified in childhood, the consequences from which a patient may seek help from an adult urologist: cryptorchidism, varicocele, and Klinefelter syndrome.