SARS-CoV-2 presence in seminal fluid: Myth or reality

COVID-19 and Oncofertility: No SARS-CoV-2 in Semen but Inflammation Seems to Affect Sperm Parameters

The COVID-19 pandemic, driven by SARS-CoV-2, led authorities to recommend halting assisted reproductive technology programs, focusing instead on fertility preservation, for cancer patients. The presence of SARS-CoV-2 in semen remains controversial. This multicentric prospective cohort study, conducted across 12 university medical centers, aimed to determine if SARS-CoV-2 is present in spermatozoa/seminal plasma in cancer patients by RT-PCR and to assess its impact on standard semen parameters. The levels of cytokines and TNF-α were measured in seminal fluid by ELISA. We enrolled 129 men who underwent sperm cryopreservation between July 7, 2020, and June 30, 2021. The 63 were included and tested for COVID-19 in nasal swab samples by RT-PCR and/or by serology. All patients were asymptomatic on the day of semen collection: 50 were uninfected, 8 had a positive nasal swab (PCR+) and 5 were seropositive. SARS-CoV-2 RNA was not detected in the seminal fluid or spermatozoa. Ejaculate volume was significantly lower in the PCR+ group compared to the uninfected group (median [IQR]: 2.6 mL [1.6-3.4] vs. 4.6 mL [2.6-5.2] p < 0.05). Total and progressive motility were lower in the PCR+ group compared to the seropositive group (32.5% [25.0-45.0] vs. 50% [49.0-55.0] p < 0.05, and 22.5% [10.0; 32.5] vs. 44.5% [40-49] p < 0.05). Higher TNF-α level was observed in the PCR+ group (1.9 pg/mL [0-3.9]) compared to the uninfected group (0 pg/mL [0-0.4]) p < 0.05. Although SARS-CoV-2 was not detected in the sperm samples of cancer patients who were PCR+, the infection appears to impact sperm parameters, likely due to inflammation.

Investigating the mode of transmission of COVID-19 through genital secretions, semen, the birth canal, and lactation: A systematic review

In a global pandemic, the coronavirus has brought new challenges to reproductive and sexual health. This systematic review has been conducted with the aim of investigating a) the transmission of coronavirus disease 2019 (COVID-19) through female-to-male sexual secretions and vice versa, b) vertical transmission to the fetus, c) transmission to the newborn through the birth canal, and d) transmission through breast milk. In this review study, to find related articles, databases were searched using English and Persian keywords from the beginning of 2019 to the end of 2023. Based on the entry and exit criteria and the qualitative evaluation of the studies based on the STROBE criterion, the final studies were summarized. According to the initial search, 5970 articles were reviewed. After removing duplicate articles and the inappropriateness of the title, the abstract of the article was not related to the objectives of the project, there was no relevant study, and retrospective studies were excluded. Finally, 120 articles were selected as final articles. The general results show that transmission of the virus through the vagina to the blood of the fetus causing septicemia, vertical transmission from the mother to the fetus, transmission through the water bag, genital secretions, and ejaculate fluid are considered rare and ruled out. Transmission through rectal secretions during anal or oral sex requires more extensive studies. It is not possible to transmit the virus through breast milk. The long-term reproductive impact of COVID-19 on the reproductive systems of women and men is unclear.

Impact of COVID-19 on testicular function: a systematic review and meta-analysis

INTRODUCTION

Studies investigating the effects of SARS-CoV-2 on male reproductive function are few and heterogeneous, and results are often conflicting. This systematic review and meta-analysis was carried out on studies conducted in men with active or anamnestic SARS-CoV-2 infection to evaluate its consequences on the male sex hormone profile and semen parameters.

MATERIALS AND METHOD

This meta-analysis follows the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols. PubMed, Scopus, Cochrane, and Embase databases were searched to identify relevant studies. We originally selected 3553 articles. After the eligibility phase, 16 articles met our inclusion criteria encompassing 11 case-control studies and 5 cohort studies (2 prospective and 3 retrospective studies). We performed the quantitative analysis with Comprehensive Meta-Analysis Software. Cochran-Q and heterogeneity (I2) indexes were used to assess statistical heterogeneity. Sensitivity analysis and publication bias tests were also performed.

RESULTS

Overall, 1250 patients with active or recent (up to 80 days before) COVID-19 infection and 1232 matched healthy controls were included. Sperm concentration, total sperm count, and total motility were significantly lower in patients compared with controls. Patients also showed lower levels of total testosterone and follicle-stimulating hormone, and higher levels of luteinizing hormone, 17β-estradiol, and prolactin compared with healthy controls. None of the included studies found the presence of SARS-CoV-2 mRNA in the semen of infected patients.

CONCLUSION

The present systematic review and meta-analysis suggests the presence of an association between SARS-CoV-2 infection and primary testicular damage manifested with a picture of altered steroidogenesis and worsening spermatogenesis. The absence of the virus in the seminal fluid indicates a low possibility of sexual transmission of the infection to partners and offspring. However, our findings mostly show short-term follow-up, while few studies have considered the long-term consequences of the viral infection, thus further studies are needed to evaluate the long-term consequences on male reproductive health.

Examination of SARS-CoV-2 RNA in joint synovial fluid of patients with COVID-19 and acute knee arthritis

BACKGROUND

It has not yet been fully established that there is coronavirus disease 2019 (COVID-19) involvement in the synovial fluid and it remains a topic of debate.

OBJECTIVE

The aim of this study was to evaluate the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in knee joint synovial fluid of patients with COVID-19.

METHODS

This retrospective study was conducted with an initial screening of patients who were admitted to a tertiary pandemic hospital due to COVID-19 symptoms, and underwent treatment for COVID-19 between March and June 2020.

RESULTS

A total of 2476 patients were hospitalized or received treatment for a possible diagnosis of COVID-19. While the RT-PCR test was positive in 318 patients (12.8%), 2158 (87.2%) were computed tomography positive but reverse transcription-polymerase chain reaction (RT-PCR) negative. Twelve patients were consulted due to acute joint effusion. Of five patients with knee joint effusion and a positive RT-PCR test, the synovial tissue RT-PCR test was positive in only one patient.

CONCLUSION

This paper is the first to show the presence of SARS-CoV-2 in synovial fluid. This can be considered of importance for the determination and elimination of the route of transmission, thereby preventing further development and spread of the disease.

Radiological Evidence of Testicular Damage in Severe Acute Respiratory Syndrome Coronavirus 2 Infection: A Sonoelastography's Potential Role

ABSTRACT

This preliminary study aimed to evaluate the possible damage to the male reproductive system that the severe acute respiratory syndrome coronavirus 2 virus causes by quantitatively measuring and comparing the tissue stiffness of the testis and epididymis with acoustic radiation force impulse sonoelastography in patients who have COVID-19 with a healthy control group. This prospective study was conducted between February and July 2021 with 65 cases. We used sonoelastography to evaluate male patients 18 years or older, who had applied to the urology clinic with nontesticular complaints, and were found to not have any underlying testicular pathology after a clinical-laboratory evaluation. The clinical-laboratory imaging findings and reverse transcription-polymerase chain reaction test results of all patients diagnosed with COVID-19 were reviewed from the hospital database. We measured the shear wave velocity values of the epididymis and the testes of 31 proven severe acute respiratory syndrome coronavirus 2 patients and 34 healthy subjects and compared them with an independent t test. For the patient and control group subjects, the mean age was 37.55 ± 13.08 (23-71) and 40.5 ± 16.25 (18-81) years, respectively. The mean shear wave velocity values of the left-right and bilateral testes and epididymis of the patient group were statistically substantially higher ( P ˂ 0.05) than in the control group. In the receiver operating characteristic analysis, when the cutoff values for the bilateral testes and epididymis were determined as 1.39 and 1.64 m/s, respectively, the AUC was 77% to 73.4%, the sensitivity was 87% to 74%, and the specificity was 65% to 62%. Our findings show that testicular and epididymal tissue stiffness increased in patients with COVID-19. We recommend adding sonoelastography to urogenital examinations of male reproductive system in patients who are recovering from COVID-19.

SARS-CoV-2, fertility and assisted reproduction

BACKGROUND

In 2020, SARS-CoV-2 and the COVID-19 pandemic had a huge impact on the access to and provision of ART treatments. Gradually, knowledge of the virus and its transmission has become available, allowing ART activities to resume. Still, questions on the impact of the virus on human gametes and fertility remain.

OBJECTIVE AND RATIONALE

This article summarizes published data, aiming to clarify the impact of SARS-CoV-2 and the COVID-19 disease on human fertility and assisted reproduction, as well as the impact of vaccination, and from this, provide answers to questions that are relevant for people contemplating pregnancy and for health care professionals.

SEARCH METHODS

PUBMED/MEDLINE and the WHO COVID-19 database were searched from inception to 5 October 2022 with search terms focusing on 'SARS-CoV-2' and gametes, embryos, reproductive function, fertility and ART. Non-English studies and papers published prior to 2020 were excluded, as well as reviews and non-peer reviewed publications. Full papers were assessed for relevance and quality, where feasible.

OUTCOMES

From the 148 papers included, the following observations were made. The SARS-CoV-2-binding proteins, angiotensin-converting enzyme 2 (ACE2) and type II transmembrane serine protease (TMPRSS2), are expressed in the testis, but co-expression remains to be proven. There is some evidence of SARS-CoV-2 RNA in the ejaculate of COVID-19 patients with severe disease, but not in those with mild/moderate disease. SARS-CoV-2 infection can impair spermatogenesis, but this seems to resolve after one spermatogenic cycle. Testosterone levels seem to be lower during and after COVID-19, but long-term data are lacking; disease severity may be associated with testosterone levels. COVID-19 cannot be considered a sexually transmitted disease. There is no co-expression of ACE2 and TMPRSS2 in the myometrium, uterus, ovaries or fallopian tubes. Oocytes seem to have the receptors and protease machinery to be susceptible to SARS-CoV-2 infection; however, viral RNA in oocytes has not been detected so far. Women contemplating pregnancy following COVID-19 may benefit from screening for thyroid dysfunction. There is a possible (transient) impact of COVID-19 on menstrual patterns. Embryos, and particularly late blastocysts, seem to have the machinery to be susceptible to SARS-CoV-2 infection. Most studies have not reported a significant impact of COVID-19 on ovarian reserve, ovarian function or follicular fluid parameters. Previous asymptomatic or mild SARS-CoV-2 infection in females does not seem to negatively affect laboratory and clinical outcomes of ART. There are no data on the minimum required interval, if any, between COVID-19 recovery and ART. There is no evidence of a negative effect of SARS-CoV-2 vaccination on semen parameters or spermatogenesis, ovarian function, ovarian reserve or folliculogenesis. A transient effect on the menstrual cycle has been documented. Despite concerns, cross reactivity between anti-SARS-CoV-2 spike protein antibodies and Syncytin-1, an essential protein in human implantation, is absent. There is no influence of mRNA SARS-CoV-2 vaccine on patients' performance during their immediate subsequent ART cycle. Pregnancy rates post-vaccination are similar to those in unvaccinated patients.

WIDER IMPLICATIONS

This review highlights existing knowledge on the impact of SARS-CoV-2 infection or COVID-19 on fertility and assisted reproduction, but also identifies gaps and offers suggestions for future research. The knowledge presented should help to provide evidence-based advice for practitioners and couples contemplating pregnancy alike, facilitating informed decision-making in an environment of significant emotional turmoil.

Immunisation against COVID-19 in Pregnancy and of Women Planning Pregnancy

Following reports of the first human SARS-CoV2 infection in December 2019 from Wuhan Province, China, there was such rapid spread that by March 2021, the World Health Organization (WHO) had declared a pandemic. Over 6.5 million people have died from this infection worldwide, although this is most likely an underestimate. Until vaccines became available, mortality and severe morbidity were costly in terms of life lost as well as the cost of supporting the severely and acutely ill. Vaccination changed the landscape, and following worldwide adoption, life has gradually been returning to normal. The speed of production of the vaccines was unprecedented and undoubtedly ushered in a new era in the science of fighting infections. The developed vaccines were on the already known platforms for vaccine delivery: inactivated virus, virus vector, virus-like particles (VLP) subunit, DNA and mRNA. The mRNA platform was used for the first time to deliver vaccines to humans. An understanding of these platforms and the pros and cons of each are important for clinicians who are often challenged by the recipients on the advantages and risks of these vaccines. These vaccines have so far and reassuringly been shown to be safe in reproduction (with no effect on gametes) and pregnancy (not associated with congenital malformations). However, safety remains paramount and continuing vigilance is critical, especially against rare fatal complications such as vaccine-induced thrombocytopenia and myocarditis. Finally, the waning immunity months after vaccination means repeated immunisation is likely to be ongoing, but just how often and how many such revaccinations should be recommended remains uncertain. Research into other vaccines and alternate delivery methods should continue as this infection is likely to be around for a long time.

Insights into the Scenario of SARS-CoV-2 Infection in Male Reproductive Toxicity

COVID-19 has become a significant public health concern that has catastrophic consequences for society. Some preliminary evidence suggests that the male reproductive system may be an infection target for SARS-CoV-2. SARS-CoV-2 may be transmitted sexually, according to preliminary research. Testicular cells exhibit a high level of the angiotensin-converting enzyme 2 (ACE2) receptor, which enhances the entry of the SARS-CoV-2 into host cells. Some instances of COVID-19 have been documented to exhibit hypogonadism during the acute stage. Furthermore, systemic inflammatory reactions triggered by SARS-CoV-2 infection may cause oxidative stress (OS), which has been shown to have profoundly deleterious consequences on testicular functioning. This work gives a clear picture of how COVID-19 may affect male reproductive systems and calls attention to the many unanswered questions about the mechanisms by which this virus can be linked to men's health and fertility.

Validation of a SARS-CoV-2 RT-PCR assay: a requirement to evaluate viral contamination in human semen

RESEARCH QUESTION

Is it possible to validate an accurate and reliable method for direct detection of SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR) in human semen fractions?

DESIGN

This qualitative improvement study aimed to provide a prospective validation of SARS-CoV-2 detection in male semen. The SARS-CoV-2 genome was detected by multiplex real-time RT-PCR on patient samples that underwent routine semen analyses for infertility at the Center for Reproductive Medicine at the University Hospital of Clermont-Ferrand. Samples comprised surplus semen collected for treatment with assisted reproductive technology. Seminal fluid and spermatozoa fractions were isolated with density gradient centrifugation and cryopreserved. Positive samples were prepared with a standard of inactivated SARS-CoV-2 particles.

RESULTS

The analytical method was validated in both seminal fluid and spermatozoa fractions. In both semen fractions, the assay was repeatable, reproducible and showed high sensitivity with a limit of detection of 0.33 SARS-CoV-2 genome copies/µl. The limit of quantification was 1 copy of the SARS-CoV-2 genome/µl. The method was effective regardless of semen quality (normal and altered sperm parameters), number of spermatozoa or the cryoprotectant media used to freeze spermatozoa.

CONCLUSION

This validated RT-PCR assay provided accurate and reliable screening of SARS-CoV-2 in seminal fluid and spermatozoa fractions. This method is essential to ensure protection against viral contamination in the cryobanking process.

Urological complications of COVID-19: a systematic review

PURPOSE

COVID-19 continues to be an urgent World issue. Receptors of angiotensin converting enzyme 2 (ACE2), gateway of SARS-CoV-2, are present in the lungs, bladder, prostate, and testicles. Therefore, these organs face high risk of damage caused by the virus and this mechanism may explain non-respiratory symptoms of the disease.

MATERIALS AND METHODS

This systematic review, guided by the PRIMSA statement, was proposed to elucidate possible urological complications of COVID-19. Searches were carried out in Medline (PubMed), Cochrane (CENTRAL), Embase, MedRxiv and LILACS. Bias analysis was made using the specific Newcastle-Ottawa Scale for each study design.

RESULTS

Search was carried out until April 2022, and 8,477 articles were identified. Forty-nine of them were included in this systematic review. There is evidence that lower urinary tract symptoms and acute scrotum may be signs of COVID-19 in men, although in a small proportion. Also, the disease may have a transitory impact on male fertility, evidenced by several alterations in sperm counts. However, it must be clarified whether this impact is transitory, or may last for longer periods. Several patients showed reduction of total value of testosterone. Two authors linked low levels of testosterone with worse outcomes of COVID-19, suggesting that the hormone may be used as an early biomarker of the severity of the disease. Moreover, it is extremely unlikely that SARS-CoV-2 is transmitted by semen.

CONCLUSION

This systematic review identified possible repercussions of COVID-19 in the urinary as well as in the male reproductive system.

The potential impact of COVID-19 on male reproductive health

The SARS-CoV-2 virus continues to overwhelm health care systems impairing human to human social and economic interactions. Invasion or damage to the male reproductive system is one of the documented outcomes of viral infection. Existing studies have reported that SARS-CoV-2 may contribute to this loss in relation to inflammatory responses and the formation of cytokine storms in COVID-19 patients. Although direct infection of the testes and entry of SARS-CoV-2 into semen as well as subsequent consequences on the male reproductive system need to be studied more systematically, warnings from two organising ASRM and SART for prospective parents when infected with SARS-CoV-2 should be considered. In the context of an increasingly complex pandemic, this review provides preliminary examples of the potential impact of COVID-19 on male reproductive health and guidance for prospective parents currently infected with or recovering from SARS-CoV-2.

COVID-19 Infections in Gonads: Consequences on Fertility?

COVID-19 may influence human fertility and sexuality in several ways. Different cell types in gonads show a constitutive expression of angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine subtype 2 (TMPRSS2), which provide potential entry pathways for SARS-CoV-2. In addition to the biological effects of a COVID-19 infection on the gonads, the impact of the ongoing COVID-19 pandemic on mental health issues and sexual behavior may affect reproduction. This review summarizes the current knowledge on the influence of COVID-19 on the gonads and discusses possible consequences on human fertility. In this context, the close interaction between the hypothalamic-pituitary-adrenal axis and the hypothalamic-pituitary-gonadal axis in response to COVID-19-related stress is discussed. Some women noticed changes in their menstrual cycle during the COVID-19 pandemic, which could be due to psychological stress, for example. In addition, occasional cases of reduced oocyte quality and ovarian function are described after COVID-19 infection. In men, COVID-19 may cause a short-term decrease in fertility by damaging testicular tissue and/or impairing spermatogenesis. Moreover, decreased ratio testosterone/LH and FSH/LH in COVID-19 compared to aged-matched healthy men has been reported. Available data do not suggest any effect of the available SARS-CoV-2 vaccines on fertility. The effects of long COVID on human fertility have been reported and include cases with premature ovarian failure and oligomenorrhoea in women and erectile dysfunction in men. Despite the increasing knowledge about the effects of COVID-19 infections on human gonads and fertility, the long-term consequences of the COVID-19 pandemic cannot yet be assessed in this context.

4BNT162b2 mRNA Covid-19 Vaccine and semen: what do we know?

Background

The effects of an mRNA COVID‐19 vaccine on spermatozoa parameters are not known. The aim of this study was to evaluate the effect of the BNT162b2 mRNA COVID‐19 vaccine on human semen, comparing spermatozoa parameters before and after vaccine inoculation.

Materials and methods

In this single‐center prospective study, voluntary subjects who received mRNA vaccines from February to July 2021 were enrolled. The study population included male subjects aged between 18 and 45 years who completed the BNT162b2 mRNA COVID‐19 vaccine cycle. All subjects were evaluated before the first dose of vaccine (T0) and after 3 months (T1) with semen analysis and further analysis of seminal plasma, including colorimetric determination of reactive oxygen metabolites (d‐ROM test), electrolytes, and interleukin 6 (IL‐6) assessment by enzyme‐linked immunosorbent assay technology.

Results

The experimental sample included 47 subjects (age: 29.3 ± 6.0 years, range 24–32; body mass index: 23.15 ± 2.5 kg/m², range 19.2–28.0). All the subjects reported no systemic side effects. No significant differences were observed in any spermatozoa parameter between T0 and T1. A subanalysis was performed in oligoazoospermic and asthenozoospermic subjects, confirming the same results. Electrolyte analysis also showed no significant differences before and after vaccine inoculation. Finally, no significant differences were observed in T0, compared to T1 for the d‐ROM test and IL‐6.

Discussion and conclusion

In this study, no significant differences in spermatozoa parameters before and after vaccine inoculations were found. Furthermore, oxidative stress analysis,, the activity of the cell membrane, and IL‐6, as a marker of inflammation, was not affected by the mRNA COVID‐19 vaccine. These results suggest that this vaccine is safe for male semen quality.

Impacts of COVID-19 and SARS-CoV-2 on male reproductive function: a systematic review and meta-analysis protocol

INTRODUCTION

COVID-19 pandemic caused by SARS-CoV-2 has become a global health challenge. SARS-CoV-2 can infect host cells via the ACE2 receptor, which is widely expressed in the corpus cavernosum, testis and male reproductive tract, and participates in erection, spermatogenesis and androgen metabolism. Also, the immune response and persistent fever resulting from COVID-19 may lead to damage of the testicular activity, consequently compromising male fertility.

METHODS AND ANALYSIS

PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library, China National Knowledge Infrastructure, China Science and Technology Journal database, Chinese Biomedical Databases and Wanfang Data will be systematically searched for observational studies (case-control and cohort) published up to March 2021 in English or in Chinese literature on the impacts of COVID-19 and SARS-CoV-2 on male reproductive function. This protocol will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines and Meta-analysis of Observational Studies in Epidemiology. The primary outcome will be semen parameters, and the additional outcomes will include: (a) detection of SARS-COV-2 in semen, (b) male sexual hormones, (c) sperm DNA fragmentation index, (d) erectile function, (e) evaluation of testis and also the male genital tract. Two reviewers will independently extract data from the included studies based on a predesigned data extraction form. The risk of bias of included studies will be evaluated through the Newcastle-Ottawa Scale for observational studies. Review Manager software V.5.3 will be used for statistical analysis. Q statistic and I² test will be performed to assess the heterogeneity among studies. Sensitivity analysis will be used to explore the robustness of pooled effects. We will use the Grading of Recommendations Assessment, Development and Evaluation system to assess the quality of evidence.

ETHICS AND DISSEMINATION

Ethical approval is not required and results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021245161.

Evaluation of SARS-CoV-2 in semen, seminal plasma, and spermatozoa pellet of COVID-19 patients in the acute stage of infection

To date, there is limited information about the presence of SARS-CoV-2 in semen especially in the acute phase of the infection. While available data from cohort studies including a total of 342 patients in the acute or recovery phase of the infection are reassuring, one study mentioned detecting virus in the semen of 6/38 COVID-19 patients. Here we assessed SARS-CoV-2 presence in the semen of COVID-19 positive patients in the acute stage of infection, within 24 hours of the positive nasopharyngeal swabs. Semen, seminal plasma and spermatozoa pellet were screened for SARS-CoV-2 and manual or airborne contamination during semen sampling. Among the 32 COVID-19 volunteers, the median interval from the onset of symptoms to semen collection was 4 days [IQR: 0-8]. Only one presented positive SARS-CoV-2 PCR in semen and seminal plasma fractions, although the spermatozoa pellet was negative. Viral cultures were all negative. We observed slightly higher concentrations of bacterial DNA in the SARS-CoV-2 positive specimen than in all negative samples. The bacteria identified neither confirm nor rule out contamination by oropharyngeal secretions during collection. SARS-CoV-2 was rarely present in semen during the acute phase of the disease. This very rare situation could be connected to oral or manual contamination during semen collection. The possible presence of SARS-CoV-2 in semen calls for nasopharyngeal viral testing and strict hygiene protocols during semen collection before assisted reproductive attempts.

Molecular diagnosis of SARS-CoV-2 in seminal fluid

PURPOSE

Due to relevant repercussions on reproductive medicine, we aimed to evaluate feasibility of RT-PCR as a detection method of SARS-CoV-2 RNA in seminal fluid.

METHODS

A qualitative determination of the RT-PCR assays in semen was performed through different approaches: (1) efficiency of RNA extraction from sperm and seminal plasma was determined using PRM1 and PRM2 mRNA and a heterologous system as control; (2) samples obtained by diluting viral preparation from a SARS-CoV-2 panel (virus cultured in Vero E6 cell lines) were tested; (3) viral presence in different fractions of seminal fluid (whole sample, seminal plasma and post-centrifugation pellet) was evaluated. Semen samples from mild and recovered COVID-19 subjects were collected by patients referring to the Infectious Disease Department of the Policlinico Umberto I Hospital - "Sapienza" University of Rome. Control subjects were recruited at the Laboratory of Seminology-Sperm Bank "Loredana Gandini'' of the same hospital.

RESULTS

The control panel using viral preparations diluted in saline and seminal fluid showed the capability to detect viral RNA presence with C_t values depending on the initial viral concentration. All tested semen samples were negative for SARS-CoV-2, regardless of the nasopharyngeal swab result or seminal fluid fraction.

CONCLUSION

These preliminary data show that RT-PCR for SARS-CoV-2 RNA testing appears to be a feasible method for the molecular diagnosis of SARS-CoV-2 in seminal fluid, supported by results of the control panel. The ability to detect SARS-CoV-2 in semen is extremely important for reproductive medicine, especially in assisted reproductive technology and sperm cryopreservation.

The Sexual Long COVID (SLC): Erectile Dysfunction as a Biomarker of Systemic Complications for COVID-19 Long Haulers

Introduction

Long term complications of COVID-19, the disease caused by the SARS-CoV-2, involve many organ systems, dramatically worsening the quality of life, and finally contributing to impaired physical functioning. Despite the presence of well-identified pathogenetic mechanisms, the effect of “Long COVID” on sexual health has been only marginally addressed.

Objectives

To provide coverage of the current literature on long COVID, its epidemiology, pathophysiology, and relevance for erectile function. Methods. Comprehensive review of literature pertaining to the epidemiology and pathophysiology of long COVID, and its relevance for erectile function.

Results

Symptoms of long COVID are highly prevalent and involve almost all systems of the human body, with a plethora of clinical manifestations which range from minor nuisances to life-threatening conditions. “Brain fog” and fatigue are the most common complaints, although other neuropsychiatric complications, including sensory dysfunctions, anxiety, depression, and cerebrovascular events have also been reported. The respiratory and cardiovascular systems are also affected, with dyspnea, pulmonary fibrosis, endothelial dysfunction, and myocarditis occurring in some COVID long haulers. A subset of patients might develop endocrine manifestations, including onset of diabetes, thyroid dysfunction, and hypogonadism. Overall, long COVID features many complications which can impair erectile function by multiple pathogenetic mechanisms, and which could require tailored treatment: (i) careful investigation and management from the sexual medicine expert are therefore much needed, (ii) and future research on this topic is warranted.

Conclusion

in COVID-19 long haulers, several complications can adversely affect erectile function which, upon future tailored studies, could be used as biomarker for the severity of the long COVID disease and for its follow-up.

Sansone A, Mollaioli D, Limoncin E et al. The Sexual Long COVID (SLC): Erectile Dysfunction as a Biomarker of Systemic Complications for COVID-19 Long Haulers. Sex Med Rev 2022;10:271–285.

Male Sexual Health and Sexual Behaviors during the First National COVID-19 Lockdown in a Western Country: A Real-Life, Web-Based Study

Restriction measures enacted during the COVID-19 pandemic had severe effects on male sexual and reproductive health. We aimed to investigate the real-life impact and perception of sexual function in 2020 in Italy, as the first Western country experiencing a national lockdown by measuring relative search volume for keywords pertaining to sexual health and behaviors provided by Google Trends and sales data for pro-erectile treatments. No significant change was observed for erectile dysfunction and premature ejaculation. Interest towards most phosphodiesterase type 5 inhibitors decreased significantly during lockdown (e.g., sildenafil, p = 0.0002; tadalafil p = 0.0016), then reverted to pre-lockdown levels (e.g., sildenafil, p < 0.0001; tadalafil p < 0.0001), mirroring a concomitant sales decrement (p = 0.0292). A subsequent recovery to previous levels at the end of the social confinement was also found (e.g., after vs. before lockdown, sildenafil, p = 0.8459; tadalafil p = 0.1166). During lockdown, interest towards pornography significantly increased during restrictions (p = 0.0053) and remained high (after vs. before lockdown, p = 0.0004), whereas interest towards paid and casual sex declined (p = 0.0015 and p = 0.049, respectively), then reverted to previous levels (after vs. before lockdown, p = 0.3969 and 0.8373, respectively). During the first Italian lockdown, we observed a transient but measurable decrease of sexual health-seeking behaviors and changes in sexual behaviors, with unknown impact for sexual medicine and public health.

The Burden of Hormonal Disorders: A Worldwide Overview With a Particular Look in Italy

Endocrine diseases have a considerable impact on public health from an epidemiological point of view and because they may cause long-term disability, alteration of the quality-of-life of the affected patients, and are the fifth leading cause of death. In this extensive review of the literature, we have evaluated the prevalence of the different disorders of endocrine interest in the world and Italy, highlighting their epidemiological, clinical, and economic impact.

Finding a Balance in the Vaginal Microbiome: How Do We Treat and Prevent the Occurrence of Bacterial Vaginosis?

Bacterial vaginosis (BV) has been reported in one-third of women worldwide at different life stages, due to the complex balance in the ecology of the vaginal microbiota. It is a common cause of abnormal vaginal discharge and is associated with other health issues. Since the first description of anaerobic microbes associated with BV like Gardnerella vaginalis in the 1950s, researchers have stepped up the game by incorporating advanced molecular tools to monitor and evaluate the extent of dysbiosis within the vaginal microbiome, particularly on how specific microbial population changes compared to a healthy state. Moreover, treatment failure and BV recurrence rate remain high despite the standard antibiotic treatment. Consequently, researchers have been probing into alternative or adjunct treatments, including probiotics or even vaginal microbiota transplants, to ensure successful treatment outcomes and reduce the colonization by pathogenic microbes of the female reproductive tract. The current review summarizes the latest findings in probiotics use for BV and explores the potential of vaginal microbiota transplants in restoring vaginal health.

The presence of SARS-CoV-2 virus in semen samples of patients with COVID-19 pneumonia

The SARS‐CoV‐2 set off a pandemic involving millions of people around the world. The topic of discussion is the possible viral detection in different body fluids than respiratory droplets. Therefore, we evaluated the possible presence of SARS‐CoV‐2 in semen and urine samples. Thirty patients were included in the study aged 35.67 ± 6.84 years. The day after the pharyngeal and/or nose swab of SARS‐CoV‐2 was positive, urine and semen samples were taken from patients, and the presence of SARS‐CoV‐2 was investigated. Laboratory tests and chest CT findings were evaluated simultaneously. SARS‐CoV‐2 was detected in four (13.3%) patients’ semen samples and in seven (23.3%) patients’ urine samples. White blood cell (WBC), neutrophil, C‐reactive protein (CRP), ferritin, alanine transaminase (ALT), lactate dehydrogenase (LDH) and procalcitonin were significantly higher in patients with SARS‐CoV‐2 in semen (p < .05), though no statistical difference was found in urine (p > .05). Patients with severe pneumonia findings in Chest CT images are likely to be PCR positive in semen and urine samples (p = .005, p = .001). SARS‐CoV‐2 was not detected in urine and semen samples of patients after they had recovered (average duration 23 ± 4 days). SARS‐CoV‐2 can be detected in the urogenıtal fluıds of patients with severe clinical conditions and high viral load.

SARS-CoV-2 vs. human gametes, embryos and cryopreservation

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, is an unprecedented global situation, and all countries have adopted their own measurements to mitigate the spread of the virus in the first as well as in the subsequent waves of infection. All measures, especially in the first wave of the pandemic, were in combination with recommendations provided by professional and scientific organizations. Similar measures were applied to specific procedures, such as the management of infertility, including in vitro fertilization-embryo transfer (IVF-ET) treatments. Although there is no clear scientific evidence yet that the SARS-CoV-2 may exert negative effects on IVF outcome, especially at the early stages, several clinical reports indicate that the virus may impact male fertility through specific receptors presented at the somatic cells of the testis and used by the virus in order to gain entry to the respective cells. Nevertheless, it is not unreasonable to suspect that the virus may affect sperm function as well as oocyte performance directly through specific receptors or indirectly through other signaling pathways. Despite the good practice of IVF laboratory techniques, culture media may also be contaminated during equilibration when airborne virus's particles can contaminate culture media from an already infected embryology area or staff. Furthermore, although there is no clinical evidence, liquid nitrogen could be a route of infection for gametes and embryos when it has been contaminated during production or transportation. Therefore, cryopreservation of gametes and embryos must be virus-free. This communication aims to provide some aspects of the possible impact of the virus on gametes and embryos and how it may affect the cryopreservation procedures.Abbreviations: ACE2: angiotensin- converting enzyme 2; ART: assisted reproductive technology; ASRM: American Society for Reproductive Medicine; CDC: Centers for Disease Control and Prevention; COVID-19: coronavirus disease 2019; ESHRE: European Society of Human Reproduction and Embryology; ET: embryo transfer; FSH: follicle stimulating hormone; IFFS: International Federation of Fertility Societies; IVF: in vitro fertilization; LH: luteinizing hormone; LN: liquid nitrogen; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; T: testosterone; WHO: World Health Organization.

Effects of SARS-CoV-2 infection on human reproduction

The worldwide infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) impacts human health and life on multiple levels. People infected with SARS-CoV-2 suffer from physical disorders and psychological distress. At present, no direct evidence indicates that SARS-CoV-2 negatively influences human reproduction, and the possibility that gametes and embryos are affected requires further investigation. To evaluate the potential effects of SARS-CoV-2 infection on human reproduction and fetal health, this review summarizes the basic and clinical research of SARS-CoV-2 on reproduction up to date, hoping to offer guidance and advice to people at reproductive age and provide clues for the prevention and treatment of associated diseases.

Sperm cryopreservation during the SARS-CoV-2 pandemic

PURPOSE

Sperm cryopreservation is fundamental in the management of patients undergoing gonadotoxic treatments. Concerns have risen in relation to SARS-CoV-2 and its potential for testicular involvement, since SARS-CoV-2-positive cryopreserved samples may have unknown effects on fertilization and embryo safety. This study therefore aimed to analyze the safety of sperm cryopreservation for cancer patients after the onset of the pandemic in Italy, through assessment of the risk of SARS-CoV-2 exposure and viral RNA testing of semen samples.

METHODS

We recruited 10 cancer patients (mean age 30.5 ± 9.6 years) referred to our Sperm Bank during the Italian lockdown (from March 11th to May 4th 2020) who had not undergone a nasopharyngeal swab for SARS-CoV-2 testing. Patients were administered a questionnaire on their exposure to COVID-19, and semen samples were taken. Before cryopreservation, SARS-CoV-2 RNA was extracted from a 150 µl aliquot of seminal fluid in toto using QIAamp viral RNA kit (Qiagen) and amplified by a real time RT PCR system (RealStar SARS-CoV2 RT PCR, Altona Diagnostics) targeting the E and S genes.

RESULTS

The questionnaire and medical interview revealed that all patients were asymptomatic and had had no previous contact with COVID-19 infected patients. All semen samples were negative for SARS-CoV-2 RNA.

CONCLUSION

This preliminary assessment suggests that a thorough evaluation (especially in the setting of a multidisciplinary team) and molecular confirmation of the absence of SARS-CoV-2 in seminal fluid from asymptomatic cancer patients may assist in ensuring the safety of sperm cryopreservation.

Gender susceptibility to COVID-19: a review of the putative role of sex hormones and X chromosome

BACKGROUND

The recent emergence of COVID-19 poses a global health emergency. One of the most frequently reported data is sex-related severity and mortality: according to the last available analysis on 239,709 patients in Italy, lethality is 17.7% in men and 10.8% in women, with 59% of total deaths being men. Interestingly, the infection rate is lower in males than in females, with 45.8% and 54.2% of positive cases, respectively, suggesting that gender-related factor may worsen disease evolution. A tentative hypothesis to explain these findings is the role of angiotensin-converting enzyme 2 (ACE2) and serine protease TMPRSS2 involved in viral infection.

PURPOSE

In this review, we summarize the available evidence pointing to gender-related differences in ACE2 and TMPRSS2 expression, from both genetic and endocrine points of view.

RESULTS

Altogether, available evidence points toward two not-mutually exclusive mechanisms in gender susceptibility to COVID-19 by sex hormonal regulation of ACE2 and TMPRSS2. On one hand, ACE2 expression could be increased in women, either by estrogens or constitutively by X chromosome inactivation escape or by reduced methylation, providing a larger reservoir of ACE2 to maintain the fundamental equilibrium of RAS regulatory axis. On the other, low levels of androgens in women may keep at low levels TMPRSS2 expression, representing a further protective factor for the development of COVID-19 infection, despite the increased expression of ACE2, which represents the Trojan horse for SARS-CoV-2 entry.

CONCLUSIONS

Both mechanisms consistently point to the role of sex hormones and sex chromosomes in the differential severity and lethality of COVID-19 in men and women.

Short-term effects of COVID-19 on semen parameters: A multicenter study of 69 cases

Objective

COVID‐19, which is known to be caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), is a global health problem that can cause multiorgan damage because of its use of the angiotensin‐converting enzyme 2 (ACE2) receptor in its pathophysiology. We aimed to investigate whether SARS‐CoV‐2 had a short‐term effect on spermatogenesis, which plays an important role in male reproductive health as it has abundant ACE2 expression in testicular tissue.

Material and methods

This multicenter study included 69 patients aged 20–45 years, who admitted to our hospitals between April 2020 and October 2020 with a history of a positive test result for SARS‐CoV‐2 based on the nasopharyngeal or oropharyngeal swab samples and had recovered from the disease at least three months earlier and who had undergone a spermiogram test in the hospital database within the last year before the onset of disease. The patients were divided into two groups according to their COVID‐19 symptoms being mild or moderate, depending on whether they had received home treatment or required hospitalization for oxygen therapy. Semen samples taken before and after COVID‐19 were compared within and between the groups in terms of sperm parameters.

Results

The mean age of the patients included in the study was 30.4±4.8 years in the mild symptomatic COVID‐19 group and 31.06±4.2 years in the moderate symptomatic group. When the spermiogram samples of the patients before and after COVID‐19 were evaluated, it was found that motility and vitality significantly decreased in the mild symptomatic group, while the decrease in all semen parameters was statistically significant in the moderate symptomatic group.

Conclusion

Although the mechanism by which COVID‐19 causes testicular involvement remains uncertain, its short‐term results on spermatogenesis reveals that COVID‐19 negatively affects sperm parameters.

"Mask up to keep it up": Preliminary evidence of the association between erectile dysfunction and COVID-19

Background

Erectile dysfunction (ED), as the hallmark of endothelial dysfunction, could be a short‐ or long‐term complication of COVID‐19. Additionally, being ED a clinical marker and predictor of non‐communicable chronic diseases, particularly cardiovascular, subjects with ED could potentially have a higher risk of contracting COVID‐19.

Objectives

To investigate the prevalence of ED among subjects with a reported diagnosis of COVID‐19 and to measure the association of COVID‐19 and ED.

Materials and methods

We reviewed data from the Sex@COVID online survey (performed between April 7 and May 4, 2020, in Italy) to retrieve a sample of Italian male sexually active subjects with reported SARS‐CoV‐2 infection. A matching sample of COVID‐19‐negative male sexually active subjects was also retrieved using propensity score matching in a 3:1 ratio. The survey used different standardized psychometric tools to measure effects of lockdown and social distancing on the intrapsychic, relational, and sexual health of Italian subjects.

Results

One hundred subjects were included in the analysis (25 COVID‐positive; 75 COVID‐negative). The prevalence of ED, measured with the Sexual Health Inventory for Men, was significantly higher in the COVID+ group (28% vs. 9.33%; p = 0.027). Logistic regression models confirmed a significant effect of COVID‐19 on the development of ED, independently of other variables affecting erectile function, such as psychological status, age, and BMI [OR 5.66, 95% CI: 1.50–24.01]. Likewise, subjects with ED were more likely to have COVID‐19, once corrected for age and BMI [OR 5.27, 95% CI: 1.49–20.09].

Discussion and conclusion

On top of well‐described pathophysiological mechanisms, there is preliminary evidence in a real‐life population of ED as a risk factor of developing COVID‐19 and possibly occurring as a consequence of COVID‐19. Universal vaccination against the COVID‐19 and the personal protective equipment could possibly have the added benefit of preventing sexual dysfunctions.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): a Systemic Infection

To date, seven identified coronaviruses (CoVs) have been found to infect humans; of these, three highly pathogenic variants have emerged in the 21st century. The newest member of this group, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first detected at the end of 2019 in Hubei province, China. Since then, this novel coronavirus has spread worldwide, causing a pandemic; the respiratory disease caused by the virus is called coronavirus disease 2019 (COVID-19). The clinical presentation ranges from asymptomatic to mild respiratory tract infections and influenza-like illness to severe disease with accompanying lung injury, multiorgan failure, and death. Although the lungs are believed to be the site at which SARS-CoV-2 replicates, infected patients often report other symptoms, suggesting the involvement of the gastrointestinal tract, heart, cardiovascular system, kidneys, and other organs; therefore, the following question arises: is COVID-19 a respiratory or systemic disease? This review aims to summarize existing data on the replication of SARS-CoV-2 in different tissues in both patients and ex vivo models.

Presence of SARS-CoV-2 RNA in Semen-Cohort Study in the United States COVID-19 Positive Patients

On 31 December 2019, China informed the World Health Organization they were facing a viral pneumonia epidemic of a new type of Coronavirus. Currently, 10 months later, more than 43,000,000 people have been infected, and about 1,150,000 deceased worldwide from the disease. Knowledge about the virus is updated daily, and its RNA was isolated from several human secretions, e.g., throat, saliva, pulmonary alveolar washing, and feces. So far, only one publication found the presence of SARS-CoV-2 in semen. In this 5-month cross-sectional study, we recruited 15 patients diagnosed with a positive nasal swab for SARS-CoV-2 with no or mild symptoms in our institution. A semen sample after a shower was retrieved and tested for viral RNA in the semen. The samples were tested for the viral RNA with RT-PCR with two different genetic probes. The samples were re-tested 24 h after the first test to confirm the results. The SARS-Cov-2 viral RNA was present in 1/15 patients [6.66%] in our sample. Even in a small sample, the RNA from SARS-CoV-2 can be isolated from human semen. This information should alert the scientific community and public health officials about a possible new form of transmission of the disease and long-term clinical effects on the population.

COVID-19 may affect male fertility but is not sexually transmitted: a systematic review

Objective

To determine if SARS-CoV-2, which has led to the rapidly spreading COVID-19 global pandemic, is sexually transmitted. Since the putative receptor for the virus is identified in reproductive organs, it is also important to examine if COVID-19 may affect human fertility.

Evidence Review

A systematic review of English publications was conducted up to December 11, 2020 in PubMed, NIH iCite COVID-19 portfolio, Cochrane Library, and Google Scholar databases, searching for SARS-CoV-2 in the testes; seminal, prostatic, and vaginal fluids; and cervical smears. A total of 1,997 records were identified, duplicates were removed, and 1,490 records were reviewed for eligibility by examining titles and abstracts. Subsequently, 202 full-text relevant articles were reviewed by 2 independent reviewers. Forty-seven studies (literature reviews, editorials, and guidelines) were assessed qualitatively, and 23 studies that tested the male and female reproductive tracts of patients with COVID-19 for SARS-CoV-2 were quantitatively analyzed.

Results

No epidemiological investigations to date have described evidence suggesting that COVID-19 is an STD. While angiotensin-converting enzyme 2 receptor is found in the reproductive organs, the lack of co-expression of the TMPRSS2 modulatory protein, required for SARS-CoV-2 cell entry, in testicular cells, sperm, or oocytes, argues against the hypothesis that gametes transmit SARS-CoV-2. Molecular detection studies of SARS-CoV-2 RNA in the male and female reproductive tracts were summarized: 98.0% (293/299) of the seminal fluids, 16/17 testicular biopsies, all 89 prostatic fluids, 98.3% (57/58) of the vaginal fluids, all 35 cervical smears, and all 16 oocyte samples tested negative for SARS-CoV-2. None of the studies confirmed sexual transmission of SARS-CoV-2. Nonetheless, COVID-19 may have detrimental effects on male reproduction by inducing orchitis and/or decreasing testosterone levels, sperm counts, and motility.

Conclusion

On the basis of the current worldwide published information, COVID-19 is not an STD. This information is important for clinicians, proposed guidelines for public health, U.S. Food and Drug Administration guidelines for gamete and tissue donor eligibility, and fertility treatments. Universal precautions, currently practiced worldwide, are adequate and sufficient at this time to prevent the transmission of known or unknown viral infections. We suggest that recovered patients of COVID-19, especially those with infertility, should be evaluated for their ovarian and testicular function.

COVID-19 and male reproduction: Current research and unknown factors

BACKGROUND

The testes are suspected target organs of SARS-CoV-2. However, the results of studies on the effect of COVID-19 on male reproduction are controversial.

OBJECTIVE

To summarize current research on the effects of COVID-19 on male reproduction.

METHODS

A systematic review of English literature was performed using PubMed and Ovid Embase up to 18 August 2020. Research articles on the presence of SARS-CoV-2 in semen, the effects of the virus on semen parameters and any pathological changes in the testes were evaluated.

RESULTS

Fourteen studies were included in this review. Six of 176 survivors (3.4%) and 1 of 13 decedents (7.7%) in 2 of 12 studies were positive for viral RNA in semen and testicular tissue, respectively. After stratification of patient groups, we found that the virus was detected in the relatively early stage of infection, 6-16 days after disease onset, in semen from survivors. Two of 3 studies reported that some participants had substandard semen quality after COVID-19, and 1 study found that COVID-19 may impair semen quality in a severity-related manner. Pathological analyses showed that injuries to the seminiferous tubule occurred in all decedents (N = 11). Another study found that orchitic and testis fibrin microthrombi occurred in patients with fatal disease (100%, N = 2). Scrotal discomfort of orchiepididymitis or spermatic cord inflammation has also been reported in COVID-19 patients.

CONCLUSION

Current studies suggest that semen is rarely considered a carrier of SARS-CoV-2 genetic material during the infection period but not in the semen of recovered patients. Fatal COVID-19 may cause testicular structure damage without the presence of virus.

Addressing male sexual and reproductive health in the wake of COVID-19 outbreak

PURPOSE

The COVID-19 pandemic, caused by the SARS-CoV-2, represents an unprecedented challenge for healthcare. COVID-19 features a state of hyperinflammation resulting in a "cytokine storm", which leads to severe complications, such as the development of micro-thrombosis and disseminated intravascular coagulation (DIC). Despite isolation measures, the number of affected patients is growing daily: as of June 12th, over 7.5 million cases have been confirmed worldwide, with more than 420,000 global deaths. Over 3.5 million patients have recovered from COVID-19; although this number is increasing by the day, great attention should be directed towards the possible long-term outcomes of the disease. Despite being a trivial matter for patients in intensive care units (ICUs), erectile dysfunction (ED) is a likely consequence of COVID-19 for survivors, and considering the high transmissibility of the infection and the higher contagion rates among elderly men, a worrying phenomenon for a large part of affected patients.

METHODS

A literature research on the possible mechanisms involved in the development of ED in COVID-19 survivors was performed.

RESULTS

Endothelial dysfunction, subclinical hypogonadism, psychological distress and impaired pulmonary hemodynamics all contribute to the potential onset of ED. Additionally, COVID-19 might exacerbate cardiovascular conditions; therefore, further increasing the risk of ED. Testicular function in COVID-19 patients requires careful investigation for the unclear association with testosterone deficiency and the possible consequences for reproductive health. Treatment with phosphodiesterase-5 (PDE5) inhibitors might be beneficial for both COVID-19 and ED.

CONCLUSION

COVID-19 survivors might develop sexual and reproductive health issues. Andrological assessment and tailored treatments should be considered in the follow-up.

An Update on the Relationship of SARS-CoV-2 and Male Reproduction

Since the outbreak of the COVID-19, up to now, infection cases have been continuously rising to over 200 million around the world. Male bias in morbidity and mortality has emerged in the COVID-19 pandemic. The infection of SARS-CoV-2 has been reported to cause the impairment of multiple organs that highly express the viral receptor angiotensin-converting enzyme 2 (ACE2), including lung, kidney, and testis. Adverse effects on the male reproductive system, such as infertility and sexual dysfunction, have been associated with COVID-19. This causes a rising concern among couples intending to have a conception or who need assisted reproduction. To date, a body of studies explored the impact of SARS-CoV-2 on male reproduction from different aspects. This review aims to provide a panoramic view to understand the effect of the virus on male reproduction and a new perspective of further research for reproductive clinicians and scientists.

Viral infections and implications for male reproductive health

Viral infections have haunted humankind since times immemorial. Overpopulation, globalization, and extensive deforestation have created an ideal environment for a viral spread with unknown and multiple shedding routes. Many viruses can infect the male reproductive tract, with potential adverse consequences to male reproductive health, including infertility and cancer. Moreover, some genital tract viral infections can be sexually transmitted, potentially impacting the resulting offspring's health. We have summarized the evidence concerning the presence and adverse effects of the relevant viruses on the reproductive tract (mumps virus, human immunodeficiency virus, herpes virus, human papillomavirus, hepatitis B and C viruses, Ebola virus, Zika virus, influenza virus, and coronaviruses), their routes of infection, target organs and cells, prevalence and pattern of virus shedding in semen, as well as diagnosis/testing and treatment strategies. The pathophysiological understanding in the male genital tract is essential to assess its clinical impact on male reproductive health and guide future research.

Impact of SARS-CoV-2 on Male Reproductive Health: A Review of the Literature on Male Reproductive Involvement in COVID-19

Coronavirus Disease 2019 (COVID-19) has created a global pandemic. Global epidemiological results show that elderly men are susceptible to infection of COVID-19. The difference in the number of cases reported by gender increases progressively in favor of male subjects up to the age group ≥60-69 (66.6%) and ≥70-79 (66.1%). Through literature search and analysis, we also found that men are more susceptible to SARS-CoV-2 infection than women. In addition, men with COVID-19 have a higher mortality rate than women. Male represents 73% of deaths in China, 59% in South Korea, and 61.8% in the United States. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the pathogen of COVID-19, which is transmitted through respiratory droplets, direct and indirect contact. Genomic analysis has shown that SARS-CoV-2 is 79% identical to SARS-CoV, and both use angiotensin-converting enzyme 2 (ACE2) as the receptor for invading cells. In addition, Transmembrane serine protease 2 (TMPRSS2) can enhance ACE2-mediated virus entry. However, SARS-CoV-2 has a high affinity with human ACE2, and its consequences are more serious than other coronaviruses. ACE2 acts as a "gate" for viruses to invade cells and is closely related to the clinical manifestations of COVID-19. Studies have found that ACE2 and TMPRSS2 are expressed in the testis and male reproductive tract and are regulated by testosterone. Mature spermatozoon even has all the machinery required to bind SARS-CoV-2, and these considerations raise the possibility that spermatozoa could act as potential vectors of this highly infectious disease. This review summarizes the gender differences in the pathogenesis and clinical manifestations of COVID-19 and proposes the possible mechanism of orchitis caused by SARS-CoV-2 and the potential transmission route of the virus. In the context of the pandemic, these data will improve the understanding of the poor clinical outcomes in male patients with COVID-19 and the design of new strategies to prevent and treat SARS-CoV-2 infection.

Mechanisms by Which SARS-CoV-2 May Impact Male Fertility

The COVID-19 pandemic is unlike anything we have experienced in over a century. In the USA, waves of COVID-19 have migrated from the Northeast to the Sun Belt to the Midwest over the past year. Compared with females, males are more susceptible to SARS-CoV-2 infection, have more severe COVID-19 disease, and have higher death rates. In many countries, men are consistently more likely to die by a factor of almost 2. This article describes some of the mechanisms by which COVID-19 may be associated with male infertility, as discussed by Dutta and Sengupta.

Twenty-First Century Viral Pandemics: A Literature Review of Sexual Transmission and Fertility Implications in Men

INTRODUCTION

The 21st century has seen a series of viral pandemics that have collectively infected millions of individuals. To understand factors that may contribute to viral spread and address long-term health sequelae for survivors, it is important to review evidence regarding viral presence in semen, sexual transmission potential, and possible effects on fertility.

AIM

To review the current literature regarding the sexual transmissibility of recent viral pandemics and their effects on semen parameters and fertility. We review evidence for the following viruses: Ebola, Zika, West Nile, pandemic influenza, severe acute respiratory syndrome (SARS), and SARS-corona virus-2 (SARS-CoV-2).

METHODS

A literature search was conducted to identify relevant studies. Titles and abstracts were reviewed for relevance. References from identified articles were searched and included, if appropriate.

MAIN OUTCOME MEASURES

The main outcome measure of this study was reviewing of peer-reviewed literature.

RESULTS

Both the Ebola virus and Zika virus are present in semen, but only the Zika virus shows consistent evidence of sexual transmission. Current evidence does not support the presence of the West Nile virus, pandemic influenza, SARS, and SARS-CoV-2 in semen. The Zika virus appears to alter semen parameters in a way that diminishes fertility, but the effect is likely time limited. The West Nile virus and SARS have been associated with orchitis in a small number of case reports. Viruses that cause febrile illness, such as pandemic influenza, SARS, and SARS-CoV-2, are associated with decreased sperm count and motility and abnormal morphology. SARS and SARS-CoV-2 may interact with angiotensin-converting enzyme 2 receptors present in the testes, which could impact spermatogenesis.

CONCLUSIONS

We have reported the presence in semen, sexual transmission potential, and fertility side effects of recent viral pandemics. Overall, semen studies and fertility effects are highly understudied in viral pandemics, and rigorous study on these topics should be undertaken as novel pandemics emerge. Payne K, Kenny P, Scovell JM, et al. Twenty-First Century Viral Pandemics: A Literature Review of Sexual Transmission and Fertility Implications for Men. Sex Med Rev 2020;8:518-530.

Absence of SARS-CoV-2 in semen of a COVID-19 patient cohort

Background

Since SARS‐CoV‐2 infection was first identified in December 2019, the novel coronavirus‐induced pneumonia COVID‐19 spread rapidly and triggered a global pandemic. Recent bioinformatics evidence suggested that angiotensin‐converting enzyme 2—the main cell entry target of SARS‐CoV‐2—was predominantly enriched in spermatogonia, Leydig and Sertoli cells, which suggests the potential vulnerability of the male reproductive system to SARS‐CoV‐2 infection.

Objectives

To identify SARS‐CoV‐2 RNA in seminal plasma and to determine semen characteristics from male patients in the acute and recovery phases of infection.

Methods

From February 26 to April 2, 2020, 23 male patients with COVID‐19 were recruited. The clinical characteristics, laboratory findings and chest computed tomography scans of all patients were recorded in detail. We also investigated semen characteristics and the viral RNA load in semen from these patients in the acute and recovery phases of SARS‐CoV‐2 infection using approved methods.

Results

The age range of the 23 patients was 20‐62 years. All patients tested negative for SARS‐CoV‐2 RNA in semen specimens. Among them, the virus had been cleared in 11 patients, as they tested negative. The remaining 12 patients tested negative for SARS‐CoV‐2 RNA in semen samples, but were positive in sputum and fecal specimens. The median interval from diagnosis to providing semen samples was 32 days, when total sperm counts, total motile sperm counts, and sperm morphology of the patients were within normal ranges.

Discussion and Conclusion

In this cohort of patients with a recent infection or recovering from COVID‐19, there was no SARS‐CoV‐2 RNA detected in semen samples, which indicates the unlikely possibility of sexual transmission through semen at about 1 month after first detection.

SARS-CoV-2 and the next generations: which impact on reproductive tissues?

Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) is a severe global pandemic, affecting mostly the respiratory system. Understandably, attention is also being directed towards the urogenital tract. In this work, expression patterns of various host molecules possibly involved in viral entry and replication were investigated in human female and male reproductive systems by inquiring online repositories, including the Human Protein Atlas, GTEx, FANTOM5. Our findings highlight that male reproductive tissues could be targeted by SARS-CoV-2, particularly the testis since it co-expresses the receptor (ACE2) and the protease (TMPRSS) needed for viral entry. We hypothesized that SARS-CoV-2 infection could have repercussions on the fertility status of male individuals Potential infectivity of SARS-CoV-2 in reproductive tissues should be considered in reproductive medicine and management of in vitro fertilization in present and future generations.

Investigation of SARS-CoV-2 in Semen of Patients in the Acute Stage of COVID-19 Infection

Introduction

The presence of new coronavirus (SARS-CoV-2) in semen and the possibility of sexual transmission have become new subjects of curiosity. There is a discrepancy regarding this issue in the literature. The presence of SARS-CoV-2 in semen has been investigated in a limited number of studies, and mostly in recovering patients. We aimed to investigate the presence of SARS-CoV-2 RNA in semen of patients with a positive nasopharyngeal swab test for SARS-CoV-2 in the acute stage.

Methods

We enrolled adult male patients who were hospitalized with confirmed SARS-COV-2 infection in the study. In addition to routine laboratory and radiological tests, semen sample was obtained from volunteers and transferred to the Turkish Public Health Institution, National Virology Laboratory. The samples were processed for the detection of SARS-CoV-2 RNA on the day of collection.

Results

Sixteen patients were included in the study. The median age was 33.5 years (18–54). All but one had respiratory symptoms. None of the patients had a history or symptoms of urogenital disease. All semen samples were obtained during hospitalization and in the acute stage of the infection. The median time to obtain a semen sample after positive nasopharyngeal test was 1 day (0–7). All semen samples were detected as negative for SARS-CoV-2 PCR.

Discussion/Conclusion

Although all semen samples were obtained in acute stage of the infection when the nasopharyngeal swab test was positive, we did not detect SARS-CoV-2 in semen. The results of our study support the thought that sexual transmission via semen does not have an important role in the person-to-person transmission of SARS-CoV-2. We think that our study will provide new information to fill the gap in the literature.

SARS-CoV-2 infection, male fertility and sperm cryopreservation: a position statement of the Italian Society of Andrology and Sexual Medicine (SIAMS) (Società Italiana di Andrologia e Medicina della Sessualità)

PURPOSE

The recent pandemic of severe acute respiratory syndrome (SARS) due to coronavirus (CoV) 2 (SARS-CoV-2) has raised several concerns in reproductive medicine. The aim of this review is to summarize available evidence providing an official position statement of the Italian Society of Andrology and Sexual Medicine (SIAMS) METHODS: A comprehensive Pubmed, Web of Science, Embase, Medline and Cochrane library search was performed. Due to the limited evidence and the lack of studies, it was not possible to formulate recommendations according to the Oxford 2011 Levels of Evidence criteria.

RESULTS

Several molecular characteristics of the SARS-CoV-2 can justify the presence of virus within the testis and possible alterations of spermatogenesis and endocrine function. Orchitis has been reported as a possible complication of SARS-CoV infection, but similar findings have not been reported for SARS-CoV-2. Alternatively, the orchitis could be the result of a vasculitis as COVID-19 has been associated with abnormalities in coagulation and the segmental vascularization of the testis could account for an orchitis-like syndrome. Finally, available data do not support the presence of SARS-CoV-2 in plasma seminal fluid of infected subjects.

CONCLUSION

Data derived from other SARS-CoV infections suggest that in patients recovered from COVID-19, especially for those in reproductive age, andrological consultation and evaluation of gonadal function including semen analysis should be suggested. Studies in larger cohorts of currently infected subjects are warranted to confirm (or exclude) the presence of risks for male gametes that are destined either for cryopreservation in liquid nitrogen or for assisted reproduction techniques.

SARS-CoV-2 in the semen: Where does it come from?

Background

The recent report of SARS‐CoV‐2 presence in semen samples of six patients, including two subjects who were recovering from the clinical disease, re‐opened the discussion on possible male genital tract infection, virus shedding in semen, sexual transmission and safety of fertility treatments during the pandemic period.

Objectives

To explore current data and hypothesis on the possible sites of SARS‐CoV‐2 infection in the male reproduction system.

Materials and methods

We reviewed the current literature to describe: a) the evidences on angiotensin‐converting enzyme 2 (AC2E) and transmembrane serine protease 2 (TMPRSS2) expression in the testes, accessory glands (including prostate) and the urinary tract; b) other coronaviruses’ (SARS and MERS) ability to infect these sites.

Results

The co‐expression of both ACE2 and TMPRSS2 genes was reported in spermatogonial stem cells, elongated spermatids, in at least a small percentage of prostate hillock cells and in renal tubular cells. Testicular damage was described in autopsies of SARS patients, without evidence of the virus in the specimens. Prostate is a known infection site for MERS‐CoV. SARS‐CoV‐2 was detected in urines.

Discussion

There are still al lot of open questions on the effects of SARS‐CoV‐2 infection on the male reproductive tract. The presence of receptors is not a proof that the testis provides a site for viral infection and it is still unknown if SARS‐CoV‐2 is capable to pass the blood‐testis barrier. The possibility of a prostate involvement has not been investigated yet: we have no data, but theoretically it cannot be excluded. Moreover, the RNA detected in semen could have been just a residual of urinary shedding.

Conclusion

Opening our prospective beyond the testis could be the key to better understand the possibility of a semen‐related viral transmission as well as COVID19 short and long‐term effects on male reproductive function.

[SARS-CoV-2 pandemic and assisted reproduction]

La pandemia por el nuevo virus SARS-CoV-2 ha provocado un proceso de adaptación a la nueva situación por parte de toda de la sociedad y, con ello, los centros de reproducción asistida. Tras la fase aguda de la crisis sanitaria, en la que se redujo de forma drástica la actividad, se han reanudado los ciclos, guiados por las recomendaciones de las sociedades científicas.

En este artículo revisamos toda la información publicada respecto al virus y el sistema reproductivo, señalando la presencia de enzima convertidora de angiotensina tipo ii(angiotensin-converting enzyme 2, ACE2) en el sistema reproductivo femenino y masculino, a nivel testicular, ovárico, endometrial y a nivel embrionario. Además, realizamos un análisis comparativo entre las recomendaciones de las sociedades científicas en cuanto al cribado de la infección, las normas de funcionamiento y las medidas generales de laboratorio.