Demographic and socio-economic differences between men seeking infertility evaluation and those seeking surgical sterilization: from the National Survey of Family Growth

Vasectomy interest and awareness among patients and their partners in prenatal clinics in the United States

OBJECTIVE

Although vasectomy is safer, more effective and less expensive than tubal ligation, rates of permanent contraception are consistently higher in women than in men. We sought to explore vasectomy interest and awareness in patients and their partners during prenatal visits, a time when contraceptive counselling is typically performed.

METHODS

Anonymous surveys were distributed between January and July 2019 to a cross-sectional, convenience sample of pregnant women and their partners, if available, presenting for outpatient prenatal care at two hospitals (one public, one private) serving different patient populations in Chicago, Illinois, USA. Survey questions gauged participant awareness and interest in vasectomies.

RESULTS

Surveys were completed by 436 individuals (78% female, 24% male). Seventy percent of respondents indicated interest in vasectomy after achieving optimal family size, but most respondents had never discussed it with their healthcare provider. Factors associated with vasectomy interest included being partnered, having a lower household income, and knowing someone who has had a vasectomy. Almost 50% of respondents would be interested in obtaining information about vasectomies from their obstetrician or prenatal care provider.

CONCLUSIONS

Many patients and their male partners in the prenatal clinic setting were interested in vasectomy as a method for permanent contraception, but most respondents had never received counselling. Since comprehensive prenatal care includes contraceptive planning, obstetric providers are uniquely positioned to educate individuals on vasectomy.

One size does not fit all: variations by ethnicity in demographic characteristics of men seeking fertility treatment across North America

OBJECTIVE

To compare racial differences in male fertility history and treatment.

DESIGN

Retrospective review of prospectively collected data.

SETTING

North American reproductive urology centers.

PATIENT(S)

Males undergoing urologist fertility evaluation.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Demographic and reproductive Andrology Research Consortium data.

RESULT(S)

The racial breakdown of 6,462 men was: 51% White, 20% Asian/Indo-Canadian/Indo-American, 6% Black, 1% Indian/Native, <1% Native Hawaiian/Other Pacific Islander, and 21% "Other". White males sought evaluation sooner (3.5 ± 4.7 vs. 3.8 ± 4.2 years), had older partners (33.3 ± 4.9 vs. 32.9 ± 5.2 years), and more had undergone vasectomy (8.4% vs. 2.9%) vs. all other races. Black males were older (38.0 ± 8.1 vs. 36.5 ± 7.4 years), sought fertility evaluation later (4.8 ± 5.1 vs. 3.6 ± 4.4 years), fewer had undergone vasectomy (3.3% vs. 5.9%), and fewer had partners who underwent intrauterine insemination (8.2% vs. 12.6%) compared with all other races. Asian/Indo-Canadian/Indo-American patients were younger (36.1 ± 7.2 vs. 36.7 ± 7.6 years), fewer had undergone vasectomy (1.2% vs. 6.9%), and more had partners who underwent intrauterine insemination (14.2% vs. 11.9%). Indian/Native males sought evaluation later (5.1 ± 6.8 vs. 3.6 ± 4.4 years) and more had undergone vasectomy (13.4% vs. 5.7%).

CONCLUSION(S)

Racial differences exist for males undergoing fertility evaluation by a reproductive urologist. Better understanding of these differences in history in conjunction with societal and biologic factors can guide personalized care, as well as help to better understand and address disparities in access to fertility evaluation and treatment.

Are Infertile Men Less Healthy Than Fertile Men? An Analysis of the National Survey for Family Growth

OBJECTIVE

To characterize the general health status of infertile men in the United States using a nationally representative sample of men.

METHODS

Using the National Survey for Family Growth from 2011 to 2017, infertile subgroups were created using a range of inclusion criteria. Univariate and multivariate analyses were conducted comparing these men to fertile men.

RESULTS

Using population estimates, 6.5 million men with reduced fertility potential were compared to 26 million fertile men. After controlling for demographic and healthcare utilization factors, these groups did not have significantly different rates of key medical co-morbidities, including cancer, obesity, and overall disability. Looking at the subset of men who had received a specific infertility diagnosis, estimated as a population of nearly 600,000 men, this pattern held, in that there were no significant differences in the rates of medical co-morbidities. Notably, the rate of male infertility evaluation among potentially infertile men was only 50%. These findings also persisted after a propensity-matched analysis.

CONCLUSION

In this cohort, there was no significant relationship between infertility and specific medical co-morbidities. We must consider the influence of sample selection as we continue to investigate the relationship between medical co-morbidities and reduced fertility potential. Given the persistent low rates of infertility evaluation, even among men who seek medical advice to conceive, we must continue to search for ways to characterize the infertile male population while simultaneously working to improve access.

Men Who Have Undergone Vasectomy are Healthier Than Non-sterilized Fertile Men: An Analysis of the Nation Survey for Family Growth

OBJECTIVE

To evaluate the health status of men who have undergone vasectomy versus nonsterilized fertile men.

METHODS

Using the National Survey for Family Growth from 2002 to 2017, univariate and multivariate analyses were performed on demographic and health data, including health status and health care utilization.

RESULTS

Men who have undergone vasectomy are more likely to be older, healthier, have more children, identify as non-Hispanic white, be married, have a higher level of education, earn a higher mean household income, and were more likely to be privately insured than non-sterilized fertile men. On multivariate analysis, men who underwent vasectomy had a better health status despite being older.

CONCLUSION

There are significant socioeconomic and health differences between men who elect vasectomy and non-sterilized fertile men. These differences should be considered when considering using sterilized men as a proxy for proven fertile men in epidemiological studies.

Association between infertility and mental health of offspring in the United States: a population based cohort study

There exist conflicting data in regard to the health outcomes of offspring born to infertile couples and follow up of offspring can be challenging. The objective of the study was to determine the association between infertility in men and women and the mental health of their offspring. The present study analyzes data obtained from the IBM Marketscan™ Commercial Claims and Encounters database from 2007 through 2015. Overall, 271,603 children of males with male factor infertility, 328,571 children of females with female factor infertility, 663,568 children of males who later underwent vasectomy were identified. The odds of psychosis were increased in offspring of those with male factor infertility (OR 1.25, 95% CI 1.22-1.29) and female factor infertility (OR 1.20, 95% CI 1.17-1.23). Offspring of infertile males (OR 1.19, 95% CI 1.13-1.26) and infertile females (OR 1.20, 95% CI 1.14-1.26) had an increased odds of autism compared to the reference group. In addition, offspring of infertile males (OR 1.48, 95% CI 1.28-1.7) and infertile females (OR 1.52, 95% CI 1.33-1.73) had higher odds of being diagnosed with an intellectual disability. Therefore, offspring of infertile men or women may have an increased risk of developing psychosis, autism, or intellectual disability.

Phenylethanol glycosides from Cistanche tubulosa improved reproductive dysfunction by regulating testicular steroids through CYP450-3β-HSD pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Cistanche tubulosa (Schenk) R. Wight has been used frequently in traditional folk medicine for treatment of male sexual dysfunction (MSD). Phenylethanol glycosides, the main components of C. tubulosa, possess a variety of pharmacological activities due to their multiple properties. However, the underlying mechanism by which phenylethanol glycosides from C. tubulosa (CPhGs) regulates testicular steroids has not been elucidated to date.

AIM OF THE STUDY

This study is to determine whether CPhGs promotes the reproductive functions of mice through CYP450-3β-HSD pathway of testosterone synthesis.

MATERIALS AND METHODS

The major compositions of C. tubulosa (CPhGs) were quantified by high performance liquid chromatography (HPLC). The model of reproductive injury in mice were induced by injection of hydrocortisone (HCT). Different doses of CPhGs (72, 145 and 289 mg/kg) and testosterone propionate (TP, positive control drug) were administrated intragastrically for 14 d. The reproductive functions (erectile incubation period, capture and ejaculation incubation period, number of captures and ejaculations) and organ weights (testicle, epididymis, seminal vesicle and penis) were then determined. The levels of luteinizing hormone and testosterone in serum were quantified by radioimmunoassay. The key enzymes in testosterone synthesis pathways such as steroidogenic acute regulatory protein (StAR), cytochrome P450 cholesterol side chain cleavage enzyme (P450scc/CYP11A1) and 3β-hydroxysteroid dehydrogenase (3β-HSD) in the testis were assessed by immunofluorescence (IF) staining or/and Western blot (WB) analysis.

RESULTS

The results illustrated that the low dose of CPhGs (72 mg/kg) had no significant protective effect against the reproductive injury caused by HCT, while the moderate dose of CPhGs (145 mg/kg) improved the damaged reproductive ability and the declined levels of luteinizing hormone and testosterone in the model mice (P < 0.001, P < 0.05, respectively). In particular, high dose of CPhGs (289 mg/kg) was most effective in improving HCT-induced changes in body weight (P < 0.01), reducing the incubation period of the erectile (P < 0.001), capture (P < 0.05) and ejaculation (P < 0.01), and increasing the number of captures and ejaculations (P < 0.01, P < 0.05, respectively). The weights of testcle, epididymis, seminal vesicle and penis (P < 0.001, P < 0.01, P < 0.01, P < 0.001, respectively) were improved by high dose of CPhGs. The levels of testosterone and its upstream luteinizing hormone were up-regulated by high dose of CPhGs (P < 0.001). Meanwhile, the expressions of the key steroidogenic enzymes including CYP11A1 and 3β-HSD were significantly up-regulated after CPhGs treatment (P < 0.001), demonstrated that CPhGs exerted the effect through enhancing testosterone biosynthesis via CYP450-3β-HSD pathway.

CONCLUSIONS

CPhGs could significantly protect against HCT-induced deleterious reproductive dysfunction and testis injury. The protective effects were exerted by up-regulating synthesis of testosterone via the CYP450-3β-HSD pathway in Leydig cells.

Limitations and opportunities in male fertility databases

Over the last several years, the male component of reproduction has begun to gain clinical momentum. The medical literature has traditionally focused on infertility from the female perspective, but recent publications have demonstrated that male infertility is an important marker of overall health for infertile men as well as their family members. In order to perform large-scale, quality research related to male infertility, comprehensive databases are necessary. Currently, research in male infertility is limited by the fact that there is not a centralized, comprehensive database specifically designed to collect patient information related to male fertility. A database of this nature exists for female infertility research in the form of the Society for Assisted Reproductive Technology (SART) clinical summary report and the National ART Surveillance System (NASS) published by the Centers for Disease Control (CDC). This review outlines the strengths and weaknesses of several male fertility data sources, including the National Survey of Family Growth, the Reproductive Medicine Network, the Andrology Research Consortium (ARC), the Truven Health MarketScan^® databases, the Utah Population Database, and data available from the Ober Lab related to the Hutterites. While each of these sources has been instrumental in the creation of meaningful research within the field of male fertility, a need remains for the creation of a centralized database for use in future male fertility research. The ideal database would consist of vast amounts of patient data which link individuals and couples to biologic specimens as well as data from family members, designed with parameters specifically purposed for male fertility research. The use of electronic medical records (EMR) systems such as Epic may play a role in the development of such a database going forward. At present, although some information is available through current databases, researchers must utilize suboptimal data sources to perform studies.

Echinacoside Increases Sperm Quantity in Rats by Targeting the Hypothalamic Androgen Receptor

Male infertility is a major health issue with an estimated prevalence of 4.2% of male infertility worldwide. Our early work demonstrated that Cistanche extracts protect against sperm damage in mice and that echinacoside (ECH) is one of the major active components. Here we report an essential role for ECH, a natural product that reverses or protects against oligoasthenospermia in rats. ECH was assayed by HPLC, the quantity and quality of sperm was evaluated and hormone levels were determined by radioimmunosorbent assay. ECH reduced levels of androgen receptor (AR) and key steroidogenic-related genes as determined by Western blot and qPCR analysis. The interaction between ECH and AR were evaluated by indirect ELISA and molecular docking. The results show that ECH combined with hypothalamic AR in the pocket of Met-894 and Val-713 to inhibit transfer of AR from the cytoplasm to nuclei in the hypothalamus. While negative feedback of sex hormone regulation was inhibited, positive feedback was stimulated to increase the secretion of luteinizing hormone and testosterone subsequently enhancing the quantity of sperm. Taken together, these data demonstrate that ECH blocks AR activity in the hypothalamus to increase the quantity of sperm and protect against oligoasthenospermia in rats.

Male infertility is associated with altered treatment course of men with cancer

This study aims to evaluate whether cancer treatments differ in infertile men compared to men who have undergone vasectomy and age-matched controls. We analyzed subjects from the Truven Health MarketScan Claims database from 2001 to 2009. Infertile men were identified through diagnosis and treatment codes. Comparison groups included vasectomized men and an age-matched cohort who were not infertile and had not undergone vasectomy. We considered cancer types previously associated with infertility that were diagnosed after the diagnosis of infertility. The treatment regimens were determined based on the presence of claims with CPT codes for chemotherapy (CTX), radiation (RTX) or surgical treatment (ST) for each entity in all study groups. Cases with multimodal treatments were also identified. As a result, CTX was similarly distributed among the infertile, vasectomized, and control groups. In contrast, RTX treatment length was shorter in infertile men. The frequency of multimodal treatment (i.e., radiation and chemotherapy) was twofold lower in men with infertility compared to other men. By focusing on treatment patterns for each cancer type among these groups, the duration of RTX and CTX was shorter in infertile men diagnosed with NHL compared to controls. We conclude that Infertile men diagnosed with cancer and specific cancer types experience different treatment courses, with shorter RTX and less combined RTX/CTX compared to fertile and vasectomized men. These differences could reflect differences in stage at presentation, biological behavior, or treatment responses in infertile men.

Echinacoside and Cistanche tubulosa (Schenk) R. wight ameliorate bisphenol A-induced testicular and sperm damage in rats through gonad axis regulated steroidogenic enzymes

ETHNOPHARMACOLOGICAL RELEVANCE

Male infertility has been increasing over the last decades and being a pressing health problem nowadays. Cistanche tubulosa (CT) is a traditional Chinese medicine used to boost male sexual function. Echinacoside (ECH) is one of the major compounds exist in CT and might be a potential agent to protect testis and sperm injury.

AIM OF THE STUDY

To investigate the mechanisms behind the possible protective effects of CT and ECH against testicular and sperm toxicity.

MATERIALS AND METHODS

CT was identified by 5.8s gene sequencing. The major compositions (echinacoside and acteoside) of CT were quantified by HPLC method. The adult male Sprague-Dawley rats were exposed to BPA, CT or ECH for 42 consecutive days. The sperm parameters were observed by dark-field microscope; serum hormone levels (FSH, LH and testosterone) were tested by radio immunosorbent; LDH-x activity were evaluated using commercial kits; the expressions of the key steroidogenic enzymes were evaluated by qRT-PCR, heat map, immunofluorescence and western blot.

RESULTS

The CT and ECH treatments against BPA-induced testicular and sperm toxicity showed that CT and ECH have reversed BPA-induced abnormality in sperm characteristics, testicular structure and normalized serum testosterone. This was concomitant with the increased expression of LDH-x as well as the key steroidogenic enzymes including StAR, CYP11A1, 3β-HSD, 17β-HSD and CYP17A1, suggesting that CT and ECH enhanced testosterone biosynthesis.

CONCLUSIONS

CT and ECH attenuated poor sperm quality and testicular toxicity in rats through up-regulation steroidogenesis enzymes and ECH is the active compound of CT as a potential natural reproductive agent.