Sperm antibodies after intraperitoneal insemination of sperm: a preliminary report

Infertility due to antisperm antibodies

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

Antisperm antibodies: origin, regulation, and sperm reactivity in human infertility

OBJECTIVE

To follow-up and expand discussion on the action mechanisms of antisperm antibodies in human infertility, the etiology and control of antisperm antibody induction, sperm antigens involved in immunoinfertility, and strategies for therapy.

DESIGN

A review of the recent literature with an emphasis on female immunoinfertility.

RESULTS

The role of antisperm antibodies in clinical infertility continues to be defined. Through assisted reproductive technologies, antisperm antibodies were shown to exert detrimental effects on different prefertilization and possibly postfertilization events. The female reproductive tract is part of the common mucosal immune system and is able to mount effective immune responses against infectious agents, foreign antigens, and, occasionally, sperm cells. Sperm membranes and constituents contain numerous antigenic components foreign to the human body, and yet antisperm antibodies become problematic in few women exposed to semen. Semen and sperm cells contain immunosuppressive factors capable of inhibiting different immune cells. Fertile women apparently produce antisperm antibodies but also possess neutralizing serum anti-idiotypic antibodies that are lacking in virgin and immunoinfertile women.

CONCLUSIONS

Antisperm antibodies can affect adversely human fertility but normally may be controlled by anti-idiotypic antibodies, which along with immunosuppressor factors in semen prevent their induction to a significant degree. This balance between detrimental and "beneficial" immune response to sperm may be shifted toward an antisperm antibody response by stimulatory factors such as infection. Therapies may be devised to stimulate the anti-idiotypic antibody system, to induce immune tolerance to sperm antigens, and to use antigens to adsorb antisperm antibodies from spermatozoa.

Lack of immunization after intraperitoneal insemination of spermatozoa

Twenty infertile patients with normal tubal patency were inseminated intraperitoneally (11 once, seven twice, and two three times) with spermatozoa (mean 14 x 10(6), range 0.6-48 x 10(6)) prepared by the standard swim-up technique. The occurrence of immunization to spermatozoa was looked for by the Gelatin Agglutination Test (GAT) and Tray Agglutination Test (TAT). Both tests gave negative results for all the controls (10 pregnant and 10 puerperal women). Antisperm antibodies were measured in the serum before, 30 d and 4-7 months after Intraperitoneal Insemination (IPI). The last check was done for only 14 patients, since six became pregnant as a consequence of the first treatment. Of the 14 patients studied after 4-7 months, seven had two, and two had three IPI. In the group of inseminated patients, 18 women with no basal sperm antibody did not show evidence of antibody formation after the treatment and it was not increased after insemination in the two patients who already had low antibody titre (1/32). In conclusion, despite the large number of spermatozoa inseminated and even after several IPI attempts, there was no evidence of de novo production of or increase in already present anti-sperm antibodies according to the methods used for the detection of ASA in this study.

Pregnancy rates after peritoneal ovum-sperm transfer

We present the technique of peritoneal ovum-sperm transfer as an option for treatment in couples with unexplained infertility factors. In 1989 we reported the first successful pregnancy, in the United States, after transferring sperm and oocyte into the peritoneal cavity. We now report the results of a prospective study of this procedure. Twelve women with unexplained infertility underwent 23 cycles of peritoneal ovum-sperm transfer. Ovulation stimulation was achieved with human menopausal gonadotropin. Ultrasonographically directed oocyte recovery was performed by the transvaginal route with the patient under local anesthesia and sedation. After oocyte recovery, 4.5 +/- 0.4 (mean +/- SE) oocytes and 13.3 +/- 1.0 (mean +/- SE) x 10(6) motile spermatozoa were transferred into the pouch of Douglas. Six clinical pregnancies occurred in 23 stimulated cycles for a pregnancy rate of 26% per cycle. This value compares with the overall pregnancy rates of 16% for in vitro fertilization and 27% for gamete intrafallopian transfer reported by the In Vitro Fertilization Registry. Thus these preliminary data suggest that peritoneal ovum-sperm transfer is at least as successful as in vitro fertilization and gamete intrafallopian transfer. Advantages of peritoneal ovum-sperm transfer over gamete intrafallopian transfer include its being an office nonsurgical procedure not necessitating a general anesthetic and decreased cost. Therefore peritoneal ovum-sperm transfer is a reasonable first approach in couples with unexplained infertility.