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Yessirkepov M, Kocyigit BF, Zhakipbekov K, Adilbekov E, Sultanbekov K, Akaltun MS. Uncovering the link between inflammatory rheumatic diseases and male reproductive health: a perspective on male infertility and sexual dysfunction. Rheumatol Int 2024:10.1007/s00296-024-05602-8. [PMID: 38693253 DOI: 10.1007/s00296-024-05602-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024]
Abstract
Inflammatory rheumatic diseases (IRDs) refer to a range of persistent disorders that have a major influence on several physiological systems. Although there is much evidence connecting IRDs to sexual dysfunction and fertility problems, research specifically focusing on male infertility in relation to these diseases is sparse. This review addresses the complicated connection between IRDs and male infertility, emphasising the physiological, psychological, and pharmacological aspects that influence reproductive health outcomes in men with rheumatic conditions. We explore the effects of IRDs and their treatments on many facets of male reproductive well-being, encompassing sexual functionality, semen characteristics, and hormonal balance. Additionally, we present a comprehensive analysis of the present knowledge on the impact of several categories of anti-rheumatic drugs on male reproductive function. Although there is an increasing awareness of the need of addressing reproductive concerns in individuals IRDs, there is a noticeable lack of research especially dedicated to male infertility. Moving forward, more comprehensive research is needed to determine the prevalence, risk factors, and mechanisms driving reproductive difficulties in males with IRDs. We can better assist the reproductive health requirements of male IRD patients by expanding our understanding of male infertility in the setting of rheumatic disorders and implementing holistic methods to care.
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Affiliation(s)
- Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Burhan Fatih Kocyigit
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Adana City Research and Training Hospital, Adana, Türkiye, Turkey
| | - Kairat Zhakipbekov
- Department of Organization and Management and Economics of Pharmacy and Clinical Pharmacy, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | | | - Kassymkhan Sultanbekov
- Department Social Health Insurance and Public Health, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Mazlum Serdar Akaltun
- Faculty of Medicine, Department of Physical Medicine and Rehabilitaton, Gaziantep University, Gaziantep, Türkiye, Turkey.
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Kocyigit BF, Fedorchenko Y, Sultanbekov K, Ozturk GY, Yessirkepov M. Exploring complex links: inflammatory rheumatic diseases and men's health. Rheumatol Int 2024; 44:757-764. [PMID: 38488864 DOI: 10.1007/s00296-024-05549-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/25/2024] [Indexed: 03/17/2024]
Abstract
This article examines the complex interactions between inflammatory rheumatic diseases (IRDs) and men's health. It delves into the effects of IRDs on reproductive health, erectile dysfunction, prostate involvement, male osteoporosis, body composition, physical activity, and coping mechanisms. The findings show that the prevalence of sexual dysfunction varies among different diseases, underscoring the necessity for comprehensive counseling. The link between IRDs and prostate health, with a substantial rise in benign prostatic hyperplasia among IRD patients, demonstrates the condition's importance. In contrast to popular belief, osteoporosis mostly affects women; the current study highlights the growing identification of male osteoporosis, particularly in the setting of IRDs. Male RA patients had a significant loss in bone mineral density, highlighting the importance of increasing awareness and tailored therapy to address osteoporosis in men. IRDs affect body composition, with male RA patients showing imbalances characterized by decreased lean body mass and increased fat mass. Given the dynamic nature of these conditions, coping with IRDs necessitates thorough and individualized diversified approaches. The complex link between IRDs and men's health demands continuing research, including longitudinal studies and tailored therapies. The essay promotes a patient-centered approach, recognizing the unique obstacles that males with IRDs confront.
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Affiliation(s)
- Burhan Fatih Kocyigit
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Adana City Research and Training Hospital, Adana, Turkey.
| | - Yuliya Fedorchenko
- Department of Pathophysiology, Ivano-Frankivsk National Medical University, Ivano-Frankivs'k, Ukraine
| | - Kassymkhan Sultanbekov
- Department Social Health Insurance and Public Health, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Gulsah Yasa Ozturk
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Adana City Research and Training Hospital, Adana, Turkey
| | - Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
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3
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Fertility preservation for patients with melanoma. Melanoma Res 2022; 32:303-308. [PMID: 35855660 DOI: 10.1097/cmr.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The advent of immunotherapy and targeted therapy has outstandingly improved the prognosis in subjects with melanoma. Their use is now advocated also in earlier stages as an adjuvant therapy, and some neoadjuvant clinical trials are ongoing. Consequently, survivors free of disease are increasing, as well as those exposed to these new agents. Parenthood in survivors is, therefore, receiving growing interest. Evidence on the effects of immunotherapy and targeted therapy on future fertility is limited, but not entirely reassuring, in particular for immunotherapy. The necessity of delaying pregnancy seeking up to the end of treatments and follow-up (iatrogenic aging) is an additional albeit neglected source of concern, in particular for women in their late 30s. Subjects with melanoma should be informed on the multifaceted issue of future fertility at the time of cancer diagnosis. Available options of fertility preservations, including sperm and oocytes storage, should also be discussed, especially considering that at the age 0-39, melanoma represents the second most frequent neoplasia. In the decision-making process, most attention should be given to sex, age, and exposure to immunotherapy.
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Leathersich S, Hart RJ. Immune infertility in men. Fertil Steril 2022; 117:1121-1131. [PMID: 35367058 DOI: 10.1016/j.fertnstert.2022.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/30/2022] [Accepted: 02/09/2022] [Indexed: 11/04/2022]
Abstract
Male factors are implicated as the cause of roughly half of cases of infertility, and the presence of antisperm antibodies (ASA) may be responsible for some of these. Their presence is associated with a reduction in natural conception and live birth and impacts the success of assisted reproductive technologies. Interpretation of the data regarding ASAs and fertility is complicated by a lack of standardization in testing methodology and test thresholds and a lack of data on their prevalence in the healthy fertile population. Although their pathogenesis remains elusive, and many cases are idiopathic, a disruption in the immunologic blood-testis barrier (BTB) appears to contribute to the formation of ASA. As delineation of the specific antigen targets of ASA advances, it has been recognized that they may affect almost all aspects of sperm function, and ASA against different targets likely have specific mechanisms of impairing fertility. Intracytoplasmic sperm injection (ICSI) appears to be the most reliable method by which to overcome fertility impairment due to ASA, achieving similar outcomes to ASA-negative patients with regard to fertilization rates, embryonic development, clinical pregnancy rates, and live birth rates. The lack of consistency in testing for and reporting ASA remains a substantial barrier to achieving clarity in describing their role in infertility and the optimal management approach, and future research should use a unified approach to the detection and description of ASA. Determination of the specific antigens targeted by ASA, and their function and clinical relevance, would contribute to improving the understanding of ASA-mediated impacts on fertility and tailoring treatment appropriately to achieve the best outcomes for patients.
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Affiliation(s)
- Sebastian Leathersich
- King Edward Memorial Hospital, Perth, Australia; Fertility Specialists of Western Australia, Claremont, Australia
| | - Roger J Hart
- King Edward Memorial Hospital, Perth, Australia; Fertility Specialists of Western Australia, Claremont, Australia; Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia.
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Chatzimeletiou K, Fleva A, Sioga A, Georgiou I, Nikolopoulos TT, Markopoulou M, Petrogiannis N, Anifandis G, Patrikiou A, Kolibianakis E, Giannakou A, Grimbizis G. Effects of Different Drug Therapies and COVID-19 mRNA Vaccination on Semen Quality in a Man with Ankylosing Spondylitis: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:173. [PMID: 35208497 PMCID: PMC8875133 DOI: 10.3390/medicina58020173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Ankylosing spondylitis (AS) is a condition that affects 0.1% to 0.5% of the adult population. The aim of this case report was to investigate the possible effects of the drugs taken for treatment of AS as well as mRNA vaccination for COVID-19 on semen quality by performing a highly detailed analysis. Materials and Methods: Sperm characteristics were examined by light microscopy, DNA fragmentation (DFI) was analysed by flow cytometry and morphology was evaluated by transmission electron microscopy (TEM). Results: Semen analysis under therapy with (1) celecoxib and sulphasalazine showed: concentration 47 million/mL, 53% progressive motility, 7% normal morphology and 9.6% DFI, (2) Golimumab and before mRNA Vaccination showed: concentration 108 million/mL, 82% progressive motility, 1% normal morphology and 7.6% DFI, and (3) Golimumab and after 3 doses of mRNA Vaccination showed: concentration 142 million/mL, 85% progressive motility, 1% normal morphology and 6.8% DFI. TEM revealed head, neck and tail abnormalities, as well as the presence of cells with incomplete spermiogenesis white cells and phagocytes in the sample under therapy with celecoxib and sulphasalazine. Golimumab treatment lead to an increased incidence of elongated heads but in general reduced inflammation as no white cells were evident in TEM. Conclusion: The anti-inflamatory drugs celecoxib and sulphasalazine had no adverse effect on sperm quality as all parameters were within normal limits and the patient achieved under that treatment 2 pregnancies following natural conception that lead to the birth of a healthy boy and girl respectively. Anti-TNFa treatment with Golimumab exerted a negative effect on morphology but not on concentration, motility and DFI. After 3 doses of mRNA Vaccination, sperm concentration increased while motility, morphology and DFI remained similar to the values before vaccination suggesting no negative effect of the mRNA vaccine for COVID-19 on sperm quality.
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Affiliation(s)
- Katerina Chatzimeletiou
- Unit for Human Reproduction, 1st Department of Obstetrics & Gynaecology, ‘Papageorgiou’ General Hospital, Aristotle University Medical School, 56403 Thessaloniki, Greece; (T.-T.N.); (A.P.); (E.K.); (G.G.)
| | - Alexandra Fleva
- Department of Immunology and Histocompatibility, ‘Papageorgiou’ General Hospital, 56403 Thessaloniki, Greece; (A.F.); (M.M.); (A.G.)
| | - Antonia Sioga
- Laboratory of Histology and Embryology, Aristotle University Medical School, 54124 Thessaloniki, Greece;
| | - Ioannis Georgiou
- Laboratory of Medical Genetics, School of Medicine, University of Ioannina and Medical Genetics and Assisted Reproduction Unit, Department of Obstetrics and Gynecology, University Hospital of Ioannina, 45110 Ioannina, Greece;
| | - Theodoros-Thomas Nikolopoulos
- Unit for Human Reproduction, 1st Department of Obstetrics & Gynaecology, ‘Papageorgiou’ General Hospital, Aristotle University Medical School, 56403 Thessaloniki, Greece; (T.-T.N.); (A.P.); (E.K.); (G.G.)
| | - Maria Markopoulou
- Department of Immunology and Histocompatibility, ‘Papageorgiou’ General Hospital, 56403 Thessaloniki, Greece; (A.F.); (M.M.); (A.G.)
| | | | - George Anifandis
- Department of Obstetrics and Gynecology, School of Health Sciences, Faculty of Medicine, University of Thessaly, 41200 Larisa, Greece;
| | - Antonios Patrikiou
- Unit for Human Reproduction, 1st Department of Obstetrics & Gynaecology, ‘Papageorgiou’ General Hospital, Aristotle University Medical School, 56403 Thessaloniki, Greece; (T.-T.N.); (A.P.); (E.K.); (G.G.)
| | - Efstratios Kolibianakis
- Unit for Human Reproduction, 1st Department of Obstetrics & Gynaecology, ‘Papageorgiou’ General Hospital, Aristotle University Medical School, 56403 Thessaloniki, Greece; (T.-T.N.); (A.P.); (E.K.); (G.G.)
| | - Anastasia Giannakou
- Department of Immunology and Histocompatibility, ‘Papageorgiou’ General Hospital, 56403 Thessaloniki, Greece; (A.F.); (M.M.); (A.G.)
| | - Grigoris Grimbizis
- Unit for Human Reproduction, 1st Department of Obstetrics & Gynaecology, ‘Papageorgiou’ General Hospital, Aristotle University Medical School, 56403 Thessaloniki, Greece; (T.-T.N.); (A.P.); (E.K.); (G.G.)
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Boussaid S, Makhlouf Y, Rekik S, Jammali S, Cheour E, Sahli H, Elleuch M, Ben Saad H. The effects of autoimmune rheumatic-related diseases on male reproductive health: A systematic review. J Reprod Immunol 2022; 150:103472. [PMID: 34998078 DOI: 10.1016/j.jri.2021.103472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 11/24/2021] [Accepted: 12/30/2021] [Indexed: 11/26/2022]
Abstract
Autoimmune rheumatic-related diseases (ARRDs) have physical and psychological impact on patients, including their sexual life. While many studies have investigated fertility problems in females, data on males-related fertility are scarce, which explains the lack of guidance. The main objective of this systematic review was to evaluate the reproductive health in males with ARRDs. This systematic review followed the preferred reporting items for systematic reviews guidelines. Original articles from Pubmed and Scopus, published until September 16, 2021, and tackling the effects of ARRDs and/or ARRDs treatments on male fertility and/or pregnancy outcomes, were included. A total of twenty-five studies met the inclusion criteria. They were published between 1981 and 2018. The studied ARRDs were spondyloarthritis (n = 9), systematic lupus erythematosus (SLE, n = 6), Behcet disease (BD, n = 5), rheumatoid arthritis (RA, n = 5), antiphospholipid syndrome (n = 1), and dermatomyositis (n = 1). The most reported effects of ARRDs on fertility are i) high levels of reproductive hormones, mainly in RA and SLE; ii) impaired semen quality in SLE, spondyloarthritis, and BD; and iii) higher rate of varicocele in BD and spondyloarthritis. Regarding the treatments effects, i) conventional synthetic disease-modifying anti-rheumatic drugs (e.g.; methotrexate and salazopyrine) increase testosterone level, ii) cyclophosphamide impairs fertility, iii) anti-tumor necrosis factor agents are associated with improvement in semen quality, and iv) no increased number of miscarriages or congenital abnormalities in children fathered by BD was reported. To conclude, both ARRDs and their treatments alter fertility in males with ARRDs. In practice, in addition to the conventional semen analysis, screening for infertility seems legitimate in males with ARRDs.
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Affiliation(s)
- Soumaya Boussaid
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia; Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia; Research Unit LR 05 SP 01, la Rabta Hospital, Tunisia.
| | - Yasmine Makhlouf
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia; Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia.
| | - Sonia Rekik
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia; Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia; Research Unit LR 05 SP 01, la Rabta Hospital, Tunisia.
| | - Samia Jammali
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia; Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia; Research Unit LR 05 SP 01, la Rabta Hospital, Tunisia.
| | - Elhem Cheour
- Pain Treatment center, Tunisia; Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia; Research Unit LR 05 SP 01, la Rabta Hospital, Tunisia.
| | - Hela Sahli
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia; Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia; Research Unit LR 05 SP 01, la Rabta Hospital, Tunisia.
| | - Mohamed Elleuch
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia; Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia.
| | - Helmi Ben Saad
- Université de Sousse, Faculté de Médecine de Sousse, Service de Physiologie et Explorations Fonctionnelles, Sousse, Tunisie; Université de Sousse, Hôpital Farhat HACHED, Service de Physiologie et Explorations Fonctionnelles, Sousse, Tunisia; Université de Sousse, Hôpital Farhat HACHED, Laboratoire de recherche LR12SP09 «Insuffisance cardiaque», Sousse, Tunisia.
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7
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Perez-Garcia LF, Röder E, Goekoop RJ, Hazes JMW, Kok MR, Smeele HTW, Tchetverikov I, van der Helm-van Mil AHM, van der Kaap JH, Kok P, Krijthe BP, Dolhain RJEM. Impaired fertility in men diagnosed with inflammatory arthritis: results of a large multicentre study (iFAME-Fertility). Ann Rheum Dis 2021; 80:1545-1552. [PMID: 34373257 PMCID: PMC8600610 DOI: 10.1136/annrheumdis-2021-220709] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/09/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The impact of inflammatory arthritis (IA) on male fertility remains unexplored. Our objective was to evaluate the impact of IA on several male fertility outcomes; fertility rate (number of biological children per man), family planning, childlessness and fertility problems. METHODS We performed a multicentre cross-sectional study (iFAME-Fertility). Men with IA 40 years or older who indicated that their family size was complete were invited to participate. Participants completed a questionnaire that included demographic, medical and fertility-related questions. To analyse the impact of IA on fertility rate, patients were divided into groups according to the age at the time of their diagnosis: ≤30 years (before the peak of reproductive age), between 31 and 40 years (during the peak) and ≥41 years (after the peak). RESULTS In total 628 participants diagnosed with IA were included. Men diagnosed ≤30 years had a lower mean number of children (1.32 (SD 1.14)) than men diagnosed between 31 and 40 years (1.60 (SD 1.35)) and men diagnosed ≥41 years (1.88 (SD 1.14)).This was statistically significant (p=0.0004).The percentages of men diagnosed ≤30 and 31-40 years who were involuntary childless (12.03% vs 10.34% vs 3.98%, p=0.001) and who reported having received medical evaluations for fertility problems (20.61%, 20.69% and 11.36%, p=0.027) were statistically significant higher than men diagnosed ≥41 years. CONCLUSIONS This is the first study that shows that IA can impair male fertility. Men diagnosed with IA before and during the peak of reproductive age had a lower fertility rate, higher childlessness rate and more fertility problems. Increased awareness and more research into the causes behind this association are urgently needed.
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Affiliation(s)
| | - Esther Röder
- Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Johanna M W Hazes
- Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marc R Kok
- Rheumatology and Clinical Immunology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | | | - Ilja Tchetverikov
- Rheumatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Annette H M van der Helm-van Mil
- Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jos H van der Kaap
- Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Rheumatology, Admiraal De Ruyter Hospital, Goes, The Netherlands
| | - Petra Kok
- Rheumatology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Bouwe P Krijthe
- Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Rheumatology, Sint Franciscus Vlietland Group, Rotterdam, The Netherlands
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Finelli R, Leisegang K, Finocchi F, De Masi S, Agarwal A, Damiani G. The impact of autoimmune systemic inflammation and associated medications on male reproductive health in patients with chronic rheumatological, dermatological, and gastroenterological diseases: A systematic review. Am J Reprod Immunol 2021; 85:e13389. [PMID: 33420722 DOI: 10.1111/aji.13389] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/04/2021] [Indexed: 01/13/2023] Open
Abstract
Autoimmune disorders currently affect 5%-8% of the global population, characterized by an aberrant chronic inflammatory response to self-antigens. The aim of this study was to systematically review the current available evidence investigating the impact of systemic autoimmune diseases and associated immunosuppressive treatment on fertility parameters of adult men. Clinical trials, observational studies, and case reports written in English and reporting semen analysis, evaluation of seminal oxidative stress, and/or sperm DNA fragmentation in patients affected by psoriasis and psoriatic arthritis, celiac disease, inflammatory bowel diseases, systemic lupus erythematosus, ankylosing spondylitis, hidradenitis suppurativa, uveitis, dermatomyositis, and rheumatoid arthritis were collected by searching on PubMed, EMBASE, OVID, Scopus, and Cochrane Library databases, with no limit of time. The study quality and the extent of bias in design, methods, and outcome assessment were evaluated by applying the Joanna Briggs Institute Critical Appraisal tools. Evidence suggested that various autoimmune diseases or relevant medications can adversely affect male fertility parameters and that patients may benefit of counseling and sperm cryopreservation. Clinical trials further investigating any adverse effect of autoimmunity and related thereby on male infertility are warranted, to develop appropriate guidelines for males diagnosed and treated for autoimmune disorders.
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Affiliation(s)
- Renata Finelli
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Kristian Leisegang
- School of Natural Medicine, University of the Western Cape, Cape Town, South Africa
| | - Federica Finocchi
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | | | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Giovanni Damiani
- Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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9
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Bermas BL. Paternal safety of anti-rheumatic medications. Best Pract Res Clin Obstet Gynaecol 2020; 64:77-84. [DOI: 10.1016/j.bpobgyn.2019.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022]
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10
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Perez-Garcia LF, Te Winkel B, Carrizales JP, Bramer W, Vorstenbosch S, van Puijenbroek E, Hazes JMW, Dolhain RJEM. Sexual function and reproduction can be impaired in men with rheumatic diseases: A systematic review. Semin Arthritis Rheum 2020; 50:557-573. [PMID: 32165034 DOI: 10.1016/j.semarthrit.2020.02.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/14/2020] [Accepted: 02/08/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Information about the possible effect of rheumatic diseases on male sexual function and reproduction (sexual health) is scarce and difficult to summarize. Factors known to impair sexual health, such as inflammation, medication use and hypogonadism can be present in a significant proportion of male patients with rheumatic diseases. OBJECTIVES The objective of our study was to systematically review the literature for the influence of paternal rheumatic disease on sexual health, such as sexual function, reproductive hormones, male fertility, pregnancy and offspring outcomes. DATA SOURCES English language articles identified through Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar and the Clinical trial registries of Europe and the USA published until February 2019. STUDY APPRAISAL AND SYNTHESIS METHODS Literature was synthesized in narrative form and in summary tables. Outcomes were categorized as: sexual function, reproductive hormones, fertility and pregnancy and offspring outcomes. Results are presented per category and per disease. RESULTS 9735 articles were identified with our search strategy. After removal of duplicates, excluding articles by screening titles and abstracts and assessing eligibility by reading 289 fulltext articles, 87 articles fulfilled the eligibility criteria. All included studies enrolled patients diagnosed with a rheumatic disease and had results at least on one of the outcome categories. Sexual function was the most common category, followed by reproductive hormones, fertility and pregnancy and offspring outcomes. Sexual function is impaired in a high proportion of patients with rheumatic diseases. This was statistically significant in most of the studies where a control group was available. Clinically relevant abnormalities in reproductive hormones were mainly identified in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) and a positive correlation with disease activity were reported. Semen quality in men with rheumatic diseases can be impaired in patients with SLE, SpA, sarcoidosis, BD and MWS. Sperm count and motility were the most common semen quality parameters affected. No negative effect of paternal RA and vasculitis on pregnancy outcomes were reported in 3 studies. No studies reporting the effect of paternal disease on offspring outcomes were identified. LIMITATIONS Most of the studies included in this review suffer from an inconsistent methodological quality, definitions of outcomes varied in several studies, a wide variety of screening questionnaires and/or diagnostic tools were used and results might only apply to the specific populations that were studied. CONCLUSIONS This systematic review suggests that sexual health is impaired in men with rheumatic diseases. The degree and extent of sexual health impairment vary per disease. More research is needed to fully understand the link between rheumatic diseases and impaired male sexual health. Meanwhile, rheumatologists should be aware of this association and discuss it with their patients. IMPLICATIONS OF KEY FINDINGS Sexual health of men with rheumatic diseases can be impaired by the disease itself. Especially in men trying to conceive, information on sexual function, reproductive hormones and sperm quality are needed to identify these problems. Treatment resulting in lower disease activity can improve overall sexual health in man with rheumatic diseases and facilitate their journey to fatherhood. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO 2018 CRD42018099845.
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Affiliation(s)
- L F Perez-Garcia
- Department of Rheumatology, Erasmus MC, University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
| | - B Te Winkel
- Netherlands Pharmacovigilance Centre Lareb, Goudsbloemvallei 7, 5237 MH, 's-Hertogenbosch, the Netherlands
| | - J P Carrizales
- Servicio de Reumatología, Universidad Autónoma de Nuevo León, Hospital Universitario, Monterrey, Mexico
| | - W Bramer
- Medical Library, Erasmus MC, University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - S Vorstenbosch
- Netherlands Pharmacovigilance Centre Lareb, Goudsbloemvallei 7, 5237 MH, 's-Hertogenbosch, the Netherlands
| | - E van Puijenbroek
- Netherlands Pharmacovigilance Centre Lareb, Goudsbloemvallei 7, 5237 MH, 's-Hertogenbosch, the Netherlands; PharmacoTherapy, Epidemiology and Economics, University of Groningen, Groningen Research Institute of Pharmacy, Broerstraat 4, 9712 CP, Groningen, the Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - R J E M Dolhain
- Department of Rheumatology, Erasmus MC, University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
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Paternal exposure to antirheumatic drugs—What physicians should know: Review of the literature. Semin Arthritis Rheum 2018; 48:343-355. [DOI: 10.1016/j.semarthrit.2018.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/19/2017] [Accepted: 01/09/2018] [Indexed: 12/11/2022]
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Chatzimeletiou K, Galanis N, Karagiannidis A, Sioga A, Pados G, Goulis D, Kalpatsanidis A, Tarlatzis BC. Fertility potential in a man with ankylosing spondylitis as revealed by semen analysis by light, electron and fluorescence microscopy. SAGE Open Med Case Rep 2018; 6:2050313X18759898. [PMID: 29511542 PMCID: PMC5825999 DOI: 10.1177/2050313x18759898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 01/23/2018] [Indexed: 11/16/2022] Open
Abstract
Ankylosing spondylitis affects 0.1%–0.5% of the adult population. The aim was to investigate the possible effects of both the disease and its treatment on semen quality by performing a highly detailed analysis in a man with ankylosing spondylitis, presenting for infertility. Sperm characteristics were evaluated by light microscopy, morphology by electron microscopy (transmission electron microscopy), DNA fragmentation by terminal deoxynucleotidyl transferase dUTP nick end labeling using fluorescence microscopy and chromosomal abnormalities by fluorescence in situ hybridisation using probes for chromosomes 13,15,16,18,21,22,X and Y. There was no evidence for an effect of either ankylosing spondylitis or its treatment with celecoxib and sulphasalazine on sperm quality as all parameters including concentration, motility, DNA fragmentation and aneuploidy incidence were within normal limits. Transmission electron microscopy, however, revealed a high incidence of head, neck and tail abnormalities, as well as the presence of immature sperm and phagocytes. Hysteroscopic removal of an endometrial polyp enabled the achievement of a spontaneous pregnancy and the delivery of a healthy boy.
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Affiliation(s)
- Katerina Chatzimeletiou
- Unit for Human Reproduction, 1 Department of Obstetrics & Gynaecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikiforos Galanis
- Department of Orthopaedics, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandros Karagiannidis
- Department of Orthopaedics, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonia Sioga
- Laboratory of Histology and Embryology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Pados
- Unit for Human Reproduction, 1 Department of Obstetrics & Gynaecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Goulis
- Unit for Human Reproduction, 1 Department of Obstetrics & Gynaecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonis Kalpatsanidis
- Unit for Human Reproduction, 1 Department of Obstetrics & Gynaecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Basil C Tarlatzis
- Unit for Human Reproduction, 1 Department of Obstetrics & Gynaecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Berg KH, Rohde G, Prøven A, Almås E, Benestad EEP, Østensen M, Haugeberg G. Exploring the relationship between demographic and disease-related variables and perceived effect of health status on sexual activity in patients with axial spondyloarthritis: associations found only with non-disease variables. Scand J Rheumatol 2017; 46:461-467. [DOI: 10.1080/03009742.2017.1279684] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- KH Berg
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - G Rohde
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
- Department of Clinical Research, Sørlandet Hospital, Kristiansand, Norway
| | - A Prøven
- Department of Rheumatology, Martina Hansens Hospital, Bærum, Norway
| | - E Almås
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - EEP Benestad
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - M Østensen
- Department of Clinical Research, Sørlandet Hospital, Kristiansand, Norway
| | - G Haugeberg
- Department of Clinical Research, Sørlandet Hospital, Kristiansand, Norway
- Department of Neuroscience, Division of Rheumatology, Norwegian University of Science and Technology, Trondheim, Norway
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Farhat J, Farhat SCL, Braga ALF, Cocuzza M, Borba EF, Bonfá E, Silva CA. Ozone decreases sperm quality in systemic lupus erythematosus patients. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:212-9. [PMID: 27267639 DOI: 10.1016/j.rbre.2015.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 07/06/2015] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To investigate the deleterious effects of air pollutants exposure in the Sao Paulo metropolitan region on semen quality in systemic lupus erythematosus (SLE). METHODS A seven-years longitudinal repeated-measures panel study was performed at the Laboratory of Experimental Air Pollution and Rheumatology Division. Two semen samples from 28 post-pubertal SLE patients were analyzed. Daily concentrations of air pollutants exposure: PM10, SO2, NO2, ozone, CO, and meteorological variables were evaluated on 90 days before each semen collection dates using generalized estimating equation models. RESULTS Intravenous cyclophosphamide (IVCYC) and ozone had an association with a decrease in sperm quality of SLE patients. IVCYC was associated with decreases of 64.3 million of spermatozoa/mL (95% CI 39.01-89.65; p=0.0001) and 149.14 million of spermatozoa/ejaculate (95% CI 81.93-216.38; p=0.017). With regard to ozone, the most relevant adverse effects were observed from lags 80-88, when the exposure to an interquartile range increase in ozone 9-day moving average concentration led to decreases of 22.9 million of spermatozoa/mL (95% CI 5.8-40.0; p=0.009) and 70.5 million of spermatozoa/ejaculate (95% CI 12.3-128.7; p=0.016). Further analysis of 17 patients that never used IVCYC showed association between exposure to ozone (80-88 days) and decrease of 30.0 million of spermatozoa/mL (95% CI 7.0-53.0; p=0.011) and 79.0 million of spermatozoa/ejaculate (95% CI 2.1-155.9; p=0.044). CONCLUSION Ozone and IVCYC had a consistent adverse effect on semen quality of SLE patients during spermatogenesis. Minimizing exposure to air pollution should be taken into account, especially for patients with chronic systemic inflammatory diseases living in large cities.
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Affiliation(s)
- Juliana Farhat
- Group of Environmental Epidemiology Studies, Laboratory of Experimental Air Pollution, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Sylvia Costa Lima Farhat
- Group of Environmental Epidemiology Studies, Laboratory of Experimental Air Pollution, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alfésio Luís Ferreira Braga
- Group of Environmental Epidemiology Studies, Laboratory of Experimental Air Pollution, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil; Group of Environmental Exposure and Risk Assessment Studies, Post-Graduate Program in Public Health, Universidade Católica de Santos, Santos, SP, Brazil
| | - Marcello Cocuzza
- Division of Urology, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eduardo Ferreira Borba
- Division of Rheumatology, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eloisa Bonfá
- Division of Rheumatology, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Clovis Artur Silva
- Division of Rheumatology, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil; Unit of Pediatric Rheumatology, Instituto da Criança, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil.
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Farhat J, Farhat SCL, Braga ALF, Cocuzza M, Borba EF, Bonfá E, Silva CA. O ozônio diminui a qualidade do sêmen em pacientes com lúpus eritematoso sistêmico. REVISTA BRASILEIRA DE REUMATOLOGIA 2016. [DOI: 10.1016/j.rbr.2015.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Tiseo BC, Cocuzza M, Bonfá E, Srougi M, Clovis A. Male fertility potential alteration in rheumatic diseases: a systematic review. Int Braz J Urol 2016; 42:11-21. [PMID: 27120778 PMCID: PMC4811221 DOI: 10.1590/s1677-5538.ibju.2014.0595] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 09/17/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Improved targeted therapies for rheumatic diseases were developed recently resulting in a better prognosis for affected patients. Nowadays, patients are living longer and with improved quality of life, including fertility potential. These patients are affected by impaired reproductive function and the causes are often multifactorial related to particularities of each disease. This review highlights how rheumatic diseases and their management affect testicular function and male fertility. MATERIALS AND METHODS A systematic review of literature of all published data after 1970 was conducted. Data was collected about fertility abnormalities in male patients with systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis, ankylosing spondylitis, Behçet disease and gout. Two independent researchers carried out the search in online databases. RESULTS A total of 19 articles were included addressing the following diseases: 7 systemic lupus erythematosus, 6 Behçet disease, 4 ankylosing spondylitis, 2 rheumatoid arthritis, 2 dermatomyositis and one gout. Systemic lupus erythematosus clearly affects gonadal function impairing spermatogenesis mainly due to antisperm antibodies and cyclophosphamide therapy. Behçet disease, gout and ankylosing spondylitis patients, including those under anti-TNF therapy in the latter disease, do not seem to have reduced fertility whereas in dermatomyositis, the fertility potential is hampered by disease activity and by alkylating agents. Data regarding rheumatoid arthritis is scarce, gonadal dysfunction observed as consequence of disease activity and antisperm antibodies. CONCLUSIONS Reduced fertility potential is not uncommon. Its frequency and severity vary among the different rheumatic diseases. Permanent infertility is rare and often associated with alkylating agent therapy.
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Affiliation(s)
- Bruno Camargo Tiseo
- Departamento de Urologia da Faculdade de Medicina da Universidade de São Paulo, Brasil
| | - Marcello Cocuzza
- Departamento de Urologia da Faculdade de Medicina da Universidade de São Paulo, Brasil
| | - Eloisa Bonfá
- Divisão de Reumatologia da Faculdade de Medicina da Universidade de São Paulo, Brasil
| | - Miguel Srougi
- Departamento de Urologia da Faculdade de Medicina da Universidade de São Paulo, Brasil
| | - A Clovis
- Divisão de Reumatologia da Faculdade de Medicina da Universidade de São Paulo, Brasil
- Unidade de Reumatologia Pediátrica do Departamento de Pediatria da Faculdade de Medicina da Universidade de São Paulo, Brasil
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Micu MC, Micu R, Surd S, Gîrlovanu M, Bolboacă SD, Ostensen M. TNF-α inhibitors do not impair sperm quality in males with ankylosing spondylitis after short-term or long-term treatment. Rheumatology (Oxford) 2014; 53:1250-5. [DOI: 10.1093/rheumatology/keu007] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Uzunaslan D, Saygin C, Hatemi G, Tascilar K, Yazici H. No appreciable decrease in fertility in Behçet's syndrome. Rheumatology (Oxford) 2013; 53:828-33. [PMID: 24369417 DOI: 10.1093/rheumatology/ket436] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Behçet's syndrome (BS) follows an active course during the childbearing years in both men and women. We formally surveyed the infertility rate and the effect of drugs and types of organ involvement on fertility in BS. METHODS We compared fertility among BS patients with and without major organ involvement with those with FMF, AS and healthy controls. A structured interview was performed and the medical records of the patients were reviewed to confirm the sites of involvement and drugs they used during their entire follow-up. RESULTS The number of female patients who were not able to ever conceive, who were not able to conceive before or after disease onset or who were able to conceive late or only with assisted reproductive technology was not increased among the BS group. The same was true for the male patients to successfully achieve a conception and/or father a child. The average number of children, miscarriages, terminations and ectopic pregnancies were similar among the groups. Infertility was more common in BS patients with major organ involvement who used cyclophosphamide (CYC) compared with those who did not (P = 0.009). CONCLUSION Infertility is not appreciably increased among BS patients attending a dedicated outpatient clinic. Major organ involvement does not increase the risk of infertility and CYC is the only drug that seems to compromise fertility in BS.
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Affiliation(s)
- Didem Uzunaslan
- Cerrahpasa Tip Fakultesi, Ic Hastaliklari Anabilim Dali, Romatoloji Bilim Dali, Fatih, Istanbul 34098, Turkey.
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Ramonda R, Foresta C, Ortolan A, Bertoldo A, Oliviero F, Lorenzin M, Pizzol D, Punzi L, Garolla A. Influence of tumor necrosis factor α inhibitors on testicular function and semen in spondyloarthritis patients. Fertil Steril 2013; 101:359-65. [PMID: 24332378 DOI: 10.1016/j.fertnstert.2013.10.048] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/27/2013] [Accepted: 10/29/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate sperm parameters and sexual hormones in young males affected with spondyloarthritis (SpA) before and after 1 year of anti-tumor necrosis factor (TNF) α treatment. DESIGN Prospective case-control study. SETTING Rheumatology and human reproduction pathology units at a university hospital. PATIENTS Ten SpA outpatients attending the rheumatology clinic; 20 healthy control subjects attending the unit of human reproduction pathology within an infertility prevention program. INTERVENTIONS At baseline and after a 12-month treatment, disease activity was assessed and an andrologic evaluation made. MAIN OUTCOME MEASURE(S) Rheumatologists assessed anamnestic, clinical, functional, and biomarker data. Andrologists evaluated semen analysis, fluorescence in situ hybridization for chromosomes X, Y, 13, 18, and 21, FSH, LH, and T plasma levels, and testicular color Doppler ultrasound. RESULTS At baseline, SpA patients showed reduced sperm motility, higher plasma LH and FSH, and lower T levels compared with control subjects; a significant correlation between disease activity and sperm quality was found. After treatment, a statistically significant decrease in sperm aneuploidies and normal hormone levels were observed. CONCLUSIONS Although inflammation in SpA appears to be related to impaired testicular function, anti-TNF-α agents seem to be safe on testicular function and fertility.
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Affiliation(s)
- Roberta Ramonda
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Carlo Foresta
- Unit of Human Reproduction Pathology, Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Augusta Ortolan
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Alessandro Bertoldo
- Unit of Human Reproduction Pathology, Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Francesca Oliviero
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | | | - Damiano Pizzol
- Unit of Human Reproduction Pathology, Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Leonardo Punzi
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Andrea Garolla
- Unit of Human Reproduction Pathology, Department of Molecular Medicine, University of Padua, Padua, Italy.
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Testicular Sertoli cell function in ankylosing spondylitis. Clin Rheumatol 2013; 32:1075-9. [DOI: 10.1007/s10067-013-2215-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 01/23/2013] [Accepted: 02/07/2013] [Indexed: 10/27/2022]
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Penile alterations with severe sperm abnormalities in antiphospholipid syndrome associated with systemic lupus erythematosus. Clin Rheumatol 2012; 32:109-13. [DOI: 10.1007/s10067-012-2083-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 07/19/2012] [Accepted: 08/29/2012] [Indexed: 10/27/2022]
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