Simplified sperm testing devices: a possible tool to overcome lack of accessibility and inconsistency in male factor infertility diagnosis. An opportunity for low- and middle- income countries

Background

Manual semen assessment (MSA) is a key component in a male’s fertility assessment. Clinicians rely on it to make diagnostic and treatment decisions. When performed manually, this routine laboratory test is prone to variability due to human intervention which can lead to misdiagnosis and consequently over- or under- treatment. For standardisation, continuous training, quality control (QC) programs and pricy Computer-Assisted Sperm Analysis (CASA) systems have been proposed, yet, without resolving intra- and inter-laboratory variability. In response, promising simplified sperm testing devices, able to provide cost-effective point-of-care male infertility diagnosis are prospected as a plausible solution to resolve variability and increase access to sperm testing.

Materials and methods

A throughout literature research for semen testing, sperm analysis, smart-phone assisted semen analysis, ‘at-home’ semen testing, male infertility, infertility in developing countries, infertility in low- and middle-income countries (LMIC) and quantitative sperm analysis was performed. A total of 14 articles, specific to ‘at-home’ simplified sperm assessment, were included to treat the core subject.

Results

Continuous training and consistent QC, are sine qua none conditions to achieve accurate and comparable MSA. Compliance does not rule-out variability, nevertheless. Emerging simplified sperm assessment devices are an actual alternative to resolve the lack of standardisation and accessibility to sperm analysis. YO ® , SEEM ® , and ExSeed ® are commercially available, user-friendly smartphone-based devices which can accurately measure volume, sperm concentration (millions/ml) and total motile sperm count. More broadly, by cost-effectiveness, availability, accuracy and convenient application, these devices could effectively select patients for first-line artificial reproduction treatments such as intrauterine insemination.

Conclusions

Accuracy and cost-effectiveness make smart-phone based sperm testing devices a practical and realistic solution to overcome variability in MSA. Importantly, these tools represent an actual opportunity to standardise and improve male subfertility diagnosis and treatment, especially in LMIC. However, before clinical application is possible, guidelines, further testing with special attention on accuracy in washed sperm, availability, cost-benefit and reliability are required.

Time has come to include Human Papillomavirus (HPV) testing in sperm donor banks

HPV is well known as a potential cause of cervical cancer. Less well known is its link to temporal subfertility that is caused by binding of infectious virions to the spermatozoa's head which induces sperm-DNA damage and causes a reduction in clinical pregnancy rates in women receiving HPV positive semen. This impact on the global fertility burden remains greatly underestimated and underexplored. This risk of reduced fertility due to infectious HPV in sperm is especially important when donor sperm insemination is considered, since testing for the presence of HPV virions before use seems warranted. We tested 514 donor sperm samples from 3 different sperm banks for 18 different HPV types. Overall 3.9% (20/514) of tested donor sperm was positive for HPV, with different prevalence among the 3 different sperm banks (3.6% bank A, 3.1% bank B and 16.7% bank C). Also the HPV virion per spermatozoon ratio in donor samples was similar across the different sperm banks (95% CI 0,01 to 1,07 HPV virions/spermatozoon). When HPV positive donor sperm was used, no clinical pregnancies resulted, whereas when HPV negative donor sperm was used the clinical pregnancy rate was 14.6%. From both a cost/benefit and a safety point of view we recommend that donor sperm should always be tested for HPV before using it for insemination.

Circulating tumour cell (CTC) detection: a direct comparison between the CellSearch system, the AdnaTest, CK19/MAM RT-PCR and unmethylated/methylated free DNA in patients with metastatic breast cancer

Abstract #5025

Introduction: The detection, enumeration and isolation of CTC has considerable potential to influence the clinical management of patients with breast cancer. There is however a substantial variability in the rates of positive samples using existing detection techniques. This study was designed to compare the sensitivities and specificities of three techniques for detecting CTC in blood of patients with metastatic breast cancer (MBC). Furthermore, correlations between CTC and circulating total and tumor-related methylated DNA were investigated.
 Material and Methods: The presence of CTC in blood samples of 80 patients with MBC and 20 healthy controls was assessed by two commercial systems: i) the CellSearch System (Veridex LLC, Warren, NJ), in which epithelial cells are immunomagnetically separated and fluorescently labeled, and nucleated (DAPI+) cells with the EpCAM+, cytokeratin (CK) 8/18/19+, and CD45- phenotype are counted as CTC and ii) the AdnaTest and a real-time qRT-PCR assay for the detection of CK-19 and mammaglobin (MAM) transcripts. Plasma total DNA levels were measured by a qPCR method. Sera were analyzed by methylation-specific qPCR for three methylated markers: APC, RASSF1A and ESR1. The results obtained with AdnaTest are being analyzed and will be presented at the meeting.
 Results: Numbers of CTC identified by the CellSearch test were significantly higher in blood samples of patients with MBC than in healthy controls: the median number of CTC detected in 7.5 ml of blood was 1 (range 0-2617) in patients with MBC and 0 (range 0-1) in controls (P<0.001). Using ≥2 cells as a threshold for positivity, which corresponds to 100% specificity in the control population, 34% of samples from patients with MBC were positive with the CellSearch test. Using a cut-off to ensure 100% specificity in the control population, 31% of patients were positive for CK-19, 49% for MAM and 61% for CK-19 and/or MAM by qRT-PCR. When the CellSearch test and the qRT-PCR for CK-19 and MAM were compared, the concordance was 57%. Positive samples with the CellSearch test, but not with the qRT-PCR assay, also showed significantly higher levels of circulating total DNA and were more likely to be positive for one of the methylated DNA markers in serum.
 Conclusion : We observed a substantial variation in the detection rates of CTC in blood from breast cancer patients using different techniques. A higher rate of positive samples was observed using a combined qRT-PCR approach for CK-19 and MAM, which suggests that this is currently the most sensitive technique for detecting CTC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5025.

Isolation of circulating tumour cells in patients with metastatic breast cancer by filter technology

Abstract #5026

Introduction. Metastasis is the leading cause of cancer-related death. For several decades, numerous attempts have been made to develop reliable assays enabling the detection and enumeration of circulating tumor cells (CTC) in the peripheral blood. The LeukoLOCK™ Total RNA Isolation System (Ambion®) combines leukocyte depletion filter technology intended to isolate leukocytes from whole blood, with RNALater® as a means of stabilizing the RNA in the cells captured on the filter. We hypothesized that this innovative system would also allow for the isolation of carcinoma cells by filtration, because of their larger size in comparison to peripheral blood leukocytes. The RNA extracted from the filter device could thus be used for further quantification of CTCs by qRT-PCR.
 Materials and methods. The CellSearch™ Circulating Tumor Cell Test (Veridex®) was used to enrich and enumerate CTCs in all of the blood samples. The CellSearch System™utilizes iron nano-particles (ferrofluid) conjugated to EpCAM to capture CTC. Immuno-fluorescent staining for cytokeratins (CK) 8,18,19 and the nucleus (DAPI) is used to positively identify intact CTC. CTC are defined as nuclear cells, expressing cytokeratins and lacking CD45 expression. Blood samples of 5 patients with known elevated CTC were screened again after filtration with the LeukoLOCK™filter device to ensure that CTC did not slip through the filter (Table 1). The cell count obtained with the Veridex system was compared in these 5 samples, with the quantification CK19 and mammaglobin (MAM) transcripts obtained from the cells retained by the filter. In a further study on 79 patients with metastatic breast cancer, CTCs were enumerated using LeukoLOCK™Total RNA Isolation System (Ambion®) as a means of RNA isolation and compared with the Veridex system. qRT-PCR was performed to detect the presence of CTC transcripts for CK19 in the total RNA obtained from the cells captured on the filter in all of the 79 cases.
 Results. In only one sample (PAT113) could one CTC be detected in the filtered blood. The values obtained for RGE for both CK19 and MAM are in agreement with that observation.
 
 A significant correlation was found between CTC levels and qRT-PCR normalized relative gene expression (nRGE) values for CK19 originating from the total cell population captured by the LeukoLOCK™filter device (n=79, r=0.446, p<0.001).
 Conclusion. The LeukoLOCK™ system does not only enrich for leukocytes but can be considered as a reliable system for the enrichment and stabilization of CTC in patients with MBC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5026.

The correlation of the AKT/mTOR/p70S6K1 pathway and VEGF in human epithelial ovarian cancer

16081

Background: The Akt/mTOR/p70S6K1 (Amp) pathway is activated in a proportion of epithelial ovarian cancers. The ribosomal protein pS6 and p4EBP1 are downstream targets and presumed representative for the pathway's activity. VEGF and angiogenesis in ovarian cancer play an important role as bevacizumab induces high response rates and prolongs progression-free survival in women with relapsed ovarian cancer in two phase II trials. The Amp pathway has proven to be correlated with HIF1alfa and VEGF A expression in vitro. Material and Methods: Our primary objective was to evaluate correlation between this pathway in human subject tissues and angiogenesis using VEGF A and pVEGFR2. Our second objective was to evaluate if different metastatic abdominal (peritoneal and/or omental) lesions show the same pathway hyperactivity and/or angiogenesis as the primary tumour, because relapses usually involve metastatic abdominal lesions. Epithelial ovarian cancer paraffin imbedded material from 1999–2004 was collected. A tissue micro array was build with three samples per paraffin block. Immunohistochemical staining was performed using pS6, p4EBP1, pAKT, VEGF and pVEGFR2. Results: 89 patients were collected with a median age of 69.8y. Patients were FIGO stage I in 21%, stage II in 4%, stage III in 62% and 11% stage IV. Histological examination showed in 53% serous papillary tumours, 25.8% endometroid tumours, clear cell carcinoma in 11.2% and mucinous tumours in 4.5%. 65 patients had available tissue material of both primary tumour as well as other (multiple) metastatic abdominal disease tissue. The results of the immunohistochemical staining as well as the correlation analysis will be presented. Conclusion: Although anti-angiogenesis seems to be very active against human epithelial ovarian cancer, it is at present associated with unacceptable treatment induced toxicities. Inhibiting the Amp pathway with mTOR inhibitors could potentially also inhibit angiogenesis in ovarian cancer with the potential of more manageable side effects. This study will provide some evidence on the relationship between the Amp pathway and the VEGF pathway in human epithelial ovarian cancer.

No significant financial relationships to disclose.