Complete or partial loss of the Y chromosome in an unselected cohort of 865 non-vasectomized, azoospermic men

BACKGROUND

Structural abnormalities as well as minor variations of the Y chromosome may cause disorders of sex differentiation or, more frequently, azoospermia. This study aimed to determine the prevalence of loss of Y chromosome material within the spectrum ranging from small microdeletions in the azoospermia factor region (AZF) to complete loss of the Y chromosome in azoospermic men.

RESULTS

Eleven of 865 azoospermic men (1.3%) collected from 1997 to 2022 were found to have a karyotype including a 45,X cell line. Two had a pure 45,X karyotype and nine had a 45,X/46,XY mosaic karyotype. The AZF region, or part of it, was deleted in eight of the nine men with a structural abnormal Y-chromosome. Seven men had a karyotype with a structural abnormal Y chromosome in a non-mosaic form. In addition, Y chromosome microdeletions were found in 34 men with a structural normal Y chromosome. No congenital malformations were detected by echocardiography and ultrasonography of the kidneys of the 11 men with a 45,X mosaic or non-mosaic cell line.

CONCLUSIONS

In men with azoospermia, Y chromosome loss ranging from small microdeletions to complete loss of the Y chromosome was found in 6.1% (53/865). Partial AZFb microdeletions may give a milder testicular phenotype compared to complete AZFb microdeletions.

P-711 Differences in live birth results using donor or partner semen in single women, same-sex and different-sex couples. A Danish Nationwide register-based Cohort Study

Study question

Are there any differences in the chance of a live birth using donor or partner semen in the different groups of women attending fertility clinics?

Summary answer

The chance of a live birth improves using donor semen for Intrauterine Insemination (IUI) treatments. No difference is observed for In Vitro Fertilization (IVF) treatments.

What is known already

Few studies regarding the efficacy of ART treatments using donor semen are available and most of them focus only on IUI treatments. Moreover, they usually do not take into account the different groups of women utilizing them or possible differences with the use of male partner semen.

Study design, size, duration

Danish nationwide cohort study based on health registers including all ART treatments from 2007 to 2017. The number of treatments in women using donor semen was 31540 for IUI and 7770 for IVF. For women using partner semen the number of treatments was 80949 for IUI and 74425 for IVF. ART treatments in women using donor semen were further subdivided into three groups based on women's relationship status: different-sex couples single women, and same-sex couples.

Participants/materials, setting, methods

Live birth chance per ART treatment cycle, IUI or IVF, using donor or partner semen has been assessed. In a subanalysis, the difference in a live birth was also evaluated comparing women using partner semen and women using donor semen stratified according to the partner with whom they attend the fertility clinics. The crude and confounders adjusted odds ratio (OR and aOR) were obtained by multilevel logistic regression.

Main results and the role of chance

A live birth was obtained in 13.9% of IUI treatments in women using donor semen compared to 12.3% in women using partner semen with an aOR of 1.33 (95% CI: 1.27-1.40). More in detail, for different groups of women using donor semen the aOR of live birth after IUI treatments was: aOR 1.48 (95% CI: 1.38-1.59) in women with male partners using donor semen, aOR 1.20 (95% CI: 1.13-1.28) in single women and aOR 1.46 (95% CI: 1.32-1.62) in women with female partners using donor semen.

For what concern IVF treatments, 20.7% of treatments in women using donor semen and 25.7% of treatments in women using partner semen resulted in a live birth. The aOR was 0.99 (95% CI: 0.92-1.06). Moreover, for the different groups of women using donor semen compared to women using partner semen, the aOR of live birth after IVF treatments was: aOR 1.16 (95% CI: 1.02-1.32) in women with male partners using donor semen, aOR 0.88 (95% CI: 0.80-0.96) in single women, and aOR 1.20 (95% CI: 1.00-1.44), in women with female partners using donor semen.

Limitations, reasons for caution

Being an observational study, it is not possible to exclude the presence of unknown confounders or residual confounding which might affect the results.

Wider implications of the findings

This is one of the few studies assessing the ART success chances using donor or partner semen with attention to the now diverse population groups receiving ART treatments. We hope our results would be useful to healthcare professionals to better advise and help all women and couples attending fertility clinics

Trial registration number

not applicable

P-021 Increased oxidative stress affects semen quality negatively and is associated with reduced levels of seminal glutathione

Study question

Do increased levels of oxidative stress (OS) and seminal antioxidant affect semen quality?

Summary answer

Increased OS measured by MiOXSYS negatively affected sperm concentration, motility, and total motile sperm count (TMSC). Reduced levels of seminal glutathione are associated with OS.

What is known already

The enzymatic seminal antioxidants superoxide dismutase (SOD) and catalase (CAT), and the non-enzymatic antioxidant glutathione possess important roles in the defense against oxidative damage and form the first line of defense against reactive oxygen species (ROS). It is known from the literature, that excessive levels of ROS are highly implicated in the pathogenesis of male infertility.

The level of oxidative stress can be estimated by MiOXSYS Analyzer (Aytu BioScience Inc.) expressing the ‘oxidative reduction potential’ (ORP). Assessing ORP is one of the latest advancements in male infertility diagnostics, providing sensitive detection of increased OS in semen.

Study design, size, duration

This correlation study aims to explore the level of OS in a small cross-section of potentially infertile Danish males. Eighty-one (81) males from the Fertility Clinic at Odense University Hospital delivered a semen sample. The level of OS was compared to semen parameters and levels of SOD, CAT, and glutathione.

Participants/materials, setting, methods

Semen samples were collected and analyzed according to 2010 WHO criteria (concentration, volume, and %motility). TMSC was included additionally. A direct measure of OS was performed on raw sperm using MiOXSYS. Three assays were applied (Sigma-Aldrich and Abcam) to measure the enzymatic activity of SOD and CAT, and the level of total glutathione in the sperm samples. Spectrophotometric analysis of the absorbance in a plate reader was used to quantify the biochemical level of antioxidants.

Main results and the role of chance

Results showed that 43.2% of all study participants had increased levels of OS. Statistical analysis revealed a significant correlation (p< 0.01) between increased OS and reduced concentration, motility, and TMSC in the ejaculates. When adjusted for smoke, motility and TMSC were found to be significant (p < 0.05). Adjusting for weekly alcohol intake and body mass index (BMI) did not affect the correlation. Collectively, the results demonstrated that sperm abnormalities are related to increased levels of OS, suggesting OS to be a mediator of male fertility potential.

Furthermore, a negative correlation (p< 0.05) was found between the reduced level of seminal glutathione and increased levels of OS. The finding suggests that OS is increased in the spermatozoa when the level of glutathione is low. No significant correlation between OS and reduced SOD or CAT was found.

A potential inverse relationship between the effect of SOD on CAT and GSH levels was investigated, but no significant relationship was identified. There were no statistical indications that the level of SOD is associated with the levels of CAT and GSH.

Limitations, reasons for caution

Morphology was not included as a part of the WHO criteria due to time limitations. DNA fragmentation analysis was not included, but future research should be devoted to this aspect.

Wider implications of the findings

The findings support a suggestion of an association between high OS levels in semen and reduced semen quality. It was expected that at least 30% of men would show excessive OS in sperm. The study population of the Fertility-Clinic showed higher OS than what was presented in the general population.

Trial registration number

Not applicable

P-468 Organotypic culture of testicular tissue from infant boys with cryptorchidism

Study question

Can organotypic culture support the survival and maturation of germ cells and niche-related cells within testicular tissue from infant boys with cryptorchidism?

Summary answer

The testicular structure and the number of germ cells were maintained during organotypic culture, whereas Sertoli cells and peritubular myoid cells (PTMCs) matured.

What is known already

Testicular tissue cryopreservation (TTC) is a strategy to safeguard the fertility of prepubertal boys who face a risk of infertility. Organotypic culture of immature testicular tissue from mice achieved production of spermatozoa. Similarly, the culture of human fetal gonads resulted in the generation of competent spermatids. However , in vitro spermatogenesis by organotypic culture of human prepubertal testicular tissue has not been achieved. It is also unknown whether germ cells as well as its niche-related cells, in testicular tissue from infant boys with cryptorchidism, can maintain and mature under in vitro conditions.

Study design, size, duration

Testicular tissue was cryopreserved from four infant boys with bilateral cryptorchidism undergoing orchidopexy (age range: 0.5-1.4 years), as part of a fertility preservation program. Culture media with and without retinoic acid were tested. Testicular fragments were harvested at 30 days and 60 days after culture and evaluated by histological assessment of tissue structure, germ cell development, and immunohistochemical staining for germ cell and somatic cell markers.

Participants/materials, setting, methods

Cryopreserved-thawed testicular tissue was cut into fragments (1-2 mm3) and placed on top of agarose gel stands and cultured at 34oC with 5% CO2 in Minimum Essential Medium-alpha supplemented with knockout serum replacement, human umbilical cord plasma, Activin A, hormones, growth factors, with or without retinoic acid. Immunohistochemical analyses were performed using germ cell markers (MAGE-A, GAGE, and VASA), Sertoli cell maturation markers (AMH, AR, SOX9), PTMC marker (alpha-SMA).

Main results and the role of chance

Following the 60-day culture, the lumen of the seminiferous tubules had developed. The number of germ cells per tubule remained stable during this period. However, no further germ cell maturation was observed. Germ cells showed different phenotypes of MAGEA, GAGE, and VASA expression with no significant difference in number. The number of SOX9-positive Sertoli cells was significantly increased from 30 days to 60 days of culture (p <0.0001). No difference in AMH expression was observed, while AR expression in Sertoli cells was induced during culture. Alpha-SMA expression was detected in the PTMCs surrounding the seminiferous tubules. The two different culture conditions, with and without retinoic acid in the culture media, did not affect cell survival or maturation.

Limitations, reasons for caution

The small number of testicular biopsies available is a limitation.

Wider implications of the findings

Our organotypic culture conditions support the long-term survival of germ cells in testicular tissue from infant boys with cryptorchidism. Thus, further studies are needed to induce the maturation of germ cells under similar experimental conditions.

Trial registration number

not applicable

Developmental stage and morphology of the competent blastocyst are associated with sex of the child but not with other obstetric outcomes: a multicenter cohort study

STUDY QUESTION

Are transfer day, developmental stage and morphology of the competent blastocyst in pregnancies leading to live birth associated with preterm birth, birthweight, length at birth and sex of the child?

SUMMARY ANSWER

A high score in blastocyst developmental stage and in trophectoderm (TE) showed a significant association with the sex of the child, while no other associations with obstetric outcomes were observed.

WHAT IS KNOWN ALREADY

The association between blastocyst assessment scores and obstetric outcomes have been reported in small single-center studies and the results are conflicting.

STUDY DESIGN, SIZE, DURATION

Multicenter historical cohort study based on exposure data (transfer day (blastocyst developmental stage reached by Day 5 or Day 6)) blastocyst developmental stage (1-6) and morphology (TE and inner cell mass (ICM): A, B, C)) and outcome data (preterm birth, birthweight, length at birth, and sex of the child) from women undergoing single blastocyst transfer resulting in a singleton pregnancy and live birth.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data from 16 private and university-based facilities for clinical services and research were used. A total of 7246 women, who in 2014-2018 underwent fresh-embryo transfer with a single blastocyst or frozen-thawed embryo transfer (FET) with a single blastocyst resulting in a singleton pregnancy were identified. Linking to the Danish Medical Birth Registry resulted in a total of 4842 women with a live birth being included. Cycles with pre-implantation genetic testing and donated gametes were excluded. The analyses were adjusted for female age (n = 4842), female BMI (n = 4302), female smoking (n = 4290), parity (n = 4365), infertility diagnosis (n = 4765), type of treatment (n = 4842) and center (n = 4842); some analyses additionally included gestational age (n = 4368) and sex of the child (n = 4833).

MAIN RESULTS AND THE ROLE OF CHANCE

No statistically significant associations between blastocyst assessment scores (transfer day, developmental stage, TE, ICM) and preterm birth (8.3%) or birthweight (mean 3461.7 g) were found. The adjusted association between blastocysts with a TE score of C and a TE score of A and length at birth (mean 51.6 cm) were statistically significant (adjusted mean difference 0.4 cm (95% CI: 0.02; 0.77)). Blastocysts transferred with developmental stage score 5 compared to blastocysts transferred with score 3 had a 34% increased probability of being a boy (odds ratio (OR) 1.34 (95% CI: 1.09; 1.64). Further, TE score B blastocysts compared to TE score A blastocysts had a 31% reduced probability of being a boy (OR 0.69 (95% CI: 0.60; 0.80)).

LIMITATIONS, REASONS FOR CAUTION

It is possible that some residual confounding remains.

WIDER IMPLICATIONS OF THE FINDINGS

Blastocyst selection during ART does not appear to introduce any negative effects on obstetric outcome. Therefore, clinicians and patients can be reassured that the assessment scores of the selected blastocyst will not in themselves pose a risk of preterm birth or affect birthweight and the length at birth.

STUDY FUNDING/COMPETING INTEREST(S)

Unrestricted grant from Gedeon Richter Nordics AB, Sweden. None of the authors have any competing interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

P-681 Will the hCG trigger dose used for final oocyte maturation in IVF impact endogenous progesterone during the luteal phase? - A randomized controlled trial

Study question

Is there an association between the hCG dose used for ovulation trigger and the endogenous progesterone production during the luteal phase?

Summary answer

Increased hCG dosing significantly increased the endogenous progesterone level during the luteal phase.

What is known already

During the luteal phase of an IVF treatment, the endogenous progesterone (P4) production is negatively impacted due to reduced circulating endogenous LH, caused by negative feed-back of elevated steroids; thus, luteal phase support (LPS) with exogenous P4 remains mandatory in IVF. Apart from inducing final oocyte maturation, the gold standard HCG trigger also functions as an early LPS, boosting P4 production by the corpora lutea (CL). P4 plays a pivotal role for embryo implantation and pregnancy, and an optimal P4 level around peri-implantation seems to be essential for the reproductive outcomes of fresh and frozen/thaw embryo transfer cycles.

Study design, size, duration

A randomized controlled 4-arm study, including a total of 127 IVF patients, enrolled from January 2015 until September 2019 at the Fertility Clinic, Odense University Hospital, Denmark.

Participants/materials, setting, methods

IVF patients with ≤ 11 follicles ≥ 12 mm were randomized to four groups. Groups 1-3 were triggered with: 5.000 IU, 6.500 IU or 10.000 IU, hCG, respectively, receiving a LPS consisting of 17-α-hydroxy-progesterone (17α OH P4) to distinguish the endogenous P4 from the exogenous supplementation. Group 4 (control) was randomized to a 6.500 IU hCG trigger and standard LPS. A total of eight blood samples were drawn during the early luteal phase.

Main results and the role of chance

A total of 94 patients completed the study: 21, 22, 25 and 26 patients in each group, respectively. Baseline characteristics were similar, except for the endogenous LH level and cycle lengths. There were no significant differences between groups regarding ovarian stimulation, number of oocytes and embryos. The median number of follicles ≥ 12mm on the day of trigger was 8.5, resulting in 6.6 oocytes being retrieved. Significant differences in P4 levels were seen at OPU+8 (p < 0.001), OPU+10 (p < 0.001) and OPU+14 (p < 0.001), with positive correlations between P4 level and hCG dose. Groups compared individually showed significant difference in P4 between low and high trigger dose at OPU+4 group 1 and 3 (p = 0.037) and OPU+8 group 1 and 3 (p = 0.007) and between all the three groups around implantation at OPU+6 group 1 and 2 (p = 0.011), group 2 and 3 (p = 0.042) and group 1 and 3 (p < 0.001). Higher P4 levels around implantation were related to follicle count and to pregnancy. After logistic regression analyses there were still significant individual differences between the groups.

Limitations, reasons for caution

Although patients were randomized and strict inclusion and exclusion criteria were used, the RCT was un-blinded, including a relatively small number of patients. Moreover, for dosing purposes urinary hCG as well as recombinant hCG was used and pharmacokinetics differ. Finally, the P4 level could be influenced by circadian fluctuations.

Wider implications of the findings

This is the first study to explore dose-responses in circulating P4 after hCG trigger in IVF patients. Increasing the hCG trigger dose increased the endogenous P4 around peri-implantation. Personalizing the hCG trigger dose could be a key point to secure the most optimal P4 mid-luteal phase P4 level.

Trial registration number

Eudract 2013-003304-39

P–681 Will the hCG trigger dose used for final oocyte maturation in IVF impact endogenous progesterone during the luteal phase? - A randomized controlled trial

Study question

Is there an association between the hCG dose used for ovulation trigger and the endogenous progesterone production during the luteal phase?

Summary answer

Increased hCG dosing significantly increased the endogenous progesterone level during the luteal phase.

What is known already

During the luteal phase of an IVF treatment, the endogenous progesterone (P4) production is negatively impacted due to reduced circulating endogenous LH, caused by negative feed-back of elevated steroids; thus, luteal phase support (LPS) with exogenous P4 remains mandatory in IVF. Apart from inducing final oocyte maturation, the gold standard HCG trigger also functions as an early LPS, boosting P4 production by the corpora lutea (CL). P4 plays a pivotal role for embryo implantation and pregnancy, and an optimal P4 level around peri-implantation seems to be essential for the reproductive outcomes of fresh and frozen/thaw embryo transfer cycles.

Study design, size, duration

A randomized controlled 4-arm study, including a total of 127 IVF patients, enrolled from January 2015 until September 2019 at the Fertility Clinic, Odense University Hospital, Denmark.

Participants/materials, setting, methods

IVF patients with ≤ 11 follicles ≥ 12 mm were randomized to four groups. Groups 1–3 were triggered with: 5.000 IU, 6.500 IU or 10.000 IU, hCG, respectively, receiving a LPS consisting of 17-α-hydroxy-progesterone (17α OH P4) to distinguish the endogenous P4 from the exogenous supplementation. Group 4 (control) was randomized to a 6.500 IU hCG trigger and standard LPS. A total of eight blood samples were drawn during the early luteal phase.

Main results and the role of chance

A total of 94 patients completed the study: 21, 22, 25 and 26 patients in each group, respectively. Baseline characteristics were similar, except for the endogenous LH level and cycle lengths. There were no significant differences between groups regarding ovarian stimulation, number of oocytes and embryos. The median number of follicles ≥ 12mm on the day of trigger was 8.5, resulting in 6.6 oocytes being retrieved. Significant differences in P4 levels were seen at OPU+8 (p < 0.001), OPU+10 (p < 0.001) and OPU+14 (p < 0.001), with positive correlations between P4 level and hCG dose. Groups compared individually showed significant difference in P4 between low and high trigger dose at OPU+4 group 1 and 3 (p = 0.037) and OPU+8 group 1 and 3 (p = 0.007) and between all the three groups around implantation at OPU+6 group 1 and 2 (p = 0.011), group 2 and 3 (p = 0.042) and group 1 and 3 (p < 0.001). Higher P4 levels around implantation were related to follicle count and to pregnancy. After logistic regression analyses there were still significant individual differences between the groups.

Limitations, reasons for caution

Although patients were randomized and strict inclusion and exclusion criteria were used, the RCT was un-blinded, including a relatively small number of patients. Moreover, for dosing purposes urinary hCG as well as recombinant hCG was used and pharmacokinetics differ. Finally, the P4 level could be influenced by circadian fluctuations.

Wider implications of the findings: This is the first study to explore dose-responses in circulating P4 after hCG trigger in IVF patients. Increasing the hCG trigger dose increased the endogenous P4 around peri-implantation. Personalizing the hCG trigger dose could be a key point to secure the most optimal P4 mid-luteal phase P4 level.

Trial registration number

Eudract 2013–003304–39

Association between use of phthalate-containing medication and semen quality among men in couples referred for assisted reproduction

STUDY QUESTION

Does phthalate exposure from prescription drugs affect semen quality?

SUMMARY ANSWER

Exposure to phthalate-containing drugs is associated with poor semen quality.

WHAT IS KNOWN ALREADY

Phthalates and their metabolites have been shown to disrupt the hormone signalling in animal studies. One study has shown associations between medicinal phthalate exposure and poor semen quality, suggesting similar effects in humans.

STUDY DESIGN, SIZE, DURATION

We included 18 515 males with poor semen quality (cases) and 31 063 males with normal semen quality (controls) registered in the Danish IVF Registry from 2006 to 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Exposure to phthalate-containing drugs was assessed from the Danish Register of Medicinal Product Statistics. Outcome measures were obtained at the first contact with the fertility clinic, and categorized according to the International Classification of Diseases (ICD-10). The association between current use of phthalate-containing medications <90 days prior to semen sampling and reduced semen quality was analysed using unconditional logistic regression, adjusting for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 57 cases and 72 controls redeemed at least one prescription for a drug containing ortho-phthalates in the 90 days before their first semen sample, yielding an adjusted odds ratio (OR) of 1.30 (95% CI: 0.91-1.85) for poor semen quality when compared to males exposed to phthalate-free generic drugs. Similarly, 81 cases and 78 controls exposed to a drug containing polymers had increased odds of poor semen quality (OR = 1.71, 95% CI: 1.24-2.35). Current exposure to polymer containing products from alimentary tract and metabolism drugs was associated with the highest OR of 2.80 (95% CI: 1.63-4.84). Comparing males exposed to drugs containing ortho-phthalates or polymers with males unexposed to prescription drugs, we found adjusted ORs of 1.32 (95% CI: 0.93-1.87) and 1.73 (95% CI: 1.26-2.36), respectively. We saw no clear relationship between degree of exposure and odds of poor semen quality.

LIMITATIONS, REASONS FOR CAUTION

The reliance on ICD-10 based register data restricted our ability to relate phthalate exposure to detailed semen parameters. Furthermore, due to imperfections in the registry, we could only include the first semen sample and could not follow semen quality over time.

WIDER IMPLICATIONS OF THE FINDINGS

Our results support the likely negative effect of phthalate exposure from medicinal drugs on semen quality. As exposures from medicinal products are readily avoidable, our findings may be of relevance to regulatory authorities.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by Odense University Hospital, Denmark (Grant number A1003). None of the authors declare conflict of interest.

Increased Use of Medications for Erectile Dysfunction in Men With Ulcerative Colitis and Crohn's Disease Compared to Men Without Inflammatory Bowel Disease: A Nationwide Cohort Study

BACKGROUND

Men with inflammatory bowel disease (IBD) may have decreased sexual function due to factors related to the underlying disease, medication, and/or surgery. We aimed to examine the use of erectile dysfunction (ED) medications in men with IBD.

METHODS

This is a nationwide cohort study based on the Danish registries, comprising all men >18 years old with IBD during 1 January 1995 through December 2016. The cohorts included 31,498 men with IBD and 314,980 age-matched men without IBD. Our main outcome was a first prescription of an ED medication. Cox regression analyses were used to estimate the hazard rate (HR) for use of ED medications, controlled for multiple time-varying covariates.

RESULTS

Overall, 21,966 (69.7%) men had ulcerative colitis (UC) while 9532 (30.3%) had Crohn's disease (CD). Men with a first ED prescription numbered 3749 (11.9%) (men with IBD) and 30,635 (9.7%) (men without IBD). Adjusting for central nervous system and intestinal anti-inflammatory medications, systemic corticosteroids and co-morbidities, the HR was 1.19 (95% CI: 1.13-1.26) (IBD and no prior IBD operation), and 1.31 (95% CI: 1.20-1.43) (IBD and prior IBD operation). The adjusted HR for UC was 1.17 (95% CI: 1.10-1.24) (no operation) and 1.43 (95% CI: 1.27-1.61) (prior operation), and for CD 1.26 (95% CI: 1.15-1.38) (no operation) and 1.20 (95% CI: 1.06-1.35) (prior operation).

DISCUSSION

Men with IBD are more likely to fill an ED prescription than men without IBD. This result is significant regardless of a history of IBD surgery.

DNA fragmentation in spermatozoa: a historical review

Sperm DNA Fragmentation has been extensively studied for more than a decade. In the 1940s the uniqueness of the spermatozoa protein complex which stabilizes the DNA was discovered. In the fifties and sixties, the association between unstable chromatin structure and subfertility was investigated. In the seventies, the impact of induced DNA damage was investigated. In the 1980s the concept of sperm DNA fragmentation as related to infertility was introduced as well as the first DNA fragmentation test: the Sperm Chromatin Structure Assay (SCSA). The terminal deoxynucleotidyl transferase nick end labelling (TUNEL) test followed by others was introduced in the nineties. The association between DNA fragmentation in spermatozoa and pregnancy loss has been extensively investigated spurring the need for a therapeutic tool for these patients. This gave rise to an increased interest in the aetiology of DNA damage. The present decade continues within this research area. Some of the more novel methods recently submerging are sorting of cells with increased DNA fragmentation and hyaluronic acid (HA) binding techniques. The clinical value of these tests remains to be elucidated. In spite of half a century of research within the area, this analysis is not routinely implemented into the fertility clinics. The underlying causes are multiple. The abundance of methods has impeded the need for a clinical significant threshold. One of the most promising methods was commercialized in 2005 and has been reserved for larger licensed laboratories. Myriads of reviews and meta‐analyses on studies using different assays for analysis of DNA fragmentation, different clinical Artificial Reproductive Treatments (ART), different definitions of successful ART outcome and small patient cohorts have been published. Although the area of DNA fragmentation in spermatozoa is highly relevant in the fertility clinics, the need for further studies focusing on standardization of the methods and clinical implementation persists.

Prevalence of small testicular hyperechogenic foci in subgroups of 382 non-vasectomized, azoospermic men: a retrospective cohort study

Testicular hyperechogenic foci (THF) are associated with Klinefelter's syndrome, cryptorchidism, infertility, and testicular germ cell neoplasia. The aims of the study were to evaluate THF in relation to etiology of azoospermia and to Sertoli cell dysfunction. The structures inside the scrotum of consecutive non‐vasectomized, azoospermic were examined by ultrasonography, and hormone (FSH, LH, testosterone, and prolactin), and genetic analyses (karyotype, Y microdeletions, and CFTR mutations) were performed. At testicular ultrasonography, patients were graduated into: pronounced THF (>7 THF per transducer field), distributed universally (uTHF) or collected in plaques (pTHF), borderline THF (bTHF; 3–7 THF per transducer field), or no THF (<3 THF per transducer field). Diagnostic testicular biopsy was taken open or with TruCut needle (14G). THF status was sufficiently described in 382 of 449 potential participants, and testicular histology was available in 300 cases. Presence of ultrasonographically detectable THF was compared to presence of testicular microlithiasis (TM) detected histologically. Sertoli cell dysfunction was investigated in a subgroup using a three‐stage immunoperoxidase technique for detection of cytokeratin‐18 (CK‐18). The prevalence of THF was 13.4%. uTHF was found in 11 men (2.9%), the pattern was bilateral in four while other four had bTHF in the other testis. pTHF was detected in eight cases (2.1%), and except for one case with Klinefelter's syndrome, pTHF was in all cases occurring unilaterally. bTHF was detected in 32 cases (8.4%), bilaterally in 17 (53%). Pronounced THF was significantly associated with testicular malignancy. CK‐18 was detected in more azoospermic men with sperm production in ≤50% seminiferous tubules than in azoospermic men with spermatogenesis in ≥90% of seminiferous tubules and normal controls (p < 0.05). Unfortunately, TM detected histologically was not detected in any patient expressing THF, and neither THF nor TM was detected in any of the patients examined for CK‐18. Sertoli cell dysfunction was not associated with testicular microlithiasis or hyperechogenic foci.

Cryopreservation of ovarian tissue for fertility preservation in a large cohort of young girls: focus on pubertal development

STUDY QUESTION

Is there an association between the need for medical puberty induction and the diagnosis or treatment received in girls who have undergone cryopreservation of ovarian tissue for fertility preservation?

SUMMARY ANSWER

There was a clear association between the intensity of treatment received and requirement for medical puberty induction but no association with the diagnosis.

WHAT IS KNOWN ALREADY

Although it cannot be predicted which girls will become infertile or develop premature ovarian insufficiency (POI) following intensive chemotherapy or irradiation, patients who are at high risk of POI should be offered ovarian tissue cryopreservation (OTC). This includes girls who are planned to receive either high doses of alkylating agents, conditioning regimen before stem cell transplantation (SCT), total body irradiation (TBI) or high radiation doses to the craniospinal, abdominal or pelvic area.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study. In total, 176 Danish girls under 18 years of age have had OTC performed over a period of 15 years. An overview of the girls' diagnoses and mean age at OTC as well as the number of deceased is presented. Of the 176 girls, 38 had died and 46 girls were still younger than 12 years so their pubertal development cannot be evaluated yet. For the 60 girls who had OTC performed after 12 years of age, the incidence of POI was evaluated and in the group of 32 girls who were younger than 12 years at OTC, the association between the diagnosis and received treatment and the requirement for medical puberty induction was examined.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The need for medical puberty induction was assessed in 32 girls who were prepubertal at the time of OTC.

MAIN RESULTS AND THE ROLE OF CHANCE

Indications for OTC were allogeneic SCT for leukaemia, myelodysplastic syndrome or benign haematological disorders, autologous SCT for lymphoma or sarcoma, and irradiation to the pelvis or to the spinal axis. The mean age at OTC of the 176 girls were 11.3 years. The two most prevalent diagnoses of the 176 girls were malignant tumours and malignant haematological diseases. Among the 32 prepubertal girls, 12 received high dose chemotherapy and either TBI prior to SCT or irradiation to the pelvis, abdomen or the spinal axis, 13 received high dose alkylating agents but no irradiation prior to SCT, six received alkylating agents as part of conventional chemotherapy and one patient had a genetic metabolic disorder and did not receive gonadotoxic treatment. Among these 32 girls, 23 did not undergo puberty spontaneously and thus received medical puberty induction. Among the nine girls, who went through spontaneous puberty, four had received high dose alkylating agents and five had received conventional chemotherapy.

LIMITATIONS REASONS FOR CAUTION

All information was retrieved retrospectively from patient records, and thus some information was not available.

WIDER IMPLICATIONS OF THE FINDINGS

OTC should be recommended to all young girls, who present a high risk of developing ovarian insufficiency and/or infertility following high dose chemotherapy and/or irradiation.

STUDY FUNDING/COMPETING INTERESTS

The Childhood Cancer Foundation (2012-2016) and the EU interregional project ReproHigh are thanked for having funded this study. They had no role in the study design, collection and analysis of the data or writing of the report. The authors have no conflict of interest to disclose.

Live birth and adverse birth outcomes in women with ulcerative colitis and Crohn's disease receiving assisted reproduction: a 20-year nationwide cohort study

OBJECTIVE

To examine the chance of live births and adverse birth outcomes in women with ulcerative colitis (UC) and Crohn's disease (CD) compared with women without inflammatory bowel disease (IBD) who have undergone assisted reproductive technology (ART) treatments.

METHODS

This was a nationwide cohort study based on Danish health registries, comprising all women with an embryo transfer during 1 January 1994 through 2013. The cohorts comprised 1360 ART treatments in 432 women with UC, 554 ART treatments in 182 women with CD and 148,540 treatments in 52,489 women without IBD. Our primary outcome was live births per ART treatment cycle. We controlled for multiple covariates in the analyses. Our secondary outcomes were adverse birth outcomes.

RESULTS

The chance of a live birth for each embryo transfer was significantly reduced in ART treatments in women with UC (OR=0.73, 95% CI 0.58 to 0.92), but not significantly reduced in the full model of ART treatments in women with CD (OR=0.77, 95% CI 0.52 to 1.14). Surgery for CD before ART treatment significantly reduced the chance of live birth for each embryo transfer (OR=0.51, 95% CI 0.29 to 0.91). In children conceived through ART treatment by women with UC, the OR of preterm birth was 5.29 (95% CI 2.41 to 11.63) in analyses including singletons and multiple births; restricted to singletons the OR was 1.80, 95% CI 0.49 to 6.62.

CONCLUSIONS

Our results suggest that women with UC and CD receiving ART treatments cannot expect the same success for each embryo transfer as other infertile women. Women with CD may seek to initiate ART treatment before needing CD surgery. Increased prenatal observation in UC pregnancies after ART should be considered.

Use of selective serotonin reuptake inhibitors reduces fertility in men

Clinical review of the present data on the effects of selective serotonin reuptake inhibitors (SSRIs) on male fertility was the objective of the study. PubMed and Scopus were searched for publications in English or Danish and reviewed. Human trials, animal studies and in vitro studies were included. Use of SSRIs negatively affects semen parameters in most studies. In some studies, SSRIs are also shown to reduce DNA integrity. SSRIs can also delay ejaculation. Depression and anxiety can cause reduced libido, erectile dysfunction and delayed ejaculation as well. The use of SSRIs seems to reduce male fertility by affecting semen parameters, although most studies have a degree of confounding by indication caused by the underlying depression.

Outcomes of transplantations of cryopreserved ovarian tissue to 41 women in Denmark

STUDY QUESTION

What are the results of transplanting cryopreserved ovarian tissue?

SUMMARY ANSWER

The transplanted ovarian tissue can last up to 10 years, with no relapses following the 53 transplantations, and the chance of a successful pregnancy is currently around one in three for those with a pregnancy-wish.

WHAT IS KNOWN ALREADY

Cryopreservation of ovarian tissue is now gaining ground as a valid method for fertility preservation. More than 36 children worldwide have now been born following this procedure.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study of 41 women who had thawed ovarian tissue transplanted 53 times over a period of 10 years, including 1 patient who was lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 41 Danish women, who had in total 53 transplantations, were followed for ovarian function and fertility outcome. Safety was assessed by monitoring relapse in cancer survivors.

MAIN RESULTS, AND THE ROLE OF CHANCE

Among 32 women with a pregnancy-wish, 10 (31%) had a child/children (14 children in total); this included 1 woman with a third trimester on-going pregnancy. In addition, two legal abortions and one second trimester miscarriage occurred. A total of 24 clinical pregnancies were established in the 32 women with a pregnancy-wish. The tissue remained functional for close to 10 years in some cases and lasted only a short period in others. Three relapses occurred but were unlikely to be due to the transplanted tissue.

LIMITATIONS, REASONS FOR CAUTION

Self-report through questionnaires with only in-one hospital formalised follow-up of transplanted patients could result in unreported miscarriages. The longevity of the tissue may vary by few months compared with those reported because some patients simply could not remember the date when the tissue became non-functional.

WIDER IMPLICATIONS OF THE FINDINGS

Cryopreservation of ovarian tissue is likely to become integrated into the treatment of young women, with cancer, who run a risk of losing their fertility. The full functional lifespan of grafts is still being evaluated, because many of the transplanted women have continued to maintain ovarian activity. Some of our first cases have had tissue functioning for ∼ 10 years.

Retrograde ejaculation and sexual dysfunction in men with diabetes mellitus: a prospective, controlled study

Retrograde ejaculation (RE) and erectile dysfunction may be caused by diabetes mellitus (DM), but the prevalence of RE among DM patients is unknown. A prospective, blinded case-control study comparing men with DM with matched controls according to RE and erectile dysfunction was performed. Twenty-seven men with DM matched the inclusion criteria and agreed to participate in the study, and of these 26 delivered an ejaculate. We were able to recruit 18 matching controls, and of these 16 delivered an ejaculate. Nine of 26 men with DM who delivered an ejaculate had RE, whereas none of 16 controls had RE (p < 0.01). The mean duration of DM was longer for DM patients with RE (20 years) compared with DM patients in whom RE could not be demonstrated (13 years), but the difference was not statistically significant. RE could not be associated with BMI, waist circumference, blood pressure, Haemoglobin A1c (HgbA1c), high-density lipoprotein HDL cholesterol, triglycerides, fasting glucose, or s-testosterone. Diabetics suffering from RE more frequently exhibited erectile dysfunction compared with non-diabetics and diabetics without RE, and the last-mentioned group again more frequently than controls. These findings could not be explained by use of antihypertensive drugs. Whereas none of the included control participants showed signs of abnormal ejaculation, every third man with DM exhibited retrograde ejaculation. It is important to be aware of this association, and that post-ejaculatory urine is routinely analysed from aspermic fertility clinic attendants and diabetics with low ejaculate volumes.

Neonatal outcome and congenital malformations in children born after ICSI with testicular or epididymal sperm: a controlled national cohort study

STUDY QUESTION

Does neonatal outcome including congenital malformations in children born after ICSI with epididymal and testicular sperm [testicular sperm extraction (TESE)/percutaneous epididymal sperm aspiration (PESA)/testicular sperm aspiration (TESA) (TPT)] differ from neonatal outcome in children born after ICSI with ejaculated sperm, IVF and natural conception (NC)?

SUMMARY ANSWER

Children born after TPT have similar neonatal outcome, including total malformation rates, as have children born after ICSI and IVF with ejaculated sperm. Testing for variance over the four groups may indicate smaller differences in specific malformation rates with TPT as the highest risk group.

WHAT IS KNOWN ALREADY

Regarding neonatal outcome as well as congenital malformations in children born after TPT, studies are few, with limited sample size, heterogeneous and often performed without relevant control groups.

STUDY DESIGN, SIZE, DURATION

Population-based cohort study including all Danish children born after TPT and fresh embryo transfer in Denmark from 1995 to 2009. Children born after transfer of frozen-thawed embryos were excluded. Control groups of children conceived by ICSI with ejaculated sperm, IVF and NC were identified by cross-linkage of the Danish IVF Register, Medical Birth Register (MBR) and National Hospital Discharge Register (HDR).

PARTICIPANTS/MATERIALS, SETTING

The study group consisted of 466 children born after TPT, while the control groups consisted of 8967 (ICSI with ejaculated sperm), 17 592 (IVF) and 63 854 (NC) children. Neonatal outcomes and congenital malformations were analysed for singletons and twins separately. Risk estimates for low birthweight (LBW, <2500 g) and preterm birth (PTB, <37 gestational weeks) were adjusted for maternal age, parity, child gender and year of childbirth. The study group was identified from the Danish national database on children born after TPT. Control groups were obtained from the IVF register and the MBR. All information included in the study was retrieved from the national registers.

MAIN RESULTS AND THE ROLE OF CHANCE

Considering singletons and twins as one group, the sex ratio (♂/♀) was significantly lower for children born after TPT (0.89) compared with conventional IVF (1.11; P = 0.017) but did not differ significantly when compared with ICSI with ejaculated sperm (0.94) and NC (1.05). The mean birthweight (BW) for singletons did not differ significantly between groups when including only first-born children. The mean gestational age (GA) in the TPT singletons (279 ± 12 days) was significantly higher compared with IVF (276 ± 18 days; P = 0.02), but similar to ICSI with ejaculated sperm and NC singletons when including only first-born children (277 ± 16 days and 279 ± 14 days, respectively). Rate of stillbirths, perinatal and neonatal mortality in the group of TPT singletons did not differ significantly from any of the control groups. Comparable results were found for the TPT twin group, except for perinatal mortality, which was significantly lower in the TPT group compared with naturally conceived twins. The adjusted risk of LBW was significantly higher for TPT versus NC singletons [adjusted odds ratio (AOR) = 0.67 (0.48-0.93)]; however AOR for PTB was similar in the two groups. Regarding twins, similar adjusted risks were observed for PTB and LBW between the TPT and all three control groups. Significantly more Caesarean sections were performed after IVF (27.3% for singletons) and ICSI (25.1% for singletons) with ejaculated sperm compared with the TPT group (16.4% for singletons). The total rate of congenital malformations in the TPT group was 7.7% and did not differ significantly from any of the control groups. However, singleton TPT boys showed an increased rate of cardiac malformations (3.6%) compared with singleton boys after IVF (1.4%; P = 0.04) and NC (1.1%; P = 0.02). Considering the level of male infertility as a continuum over the four groups, tests for variance in the rate of cardiac malformations in singleton boys, and undescended testicles for singleton as well as twin boys were each significantly increased from NC to IVF to ICSI to TPT (P < 0.001). The rate of hypospadias showed the same pattern, but the TPT group did not differ significantly compared with the control groups.

LIMITATIONS, REASONS FOR CAUTION

One of the limitations is that the TPT group could not be classified according to testicular or epididymal sperm, as these data were not available in the IVF register. Another limitation is that registry-based studies are encumbered with the risk of reporting or coding errors or missing data due to insufficient coding. However, the quality of data on congenital malformations in HDR has, in other studies, been validated and found acceptable for epidemiological research, and furthermore, recordings on study and control groups are performed similarly.

WIDER IMPLICATIONS OF THE FINDINGS

Accumulating data show that TPT treatment is equally safe as conventional ICSI and IVF treatment and as NC with regard to neonatal outcome including congenital malformation.

STUDY FUNDING/POTENTIAL COMPETING INTERESTS

This study is supported by Laboratory of Reproductive Biology, Scientific Unit, Horsens Hospital. No competing interests declared.

Left ventricular dysfunction in Klinefelter syndrome is associated to insulin resistance, abdominal adiposity and hypogonadism

OBJECTIVE

Epidemiological data suggest there is an increased risk of dying from heart disease among patients with Klinefelter syndrome (KS). Due to high prevalence of hypogonadism and metabolic syndrome, we speculated that patients with KS may have subclinical changes in the left ventricular function. Therefore, the aim was to assess left ventricular long axis function by tissue Doppler echocardiography in patients with KS and relate these findings to the metabolic status and testosterone levels.

DESIGN

Cross-sectional study. Out-patient clinic.

PATIENTS

We investigated 25 unselected patients with KS, recruited from endocrine and fertility clinics. Twenty-five age-matched males served as controls.

MEASUREMENTS

Left ventricular systolic long axis function (velocities and strain rate) assessed by tissue Doppler echocardiography related to free testosterone, fasting values of plasma glucose, insulin, homeostasis model assessment (HOMA)-index, cholesterol and triglycerides in addition to dual energy X-ray absorptiometry (DEXA) scan derived assessment of truncal body fat.

RESULTS

The long axis function was significantly reduced in patients with KS (peak systolic velocities 4.4 +/- 1.3 vs. 5.3 +/- 1.0 cm/s, P < 0.01 and strain rate -1.3 +/- 0.3 vs.-1.6 +/- 0.3 s(-1), P < 0.01). However, the ventricular dysfunction was mainly attributed KS patients with metabolic syndrome. The peak systolic velocities were significantly correlated to truncal body fat (r = -0.72, P < 0.01) and free testosterone (r = 0.63, P < 0.01), but uncorrelated to plasma glucose, insulin and HOMA-index.

CONCLUSION

Systolic long axis function is decreased in patients with KS and metabolic syndrome. The decrease in myocardial systolic function was significantly related to truncal body fat and hypogonadism, but not correlated to insulin sensitivity.

Parameters predicting the implantation rate of thawed IVF/ICSI embryos: a retrospective study

Single embryo transfer is becoming increasingly popular in IVF/ICSI. More IVF/ICSI cycles therefore include freezing of high quality embryos, and the cumulative effect of such cycles becomes more important. To improve the results obtained using frozen-thawed embryos, the predictive value of embryo and patient characteristics was analysed retrospectively. Excess embryos were frozen on day 2 according to routine procedures and thawed 24 h before transfer. The women were either treated with oestradiol/progesterone, or the transfer took place after a natural cycle. Of 1777 embryos thawed, 1360 survived (survival rate 76.5%). In the 410 transfer cycles, 819 embryos were transferred, giving 109 positive serum HCG tests and 69 clinical pregnancies. The implantation rate was 10.4%. Five parameters were positively related to implantation: (i) four or more cells at the freezing time (day 2); (ii) resumption of mitosis after thawing; (iii) more than six cells at transfer (day 3); (iv) assisted hatching and (v) child in a previous fresh cycle. The relative predictive value of these parameters may be a guideline for the selection of embryos used for transfer. Assisted hatching may become routine in freeze-thaw cycles if its utility is confirmed in subsequent studies.

Assisted hatching improves implantation rates on cryopreserved-thawed embryos. A randomized prospective study

BACKGROUND

Focus on the hatching process has so far been in the field of fresh embryos. Cryopreserved-thawed embryos have a lower rate of pregnancy than fresh embryos, which might be due to hardening of the zona pellucida.

METHODS

During a 2 year period, a prospective randomized study enrolling 253 cryopreserved-thawed cycles was performed on day 2 embryos. Pseudorandomization to assisted hatching or a control group was done on the basis of even and odd dates for thawing. One hour before embryo transfer, hatching was carried out using acidic Tyrode's solution.

RESULTS

Among 136 embryos exposed to assisted hatching, 11.4% (30) were implanted compared with only 5.8% (13) of 117 embryos not exposed to assisted hatching (P<0.05, chi(2) test). No difference in the rate of clinical pregnancy and positive serum HCG was observed between the two groups. Very few women >38 years old were included in the study, and no significant difference according to age could be found between the groups.

CONCLUSIONS

These results show that assisted hatching using acidic Tyrode's solution increases the implantation rate of cryopreserved-thawed embryos (P<0.05).

Genetic analysis of males from intracytoplasmic sperm injection couples

A total of 392 men referred for intracytoplasmic sperm injection (ICSI) participated in genetic analysis. The control group consisted of 100 normal fertile males. Chromosome and DNA analyses were performed to investigate the frequency of Y-chromosome microdeletions and CFTR mutations (the controls underwent DNA analysis only). An abnormal karyotype was found in 4.6% of all males, but the frequency among men with azoospermia was higher, at 11.7%. Y-chromosome microdeletions were found only among men with azoospermia (6.5%) and men with extreme oligospermia (2%). Compound heterozygosity for CFTR mutations was found in men with azoospermia (3.9%) and congenital bilateral absence of vas deferens (CBAVD) only. We conclude that all couples referred for ICSI should be offered chromosome analysis. DNA analysis for Y-chromosome microdeletions should be reserved for men with azoospermia or extreme oligospermia (<1 x 106 spermatozoa). Analysis for CFTR mutations should be limited to those with obstructive azoospermia or those with a family history of cystic fibrosis.

Serological investigation of Mycoplasma genitalium in infertile women

BACKGROUND

The role of Mycoplasma genitalium in the pathogenesis of pelvic inflammatory disease has not been characterized.

METHODS

Sera from 308 infertile women were investigated for antibodies to M. genitalium by immunoblotting. Women with tubal factor infertility (TFI) made up 132 of the patients, 67 of the women had an infertile male partner and 109 were infertile for unknown reasons.

RESULTS

Of the TFI patients 29 (22.0%) were seropositive to the major adhesin, MgPa, of M. genitalium versus 11 (6.3%) in the group of women with normal tubes. No cross-reactions between MgPa and P1 of the related Mycoplasma pneumoniae were found. Besides, MgPa positive sera were confirmed by immunoblotting using a cloned fragment of the C-terminal part of MgPa specific to M. genitalium. Chlamydia trachomatis is known to be able to cause infertility as a result of salpingitis. Therefore, the sera were tested against C. trachomatis using a commercial ELISA test. Seventy-five (56.8%) of the TFI patients were seropositive to C. trachomatis. Eight (27.6%) TFI patients seropositive to MgPa were negative to C. trachomatis.

CONCLUSIONS

This study indicates that M. genitalium may be an independent risk factor in the development of an inflammatory process leading to scarring of the uterine tubes in women and thereby causing infertility.

Birth of a healthy girl after ICSI with ejaculated spermatozoa from a man with non-mosaic Klinefelter's syndrome

Klinefelter's syndrome is a major contributor to male infertility. Recent reports of births after ICSI with especially testicular spermatozoa from infertile men with this syndrome are promising. The birth of a healthy girl after ICSI treatment with ejaculated spermatozoa from a man with non-mosaic Klinefelter's syndrome is reported. The non-mosaic karyotype was confirmed by chromosome analysis of both peripheral blood leukocytes and fibroblasts from a skin biopsy. In conclusion, in a very few cases, men with apparently non-mosaic Klinefelter's syndrome have ejaculated spermatozoa that can result in a birth of a healthy child following ICSI.

Pregnancy rates in relation to time intervals between repeat sperm-retrieval procedures

A total of 76 repeat sperm retrievals were carried out in 47 azoospermic men. The outcome of the procedures was evaluated regarding to the interval between two successive procedures. Sperm motility and pregnancy rate were not increased by increasing the interval between two successive sperm retrievals from less than 90 days to more than 180 days. The pregnancy rate declined from 50% with a less than 90-day interval to 25% with a more than 180-day interval. The trend did not quite reach the significance level. Pregnancy was obtained in only 27% of the couples where TESE was done the last time against 48 and 57% where PESA and TESA, respectively, were performed the last time (p < .05). This study suggests that sperm retrieval procedures in men with obstructive azoospermia can be carried out with time intervals of only 3 months to obtain an optimal pregnancy rate, and it might suggest that an epididymal aspiration procedure should be preferred for a TESE.

Occurrence of gonadoblastoma in females with Turner syndrome and Y chromosome material: a population study

The presence of Y chromosome material in patients with Turner syndrome is a risk factor for the development of gonadoblastoma. However, no cases with gonadoblastoma or other ovarian malignancies have been found in epidemiological studies of cancer, morbidity, or mortality in Turner syndrome. We examined 114 females with Turner syndrome for the presence of Y chromosome material by PCR. Initially, five different primer sets were used. Y Chromosome-positive individuals were further examined with an additional four primer sets. We found 14 (12.2%; 95% confidence interval, 6.9-19.7%) patients who had Y chromosome material. The karyotype in 7 of these patients did not suggest the presence of Y chromosome material. Seven of the patients had been ovariectomized before entering the study due to verified Y chromosome material, whereas three patients were operated upon after the DNA analysis. The histopathological evaluations showed that 1 of the 10 ovariectomized patients actually had a gonadoblastoma. The rest of the patients did not have gonadoblastoma or carcinoma in situ on histopathological evaluation. Three patients (age, >50 yr) positive for Y chromosome material chose not to have ovariectomy performed, and detailed ultrasonographies did not suggest the presence of gonadoblastoma. The frequency of Y chromosome material is high in Turner syndrome (12.2%), but the occurrence of gonadoblastoma among Y-positive patients seems to be low (7-10%), and the risk may have been overestimated in previous studies, perhaps due to problems with selection bias. This study emphasizes the need for prospective unbiased studies.

[Infertility due to azoospermia. Causes, examination methods and therapeutic strategies]

Azoospermia can be due to a genetic defect (abnormal karyotype, Y chromosome micro-deletion or cystic fibroses carrier), genital tract infection or trauma. Examination of azoospermic men includes ultrasound examination of the scrotal contents, prostate and seminal vesicles, hormone analysis, genetic examinations and testis biopsy. Some patients with obstructive azoospermia can be cured surgically. If passage can not be established through the genital tract, sperm can be obtained from the epididymis or testis for micro-insemination of oocytes from the female partner. No increased occurrence of malformations among children born after micro-insemination has been found, but an increased occurrence of severe reduced semen quality may be expected, when the "ICSI boys" grow up. Freezing of additional sperm or testis tissue is recommended.

[Male infertility--diagnosis and treatment]

Infertility is often due to subfertility in both partners. Investigations of the male partner includes history taking, physical examination (possibly supplemented with ultrasonography), and semen analysis. In addition to the sperm count, and sperm morphology and motility, numerous other seminal parameters are of interest. In particular, the acrosome reaction test and testing for seminal round cell subpopulations are now widely used. In the event of anomalies, causal treatment is preferable to symptomatic therapy. Significant future progress in the management of male infertility is predicated upon an improved understanding of the mechanisms involved in testicular differentiation and spermatogenesis.

Effect of a combined GnRH/hCG therapy in boys with undescended testicles: evaluated in relation to testicular localization within the first week after birth

Among 509 boys referred with undescended testicles, 112 had true undescended testicles unilaterally and 62 bilaterally. Patients with true undescended testicles were offered hormonal treatment unless the condition was associated with hernia or previous operations. Boys less than 5 years old were primarily treated with gonadotrophin releasing hormone (GnRH), while boys more than 5 years old were primarily treated with human chorionic gonadotrophin (hCG). If the effect of the primary treatment was insufficient the other hormone was given. Testicular descent was obtained for 64% (23/36) of the intraabdominally located testicles in boys with bilaterally undescended testicles versus only 14% (3/21) in boys with unilaterally undescended testicles (p < .001). Treating 1 to 4 years old boys with GnRH resulted in descent in 16 of 95 testicles and secondary treatment with hCG yielded an additional 34, whereas secondary treatment of 5 to 13 years old boys with GnRH added only 10 descended testicles to 51 of 101 testicles. Reading the maternity records of 272 of the boys support other studies showing that testicles may reascend. Boys with endocrinological or "surgical" causes of incomplete testicular descent were relatively more likely to have had one or two undescended testicles during the first postnatal week compared with boys found to have only retractile testicles (p < .001). Treatment with hormones resulted in descent in 56% of boys whose testicles were both descended within one week after birth. Conversely, only 1 of 20 boys with unilateral testicular undescent postnatally was sufficiently treated with hormones (p < .001). The hormonal effect in boys with bilaterally undescended testicles at delivery did not differ significantly from boys with either one or none undescended testicle postnatally. In 35 of 51 boys (69%) in whom the hormonal effect was insufficient, operation revealed a "surgical cause" of the incomplete testicular descent.

Nonsperm cells in human semen: with special reference to seminal leukocytes and their possible influence on fertility

Nonspermatozoal cells (NSC) in semen, including immature germ cells, leukocytes (WBC) and epithelial cells, are normally found in a concentration less than 15% of the sperm concentration. Cytological staining methods and immunoenzymatic assays for characterization of seminal WBC and methods for detection of various enzymes from WBC are evaluated. Criteria for abnormally high levels of WBC in semen, caused by exogenic factors (e.g., infection) and possibly by endogenic factors (e.g., abnormal sperm), are discussed. Leukocytospermia is associated with reduced in vitro fertilization rate, and experimentally-measured sperm functions (e.g., motility) are inhibited by high concentrations of certain WBC products (e.g., reactive oxygen species and interferon-gamma). At the present stage, the following procedures could be used to evaluate WBC in ejaculates from infertile patients: (1) count the number of NSC using a hemocytometer. (2) Determine the number of WBC in percentage of NSC in smears using the Papanicolaou staining technique, or an immuno-enzymatic assay using monoclonal antibodies to the different kinds of WBC. (3) If, abnormally high levels of WBC (according to the WHO criteria or based on a percentile determined from examination of normal, fertile men) is detected, a second ejaculate should be examined 3 months later. (4) Persistent leukocytospermia should indicate physical and microbiological examinations, after which antibiotic treatment may be indicated.

Effect of cytokines on sperm motility and ionophore-stimulated acrosome reaction

The effects of soluble products from leukocytes (WBC) on sperm motility and calcium ionophore-stimulated acrosome reaction (AR) were examined. Supernatants of mononuclear WBC, isolated from peripheral blood and stimulated by the lectins Phytolacca americana (pokeweed mitogen) or concanavalin A, caused a weak but significant inhibition of progressive sperm motility. The recombinant cytokine interferon-gamma (IFN-gamma) in high concentrations inhibited motility of sperm from 5 of 8 donors tested. The recombinant cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin-8 (IL-8) did not show any effect on sperm motility. Reactive oxygen species (ROS) produced by stimulation of polymorphonuclear WBC with a phorbol ester (PMA) tended to inhibit sperm motility. Neither supernatants from lectin-stimulated mononuclear WBC, IFN-gamma, TNF-alpha, IL-8, nor ROS showed any significant effect on the ionophore-challenged AR.

Nonspermatozoal cells in semen: relationship to other semen parameters and fertility status of the couple

In semen samples from 94 men from infertile couples and 42 control patients proven to be fertile the occurrence of different kinds of nonspermatozoal cells (NSC) was examined. The findings were evaluated in relation to other seminal parameters and to the fertility status of the couple. The ratios of NSC to sperm and primary spermatocytes to spermatids revealed increasing values with decreasing sperm counts. Especially in a group where the semen samples contained > or = 6 x 10(6) motile sperm per mL and no infertility factor was detectable in the woman, the concentration of leukocytes was high, with three of eight patients having > or = 10(6) leukocytes per mL. A high proportion of abnormal sperm seemed to occur more frequently where the cause of infertility could be found in the man. A high number of leukocytes was neither significantly associated to an increased proportion of abnormal sperm nor to sperm motility evaluated by recording the percentage of motile sperm and the 1-h migration distance in sodium hyaluronate medium. No correlation between concentration of lymphocytes and presence of antisperm antibodies in seminal plasma was detectable.

Uterus didelphys associated with duplex kidneys and ureters

In a patient with uterus didelphys, four kidneys and four ureters were detected. The sister too has a didelphic uterus.

[H-Y antigen and development of a testis in a girl with XY karyotype]

A phenotypical girl aged 16 years with primary amenorrhoea had an XY-karyotype and reacted positively to serologically demonstrable H-Y antigen. The left gonad was an immature testis while the right was a streak gonad with a gonadoblastoma. The value of H-Y antigen determinations in the diagnosis and choice of treatment is discussed.

Reduced level of sex-specific antigen (H-Y antigen) on lymphocytes in some patients with bilateral cryptorchidism

Sex-specific (Sxs) antigen on the surface of nucleated cells from normal human males seems to be essential for the formation of testes. The relative quantity of the antigen on lymphocytes was evaluated by absorption experiments in a complement-dependent cytotoxicity test or in an ELISA technique using antisera against Sxs antigen produced by immunization of female rats. Lymphocytes from 13 normal males were Sxs-antigen positive, and cells from 12 normal females were characterized as Sxs-antigen negative. However, in the testing of lymphocytes from nine boys with bilateral cryptorchidism, only six revealed a normal male absorption pattern, whereas the antigen level on cells from three boys, all of them with normal karyotype, was reduced compared with the normal male level. No correlation between Sxs-antigen level and testosterone response after treatment with hCG could be demonstrated.

[Studies with azlocillin, mezlocillin, penicillin-g-potassium and sisomicin on tolerance in the cornea and the kinetics of inhibiting concentrations in the cornea and aqueous humor in rabbits]

We studied the effect of azlocillin, mezlocillin and sisomicin in concentrations of 1, 2.5 and 5% on the regeneration of stromal corneal wounds in rabbits following subconjunctival injections and treatment with eye drops. Concentrations of the antibiotics were also determined in corneal tissue and in aqueous humor and compared with that of penicillin G-potassium. Together with azlocillin, sisomicin proved to be the most effective and the safest. Mezlocillin only inhibited wound regeneration slightly and thus mezlocillin appears to be inferior to the other two antibiotics investigated in the local treatment of the eye.