Professional Documents
Culture Documents
142-147, 1995
Introduction
It is known that auto-antibodies to spermatozoa impair fertility.
Those bound to the sperm surface are considered to be
especially important (Eggert-Kruse et ai, 1991). The presence
of such antibodies in men has been shown to be associated
with genital infections, vasectomy, trauma or certain anatomical
abnormalities (for a review see Isidori et ai, 1988). The effects
that male antisperm antibodies have on fertility are still not
very well known, which is reflected in the various treatment
modalities. In addition, the results of these treatments are
sometimes difficult to interpret because this condition is
anything but absolute. Spontaneous pregnancies occur,
although long periods are often involved (Shulman, 1986).
142
Downloaded from http://humrep.oxfordjournals.org/ at National Pingtung University of Science and Technology on March 31, 2013
Statistical analyses
Fisher's exact test was used to compare the pregnancy rates
before cross-over and also in the whole material, based on the
assumption that a couple's probability of pregnancy using one
method did not depend on the conditions in which the previous
method had been applied unsuccessfully. This test was also
employed for comparison of sperm washing methods between
the groups, and for analysis of previous female fertility.
To test the homogeneity of the couples as regards antibody
levels, semen parameters and duration of infertility between
the two groups, the Mann-Whitney rank sum test was used.
It was also used to assess the differences in antibody levels
and in duration of infertility between pregnant and nonpregnant couples.
Student's paired Mest was employed to determine significant
changes in antibody levels (IgG-MAR and TAT), sperm count
and motility before and after treatment. Using multiple analysis
of variance, semen parameters were analysed between the
couples who first started with IUI and those who were treated
by IUI after cross-over.
The chosen level of significance was P < 0.05.
143
Downloaded from http://humrep.oxfordjournals.org/ at National Pingtung University of Science and Technology on March 31, 2013
Trial design
The ethical committee of the Family Federation of Finland
approved the study protocol. By drawing a sealed envelope,
the couples were randomized to undergo either up to three
IUI, or oral prednisolone therapy of the men combined with
timed intercourse in three consecutive menstrual cycles of the
female partner. Cross-over to the other treatment was carried
out if no pregnancy occurred in the first stage.
Prednisolone treatment was modified from the regimen
described by Hendry et al. (1986). A dose of 20 mg of
prednisolone (Prednisolon 5 mg; Leiras Oy, Turku, Finland)
was taken once a day with meals on days 1-10 of the female
partner's menstrual cycle, followed by 5 mg on days 11 and
12. In the pre-treatment visit the couples were informed about
the side-effects associated with this steroid. The men were
advised to abstain from alcohol and heavy sports during the
study period. After three cycles, the antibody levels were remeasured and semen analysis performed. The couples were
then seen and asked a non-leading question about the possible
side-effects.
Clomiphene citrate was used in 62% (67/108) of IUI
cycles and 54% (52/96) of timed intercourse cycles. Ovulation
detection was performed daily by use of urinary luteinizing
hormone (LH) home test kits (ClearplanR; Unipath, Bedford,
UK), beginning 3-4 days before expected ovulation. During
the three-cycle prednisolone therapy, couples were instructed
to have intercourse in each cycle in the evening of the day of
the LH rise and on the following day. In IUI cycles, timing
of ovulation was also checked by transvaginal ultrasonography.
IUI was performed the day after onset of the LH surge, by
injecting ~1 ml of spermatozoa in culture medium with a
Kremer-Delafontaine catheter (Prodimed, Neuilly-en-Thelle,
France). If no pregnancy occurred, up to three IUI cycles took
place, after which antibody tests were repeated.
Table I. Reason for withdrawal of six couples and some immunological characteristics of the men
Patient no.
Randomized
to start with
No. of treated
cycles
IgGa
IgAb
TAT
28
IUI
100
ND
1:256
IUI
76
ND
1:64
IUI
95
ND
1:64
TI
70
1:128
TI
98
89
1:512
IUI
95
64
1:128
40
41
43
45
46
Ig = immunoglobulin; TAT = tray agglutination test; IUI = intra-uterine insemination; TI = timed intercourse;
ND = not done
Direct mixed antiglobulin reaction (MAR) test.
b
Flow cytometry.
a
Table II. Comparison of initial semen parameters, antibody levels and duration of infertility in couples who first started with intra-uterine insemination (IUI),
with those starting with timed intercourse (TI)a
IUI first (n = 19)
b
IgG (%)
IgAc (%)
Total sperm count per ejaculate (X10 6 )
Progressive motility (%)
Duration of infertility (years)
a
144
82 25
38 9d
258 248
57 19
5.2 4.4
TI first (n = 21)
80 27
51 T
174 127
46 21
5.4 3.6
P
0.9
0.3
0.5
0.05
0.8
Downloaded from http://humrep.oxfordjournals.org/ at National Pingtung University of Science and Technology on March 31, 2013
Results
In all, 40 couples either completed the study or the female
partner conceived and treatment was stopped. The reasons for
withdrawal of six couples are given in Table I. None of
them withdrew because of steroidal side-effects. One- man
complained of mild dyspepsia; two others of erythema on the
face and chest. No sleeplessness or irritability was reported.
Of the 40 men above, 19 (48%) had had some predisposing
factors for antisperm antibodies in their past: eight men had
had genital tract infections, five had had operations because
of inguinal hernias, three had suffered from cryptorchidism
and two from left-sided varicocele. One man had a unilateral
obstruction of the epididymis as a result of surgery. Interestingly, operated inguinal hernias predisposed the subjects to
very strong IgG-MAR positivity (>90%), whereas the other
factors were associated with more variable MAR values. In
these five men, serum TAT results were also clearly positive
(1:64-1:1024).
The mean duration of infertility in these couples up to the
start of the study was 5.3 years (SD 3.4; range 1-18). Infertility
was primary in 32 couples (80%). Previous fertility of the
female partner was not a significant predictor of pregnancy,
even though a slight association was noted (P = 0.09). A total
Table III. Pregnancies per cycle and couple before cross-over and for the whole study
Before cross-over
IUI
Prednisolone + TI
Per cycle
(%)
Per couple
(%)
Per cycle
(%)
Per couple
(%)
8/48 (17)
0/63 (0)
8/19 (42)a
0/21 (0)
9/108 (8)
1/96(1)
9/40 (23)b
1/32 (3)
Discussion
In the present study, IUI proved to be superior to low-dose,
cyclic prednisolone therapy with timed intercourse when the
male partner had sperm-associated IgG and/or IgA immunoglobulins. Limited success with IUI has been reported by
Kremer et al. (1978). On the other hand, Francavilla et al.
IgGa
IgAb
Prednisolone + TI
IUI
IUI
IUI
IUI
IUI
IUI
IUI
IUI
IUI
10
98
94
63
97
100
95
55
77
95
ND
ND
24
34
13
51
ND
ND
73
0
TAT
:16
: 128
:1024
:64
:64
: 128
:16
: 128
:256
: 128
(1992) failed to obtain pregnancies by IUI when all spermatozoa were IgG and/or IgA antibody-coated, irrespective of the
other semen parameters. In our study, timing of ovulation
was based on urinary LH rise and checked by transvaginal
ultrasonography, thus optimizing the timing of insemination.
When monitoring the female partner during these cycles, it is
possible to recognize and avoid problems that may be involved.
The importance of adequate ovulation has been reported by
Margalioth et al. (1988), who had some success with IUI,
especially when gonadotrophin stimulation of the female
partner was employed.
IUI may be of help if the primary obstacle to fertility is
sperm penetration through the cervical mucus, as suggested
with regard to locally produced IgA antibody (Jager et al.,
1980). The benefit of IUI may also be in overcoming problems
in sperm capacitation and acrosome reaction. As Lansford
et al. (1990) showed, premature acrosomal loss shortly after
ejaculation may be associated with sperm-bound antibodies.
If the lifespan of these spermatozoa is decreased, IUI with
appropriate timing has to be performed to enhance the probability of achieving pregnancy.
The effect of semen preparation on sperm-associated
immunoglobulins is interesting. Simply centrifuging and resuspending specimens has been considered to be inadequate in
separating antibodies from the sperm surface. This has been
shown by Haas et al. (1988), who used a radioimmunoassay
method to measure antibody levels after multiple washings.
However, flow cytometric data suggest that the first wash
145
Downloaded from http://humrep.oxfordjournals.org/ at National Pingtung University of Science and Technology on March 31, 2013
146
References
Almagor,M., Margalioth,E.J. and Yaffe.H. (1992) Density differences
between spermatozoa with antisperm autoantibodies and
spermatozoa covered with antisperm antibodies from serum. Hum.
Reprod., 7,959-961.
Bals-Pratsch,M., D6ren,M., Karbowski,B., Schneider,H.P.G. and
Nieschlag,E. (1992) Cyclic corticosteroid immunosuppression is
unsuccessful in the treatment of sperm antibody-related male
infertility. Hum. Reprod., 7, 99-104.
Barratt,C.L.R., Dunphy,B.C, McLeodJ. and CookeJ.D. (1992) The
poor prognostic value of low to moderate levels of sperm surfacebound antibodies. Hum. Reprod., 7, 95-98.
Bronson,R.A., Cooper.S.W. and Rosenfeld.D.L. (1987) Seminal fluid
antisperm antibodies do not reflect those present of the sperm
surface. Fertil. Steril., 48, 505-506.
Clarke.G.N.,
Lopata,A.,
McBain,J.C,
Baker,H.W.G.
and
Johnston,W.I.H. (1985) Effects of sperm antibodies in males on
human in vitro fertilization (IVF). Am. J. Reprod. Immunol.
Microbioi, 8, 62-66.
Duleba,A.J., Rowe,T.C, Ma,P. and Collins.J.A. (1992) Prognostic
factors in assessment and management of male infertility. Hum.
Reprod, 7, 1388-1393.
Eggert-Kruse,W., Hofsap,A., Haury,E., Tilgen,W., Gerhard.I. and
Runnebaum,B. (1991) Relationship between local anti-sperm
Downloaded from http://humrep.oxfordjournals.org/ at National Pingtung University of Science and Technology on March 31, 2013
Downloaded from http://humrep.oxfordjournals.org/ at National Pingtung University of Science and Technology on March 31, 2013
\A1