Treatment Of Male Factor Infertility Research Articles

The effect of Chinese herbal medicine on male factor infertility: study protocol for a randomized controlled trial.

The global prevalence of infertility is 9%, with male factors potentially accounting for 40% to 60% of cases. Conventional treatments can be ineffective, invasive, costly, and linked to adverse effects and high risks. Previous studies have shown that, Chinese herbal medicine (CHM) can regulate the hypothalamus-pituitary-testis axis, improve sperm abnormalities and quality, mitigate oxidative stress, and decrease DNA fragmentation index (DFI). Yet, the evidence backing the use of Chinese herbal medicine (CHM) for treating male factor infertility lacks conviction due to study design limitations, and there remains a scarcity of studies on the live birth rate following CHM treatment for male factor infertility. Here, we describe the rationale and design of a randomized waitlist-controlled trial to evaluate the effect of CHM on the live birth rate among males with infertility. This study is a single-center, randomized, waitlist-controlled study. A total of 250 couples diagnosed with male factor infertility will be enrolled in this study and then randomly allocated into two groups in a 1:1 ratio. Male participants in CHM group (treatment group) will receive CHM once a day for 3 months. Male participants in the waitlist group (control group) will not receive any treatment for 3 months. After 3 months, participants in both groups need to be followed up for another 12 months. The primary outcome will be the live birth rate; secondary outcomes include semen quality parameters, DFI and pregnancy related outcomes. Safety will also be assessed. The purpose of this trial is to explore the effects and safety of CHM on the live birth rate among couples dealing with male factor infertility. The outcome of this trial may provide a viable treatment option for male factor infertility. Chinese Clinical Trial Registry: ChiCTR2200064416. Registered on 7 October 2022, https://www.chictr.org.cn.

#355 : “No One Asked Me If I’m Alright”: A Mixed Methods Study Exploring Information/Support Needs and Challenges Engaging Men Diagnosed with Male-Factor Infertility

Background and Aims: Men desire to be actively involved in preconception care. However, health systems do not consistently or proactively engage men and there is little acknowledgement of their needs during this time. The lack of gender-specific service provision in infertility treatment likely contributes to men’s poorer mental wellbeing following infertility diagnosis and infertility treatment. This research sought to understand males’ psychosocial and support needs when diagnosed with male-factor infertility. Method: Mixed methods design, assessing men who had undergone diagnosis and/or treatment for male-factor infertility in past five years within Australia. Study comprised: 1) online survey (assessing psychological functioning, fertility knowledge, information sources, social support and perception of resources) and 2) semi-structured interviews to further explore participants’ lived experiences of male-factor infertility. Participants were recruited through Andrology clinics, social media, infertility support pages and ANZICA counsellors. Results: During their infertility journeys, participants mostly received information fertility doctors/nurses and the internet. However, their preferred method of informational knowledge would be through a verified male infertility website. Qualitative data were analysed by reflexive thematic analysis, which resulted in three key themes, each with two sub-themes, summarising pertinent aspects of men’s lived experiences when diagnosed with male-factor infertility (Figure 1). The majority of participants were in later stages of their fertility journey, indicating they felt more prepared to discuss their experiences given most (or all) of the initial-stage emotional and physical intensity of their diagnosis and active treatment had passed. Conclusion: There is a clear need for in/fertility services to implement proactive support approaches that engage directly with male patients and acknowledge the complexity of lived experiences when receiving a diagnosis of male-factor infertility.

P-560 Stigma related to male infertility in China: a scale development and validation study

Abstract Study question Is it possible to develop a trustworthy instrument to evaluate the infertile men's stigma and to document fully all methodological steps, including validation? Summary answer The Male Infertility Stigma Scale (MISS) has been developed to evaluate the stigma status of infertile men with a good reliability and validity. What is known already Infertile men regard childless as a hidden stigma, which influence all the dimensions of their lives and well-being. Most instruments focus exclusively on women and no questionnaires have been directed at infertile men. Study design, size, duration A cross-sectional study was conducted to analyse the validity and reliability of MISS. This was a one-centre study in the Center of Reproductive Medicine of the Third Affiliated Hospital of Guangzhou Medical University between January 2019 to May 2019. Participants/materials, setting, methods This study was carried out on men (n = 432) with a diagnosis and treatment for male-factor infertility. Item generation and reduction of MISS was formed by combining literature review, interviews of experts and patients, and related scale. Exploratory factor analysis (n = 216) and confirmatory factor analysis (n = 216) were performed to indicate the scale constructs. In addition, reliability analyses including internal consistency and test–retest analysis (n = 18)were carried out. Validity was analyzed by convergent validity and content validity. Main results and the role of chance This study developed a 18-item MISS with three dimensions (social marginalization, self-devaluation, psychological insecurity). Exploratory factor analysis indicated that these three dimensions explained 60.14% of total variances.The confirmatory factor analysis showed that the construct of the MISS fitted well with the hypothetical model. The Cronbach's α,split-half coefficient and test–retest correlation coefficient for the whole scale was 0.951, 0.884,and 0.945, respectively. The associations of the MISS with other measure suggested good convergent validity. The Content Validity Index (CVI) was 0.988. Limitations, reasons for caution The reliability and validity of the MISS developed in this study were verified only among the infertility men in Guangzhou and the discriminant validity of dimension 3(psychological insecurity) in this survey was a little poor. The convenience sampling method precluded the validity and generalization of the conclusions. Wider implications of the findings This study may create an effective evaluation measurement to understand the stigma status of infertile men. Future studies should focus on using the MISS in larger samples with different characterizations, such as different areas, and then taking some measures to help them . Trial registration number None

MP01-03 XENO-FREE PEPTIDE-FUNCTIONALIZED BIOINKS IMPROVE EX VIVO CULTURE OF HUMAN TESTICULAR TISSUES

You have accessJournal of UrologyCME1 Apr 2023MP01-03 XENO-FREE PEPTIDE-FUNCTIONALIZED BIOINKS IMPROVE EX VIVO CULTURE OF HUMAN TESTICULAR TISSUES Meghan Robinson and Ryan Flannigan Meghan RobinsonMeghan Robinson More articles by this author and Ryan FlanniganRyan Flannigan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003212.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The development of human in vitro spermatogenesis (IVS) is a promising regenerative platform for the treatment of male factor infertility. IVS has been demonstrated in rodent models, but despite decades of research remains a challenge in the human sphere. A promising strategy may be to culture fragments of testis tissues in hydrogels. Hydrogels can be functionalized to sequester matrix and signaling peptides in a local manner mimicking tissue niche function. In this study we investigated the use of xeno-free hydrogels functionalized with biomimetic peptide motifs for their ability to improve ex vivo culture of human testicular tissues. METHODS: Human testicular tissues were obtained from hormone-treated gender affirmation patients following informed consent, gently teased apart, cut into small fragments and mixed into bioinks (VitroInk) containing either YIGSR (laminin), COL (collagen), or MMPs (matrix metalloproteinases) peptide motifs, then printed into ∼1 cm3 droplets using a BioX6 extrusion bioprinter (Figure 1A). 1 mL of media was placed on each and they were cultured in 34°C at 5% CO2 and ambient oxygen (21%) for 12 days, with 50% media changes every other day. The media consisted of Human Plasma-Like Medium (HPLM) with 15% CTS™ KnockOut™ SR XenoFree Medium, vitamins, metabolites, antioxidants, growth factors and hormones known to be present in the testis niche. Tissues were analyzed after 12 days by quantitative real-time polymerase chain reaction (qPCR) for gene expression associated with apoptosis, somatic cell function, spermatogonial stem cell maintenance, and spermatogenesis. RESULTS: After 12 days gene expression associated with somatic cell function and spermatogenesis was higher than suspension culture controls in all hydrogel groups (Figure 1B). Compared to freshly harvested testicular tissues, COL- and YIGSR-functionalized hydrogels exhibited similar expression levels of genes associated with somatic cell function, and the highest increased levels of genes associated with early spermatogenesis (Figure 1B). CONCLUSIONS: COL- or YIGSR peptide-functionalized hydrogels sustain testicular tissue function ex vivo in short-term cultures, whereas suspension culture exhibited tissue function loss, suggesting the utility of functionalized hydrogels for human IVS. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Meghan Robinson More articles by this author Ryan Flannigan More articles by this author Expand All Advertisement PDF downloadLoading ...

EDITORIAL COMMENT

This interesting article concludes that “home semen testing can significantly reduce the time for evaluation and treatment for male factor infertility.” This conclusion, based on the assumption and supported by the use of multiple layers of statistical modeling, predicts that a man, discovering that his sperm count is significantly low after using a convenient at-home test, will now promptly find his way to a urologist's office. The validity of this clinical paradigm is beyond the scope of statistical manipulation.

Myo-inositol in the treatment of male factor infertility

About 187 million couples worldwide suffer from infertility, with the male factor being diagnosed in 2070% of cases. The main cause of idiopathic infertility has been recognized as the adverse effects of reactive oxygen species. On the one hand, the cellular antioxidant defense is a highly efficient multilevel system; therefore, the pharmacological targets may vary. On the other hand, antioxidant enzymes (superoxide dismutase, catalase, peroxidase) have high activity and specificity, which limits the pharmacological capabilities of direct antioxidants. Indirect methods, such as the normalization of mitochondrial function, are more promising. Mitochondria play a key role in providing energy for sperm motility (one of the main factors of male fertility). Myo-inositol (MI) derivatives involved in cell signaling regulate intracellular Ca2+ ion levels affecting mitochondrial oxidative metabolism and adenosine triphosphate production. Thus, mitochondrial antioxidants are of particular interest for therapeutic strategies. Currently, various routes and regimens of MI use in the treatment of males with oligo-astheno-teratozoospermia (OAT) are being considered in clinical practice. MI-based oral nutraceutical complexes for the treatment of male factor infertility contain both direct and indirect antioxidants. In vitro studies revealed damage to mitochondrial cristae in the sperm intermediate tract in patients with OAT. Experimental studies have demonstrated that mitochondrial structure is restored when sperm are incubated in an MI-containing medium. Clinical studies confirmed that sperm incubation in such an environment leads to increased sperm motility and viability in patients with OAT. Intravaginal administration of MI showed increased total sperm motility and an increased proportion of progressively motile sperm. It is the progressive motility that is considered the best marker for identifying quality and healthy sperm. This type of sperm is usually used for in vitro fertilization techniques. In addition, intravaginal MI administration improved the quality of cervical mucus and reduced its viscosity and crystallization. The effect of intravaginal MI on cervical mucus can be considered as an additional independent factor in increasing fertility.

Endometrial preservation during resection of type II and type III submucosal fibroids.

Hysteroscopic myomectomy is considered the gold-standard treatment of submucosal fibroids. However, it is associated with disruption of the endometrium which may lead to complications such as intrauterine adhesions and loss of functional endometrium. In this video article we describe a technique to resect Type III and Type II fibroids whilst minimising the loss of overlying endometrium. We present two patients with type II/III submucosal fibroids with minimal or no intracavitary component. The resection technique we demonstrate comprises either making an endometrial incision or making a small opening in the overlying endometrium to expose the fibroid pseudocapsule. Subsequent steps of resection are then performed through this small opening. Thus, complete resection is achieved without further resection of the endometrium. Evidence of endometrial healing and absence of intrauterine synechiae on follow up outpatient hysteroscopy or ultrasound scan. Full resection was achieved in both patients with no or minimal loss of overlying endometrium. A follow up outpatient hysteroscopy was performed 8 weeks later in the first patient, demonstrating completely healed uterine cavity. She had a successful conception and delivery following IVF treatment for male factor infertility. The second patient is currently in the process of IVF treatment. Our technique enables endometrial preservation and potentially better reproductive outcomes following resection of type II and type III submucosal fibroids. Larger scale studies are required to elucidate long term outcomes on bigger patient population.

Oocyte activation deficiency and assisted oocyte activation: mechanisms, obstacles and prospects for clinical application.

BACKGROUNDOocyte activation deficiency (OAD) is attributed to the majority of cases underlying failure of ICSI cycles, the standard treatment for male factor infertility. Oocyte activation encompasses a series of concerted events, triggered by sperm-specific phospholipase C zeta (PLCζ), which elicits increases in free cytoplasmic calcium (Ca2+) in spatially and temporally specific oscillations. Defects in this specific pattern of Ca2+ release are directly attributable to most cases of OAD. Ca2+ release can be clinically mediated via assisted oocyte activation (AOA), a combination of mechanical, electrical and/or chemical stimuli which artificially promote an increase in the levels of intra-cytoplasmic Ca2+. However, concerns regarding safety and efficacy underlie potential risks that must be addressed before such methods can be safely widely used.OBJECTIVE AND RATIONALERecent advances in current AOA techniques warrant a review of the safety and efficacy of these practices, to determine the extent to which AOA may be implemented in the clinic. Importantly, the primary challenges to obtaining data on the safety and efficacy of AOA must be determined. Such questions require urgent attention before widespread clinical utilization of such protocols can be advocated.SEARCH METHODSA literature review was performed using databases including PubMed, Web of Science, Medline, etc. using AOA, OAD, calcium ionophores, ICSI, PLCζ, oocyte activation, failed fertilization and fertilization failure as keywords. Relevant articles published until June 2019 were analysed and included in the review, with an emphasis on studies assessing large-scale efficacy and safety.OUTCOMESContradictory studies on the safety and efficacy of AOA do not yet allow for the establishment of AOA as standard practice in the clinic. Heterogeneity in study methodology, inconsistent sample inclusion criteria, non-standardized outcome assessments, restricted sample size and animal model limitations render AOA strictly experimental. The main scientific concern impeding AOA utilization in the clinic is the non-physiological method of Ca2+ release mediated by most AOA agents, coupled with a lack of holistic understanding regarding the physiological mechanism(s) underlying Ca2+ release at oocyte activation.LIMITATIONS, REASONS FOR CAUTIONThe number of studies with clinical relevance using AOA remains significantly low. A much wider range of studies examining outcomes using multiple AOA agents are required.WIDER IMPLICATIONSIn addition to addressing the five main challenges of studies assessing AOA safety and efficacy, more standardized, large-scale, multi-centre studies of AOA, as well as long-term follow-up studies of children born from AOA, would provide evidence for establishing AOA as a treatment for infertility. The delivery of an activating agent that can more accurately recapitulate physiological fertilization, such as recombinant PLCζ, is a promising prospect for the future of AOA. Further to PLCζ, many other avenues of physiological oocyte activation also require urgent investigation to assess other potential physiological avenues of AOA.STUDY FUNDING/COMPETING INTERESTSD.G. was supported by Stanford University’s Bing Overseas Study Program. J.K. was supported by a Healthcare Research Fellowship Award (HF-14-16) made by Health and Care Research Wales (HCRW), alongside a National Science, Technology, and Innovation plan (NSTIP) project grant (15-MED4186-20) awarded by the King Abdulaziz City for Science and Technology (KACST). The authors have no competing interests to declare.

Predicting the testicular function in non-obstructive azoospermia via targeted gene panel

BackgroundMen with non-obstructive azoospermia constitute a challenging subgroup of male infertility patients in whom a genetic cause of defective spermatogenesis may be a contributing factor. The aim of this prospective observational cohort study was to determine whether assessment of meiotic nuclear division 1 (MND1) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) gene expression (MND1/GAPDH) in testicular tissue could be a prognostic indicator for sperm retrieval and ICSI outcome in patients with non-obstructive azoospermia. The study participants underwent clinical evaluation, conventional semen analysis, serum follicular stimulating hormone (FSH), testosterone assay, scrotal ultrasound examination, microsurgical testicular sperm extraction (mTESE), and assessment of MND1/GAPDH gene expression levels in testicular tissue via quantitative polymerase chain reaction (qPCR) techniques.ResultsThe MND1/GAPDH level was associated with the likelihood of identifying sperm in testicular biopsies (odds ratio (OR) 1.25, 95% confidence intervals (CI) 1.14 to 1.34, p < 0.0001), which was confirmed by the pairwise comparison of high vs. low levels of MND1/GAPDH (OR 5.34, 95% CI 1.97 to 13.16, p = 0.0006). The level of FSH was inversely associated with a lower chance of finding sperm (OR 0.37, 95% CI 0.20 to 0.65, p = 0.001). Compared with small testicular volume, normal volume was inversely associated with the chance of sperm presence (OR 0.16, 95% CI 0.06 to 0.47, p = 0.0002). However, there was no correlation between MND1/GAPDH levels and ICSI outcome.ConclusionGene expression analysis to predict the likelihood of sperm retrieval following mTESE in patients with non-obstructive azoospermia provides a new avenue for future research, diagnosis and treatment of male factor infertility. Before its wider clinical application, however, this proof-of-concept should be tested in a large multinational, multicenter observational study.

An integrated overview on the regulation of sperm metabolism (glycolysis-Krebs cycle-oxidative phosphorylation)

An overview of the sperm metabolism is presented; using the stallion as a model we review glycolysis, Krebs Cycle and oxidative phosphorylation, paying special attention to the interactions among them. In addition, metabolism implies a series of coordinated oxidation-reduction reactions and in the course of these reactions reactive oxygen species (ROS) and reactive oxoaldehydes are produced ; the electron transport chain (ETC) in the mitochondria is the main source of the anion superoxide and hydrogen peroxide, while glycolysis produces 2-oxoaldehydes such as methylglyoxal as byproducts; due to the adjacent carbonyl groups are strong electrophiles (steal electrons oxidizing other compounds). Sophisticated mechanisms exist to maintain redox homeostasis, because ROS under controlled production also have important regulatory functions in the spermatozoa. The interactions between metabolism and production of reactive oxygen species are essential for proper sperm function, and deregulation of these processes rapidly leads to sperm malfunction and finally death. Lastly, we briefly describe two techniques that will expand our knowledge on sperm metabolism in the coming decades, metabolic flow cytometry and the use of the “omics” technologies, proteomics and metabolomics, specifically the micro and nano proteomics/metabolomics. A better understanding of the metabolism of the spermatozoa will lead to big improvements in sperm technologies and the diagnosis and treatment of male factor infertility.

Infertility insurance: What coverage exists for physician trainees?

We aimed to describe infertility insurance coverage provided to male and female fellows working at institutions that offer advanced infertility training. Faculty and fellows working within U.S. and Canadian andrology or reproductive endocrinology and infertility (REI) programs were contacted and asked for a copy of their institutional health insurance summary of benefits. Documents were assessed for coverage of diagnosis and treatment, shared costs, and maximum lifetime coverage for infertility care. Insurance policies from 24 institutions were reviewed; 16 of 24 (66%) institutions covered costs related to the diagnosis of infertility. Six institutions (25%) offered coverage for diagnosis but not treatment. There were 15 (62.5%) institutions that offered some amount of coverage for the treatment of infertility, and the average lifetime maximum was $16 100. Only six of 24 (25%) plans explicitly described a covered male-specific treatment, which included sperm extraction (12.5%), varicocele repair (4.2%), and sperm cryopreservation (8.3%). For physician trainees, infertility insurance coverage is not universal, policies are not transparent, and treatment for male factor infertility is often omitted. With high costs of infertility treatment, variable insurance coverage, and debt and time constraints, residents and fellows are a particularly vulnerable population that may experience significant financial toxicity when faced with infertility.

Endometriosis does not impact live-birth rates in frozen embryo transfers of euploid blastocysts

To determine whether subfertility in patients with endometriosis is due to impaired endometrial receptivity by comparing pregnancy and live-birth outcomes in women with endometriosis versus two control groups without suspected endometrial factors: noninfertile patients who underwent assisted reproduction to test embryos for a single-gene disorder and couples with isolated male factor infertility. Retrospective cohort. Multicenter private practice. All patients aged 24 to 44 years undergoing euploid frozen blastocysts transfer from January 2016 through March2018. None. Live birth, clinical pregnancies, pregnancy losses, and aneuploid rates in preimplantation genetic testing for aneuploidy cycles. The analysis included 459 euploid frozen embryo transfer cycles among 328 unique patients. There were no differences in clinical pregnancy, pregnancy loss, or live-birth rates in patients with endometriosis compared with both control groups. The aneuploidy rates were lowest in the preimplantation genetic testing for monogenic disorders cohort, and the endometriosis patients had aneuploidy rates similar to those of the male factor infertility patients. It is unclear whether endometriosis primarily affects invitro fertilization outcomes via oocyte quality or the endometrium. By controlling for embryo quality using euploid frozen embryo transfer cycles, we found no difference in pregnancy outcomes in patients with endometriosis compared with patients undergoing treatment for male factor infertility and noninfertile patients.

CORRELATION BETWEEN SERUM AND FOLLICULAR VITAMIN D LEVELS AND INTRA CYTOPLASMIC SPERM INJECTION OUTCOME

In vitro fertilization (IVF) has been performed for more than 40 years, and it is estimated that in developed countries, more than 1 % of all births are generated from assisted reproductive therapies (ART).Intracytoplasmic sperm injection (ICSI) is the procedure that includes direct injection of a solitary spermatozoon into a mature oocyte. ICSI has effectivelypermitted the treatment of male factor infertility; ICSI outcome is often affected by many factors such as: the woman’s age and initial FSH levels, serum E2 concentration on the day of hCG administration, the number of mature oocytes and high-qualityembryos available for replacement at the end of treatment.Recently, growing interest in vitamin D has emerged from findings that demonstrate a low vitamin D status in populations, People at higher risk for vitamin D deficiency include women with dark skin and those who cover their skin with clothing due to religious or cultural beliefs or those who regularly use sunscreens. It is thought that vitamin D has an important role in reproduction processes and its significance in infertility therapy. Vitamin D is categorized in to three groups; normal vitamin Insufficient vitamin D and deficient vitamin D.

The SLC7A11: sperm mitochondrial function and non-canonical glutamate metabolism.

Spermatozoa are redox-regulated cells, and stallion spermatozoa, in particular, present an intense mitochondrial activity in which large amounts of reactive oxygen species (ROS) are produced. To maintain the redox potential under physiological conditions, sophisticated mechanisms ought to be present, particularly in the mitochondria. In the present study, we investigated the role of the SLC7A11 antiporter. This antiporter exchanges intracellular glutamate for extracellular cystine. In the spermatozoa, cystine is reduced to cysteine and used for GSH synthesis. The importance of the antiporter for mitochondrial functionality was studied using flow cytometry and UHPLC/MS/MS approaches. Intracellular GSH increased in the presence of cystine, but was reduced in the presence of Buthionine sulphoximine (BSO), a γ-glutamylcysteine synthetase inhibitor (P < 0.001). Inhibition of the SLC7A11 antiporter with sulfasalazine caused a dramatic drop in intracellular GSH (P < 0.001) and in the percentage of spermatozoa showing active mitochondria (P < 0.001). These findings suggest that proper functionality of this antiporter is required for the mitochondrial function of spermatozoa. We also describe that under some conditions, glutamate may be metabolized following non-conventional pathways, also contributing to sperm functionality. We provide evidences, that the stallion spermatozoa have important metabolic plasticity, and also of the relation between redox regulation and metabolic regulation. These findings may have important implications for the understanding of sperm biology and the development of new strategies for sperm conservation and treatment of male factor infertility.

INFERTILITY INSURANCE: WHAT COVERAGE EXISTS FOR RESIDENTS AND FELLOWS?

We aimed to evaluate infertility insurance coverage provided to physician trainees at institutions that offer advanced infertility training. A descriptive study examining health insurance documentation regarding coverage for infertility services. Health insurance summary plan documents from US institutions with post-graduate physician training in Andrology and/or Reproductive Endocrinology and Infertility (REI) fellowships were obtained either from fellows themselves, the GME office, or the program website. The summary of benefits documents were individually examined for their descriptions of coverage for infertility services by two authors (WM and EJ). Assessment of coverage for diagnosis, treatment and any discussion of shared costs or maximum lifetime coverage were included. We also assessed for descriptive text specifically indicating services for male infertility care as well as coverage for cryopreservation. Statistical analysis using a fisher exact test was used to evaluate whether having an Andrology program was predictive of an institution including male-specific language in its insurance policy. We reviewed documents from 24 unique institutions, which included 14 out of the 18 US Andrology fellowships and 18 out of the 48 US REI fellowships. There were 15 of 24 (62.5%) institutions reporting coverage for the treatment of infertility, 6 (25%) institutions that covered diagnosis but not treatment, and 3 (12.5%) institutions that excluded diagnostic or treatment coverage completely. Among the 15 institutions that provided coverage for treatment, 13 reported the lifetime maximum amount, which averaged $14,885 (range of $2,500 - $25,000). In total, we identified only 7 out of 24 (29%) policies that included male-specific language. Only 4 out of 24 (16.7%) plans explicitly described a covered male-specific treatment. Having an Andrology program did not significantly increase the likelihood of including male-specific language in institutional insurance policies. We found that for physician trainees, infertility insurance coverage is variable and treatment for male factor infertility is commonly omitted or minimally mentioned in insurance coverage documents. With high costs of infertility treatment, residents and fellows may represent a particularly vulnerable population when faced with fertility concerns.

Significance of pro-angiogenic estrogen metabolites in normal follicular development and follicular growth arrest in polycystic ovary syndrome.

Do alterations in pro- and anti-angiogenic estrogen metabolites in follicular fluid (FF) contribute to the follicular growth arrest and anovulation associated with polycystic ovary syndrome (PCOS)? FF of PCOS women with anovulation have reduced levels of pro-angiogenic estrogen metabolites (EMs) and vascular endothelial growth factor (VEGF) compared to that of fertile women with regular menstrual cycles, but exogenous gonadotropins increase the pro-angiogenic EMs and VEGF levels in PCOS women. PCOS is characterized by the arrest of follicular development that leads to chronic anovulation. Follicular arrest is generally associated with elevated plasma levels of luteinizing hormone (LH), androgens and anti-Mullerian hormone (AMH). There is also reduced angiogenesis in the follicles of PCOS women compared to those of normal cycling women. It is known that angiogenesis is a critical factor during follicular development. We and other investigators have explored the role of EMs in ovarian angiogenesis, particularly in human corpus luteum function, showing that 4-hydroxyestrone (4-OHE1) and 16-ketoestradiol (16-kE2) have pro-angiogenic effects while 2-methoxyestradiol (2-ME2) and 2-methoxyestrone (2-ME1) have anti-angiogenic effects. Additionally, 2-hydroxyestradiol (2-OHE2), which is produced in the ovary, has proliferative and pro-angiogenic properties. We hypothesized that EMs could be involved in angiogenesis necessary for ovarian follicular development in fertile women, and that dysregulation of these factors may contribute to follicular arrest in PCOS. The relationship between EMs, VEGF and AMH in the pathophysiology of follicular arrest in PCOS has not been previously studied at a follicular level in anovulatory women without ovulation induction. This is a comparative experimental study of serum and FF collected from different sized follicles (antral ˂10 mm and dominant ˃16 mm) of women with and without ovarian stimulation. The study included women with regular menstrual cycles who were proven to be fertile (n = 20) and PCOS women with follicular arrest who were candidates for ovarian drilling (n = 17), as well as other patients requiring ovarian stimulation, i.e. control women undergoing IVF for male factor infertility (n = 12) and PCOS women undergoing IVF (n = 17). In vitro studies were carried out on granulosa-lutein cells (GCs) obtained from subsets of women undergoing IVF for male factor infertility (n = 6) and PCOS women undergoing IVF (n = 6). GCs were maintained in culture for up to 6 days. Intrafollicular estradiol, estrone and EMs concentrations were determined by high performance liquid chromatography-mass spectrometry. Testosterone in serum was measured by RIA, and LH, FSH and sex hormone-binding globulin in serum were measured with IRMA kits. AMH was determined in serum and FF by enzyme linked immunosorbant assay (ELISA). VEGF levels were measured in FF and conditioned medium by ELISA. Conditioned medium were obtained from cultured GCs. The angiogenic potential was assessed by in vitro angiogenic assays. Pro-angiogenic EMs (4-OHE1, 16-kE2 and 2-OHE2) and VEGF were lower in FF of antral follicles of PCOS women with follicular arrest compared those of fertile women with ovulatory cycles (P < 0.05). In contrast, higher concentrations of AMH were found in FF of antral follicles from PCOS women with follicular arrest compared to those of fertile women with ovulatory cycles (P < 0.05). Exogenous gonadotropins used in IVF increased pro-angiogenic EMs and VEGF production in PCOS women, reaching similar profiles compared to control women receiving gonadotropins in their IVF treatment for male factor infertility. The pro-angiogenic EM 2-OHE2 increased the angiogenic potential and VEGF levels of GCs from PCOS women compared to the basal condition (P < 0.05). These findings suggest that there is a role for pro-angiogenic EMs in the control of follicular VEGF production. The limitations include the possibility that in vitro analysis of GCs might not reflect the in vivo mechanisms involved in the pro-angiogenic action of 2-OHE2 since GCs obtained at the time of oocyte retrieval belong to a very early stage of the luteal phase and might not be representative of GCs during follicular growth. Therefore, our findings do not conclusively rule out the possibility that other in vivo mechanisms also account for defective angiogenesis observed in PCOS. The present study highlights the significance of EMs, angiogenic factors and AMH and their interaction in the pathophysiology of follicular development in PCOS. This study provides new insights into the role of pro-angiogenic factors in follicular arrest in PCOS. This study was funded by CONICYT/FONDECYT 1140693 and NIH grant R01HD083323. All authors declare no conflict of interest. N/A.

Stimulation of Leydig and Sertoli Cellular Secretory Function by Anti-Oestrogens: Tamoxifen.

Tamoxifen is a selective oestrogen receptor modulator (SERM). SERMs act on oestrogen receptors to inhibit oestradiol mediated negative feedback on the hypothalamic-pituitary-gonadal (HPG) axis, thereby upregulating gonadotrophin secretion and release from the pituitary. Hence, Tamoxifen is used to upregulate activation of the HPG axis in the treatment of male-factor infertility. However, due to a lack of robust evidence, Tamoxifen has not been FDA approved for use in male-factor infertility and so its use is currently off-label. In this study, we performed a literature search of the OVID medline database and identified 37 studies describing the effects of tamoxifen which we then reviewed. Evidence suggests Tamoxifen effectively increases androgen levels and sperm concentrations in males with idiopathic oligozoospermia. Evidence for increased motility and pregnancy rates in these patients is less conclusive. Further randomised control trials are needed to elucidate the safety of Tamoxifen combination therapies and their efficacy in improving pregnancy rates.

Comparative proteomic analysis of round and elongated spermatids during spermiogenesis in mice.

Spermiogenesis in mammals is an exclusive process during which haploid round spermatids mature into spermatozoa in the testis. Any abnormality in the process of spermiogenesis may result in male infertility. The aim of the present study was to characterize the differentially expressed proteins between round and elongated spermatids in mice using label-free quantitative mass spectrometry. Of the 2411 proteins identified in this study, 333 were differentially expressed with a ≥10-fold change, including 208 upregulated proteins and 125 downregulated proteins in round spermatids relative to elongated spermatids. Gene Ontology analysis showed that these differentially expressed proteins were categorized into 10 types of subcellular localizations, 9 molecular functions, and were involved in 9 biological processes. All the identified proteins participated in 268 different pathways. In addition, ubiquitin-mediated proteolysis and the proteasome pathway, autophagy, lysosome, and apoptosis pathways were involved in the mechanism of spermiogenesis. Our data may provide valuable information for a better understanding of spermiogenesis and help improve the diagnosis and treatment of male factor infertility.

AUTHOR REPLY

We appreciate the reviewer's comments regarding our manuscript. The inconsistent adoption of WHO V (2010) semen analysis reference ranges can result in numerous unintended consequences, including inconsistencies in the diagnosis and treatment of male factor infertility depending simply on the location of the patient's evaluation. Patients commonly express confusion and dismay when being categorized as “normal” at one center and “infertile” at another, and this scenario can also result in uncertainty on the part of physicians unfamiliar with the field of reproductive medicine. We agree with the reviewer that more consistent adoption of contemporary WHO semen analysis reference ranges would greatly help rectify this situation and provide patients and clinicians alike with great clarity. However, we suspect that a primary reason for the inconsistent adoption of the WHO V reference ranges is the fact that these values do not represent a true boundary between the “fertile” and “infertile” states. Rather, these values are arbitrary cut-points selected at the 5th centile value for each parameter, derived from data from an international cohort of fertile males. Given the fact that the contemporary reference values are not derived to differentiate fertile from infertile men, many centers continue to use the older reference ranges because they feel that they do a better job discriminating fertility from infertility. Until reference ranges that more clearly separate these two groups are implemented, inconsistent adoption will likely persist. Unfortunately, given the high degree of overlap in semen analysis values for fertile and infertile men, we suspect that such reference ranges will not be generated any time soon.

Sildenafil's impact on male infertility: what has changed in 20 years?

Sildenafil has had a dramatic influence on the field of sexual medicine over the past 20 years. Not only have phosphodiesterase-5 (PDE5) inhibitors improved the treatment of erectile dysfunction (ED), they have indirectly contributed to the treatment of male factor infertility. A review of the literature between 1998 - 2018 was performed using PubMed with regards to sildenafil and male infertility. Numerous studies have demonstrated sildenafil's safety and efficacy for treating ED. Sildenafil does not alter semen parameters, and, in fact, may positively affect semen parameters. Sildenafil is helpful for treating ED caused by the psychological stress of infertility treatments. Sildenafil has improved the treatment of ED and may have a benefit on semen parameters. This has aided in the management of male factor infertility, and has contributed to hundreds of thousands of pregnancies that would have been more difficult, as it was before its advent.