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Semen analysis in adolescents with familial Mediterranean fever
Journal of Pediatric Urology (2019) 15, 342.e1e342.e7
Semen analysis in adolescents with familial Mediterranean fever G. Kaya Aksoy a,*, M. Koyun a, M.F. Usta b, E. C ¸ omak a, S. Akman a a
Akdeniz University, School of Medicine, Department of Pediatric Nephrology, Antalya, Turkey
b Akdeniz University, School of Medicine, Department of Urology, Antalya, Turkey
* Corresponding author. Tel.: þ90 242 249 6000/6523; fax: þ90 242 227 4320. [email protected] (G. Kaya Aksoy) Keywords Familial Mediterranean fever; Sperm; Infertility; Adolescent; Semen abnormality
Abbreviations AUC, Area under the curve; CRP, C-reactive protein; ESR, Erythrocyte sedimentation rate; FMF, Familial Mediterranean Fever; FSH, Follicle stimulating hormone; LH, Luteinizing hormone; MEFV, Familial Mediterranean Fever gene; SAA, Serum amyloid A
Summary Background Little is known about sperm health in male patients with familial Mediterranean fever (FMF). In this study, the authors aimed to search the frequency of sperm abnormalities of adolescent boys with FMF and also to investigate whether disease activity or colchicine treatment have negative effects on sperm parameters. Method The male adolescents older than 14 years with a diagnosis of FMF were investigated retrospectively. Tel Hashomer and pediatric FMF clinical criteria were used for diagnosis of FMF. Patients who had semen analysis were included in the study. Result Mean age at the diagnosis was 11.13 3.82 years, and mean age at the study was 14.50 0.70 years. The mean sperm concentration was found as 66.26 41.02 million/ml (N > 15 million/ml), the mean total sperm count 113.42 132.39 million
(N > 39 million), and the mean sperm motility 51.78 23.70% (N > 40%). Only 8 of 19 (42.1%) patients had normal sperm parameters. Sperm concentration was reduced in two cases, total sperm count was reduced in four patients, and motility was reduced in nine cases. The presence of FMF attacks under treatment was found to be a risk factor for decreased motility in the study group by multivariate regression analysis (odds ratio 0.076, [95% confidence interval 0.005e0.648], P Z 0.031). Erythrocyte sedimentation rate at the time of diagnosis was high in patients with low sperm counts compared with those with normal sperm counts (56.00 8.51 vs 24.35 6.32, P: 0.03). Mean colchicine dose at the time of sperm analysis was higher in patients with low sperm motility than that with normal sperm motility (1.72 0.18 vs 1.25 0.08, P: 0.02).
Conclusion Sperm abnormalities of male patients with FMF is not infrequent, and it is linked to both inflammation due to uncontrolled disease and colchicine therapy.
Received 12 October 2018 Revised 25 March 2019 Accepted 1 April 2019 Available online 5 April 2019
Table The laboratory finding and colchicine dose of FMF patients with normal and abnormal semen parameters (n Z 19) Variable
Sperm concentrationa
Mean CRP Mean ESR Mean SAA Mean colchicine dose (mg/day)
0.12 2.50 7.28 1.50
Normal
0.02 0.50 4.42 1.21
Total sperm countb
Motilityc
Low
P
Normal
Low
P
Normal
Low
P
0.89 0.55 9.06 2.21 49.66 35.53 1.25 0.25
0.28 0.36 0.50 0.46
0.95 0.63 9.27 2.50 51.06 41.45 1.37 0.77
0.27 0.09 5.00 1.78 23.22 16.01 1.88 0.42
0.92 0.83 0.68 0.32
1.35 0.93 10.40 3.61 73.84 61.93 1.25 0.08
0.21 0.04 6.11 1.44 13.38 7.27 1.72 0.18
0.32 0.76 0.56 0.02
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; SAA, serum amyloid A. a Normal sperm concentration >15 million. b Normal total count >39 million. c Normal motility rate >40%. https://doi.org/10.1016/j.jpurol.2019.04.001 1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Semen analysis in adolescents
Introduction Familial Mediterranean fever (FMF), the most common monogenic autoinflammatory disease, is an autosomal recessively inherited disease seen most frequently in countries bordering the Mediterranean sea. Mutations and deletions in the MEFV gene (16p13.3), which encodes the protein pyrin, are responsible for the disease in a great majority of patients [1]. The disease is characterized with self-limiting inflammatory episodes (called ‘attacks’), amyloid deposition in tissues, and also the subsequent damage sustained by many different tissues and organs in the body [2]. Thus, reducing the number of attacks and preventing the development of tissue damage are very important in the management of patients with FMF. Colchicine, owing to its anti-inflammatory properties, is used as the first-line treatment in patients with FMF. Colchicine interacts with tubulin and prevents microtubule polymerization, thus causing antimitotic effects. It also decreases expression of adhesion molecules (E-selectin and L-selectin) in membranes and inhibits neutrophil chemotaxis [3]. In addition, it has been shown to inhibit pore formation which is required for caspase-1 maturation and IL-1b release being P2X group purinergic receptors [4]. The most frequently observed side-effect of colchicine is on the gastrointestinal system, and this side-effect is observed in around 10% of patients within the first month of treatment with colchicine [5]. Other side-effects such as vitamin B12 deficiency, myopathy, reversible peripheral neuritis, bone marrow suppression, and alopecia are observed less often [6]. Azoospermia was first reported in a male patient with FMF in 1972 [7]. Several studies have associated azoospermia with amyloid deposition in the testicular tissue of patients with FMF [8,9], whereas others have suggested that it was related to colchicine therapy [10], which is reportedly due to the antimitotic properties of colchicine [3]. These findings suggest that both inadequate treatment and overtreatment of FMF could have negative effects on sperm development. This issue has attracted attention because of the fact that it is a subject that has been rarely researched, and to the authors’ knowledge, there has been no study of this effect in the pediatric age group. Therefore, in this study, the aim was to investigate the frequency of sperm abnormalities in adolescent boys with FMF and also to investigate whether disease activity or colchicine treatment was associated with the alterations in sperm parameters.
342.e2 provided informed consent for the study. Ethics committee approval was received from Akdeniz University Medical Faculty for this study (6.3.2019/231). The diagnosis of FMF was made according to Tel Hashomer diagnosis criteria for patients who applied before April 2009 and to the Turkish FMF pediatric diagnosis criteria after April 2009 [11,12]. The diagnoses of patients who were initially diagnosed with the Tel Hashomer criteria were reevaluated with the Turkish FMF pediatric diagnosis criteria. Those who did not fulfill the second criteria were excluded from the study. Demographic data, complaints at the time of application, MEFV mutation types, colchicine dose, and patients’ number of attacks within the 3 months before sperm analysis were recorded. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and serum amyloid A (SAA) values were recorded at the time of admission, at attack onset, and during sperm analysis. Hemoglobin analysis was performed regularly every 3 months. Anemia was defined using World Health Organization (WHO) standards for age [13]. Peripheral venous blood was used for MEFV mutation analyses; DNA extraction was performed from lymphocytes with the standard methods, and all patients were scanned for exon 2 and 10 mutations of the MEFV gene. The starting dose of colchicine was 0.5 mg/day under the age of 5, 1 mg/day for children aged 5e10 years, and 1.5 mg/day for children older than 10 years. The dose was increased when required up to a maximum of 1.5 mg/day in children aged 5e10 years and 2 mg/day in children older than 10 years [14]. Sperm analysis was performed as per the methods outlined by the fifth edition of WHO laboratory manual for the examination and processing of human semen. Samples were obtained by masturbation in a private room at the andrology laboratory after at least 3 days of abstinence, and the ejaculate was placed in a clean, wide-mouthed, non-toxic plastic container. The semen was incubated in an incubator at 37 C to be liquefied. Macroscopic examination of semen was initiated immediately after liquefaction or within 30 min to 1 h after ejaculation. Color, viscosity, volume, and pH were evaluated with macroscopic examination, and total sperm count, motility, viability, and morphology were analyzed via microscopic examination. Microscopic examination was performed at 37 C using a 22 22 lamella, providing a depth of 20 mm. Normal values were defined as total sperm count >39 million, sperm concentration >15 million/ml, and total motility >40% [15].
Statistical analysis
Method The medical records of male adolescents older than 14 years with a diagnosis of FMF who were followed up at the institution between January 2015 and December 2017 were retrospectively reviewed. Patients who underwent sperm analysis during their follow-up and patients with a puberty stage above Tanner stage 5 and testicular volume greater than 4 ml were included in the study. Patients who did not agree to participate in the study and those with missing medical data were excluded from the study. Also patients with a history of testicular torsion and orchitis were excluded from the study. All patients and their families
Descriptive statistics were presented as frequency, percentage, mean, standard deviation, median, minimum, and maximum values. Shapiro Wilks test, histogram, and QeQ graphics was used for evaluation of normality of distribution. The Fisher’s exact test or Pearson Chi-squared test was used in the analysis of the relationships between categorical variables. For the comparison of continuous variables, the Students t-test was used with normal distribution, whereas the ManneWhitney U test was used in the contrary case. To assess diagnostic value of ESR, the authors plotted receiver operating characteristic curve and computed area under the curve (AUC). Multiple logistic
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G. Kaya Aksoy et al.
regression analysis was performed to define risk factors, and odds ratio (OR) and 95% confidence intervals (CIs) were calculated in multiple logistic regression analysis for the assessment of risk factors. Statistical analyses were performed by using the SPSS 21.0 packaged program for Windows. P values < 0.05 were accepted to show statistical significance.
Results Characteristics of the study cohort Medical records were obtained from 72 male patients with FMF diagnosis older than 14 years. During the follow-up period, 21 of these patients were planned to perform sperm analysis. However, two patients could not be evaluated because the patient’s consent could not be obtained. Nineteen male adolescents were included in the study. The mean age of the patients was 14.50 0.70, mean age at the time of diagnosis was 11.13 3.82, and median follow-up time was 3.12 (range from 1.08 to 14.58 years) years. Eight of the 19 patients had homozygous MEFV gene mutation, 7 had compound heterozygous MEFV gene mutation, one had heterozygous MEFV gene mutation, and 3 patients had no mutations. At the time of diagnosis, fever was present in 15 patients (78.9%), abdominal pain in 14 (73.7%), and arthralgia in 7 (36.8%) (Table 1).
Table 1 Demographic and clinical characteristics of the patients with FMF (n Z 19). Mean age (years) Mean age at diagnosis (years) Median follow-up time (years) MEFV mutation (%) Homozygous (%) M694V M680I V726A R202Q Compound heterozygous (%) M694V/V726A M694V/E230K M694V/R202Q E148Q/M680I M680I/V726A M680I/R202Q Heterozygous M680I/N Complaint at application Fever (%) Abdominal pain (%) Arthralgia (%) Median time between beginning of clinical findings and diagnosis (months) Mean colchicine starting dose (mg/day) Mean colchicine dose at the time of sampling (mg/day) FMF, familial Mediterranean fever.
14.50 0.70 11.13 3.82 3.12 (1.08e14.58) 16 (84) 8 (42) 5 (26) 1 (5) 1 (5) 1 (5) 7 (36) 2 (10) 1 (5) 1 (5) 1 (5) 1 (5) 1 (5) 1 (5) 1 (5) 15 (79) 14 (73) 7 (37) 2.45 (0.58e9.18) 1.16 1.47
The median time between the initial clinical findings and diagnosis was 2.45 (range from 0.58 to 9.18) months. The mean starting dose of colchicine was 1.16 mg/day, and the mean colchicine dose used at the time of spermogram sampling was 1.47 mg/day. Colchicine dose was increased in 9 patients (47.7%) who had attacks under treatment, 4 of whom had 3 attacks and the remaining 5 had 2 attacks. Six of 9 patients had attacks within the first 6 months of therapy, whereas 3 had attacks between 6 and 10 months. The median time between the last attack and the sperm sampling in these 9 patients is 2.6 years (range from 2.20 to 3.06 years). None of the patients were colchicine resistant.
Evaluation of sperm analysis results The mean sperm concentration was 66.26 41.02 million/ ml (Normal: >15 million/ml), mean total sperm count was 113.42 132.39 million (Normal: >39 million), and mean sperm motility was 51.78 23.70% (Normal: >40%). No significant relationship was determined between complaint at application and MEFV gene mutation with any of these parameters (mean sperm concentration, count and motility). Also, M694V mutation was not significantly associated with semen parameters (Table 2). However, mean total sperm count and motility, but not sperm concentration, of the patients who had attack under colchicine treatment were lower that those of attack-free patients (81.44 40.31 vs 142.20 44.85, P: 0.034 and 40.56 4.81 vs 61.90 8.35, P: 0.020) (Table 2). All sperm parameters were at normal levels in only 8 of the 19 boys included in the study (42.1%). Low sperm concentration was observed in 2 patients (10.5%), low total sperm count was observed in 4 (21%), and decrease in sperm motility was observed in 9 patients (47.3%). Four patients had abnormalities in two of the three sperm parameters, whereas none had abnormalities in all three sperm parameters. The demographic and clinical characteristics of patients with sperm abnormality are presented on Table 3. Table 4 presents the demographic and clinical characteristics of patients with normal and abnormal semen parameters. The mean age at the time of sperm analysis and at diagnosis was similar between patients with normal and abnormal semen parameters. It was found that ESR values were higher at the time of diagnosis and in the attack-free period in patients with low total sperm counts compared with that of those with normal total sperm counts (56.00 8.51 vs 24.35 6.32, P: 0.03), whereas CRP and SAA levels were similar (Table 4). Anemia was investigated because it may be a cause of elevated ESR. Hemoglobin (Hg) values were found to be lower than age-specific reference ranges in two of the patients, but the sedimentation values of these two patients were not increased (Hg values 10.3 and 10.9 gr/dl). When the ESR distribution graph was evaluated, the ESR cutoff value for patients with oligospermia was found to be 30 mm/h with a sensitivity of 100.0% and specificity of 73.3% (AUC 0.858, P: 0.032).
Effect of colchicine treatment It was found that the mean colchicine dose at the time of sperm analysis was higher in patients with low sperm
Semen analysis in adolescents
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Table 2 Comparison of clinical characteristics, MEFV gene mutations, and attack presence of FMF patients according to sperm characteristics (n Z 19). Variable - values Fever
Abdominal pain
Arthralgia
MEFV mutation
M694V mutation
Presence of attack under colchicine treatment
Sperm concentration Yes No p Yes No p Yes No p Homozygous and compound heterozygous (n Z 15) Heterozygous mutation and without mutation (n Z 4) p Yes (n Z 9) No (n Z 10) p Yes (n Z 9) No (n Z 10) p
Total sperm count
Motility
85.02 23.37 220.00 109.23 0.76 85.02 26.62 193.10 87.71 0.22 140.71 66.76 97.50 30.16 0.35 91.33 9.52
53.32 47.25 0.48 49.71 57.60 0.45 58.52 48.17 0.44 36.67
74.67 23.67
128.47 37.70
52.60 6.23
0.85 71.32 79.12 0.26 58.00 73.70 0.46
0.93 86.32 10.54 115.36 41.65 0.86 81.44 40.31 142.20 44.85 0.034
0.26 39.84 49.35 0.98 40.56 61.90 0.020
67.40 62.00 0.84 60.36 82.80 0.35 56.29 72.08 0.33 68.27
11.39 15.59 10.15 21.99 16.69 11.50 10.60
10.28 23.67 10.14 15.53
5.97 14.49 6.65 9.55 8.14 7.23 5.20
6.15 5.48 4.81 8.35
FMF, familial Mediterranean fever. Bold font indicates the p values.
motility than in those with normal sperm motility (1.72 0.18 vs 1.25 0.08, P: 0.02) (Table 3). This relationship was not detected for total sperm count and concentration. Mean colchicine use time was determined to be 4.68 3.94 months, and the mean cumulative colchicine dose was calculated as 1375.10 275.50 mg. No relationship was found between any of the semen parameters and mean colchicine use time or mean cumulative colchicine dose.
Analysis of risk factors The risk factors for decreased sperm motility in FMF patients were analyzed by multiple logistic regression analysis (Table 5). The presence of FMF attacks under treatment was found to be a risk factor for decreased motility in the study group by multivariate regression analysis (OR 0.076 [95% CI 0.005e0.648], P Z 0.031). However, no risk factor affecting sperm concentration or count was detected with logistic regression analysis.
Discussion In this study, the authors have found that more than half of the adolescent patients with FMF had abnormal semen parameters (mostly low sperm motility). There is little data regarding the frequency of infertility and sperm health in male patients with FMF, and as far as the authors know, this is the first study evaluating spermogram findings of adolescent boys with FMF. Abnormal semen parameters have been reported as a rare complication of FMF [16]. In the study, both total sperm count and motility were low in patients who had attack while under colchicine
treatment; furthermore, they were found to have higher inflammation activity and had undergone a significant increase in colchicine dose. On the other hand, it was found that ESR, an indicator of inflammation, was high in patients with low total sperm counts, whereas mean colchicine dose was higher in patients with low sperm motility. In the literature, the relationship between high ESR and elevation of inflammatory plasma proteins has been shown [17]. Some proteins, such as transferrin, have been shown to be increased in the testicle during inflammation [18]. However, from the results, the authors can only speculate that higher levels of ESR without elevations in CRP or SAA in patients with FMF may be a sign of local inflammation in the testicle which may be associated with the expression of testicular transferrin. However, the findings suggest that inflammation is linked to low sperm counts, whereas colchicine may be responsible for low sperm motility. In the literature, the azoospermia associated with FMF has been generally linked to the amyloid deposition in testicles [9]. Amyloid deposition has been suggested to disturb sperm transport by damaging intratesticular canaliculi which leads to obstructive azoospermia or directly disrupting sperm production via adverse effect on the seminiferous tubules [9]. Testicle biopsy was not performed in any of the study patients and accordingly the presence of testicle amyloid was not researched. Patients had normal SAA levels, did not have proteinuria, and the duration with diagnosis was below expected levels for amyloid development. For these reasons, the authors do not believe that the patients had amyloid deposition at a degree which would cause alterations in semen parameters. As is known, the inflammatory response occurring during FMF attacks is responsible for peritonitis, pleuritis, and/or arthritis. Particularly, mediators such as IL-1b are
Demographic and clinical characteristics of FMF patients with semen abnormality.
Patient no.
Age (year)
Age at diagnosis (year)
Symptoms at application
MEFV mutation
Presence of FMF attack under colchicine treatment
Cumulative colchicine dosage (mg)
Colchicine dose at the time of analysis (mg/day)
Sperm concentration (N > 15 million/ml)
Total sperm count (N > 39 million)
Motility (N>40%)
1 2 3
15.1 15.6 17.2
12.8 12.6 14.1
V726A/V726A M694V/M694V M680I/normal
Yes Yes No
1100 2190 1050
1.5 2 1
35 51 11
21 26 44
60 36 85
4
15.6
13.0
M694V/M694V
Yes
730
1
15
29
32
5 6 7 8 9 10 11
15.9 17.5 15.9 15.7 16.2 14.9 14.5
12.1 13.5 14.3 13.5 15.1 14.1 11.3
Abdominal pain and arthralgia Fever and abdominal pain Fever, abdominal pain and arthralgia Fever, abdominal pain and arthralgia Abdominal pain Fever and abdominal pain Arthralgia Fever and abdominal pain Fever and abdominal pain Fever and abdominal pain Fever and abdominal pain
M694V/V726A no mutation M694V/M694V No mutation R202Q/R202Q M694V/M694V M680I/M680I
Yes Yes No No Yes Yes Yes
1640 2190 3285 1095 548 560 1650
1.5 1.5 3 1.5 1.5 1.5 1.5
67 50 42 52 26 98 11
102 45 21 41 39 68 51
20 28 27 36 19 37 0
342.e5
Table 3
FMF, familial Mediterranean fever. Bold font used to highlight abnormal values.
Table 4
The demographic and clinical characteristics of FMF patients with normal and abnormal semen parameters (n Z 19).
Variable
Mean age (year) Mean age at diagnosis (year) At the time of diagnosis (at attack-free period)
Sperm concentration
Total sperm count
Motility
Low (<15 million) (n Z 2)
P
Normal (>39 million) (n Z 15)
Low (<39million) (n Z 4)
P
Normal (>40%) (n Z 10)
Low (<40%) (n Z 9)
P
15.74 0.27 10.97 0.96 1.10 0.99 24.25 10.12 173.90 123.20 0.12 0.02 2.50 0.50 7.28 4.42 1.50 1.21
15.50 1.50 12.50 1.50 5.82 2.80 31.84 6.67 387.62 286.65 0.89 0.55 9.06 2.21 49.66 35.53 1.25 0.25
0.67 0.68 0.77 0.79 0.51 0.28 0.36 0.50 0.46
15.97 0.31 10.77 1.09 3.89 2.61 24.35 6.32 72.38 31.43 0.95 0.63 9.27 2.50 51.06 41.45 1.37 0.77
14.75 0.25 12.50 0.64 12.37 7.18 56.00 8.51 467.50 432.50 0.27 0.09 5.00 1.78 23.22 16.01 1.88 0.42
0.06 0.61 0.26 0.03 0.31 0.92 0.83 0.68 0.32
16.20 0.38 10.50 1.59 1.68 0.62 22.12 8.33 86.22 34.57 1.35 0.93 10.40 3.61 73.84 61.93 1.25 0.08
15.17 0.31 11.83 0.61 9.83 5.34 40.89 7.92 312 293 0.21 0.04 6.11 1.44 13.38 7.27 1.72 0.18
0.06 0.93 0.89 0.07 0.08 0.32 0.76 0.56 0.02
Mean CRP Mean ESR Mean SAA At the time of sperm analysis Mean CRP Mean ESR Mean SAA Mean colchicine dose at the time of sperm analysis (mg/day) Mean colchicine usage time (months) 4.26 3.56 5.12 4.32 0.69 4.56 4.014 4.99 3.62 0.14 4.13 3.744. 5.25 4.165. 0.09 Mean cumulative colchicine dose (mg) 2462.64 392.18 1350.00 300.50 0.56 2447.33 436.84 1963.75 533.65 0.45 1825.71 316.03 2648.75 529.72 0.49 FMF, familial Mediterranean fever; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; SAA, serum amyloid A. The bold font used to highlight p values.
G. Kaya Aksoy et al.
Normal (>15 million) (n Z 17)
Semen analysis in adolescents
342.e6
Table 5 Evaluation of risk factors for decreased motility in children with FMF by multivariate logistic regression analysis (n Z 19). Variable
P
OR
95% CI
Presence of FMF attack under treatment Mean ESR (mm/h) Mean cumulative colchicine dose (mg) MEFV mutation (homozygous)
0.031
0.076
0.005e0.648
0.692 0.610
0.970 1.000
0.803e1.113 0.999e1.001
0.998
0.001
0.002e6234
FMF, familial Mediterranean fever; OR, odds ratio; CI, confidence interval.
responsible for the inflammatory response associated with FMF [19]. Dobrakowski et al. [20] evaluated the effect of the total oxidative stress on the sperm quality and showed that IL-1b, IL-10, and IL-12 were associated with high oxidative stress and suggested that this may have had negative effects on sperm quality. There is a considerable amount of studies evaluating the effects of systemic inflammation on male fertility [21e23]. When the sperm parameters of 52 patients with inflammatory bowel disease were examined, it was observed that these patients had worse sperm quality than the control group. The authors particularly emphasized that TNF-a production in the testicles might be responsible for the increase in its levels in patients with inflammatory diseases [21]. Likewise, the sperm count and motility of the untreated male patients diagnosed with psoriasis were determined to be low compared with the control group [22]. For Behc ¸et’s disease, fertility may be affected both by the resulting inflammatory process and reasons such as genital aphthous ulcers and epididymitis [23]. In the study, it was determined that higher colchicine dose decreased sperm motility. In a study by Sarıca et al., which evaluated the causes of infertility in patients with Behc ¸et’s disease, it was suggested that colchicine used for the treatment was as effective as inflammation, genital ulcer, and epididymitis [23]. Ben-Chetrit et al. [24] determined that the sperm motility was dependent on microtubule movement; thus, it was considered that colchicine treatment would adversely affect sperm motility (depending on duration with treatment and dosage). However, in studies evaluating the adverse effects of colchicine treatment on sperm, no conclusive evidence has been shown in regard to whether the treatment or the primary disease was the primary reason for the deterioration in sperm parameters in diseases characterized with inflammatory activity, such as FMF or Behc ¸et’s disease [10]. However, one particular study has reported that colchicine treatment does not have any impact on sperm quality [25]. This study has some limitations. First of all, the number of patients with sperm analysis was low, and also the authors did not have a control group comprising healthy patients with similar ages. Also, serum luteinizing hormone, follicle-stimulating hormone, and testosterone levels were not evaluated synchronously with the sperm analysis. In addition, no testicle biopsy was conducted to determine
the presence of testicle amyloid deposition in the patients with low sperm count and motility. However, the duration of disease was rather low in all patients, and therefore, the authors believe that the patients would not have had significant amyloid deposition which could cause sperm abnormalities. The authors conclude that sperm abnormalities in male patients with FMF are not infrequent and may be linked to both inflammation due to uncontrolled disease and colchicine therapy. The authors suggest that physicians should take care to optimal colchicine dose by applying the minimum dose required to prevent clinical and subclinical inflammation. Further studies with higher numbers of patients including a control group would be beneficial to clarify this subject.
Author statements Ethical approval Ethics committee approval was received from Akdeniz University Medical Faculty for this study (6.3.2019/231).
Funding None declared.
Competing interests None declared.
References [1] Sarı I, Birlik M, Kasifoglu T. Familial Mediterranean fever: an updated review. Eur J Rheumatol 2014;1(1):21e33. [2] Gangemi S, Manti S, Procopio V, Casciaro M, Di Salvo E, Cutrupi M, et al. Lack of clear and univocal genotypephenotype correlation in familial Mediterranean fever patients: a systematic review. Clin Genet 2018;94(1):81e94. [3] Cronstein BN, Molad Y, Reibman J, Balakhane E, Levin RI, Weissmann G. Colchicine alters the quantitative qualitative display of selectins on endothelial cells and neutrophils. J Clin Investig 1995;96(2):994e1002. [4] Marques- Da Silva C, Chaves MM, Castro NG, Coutinho-Silva R, Guimaraes MZP. Colchicine inhibits cationic dye uptake induces by ATP in P2X2 and P2X7 receptor-expressing cell: implications for its therapeutic action. Br J Pharmacol 2011; 163(5):912e26. [5] Jayaprakash V, Ansell G, Galler D. Colchicine overdose: the devil is in the detail. N Z Med J 2007;120(1248):U2402. ¨ zen S, Batu ED, Demir S. Familial Mediterranean fever: [6] O recent developments in pathogenesis and new recommendations for management. Front _Immunol 2017;8:253. [7] Merlin HE. Azoospermia caused by colchicine-A case report. Fertil Steril 1972;23(3):180e1. [8] Ben-Chetrit E, Backenroth R, Haimov-Kochman R, Pizov G. Azoospermia in familial Mediterranean fever patients: the role of colchicines and amyloidosis. Ann Rheum Dis 1998;57(4): 259e60. [9] Haimov-Kochman R, Prus D, Ben-Chetrit E. Azoospermia due to testicular amyloidosis in a patient with familial Mediterranean fever. Hum Reprod 2001;16(6):1218e20.
342.e7 [10] Haimov-Kochman R, Ben-Chetrit E. The effect of colchicine treatment on sperm production and function: a review. Hum Reprod 1998;13(2):360e2. [11] Anonymous. Tel Hashomer criteria for the diagnosis of FMF. In: Sohar E, Gafni J, Pras M, editors. Familial Mediterranean fever. Proceedings of the 1st international congress on FMF (Jerusalem 1997). Freud: Tel Aviv; 1997. p. 207. ¨ zen S, O ¨ zc [12] Yalc ¸ınkaya F, O ¸akar ZB, Aktay N, C ¸ akar N, Du ¨zova A, et al. A new set of criteria for the diagnosis of familial Mediterranean fever in childhood. Rheumatology 2009;48(4): 395e8. [13] World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva, Switzerland: World Health Organization; 2011. [14] Barut K, Sahin S, Adrovic A, Sinoplu AB, Yucel G, Pamuk G, et al. Familial Mediterranean fever in childhood: a singlecenter experience. Rheumatol Int 2018;38(1):67e74. [15] Cooper TG, Noonan E, Eckardstein S, Auger J, Baker HW, Behre HM, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update 2010; 16(3):231e45. ¨ zcan AJ, Savan K. The impact of familial med[16] Yanmaz MN, O iterrenean fever on reproductive system. Clin Rheumatol 2014;33(10):1385e8. [17] Romette J, di Costanzo-Dufetel J, Charrel M. Inflammatory syndrome and changes in plasma proteins. Pathol Biol (Paris) 1986;34(9):1006e12. [18] Nynca J, Dietrich MA, Ademek M, Steinhagen D, Bilinska B, Hejmej A, et al. Purification, characterization and expression of transferrin from rainbow trout seminal plasma. Comp Biochem Physiol B Biochem Mol Biol 2017;208e209: 39e46.
G. Kaya Aksoy et al. [19] Ben-Chetrit E, Levy M. Reproductive system in familial Mediterranean fever: an overview. Ann Rheum Dis 2003;62(10): 916e9. [20] Dobrakowski M, Kasperczyk S, Horak S, Chyra-Jach D, Birkner E, Kasperczyk A. Oxidative stress and motility impairment in the semen of fertile males. Andrologia 2017; 49(10). https://doi.org/10.1111/and.12783 [Epub ahead of print]. [21] Valer P, Algaba A, Santos D, Fuentes ME, Nieto E, Gisbert JP, et al. Evaluation of the quality of semen and sexual function in men with inflammatory bowel disease. Inflamm Bowel Dis 2017;23(7):1144e53. [22] Caldarola G, Milardi D, Grande G, Quercia A, Baroni S, Morelli R, et al. Untreated psoriasis impairs male fertility: a case-control study. Dermatology 2017;233(2e3):170e4. [23] Sarica K, Su ¸el C. ¨zer O, Gu ¨rler A, Baltaci S, Ozdiler E, Dinc Urological evaluation of Behc ¸et patients and the effect of colchicine on fertility. Eur Urol 1995;27(1):39e42. [24] Ben-Chetrit A, Ben-Chetrit E, Nitzan R, Rom M. Colchicine inhibits spermatozoal motility in vitro. Int J Fertil Menopausal Stud 1993;38(5):301e4. [25] Both T, van Laar JA, Bonte-Mineur F, van Hagen PM, van Daele PL. Colchicine has no negative effect on fertility and pregnancy. Ned Tijdschr Geneeskd 2012;156(12):A4196.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpurol.2019.04.001.
Semen analysis in adolescents with familial Mediterranean fever G. Kaya Aksoy a,*, M. Koyun a, M.F. Usta b, E. C ¸ omak a, S. Akman a a
Akdeniz University, School of Medicine, Department of Pediatric Nephrology, Antalya, Turkey
b Akdeniz University, School of Medicine, Department of Urology, Antalya, Turkey
* Corresponding author. Tel.: þ90 242 249 6000/6523; fax: þ90 242 227 4320. [email protected] (G. Kaya Aksoy) Keywords Familial Mediterranean fever; Sperm; Infertility; Adolescent; Semen abnormality
Abbreviations AUC, Area under the curve; CRP, C-reactive protein; ESR, Erythrocyte sedimentation rate; FMF, Familial Mediterranean Fever; FSH, Follicle stimulating hormone; LH, Luteinizing hormone; MEFV, Familial Mediterranean Fever gene; SAA, Serum amyloid A
Summary Background Little is known about sperm health in male patients with familial Mediterranean fever (FMF). In this study, the authors aimed to search the frequency of sperm abnormalities of adolescent boys with FMF and also to investigate whether disease activity or colchicine treatment have negative effects on sperm parameters. Method The male adolescents older than 14 years with a diagnosis of FMF were investigated retrospectively. Tel Hashomer and pediatric FMF clinical criteria were used for diagnosis of FMF. Patients who had semen analysis were included in the study. Result Mean age at the diagnosis was 11.13 3.82 years, and mean age at the study was 14.50 0.70 years. The mean sperm concentration was found as 66.26 41.02 million/ml (N > 15 million/ml), the mean total sperm count 113.42 132.39 million
(N > 39 million), and the mean sperm motility 51.78 23.70% (N > 40%). Only 8 of 19 (42.1%) patients had normal sperm parameters. Sperm concentration was reduced in two cases, total sperm count was reduced in four patients, and motility was reduced in nine cases. The presence of FMF attacks under treatment was found to be a risk factor for decreased motility in the study group by multivariate regression analysis (odds ratio 0.076, [95% confidence interval 0.005e0.648], P Z 0.031). Erythrocyte sedimentation rate at the time of diagnosis was high in patients with low sperm counts compared with those with normal sperm counts (56.00 8.51 vs 24.35 6.32, P: 0.03). Mean colchicine dose at the time of sperm analysis was higher in patients with low sperm motility than that with normal sperm motility (1.72 0.18 vs 1.25 0.08, P: 0.02).
Conclusion Sperm abnormalities of male patients with FMF is not infrequent, and it is linked to both inflammation due to uncontrolled disease and colchicine therapy.
Received 12 October 2018 Revised 25 March 2019 Accepted 1 April 2019 Available online 5 April 2019
Table The laboratory finding and colchicine dose of FMF patients with normal and abnormal semen parameters (n Z 19) Variable
Sperm concentrationa
Mean CRP Mean ESR Mean SAA Mean colchicine dose (mg/day)
0.12 2.50 7.28 1.50
Normal
0.02 0.50 4.42 1.21
Total sperm countb
Motilityc
Low
P
Normal
Low
P
Normal
Low
P
0.89 0.55 9.06 2.21 49.66 35.53 1.25 0.25
0.28 0.36 0.50 0.46
0.95 0.63 9.27 2.50 51.06 41.45 1.37 0.77
0.27 0.09 5.00 1.78 23.22 16.01 1.88 0.42
0.92 0.83 0.68 0.32
1.35 0.93 10.40 3.61 73.84 61.93 1.25 0.08
0.21 0.04 6.11 1.44 13.38 7.27 1.72 0.18
0.32 0.76 0.56 0.02
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; SAA, serum amyloid A. a Normal sperm concentration >15 million. b Normal total count >39 million. c Normal motility rate >40%. https://doi.org/10.1016/j.jpurol.2019.04.001 1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Semen analysis in adolescents
Introduction Familial Mediterranean fever (FMF), the most common monogenic autoinflammatory disease, is an autosomal recessively inherited disease seen most frequently in countries bordering the Mediterranean sea. Mutations and deletions in the MEFV gene (16p13.3), which encodes the protein pyrin, are responsible for the disease in a great majority of patients [1]. The disease is characterized with self-limiting inflammatory episodes (called ‘attacks’), amyloid deposition in tissues, and also the subsequent damage sustained by many different tissues and organs in the body [2]. Thus, reducing the number of attacks and preventing the development of tissue damage are very important in the management of patients with FMF. Colchicine, owing to its anti-inflammatory properties, is used as the first-line treatment in patients with FMF. Colchicine interacts with tubulin and prevents microtubule polymerization, thus causing antimitotic effects. It also decreases expression of adhesion molecules (E-selectin and L-selectin) in membranes and inhibits neutrophil chemotaxis [3]. In addition, it has been shown to inhibit pore formation which is required for caspase-1 maturation and IL-1b release being P2X group purinergic receptors [4]. The most frequently observed side-effect of colchicine is on the gastrointestinal system, and this side-effect is observed in around 10% of patients within the first month of treatment with colchicine [5]. Other side-effects such as vitamin B12 deficiency, myopathy, reversible peripheral neuritis, bone marrow suppression, and alopecia are observed less often [6]. Azoospermia was first reported in a male patient with FMF in 1972 [7]. Several studies have associated azoospermia with amyloid deposition in the testicular tissue of patients with FMF [8,9], whereas others have suggested that it was related to colchicine therapy [10], which is reportedly due to the antimitotic properties of colchicine [3]. These findings suggest that both inadequate treatment and overtreatment of FMF could have negative effects on sperm development. This issue has attracted attention because of the fact that it is a subject that has been rarely researched, and to the authors’ knowledge, there has been no study of this effect in the pediatric age group. Therefore, in this study, the aim was to investigate the frequency of sperm abnormalities in adolescent boys with FMF and also to investigate whether disease activity or colchicine treatment was associated with the alterations in sperm parameters.
342.e2 provided informed consent for the study. Ethics committee approval was received from Akdeniz University Medical Faculty for this study (6.3.2019/231). The diagnosis of FMF was made according to Tel Hashomer diagnosis criteria for patients who applied before April 2009 and to the Turkish FMF pediatric diagnosis criteria after April 2009 [11,12]. The diagnoses of patients who were initially diagnosed with the Tel Hashomer criteria were reevaluated with the Turkish FMF pediatric diagnosis criteria. Those who did not fulfill the second criteria were excluded from the study. Demographic data, complaints at the time of application, MEFV mutation types, colchicine dose, and patients’ number of attacks within the 3 months before sperm analysis were recorded. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and serum amyloid A (SAA) values were recorded at the time of admission, at attack onset, and during sperm analysis. Hemoglobin analysis was performed regularly every 3 months. Anemia was defined using World Health Organization (WHO) standards for age [13]. Peripheral venous blood was used for MEFV mutation analyses; DNA extraction was performed from lymphocytes with the standard methods, and all patients were scanned for exon 2 and 10 mutations of the MEFV gene. The starting dose of colchicine was 0.5 mg/day under the age of 5, 1 mg/day for children aged 5e10 years, and 1.5 mg/day for children older than 10 years. The dose was increased when required up to a maximum of 1.5 mg/day in children aged 5e10 years and 2 mg/day in children older than 10 years [14]. Sperm analysis was performed as per the methods outlined by the fifth edition of WHO laboratory manual for the examination and processing of human semen. Samples were obtained by masturbation in a private room at the andrology laboratory after at least 3 days of abstinence, and the ejaculate was placed in a clean, wide-mouthed, non-toxic plastic container. The semen was incubated in an incubator at 37 C to be liquefied. Macroscopic examination of semen was initiated immediately after liquefaction or within 30 min to 1 h after ejaculation. Color, viscosity, volume, and pH were evaluated with macroscopic examination, and total sperm count, motility, viability, and morphology were analyzed via microscopic examination. Microscopic examination was performed at 37 C using a 22 22 lamella, providing a depth of 20 mm. Normal values were defined as total sperm count >39 million, sperm concentration >15 million/ml, and total motility >40% [15].
Statistical analysis
Method The medical records of male adolescents older than 14 years with a diagnosis of FMF who were followed up at the institution between January 2015 and December 2017 were retrospectively reviewed. Patients who underwent sperm analysis during their follow-up and patients with a puberty stage above Tanner stage 5 and testicular volume greater than 4 ml were included in the study. Patients who did not agree to participate in the study and those with missing medical data were excluded from the study. Also patients with a history of testicular torsion and orchitis were excluded from the study. All patients and their families
Descriptive statistics were presented as frequency, percentage, mean, standard deviation, median, minimum, and maximum values. Shapiro Wilks test, histogram, and QeQ graphics was used for evaluation of normality of distribution. The Fisher’s exact test or Pearson Chi-squared test was used in the analysis of the relationships between categorical variables. For the comparison of continuous variables, the Students t-test was used with normal distribution, whereas the ManneWhitney U test was used in the contrary case. To assess diagnostic value of ESR, the authors plotted receiver operating characteristic curve and computed area under the curve (AUC). Multiple logistic
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G. Kaya Aksoy et al.
regression analysis was performed to define risk factors, and odds ratio (OR) and 95% confidence intervals (CIs) were calculated in multiple logistic regression analysis for the assessment of risk factors. Statistical analyses were performed by using the SPSS 21.0 packaged program for Windows. P values < 0.05 were accepted to show statistical significance.
Results Characteristics of the study cohort Medical records were obtained from 72 male patients with FMF diagnosis older than 14 years. During the follow-up period, 21 of these patients were planned to perform sperm analysis. However, two patients could not be evaluated because the patient’s consent could not be obtained. Nineteen male adolescents were included in the study. The mean age of the patients was 14.50 0.70, mean age at the time of diagnosis was 11.13 3.82, and median follow-up time was 3.12 (range from 1.08 to 14.58 years) years. Eight of the 19 patients had homozygous MEFV gene mutation, 7 had compound heterozygous MEFV gene mutation, one had heterozygous MEFV gene mutation, and 3 patients had no mutations. At the time of diagnosis, fever was present in 15 patients (78.9%), abdominal pain in 14 (73.7%), and arthralgia in 7 (36.8%) (Table 1).
Table 1 Demographic and clinical characteristics of the patients with FMF (n Z 19). Mean age (years) Mean age at diagnosis (years) Median follow-up time (years) MEFV mutation (%) Homozygous (%) M694V M680I V726A R202Q Compound heterozygous (%) M694V/V726A M694V/E230K M694V/R202Q E148Q/M680I M680I/V726A M680I/R202Q Heterozygous M680I/N Complaint at application Fever (%) Abdominal pain (%) Arthralgia (%) Median time between beginning of clinical findings and diagnosis (months) Mean colchicine starting dose (mg/day) Mean colchicine dose at the time of sampling (mg/day) FMF, familial Mediterranean fever.
14.50 0.70 11.13 3.82 3.12 (1.08e14.58) 16 (84) 8 (42) 5 (26) 1 (5) 1 (5) 1 (5) 7 (36) 2 (10) 1 (5) 1 (5) 1 (5) 1 (5) 1 (5) 1 (5) 1 (5) 15 (79) 14 (73) 7 (37) 2.45 (0.58e9.18) 1.16 1.47
The median time between the initial clinical findings and diagnosis was 2.45 (range from 0.58 to 9.18) months. The mean starting dose of colchicine was 1.16 mg/day, and the mean colchicine dose used at the time of spermogram sampling was 1.47 mg/day. Colchicine dose was increased in 9 patients (47.7%) who had attacks under treatment, 4 of whom had 3 attacks and the remaining 5 had 2 attacks. Six of 9 patients had attacks within the first 6 months of therapy, whereas 3 had attacks between 6 and 10 months. The median time between the last attack and the sperm sampling in these 9 patients is 2.6 years (range from 2.20 to 3.06 years). None of the patients were colchicine resistant.
Evaluation of sperm analysis results The mean sperm concentration was 66.26 41.02 million/ ml (Normal: >15 million/ml), mean total sperm count was 113.42 132.39 million (Normal: >39 million), and mean sperm motility was 51.78 23.70% (Normal: >40%). No significant relationship was determined between complaint at application and MEFV gene mutation with any of these parameters (mean sperm concentration, count and motility). Also, M694V mutation was not significantly associated with semen parameters (Table 2). However, mean total sperm count and motility, but not sperm concentration, of the patients who had attack under colchicine treatment were lower that those of attack-free patients (81.44 40.31 vs 142.20 44.85, P: 0.034 and 40.56 4.81 vs 61.90 8.35, P: 0.020) (Table 2). All sperm parameters were at normal levels in only 8 of the 19 boys included in the study (42.1%). Low sperm concentration was observed in 2 patients (10.5%), low total sperm count was observed in 4 (21%), and decrease in sperm motility was observed in 9 patients (47.3%). Four patients had abnormalities in two of the three sperm parameters, whereas none had abnormalities in all three sperm parameters. The demographic and clinical characteristics of patients with sperm abnormality are presented on Table 3. Table 4 presents the demographic and clinical characteristics of patients with normal and abnormal semen parameters. The mean age at the time of sperm analysis and at diagnosis was similar between patients with normal and abnormal semen parameters. It was found that ESR values were higher at the time of diagnosis and in the attack-free period in patients with low total sperm counts compared with that of those with normal total sperm counts (56.00 8.51 vs 24.35 6.32, P: 0.03), whereas CRP and SAA levels were similar (Table 4). Anemia was investigated because it may be a cause of elevated ESR. Hemoglobin (Hg) values were found to be lower than age-specific reference ranges in two of the patients, but the sedimentation values of these two patients were not increased (Hg values 10.3 and 10.9 gr/dl). When the ESR distribution graph was evaluated, the ESR cutoff value for patients with oligospermia was found to be 30 mm/h with a sensitivity of 100.0% and specificity of 73.3% (AUC 0.858, P: 0.032).
Effect of colchicine treatment It was found that the mean colchicine dose at the time of sperm analysis was higher in patients with low sperm
Semen analysis in adolescents
342.e4
Table 2 Comparison of clinical characteristics, MEFV gene mutations, and attack presence of FMF patients according to sperm characteristics (n Z 19). Variable - values Fever
Abdominal pain
Arthralgia
MEFV mutation
M694V mutation
Presence of attack under colchicine treatment
Sperm concentration Yes No p Yes No p Yes No p Homozygous and compound heterozygous (n Z 15) Heterozygous mutation and without mutation (n Z 4) p Yes (n Z 9) No (n Z 10) p Yes (n Z 9) No (n Z 10) p
Total sperm count
Motility
85.02 23.37 220.00 109.23 0.76 85.02 26.62 193.10 87.71 0.22 140.71 66.76 97.50 30.16 0.35 91.33 9.52
53.32 47.25 0.48 49.71 57.60 0.45 58.52 48.17 0.44 36.67
74.67 23.67
128.47 37.70
52.60 6.23
0.85 71.32 79.12 0.26 58.00 73.70 0.46
0.93 86.32 10.54 115.36 41.65 0.86 81.44 40.31 142.20 44.85 0.034
0.26 39.84 49.35 0.98 40.56 61.90 0.020
67.40 62.00 0.84 60.36 82.80 0.35 56.29 72.08 0.33 68.27
11.39 15.59 10.15 21.99 16.69 11.50 10.60
10.28 23.67 10.14 15.53
5.97 14.49 6.65 9.55 8.14 7.23 5.20
6.15 5.48 4.81 8.35
FMF, familial Mediterranean fever. Bold font indicates the p values.
motility than in those with normal sperm motility (1.72 0.18 vs 1.25 0.08, P: 0.02) (Table 3). This relationship was not detected for total sperm count and concentration. Mean colchicine use time was determined to be 4.68 3.94 months, and the mean cumulative colchicine dose was calculated as 1375.10 275.50 mg. No relationship was found between any of the semen parameters and mean colchicine use time or mean cumulative colchicine dose.
Analysis of risk factors The risk factors for decreased sperm motility in FMF patients were analyzed by multiple logistic regression analysis (Table 5). The presence of FMF attacks under treatment was found to be a risk factor for decreased motility in the study group by multivariate regression analysis (OR 0.076 [95% CI 0.005e0.648], P Z 0.031). However, no risk factor affecting sperm concentration or count was detected with logistic regression analysis.
Discussion In this study, the authors have found that more than half of the adolescent patients with FMF had abnormal semen parameters (mostly low sperm motility). There is little data regarding the frequency of infertility and sperm health in male patients with FMF, and as far as the authors know, this is the first study evaluating spermogram findings of adolescent boys with FMF. Abnormal semen parameters have been reported as a rare complication of FMF [16]. In the study, both total sperm count and motility were low in patients who had attack while under colchicine
treatment; furthermore, they were found to have higher inflammation activity and had undergone a significant increase in colchicine dose. On the other hand, it was found that ESR, an indicator of inflammation, was high in patients with low total sperm counts, whereas mean colchicine dose was higher in patients with low sperm motility. In the literature, the relationship between high ESR and elevation of inflammatory plasma proteins has been shown [17]. Some proteins, such as transferrin, have been shown to be increased in the testicle during inflammation [18]. However, from the results, the authors can only speculate that higher levels of ESR without elevations in CRP or SAA in patients with FMF may be a sign of local inflammation in the testicle which may be associated with the expression of testicular transferrin. However, the findings suggest that inflammation is linked to low sperm counts, whereas colchicine may be responsible for low sperm motility. In the literature, the azoospermia associated with FMF has been generally linked to the amyloid deposition in testicles [9]. Amyloid deposition has been suggested to disturb sperm transport by damaging intratesticular canaliculi which leads to obstructive azoospermia or directly disrupting sperm production via adverse effect on the seminiferous tubules [9]. Testicle biopsy was not performed in any of the study patients and accordingly the presence of testicle amyloid was not researched. Patients had normal SAA levels, did not have proteinuria, and the duration with diagnosis was below expected levels for amyloid development. For these reasons, the authors do not believe that the patients had amyloid deposition at a degree which would cause alterations in semen parameters. As is known, the inflammatory response occurring during FMF attacks is responsible for peritonitis, pleuritis, and/or arthritis. Particularly, mediators such as IL-1b are
Demographic and clinical characteristics of FMF patients with semen abnormality.
Patient no.
Age (year)
Age at diagnosis (year)
Symptoms at application
MEFV mutation
Presence of FMF attack under colchicine treatment
Cumulative colchicine dosage (mg)
Colchicine dose at the time of analysis (mg/day)
Sperm concentration (N > 15 million/ml)
Total sperm count (N > 39 million)
Motility (N>40%)
1 2 3
15.1 15.6 17.2
12.8 12.6 14.1
V726A/V726A M694V/M694V M680I/normal
Yes Yes No
1100 2190 1050
1.5 2 1
35 51 11
21 26 44
60 36 85
4
15.6
13.0
M694V/M694V
Yes
730
1
15
29
32
5 6 7 8 9 10 11
15.9 17.5 15.9 15.7 16.2 14.9 14.5
12.1 13.5 14.3 13.5 15.1 14.1 11.3
Abdominal pain and arthralgia Fever and abdominal pain Fever, abdominal pain and arthralgia Fever, abdominal pain and arthralgia Abdominal pain Fever and abdominal pain Arthralgia Fever and abdominal pain Fever and abdominal pain Fever and abdominal pain Fever and abdominal pain
M694V/V726A no mutation M694V/M694V No mutation R202Q/R202Q M694V/M694V M680I/M680I
Yes Yes No No Yes Yes Yes
1640 2190 3285 1095 548 560 1650
1.5 1.5 3 1.5 1.5 1.5 1.5
67 50 42 52 26 98 11
102 45 21 41 39 68 51
20 28 27 36 19 37 0
342.e5
Table 3
FMF, familial Mediterranean fever. Bold font used to highlight abnormal values.
Table 4
The demographic and clinical characteristics of FMF patients with normal and abnormal semen parameters (n Z 19).
Variable
Mean age (year) Mean age at diagnosis (year) At the time of diagnosis (at attack-free period)
Sperm concentration
Total sperm count
Motility
Low (<15 million) (n Z 2)
P
Normal (>39 million) (n Z 15)
Low (<39million) (n Z 4)
P
Normal (>40%) (n Z 10)
Low (<40%) (n Z 9)
P
15.74 0.27 10.97 0.96 1.10 0.99 24.25 10.12 173.90 123.20 0.12 0.02 2.50 0.50 7.28 4.42 1.50 1.21
15.50 1.50 12.50 1.50 5.82 2.80 31.84 6.67 387.62 286.65 0.89 0.55 9.06 2.21 49.66 35.53 1.25 0.25
0.67 0.68 0.77 0.79 0.51 0.28 0.36 0.50 0.46
15.97 0.31 10.77 1.09 3.89 2.61 24.35 6.32 72.38 31.43 0.95 0.63 9.27 2.50 51.06 41.45 1.37 0.77
14.75 0.25 12.50 0.64 12.37 7.18 56.00 8.51 467.50 432.50 0.27 0.09 5.00 1.78 23.22 16.01 1.88 0.42
0.06 0.61 0.26 0.03 0.31 0.92 0.83 0.68 0.32
16.20 0.38 10.50 1.59 1.68 0.62 22.12 8.33 86.22 34.57 1.35 0.93 10.40 3.61 73.84 61.93 1.25 0.08
15.17 0.31 11.83 0.61 9.83 5.34 40.89 7.92 312 293 0.21 0.04 6.11 1.44 13.38 7.27 1.72 0.18
0.06 0.93 0.89 0.07 0.08 0.32 0.76 0.56 0.02
Mean CRP Mean ESR Mean SAA At the time of sperm analysis Mean CRP Mean ESR Mean SAA Mean colchicine dose at the time of sperm analysis (mg/day) Mean colchicine usage time (months) 4.26 3.56 5.12 4.32 0.69 4.56 4.014 4.99 3.62 0.14 4.13 3.744. 5.25 4.165. 0.09 Mean cumulative colchicine dose (mg) 2462.64 392.18 1350.00 300.50 0.56 2447.33 436.84 1963.75 533.65 0.45 1825.71 316.03 2648.75 529.72 0.49 FMF, familial Mediterranean fever; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; SAA, serum amyloid A. The bold font used to highlight p values.
G. Kaya Aksoy et al.
Normal (>15 million) (n Z 17)
Semen analysis in adolescents
342.e6
Table 5 Evaluation of risk factors for decreased motility in children with FMF by multivariate logistic regression analysis (n Z 19). Variable
P
OR
95% CI
Presence of FMF attack under treatment Mean ESR (mm/h) Mean cumulative colchicine dose (mg) MEFV mutation (homozygous)
0.031
0.076
0.005e0.648
0.692 0.610
0.970 1.000
0.803e1.113 0.999e1.001
0.998
0.001
0.002e6234
FMF, familial Mediterranean fever; OR, odds ratio; CI, confidence interval.
responsible for the inflammatory response associated with FMF [19]. Dobrakowski et al. [20] evaluated the effect of the total oxidative stress on the sperm quality and showed that IL-1b, IL-10, and IL-12 were associated with high oxidative stress and suggested that this may have had negative effects on sperm quality. There is a considerable amount of studies evaluating the effects of systemic inflammation on male fertility [21e23]. When the sperm parameters of 52 patients with inflammatory bowel disease were examined, it was observed that these patients had worse sperm quality than the control group. The authors particularly emphasized that TNF-a production in the testicles might be responsible for the increase in its levels in patients with inflammatory diseases [21]. Likewise, the sperm count and motility of the untreated male patients diagnosed with psoriasis were determined to be low compared with the control group [22]. For Behc ¸et’s disease, fertility may be affected both by the resulting inflammatory process and reasons such as genital aphthous ulcers and epididymitis [23]. In the study, it was determined that higher colchicine dose decreased sperm motility. In a study by Sarıca et al., which evaluated the causes of infertility in patients with Behc ¸et’s disease, it was suggested that colchicine used for the treatment was as effective as inflammation, genital ulcer, and epididymitis [23]. Ben-Chetrit et al. [24] determined that the sperm motility was dependent on microtubule movement; thus, it was considered that colchicine treatment would adversely affect sperm motility (depending on duration with treatment and dosage). However, in studies evaluating the adverse effects of colchicine treatment on sperm, no conclusive evidence has been shown in regard to whether the treatment or the primary disease was the primary reason for the deterioration in sperm parameters in diseases characterized with inflammatory activity, such as FMF or Behc ¸et’s disease [10]. However, one particular study has reported that colchicine treatment does not have any impact on sperm quality [25]. This study has some limitations. First of all, the number of patients with sperm analysis was low, and also the authors did not have a control group comprising healthy patients with similar ages. Also, serum luteinizing hormone, follicle-stimulating hormone, and testosterone levels were not evaluated synchronously with the sperm analysis. In addition, no testicle biopsy was conducted to determine
the presence of testicle amyloid deposition in the patients with low sperm count and motility. However, the duration of disease was rather low in all patients, and therefore, the authors believe that the patients would not have had significant amyloid deposition which could cause sperm abnormalities. The authors conclude that sperm abnormalities in male patients with FMF are not infrequent and may be linked to both inflammation due to uncontrolled disease and colchicine therapy. The authors suggest that physicians should take care to optimal colchicine dose by applying the minimum dose required to prevent clinical and subclinical inflammation. Further studies with higher numbers of patients including a control group would be beneficial to clarify this subject.
Author statements Ethical approval Ethics committee approval was received from Akdeniz University Medical Faculty for this study (6.3.2019/231).
Funding None declared.
Competing interests None declared.
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Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpurol.2019.04.001.