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Coexistence of spermatozoa morphological abnormalities in the semen of subfertile men with varicocele
European Journal of Obstetrics & Gynecology and Reproductive Elsevier
EUROBS
175
B~olo~,, 31 (1990) 175-181
00985
Coexistence of spermatozoa morphological abnormalities in the semen of subfertile men with varicocele Dimitrios Panidis, David Rousso, Georgios Vlassis and Achilleas Kalogeropoulos Third Department
of Obstetrics and Gynaecology, Anstotehan Accepted
for publication
Umversrty of Thessalonrki, Greece
20 November
1989
Summary
Spermatozoal morphology in semen specimens from 107 subfertile men with varicocele, aged from 18 to 50 years, were evaluated from Papanicolaou-stained smears, in order to investigate: (a) the frequency of abnormalities in the neck and tail of spermatozoa with an abnormal head; and (b) the ability of prediction of the morphology of one sperm part when the morphology of another is known. It was found that: (1) Morphological abnormalities in the neck are significantly more frequent (p < 0.01) in spermatozoa with an abnormal head than in spermatozoa with a normal head. (2) Morphological abnormalities in the tail and cytoplasmic droplet are also more frequent, although not significantly, in spermatozoa with an abnormal head. (3) The proportional reduction in error (PRE) was low in all cases. Our results show that spermatozoa with abnormal heads present morphological abnormalities of their other parts more often than spermatozoa with normal heads. However, no prediction can ‘be made on the nature of the morphology of a part of a spermatozoon on the basis of knowledge of the morphology of another of its parts. Human
spermatozoa;
Spermatozoal
morphology
Introduction
In 1965, MacLeod was the first to announce detailed study about semen analysis in men with varicocele [17]. He suggested that vericocele is accompanied by spermatozoa number and motility decrease, but mainly by an increase in the
Correspondence:
Assist. Prof. Dimitrios
002%2243/90/$03.50
Panidis,
119 Mitropoleos
0 1990 Elsevier Science Publishers
Str., 546 22 Thessaloniki,
B.V. (Biomedical
Division)
Greece.
number of spermatozoa with abnormalities in the head, specifically those with a tapering and amorphous head. Spermatozoa morphology is considered to be one of the most important parameters in the evaluation of the potential fertility of a semen specimen [7,11,22,33]. Its importance is supported by the fact that a higher percentage of abnormal sperm forms is found in subfertile than in fertile men [16]. Furthermore, spermatozoa with an abnormal morphology present with motility disturbances [13], cannot easily penetrate the ovulatory cervical mucus [24] and the female genital system [14], and present a decreased fertilizing capacity of the zona-free hamster ova [14]. Moreover, morphology is the most significant sperm factor related to fertilization in vitro [15]. Finally, even if pregnancy is achieved by semen with a high proportion of morphological abnormal spermatozoa, spontaneous abortion rate is extremely high [21]. It is known that more than one abnormality may be encountered in the same spermatozoon. In such cases the spermatozoon is initially classified as abnormal in order to establish the percentage of normal and abnormal forms, and subsequently each abnormality is noticed separately, so that the percentage of each kind of abnormality may be established. This particular procedure is followed because it is the kind of abnormality and not the number of abnormal forms that is the more important for fertility [6]. During the evaluation of spermatozoa1 morphology, we observed that spermatozoa with abnormal heads demonstrate abnormalities in the neck or tail more frequently than do spermatozoa with normal heads. Since similar findings have not been reported in literature on this subject, this study on semen specimens of subfertile men with varicocele was undertaken with a view towards establishing: (1) the frequency of morphological abnormalities in the neck and tail of spermatozoa with abnormal or normal heads; and (2) the ability of prediction of the morphology of a sperm part when the morphology of another of its parts is known. Materials and Methods
Semen specimens taken from 107 men, aged from 18 to 50 years (mean 32.7 f 5.9 years), who attended the Fertility Center of our Department, were studied. These men had not achieved any pregnancies for more than a year (mean 4.3 f 3.4 years), despite the fact that their wives did not show any of the established causes of infertility. All men had complete development of the secondary sex characteristics, a mean testicular volume of 18.9 + 3.1 cm3 (range 11.5-26.0 cm3), and severe (32 men), moderate (36 men) or mild (39 mild) left lateral varicocele. Varicocele was defined as severe when it was palpable and visible without application of Valsalva manoeuvre, moderate when it was palpable, but visible only after the Valsalva manoeuvre was applied, and mild when a simple palpable vein existed which inflated after the Valsalva manoeuvre application. Two semen specimens were examined, from each individual, with a 6 to 8 week interval. The semen was collected by masturbation into sterilized glass containers after a 3 to 6 day abstinence. After evaluation of the liquefaction and measurement of viscosity and volume, motility was measured, at room temperature (22-25 o C), 1 h after ejaculation.
Sperm morphology was evaluated from Papanicolaou-stained smears and the classification of abnormal sperm forms was made according to the guide-lines of the W.H.O. [31]. One hundred spermatozoa were studied from each semen specimen, and all the smears were evaluated by the same individual. The percentage of motile spermatozoa was measured by the multiple-exposure photography (MEP) method [19,22], while the sperm concentration was determined in an undiluted semen specimen with the use of Makler’s Counting Chamber [20]. Results
Table I shows the mean value and range of single and multiple spermatozoa morphological abnormalities in semen specimens of 107 subfertile men with varicocele. As shown from this table, the most frequent single morphological abnormality concerned the head, followed by that of the neck, the tail, and the cytoplasmic droplet. The most frequent double abnormalities were those of the head and neck, followed by those of the head and tail and those of the head and cytoplasmic droplet. Finally, among the triple morphological abnormalities the most frequently encountered were those of the head, neck and cytoplasmic droplet, followed by those of the head, cytoplasmic droplet and tail, and those of the head, neck and tail. The frequency of morphological abnormalities of the neck, tail and cytoplasmic droplet, when the head was normal or abnormal, is presented in Table II. This Table shows that the frequency of morphological abnormalities, when the head was normal, was 6.0% for the neck, 1.0% for the cytoplasmic droplet and 3.1% for the tail. The respective values, when the head was abnormal, were 40.1% 13.6% and 12.0%. Statistical analysis (x2 with Yate’s correction) showed that morphological abnormalities in the neck were significantly higher (p < 0.01) when the head was
TABLE
I
The percentage Abnormal
of single and multiple
sperm forms
abnormalities
of the spermatozoa Values % Mean f SD
Head Neck Cytoplasmic Tall
droplet
Head + neck Head + cytoplasmic Head + tail
droplet
Head + neck + cytoplasmic droplet Head + neck + tail Head + cytoplasmic droplet + tail Total
range
36.60 f 10.20 1.27+ 1.50 0.22* 1.11 0.66* 1.21
4-52 O-8 o-11 o-7
28.47 f 7.40* 8.75*
9.92 4.67 6.37
7-57 o-19 o-33
2.82+ 0.25+ 0.46+
3.17 0.55 0.87
o-15 o-2 O-6
80.90+11.00
52-100
178 TABLE II The percentage of coexisting morphological abnormalities when the head was normal or abnormal Head
Neck (W
Cytoplasmic droplet (W
Tail (W
1. Normal 2. Abnormal
6.0 40.1
1.0 13.6
3.1 12.0
TABLE III Statistical evaluation of relation between morphological abnormalities in the head and the other parts of the spermatozoon Abnormal head
X2
P
1. Abnormal neck 2. Abnormal cytoplasmic droplet 3. Abnormal tail
7.34 1.57 0.64
< 0.01 > 0.05 > 0.05
abnormal, while there was no significant correlation between morphological abnormalities of the head and either the tail or cytoplasmic droplet (Table III). Goodman and Kurskal’s X factor (proportional reduction in error) was used for our data, which shows the ratio of reduction of error in predicting the values of one variable when the value of another variable is known. We evaluated, in other words, the predictability of morphological abnormalities in the neck, tail and cytoplasmic droplet, when the head was known morphology, and vice versa. The low value of h in all the cases supports the view that it is not possible to predict the morphology of a specific part of the spermatozoon based on the known morphology of another part. No correlation was found between the severity of varicocele and the frequency of the existence or coexistence of morphological abnormalities of the spermatozoa. The semen parameters of the 107 subfertile men that we studied are presented in Table IV. As can be seen from this Table, the main semen parameters for the subfertile men with varicocele (morphology, motility, number of spermatozoa) were
TABLE IV Semen parameters in 107 subfertile men with varicocele and in 114 fertile men Semen parameters
Subfertile men with varicocele (Values W)
Fertile men (Values I)
mean f SD
range
mean f SD
range
Liquefaction (min) Volume (ml) Number of spermatozoa (106/ml) Motile spermatozoa (W) Normal sperm forms (W)
20.8* 7.4 3.8ic 1.6 43.Ok42.3 37.5 f 19.2 19.1*11.0
10.0-45.0 0.7-9.0 1.5-264.0 0 -80.2 0 -48.0
22.4f 8.7 3.7* 1.5 72.0 f 61.6 56.6 -f 13.5 51.7 f 13.0
10.0-50.0 0.9-7.8 5.1-352.0 20.7-90.1 23.0-87.0
179
significantly lower (p -C0.001) than those for the fertile men [22], while the two above-mentioned groups had no significantly different secondary parameters (liquefaction, volume). It was noted that from the 107 men that were studied, the number of spermatozoa was < 20. 106/rnl in 32 men (30%), the motile spermatozoa < 40% in 52 men (49%) and the normal sperm forms -C40% in 105 men (98%). Discussion
It is generally admitted that varicocele constitutes the most frequent cause for male subfertility [4,10], although it has sometimes been disputed by some researchers [2,3,25,27,30]. This aspect is supported by the facts: (a) that varicocele appears more frequently in subfertile men [4,10,28]; (b) that a high percentage of men with varicocele (25-50%) present with abnormal sperm forms [12,18]; and (c) that semen quality improvement and increase of pregnancy achievement percentage resulted after surgical treatment of varicocele [1,2,5,10,25,26,29,30,32]. MacLeod was the first to announce a detailed study on semen analysis in men with varicocele [17]. He pointed out that 65% of the subfertile men with varicocele showed an abnormal number of spermatozoa, and that 90% showed abnormal morphology and motility. In our study the significantly higher percentage of men having spermatozoa with abnormal morphology and motility rather thau abnormal number shows that the two first parameters (morphology mainly) are more sensitive than the third with regard to the deleterious effect of varicocele. This finding is particularly significant, since it is known that morphology and motility are more important for fertilization than the number of spermatozoa [7,22,23]. The most interesting finding of our study, which has not been mentioned in the literature on this subject, was the significant rise in morphological abnormalities in the neck and the lesser rise in the ratio of morphological abnormalities in the tail and cytoplasmic droplet in spermatozoa with an abnormal head (Tables II and III). It is known that sperm-head morphology is developed in the testes, while the morphology of the neck and tail may be altered when the spermatozoa come in contact with seminal fluid [8]. Therefore, the morphological abnormalities of the neck and tail noted in spermatozoa with abnormal heads may have been caused by the testes or the seminal fluid. However, since the semen specimens were taken from potentially fertile men without any prostate or seminal vesicles disfunction, the above-mentioned abnormalities must be attributed to the testes. It has been pointed out that the kind of morphological abnormality rather than the number of abnormal sperm forms is the most important factor for the evaluation of male fertility potential [9]. There are indications supporting the view that sperm-head abnormalities to the extent of 40% are not accompanied by sterility, while the same percentage of neck or tail abnormalities does constitute a sterility factor [9]. Therefore, abnormalities of the neck or tail in spermatozoa are more important for fertilization than head abnormalities. In this light, the neck or tail abnormalities in spermatozoa with abnormal heads can be considered to be a factor in excluding spermatozoa from the process which begins in the male reproductive system and is taken up by the female reproductive system in which, as is known,
spermatozoa with abnormal morphology cannot easily penetrate the ovulatory cervical mucus [24]. In spite of the fact that spermatozoa with abnormal heads more frequently showed abnormalities of the neck or tail than spermatozoa with normal heads, the proportional reduction in error (PRE) was low. This shows that knowledge of the morphology of one part of the sperm does not help in predicting the morphology of another of its parts. References 1 Brown JS, Dubin L, Hot&kiss RS. The varicocele as related to fertility. Fertil Steril 1967;18:46-51. 2 Brown JS. Varicocelectomy in the subfertile male: a ten-years experience with 295 cases. Fertil Steril 1976;27:1046-1052. 3 Bsat FA, Masabni R. Effectiveness of varicocelectomy in varicoceles diagnosed by physical examination versus Doppler studies. Fertil Steril 1978; 50: 321-324. 4 Dubin L, Amelar RD. Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 1971; 22:469-478. 5 Dubin L, Amelar RD. Varicocelectomy as therapy in male infertility: a study of 504 cases. J Urol 1975;113:640-647. 6 Eliasson R. Analysis of semen. In: Hafez ESE, Evans TN, eds. Human reproduction, conception and contraception. New York: Harper and Row Publisher, 1973:39-44. 7 Eliasson R. Analysis of semen. In: Behrman SJ, Kistler RW, eds. Progress in infertility. Boston: Little Brown and Co., 1975. 8 Eliasson R, Lindholmer C. Function of male accessory genital organs. In: Hafez ESE, ed. Human semen and fertility regulation in men. St. Louis: The C.V. Mosby Company, 1976:44-50. 9 Eliasson R. Analysis of semen and cervical mucus. Xth world congress on fertility and sterility, Madrid, Spain, Male Course, 1980. 10 Greenberg SH, Lipshultz LI, Wein AJ. Experience with 425 subfertile male patients. J Urol 1988;119:507-512. 11 Homonnai ZT, Paz G, Weiss JN, David MP. Quality of semen obtained from 627 fertile men. Inter J Androl 1980;3:217-228. 12 Johnson D, Pohl D, Rivera-Correa H. Varicocele: an invecuous condition. South Med J 1970;63:34-40. 13 Katz DF, Die1 L, Overstreet JW. Difference in the movement of morphologically normal and abnormal human seminal spermatozoa. Biol Reprod 1982;26:566-570. 14 Krzanowska H. The passage of abnormal spermatozoa through the uterotubular junction of the mouse. J Reprod Fertil 1974;38:81-83. 15 Liu DY, Baker HWG. The proportion of human sperm with poor morphology but normal intact acrosomes detected with pisum sativum agglutinin correlates with fertilization in vitro. Fertil Steril 1988;50:288-293. 16 MacLeod J. Semen quality in one thousand men of known fertility and in eight hundred cases of infertile marriage. Fertil Steril 1951;2:115-119. 17 MacLeod J. Seminal cytology in the presence of varicocele. Fertil Steril 1965;16:735-757. 18 MacLeod J. Further observations on the role of varicocele in human male infertility. Fertil Steril 1969;20:545-548. 19 Makler A. A new multiple exposure photography method for objective spermatozoal motility determination. Fertil Steril 1978;30:192-199. 20 Makler A. The improved ten-micrometer chamber for rapid sperm count and motility evaluation. Fertil Steril 1980;33:337-338. 21 Oehninger S, Acosta AA, Morshedi M, Veek L, Swanson RJ, Simmons K, Rosenwaks Z. Corrective measures and pregnancy outcome in in vitro fertilization in patients with severe sperm morphology abnormalities. Fertil Steril 1988;50:283-287. 22 Panidis DK, Asseo PP, Papaloukas AC. Semen parameters in 114 fertile men. Eur J Obstet Gynecol Reprod Biol 1984;16:411-420.
181 23 Panidis D, Brozos G, Margaritis B, Vlassis G, Makedos G, Papaloukas A. The contributton of sperm morphology to the diagnostic approach of varicocele. Acta Endocrmol (Suppl) 1984;265:20-22. 24 Perry G, Glezerman M, Insler V. Selective filtration of abnormal spermatozoa by the cervical mucus m vitro. In: Hafez ESE, ed. Techmques of human andrology. Amsterdam, New York, Oxford: North-Holland Publishmg Company, 1977;265-280. 25 Rodriguez-Rigau LJ, Smint KD, Stemberger E. Relationship of varicocele to sperm output and fertility of male partners in infertile couples. J Urol 1978;120:691-695. 26 Rogers BJ, Van Campen H, Ueno M, Lanbert H, Bronson R, Hale R. Analysis of human spermatozoa1 fertility ability using zona-free ova. Fertil Steril 1979;32:664-669. 27 Rogers BJ, Mugatt GG, Soderdahl DW, Hale RW: Monitoring of suspected infertile men with varicocele by the sperm penetration assay. Fertil Steril 1985;44:800-804. 28 Russell JK. Varicocele in groups of fertile and subfertile males. Br Med J 1954;1:1231-1236. 29 Tulloch WS. A consideration of sterility factors in the light of subsequent pregnancies. II. Subfertihty m the male. Edinburgh Med J 1952;59:29-38. 30 Uehling DT. Fertility in men with varicocele. Int J Fertil 1968;13:58-63. 31 W.H.O. Laboratory manual for the examination of human semen and semen-cervical mucus interaction. In: Belsey MA, Eliasson R, Gallegos AJ. Moghissi KS, Paulsen CA, Prasad MRN, eds. Singapore: Press Concern, 1980:7-40. 32 Yanagimacm R, Yanagimachi H, Rogers BJ. The use of zona-free animal ova as a test system for the assessment of the fertilizmg capacity of human spermatozoa. Biol Reprod 1976;15:471-475. 33 Zukerman Z, Rodriguez-Rigau LJ, Srmth KD, Steinberger E. Frequency distribution of sperm counts in fertile and mfertile males. Fertil Steril 1977;28:1310-1313.
EUROBS
175
B~olo~,, 31 (1990) 175-181
00985
Coexistence of spermatozoa morphological abnormalities in the semen of subfertile men with varicocele Dimitrios Panidis, David Rousso, Georgios Vlassis and Achilleas Kalogeropoulos Third Department
of Obstetrics and Gynaecology, Anstotehan Accepted
for publication
Umversrty of Thessalonrki, Greece
20 November
1989
Summary
Spermatozoal morphology in semen specimens from 107 subfertile men with varicocele, aged from 18 to 50 years, were evaluated from Papanicolaou-stained smears, in order to investigate: (a) the frequency of abnormalities in the neck and tail of spermatozoa with an abnormal head; and (b) the ability of prediction of the morphology of one sperm part when the morphology of another is known. It was found that: (1) Morphological abnormalities in the neck are significantly more frequent (p < 0.01) in spermatozoa with an abnormal head than in spermatozoa with a normal head. (2) Morphological abnormalities in the tail and cytoplasmic droplet are also more frequent, although not significantly, in spermatozoa with an abnormal head. (3) The proportional reduction in error (PRE) was low in all cases. Our results show that spermatozoa with abnormal heads present morphological abnormalities of their other parts more often than spermatozoa with normal heads. However, no prediction can ‘be made on the nature of the morphology of a part of a spermatozoon on the basis of knowledge of the morphology of another of its parts. Human
spermatozoa;
Spermatozoal
morphology
Introduction
In 1965, MacLeod was the first to announce detailed study about semen analysis in men with varicocele [17]. He suggested that vericocele is accompanied by spermatozoa number and motility decrease, but mainly by an increase in the
Correspondence:
Assist. Prof. Dimitrios
002%2243/90/$03.50
Panidis,
119 Mitropoleos
0 1990 Elsevier Science Publishers
Str., 546 22 Thessaloniki,
B.V. (Biomedical
Division)
Greece.
number of spermatozoa with abnormalities in the head, specifically those with a tapering and amorphous head. Spermatozoa morphology is considered to be one of the most important parameters in the evaluation of the potential fertility of a semen specimen [7,11,22,33]. Its importance is supported by the fact that a higher percentage of abnormal sperm forms is found in subfertile than in fertile men [16]. Furthermore, spermatozoa with an abnormal morphology present with motility disturbances [13], cannot easily penetrate the ovulatory cervical mucus [24] and the female genital system [14], and present a decreased fertilizing capacity of the zona-free hamster ova [14]. Moreover, morphology is the most significant sperm factor related to fertilization in vitro [15]. Finally, even if pregnancy is achieved by semen with a high proportion of morphological abnormal spermatozoa, spontaneous abortion rate is extremely high [21]. It is known that more than one abnormality may be encountered in the same spermatozoon. In such cases the spermatozoon is initially classified as abnormal in order to establish the percentage of normal and abnormal forms, and subsequently each abnormality is noticed separately, so that the percentage of each kind of abnormality may be established. This particular procedure is followed because it is the kind of abnormality and not the number of abnormal forms that is the more important for fertility [6]. During the evaluation of spermatozoa1 morphology, we observed that spermatozoa with abnormal heads demonstrate abnormalities in the neck or tail more frequently than do spermatozoa with normal heads. Since similar findings have not been reported in literature on this subject, this study on semen specimens of subfertile men with varicocele was undertaken with a view towards establishing: (1) the frequency of morphological abnormalities in the neck and tail of spermatozoa with abnormal or normal heads; and (2) the ability of prediction of the morphology of a sperm part when the morphology of another of its parts is known. Materials and Methods
Semen specimens taken from 107 men, aged from 18 to 50 years (mean 32.7 f 5.9 years), who attended the Fertility Center of our Department, were studied. These men had not achieved any pregnancies for more than a year (mean 4.3 f 3.4 years), despite the fact that their wives did not show any of the established causes of infertility. All men had complete development of the secondary sex characteristics, a mean testicular volume of 18.9 + 3.1 cm3 (range 11.5-26.0 cm3), and severe (32 men), moderate (36 men) or mild (39 mild) left lateral varicocele. Varicocele was defined as severe when it was palpable and visible without application of Valsalva manoeuvre, moderate when it was palpable, but visible only after the Valsalva manoeuvre was applied, and mild when a simple palpable vein existed which inflated after the Valsalva manoeuvre application. Two semen specimens were examined, from each individual, with a 6 to 8 week interval. The semen was collected by masturbation into sterilized glass containers after a 3 to 6 day abstinence. After evaluation of the liquefaction and measurement of viscosity and volume, motility was measured, at room temperature (22-25 o C), 1 h after ejaculation.
Sperm morphology was evaluated from Papanicolaou-stained smears and the classification of abnormal sperm forms was made according to the guide-lines of the W.H.O. [31]. One hundred spermatozoa were studied from each semen specimen, and all the smears were evaluated by the same individual. The percentage of motile spermatozoa was measured by the multiple-exposure photography (MEP) method [19,22], while the sperm concentration was determined in an undiluted semen specimen with the use of Makler’s Counting Chamber [20]. Results
Table I shows the mean value and range of single and multiple spermatozoa morphological abnormalities in semen specimens of 107 subfertile men with varicocele. As shown from this table, the most frequent single morphological abnormality concerned the head, followed by that of the neck, the tail, and the cytoplasmic droplet. The most frequent double abnormalities were those of the head and neck, followed by those of the head and tail and those of the head and cytoplasmic droplet. Finally, among the triple morphological abnormalities the most frequently encountered were those of the head, neck and cytoplasmic droplet, followed by those of the head, cytoplasmic droplet and tail, and those of the head, neck and tail. The frequency of morphological abnormalities of the neck, tail and cytoplasmic droplet, when the head was normal or abnormal, is presented in Table II. This Table shows that the frequency of morphological abnormalities, when the head was normal, was 6.0% for the neck, 1.0% for the cytoplasmic droplet and 3.1% for the tail. The respective values, when the head was abnormal, were 40.1% 13.6% and 12.0%. Statistical analysis (x2 with Yate’s correction) showed that morphological abnormalities in the neck were significantly higher (p < 0.01) when the head was
TABLE
I
The percentage Abnormal
of single and multiple
sperm forms
abnormalities
of the spermatozoa Values % Mean f SD
Head Neck Cytoplasmic Tall
droplet
Head + neck Head + cytoplasmic Head + tail
droplet
Head + neck + cytoplasmic droplet Head + neck + tail Head + cytoplasmic droplet + tail Total
range
36.60 f 10.20 1.27+ 1.50 0.22* 1.11 0.66* 1.21
4-52 O-8 o-11 o-7
28.47 f 7.40* 8.75*
9.92 4.67 6.37
7-57 o-19 o-33
2.82+ 0.25+ 0.46+
3.17 0.55 0.87
o-15 o-2 O-6
80.90+11.00
52-100
178 TABLE II The percentage of coexisting morphological abnormalities when the head was normal or abnormal Head
Neck (W
Cytoplasmic droplet (W
Tail (W
1. Normal 2. Abnormal
6.0 40.1
1.0 13.6
3.1 12.0
TABLE III Statistical evaluation of relation between morphological abnormalities in the head and the other parts of the spermatozoon Abnormal head
X2
P
1. Abnormal neck 2. Abnormal cytoplasmic droplet 3. Abnormal tail
7.34 1.57 0.64
< 0.01 > 0.05 > 0.05
abnormal, while there was no significant correlation between morphological abnormalities of the head and either the tail or cytoplasmic droplet (Table III). Goodman and Kurskal’s X factor (proportional reduction in error) was used for our data, which shows the ratio of reduction of error in predicting the values of one variable when the value of another variable is known. We evaluated, in other words, the predictability of morphological abnormalities in the neck, tail and cytoplasmic droplet, when the head was known morphology, and vice versa. The low value of h in all the cases supports the view that it is not possible to predict the morphology of a specific part of the spermatozoon based on the known morphology of another part. No correlation was found between the severity of varicocele and the frequency of the existence or coexistence of morphological abnormalities of the spermatozoa. The semen parameters of the 107 subfertile men that we studied are presented in Table IV. As can be seen from this Table, the main semen parameters for the subfertile men with varicocele (morphology, motility, number of spermatozoa) were
TABLE IV Semen parameters in 107 subfertile men with varicocele and in 114 fertile men Semen parameters
Subfertile men with varicocele (Values W)
Fertile men (Values I)
mean f SD
range
mean f SD
range
Liquefaction (min) Volume (ml) Number of spermatozoa (106/ml) Motile spermatozoa (W) Normal sperm forms (W)
20.8* 7.4 3.8ic 1.6 43.Ok42.3 37.5 f 19.2 19.1*11.0
10.0-45.0 0.7-9.0 1.5-264.0 0 -80.2 0 -48.0
22.4f 8.7 3.7* 1.5 72.0 f 61.6 56.6 -f 13.5 51.7 f 13.0
10.0-50.0 0.9-7.8 5.1-352.0 20.7-90.1 23.0-87.0
179
significantly lower (p -C0.001) than those for the fertile men [22], while the two above-mentioned groups had no significantly different secondary parameters (liquefaction, volume). It was noted that from the 107 men that were studied, the number of spermatozoa was < 20. 106/rnl in 32 men (30%), the motile spermatozoa < 40% in 52 men (49%) and the normal sperm forms -C40% in 105 men (98%). Discussion
It is generally admitted that varicocele constitutes the most frequent cause for male subfertility [4,10], although it has sometimes been disputed by some researchers [2,3,25,27,30]. This aspect is supported by the facts: (a) that varicocele appears more frequently in subfertile men [4,10,28]; (b) that a high percentage of men with varicocele (25-50%) present with abnormal sperm forms [12,18]; and (c) that semen quality improvement and increase of pregnancy achievement percentage resulted after surgical treatment of varicocele [1,2,5,10,25,26,29,30,32]. MacLeod was the first to announce a detailed study on semen analysis in men with varicocele [17]. He pointed out that 65% of the subfertile men with varicocele showed an abnormal number of spermatozoa, and that 90% showed abnormal morphology and motility. In our study the significantly higher percentage of men having spermatozoa with abnormal morphology and motility rather thau abnormal number shows that the two first parameters (morphology mainly) are more sensitive than the third with regard to the deleterious effect of varicocele. This finding is particularly significant, since it is known that morphology and motility are more important for fertilization than the number of spermatozoa [7,22,23]. The most interesting finding of our study, which has not been mentioned in the literature on this subject, was the significant rise in morphological abnormalities in the neck and the lesser rise in the ratio of morphological abnormalities in the tail and cytoplasmic droplet in spermatozoa with an abnormal head (Tables II and III). It is known that sperm-head morphology is developed in the testes, while the morphology of the neck and tail may be altered when the spermatozoa come in contact with seminal fluid [8]. Therefore, the morphological abnormalities of the neck and tail noted in spermatozoa with abnormal heads may have been caused by the testes or the seminal fluid. However, since the semen specimens were taken from potentially fertile men without any prostate or seminal vesicles disfunction, the above-mentioned abnormalities must be attributed to the testes. It has been pointed out that the kind of morphological abnormality rather than the number of abnormal sperm forms is the most important factor for the evaluation of male fertility potential [9]. There are indications supporting the view that sperm-head abnormalities to the extent of 40% are not accompanied by sterility, while the same percentage of neck or tail abnormalities does constitute a sterility factor [9]. Therefore, abnormalities of the neck or tail in spermatozoa are more important for fertilization than head abnormalities. In this light, the neck or tail abnormalities in spermatozoa with abnormal heads can be considered to be a factor in excluding spermatozoa from the process which begins in the male reproductive system and is taken up by the female reproductive system in which, as is known,
spermatozoa with abnormal morphology cannot easily penetrate the ovulatory cervical mucus [24]. In spite of the fact that spermatozoa with abnormal heads more frequently showed abnormalities of the neck or tail than spermatozoa with normal heads, the proportional reduction in error (PRE) was low. This shows that knowledge of the morphology of one part of the sperm does not help in predicting the morphology of another of its parts. References 1 Brown JS, Dubin L, Hot&kiss RS. The varicocele as related to fertility. Fertil Steril 1967;18:46-51. 2 Brown JS. Varicocelectomy in the subfertile male: a ten-years experience with 295 cases. Fertil Steril 1976;27:1046-1052. 3 Bsat FA, Masabni R. Effectiveness of varicocelectomy in varicoceles diagnosed by physical examination versus Doppler studies. Fertil Steril 1978; 50: 321-324. 4 Dubin L, Amelar RD. Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 1971; 22:469-478. 5 Dubin L, Amelar RD. Varicocelectomy as therapy in male infertility: a study of 504 cases. J Urol 1975;113:640-647. 6 Eliasson R. Analysis of semen. In: Hafez ESE, Evans TN, eds. Human reproduction, conception and contraception. New York: Harper and Row Publisher, 1973:39-44. 7 Eliasson R. Analysis of semen. In: Behrman SJ, Kistler RW, eds. Progress in infertility. Boston: Little Brown and Co., 1975. 8 Eliasson R, Lindholmer C. Function of male accessory genital organs. In: Hafez ESE, ed. Human semen and fertility regulation in men. St. Louis: The C.V. Mosby Company, 1976:44-50. 9 Eliasson R. Analysis of semen and cervical mucus. Xth world congress on fertility and sterility, Madrid, Spain, Male Course, 1980. 10 Greenberg SH, Lipshultz LI, Wein AJ. Experience with 425 subfertile male patients. J Urol 1988;119:507-512. 11 Homonnai ZT, Paz G, Weiss JN, David MP. Quality of semen obtained from 627 fertile men. Inter J Androl 1980;3:217-228. 12 Johnson D, Pohl D, Rivera-Correa H. Varicocele: an invecuous condition. South Med J 1970;63:34-40. 13 Katz DF, Die1 L, Overstreet JW. Difference in the movement of morphologically normal and abnormal human seminal spermatozoa. Biol Reprod 1982;26:566-570. 14 Krzanowska H. The passage of abnormal spermatozoa through the uterotubular junction of the mouse. J Reprod Fertil 1974;38:81-83. 15 Liu DY, Baker HWG. The proportion of human sperm with poor morphology but normal intact acrosomes detected with pisum sativum agglutinin correlates with fertilization in vitro. Fertil Steril 1988;50:288-293. 16 MacLeod J. Semen quality in one thousand men of known fertility and in eight hundred cases of infertile marriage. Fertil Steril 1951;2:115-119. 17 MacLeod J. Seminal cytology in the presence of varicocele. Fertil Steril 1965;16:735-757. 18 MacLeod J. Further observations on the role of varicocele in human male infertility. Fertil Steril 1969;20:545-548. 19 Makler A. A new multiple exposure photography method for objective spermatozoal motility determination. Fertil Steril 1978;30:192-199. 20 Makler A. The improved ten-micrometer chamber for rapid sperm count and motility evaluation. Fertil Steril 1980;33:337-338. 21 Oehninger S, Acosta AA, Morshedi M, Veek L, Swanson RJ, Simmons K, Rosenwaks Z. Corrective measures and pregnancy outcome in in vitro fertilization in patients with severe sperm morphology abnormalities. Fertil Steril 1988;50:283-287. 22 Panidis DK, Asseo PP, Papaloukas AC. Semen parameters in 114 fertile men. Eur J Obstet Gynecol Reprod Biol 1984;16:411-420.
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