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Evaluation of Semen Parameters by Means of Automated Sperm Motion Analyzers
MALE INFERTILITY
extensive use in andrology laboratories around the world. At some infertility centers the sperm penetration assay is used to evaluate sperm function in couples with unexplained infertility and as a predictive test to determine the likelihood of human egg fertilization at the time of in vitro fertilization. At other centers it is used in the initial evaluation of men with subfertility. The authors suggest that this test should not be used routinely to evaluate infertile couples. They base their opinion on a review of the world literature and an evaluation of the reported sensitivity, specificity and predictive value of the test. To date there are major methodological differences among laboratories that make comparisons difficult. Moreover, major questions concerning the reproducibility of the assay remain. In a study by Rogers and associates 70 per cent of the men with proved fertility had at least 1 abnormal sperm penetration assay result at least once during the year they were tested. 1 In some studies as many as 30 per cent of fertile men will have penetration scores in the low range, Thus, the sperm penetration assay is not a fertility test. The predictive value of the test in determining in vitro fertilization success also is questionable, since the specificity of the test ranges from 0.51 to 1.00. As with any diagnostic test the clinician must ask how the results of this test would influence the management of the patient. In many cases the sperm penetration assay is performed without a clear-cut idea as to how the results of the test will be used. If the sperm penetration assay is positive the predictive value of the assay probably is sufficient to assume adequate sperm fertilization capability in couples with unexplained infertility or those who are considering in vitro fertilization. The predictive value of an abnormal sperm penetration assay, however, is limited and must be interpreted with caution. The sperm penetration assay is a valid attempt to provide a truly functional assay for sperm-egg interaction. Nevertheless, the test has major shortcomings that must be overcome through further research before it can be applied widely. Until then it may be a test in search of a diagnosis. John D. McConnell, M.D. 1. Rogers, B. J., Perreault, S. D., Bentwood, B. J., McCarville, C., Hale, R. W. and Soderdahl, D. W.: Variability in the human-hamster in vitro assay for fertility evaluation. Fertil. Steril., 39: 204, 1983.
Investigation of the Cause of Low Sperm Motility in Asthenozoospermic Patients by Multiple Quantitative Tests
C. H.
U. A. KNUTH AND E. NIESCHLAG, Max Planck Clinical Research Unit for Reproductive Medicine and Institute of Reproductive Medicine of the University, Munster, Federal Republic of Germany YEUNG, M. BALS-PRATSCH,
Int. J. Androl., 11: 289-299, 1988 Multiple tests were done on the ejaculates of 10 asthenozoospermic patients and nine healthy normozoospermic volunteers in an attempt to identify individually the cause of low sperm motility in these patients. Possible defects in the sperm plasma membrane and the motility apparatus of sperm, and in epididymal function affecting the development of motility, were
457
investigated. The presence of seminal sperm antibodies or any motility-inhibiting factors in the seminal plasma that could be removed by washing were also tested. Each test was positive in only one or two patients but axonemal dysfunction was identified in nine patients. Removal of seminal plasma from asthenozoospermic samples did not improve sperm motility to any greater extent than with donor ejaculates, and the motile sperm of these patients exhibited characteristics mostly similar to those of donors under various incubation conditions. Selection procedures are, therefore, required to obtain samples of good quality sperm from such asthenozoospermic ejaculates.
Editorial Comment: Asthenospermia is the most common single abnormality seen in patients who have single parameter defects on semen analysis. Despite the frequency of poor sperm motility in the subfertile male population, we have little insight into the basic mechanisms responsible. The authors analyzed 10 asthenospermic patients with a wide variety of laboratory studies. The most consistent abnormality seen in this group was an inability of sperm motility to be reactivated once the plasma membrane was removed with detergent and exogenous energy substrate added. This would indicate that at least in these 10 patients low sperm motility was due to primary abnormalities in the axoneme (the primary ultrastructural component in the sperm tail responsible for motility), rather than to defects in the plasma membrane or to abnormalities in energy generation within the sperm tail. Similar data were reported by Liu and associates. 1 If these findings are true in the larger group of subfertile men who have low sperm motility associated with decreased sperm density it is unlikely that exogenous manipulation of the sperm through washing and so forth will result in any truly significant improvement in sperm motility, since the primary defect would be at the level of the axoneme. John D. McConnell, M.D. 1. Liu, D. Y. I., Jennings, M.G. and Baker, H. W. G.:
Correlation between defective motility (asthenospermia) and ATP reactivation of demembranated human spermatozoa. Andrology, 8: 349, 1987. Evaluation of Semen Parameters by Means of Automated Sperm Motion Analyzers C. MAHONY, N. J. ALEXANDER AND R. J. SWANSON, Department of Obstetrics and Gynecology, Eastern Virginia Medical School and Department of Biological Sciences, Old Dominion University, Norfolk, Virginia
M.
Fertil. Steril., 49: 876-880, 1988 Fresh semen specimens from 46 patients and donors were evaluated for concentration, motility, velocity, and linearity using two different commercially available computerized sperm motion analyzer systems. Although no significant differences in measurement of concentration or motility were observed, significant differences in velocity and linearity were recorded. Fourteen cryopreserved/thawed samples were assessed with the same set-up parameters as fresh specimens. When discrepancies between manual and computer counts were noted, the authors changed the set-up parameters and evaluated 33 additional specimens. Again, no differences in concentration and motility, but significant differences in velocity and linearity were observed. Interlaboratory results must be correlated and
458
MALE INFERTILITY
standardization of set-up parameters of various analyzers is essential.
Comparison of Computerized Semen Analysis With the Conventional Procedure in 322 Patients
U. A. KNUTH AND E. NIESCHLAG, Max Planck Clinical Research Unit for Reproductive Medicine and Institute of Reproductive Medicine, University of Munster, Munster, Federal Republic of Germany Fertil. Steril., 49: 881-885, 1988 To compare the results of computerized image analysis for semen evaluation with classical semen analysis, semen samples from 322 consecutive patients attending our infertility clinic were studied. In men with sperm concentrations <20 X 106/ml, major discrepancies existed between both methods for sperm concentration. In many instances, debris could not be distinguished from normal sperm by the computerized system. This caused an overestimation of sperm concentration and led to a reduction of motility estimates. As a consequence, frequency distribution of motility, expressed as the percentage of motile sperm, differed to a major extent in both systems.
Editorial Comment: These 2 studies compare the measurement of sperm concentration and motility determined manually with that obtained by 2 commercially available automated semen analyzers. To date no commercial system is available that is entirely accurate over a large range of sperm densities and motilities. Problems exist with many of these systems in the accurate assessment of specimens that contain high sperm density or a substantial amount of debris. In addition, standards for automated semen evaluation systems have not been established by any scientific society. As a result, there are major methodological differences among laboratories in terms of the pre-evaluation handling of the semen specimens, as well as the parameter settings on the units themselves. No doubt the technical limitations of these machines will be resolved in the future. Thus, automated semen analysis will be of major benefit to laboratories processing large numbers of specimens. A question that remains is how computer-assisted analysis of sperm motility will aid the practicing physician in the care of the individual subfertile man. John D. McConnell, M.D. Effectiveness of Varicocelectomy in Varicoceles Diagnosed by Physical Examination Versus Doppler Studies
F. A.
BSAT AND R. MASABNI, Department of Obstetrics and Gynecology, and Department of Surgery, Urology Division, American University of Beirut Medical Center, Beirut, Lebanon
Fertil. Steril., 50: 321-323, 1988 The purpose of this study is to compare the effectiveness of varicocelectomy for improving the spermogram in treating varicoceles diagnosed by physical examination and those diagnosed by Doppler but with a negative physical examination. The charts of 112 patients were retrospectively analyzed and the patients divided in two groups: group A, where the varicocele was detected by physical examination, and group B, where
physical examination was negative but Doppler studies revealed the presence of stasis or backflow in the pampiniform plexus of the spermatic veins. In subjects complaining of infertility, the two groups were similar with regard to age distribution and duration of infertility. After varicocelectomy, 85% of patients in group A had improved spermogram, compared with only 27% in group B. This difference was statistically significant (P < 0.0001).
Editorial Comment: The repair of clinically palpable varicoceles usually results in improved semen quality, with a resultant increase in pregnancy rates. Although various methods have been recommended to aid in the diagnosis of varicocele, repair of varicoceles diagnosed by supplemental testing has not been rigorously proved to increase semen quality or pregnancy rates. In this study 85 per cent of the patients with clinically palpable varicoceles had improvement in the semen quality after varicocele repair. In contrast, only 27 per cent of the patients who had negative physical examinations but varicoceles apparent by Doppler studies had improvement in semen quality postoperatively. Indeed, the 27 per cent improvement in this latter group is well within the range seen in patients treated by placebo in various empirical drug studies of subfertile men. Although the clinical significance of varicoceles not apparent on physical examination is uncertain, it seems clear that physicians should not use the high success rates commonly cited in the varicocelectomy literature for palpable varicoceles when advising patients with nonpalpable varicoceles as to the advisability of spermatic vein ligation or embolization. John D. McConnell, M.D. Transepithelial Movement of 3 H-Androgen in Seminiferous and Epididymal Tubules: A Study Using In Vivo Micropuncture and In Vivo Microperifusion T. T. TURNER, Departments of Urology, and Anatomy and Cell Biology, University of Virginia School of Medicine, Charlottesville, Virginia Biol. Reprod., 39: 399-408, 1988 In vivo micropuncture and a new system of in vivo microperifusion were used to examine the movement of "R-androgen from blood to lumen and from interstitium to lumen in the rat testis and epididymis. Movement of "R-androgen into the seminiferous tubule lumen was restricted, with intraluminal isotope concentrations plateauing at approximately 15% of extratubular isotope concentrations whether the 3R-androgen originated in the vascular or interstitial compartments. In the caput epididymidis, intraluminal 3R-androgen plateaued at approximately 35% of serum concentrations, but when ;JR-androgens were presented directed to the basal aspect of the caput epididymidal epithelium, :iR-androgen was transported into the lumen against a concentration gradient. Intraluminal isotope concentrations were >200% of those in the epididymal interstitial compartment. Similar results were found for the cauda epididymids. Factors controlling the proluminal movement of 3 R-androgens in the rat testis and epididymis were therefore fundamentally different.
Editorial Comment: This elegant study in the rat provides new and important insight into the regulation of androgen levels in the testis and epididymis. An in vivo
extensive use in andrology laboratories around the world. At some infertility centers the sperm penetration assay is used to evaluate sperm function in couples with unexplained infertility and as a predictive test to determine the likelihood of human egg fertilization at the time of in vitro fertilization. At other centers it is used in the initial evaluation of men with subfertility. The authors suggest that this test should not be used routinely to evaluate infertile couples. They base their opinion on a review of the world literature and an evaluation of the reported sensitivity, specificity and predictive value of the test. To date there are major methodological differences among laboratories that make comparisons difficult. Moreover, major questions concerning the reproducibility of the assay remain. In a study by Rogers and associates 70 per cent of the men with proved fertility had at least 1 abnormal sperm penetration assay result at least once during the year they were tested. 1 In some studies as many as 30 per cent of fertile men will have penetration scores in the low range, Thus, the sperm penetration assay is not a fertility test. The predictive value of the test in determining in vitro fertilization success also is questionable, since the specificity of the test ranges from 0.51 to 1.00. As with any diagnostic test the clinician must ask how the results of this test would influence the management of the patient. In many cases the sperm penetration assay is performed without a clear-cut idea as to how the results of the test will be used. If the sperm penetration assay is positive the predictive value of the assay probably is sufficient to assume adequate sperm fertilization capability in couples with unexplained infertility or those who are considering in vitro fertilization. The predictive value of an abnormal sperm penetration assay, however, is limited and must be interpreted with caution. The sperm penetration assay is a valid attempt to provide a truly functional assay for sperm-egg interaction. Nevertheless, the test has major shortcomings that must be overcome through further research before it can be applied widely. Until then it may be a test in search of a diagnosis. John D. McConnell, M.D. 1. Rogers, B. J., Perreault, S. D., Bentwood, B. J., McCarville, C., Hale, R. W. and Soderdahl, D. W.: Variability in the human-hamster in vitro assay for fertility evaluation. Fertil. Steril., 39: 204, 1983.
Investigation of the Cause of Low Sperm Motility in Asthenozoospermic Patients by Multiple Quantitative Tests
C. H.
U. A. KNUTH AND E. NIESCHLAG, Max Planck Clinical Research Unit for Reproductive Medicine and Institute of Reproductive Medicine of the University, Munster, Federal Republic of Germany YEUNG, M. BALS-PRATSCH,
Int. J. Androl., 11: 289-299, 1988 Multiple tests were done on the ejaculates of 10 asthenozoospermic patients and nine healthy normozoospermic volunteers in an attempt to identify individually the cause of low sperm motility in these patients. Possible defects in the sperm plasma membrane and the motility apparatus of sperm, and in epididymal function affecting the development of motility, were
457
investigated. The presence of seminal sperm antibodies or any motility-inhibiting factors in the seminal plasma that could be removed by washing were also tested. Each test was positive in only one or two patients but axonemal dysfunction was identified in nine patients. Removal of seminal plasma from asthenozoospermic samples did not improve sperm motility to any greater extent than with donor ejaculates, and the motile sperm of these patients exhibited characteristics mostly similar to those of donors under various incubation conditions. Selection procedures are, therefore, required to obtain samples of good quality sperm from such asthenozoospermic ejaculates.
Editorial Comment: Asthenospermia is the most common single abnormality seen in patients who have single parameter defects on semen analysis. Despite the frequency of poor sperm motility in the subfertile male population, we have little insight into the basic mechanisms responsible. The authors analyzed 10 asthenospermic patients with a wide variety of laboratory studies. The most consistent abnormality seen in this group was an inability of sperm motility to be reactivated once the plasma membrane was removed with detergent and exogenous energy substrate added. This would indicate that at least in these 10 patients low sperm motility was due to primary abnormalities in the axoneme (the primary ultrastructural component in the sperm tail responsible for motility), rather than to defects in the plasma membrane or to abnormalities in energy generation within the sperm tail. Similar data were reported by Liu and associates. 1 If these findings are true in the larger group of subfertile men who have low sperm motility associated with decreased sperm density it is unlikely that exogenous manipulation of the sperm through washing and so forth will result in any truly significant improvement in sperm motility, since the primary defect would be at the level of the axoneme. John D. McConnell, M.D. 1. Liu, D. Y. I., Jennings, M.G. and Baker, H. W. G.:
Correlation between defective motility (asthenospermia) and ATP reactivation of demembranated human spermatozoa. Andrology, 8: 349, 1987. Evaluation of Semen Parameters by Means of Automated Sperm Motion Analyzers C. MAHONY, N. J. ALEXANDER AND R. J. SWANSON, Department of Obstetrics and Gynecology, Eastern Virginia Medical School and Department of Biological Sciences, Old Dominion University, Norfolk, Virginia
M.
Fertil. Steril., 49: 876-880, 1988 Fresh semen specimens from 46 patients and donors were evaluated for concentration, motility, velocity, and linearity using two different commercially available computerized sperm motion analyzer systems. Although no significant differences in measurement of concentration or motility were observed, significant differences in velocity and linearity were recorded. Fourteen cryopreserved/thawed samples were assessed with the same set-up parameters as fresh specimens. When discrepancies between manual and computer counts were noted, the authors changed the set-up parameters and evaluated 33 additional specimens. Again, no differences in concentration and motility, but significant differences in velocity and linearity were observed. Interlaboratory results must be correlated and
458
MALE INFERTILITY
standardization of set-up parameters of various analyzers is essential.
Comparison of Computerized Semen Analysis With the Conventional Procedure in 322 Patients
U. A. KNUTH AND E. NIESCHLAG, Max Planck Clinical Research Unit for Reproductive Medicine and Institute of Reproductive Medicine, University of Munster, Munster, Federal Republic of Germany Fertil. Steril., 49: 881-885, 1988 To compare the results of computerized image analysis for semen evaluation with classical semen analysis, semen samples from 322 consecutive patients attending our infertility clinic were studied. In men with sperm concentrations <20 X 106/ml, major discrepancies existed between both methods for sperm concentration. In many instances, debris could not be distinguished from normal sperm by the computerized system. This caused an overestimation of sperm concentration and led to a reduction of motility estimates. As a consequence, frequency distribution of motility, expressed as the percentage of motile sperm, differed to a major extent in both systems.
Editorial Comment: These 2 studies compare the measurement of sperm concentration and motility determined manually with that obtained by 2 commercially available automated semen analyzers. To date no commercial system is available that is entirely accurate over a large range of sperm densities and motilities. Problems exist with many of these systems in the accurate assessment of specimens that contain high sperm density or a substantial amount of debris. In addition, standards for automated semen evaluation systems have not been established by any scientific society. As a result, there are major methodological differences among laboratories in terms of the pre-evaluation handling of the semen specimens, as well as the parameter settings on the units themselves. No doubt the technical limitations of these machines will be resolved in the future. Thus, automated semen analysis will be of major benefit to laboratories processing large numbers of specimens. A question that remains is how computer-assisted analysis of sperm motility will aid the practicing physician in the care of the individual subfertile man. John D. McConnell, M.D. Effectiveness of Varicocelectomy in Varicoceles Diagnosed by Physical Examination Versus Doppler Studies
F. A.
BSAT AND R. MASABNI, Department of Obstetrics and Gynecology, and Department of Surgery, Urology Division, American University of Beirut Medical Center, Beirut, Lebanon
Fertil. Steril., 50: 321-323, 1988 The purpose of this study is to compare the effectiveness of varicocelectomy for improving the spermogram in treating varicoceles diagnosed by physical examination and those diagnosed by Doppler but with a negative physical examination. The charts of 112 patients were retrospectively analyzed and the patients divided in two groups: group A, where the varicocele was detected by physical examination, and group B, where
physical examination was negative but Doppler studies revealed the presence of stasis or backflow in the pampiniform plexus of the spermatic veins. In subjects complaining of infertility, the two groups were similar with regard to age distribution and duration of infertility. After varicocelectomy, 85% of patients in group A had improved spermogram, compared with only 27% in group B. This difference was statistically significant (P < 0.0001).
Editorial Comment: The repair of clinically palpable varicoceles usually results in improved semen quality, with a resultant increase in pregnancy rates. Although various methods have been recommended to aid in the diagnosis of varicocele, repair of varicoceles diagnosed by supplemental testing has not been rigorously proved to increase semen quality or pregnancy rates. In this study 85 per cent of the patients with clinically palpable varicoceles had improvement in the semen quality after varicocele repair. In contrast, only 27 per cent of the patients who had negative physical examinations but varicoceles apparent by Doppler studies had improvement in semen quality postoperatively. Indeed, the 27 per cent improvement in this latter group is well within the range seen in patients treated by placebo in various empirical drug studies of subfertile men. Although the clinical significance of varicoceles not apparent on physical examination is uncertain, it seems clear that physicians should not use the high success rates commonly cited in the varicocelectomy literature for palpable varicoceles when advising patients with nonpalpable varicoceles as to the advisability of spermatic vein ligation or embolization. John D. McConnell, M.D. Transepithelial Movement of 3 H-Androgen in Seminiferous and Epididymal Tubules: A Study Using In Vivo Micropuncture and In Vivo Microperifusion T. T. TURNER, Departments of Urology, and Anatomy and Cell Biology, University of Virginia School of Medicine, Charlottesville, Virginia Biol. Reprod., 39: 399-408, 1988 In vivo micropuncture and a new system of in vivo microperifusion were used to examine the movement of "R-androgen from blood to lumen and from interstitium to lumen in the rat testis and epididymis. Movement of "R-androgen into the seminiferous tubule lumen was restricted, with intraluminal isotope concentrations plateauing at approximately 15% of extratubular isotope concentrations whether the 3R-androgen originated in the vascular or interstitial compartments. In the caput epididymidis, intraluminal 3R-androgen plateaued at approximately 35% of serum concentrations, but when ;JR-androgens were presented directed to the basal aspect of the caput epididymidal epithelium, :iR-androgen was transported into the lumen against a concentration gradient. Intraluminal isotope concentrations were >200% of those in the epididymal interstitial compartment. Similar results were found for the cauda epididymids. Factors controlling the proluminal movement of 3 R-androgens in the rat testis and epididymis were therefore fundamentally different.
Editorial Comment: This elegant study in the rat provides new and important insight into the regulation of androgen levels in the testis and epididymis. An in vivo