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Ureaplasma Urealyticum (T-Mycoplasma) Infection: Does it Have a Role in Male Infertility?
0022-534 7/80/1244-0469$02.00/0
Vol. 124, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
UREAPLASMA UREALYTICUM (T-MYCOPLASMA) INFECTION: DOES IT HAVE A ROLE IN MALE INFERTILITY? SHIRISH DESAI, MARC S. COHEN, MASOOD KHATAMEE
AND
ELLIOT LEITER
From the Beth Israel Medical Center, Mount Sinai School of Medicine, New York, New York
ABSTRACT
Ureaplasma urealyticum (T-mycoplasma) has been related to male infertility by some observers. To assess further this question 150 couples who presented for infertility had semen and cervical mucus cultures for mycoplasma. Positive cultures were obtained from 69 couples. There were no significant differences in the semen analyses among patients with positive or negative cultures. The presence of mycoplasma in the semen is probably the result of contamination at the time of ejaculation. Routine investigation for the presence of mycoplasma in subfertile men is unjustified. The routine use of broad-spectrum antibiotics in subfertile patients with positive mycoplasma cultures is unnecessary. The first reported isolation of a mycoplasma from man was by Dienes and Edsall in 1937 in a patient with an abscess in Bartholin's gland. 1 Since then there have been many reports on the isolation of mycoplasma from the human urogenital tract. In the genitourinary tract 3 species have been isolated: Mycoplasma fermentans, Mycoplasma hominis and Ureaplasma (Tmycoplasma). M. fermentans is an uncommon organism that rarely is isolated. Ureaplasmas and M. hominis have been implicated in a variety of reproductive and genitourinary inflammatory disorders. However, since a large percentage of healthy individuals has mycoplasma its importance in these conditions has remained controversial. In 1972 Gnarpe and Friberg first postulated that a positive correlation existed between ureaplasma infection and human reproductive failure. 2 These authors and other investigators showed that elimination of the ureaplasma infection with doxycycline resulted in a higher conception rate. 3• 4 In 1975 Fowlkes and associates reported an over-all decrease in semen quality (volume, count, motility and morphology) in fertile patients with semen cultures positive for ureaplasma as compared to those with negative cultures. 5 Fowlkes and Klainer and their associates showed on electron microscopy particles attached to spermatozoa that they thought were suggestive of ureaplasma. 6· 7 However, de Louvois and associates failed to find any significant difference in ureaplasma isolation rates in groups of fertile and infertile couples. 8 In a controlled series they could not demonstrate a higher conception rate after eradication ofureaplasma with doxycycline. Matthews and associates found little difference in ureaplasma isolation rates in groups of fertile, infertile and pregnant patients. 9 These investigators described the almost routine use of tetracycline in unexplained infertility as a result of previous studies, which allegedly showed a relationship between male infertility and the presence of ureaplasma. Hence, the relationship of ureaplasma infection to unexplained male and female infertility remains a highly controversial subject that needs further clarification. We wanted to determine the ureaplasma frequency rates in couples with unexplained infertility and to re-investigate the reportedly deleterious effect of the presence of ureaplasma in semen on various seminal parameters.
tine studies to determine the cause of infertility. These couples with unexplained infertility were part of a much larger group of patients who originally presented to the clinic with infertility. Specimens of semen and cervical mucus were obtained and cultured for ureaplasma. Since these organisms lack a cell wall they are fragile and culturing is difficult, thus requiring much experience. Specimens were cultured and examined within an hour of collection. A sterile applicator was used and the culture plates were inoculated directly by smearing the specimens in a zig-zag fashion over the Petri dish containing the culture medium. The culture medium used is a new medium, described in 1974 for the simultaneous isolation of Neisseria gonorrhoeae, large colony mycoplasma and U. urealyticum. 10 It consists of a proteose peptone com starch agar buffered base to which is added a supplemental nutrient mixture, containing a lysed red blood cell solution, horse plasma, yeast dialysate, dextrose and a number of antimicrobial agents (vancomycin, hydrochloride, colistin, amphotericin Band trimethoprim lactate). Incubation of the specimen in this medium was done in a candle extinction jar at 35C for 48 hours. Examination was made under X40 magnification for the presence of large colony mycoplasma. The plates were flooded with urease reagent and left at room temperature for 10 to 15 seconds. U. urealyticum colonies of characteristic deep blue color and morphology are apparent under this magnification. These colonies can be differentiated from M. hominis colonies, which are larger and have a typical "fricology" appearance. Confirmation was made under XlOO magnification. Semen specimens also were analyzed according to the criteria of MacLeod and Gold: volume, count in millions per cc, total count, motility, forward progression and morphology. 11 This analysis was done by a single observer who is an experienced TABLE
I. Frequency of U. urealyticum in 150 infertile couples Pos. Semen or Cervical Cultures No.(%) Women Men Couples
TABLE 2.
MATERIALS AND METHODS
Distribution of U. urealyticum in infertile couples Culture Results
We investigated 150 couples attending an infertility clinic during 1977 and 1978. Both partners underwent extensive rou-
Husband and wife pos. Husband neg., wife pos. Husband pos., wife neg. Husband and wife neg.
Accepted for publication January 11, 1980. 469
58 (38.6) 49 (32.6) 69 (46.0)
No. Couples 38 20 11 81
470
DESAI AND ASSOCIATES TABLE
3. Semen analyses in various subgroups
Pts. With Pos. Cultures
Pts. With Neg. Cultures
Total 49 Couples
Wife Neg. 11 Cases
3.46 72.05 246.56 147.4
3.5 71.2 245.8 142.3
3.4 72.3 214.27 148.9
72.1 17.7 10.2
70.2 18.2 11.6
Av. volume (cc) Av. count (millions cc) Av. total count (millions) Av. motility index Morphology: Normal Tapering Amorphous
technician and who was unaware of the results of the ureaplasma culture tests. The frequency of positive cultures in this group was analyzed. The various parameters of seminal cytology were compared in the different groups RESULTS
Of the 150 couples 69 (46 per cent) had either one or both semen and cervical cultures positive for ureaplasma: 58 of 150 men had positive cultures (32.6 per cent) and 49 of 150 women had positive cultures (38.6 per cent) (table 1). Both partners had positive cultures in 38 instances, 20 women had positive cultures, while their partners were free of ureaplasma, and 11 men had positive cultures with their wives free of ureaplasma (table 2). Hence, in less than half of the couples one or both partners had positive cultures, in more than half of this group both partners had positive cultures and in the other half one or the other of the partners was affected. The average volume of semen in the 2 main groups (positive and negative men) was 3.46 and 3.1 cc, respectively (table 3). The average sperm count in the positive group was 72.05 million per cc as compared to 68.67 million per cc in the negative group. Also, the total count was lower in the negative group (214.27 million) compared to the positive group (246.56 million) but the difference in the 2 groups was not significant. Motility index was obtained by multiplying the percentage of motile cells with the forward progression of motility (graded 1 to 3). The average motility index in the 2 groups was similar (147.4 and 149.6 in the positive and negative groups). No striking differences were observed in the morphological characteristics of the 2 groups (table 2). There was no increase in the number of aberrant forms or spermatids in the group with positive cultures. DISCUSSION
The frequency of isolation in our series of patients was slightly less than in the series by de Louvois and associates. 8 The latter is one of the few controlled series in the literature and, hence, our isolation rates are representative. An attempt was made to analyze the various subgroups of partners with negative and positive cultures. Both partners were involved in only half of the positive group. Conjugal uniformity of the presence of ureaplasma was not evident. It is not possible to conclude from this whether the presence of ureaplasma in the semen means contamination or infection. The various parameters of semen analysis were reviewed next. In complete contrast to an earlier report no significant changes were found in these parameters. 5 The reported differences in the ejaculate volumes, counts, motility and morphology were not duplicated in this study. We believe that our study is important because it throws doubt on yet another facet of the purported relationship of the presence ofureaplasma to male infertility. Unless this question is further resolved by similar studies there seems little justification for the routine use of mycoplasma culture in investigating
Wife Pos. 38 Cases
Total 101 Couples
Wife Neg.
Wife Pos.
3.11 68.67 214.27 149.6
3.1 68.3 211.4 149.3
3.2 70.6 255.9 151.3
73.2 15.5 11.1
71.9 17.3 10.8
81 Cases
20 Cases
male infertility and the resultant, almost indiscriminate and, perhaps, unnecessary use of antibiotic therapy. It has been demonstrated repeatedly that a high proportion of apparently healthy persons have ureaplasmas. Indeed, in the first report to incriminate mycoplasma in human infertility it was concluded that unless these epidemiologic relationships were clarified the association between T-mycoplasma and infertility, and the high incidence of pregnancy after eradication of T-~ycop~asma might be coincidental.2 It is interesting that these mvest1gators have not reported since 1974. Fowlkes and :issociate~ s~owed, with the aid of electron microscopy, a physical association between the micro-organism and spermatozoa in semen of infected men. 6 A similar association was not seen in control specimens. They postulated that infertile patients with T-mycoplasma infections had an over-all decrease in semen quality compared to those lacking this organism. We believe that the presence of ureaplasma in the semen is merely the result of contamination at the time of ejaculation. To our knowledge ureaplasmas never have been isolated from the testes and no systemic effects of ureaplasma have been shown in men. The demonstration of bodies, supposedly ureaplasma, attached to spermatozoa! heads on electron microscopy remains presumptive evidence linking ureaplasma with male infertility. These particles ~ay represent other similar micro-organisms, such as chlamydiae. In a recent study it was noted that ureaplasmas did not alter the physiopathologic characteristics of vaginal fluid or cervical mucus. 12 Their presence did not alter sperm penetration and sperm viability in cervical mucosa as well. 13 Idriss and associates showed no correlation between the presence of ureaplasma and a poor post-coital test or poor cervical mucus in a controlled study. 14 Studies have shown that ureaplasma colonization of the cervix is common (49 to 83 per cent), whereas colonization in the endometrium is significantly more frequent in infertile patients (50 per cent) than among controls (7 per cent). Endometritis is the only pathological lesion related to infertility shown in association with ureaplasma. 4 This group of patients having endometrial involvement with ureaplasma may be the only patients who would benefit definitely from eradication of ureaplasma. The reported benefits of doxycycline therapy in an infertile patient harboring ureaplasma have been thrown into doubt by recent reports. 15• 16 We have not been able to demonstrate any evidence that ureaplasmas contribute to male infertility. Their presence in the seminal fluid probably is the result of contamination during ejaculation. Routine investigation for the presence of ureaplasma and the indiscriminate use of broad-spectrum antibiotics is unnecessary in these cases. REFERENCES 1. Dienes, L. and Edsall, G.: Observations on the L-Organism of Klieneberger. Proc. Soc. Exp. Biol. Med., 36: 740, 1937.
2. Gnarpe, H. and Friberg, J.: Mycoplasma and human reproductive failure. I. The occurrence of different Mycoplasmas in couples with reproductive failure. Amer. J. Obst. Gynec., 114: 727, 1972. 3. Friberg, J. and Gnarpe, H.: Mycoplasma and human reproductive
471
UREAPLASMA UREALYTICUM INFECTION
failure. III. Pregnancies in "infertile" couples treated with doxycycline for T-Omycoplasmas. Amer. J. Obst. Gynec., 116: 23,
Fertil. Steril., 30: 297, 1978. 13. Stray-Pedersen, B., Eng, J. and Reikvam, T. M.: Uterine T-myco-
1973.
plasma colonization in reproductive failure. Amer. J. Obst. Gynec., 130: 307, 1978. 14. Idriss, W. M., Patton, W. C. and Taymor, M. L.: On the etiologic role of Ureaplasma urealyticum (T-mycoplasma) infection in infertility. Fertil. Steril., 30: 293, 1978. 15. Harrison, R. F., de Louvois, J., Blades, M. and Hurley, R.: Doxycycline treatment and human infertility. Lancet, 1: 605, 1975. 16. Matthews, C. D., Clapp, K. H., Tansing, J. A. and Cox, L. W.: Tmycoplasma genital infection: the effect of doxycycline therapy on human unexplained infertility. Fertil. Steril., 30: 98, 1978.
4. Kundsin, R. B. and Driscoll, S. G.: Mycoplasmas and human reproductive failure. Surg., Gynec. & Obst., 131: 89, 1970. 5. Fowlkes, D. M., MacLeod, J. and O'Leary, W. M.: T-mycoplasmas and human infertility: correlation of infection with alterations in seminal parameters. Fertil. Steril., 26: 1212, 1975. 6. Fowlkes, D. M., Dooher, G. B. and O'Leary, W. M.: Evidence by scanning electron microscopy for an association between spermatozoa and T-mycoplasmas in men of infertile marriage. Fertil. Steril., 26: 1203, 1975. 7. Klainer, A. S. and Pollack, J. D.: Scanning electron microscopy techniques in the study of the surface structure of mycoplasmas. Ann. N. Y. Acad. Sci., 225: 236, 1973. 8. de Louvois, J., Blades, M., Harrison, R. F., Hurley, R. and Stanley, V. C.: Frequency of mycoplasma in fertile and infertile couples. Lancet, 1: 1073, 1974. 9. Matthews, C. D., Elmslie, R. G., Clapp, K. H. and Svigos, J.M.: The frequency of genital mycoplasma infection in human fertility. Fertil. Steril., 26: 988, 1975. 10. Faur, Y. C., Weisburd, M. H., Wilson, M. E. and May, P. S.: NYC medium for simultaneous isolation of Neisseria gonorrhoeae large-colony mycoplasmas and T-mycoplasmas. Appl. Microbiol., 27: 1041, 1974. 11. MacLeod, J. and Gold, R. Z.: The male factor in fertility and infertility. II. Semen quality and certain other factors in relation to ease of conception. Fertil. Steril., 4: 10, 1953.
12. Rehewy, M. S. E., Jaszczak, S., Hafez, E. S. E., Thomas, A. and Brown, W. J.: Ureaplasma urealyticum (T-mycoplasma) in vaginal fluid and cervical mucus from fertile and infertile women.
EDITORIAL COMMENT
It is clear that T-mycoplasmas do not affect sperm count and, consequently, are not a cause of oligospermia. The recent prospective study by de Louvois and associates also has failed to demonstrate a significant increase in T-mycoplasmas on primary infertility (reference 8 in article). As more articles are published T-mycoplasma as a possible agent in infertility seems less likely. Therefore, unless there is further confirmation of the beneficial effects of tetracycline in cases in which the infection is suspected the empirical use of this drug should be avoided.' Lawrence Dubin Department of Urology New York University School of Medicine
New York, New York 1. Amelar, R. D., Dubin, L. and Walsh, P. C.: Male Infertility. Philadelphia: W. B. Saunders Co., p. 85, 1977.
Vol. 124, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
UREAPLASMA UREALYTICUM (T-MYCOPLASMA) INFECTION: DOES IT HAVE A ROLE IN MALE INFERTILITY? SHIRISH DESAI, MARC S. COHEN, MASOOD KHATAMEE
AND
ELLIOT LEITER
From the Beth Israel Medical Center, Mount Sinai School of Medicine, New York, New York
ABSTRACT
Ureaplasma urealyticum (T-mycoplasma) has been related to male infertility by some observers. To assess further this question 150 couples who presented for infertility had semen and cervical mucus cultures for mycoplasma. Positive cultures were obtained from 69 couples. There were no significant differences in the semen analyses among patients with positive or negative cultures. The presence of mycoplasma in the semen is probably the result of contamination at the time of ejaculation. Routine investigation for the presence of mycoplasma in subfertile men is unjustified. The routine use of broad-spectrum antibiotics in subfertile patients with positive mycoplasma cultures is unnecessary. The first reported isolation of a mycoplasma from man was by Dienes and Edsall in 1937 in a patient with an abscess in Bartholin's gland. 1 Since then there have been many reports on the isolation of mycoplasma from the human urogenital tract. In the genitourinary tract 3 species have been isolated: Mycoplasma fermentans, Mycoplasma hominis and Ureaplasma (Tmycoplasma). M. fermentans is an uncommon organism that rarely is isolated. Ureaplasmas and M. hominis have been implicated in a variety of reproductive and genitourinary inflammatory disorders. However, since a large percentage of healthy individuals has mycoplasma its importance in these conditions has remained controversial. In 1972 Gnarpe and Friberg first postulated that a positive correlation existed between ureaplasma infection and human reproductive failure. 2 These authors and other investigators showed that elimination of the ureaplasma infection with doxycycline resulted in a higher conception rate. 3• 4 In 1975 Fowlkes and associates reported an over-all decrease in semen quality (volume, count, motility and morphology) in fertile patients with semen cultures positive for ureaplasma as compared to those with negative cultures. 5 Fowlkes and Klainer and their associates showed on electron microscopy particles attached to spermatozoa that they thought were suggestive of ureaplasma. 6· 7 However, de Louvois and associates failed to find any significant difference in ureaplasma isolation rates in groups of fertile and infertile couples. 8 In a controlled series they could not demonstrate a higher conception rate after eradication ofureaplasma with doxycycline. Matthews and associates found little difference in ureaplasma isolation rates in groups of fertile, infertile and pregnant patients. 9 These investigators described the almost routine use of tetracycline in unexplained infertility as a result of previous studies, which allegedly showed a relationship between male infertility and the presence of ureaplasma. Hence, the relationship of ureaplasma infection to unexplained male and female infertility remains a highly controversial subject that needs further clarification. We wanted to determine the ureaplasma frequency rates in couples with unexplained infertility and to re-investigate the reportedly deleterious effect of the presence of ureaplasma in semen on various seminal parameters.
tine studies to determine the cause of infertility. These couples with unexplained infertility were part of a much larger group of patients who originally presented to the clinic with infertility. Specimens of semen and cervical mucus were obtained and cultured for ureaplasma. Since these organisms lack a cell wall they are fragile and culturing is difficult, thus requiring much experience. Specimens were cultured and examined within an hour of collection. A sterile applicator was used and the culture plates were inoculated directly by smearing the specimens in a zig-zag fashion over the Petri dish containing the culture medium. The culture medium used is a new medium, described in 1974 for the simultaneous isolation of Neisseria gonorrhoeae, large colony mycoplasma and U. urealyticum. 10 It consists of a proteose peptone com starch agar buffered base to which is added a supplemental nutrient mixture, containing a lysed red blood cell solution, horse plasma, yeast dialysate, dextrose and a number of antimicrobial agents (vancomycin, hydrochloride, colistin, amphotericin Band trimethoprim lactate). Incubation of the specimen in this medium was done in a candle extinction jar at 35C for 48 hours. Examination was made under X40 magnification for the presence of large colony mycoplasma. The plates were flooded with urease reagent and left at room temperature for 10 to 15 seconds. U. urealyticum colonies of characteristic deep blue color and morphology are apparent under this magnification. These colonies can be differentiated from M. hominis colonies, which are larger and have a typical "fricology" appearance. Confirmation was made under XlOO magnification. Semen specimens also were analyzed according to the criteria of MacLeod and Gold: volume, count in millions per cc, total count, motility, forward progression and morphology. 11 This analysis was done by a single observer who is an experienced TABLE
I. Frequency of U. urealyticum in 150 infertile couples Pos. Semen or Cervical Cultures No.(%) Women Men Couples
TABLE 2.
MATERIALS AND METHODS
Distribution of U. urealyticum in infertile couples Culture Results
We investigated 150 couples attending an infertility clinic during 1977 and 1978. Both partners underwent extensive rou-
Husband and wife pos. Husband neg., wife pos. Husband pos., wife neg. Husband and wife neg.
Accepted for publication January 11, 1980. 469
58 (38.6) 49 (32.6) 69 (46.0)
No. Couples 38 20 11 81
470
DESAI AND ASSOCIATES TABLE
3. Semen analyses in various subgroups
Pts. With Pos. Cultures
Pts. With Neg. Cultures
Total 49 Couples
Wife Neg. 11 Cases
3.46 72.05 246.56 147.4
3.5 71.2 245.8 142.3
3.4 72.3 214.27 148.9
72.1 17.7 10.2
70.2 18.2 11.6
Av. volume (cc) Av. count (millions cc) Av. total count (millions) Av. motility index Morphology: Normal Tapering Amorphous
technician and who was unaware of the results of the ureaplasma culture tests. The frequency of positive cultures in this group was analyzed. The various parameters of seminal cytology were compared in the different groups RESULTS
Of the 150 couples 69 (46 per cent) had either one or both semen and cervical cultures positive for ureaplasma: 58 of 150 men had positive cultures (32.6 per cent) and 49 of 150 women had positive cultures (38.6 per cent) (table 1). Both partners had positive cultures in 38 instances, 20 women had positive cultures, while their partners were free of ureaplasma, and 11 men had positive cultures with their wives free of ureaplasma (table 2). Hence, in less than half of the couples one or both partners had positive cultures, in more than half of this group both partners had positive cultures and in the other half one or the other of the partners was affected. The average volume of semen in the 2 main groups (positive and negative men) was 3.46 and 3.1 cc, respectively (table 3). The average sperm count in the positive group was 72.05 million per cc as compared to 68.67 million per cc in the negative group. Also, the total count was lower in the negative group (214.27 million) compared to the positive group (246.56 million) but the difference in the 2 groups was not significant. Motility index was obtained by multiplying the percentage of motile cells with the forward progression of motility (graded 1 to 3). The average motility index in the 2 groups was similar (147.4 and 149.6 in the positive and negative groups). No striking differences were observed in the morphological characteristics of the 2 groups (table 2). There was no increase in the number of aberrant forms or spermatids in the group with positive cultures. DISCUSSION
The frequency of isolation in our series of patients was slightly less than in the series by de Louvois and associates. 8 The latter is one of the few controlled series in the literature and, hence, our isolation rates are representative. An attempt was made to analyze the various subgroups of partners with negative and positive cultures. Both partners were involved in only half of the positive group. Conjugal uniformity of the presence of ureaplasma was not evident. It is not possible to conclude from this whether the presence of ureaplasma in the semen means contamination or infection. The various parameters of semen analysis were reviewed next. In complete contrast to an earlier report no significant changes were found in these parameters. 5 The reported differences in the ejaculate volumes, counts, motility and morphology were not duplicated in this study. We believe that our study is important because it throws doubt on yet another facet of the purported relationship of the presence ofureaplasma to male infertility. Unless this question is further resolved by similar studies there seems little justification for the routine use of mycoplasma culture in investigating
Wife Pos. 38 Cases
Total 101 Couples
Wife Neg.
Wife Pos.
3.11 68.67 214.27 149.6
3.1 68.3 211.4 149.3
3.2 70.6 255.9 151.3
73.2 15.5 11.1
71.9 17.3 10.8
81 Cases
20 Cases
male infertility and the resultant, almost indiscriminate and, perhaps, unnecessary use of antibiotic therapy. It has been demonstrated repeatedly that a high proportion of apparently healthy persons have ureaplasmas. Indeed, in the first report to incriminate mycoplasma in human infertility it was concluded that unless these epidemiologic relationships were clarified the association between T-mycoplasma and infertility, and the high incidence of pregnancy after eradication of T-~ycop~asma might be coincidental.2 It is interesting that these mvest1gators have not reported since 1974. Fowlkes and :issociate~ s~owed, with the aid of electron microscopy, a physical association between the micro-organism and spermatozoa in semen of infected men. 6 A similar association was not seen in control specimens. They postulated that infertile patients with T-mycoplasma infections had an over-all decrease in semen quality compared to those lacking this organism. We believe that the presence of ureaplasma in the semen is merely the result of contamination at the time of ejaculation. To our knowledge ureaplasmas never have been isolated from the testes and no systemic effects of ureaplasma have been shown in men. The demonstration of bodies, supposedly ureaplasma, attached to spermatozoa! heads on electron microscopy remains presumptive evidence linking ureaplasma with male infertility. These particles ~ay represent other similar micro-organisms, such as chlamydiae. In a recent study it was noted that ureaplasmas did not alter the physiopathologic characteristics of vaginal fluid or cervical mucus. 12 Their presence did not alter sperm penetration and sperm viability in cervical mucosa as well. 13 Idriss and associates showed no correlation between the presence of ureaplasma and a poor post-coital test or poor cervical mucus in a controlled study. 14 Studies have shown that ureaplasma colonization of the cervix is common (49 to 83 per cent), whereas colonization in the endometrium is significantly more frequent in infertile patients (50 per cent) than among controls (7 per cent). Endometritis is the only pathological lesion related to infertility shown in association with ureaplasma. 4 This group of patients having endometrial involvement with ureaplasma may be the only patients who would benefit definitely from eradication of ureaplasma. The reported benefits of doxycycline therapy in an infertile patient harboring ureaplasma have been thrown into doubt by recent reports. 15• 16 We have not been able to demonstrate any evidence that ureaplasmas contribute to male infertility. Their presence in the seminal fluid probably is the result of contamination during ejaculation. Routine investigation for the presence of ureaplasma and the indiscriminate use of broad-spectrum antibiotics is unnecessary in these cases. REFERENCES 1. Dienes, L. and Edsall, G.: Observations on the L-Organism of Klieneberger. Proc. Soc. Exp. Biol. Med., 36: 740, 1937.
2. Gnarpe, H. and Friberg, J.: Mycoplasma and human reproductive failure. I. The occurrence of different Mycoplasmas in couples with reproductive failure. Amer. J. Obst. Gynec., 114: 727, 1972. 3. Friberg, J. and Gnarpe, H.: Mycoplasma and human reproductive
471
UREAPLASMA UREALYTICUM INFECTION
failure. III. Pregnancies in "infertile" couples treated with doxycycline for T-Omycoplasmas. Amer. J. Obst. Gynec., 116: 23,
Fertil. Steril., 30: 297, 1978. 13. Stray-Pedersen, B., Eng, J. and Reikvam, T. M.: Uterine T-myco-
1973.
plasma colonization in reproductive failure. Amer. J. Obst. Gynec., 130: 307, 1978. 14. Idriss, W. M., Patton, W. C. and Taymor, M. L.: On the etiologic role of Ureaplasma urealyticum (T-mycoplasma) infection in infertility. Fertil. Steril., 30: 293, 1978. 15. Harrison, R. F., de Louvois, J., Blades, M. and Hurley, R.: Doxycycline treatment and human infertility. Lancet, 1: 605, 1975. 16. Matthews, C. D., Clapp, K. H., Tansing, J. A. and Cox, L. W.: Tmycoplasma genital infection: the effect of doxycycline therapy on human unexplained infertility. Fertil. Steril., 30: 98, 1978.
4. Kundsin, R. B. and Driscoll, S. G.: Mycoplasmas and human reproductive failure. Surg., Gynec. & Obst., 131: 89, 1970. 5. Fowlkes, D. M., MacLeod, J. and O'Leary, W. M.: T-mycoplasmas and human infertility: correlation of infection with alterations in seminal parameters. Fertil. Steril., 26: 1212, 1975. 6. Fowlkes, D. M., Dooher, G. B. and O'Leary, W. M.: Evidence by scanning electron microscopy for an association between spermatozoa and T-mycoplasmas in men of infertile marriage. Fertil. Steril., 26: 1203, 1975. 7. Klainer, A. S. and Pollack, J. D.: Scanning electron microscopy techniques in the study of the surface structure of mycoplasmas. Ann. N. Y. Acad. Sci., 225: 236, 1973. 8. de Louvois, J., Blades, M., Harrison, R. F., Hurley, R. and Stanley, V. C.: Frequency of mycoplasma in fertile and infertile couples. Lancet, 1: 1073, 1974. 9. Matthews, C. D., Elmslie, R. G., Clapp, K. H. and Svigos, J.M.: The frequency of genital mycoplasma infection in human fertility. Fertil. Steril., 26: 988, 1975. 10. Faur, Y. C., Weisburd, M. H., Wilson, M. E. and May, P. S.: NYC medium for simultaneous isolation of Neisseria gonorrhoeae large-colony mycoplasmas and T-mycoplasmas. Appl. Microbiol., 27: 1041, 1974. 11. MacLeod, J. and Gold, R. Z.: The male factor in fertility and infertility. II. Semen quality and certain other factors in relation to ease of conception. Fertil. Steril., 4: 10, 1953.
12. Rehewy, M. S. E., Jaszczak, S., Hafez, E. S. E., Thomas, A. and Brown, W. J.: Ureaplasma urealyticum (T-mycoplasma) in vaginal fluid and cervical mucus from fertile and infertile women.
EDITORIAL COMMENT
It is clear that T-mycoplasmas do not affect sperm count and, consequently, are not a cause of oligospermia. The recent prospective study by de Louvois and associates also has failed to demonstrate a significant increase in T-mycoplasmas on primary infertility (reference 8 in article). As more articles are published T-mycoplasma as a possible agent in infertility seems less likely. Therefore, unless there is further confirmation of the beneficial effects of tetracycline in cases in which the infection is suspected the empirical use of this drug should be avoided.' Lawrence Dubin Department of Urology New York University School of Medicine
New York, New York 1. Amelar, R. D., Dubin, L. and Walsh, P. C.: Male Infertility. Philadelphia: W. B. Saunders Co., p. 85, 1977.