Modifiable and non-modifiable risk factors for poor sperm morphology.

STUDY QUESTION: Are common lifestyle factors associated with poor sperm morphology? SUMMARY ANSWER: Common lifestyle choices make little contribution to the risk of poor sperm morphology. WHAT IS KNOWN ALREADY: Although many studies have claimed that men's lifestyle can affect sperm morphology, the evidence is weak with studies often underpowered and poorly controlled. STUDY DESIGN, SIZE, DURATION: Unmatched case-referent study with 318 cases and 1652 referents. Cases had poor sperm morphology (<4% normal forms based on 200 sperm assessed). Exposures included self-reported exposures to alcohol, tobacco, recreational drugs as well as occupational and other factors. PARTICIPANTS/MATERIALS, SETTING, METHODS: Eligible men, aged 18 years or above, were part of a couple who had been attempting conception without success following at least 12 months of unprotected intercourse and also had no knowledge of any semen analysis before being enrolled. They were recruited from 14 fertility clinics across the UK during a 37-month period from 1 January 1999. MAIN RESULTS AND THE ROLE OF CHANCE: Risk factors for poor sperm morphology, after adjustment for centre and other risk factors, included: (i) sample production in summer [odds ratio (OR) = 1.99, 95% confidence interval (CI) 1.43-2.72]; and (ii) use of cannabis in the 3 months prior to sample collection in men aged ≤30 years (OR = 1.94, 95% CI 1.05-3.60). Men who produced a sample after 6 days abstinence were less likely to be a case (OR = 0.64, 95% CI 0.43-0.95). No significant association was found with body mass index, type of underwear, smoking or alcohol consumption or having a history of mumps. This suggests that an individual's lifestyle has very little impact on sperm morphology and that delaying assisted conception to make changes to lifestyle is unlikely to enhance conception. LIMITATIONS, REASONS FOR CAUTION: Data were collected blind to outcome and so exposure information should not have been subject to reporting bias. Less than half the men attending the various clinics met the study eligibility criteria and among those who did, two out of five did not participate. It is not known whether any of those who refused to take part did so because they had a lifestyle which they did not want subjected to investigation. Although the power of the study was sufficient to draw conclusions about common lifestyle choices, this is not the case for exposures that were rare or poorly reported. WIDER IMPLICATIONS OF THE FINDINGS: All participating clinics saw patients at no cost (under the UK National Health Service) and the study population may differ from those in countries without such provision. Even within the UK, low-income couples may choose not to undertake any investigation believing that they would subsequently be unable to afford treatment. Since a computer performed the measurements of sperm morphology, these results may not be comparable with studies where sperm morphology was assessed by other methods. STUDY FUNDING/COMPETING INTERESTS: The study was funded by the UK Health and Safety Executive, the UK Department of Environment, Transport and the Regions, the UK Department of Health (Grant Code DoH 1216760) and the European Chemical Industry Council (grant code EMSG19). No competing interests declared.

Modifiable and non-modifiable risk factors for poor semen quality: a case-referent study.

STUDY QUESTION: Are common lifestyle factors associated with low-motile sperm concentration (MSC)? SUMMARY ANSWER: Common lifestyle choices make little contribution to the risk of low MSC. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Reviews of male subfertility often highlight how aspects of men's adult lifestyle can significantly increase their risk of subfertility but the strength of supporting evidence is weak. In this study, although low MSC was associated with a history of testicular surgery, being in manual work, not wearing loose underwear and black ethnicity, no relation was found to consumption of alcohol, use of tobacco or recreational drugs or high body mass index (BMI). These results suggest that delaying assisted conception to make changes to lifestyle is unlikely to enhance conception. DESIGN: Unmatched case-referent study with 939 cases and 1310 referents. Cases had a low-MSC relative to the time since last ejaculation (<12 × 10(6) for 3 days of abstinence). Exposures included self-reported exposures to alcohol, tobacco, recreational drugs as well as occupational and other factors. PARTICIPANTS AND SETTING: Eligible men, aged 18 or above, were part of a couple who had been attempting conception without success following at least 12 months of unprotected intercourse and also had no knowledge of any semen analysis. They were recruited from 14 fertility clinics across the UK during a 37-month period from 1 January 1999. MAIN RESULTS AND THE ROLE OF CHANCE: Risk factors for low MSC, after adjustment for centre and confounding factors, included a history of testicular surgery [odds ratio = 2.39, 95% confidence interval (CI): 1.75, 3.28], being in manual work [odds ratio (OR) = 1.28, 95% CI: 1.07, 1.53] or not working (OR = 1.78, 95% CI: 1.22, 2.59) and having black ethnicity (OR = 1.99, 95% CI: 1.10, 3.63). Conversely, men who wore boxer shorts (OR = 0.76, 95% CI: 0.64, 0.92) or who had a previous conception (OR = 0.71, 95% CI: 0.60, 0.85) were less likely to be a case. No significant association was found with smoking and alcohol consumption, the use of recreational drugs, a high BMI or having a history of mumps or fever. BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION: Data were collected blind to outcome, and exposure information should not have been subject to reporting bias. Among men attending the various clinics less than half met the study eligibility criteria and among those who did, two out of five were not recruited. It is not known whether any of those who refused to take part did so because they had a lifestyle they did not want subjected to investigation. Although the power of the study was sufficient to draw conclusions about common lifestyle choices, it cannot comment on exposures that are perhaps rare and poorly reported: the finding that use of street drugs was unrelated to low MSC cannot be assumed to apply to all such drugs and all patterns of use. The case definition did not consider sperm morphology or sperm DNA integrity. GENERALIZABILITY TO OTHER POPULATIONS: All participating clinics saw patients at no cost (under the UK National Health Service) and the study population may differ from those in countries without such provision. Even within the UK, low-income couples may choose not to undertake any investigation believing that they would subsequently be unable to afford treatment.

Occupation and male infertility: glycol ethers and other exposures.

OBJECTIVES: To investigate the relation between male infertility and occupational exposures, particularly glycol ethers. METHODS: A case-referent study was designed in which men attending 14 fertility clinics in 11 centres across the UK in 1999-2002 were recruited following 12 months of unprotected intercourse and without a previous semen analysis. Cases were those with low motile sperm concentration (MSC) relative to the time since their last ejaculation (MSC <12 x 10(6) for 3 days of abstinence). Referents were other men attending these clinics and meeting the inclusion criteria. A single semen sample was collected at the clinic and analysed at the andrology laboratory serving each hospital. Concentration was determined manually with motility assessed centrally from video recordings. Exposures and confounding factors were assessed from self-completed and nurse-interviewer questionnaires, completed prior to the results of the semen analysis. The occupational histories were assessed for exposures relative to UK norms by a team of occupational hygienists blind to case status. RESULTS: Of 2118 men in employment at the time of the interview, 874 (41.3%) were cases. Work with organic solvents, particularly glycol ethers, in the 3 months before the first clinic visit was associated with the likelihood of low motile sperm count. Unadjusted odds ratios (OR) for moderate and high glycol ether exposure (compared with none) were 1.70 (95% CI: 1.11 to 2.61) and 2.54 (95% CI: 1.24 to 5.21). Adjustment for potential confounders (surgery to the testes, previous conception, wearing boxer shorts, drinking alcohol, employed in manual work) reduced the risk associated with glycol ether exposure: moderate OR = 1.46 (95% CI: 0.93 to 2.28), high OR = 2.25 (95% CI: 1.08 to 4.69). No other occupational risk factor was identified. CONCLUSIONS: Glycol ether exposure was related to low motile sperm count in men attending fertility clinics. This suggests that, at the time of the study, glycol ethers continued to be a hazard for male fertility.

Occurrence and fate of Fusarium mycotoxins during commercial processing of oats in the UK.

The commercial processing of oats is different from that of other cereals, such as wheat and maize. In northwest Europe, oats also appear to be more susceptible to contamination with HT-2 and T-2 toxins than other cereals. Mycotoxins, such as deoxynivanol and zearalenone, in cereals are already controlled by EU legislation. With regard to additional, impending legislation, this study examined HT-2 and T-2 toxins together with zearalenone, deoxynivalenol and other related toxins in a commercial oat mill and how the concentrations varied from raw oats to the final prepared oat flakes. Concentrations of each Fusarium mycotoxin fell by 90-95% during the process, with the major loss being a physical distribution occurring at the de-hulling stage. Initial studies of losses occurring at other stages, such as kilning or de-branning of prepared oat groats, suggest these to be small. The use of colour sorting after kilning showed higher concentrations of each mycotoxin in the discoloured groats. The feasibility of developing a predictive tool for the oat industry is examined.

Weight management: a comparison of existing dietary approaches in a work-site setting.

OBJECTIVES: (1). To compare the effectiveness a 2512 kJ (600 kcal) daily energy deficit diet (ED) with a 6279 kJ (1500 kcal) generalized low-calorie diet (GLC) over a 24 week period (12 weeks weight loss plus 12 weeks weight maintenance). (2). To determine if the inclusion of lean red meat at least five times per week as part of a slimming diet is compatible with weight loss in comparison with a diet that excludes lean red meat. DESIGN: Randomized controlled trial. SETTING: Large petrochemical work-site. PARTICIPANTS: One-hundred and twenty-two men aged between 18 and 55 y. MAIN OUTCOME MEASURES: Weight loss and maintenance of weight loss. INTERVENTION: Eligible volunteers were randomized to one of the four diet/meat combinations (ED meat, ED no meat, GLC meat, GLC no meat). One-third of subjects in each diet/meat combination were randomized to an initial control period prior to receiving dietary advice. All subjects attended for review every 2 weeks during the weight loss period. For the 12 week structured weight maintenance phase, individualized energy prescriptions were re-calculated for the ED group as 1.4 (activity factor) x basal metabolic rate. Healthy eating advice was reviewed with subjects in the GLC group. All subjects were contacted by electronic mail at 2 week intervals and anthropometric and dietary information requested. RESULTS: No difference was evident between diet groups in mean weight loss at 12 weeks (4.3 (s.d. 3.4) kg ED group vs 5.0 (s.d. 3.5) kg GLC group, P=0.34). Mean weight loss was closer to the intended weight loss in the 2512 kJ (600 kcal) ED group. The dropout rate was also lower than the GLC group. The inclusion of lean red meat in the diet on at least five occasions per week did not impair weight loss. Mean weight gain following 12 weeks weight maintenance was +1.1 (s.d. 1.8) kg, P<0.0001. No differences were found between groups. CONCLUSIONS: This study has shown that the individualized 2512 kJ (600 kcal) ED approach was no more effective in terms of weight loss than the 6279 kJ (1500 kcal) GLC approach. However the ED approach might be considered preferable as compliance was better with this less demanding prescription. In terms of weight loss the elimination of red meat from the diet is unnecessary. The weight maintenance intervention was designed as a low-input approach, however weight regain was significant and weight maintenance strategies require further development.

Preimplantation human embryos and embryonic stem cells show comparable expression of stage-specific embryonic antigens.

Cell-surface antigens provide invaluable tools for the identification of cells and for the analysis of cell differentiation. In particular, stage-specific embryonic antigens that are developmentally regulated during early embryogenesis are widely used as markers to monitor the differentiation of both mouse and human embryonic stem (ES) cells and their malignant counterparts, embryonic carcinoma (EC) cells. However, there are notable differences in the expression patterns of some such markers between human and mouse ES/EC cells, and hitherto it has been unclear whether this indicates significant differences between human and mouse embryos, or whether ES/EC cells correspond to distinct cell types within the early embryos of each species. We now show that human ES cells are characterized by the expression of the cell-surface antigens, SSEA3, SSEA4, TRA-1-60, and TRA-1-81, and by the lack of SSEA1, and that inner cell mass cells of the human blastocyst express a similar antigen profile, in contrast to the corresponding cells of the mouse embryo.

Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary care-secondary care interface.

OBJECTIVE: To investigate the effect of clinical guidelines on the management of infertility across the primary care-secondary care interface. DESIGN: Cluster randomised controlled trial. SETTING: General practices and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area. PARTICIPANTS: All 221 general practices in Glasgow; 214 completed the trial. INTERVENTION: General practices in the intervention arm received clinical guidelines developed locally. Control practices received them one year later. Dissemination of the guidelines included educational meetings. MAIN OUTCOME MEASURES: The time from presentation to referral, investigations completed in general practice, the number and content of visits as a hospital outpatient, the time to reach a management plan, and costs for referrals from the two groups. RESULTS: Data on 689 referrals were collected. No significant difference was found in referral rates for infertility. Fewer than 1% of couples were referred inappropriately early. Referrals from intervention practices were significantly more likely to have all relevant investigations carried out (odds ratio 1.32, 95% confidence interval 1.00 to 1.75, P=0.025). 70% of measurements of serum progesterone concentrations during the midluteal phase and 34% of semen analyses were repeated at least once in hospital, despite having been recorded as normal when checked in general practice. No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan. NHS costs were not significantly affected. CONCLUSIONS: Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice, but there are no detectable differences in outcome for patients or reduction in costs. Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors. Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care.

rpoB-based microbial community analysis avoids limitations inherent in 16S rRNA gene intraspecies heterogeneity.

Contemporary microbial community analysis frequently involves PCR-amplified sequences of the 16S rRNA gene (rDNA). However, this technology carries the inherent problem of heterogeneity between copies of the 16S rDNA in many species. As an alternative to 16S rDNA sequences in community analysis, we employed the gene for the RNA polymerase beta subunit (rpoB), which appears to exist in one copy only in bacteria. In the present study, the frequency of 16S rDNA heterogeneity in bacteria isolated from the marine environment was assessed using bacterial isolates from the red alga Delisea pulchra and from the surface of a marine rock. Ten strains commonly used in our laboratory were also assessed for the degree of heterogeneity between the copies of 16S rDNA and were used to illustrate the effect of this heterogeneity on microbial community pattern analysis. The rock isolates and the laboratory strains were also used to confirm nonheterogeneity of rpoB, as well as to investigate the versatility of the primers. In addition, a comparison between 16S rDNA and rpoB PCR-DGGE (denaturing gradient gel electrophoresis)-based community analyses was performed using a DNA mixture of nine isolates from D. pulchra. Eight out of 14 isolates from D. pulchra, all rock isolates, and 6 of 10 laboratory strains displayed multiple bands for 16S rDNA when analyzed by DGGE. There was no indication of heterogeneity for either the rock isolates or the laboratory strains when rpoB was used for PCR-DGGE analysis. Microbial community pattern analysis using 16S rDNA PCR-DGGE showed an overestimation of the number of laboratory strains in the sample, while some strains were not represented. Therefore, the 16S rDNA PCR-DGGE-based community analysis was proven to be severely limited by 16S rDNA heterogeneity. The mixture of isolates from D. pulchra proved to be more accurately described using rpoB, compared to the 16S rDNA-based PCR-DGGE.

A comparison of three gonadotrophin-releasing hormone analogues in an in-vitro fertilization programme: a prospective randomized study.

The use of gonadotrophin-releasing hormone analogues (GnRHa) has resulted in improved pregnancy rates in in-vitro fertilization (IVF) treatment cycles. Traditionally, short-acting analogues have been employed because of concerns over long-acting depot preparations causing profound suppression and luteal phase defects adversely affecting pregnancy and miscarriage rates. We randomized 60 IVF patients to receive a short-acting GnRHa, nafarelin or buserelin, or to receive a depot formulation, leuprorelin, all commenced in the early follicular phase and compared their effects on hormonal suppression and clinical outcome. We found that on day 15 of administration there was a significant difference in the suppression of oestradiol from initial concentrations, when patients on buserelin were compared with patients on nafarelin or leuprorelin (54 versus 72 and 65%; P < 0.05) and also in the number of patients satisfactorily suppressed, (80 versus 90 and 90%; P < 0.05), though there were no differences between the analogues by day 21. Similarly there was no difference in hormonal suppression during the stimulation phase or in implantation, pregnancy or miscarriage rates in comparing the three agonists. We conclude that with nafarelin and leuprorelin, stimulation with gonadotrophins may begin after 2 weeks of suppression and that long-acting GnRHa are as effective as short-acting analogues with no detrimental effects on the luteal phase.

Privatization, social structures and delivery of health care in the Slovak Republic.

Each country in Central and Eastern Europe has developed a variety of strategies for implementing interventions and improvements in their health care delivery system. Transformation efforts in the Slovak Republic have focused on decentralization, privatization, democratization and liberalization. While the pressures for change have unevenly fallen throughout Central and Eastern Europe, the Slovak Republic has initiated structural changes, particularly in the area of privatization. The concept of privatization requires further discussion especially when considering the principle of subsidiarity and the need to develop coherent social structures. Areas for structural changes in the Slovak Republic are examined in the area of privatization of transformation efforts. Characteristics of successful voluntary organizations in private economies are discussed with appropriate future concerns identified for further analysis.

Greater numbers of human spermatozoa associate with endosalpingeal cells derived from the isthmus compared with those from the ampulla.

A simple co-culture bioassay system was used to investigate whether or not the anatomical origin affected the ability of epithelial cells from the human uterine (Fallopian) tube to 'bind' spermatozoa. This study was also used to identify some of the factors which may be involved in the regulation of sperm-epithelial interactions in vitro by comparing different tissue culture models and assessing the effect of oestradiol concentration. Epithelial explants harvested from different regions of human uterine tubes were co-incubated with a known concentration of motile donor spermatozoa. All results were adjusted to reflect a standard sperm concentration of 5 x 10(6)/ml. More spermatozoa associated per field of isthmic compared to ampullary epithelium [isthmus 9.5 +/- 0.9, ampulla 7.1 +/- 0.7 (mean +/- SEM); n = 36, P < 0.05, ANOVA] and cells from post-menopausal patients had an apparently reduced ability to bind spermatozoa [isthmus 5.5 +/- 2.0, ampulla 4.3 +/- 1.4 (mean +/- SEM); n = 4]. Neither menstrual cycle stage nor addition of mid-cycle concentrations of 17beta-oestradiol (750 pmol/l) affected the number of spermatozoa which bound to epithelium from either tubal region. In addition, the number of spermatozoa which bound per field of polarized explants was greater (P < 0.05) than that bound to dissociated primary and passaged epithelial cell monolayers. This report is the first to provide evidence suggestive of a role for sperm-epithelial binding in the formation of an isthmic sperm reservoir in the human uterine tube. Results also indicate that oestrogen is not involved in the regulation of these interactions, and that cell polarity is an important factor for such associations in vitro.

Developing a skills-based study programme.

This article describes the development of a programme of preparation for nurses and midwives working within a district general hospital NHS trust. The aim is to provide appropriate education for those required to expand the scope of their professional practice.

Renal function and morphometry in the dwarf rat following a reduction in renal mass.

BACKGROUND: The compensatory increase in glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) which follows a reduction in renal mass may be mediated by growth hormone, a renal vasodilator. METHODS: GFR, ERPF and glomerular morphometry were assessed in the dwarf rat, selectively deficient in GH, and compared its Lewis base strain. Studies were performed 21-days after sham-operation, unilateral nephrectomy or subtotal nephrectomy in age-matched animals. GFR and ERPF were assessed from the renal clearance of inulin and p-aminohippurate measured under barbiturate anaesthesia. RESULTS: The dwarf rat had a lower GFR and ERPF than the Lewis rat, in proportion to its lower body weight and lower kidney weight. Kidneys from the dwarf rat had a similar number of glomeruli to the Lewis, but smaller glomerular components in proportion to a lower kidney weight. Following unilateral nephrectomy, GFR (dwarf + 58%, Lewis + 53%) and ERPF (dwarf + 58%, Lewis + 52%) increased to a similar degree in both rat strains. Glomerular diameter, volume and capillary surface area increased in proportion to kidney growth, although compensatory renal growth (dwarf + 62%, Lewis + 78%) was somewhat lower in the dwarf. Following 5/6 subtotal nephrectomy, GFR (dwarf + 143%, Lewis + 171%) increased to a similar degree in both rat strains while ERPF (dwarf + 108%, Lewis + 48%) and compensatory renal growth (dwarf + 115%, Lewis + 86%) were greater in the dwarf than the Lewis rat. Subtotal nephrectomy was also associated with an increase in the thickness of the glomerular basement membrane in both rat strains. CONCLUSIONS: The results do not support a role for GH in the compensatory increase in renal function or hypertrophy which follows a reduction in renal mass, excluding this as a potential mechanism for GH-dependent renal scarring.

Effects of growth hormone on intestinal morphology of genetically dwarf rats.

Three groups of Lewis rat were studied: dwarf rats, genetically deficient in growth hormone; rehabilitated dwarf rats treated with exogenous growth hormone (GH); and normal wild-type rats. The small intestine of each animal was removed and simple random transverse sections were taken from the proximal and distal regions. The profile areas of villi, crypt and muscle were estimated by point count analysis and combined with intestinal length measurements to obtain absolute volumes. Villus and primary mucosal surface areas were estimated from intersection counts and linear measurements were made of epithelial cell height. Distally, villous volume and surface area were reduced by 42% and 39%, respectively, in the dwarfs compared with controls. These features were significantly smaller (P < 0.01) in dwarfs distally than proximally. Crypt volume and epithelial cell height were decreased equally in both proximal and distal regions of the intestine of dwarf rats. Following GH administration both features increased, crypt volume overshooting control values. These results indicate that GH deficiency has a subtle effect on intestinal morphology and that the intestine is more sensitive distally than proximally. Reconstitution with GH is capable of reversing many of these changes.

During fetal muscle development, clones of cells contribute to both primary and secondary fibers.

All mammalian muscle fibers are formed by cell fusion, but fiber formation occurs in two successive waves. Initially a small number of large fibers (primaries) are produced and are used as a scaffold for the formation of a larger number of smaller later forming fibers (secondaries). It has been reported that different populations of myoblasts are present at different ages, but it is unclear whether separate populations of cells contribute to primary and secondary fibers during the period of fetal development. We have tested this by injecting two replication-deficient retroviruses, carrying a marker gene (lacZ), into the hind limbs of Embryonic Day (E) 15 and E17 mouse fetuses. All fetuses were killed at E19. Clusters of marked fibers (assumed to correspond to single clones) found after injection at both ages contained both primary and secondary fibers. This indicates that at these ages, a single population of cells contributes to both primary and secondary fibers.

American business ethics and health care costs.

The health care industry operates in the margin between market competition and social welfare programs. Violations of business ethics on the market side add considerably to costs. When the inefficient use of resources and market distortions due to power and ignorance as well as legal and subsidized monopolies are added, increased costs can approach $100 billion. Modest remedies are suggested.

Studies on sorbents for use in a hepatic support system.

A range of adsorbent and ion exchange materials has been tested for the sorption of fatty acids (hexanoic, octanoic and oleic), bilirubin and bromosulphthalein from human plasma. The importance of sorbent particle size for the kinetics of removal of strongly protein bound substances is shown. A system allowing the use of small particle size bioincompatible sorbents for detoxification is presented.