CCL20-CCR6 axis directs sperm-oocyte interaction and its dysregulation correlates/associates with male infertility‡.

The interaction of sperm with the oocyte is pivotal during the process of mammalian fertilization. The limited numbers of sperm that reach the fallopian tube as well as anatomic restrictions indicate that human sperm-oocyte encounter is not a matter of chance but a directed process. Chemotaxis is the proposed mechanism for re-orientating sperm toward the source of a chemoattractant and hence to the oocyte. Chemokines represent a superfamily of small (8-11 kDa), cytokine-like proteins that have been shown to mediate chemotaxis and tissue-specific homing of leukocytes through binding to specific chemokine receptors such as CCRs. Here we show that CCR6 is abundantly expressed on human sperms and in human testes. Furthermore, radioligand-binding experiments showed that CCL20 bound human sperm in a specific manner. Conversely, granulosa cells of the oocyte-surrounding cumulus complex as well as human oocytes represent an abundant source of the CCR6-specific ligand CCL20. In human ovaries, CCL20 shows a cycle-dependent expression pattern with peak expression in the preovulatory phase and CCL20 protein induces chemotactic responses of human sperm. Neutralization of CCL20 in ovarian follicular fluid significantly impairs sperm migratory responses. Conversely, analyses in infertile men with inflammatory conditions of the reproductive organs demonstrate a significant increase of CCL20/CCR6 expression in testis and ejaculate. Taken together, findings of the present study suggest that CCR6-CCL20 interaction may represent an important factor in directing sperm-oocyte interaction.

European Academy of Andrology guideline Management of oligo-astheno-teratozoospermia.

BACKGROUND: Oligo-astheno-teratozoospermia is frequently reported in men from infertile couples. Its etiology remains, in the majority of cases, unknown with a variety of factors to contribute to its pathogenesis. The aim of this European Academy of Andrology guideline was to provide an overview of these factors and to discuss available management options. MATERIALS AND METHODS: PubMed was searched for papers in English for articles with search terms: male infertility and oligo-astheno-teratozoospermia. For evidence-based recommendations, the GRADE system was applied. Issues related to urogenital infections/inflammations have not been included in this document as they will be covered by separate guidelines. RESULTS: For men with oligo-astheno-teratozoospermia, the European Academy of Andrology recommends: A general physical examination to assess signs of hypogonadism. A scrotal physical examination to assess (i) the testes and epididymes for volume and consistency, (ii) deferent ducts for total or partial absence, and (iii) occurrence of varicocoele. Performing two semen analyses, according to World Health Organization guidelines to define an oligo-astheno-teratozoospermia. An endocrine evaluation. A scrotal ultrasound as part of routine investigation. Karyotype analysis and assessment of Yq microdeletions in infertile men with a sperm concentration ≤5 × 106 /mL. Cystic fibrosis transmembrane conductance regulator gene evaluation in case of suspicion for incomplete congenital obstruction of the genital tract. Against quitting physical activity to improve the chance of achieving pregnancy. Against androgen replacement therapy to improve the chance of achieving pregnancy. Assisted reproduction techniques to improve the chance of achieving pregnancy, in case other treatment options are not available or not efficient. Androgen replacement therapy in patients with biochemical/clinical signs of hypogonadism, after completion of the fertility treatment. CONCLUSION: These guidelines can be applied in clinical work and indicate future research needs.

European Academy of Andrology guideline Management of oligo­astheno­teratozoospermia

Oligo­astheno­teratozoospermia is frequently reported in men from infertile couples. Its etiology remains, in the majority of cases, unknown with a variety of factors to contribute to its pathogenesis. The aim of this European Academy of Andrology guideline was to provide an overview of these factors and to discuss available management options.

Predomination of IL-17-producing tryptase-positive/chymase-positive mast cells in azoospermic chronic testicular inflammation.

Chronic testicular inflammation and infection have been regarded as important factors in the pathogenesis of azoospermia. As key effector cells in innate and adaptive immune system, mast cells (MCs) were observed in inflammation and autoimmune disease. Furthermore, increased expression of tryptase-positive MCs has been reported in testicular disorders associated with male infertility/subfertility. However, little is known about the potential relationship between MCs and chronic testicular inflammation in azoospermic patients. Moreover, the preferential expression of MCs' subtypes in testis of these patients is still far from being understood. Thus, this study aimed to investigate characteristics of testicular MCs as well as their subtypes in azoospermic men with chronic testicular inflammation (AZI, n = 5) by immunohistochemical techniques. Our results showed significant increase of MCs in AZI, and more importantly, considerable numbers of tryptase-positive/chymase-positive MCs could also be demonstrated in AZI, when compared to control groups representing azoospermia without chronic testicular inflammation (AZW, n = 5) and normal spermatogenesis (NT, n = 5) respectively. Most interestingly, immunofluorescence staining revealed autoimmune-associated interleukin (IL)-17-producing MCs in AZI, whereas co-expression of MC markers with tumour necrosis factor (TNF)-α, IL-10 and IL-1ß could not be detected. In conclusion, AZI is associated with significant increase of tryptase-positive/chymase-positive MCs expressing IL-17, and these MCs might contribute to the pathogenesis of AZI.

[Semen allergy]. / Spermaallergie.

A semen allergy is a type I reaction. Reliable figures about incidence/prevalence are not available. Symptoms can be characterized as local and systemic. After exposure to ejaculate, the patient may experience itching and swelling at points of contact, while systemically it may also lead to generalized urticaria with angioedema or higher grade anaphylaxis. As triggering allergens, substances in seminal plasma (SP) have been identified, which can be SP typical or SP atypical. Reactions against spermatozoa have not yet been clearly proven. With regard to SP-typical allergens, prostate-specific antigen (PSA) has been identified, while for SP-atypical allergens, medications or food allergens have been reported, which apparently accumulate in the SP and can then trigger symptoms in women with existing sensitization. The main criteria for the diagnosis of sperm allergy is freedom from symptoms when condoms are used during intercourse. In addition, skin prick tests and determination of allergen-specific IgE are used. In patients with a desire for children, washed, SP-free spermatozoa can be used for insemination. In addition, desensitization may be considered.

[Penile dermatoses]. / Penile Dermatosen.

The diagnostics of penile skin alterations represent a urological and dermatological challenge. The spectrum of differential diagnoses ranges from benign skin alterations with no clinical significance, through infections, vesiculobullous diseases and neoplasms up to acute diseases necessitating emergency interventions. Evidence-based therapy concepts are not available for all these diseases and due to the rarity an interdisciplinary cooperation is expedient and promising.

Seminal parameters of chronic male genital inflammation are associated with disturbed sperm DNA integrity.

Definition of chronic male genital tract inflammation and its impact on male infertility is still a matter of debate. In particular, DNA integrity has been reported to be disturbed in subfertile men. Thus, the aim of this study was to investigate an association of DNA integrity to altered standard semen parameters as well as inflammatory parameters such as peroxidase-positive cells, macrophages and seminal interleukin-6 concentration. Macrophages were detected by CD18/HLA-Dr staining, and DNA integrity was analysed by acridine orange staining using flow cytometry. Interleukin-6 was detected by ELISA. Normal DNA integrity showed a significant correlation to sperm number and progressive motility. Moreover, a significant inverse correlation of DNA integrity to Interleukin-6 and macrophages could be demonstrated. Further on, seminal interleukin-6 also significantly correlated to macrophages. No association has been observed between the number of peroxidase-positive cells and normal DNA integrity. As disturbed DNA integrity has been reported to negatively influence spermatozoon-egg interaction and even fertilisation rates following ICSI, and as early miscarriages have been associated with sperm DNA damage, it should be screened very carefully for male genital tract inflammations in couples undergoing infertility treatment. Measuring Interleukin-6 seems superior to assessment of the number of leucocytes alone and additional assessment of DNA integrity into the diagnostic work-up should be considered.

Differential leucocyte detection by flow cytometry improves the diagnosis of genital tract inflammation and identifies macrophages as proinflammatory cytokine-producing cells in human semen.

Genital tract inflammation is considered as a major cause of male infertility with leucocytospermia as widely used diagnostic marker. However, threshold of 10(6) leucocytes ml(-1) recommended by the WHO is a matter of debate. Moreover, leucocyte subpopulations and their impact cannot be identified by the routine peroxidase method (POM). Ejaculates of subfertile men (n = 47) were analysed by flow cytometry (FACS) using a bead-based method. Leucocytes were identified by CD18 and further divided into macrophages (HLA-Dr+/CD66abce-) and neutrophils (HLA-Dr-/CD66abce+). IL-1ß, TNF-α and IL-6 production was investigated in these subpopulations. It was found that CD18-positive cells correlated significantly with POM. However, only in samples with POM below 10(6) per millilitre, FACS detected significantly higher leucocyte numbers. Moreover, in 31% of these samples, FACS leucocyte detection reached threshold values greater than 1 × 10(6)  ml(-1) , fulfilling the criteria for diagnosis of leucocytospermia. Neutrophils were the predominating leucocyte population. Nevertheless, in 24% of samples, macrophages encountered more than 50% of leucocytes. Most interestingly, only macrophages produced significant amounts of IL-1ß, TNF-α and IL-6. It is concluded that FACS improves detection and functional differentiation of seminal leucocytes as one of the diagnostic hallmarks of male genital tract inflammation.

Immunodeviation towards a Th17 immune response associated with testicular damage in azoospermic men.

Infection and inflammation of the male reproductive tract are thought to be a primary aetiological factor of male infertility. Furthermore, several studies suggest that T lymphocytes are critically involved as regulator in the pathogenesis of male infertility under these conditions and are thought to induce autoimmune orchitis. In this context of autoimmunity the recently described T helper (Th) 17 subset has been suggested to play an essential role so that the aim of this study was to investigate the expression and characteristics of Th17 cells as well as the presence of Th17 inducing antigen presenting cells (APCs) in azoospermic testis with chronic inflammation (ATCI) compared with normal spermatogenesis. By stereological analysis, we detected base line expression of Th17 cells in Con. However, increased expression intensity and number of Th17 cells and their cytokines [interleukin (IL)-17A, IL-21, IL-22] and a decreased level of Foxp3(+) and interferon-γ(+) cells could be demonstrated in ATCI. Moreover, along with these data, increased numbers of Th17-inducing IL-23 producing CD11c(+) and CD68(+) APCs could be detected in ATCI. From these data, a picture emerges that Th17 cells orchestrated by IL-23 producing APCs are critically involved in chronic inflammation in ATCI.

[Andrology]. / Andrologie.

Andrology deals with male infertility, erectile dysfunction, loss of libido, ejaculatory disorders, hypogonadism, delayed puberty, male contraception, gynecomastia and aspects of the aging male. New trends in reproductive medicine have influenced the evaluation of andrological patients in recent years. Even loss of ejaculated spermatozoa does not necessarily exclude paternity since testicular sperm extraction has been established in men with obstructive or non-obstructive azoospermia. The most important new aspect in andrology is the publication of the World Health Organization laboratory manual for semen analysis in 2010. Dramatic changes concerning sperm motility and morphology must now be considered for the interpretation of standard semen parameters.

[Orchitis and male infertility]. / Orchitis und Infertilität.

Infections and inflammations of the genital tract are considered the most frequent causes of reduced male fertility, but conclusive epidemiological data are not available. In view of the exposure of germ cells to pathogenic components as well as the cells and mediators involved in the inflammatory processes, irreversible damage to spermatogenesis and corresponding decline of ejaculate quality are to be expected, particularly in cases of chronic orchitis. While the consequences of orchitis and epididymo-orchitis that exhibit clinical symptoms due to systemic or local infections are well known, including testicular atrophy and complete loss of fertility, those cases of inflammatory reactions of the testicles that manifest an asymptomatic or subclinical course, or are not even due to an infection, have received little attention until now. However, systematic histopathological analyses have shown a high prevalence of asymptomatic inflammatory reactions in testicular biopsies from infertile men. The mostly focal lymphocytic infiltrates correlate with the degree of damage to spermatogenesis and corresponding clinical and endocrinological parameters of testicular function. Noninvasive diagnostic techniques are not yet available so that chronic asymptomatic inflammations of the testicles as the primary cause or cofactor of male fertility disorders are underestimated. Except for administration of pathogen-specific antibiotics, treatment recommendations are to a large extent still lacking.

Mast cells in the seminal plasma of infertile men as detected by flow cytometry.

Increased numbers of mast cells (MCs) in the testis have been associated with testicular dysfunction, where accumulation of MCs occurs. Furthermore, it has been reported that MCs might affect sperm function as it has been demonstrated that MC-derived tryptase in the seminal fluid might reduce sperm motility. Although MCs have been detected in rat epididymis, only little is known about the presence of MCs in human seminal plasma. Thus, we analysed MC numbers in the ejaculate of men during routine semen analysis of male patients suspected for infertility (n = 100). MCs were detected by c-kit (CD117) expression using flow cytometry. Thereby, we detected significant numbers of MCs in the ejaculate of most patients (559 +/- 525 MCs ml(-1), mean +/- SD). However, we could neither detect a correlation with respect to MCs and sperm count, motility or morphology nor to the seminal inflammatory markers like polymorphonuclear elastase. Nevertheless, a significant correlation of MCs to spermatozoa-bound IgA (r = 0.5; P = 0.03; n = 21) was observed. It is concluded that significant numbers of MCs can be detected in the human ejaculate without necessarily influencing sperm function. A potential role of MCs in seminal plasma as well as the association between MCs and IgA on spermatozoa remains to be elucidated.

[Evidence-based drug therapy for male infertility]. / Evidenzbasierte medikamentöse Therapieansätze der Infertilität.

Evidence-based drug therapy for male infertility is often difficult because 30% of all cases of male infertility are classified as idiopathic, and another 30% need surgical treatment. Without knowledge of the underlying pathology, there is no foundation for a specific and causal treatment. Most of the currently used drug therapies are empirical at best; moreover, many of the studies on drug treatment for male infertility do not fulfill the required standards of evidence-based medicine (randomized, prospective, placebo-controlled), and the statistical endpoints used (sperm quality, pregnancy rate, baby take-home rate) are not uniform. This article, which is based on a literature survey and the current guidelines concerning drug therapy for male infertility, covers the most common treatment options. Regarding the currently insufficient scientific data for drug therapy and dietary supplements on male infertility, there is a demand for critical indications that take into consideration the possible side effects and the treatment costs. In the case of insufficient drug therapy for male infertility, reproductive medicine seems to be promising.

High percentage of apoptotic spermatozoa in ejaculates from men with chronic genital tract inflammation.

Silent chronic inflammation of genital tract (CIGT) is considered as a major contributing factor to male fertility disorders. Within CIGT, inflammatory cytokines such as TNF-alpha might induce spermatozoal apoptosis, which in turn has been shown to have a negative influence on the sperm-oocyte penetration capacity. Thus, the aim of this study was to investigate spermatozoal apoptosis in patients with fertility disorders and signs of CIGT. Apoptosis of spermatozoa was determined by expression of annexin V using flow cytometry. Apoptotic spermatozoa were further discriminated from necrotic spermatozoa by 7-amino-actinomycin (7AAD). Ejaculates of patients showing signs of CIGT (P-CIGT) such as high polymorphonuclear (PMN) elastase were compared to control ejaculates of patients lacking signs of CIGT (CON). Thereby we detected a significant correlation between PMN elastase and TNF-alpha in the seminal plasma and apoptotic spermatozoa. Furthermore, we demonstrated a significantly higher percentage of apoptotic spermatozoa in the ejaculate of P-CIGT compared to CON. Interestingly, a significantly higher percentage of apoptotic spermatozoa was detected in the swim-up fraction demonstrating motility of apoptotic spermatozoa. This is in line with the missing correlation of apoptotic spermatozoa and motility. In conclusion, patients with signs of CIGT display high numbers of apoptotic spermatozoa with progressive motility, which might have an impact on reproductive techniques such as intrauterine insemination or in-vitro fertilisation.

Relationship between anger and pruritus perception in patients with chronic idiopathic urticaria and psoriasis.

BACKGROUND: There is evidence that chronic idiopathic urticaria (CIU) and psoriasis are associated with personality based difficulties in emotional regulation particularly with regard to the feeling of anger. This deficit in emotional awareness could lead to the phenomenon that emotions are rather experienced in bodily symptoms such as pruritus. AIM: We investigated whether there is a relationship between pruritus as major symptoms in CIU and psoriasis and the experience of negative emotions. SETTING: Forty-one CIU patients and 44 psoriasis patients treated at Bonn University Hospital and 49 healthy controls were included. METHOD: Patients and controls were compared on questionnaires measuring alexithymia (TAS-20), emotional distress (SCL-90-R) and anger (STAXI). In skin-disordered patients, separate stepwise regressions with pruritus severity as dependent variable and questionnaires, skin status, duration, sex and age as independent variables were calculated. RESULTS: CIU and psoriasis patients showed higher alexithymia, emotional distress, depression, anxiety and state anger compared with controls. State anger was the only significant predictor of pruritus severity in CIU explaining 19% of variance. Depression was the only significant predictor of pruritus severity in psoriasis explaining 12% of variance. CONCLUSIONS: Our findings suggest a relationship between pruritus severity and anger in CIU. Furthermore, our results indicate a relationship between pruritus severity and depression in psoriasis.

Chronic orchitis: a neglected cause of male infertility?

Infection and inflammation of the male reproductive tract are accepted as important aetiological factors of infertility. With regard to their impact on male reproductive function, orchitis and epididymo-orchitis due to local or systemic infection as well as noninfectious aetiological factors are of particular concern. There is clinical and pathological evidence that chronic inflammatory conditions of the testes can disrupt spermatogenesis and irreversibly alter both sperm number and quality. In the majority of patients, however, diagnosis is hampered by an asymptomatic course of the disease and unspecific clinical signs. Hence, respective epidemiological data are scarce. On the other hand, systematic histopathological work-up of testicular biopsies from infertile men indicates a high prevalence of inflammatory reactions. A characteristic pattern of inflammatory lesions with focal or multifocal, predominantly peritubular lymphocyte infiltration and concomitant damage of seminiferous tubules is seen in chronic orchitis of various origins. This supports the concept that induction of testicular inflammation is associated with a T-cell-mediated autoimmune response, i.e. disruption of the immune privilege. Moreover, despite the patchy distribution of the lesions, testicular volume and score counts for spermatogenesis may be significantly reduced. In conclusion, asymptomatic inflammatory reactions in the testis should not be neglected as an underlying cause or co-factor of male infertility. However, definitive diagnosis of chronic asymptomatic orchitis still requires testicular biopsy and guidelines for the therapeutic management are not yet available.

Chronic epididymitis: impact on semen parameters and therapeutic options.

Chronic inflammatory conditions of the genital tract are frequently encountered in male fertility problems. The diagnosis, however, is hampered by a mostly asymptomatic course of the disease as well as inappropriate definitions and unspecific diagnostic criteria. With regard to their impact on male reproductive function, epididymitis seems to be more relevant than inflammation/infection of the prostate and/or seminal vesicles. Chronic epididymitis may result in reduced sperm count and motility. Impaired sperm motility because of epididymal dysfunction is frequently associated with an atypical staining behaviour of sperm tails. In many cases of chronic epididymitis, the number of leukocytes in the ejaculate is below the threshold of 10(6) per ml; therefore, consideration of additional markers of inflammation such as granulocyte elastase, pro-inflammatory cytokines (e.g. interleukin-6 or 8) or reactive oxygen species is helpful for establishing the diagnosis. Besides changes in the conventional sperm parameters, alterations in DNA integrity have been observed. Positive effects of antiphlogistic/antibiotic treatment on semen quality have been reported; however, controlled prospective studies are still lacking.

[Andrological diagnostics]. / Andrologische Diagnostik.

Andrology was included as a further subject for continuing education in the Model Ordinance on Continuing Education at the 106th German Physicians Meeting in Cologne in 2003. In addition to fertility disorders, this discipline comprises medical care for men with fertility disorders, erectile dysfunction, disorders of libido, ejaculation and coitus, various forms of hypogonadism, and delayed puberty. Furthermore, this field also covers questions concerning male contraception, gynecomastia, and male senescence. Diagnostic procedures in andrology require close interdisciplinary cooperation between gynecologists, human geneticists, and specialists in psychosomatic medicine. They include medical history, clinical examination, and laboratory analyses. Except for confirming azoospermia, it is not possible to make a definitive prognosis of fertility based on semen analysis. Functional tests allow a better assessment of the spermatozoa's fertility since 25-30% of men desiring a child exhibit reduced spermatozoan functions which cannot be verified on routine semen analysis.