Elisabeth Carlsen

Evidence for decreasing quality of semen during past 50 years.

OBJECTIVE--To investigate whether semen quality has changed during the past 50 years. DESIGN--Review of publications on semen quality in men without a history of infertility selected by means of Cumulated Index Medicus and Current List (1930-1965) and MEDLINE Silver Platter database (1966-August 1991). SUBJECTS--14,947 men included in a total of 61 papers published between 1938 and 1991. MAIN OUTCOME MEASURES--Mean sperm density and mean seminal volume. RESULTS--Linear regression of data weighted by number of men in each study showed a significant decrease in mean sperm count from 113 x 10(6)/ml in 1940 to 66 x 10(6)/ml in 1990 (p < 0.0001) and in seminal volume from 3.40 ml to 2.75 ml (p = 0.027), indicating an even more pronounced decrease in sperm production than expressed by the decline in sperm density. CONCLUSIONS--There has been a genuine decline in semen quality over the past 50 years. As male fertility is to some extent correlated with sperm count the results may reflect an overall reduction in male fertility. The biological significance of these changes is emphasised by a concomitant increase in the incidence of genitourinary abnormalities such as testicular cancer and possibly also cryptorchidism and hypospadias, suggesting a growing impact of factors with serious effects on male gonadal function.

Germ cell cancer and disorders of spermatogenesis: An environmental connection?

Why is there a small peak of germ cell tumours in the postnatal period and a major peak in young age, starting at puberty? And, paradoxically, small risk in old age, although spermatogenesis is a lifelong process? Why is this type of cancer more common in individuals with maldeveloped gonads, including undescended testis, gonadal dysgenesis and androgen insensitivity syndrome? Why has there, during the past 50 years, been a quite dramatic increase in testicular cancer in many developed countries? These are just a few of many questions concerning testicular cancer. However, the recent progress in research in the early stages of testicular cancer (carcinoma in situ testis (CIS)) allows us to begin to answer some of these questions. There is more and more evidence that the CIS cell is a gonocyte with stem cell potential, which explains why an adult man can develop a non‐seminoma, which is a neoplastic caricature of embryonic growth. We consider the possibility that CIS cells may loose their stem cell potential with ageing. Along these lines, a seminoma is regarded a gonocytoma where the single gonocytes have little or no stem cell potential. The Sertoli and Leydig cells, which are activated postnatally and during and after puberty, may play a crucial role for both the development of the CIS gonocyte and progression of the neoplasm to invasiveness. The reported increase in testicular cancer is not the only sign that male reproductive health is at risk. There are reports that undescended testis and hypospadias have become more common. Also semen quality has deteriorated, at least in some countries. The epidemiological evidence suggests that environmental factors may play a role. Are the environmental hormone disrupters (e.g. DDT, PCB, nonylphenol, bisphenol A) to be blamed for the apparently synchronised deterioration in these aspects of male reproductive health?

Human semen quality in the new millennium: a prospective cross-sectional population-based study of 4867 men

Objectives Considerable interest and controversy over a possible decline in semen quality during the 20th century raised concern that semen quality could have reached a critically low level where it might affect human reproduction. The authors therefore initiated a study to assess reproductive health in men from the general population and to monitor changes in semen quality over time. Design Cross-sectional study of men from the general Danish population. Inclusion criteria were place of residence in the Copenhagen area, and both the man and his mother being born and raised in Denmark. Men with severe or chronic diseases were not included. Setting Danish one-centre study. Participants 4867 men, median age 19 years, included from 1996 to 2010. Outcome measures Semen volume, sperm concentration, total sperm count, sperm motility and sperm morphology. Results Only 23% of participants had optimal sperm concentration and sperm morphology. Comparing with historic data of men attending a Copenhagen infertility clinic in the 1940s and men who recently became fathers, these two groups had significantly better semen quality than our study group from the general population. Over the 15 years, median sperm concentration increased from 43 to 48 million/ml (p=0.02) and total sperm count from 132 to 151 million (p=0.001). The median percentage of motile spermatozoa and abnormal spermatozoa were 68% and 93%, and did not change during the study period. Conclusions This large prospective study of semen quality among young men of the general population showed an increasing trend in sperm concentration and total sperm count. However, only one in four men had optimal semen quality. In addition, one in four will most likely face a prolonged waiting time to pregnancy if they in the future want to father a child and another 15% are at risk of the need of fertility treatment. Thus, reduced semen quality seems so frequent that it may impair the fertility rates and further increase the demand for assisted reproduction.

CAG repeat length in androgen-receptor gene and reproductive variables in fertile and infertile men

Several reports implicated a relation between the trinucleotide (CAG) repeat length in the androgen-receptor gene and male infertility, whereas others failed to find an association. We investigated the CAG repeat length in relation to sperm production and reproductive hormones in 119 infertile men and 110 men with proven fertility. We found no difference in the distribution of CAG repeat lengths between the groups and no association with reproductive parameters. This finding suggests that, within the normal range of 14-33 repeats, there is no biological link between the CAG repeat length and fertility. This lack of association was comfirmed by an analysis of the data from all previously published European studies (in total 674 infertile men and 660 controls).

Trends in the use of intracytoplasmatic sperm injection marked variability between countries

BACKGROUND ICSI is used increasingly often compared with standard IVF. The aim of the present study was to analyse the changes in the use of ICSI, and discuss possible causes and consequences. METHODS Data from National and Regional registers were analysed for trends in the use of ICSI and indications for assisted reproductive technology (ART). RESULTS The use of ICSI increased from 39.6% of ART cycles in 1997 to 58.9% in 2004 (USA 57.5%, Australia/New Zealand 58.6%, Europe 59.3%). The Nordic countries, the Netherlands and the UK used ICSI to a low extent (40.0-44.3%), whereas Austria, Belgium and Germany (68.5-72.9%) and the southern European countries like Greece, Italy and Spain used ICSI frequently (66.0-81.2%). The marked increase in the proportion of ICSI cycles seems primarily due to an increased use in couples classified as having mixed causes of infertility, unexplained infertility and advanced age together with a relative decline in tubal factor infertility. An absolute increase in the prevalence of couples with impairment in semen quality remains a possibility. CONCLUSIONS ICSI is used increasingly, but huge differences exist between countries within Europe. It is not possible to determine specific factors that explain the differences. As ICSI does not give higher pregnancy rates than IVF in couples without male factors, and as it adds additional costs, infertile couples and society may benefit from a less frequent use of ICSI in some countries.

Specific Physiological Regulation of Luteinizing Hormone Secretory Events Throughout the Human Menstrual Cycle: New Insights into the Pulsatile Mode of Gonadotropin Release

To investigate the physiological regulation of luteinizing hormone (LH) secretory events and the endogenous clearance of this hormone, we applied multiple‐parameter deconvolution analysis to serum LH concentration‐time series obtained from normal women during three phases of the menstrual cycle. The number of significant LH secretory bursts (/24 h) was maximal in the late follicular (LF) phase (27 ± 1.6; mean ± SEM), minimal in the mid‐luteal (ML) phase (10 ±1.0) and intermediate in the early follicular (EF) phase (18 ± 1.4). Similarly, the half‐duration of the secretory impulse (min) was different at each phase of the cycle with values of 6.5±1.0, 3.5±0.9 and 11 ± 1.1 during the EF, LF and ML phases, respectively. In contrast, there were no cycle‐dependent differences in the LH half‐life or in the total daily secretion of LH.

Primary testicular failure in Klinefelter's syndrome: the use of bivariate luteinizing hormone-testosterone reference charts.

Background  The diagnosis of androgen deficiency is based on clinical features and confirmatory low serum testosterone levels. In early primary testicular failure, a rise in serum LH levels suggests inadequate androgen action for the individuals physiological requirements despite a serum testosterone level within the normal range. The combined evaluation of serum LH and testosterone levels in the evaluation of testicular failure has not been widely advocated.

Varicocele Is Associated with Impaired Semen Quality and Reproductive Hormone Levels: A Study of 7035 Healthy Young Men from Six European Countries

BACKGROUND Present knowledge on the impact of varicoceles on testicular function is largely based on studies of subfertile and infertile men, making it difficult to extrapolate the impact of varicocele on the general population. OBJECTIVE To describe associations between varicocele and testicular function assessed by semen analysis and reproductive hormones in men from the general population. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional multicentre study of 7035 young men, median age 19 yr, from the general population in six European countries (Denmark, Finland, Germany, Estonia, Latvia, and Lithuania) were investigated from 1996 to 2010. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We analysed results from physical examination, conventional semen variables, and serum reproductive hormones using multivariable regression analyses. RESULTS AND LIMITATIONS A total of 1102 (15.7%) had grade 1-3 varicocele. Increasing varicocele grade was associated with poorer semen quality, even in grade 1 varicocele. In grade 3 varicocele, sperm concentration was less than half of that in men with no varicocele. Presence of varicocele was also associated with higher serum levels of follicle-stimulating hormone, lower inhibin B, and higher levels of luteinising hormone; testosterone and free testosterone were not significantly different between men with and without varicocele. This study cannot draw a conclusion on the progressiveness of varicocele or the effect of treatment. CONCLUSIONS We demonstrated an adverse effect of increasing grade of varicocele on testicular function in men not selected due to fertility status. PATIENT SUMMARY The presence and increasing grade of varicocele is adversely associated with semen quality and reproductive hormone levels in young men from the general population.

Nature of gonadotropin-releasing hormone self-priming of luteinizing hormone secretion during the normal menstrual cycle

To investigate further the nature of the gonadotropin-releasing hormone self-priming effect on luteinizing hormone release, we administered two submaximal doses of gonadotropin-releasing hormone 2 hours apart to women at three stages of the menstrual cycle and analyzed the resultant luteinizing hormone secretory episodes with deconvolution analysis. When the characteristics of the secretory episodes associated with the second gonadotropin-releasing hormone challenge were compared with those associated with the first, both an enhanced maximal secretory rate and mass of luteinizing hormone secreted was demonstrable at each phase of the cycle. No differences in the luteinizing hormone secretory event half-duration were detected when the responses to the first and second gonadotropin-releasing hormone doses were compared. These data confirm the gonadal hormone milieu-associated self-priming effect of gonadotropin-releasing hormone on luteinizing hormone release and indicate that it is the rate with which luteinizing hormone molecules are discharged from the pituitary gland, rather than the duration of the secretory episode itself, that provides for the self-priming effect.

Increased basal and pulsatile secretion of FSH and LH in young men with 47,XXY or 46,XX karyotypes.

OBJECTIVE The regulation of normal sexual maturation and reproductive function is dependent on a precise hormonal regulation at hypothalamic, pituitary, and gonadal levels. The aim of this study was to investigate the neuroendocrine integrity of the pituitary-gonadal axis in patients with primary testicular failure due to supernumerary X chromosomes. DESIGN Cross-sectional study. METHODS In this study, 7 untreated patients with primary gonadal insufficiency due to SRY-positive 46,XX (n=4) and 46,XXY karyotypes (n=3) aged 18.8 years and 25 age-matched healthy controls participated. Reproductive hormones, testicular size, and overnight LH and FSH serum profiles and overnight urine LH and FSH excretion were determined. RESULTS Basal LH and FSH secretion was elevated 6.3- and 25.4-fold respectively in the patients and the amount of LH and FSH secreted per burst were 2.0- and 6.6-fold elevated. We found significantly more LH but not FSH peaks per 24 h, as estimated by the Weibull lambda analysis. There was no difference between approximate entropy ratios or Weibull gamma analyses indicating comparable orderliness and regularity of LH and FSH secretion. Overnight urinary LH and FSH excretion was significantly elevated in patients compared with controls and correlated significantly with calculated total overnight LH and FSH secretion respectively, thus validating deconvolution. CONCLUSION In this group of patients with severe hypergonadotropic hypogonadism due to a supernumerary X chromosome, higher basal, pulsatile, and total LH and FSH secretion were associated with significantly more LH peaks per 24 h in comparison with healthy controls. Thus, our data indicate that in patients with Klinefelter syndrome and XX male karyotypes the entire hypothalamic-pituitary-gonadal axis has undergone functional changes.