Silvia Ippolito

Infertility as a proxy of general male health: results of a cross-sectional survey

OBJECTIVE To evaluate the prevalence, and clinical and seminal impact of comorbidities in white European men presenting for couple infertility. DESIGN Cross-sectional study. SETTING Academic reproductive medicine outpatient clinic. PATIENT(S) Cohort of 2,100 consecutive infertile men (noninterracial infertile couples). INTERVENTION(S) Obtaining complete demographic, clinical, and laboratory data from 2,100 consecutive infertile men with health-significant comorbidities scored via the Charlson comorbidity index (CCI; categorized 0 vs. 1 vs. ≥2) and semen analysis values assessed based on 2010 World Health Organization reference criteria. MAIN OUTCOME MEASURE(S) Assessment of the rate of comorbidities by means of CCI scores and possible associations between CCI, semen and hormonal parameters. RESULT(S) Descriptive statistics and regression models tested the associations among semen parameters, clinical characteristics, and CCI. When assessing general comorbidity prevalence, CCI 0, CCI 1, and CCI ≥2 was found in 1,921 (91.5%), 102 (4.9%), and 77 (3.6%) patients, respectively. Patient age and follicle-stimulating hormone levels increased as the general health status decreased. Conversely, the total testosterone levels and sperm concentration decreased as CCI scores increased. A higher rate of oligozoospermia and nonobstructive azoospermia was observed in patients with CCI ≥1. No differences were observed among the considered comorbidity groups in terms of testicular volume or further hormonal or seminal parameters. Both continuously coded and categorized sperm concentrations were independent predictors of CCI ≥1. Patients with sperm concentration <45.6 million/mL (most informative cutoff value) had a 2.74-fold increased risk of having a CCI ≥1. CONCLUSION(S) Decreased general health status appears to be associated with impaired male reproductive health, including lower sperm concentration, lower total testosterone levels, and higher follicle-stimulating hormone values.

When to Perform Karyotype Analysis in Infertile Men? Validation of the European Association of Urology Guidelines with the Proposal of a New Predictive Model

Known genetic alterations play a major role in perturbing male reproductive health. We sought to retrospectively validate the European Association of Urology (EAU) guidelines for karyotype analysis (KA) in a homogenous cohort of 1168 White European men presenting for primary couples infertility (noninterracial infertile couples only) and to develop a novel nomogram capable of predicting karyotype alterations. Overall, 742 (63.5%) patients would have deserved KA according to the EAU guidelines. Of those, 48 (6.9% of the assessable patients according to EAU guidelines) displayed any kind of alteration at KA. Conversely, hypothetically relying on the EAU criteria, 12 (20%) out of 60 patients with karyotype abnormalities would not have been candidates for the same genetic assessment. Overall, 694 (62.6%) patients would have been candidates for genetic workup despite having a normal karyotype. As a whole, the EAU guideline sensitivity, specificity, and discrimination were 80%, 37%, and 59%, respectively. We developed a novel nomogram, with a 2% probability cut-off, which allows for a more careful detection of KA alterations. PATIENT SUMMARY The application of the European Association of Urology guidelines for karyotype analysis does not ensure an adequate diagnostic process. In this regard, we propose a novel diagnostic tool to improve detection of alterations at karyotype analysis.

Primary, secondary and compensated hypogonadism: a novel risk stratification for infertile men

Recently, the cohort of men from the European Male Ageing Study has been stratified into different categories distinguishing primary, secondary and compensated hypogonadism. A similar classification has not yet been applied to the infertile population. We performed a cross‐sectional study enrolling 786 consecutive Caucasian‐European infertile men segregated into eugonadal [normal serum total testosterone (≥3.03 ng/mL) and normal luteinizing hormone (≤9.4 mU/mL)], secondary (low total testosterone, low/normal luteinizing hormone), primary (low total testosterone, elevated luteinizing hormone) and compensated hypogonadism (normal total testosterone; elevated luteinizing hormone). In this cross‐sectional study, logistic regression models tested the association between semen parameters, clinical characteristics and the defined gonadal status. Eugonadism, secondary, primary and compensated hypogonadism were found in 80, 15, 2, and 3% of men respectively. Secondary hypogonadal men were at highest risk for obesity [OR (95% CI): 3.48 (1.98–6.01)]. Primary hypogonadal men were those at highest risk for azoospermia [24.54 (6.39–161.39)] and testicular volume <15 mL [12.80 (3.40–83.26)]. Compensated had a similar profile to primary hypogonadal men, while their risk of azoospermia [5.31 (2.25–13.10)] and small testicular volume [8.04 (3.17–24.66)] was lower. The risk of small testicular volume [1.52 (1.01–2.33)] and azoospermia [1.76 (1.09–2.82)] was increased, although in a milder fashion, in secondary hypogonadal men as well. Overall, primary and compensated hypogonadism depicted the worst clinical picture in terms of impaired fertility. Although not specifically designed for infertile men, European Male Ageing Study categories might serve as a clinical stratification tool even in this setting.

Low Birth Weight Is Associated with a Decreased Overall Adult Health Status and Reproductive Capability - Results of a Cross-Sectional Study in Primary Infertile Patients.

Individuals born with low birth weight (LBW) risk cardiometabolic complications later in life. However the impact of LBW on general health status and male reproductive function has been scantly analysed. We investigated the clinical and seminal impact of different birth weights (BW) in white-European men presenting for primary couple’s infertility. Demographic, clinical, and laboratory data from 827 primary infertile men were compared with those of 373 consecutive fertile men. Patients with BW ≤2500, 2500–4200, and ≥4200gr were classified as having LBW, normal (NBW), and high BW (HBW), respectively. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Testicular volume was assessed with a Prader orchidometer. Semen analysis values were assessed based on 2010 WHO reference criteria. Descriptive statistics and regression models tested associations between semen parameters, clinical characteristics and BW categories. LBW, NBW and HBW were found in 71 (8.6%), 651 (78.7%) and 105 (12.7%) infertile men, respectively. LBW was more frequent in infertile patients than fertile men (p = 0.002). Infertile patients with LBW had a higher rate of comorbidities (p = 0.003), lower mean testicular volume (p = 0.007), higher FSH (p = 0.02) and lower tT levels (p = 0.04) compared to other BW groups. Higher rates of asthenozoospermia (p = 0.02) and teratozoospermia (p = 0.03) were also found in LBW men. At logistic regression models, LBW was univariably associated with pathologic progressive motility (p≤0.02) and pathologic sperm morphology (p<0.005). At multivariable logistic regression analysis, LBW achieved independent predictor status for both lower sperm motility and pathologic sperm morphology (all p≤0.04). Only LBW independently predicted higher CCI values (p<0.001). In conclusion, we found that LBW was more frequent in infertile than in fertile men. Infertile individuals with LBW showed a higher rate of comorbidities and significantly worse clinical, endocrine and semen parameters compared to other BW groups.

Testicular microbiome in azoospermic men—first evidence of the impact of an altered microenvironment

Abstract STUDY QUESTION Given the relevant role of the extracellular microenvironment in regulating tissue homeostasis, is testicular bacterial microbiome (BM) associated with germ cell aplasia in idiopathic non-obstructive azoospermia (iNOA)? SUMMARY ANSWER A steady increase of dysbiosis was observed among testis with normal spermatogenesis vs. iNOA with positive sperm retrieval and iNOA with complete germ cell aplasia. WHAT IS KNOWN ALREADY Tissue-associated BM has been reported to be a biologically important extracellular microenvironment component for numerous body habitats, but not yet for the human testis. STUDY DESIGN, SIZE, DURATION Cross-sectional study, investigating tissue-associated BM in the testis of (i) five men with iNOA and negative sperm retrieval at microdissection testicular sperm extraction (microTESE); (ii) five men with iNOA and positive sperm retrieval at microTESE; and (iii) five normozoospermic men upon orchiectomy. Every testicular specimen was histologically classified and analyzed in terms of bacterial community. PARTICIPANTS/MATERIALS, SETTING, METHODS Massive ultra-deep pyrosequencing was applied to investigate testis microbiome. Metagenome was analyzed using Quantitative Insights Into Microbial Ecology (QIIME). Tissue-associated bacterial load was quantified by digital droplet PCR. MAIN RESULTS AND THE ROLE OF CHANCE Normozoospermic men showed small amounts of bacteria in the testis, with Actinobacteria, Bacteroidetes, Firmicutes Proteobacteria as the dominating phyla; iNOA individuals had increased amounts of bacterial DNA (P = 0.02), associated with decreased taxa richness due to the lack of Bacteroidetes and Proteobacteria (P = 2 × 10−5). Specimens with negative sperm retrieval at microTESE depicted complete germ cell aplasia and a further decrease in terms of Firmicutes and Clostridia (P < 0.05), a complete lack of Peptoniphilus asaccharolyticus, but increased amount of Actinobacteria. LIMITATIONS, REASONS FOR CAUTION The limited number of specimens analyzed in this preliminary study deserves external validation. The paraneoplastic microenvironment could have an impact on the residential bacterial flora. WIDER IMPLICATION OF THE FINDINGS Human testicular microenvironment is not microbiologically sterile, containing low amounts of Actinobacteria, Bacteroidetes, Firmicutes and Proteobacteria. A dysbiotic bacterial community was associated with iNOA and complete germ cell aplasia. Novel findings on testicular BM could support future translational therapies of male-factor infertility. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by URI-Urological Research Institute free funds. Authors declared no conflict of interest. TRIAL REGISTRATION NUMBER N/A.

181 Low birth weight is associated with a higher rate of health-significant comorbidities and worse seminal parameters – results of a cross-sectional study in primary infertile patients

INTRODUCTION AND OBJECTIVES: The raise of the developmental origins of adult disease has positioned low birth weight (LBW) as a significant health issue. We assessed prevalence of, and clinical and seminal impact of different categories of weight at birth in a cohort of white-European men presenting for primary couple’s infertility. METHODS: Complete data from 757 consecutive infertile men were analyzed. Patient with birth weight 2500, 2500 e 4200, and 4200 gr were considered as having LBW, normal birth weight (NBW) and high birth weight (HBW), respectively. Comorbidities were scored with the Charlson Comorbidity Index (CCI; categorized 0 vs 1 vs 2). Body mass index (BMI) was considered for each patient using NIH cut offs [normal weight (18.5e24.9), overweight (25.0e29.9), and class 1 obesity ( 30.0)]. Testicular volume (TV) was assessed with a Prader orchidometer. Semen analysis values were assessed based on 2010 WHO reference criteria. Descriptive statistics detailed the association between semen parameters and clinical characteristics and the defined birth weight categories. RESULTS: Of all, LBW, NBW and HBW were found in 52 (6.9%), 605 (79.9%) and 100 (13.2%) men, respectively. Normal BMI value and BMI suggestive for NIH class 1 obesity was more frequently reported in LBW and HBW (p<0.001), respectively. Of all, LBW reported a higher prevalence of comorbidities (p<0.001). Likewise, hypercholesterolemia (p1⁄40.04) and hypertriglyceridemia (p1⁄40.01) were more frequently reported in both LBW and HBW. LBW had a lower mean TV (p1⁄40.02). At semen analysis, LBW men showed a higher rate of both asthenozoospermia (p1⁄40.02) and teratozoospermia (p1⁄40.02). Overall, ejaculated volume (p1⁄40.006), sperm motility (p1⁄40.02) and normal morphology (p1⁄40.04) were significantly reduced in the LBW group. Likewise, LBW patients presented higher FSH levels (p1⁄40.04) but lower circulating testosterone levels (p1⁄40.03) as compared with the other groups. At MVA, LBW achieved independent predictor status for a higher CCI value (OR 3.7; p<0.001), lower sperm motility (OR 2.7; p<0.04), and lower normal sperm morphology (OR 2.3; p<0.04). CONCLUSIONS: Current findings in infertile patients showed that LBW was associated with a significant higher rate of adult diseases. Clinical, endocrine and semen parameters were significantly worse in the LBW group. These data confirmed the importance of the theory of LBW as a significant predictor of impaired health issue.