Current Updates on Involvement of Artificial Intelligence and Machine Learning in Semen Analysis.

Background and Objectives: Infertility rates and the number of couples undergoing reproductive care have both increased substantially during the last few decades. Semen analysis is a crucial step in both the diagnosis and the treatment of male infertility. The accuracy of semen analysis results remains quite poor despite years of practice and advancements. Artificial intelligence (AI) algorithms, which can analyze and synthesize large amounts of data, can address the unique challenges involved in semen analysis due to the high objectivity of current methodologies. This review addresses recent AI advancements in semen analysis. Materials and Methods: A systematic literature search was performed in the PubMed database. Non-English articles and studies not related to humans were excluded. We extracted data related to AI algorithms or models used to evaluate semen parameters from the original studies, excluding abstracts, case reports, and meeting reports. Results: Of the 306 articles identified, 225 articles were rejected in the preliminary screening. The evaluation of the full texts of the remaining 81 publications resulted in the exclusion of another 48 articles, with a final inclusion of 33 original articles in this review. Conclusions: AI and machine learning are becoming increasingly popular in biomedical applications. The examination and selection of sperm by andrologists and embryologists may benefit greatly from using these algorithms. Furthermore, when bigger and more reliable datasets become accessible for training, these algorithms may improve over time.

Traditional, Complementary and Alternative Medicines in the Treatment of Ejaculatory Disorders: A Systematic Review.

Background and Objectives: Ejaculatory dysfunction (EjD) is a common male sexual disorder that includes premature ejaculation, delayed ejaculation, retrograde ejaculation, and anejaculation. Although psychological and pharmacological treatments are available, traditional, complementary, and alternative medicine (TCAM) is reportedly used. However, the clinical evidence for TCAM in EjD remains unclear. Therefore, this study aims to systematically review human clinical trials investigating the use of TCAM to treat EjD. Materials and Methods: A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted by searching Scopus and PubMed databases. Controlled clinical trials investigating a cohort of male patients diagnosed primarily with EjD and undergoing any TCAM intervention compared to any comparison group were included. Quality of the studies was assessed using the Cochrane Risk of Bias tool for randomized controlled trials. Results: Following article screening, 22 articles were included. Of these, 21 investigated TCAM in premature ejaculation, and only 1 investigated TCAM in retrograde ejaculation. Different TCAM categories included studies that investigated lifestyle, exercise and/or physical activities (n = 7); herbal medicine supplements (n = 5); topical herbal applications (n = 4); acupuncture or electroacupuncture (n = 3); vitamin, mineral and/or nutraceutical supplements (n = 1); hyaluronic acid penile injection (n = 1); and music therapy (n = 1). Only 31.8% (n = 7) of the included studies were found to have a low risk of bias. The available studies were widely heterogenous in the TCAM intervention investigated and comparison groups used. However, the included studies generally showed improved outcomes intra-group and when compared to placebo. Conclusions: Different TCAM interventions may have an important role particularly in the management of PE. However, more studies using standardized interventions are needed.

Unraveling the Molecular Impact of Sperm DNA Damage on Human Reproduction.

Semen analysis is the cornerstone in the investigation of fertility status of male partner. However, more advanced tests have emerged including the analysis of sperm chromatin integrity and DNA damage as markers of semen quality. This is of particular interest, as preserving the genetic information is essential to achieve a successful reproductive event. Moreover, the presence of unrepaired DNA lesions can affect cellular functions, resulting in the onset of pathological conditions associated with male infertility, and the transmission of diseases to the offspring. Hence, in this chapter, we aim to review the main factors leading to sperm DNA damage, along with the different types of damage which can occur. Furthermore, molecular mechanisms involved in DNA repair during spermatogenesis or after fertilization of the oocyte are described, and the laboratory techniques currently used in diagnostics and research, for the analysis of sperm DNA damage are also presented. Finally, the impact of sperm DNA damage on reproductive outcomes such as fertilization and pregnancy rates will be discussed with a focus on animal and human studies, along with the identification of new markers of sperm chromatin integrity.

Eurycoma longifolia (Jack) Improves Serum Total Testosterone in Men: A Systematic Review and Meta-Analysis of Clinical Trials.

Background and Objectives: Male hypogonadism is a clinical disorder characterized by reduced serum testosterone in men. Although treatment using herbal medicines, including Eurycoma longifolia, has been investigated, the benefits remain unclear. This study aims to investigate the efficacy of E. longifolia as a sole intervention to increase testosterone levels in males. Materials and Methods: We conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) according to the PRISMA guidelines. Relevant articles were retrieved from the databases PubMed, Scopus, Web of Science, Cochrane, Ovid/Embase, and Google Scholar. Results: After literature screening, a total of nine studies was included in the systematic review. Five RCTs were included in the meta-analysis. A significant improvement in total testosterone levels after E. longifolia treatment was mostly reported in both healthy volunteers and hypogonadal men. The random model effect revealed a significant increase (SMD = 1.352, 95% CI 0.565 to 2.138, p = 0.001) in the total testosterone levels in men receiving E. longifolia supplementation, which was confirmed in the hypogonadism subgroup. Conclusions: This systematic review and meta-analysis of the literature supports the possible use of E. longifolia supplementation for enhancing testosterone production. Although more research is required before its use in clinical practice, this may represent a safe and promising therapeutic option, particularly in hypogonadal men.

In vitro ameliorative effects of ellagic acid on vitality, motility and DNA quality in human spermatozoa.

Oxidative stress (OS) plays a significant role in the etiology of male infertility, resulting in the impairment of male reproduction. This condition, characterized by an imbalance in the levels of oxidizing and antioxidant species in the seminal fluid, has a harmful impact on sperm functions and DNA integrity. The present study aimed to evaluate the anti-genotoxic action of ellagic acid, a polyphenolic molecule of natural origin having a powerful antigenotoxic, anti-inflammatory and antiproliferative role. An OS condition was induced in vitro by incubating normozoospermic human semen samples in benzene for 45, 60 and 90 min. DNA integrity was evaluated by terminal deoxynucleotidyl transferase dUTP nick end labeling assay, RAPD-PCR was performed to calculate the genome template stability, while the percentage of intracellular reactive oxygen species (ROS) was assessed by the 2', 7'-dichlorofluorescein assay. Our results showed that ellagic acid has a consistent protective effect on DNA integrity, as well as on sperm vitality and motility, by counteracting generation of intracellular ROS. The results of this study suggest ellagic acid as a suitable molecule to protect sperm DNA from oxidative stress, with a potentially significant translational impact on the management of the male infertility.

COVID-19 related masks increase severity of both acne (maskne) and rosacea (mask rosacea): Multi-center, real-life, telemedical, and observational prospective study.

Masks are essential for COVID-19 prevention, but recently they were suggested to modify cutaneous facial microenvironment and trigger facial dermatoses. To evaluate mask-related rosacea and acne (maskne) in untreated patients during lockdown. In this multi-center, real-life, observational prospective study, we enrolled stable, untreated acne and rosacea patients that wore masks during lockdown at least 6 h/day. They underwent two teledermatological consultations, at the baseline and after 6 weeks. Clinical, pharmacological, and psychological data were recorded. A total 66 patients, 30 (median age: 34.0 [30.25-29.75] yoa) with acne and 36 patients (median age: 48 [43-54] years) with rosacea, were enrolled in this study. After 6 weeks of mask and quarantine, patients with acne displayed an increased Global Acne Grading Scale (GAGS) score in mask-related areas (P < .0001). Likewise, after 6 weeks of mask and quarantine, patients with rosacea displayed a worsen in both physican (P < .0001) and patient (P < .0001) reported outcomes. Remarkably, patients reported also a statistically significant decrease in their quality of life (P < .0001). Masks appear to trigger both acne and rosacea flares. Additional studies are needed to generate evidence and inform clinical decision-making.

Total antioxidant capacity-Relevance, methods and clinical implications.

Oxidative stress is pre-empted by an adequate level of antioxidants, which scavenge oxidants when they are produced in excess by different sources, including leukocytes and immature spermatozoa. Enzymatic antioxidants, such as superoxide dismutase, catalase and glutathione peroxidase, and several non-enzymatic antioxidants (proteins, vitamins and minerals), working as oxidant scavengers and cofactors of enzymatic antioxidants have been identified in seminal plasma. The total antioxidant capacity (TAC) is a diagnostic test that can be utilised in the male infertility workup. TAC measures the amount of total antioxidants in seminal plasma. Therefore, it provides an assessment of the reductive potential in seminal plasma. Several studies have investigated the diagnostic application of TAC in various andrology conditions. There is substantial evidence in the literature to show that infertile patients have lower seminal TAC in comparison with fertile men. Moreover, there is a positive correlation between TAC and seminal parameters, such as sperm concentration, motility and morphology. Evaluation of TAC together with reactive oxygen species (ROS) and sperm DNA fragmentation index (DFI) may be beneficial in the diagnosis of male infertility.

Diagnostic value of routine semen analysis in clinical andrology.

Infertility is a major health issue affecting over 48.5 million couples around the world, with the male factor accounting for about 50% of the cases. The conventional semen analysis recommended by the World Health Organization (WHO) is the cornerstone in the evaluation of male fertility status. It includes macroscopic and microscopic evaluation of the ejaculate, which reflects the production of spermatozoa in the testes, the patency of the duct system and the glandular secretory activity. Evaluation of seminal fructose, sperm vitality and leucocytes (Endtz test) are useful adjuncts to semen analysis that provide information on specific clinical conditions. Though several computer-assisted sperm analysis (CASA) systems have been developed, conventional methods for semen analysis are still widely accepted in clinical practice. This review summarises the conventional techniques used in routine semen analysis and their diagnostic value in clinical andrology.

Reactive oxygen species in male reproduction: A boon or a bane?

Reactive oxygen species (ROS) are free radicals derived from oxygen during normal cellular metabolism. ROS play a crucial role in the physiological processes and signalling pathways associated with male fertility. At physiological concentrations, ROS act as molecular mediators of signal transduction pathways involved in the regulation of the hypothalamic-pituitary-gonadal axis, spermatogenesis and steroidogenesis. They also trigger the morphological changes required for sperm maturation, such as DNA compaction and flagellar modification. Furthermore, ROS modulate crucial processes involved in the attainment of sperm fertilising ability such as capacitation, hyperactivation, acrosome reaction and sperm-oocyte fusion. Conversely, oxidative stress prevails when the concentration of ROS overwhelms the body's antioxidant defence. Various endogenous and exogenous factors enhance the synthesis of ROS resulting in the disruption of structural and functional integrity of spermatozoa through the induction of apoptotic pathway and oxidation of molecules, such as lipids, proteins and DNA. Therefore, maintenance of a balanced redox state is critical for normal male reproductive functions. This article discusses the dual role of ROS in male reproduction, highlighting the physiological role as well as their pathological implications on male fertility.

Evaluation of seminal oxidation-reduction potential in male infertility.

The role of oxidative stress in male infertility has been broadly recognised, and the search for a new marker to determine the redox environment in semen has gained considerable interest. Oxidation-reduction potential (ORP) or redox potential, is a measure of the electron transfer from antioxidants to oxidants and provides information on the redox balance. In this review, the benefits of ORP as a new oxidative stress marker, the protocol for its evaluation and the importance of its measurement in the context of male infertility are discussed. In association with the standard semen analysis, seminal ORP has been analysed to evaluate semen quality and male fertility status. However, further studies are required to establish its use in assisted reproductive techniques (ART) practice.

Proteomics and metabolomics - Current and future perspectives in clinical andrology.

Proteomics and metabolomics are emerging as promising tools to investigate the molecular mechanisms associated with male infertility. Proteins and metabolites play a pivotal role in regulating the molecular pathways associated with physiological functions of spermatozoa. Semen analysis, physical examination and laboratory work up cannot identify the etiology of infertility in 30%-40% of cases, which are classified as idiopathic. Therefore, the application of proteomics and metabolomics in the field of andrology will aid to overcome the limitations of the standard semen analysis. Understanding the molecular pathways associated with male infertility will help in planning ad hoc treatments, contributing to the clinical management of infertile patients. In this review, proteomics and metabolomics studies on spermatozoa and seminal plasma are discussed with a focus on molecular biomarkers associated with male infertility-related conditions.

Sperm DNA damage and cytokines in varicocele: A case-control study.

Varicocele is a vascular disease characterised by the abnormal enlargement of the pampiniform plexus veins and a well-known cause of male infertility. The aim of this study was to investigate the relationship between sperm DNA fragmentation (SDF) and inflammation in the pathogenesis of varicocele. We included 84 varicocele patients and 85 normozoospermic healthy controls, further analysed according to the body mass index, the smoking habit (smokers/non-smokers) and the varicocele severity (low/high grade). Semen parameters, SDF (by TUNEL) and inflammatory cytokines (by Luminex xMAP analysis) were evaluated. Varicocele patients showed significantly reduced semen parameters (volume, total sperm number, progressive motility, normal morphology) and increased SDF. Moreover, we observed a significant reduction of IFN-γ, IL-6, TNF-α and an increase of IL-10. No difference was reported according to the smoking habit, body mass index and varicocele severity. The observed cytokines pathway suggests the establishment of a chronic inflammatory condition, which may contribute to the alteration of semen quality. A thorough knowledge of the cytokine network might contribute to better understanding the link between inflammation and semen quality in varicocele and its impact on reproductive health.

A scientometric analysis of research publications on male infertility and assisted reproductive technology.

Assisted reproductive technologies (ART) are considered as one of the primary management options to address severe male factor infertility. The purpose of this study was to identify the research trends in the field of male infertility and ART over the past 20 years (2000-2019) by analysing scientometric data (the number of publications per year, authors, author affiliations, journals, countries, type of documents, subject area and number of citations) retrieved using the Scopus database. We used VOS viewer software to generate a network map on international collaborations as well as a heat map of the top scientists in this field. Our results revealed a total of 2,148 publications during this period with Cleveland Clinic Foundation contributing the most (n = 69). The current scientometric analysis showed that the research trend on ART has been stable over the past two decades. Further in-depth analysis revealed that density gradient centrifugation (46%) and intracytoplasmic sperm injection (59.2%) are the most reported techniques for sperm separation and ART, respectively. Additionally, azoospermia was the most studied clinical scenario (60.6%), with majority of articles reporting pregnancy rate (47.25%) as the primary reproductive outcome for ART. This study provides insight into the current focus of research in the area of male infertility and ART as well as the areas that require further research in future.

An online educational model in andrology for student training in the art of scientific writing in the COVID-19 pandemic.

In 2020, the COVID-19 pandemic led to the suspension of the annual Summer Internship at the American Center for Reproductive Medicine (ACRM). To transit it into an online format, an inaugural 6-week 2020 ACRM Online Mentorship Program was developed focusing on five core pillars of andrology research: scientific writing, scientific methodology, plagiarism understanding, soft skills development and mentee basic andrology knowledge. This study aims to determine mentee developmental outcomes based on student surveys and discuss these within the context of the relevant teaching and learning methodology. The mentorship was structured around scientific writing projects established by the team using a student-centred approach, with one-on-one expert mentorship through weekly formative assessments. Furthermore, weekly online meetings were conducted, including expert lectures, formative assessments and social engagement. Data were collected through final assessments and mentee surveys on mentorship outcomes. Results show that mentees (n = 28) reported a significant (p < .0001) improvement in all criteria related to the five core pillars. These results illustrate that the aims of the online mentorship program were achieved through a unique and adaptive online educational model and that our model has demonstrated its effectiveness as an innovative structured educational experience through the COVID-19 crisis.

Seminal oxidation-reduction potential levels are not influenced by the presence of leucocytospermia.

Oxidative stress (OS) is characterised by an excessive amount of reactive oxygen species (ROS) which negatively affect sperm functions. In this study, the influence of leucocytes on seminal oxidation-reduction potential (ORP) and sperm DNA fragmentation (SDF) was investigated in 1,068 men. Seminal leucocyte concentration did not correlate with SDF, unadjusted ORP, ORP normalised for sperm concentration (sORP), ORP normalised for total motile sperm concentration (motORP) or total motile sperm count (TMSC-ORP). Although receiver operator characteristic (ROC) curve analyses show that leucocytospermia does not predict high sORP values (>1.34 mV/106 spermatozoa/ml), the motORP (AUC: 0.666) and TMSC-ORP (AUC: 0.683) predict the rate of leucocytospermia significantly (p = .0195 and p = .0085 respectively). Moreover, SDF can significantly predict leucocytospermia (AUC: 0.679; p = .011) and vice versa (AUC: 0.657, p = .0298). Our data confirm the association between OS and SDF. In conclusion, motORP and TMSC-ORP may be better predictive factors of leucocytospermia, probably because sperm motility, included in motORP and TMSC-ORP calculation, is the first seminal parameter to be affected by OS. Although all these parameters are indicative of OS, ORP values, SDF and leucocytospermia should be considered independently for the evaluation of redox seminal status, as they probe distinct seminal features.

Dysregulation of Key Proteins Associated with Sperm Motility and Fertility Potential in Cancer Patients.

Cancer has adverse effects on male reproductive health. Conventional semen analysis does not explain the molecular changes in the spermatozoa of cancer patients. Currently, proteomics is being widely used to identify the fertility-associated molecular pathways affected in spermatozoa. The objective of this study was to evaluate the sperm proteome of patients with various types of cancer. Cryopreserved semen samples from patients (testicular cancer, n = 40; Hodgkin's disease, n = 32; lymphoma, n = 20; leukemia, n = 17) before starting therapy were used for proteomic analysis, while samples from fertile donors (n = 19) were included as controls. The proteomic profiling of sperm was carried out by liquid chromatography-tandem mass spectrometry, and differentially expressed proteins involved in the reproductive processes were validated by Western blotting. Bioinformatic analysis revealed that proteins associated with mitochondrial dysfunction, oxidative phosphorylation, and Sirtuin signaling pathways were dysregulated in cancer patients, while oxidative phosphorylation and tricarboxylic acid cycle were predicted to be deactivated. Furthermore, the analysis revealed dysregulation of key proteins associated with sperm fertility potential and motility (NADH:Ubiquinone oxidoreductase core subunit S1, superoxide dismutase 1, SERPINA5, and cytochrome b-c1 complex subunit 2) in the cancer group, which were further validated by Western blot. Dysfunctional molecular mechanisms essential for fertility in cancer patients prior to therapy highlight the potential impact of cancer phenotype on male fertility.

The Impact of Single- and Double-Strand DNA Breaks in Human Spermatozoa on Assisted Reproduction.

Several cellular insults can result in sperm DNA fragmentation either on one or both DNA strands. Oxidative damage, premature interruption of the apoptotic process and defects in DNA compaction during spermatogenesis are the main mechanisms that cause DNA breaks in sperm. The two-tailed Comet assay is the only technique that can differentiate single- (SSBs) from double- (DSBs) strand DNA breaks. Increased levels of the phosphorylated isoform of the H2AX histone are directly correlated with DSBs and proposed as a molecular biomarker of DSBs. We have carried out a narrative review on the etiologies associated with SSBs and DSBs in sperm DNA, their association with reproductive outcomes and the mechanisms involved in their repair. Evidence suggests a stronger negative impact of DSBs on reproductive outcomes (fertilization, implantation, miscarriage, pregnancy, and live birth rates) than SSBs, which can be partially overcome by using intracytoplasmic sperm injection (ICSI). In sperm, SSBs are irreversible, whereas DSBs can be repaired by homologous recombination, non-homologous end joining (NHEJ) and alternative NHEJ pathways. Although few studies have been published, further research is warranted to provide a better understanding of the differential effects of sperm SSBs and DSBs on reproductive outcomes as well as the prognostic relevance of DNA breaks discrimination in clinical practice.

Tracking research trends and hotspots in sperm DNA fragmentation testing for the evaluation of male infertility: a scientometric analysis.

BACKGROUND: This article describes the research trends in sperm DNA fragmentation (SDF) over the past 20 years (1999-2018) using a scientometric approach. METHODS: A stepwise approach was adopted to retrieve scientometric data (articles per year, authors, affiliations, journals, countries) from Scopus and analyze the publication pattern of SDF with reference to key areas of research in the field of Andrology. RESULTS: A total of 2121 articles were retrieved related to SDF. Our data revealed an increasing research trend in SDF (n = 33 to n = 173) over the past 20 years (R2 = 0.894). Most productive country in publications was the USA (n = 450), while Agarwal A. (n = 129) being the most productive author. Most of the articles in SDF were primarily focused on lifestyle (n = 157), asthenozoospermia (n = 135) and varicocele (130). Mechanistic studies on SDF were published twice as much as prognostic/diagnostic studies, with significant emphasis on oxidative stress. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) was the most widely used technique to evaluate SDF. Publications on SDF related to assisted reproductive techniques also showed a linear increasing trend (R2 = 0.933). CONCLUSIONS: Our analysis revealed an increasing trend in SDF publications predominantly investigating lifestyle, asthenozoospermia and varicocele conditions with TUNEL being the most widely used technique. A substantial increase in research is warranted to establish SDF as prognostic/diagnostic parameter to evaluate clinical scenarios and ART outcomes.

The Effect of Aqueous Lessertia frutescens Extract on TM3 Leydig Cells Exposed to TNF-α in vitro.

BACKGROUND: Extractions of Lessertia frutescens (Lf) are shown to have immune modulation, anti-inflammatory and antioxidant properties. However, Lf is also cytotoxic, antiproliferative, and pro-apoptotic in vitro. Furthermore, Lf extractions may influence steroidogenesis. Nevertheless, the impact on Leydig cell function has not previously been investigated. As tumor necrosis factor-alpha (TNF-α) is known to cause Leydig cell dysfunction under inflammatory conditions, it is further proposed that Lf extracts may protect against the negative impact of TNF-α on Leydig cells. The aim of the study was to investigate the effect of an aqueous Lessertia frutescens extract (LFE) on Leydig cells exposed to TNF-αin vitro. METHODS: Human chorionic gonadotrophin-stimulated TM3 Leydig cells were exposed for 24 h to (a) TNF-α (0.1, 1, 10, 100 ng/mL), (b) LFE (0.01, 0.1, 1, 10, 100 ng/mL), and (c) co-exposure to 10 ng/mL TNF-α and LFE (0.01, 0.1, 1, 10, 100 ng/mL). We analyzed cell viability, cytotoxicity, caspase 3/7 activation, testosterone concentration, and intracellular superoxide. RESULTS: TNF-α exposure decreased cell viability, increased cytotoxicity, and caspase 3/7, with no significant effect on intracellular superoxide in TM3 Leydig cells. When LFE concentrations of 0.01-10 ng/mL were tested, we observed improved vitality and reduced levels of caspase 3/7. At 100 ng/mL, LFE decreased viability and increased cytotoxicity and caspase 3/7. However, LFE did not affect intracellular superoxide. Furthermore, LFE protected against 10 ng/mL TNF-α-induced cytotoxicity and apoptosis, except at the highest concentration. LFE alone and in co-culture with 10 ng/mL TNF-α increased testosterone at high concentrations. CONCLUSIONS: In our TM3 Leydig cell model, LFE protected against TNF-α-induced cytotoxicity and early apoptosis, except at the highest experimental concentrations, where it was cytotoxic. These effects were not mediated through a change in intracellular superoxide. Although further investigations are warranted, aqueous LFE may protect against TNF-α-induced Leydig cell dysfunction.