Standards in semen examination: publishing reproducible and reliable data based on high-quality methodology.

Biomedical science is rapidly developing in terms of more transparency, openness and reproducibility of scientific publications. This is even more important for all studies that are based on results from basic semen examination. Recently two concordant documents have been published: the 6th edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen, and the International Standard ISO 23162:2021. With these tools, we propose that authors should be instructed to follow these laboratory methods in order to publish studies in peer-reviewed journals, preferable by using a checklist as suggested in an Appendix to this article.

Association of serum leptin at 24-28 weeks gestation with initiation and progression of labor in women.

Concentrations of the hormone leptin, which is produced by adipose tissue, increase with increasing BMI, whereas leptin sensitivity often declines with higher BMI. Thus, altered leptin signaling may play a role in reproductive health risks observed with increasing BMI, which include later onset and slow progression of labor. Conflicting evidence from clinical, animal and in vitro studies have suggested that leptin either promotes or inhibits labor. We hypothesized that serum leptin concentrations or serum leptin: body mass index (BMI) ratios in women may be associated with the initiation and progression of labor. Following informed consent, serum samples were collected from 90 women with singleton pregnancies at the time of routine glucose-challenge testing, for measurement of leptin. The potential influence of leptin on gestation length and cervical dilation timing were examined by multiple linear regression. Data were analyzed from 63 participants who met exclusion and inclusion criteria. Leptin concentrations (log-transformed) at 24-28 weeks gestation were not significantly correlated with first trimester BMI . Log serum leptin and leptin: BMI ratio each were significantly associated with shorter total gestation length in uncomplicated, term pregnancies. In contrast, the mid-pregnancy leptin concentrations were not associated with progression of labor, assessed by cervical dilation over time. The association between higher serum leptin and shorter gestation length is consistent with the hypothesis that leptin promotes, or is permissive for, the onset of labor.

Associations Between Prenatal Urinary Biomarkers of Phthalate Exposure and Preterm Birth: A Pooled Study of 16 US Cohorts.

Importance: Phthalate exposure is widespread among pregnant women and may be a risk factor for preterm birth. Objective: To investigate the prospective association between urinary biomarkers of phthalates in pregnancy and preterm birth among individuals living in the US. Design, Setting, and Participants: Individual-level data were pooled from 16 preconception and pregnancy studies conducted in the US. Pregnant individuals who delivered between 1983 and 2018 and provided 1 or more urine samples during pregnancy were included. Exposures: Urinary phthalate metabolites were quantified as biomarkers of phthalate exposure. Concentrations of 11 phthalate metabolites were standardized for urine dilution and mean repeated measurements across pregnancy were calculated. Main Outcomes and Measures: Logistic regression models were used to examine the association between each phthalate metabolite with the odds of preterm birth, defined as less than 37 weeks of gestation at delivery (n = 539). Models pooled data using fixed effects and adjusted for maternal age, race and ethnicity, education, and prepregnancy body mass index. The association between the overall mixture of phthalate metabolites and preterm birth was also examined with logistic regression. G-computation, which requires certain assumptions to be considered causal, was used to estimate the association with hypothetical interventions to reduce the mixture concentrations on preterm birth. Results: The final analytic sample included 6045 participants (mean [SD] age, 29.1 [6.1] years). Overall, 802 individuals (13.3%) were Black, 2323 (38.4%) were Hispanic/Latina, 2576 (42.6%) were White, and 328 (5.4%) had other race and ethnicity (including American Indian/Alaskan Native, Native Hawaiian, >1 racial identity, or reported as other). Most phthalate metabolites were detected in more than 96% of participants. Higher odds of preterm birth, ranging from 12% to 16%, were observed in association with an interquartile range increase in urinary concentrations of mono-n-butyl phthalate (odds ratio [OR], 1.12 [95% CI, 0.98-1.27]), mono-isobutyl phthalate (OR, 1.16 [95% CI, 1.00-1.34]), mono(2-ethyl-5-carboxypentyl) phthalate (OR, 1.16 [95% CI, 1.00-1.34]), and mono(3-carboxypropyl) phthalate (OR, 1.14 [95% CI, 1.01-1.29]). Among approximately 90 preterm births per 1000 live births in this study population, hypothetical interventions to reduce the mixture of phthalate metabolite levels by 10%, 30%, and 50% were estimated to prevent 1.8 (95% CI, 0.5-3.1), 5.9 (95% CI, 1.7-9.9), and 11.1 (95% CI, 3.6-18.3) preterm births, respectively. Conclusions and Relevance: Results from this large US study population suggest that phthalate exposure during pregnancy may be a preventable risk factor for preterm delivery.

Sperm Cohort-Specific Zinc Signature Acquisition and Capacitation-Induced Zinc Flux Regulate Sperm-Oviduct and Sperm-Zona Pellucida Interactions.

Building on our recent discovery of the zinc signature phenomenon present in boar, bull, and human spermatozoa, we have further characterized the role of zinc ions in the spermatozoa's pathway to fertilization. In boar, the zinc signature differed between the three major boar ejaculate fractions, the initial pre-rich, the sperm-rich, and the post-sperm-rich fraction. These differences set in the sperm ejaculatory sequence establish two major sperm cohorts with marked differences in their sperm capacitation progress. On the subcellular level, we show that the capacitation-induced Zn-ion efflux allows for sperm release from oviductal glycans as analyzed with the oviductal epithelium mimicking glycan binding assay. Sperm zinc efflux also activates zinc-containing enzymes and proteases involved in sperm penetration of the zona pellucida, such as the inner acrosomal membrane matrix metalloproteinase 2 (MMP2). Both MMP2 and the 26S proteasome showed severely reduced activity in the presence of zinc ions, through studies using by gel zymography and the fluorogenic substrates, respectively. In the context of the fertilization-induced oocyte zinc spark and the ensuing oocyte-issued polyspermy-blocking zinc shield, the inhibitory effect of zinc on sperm-borne enzymes may contribute to the fast block of polyspermy. Altogether, our findings establish a new paradigm on the role of zinc ions in sperm function and pave the way for the optimization of animal semen analysis, artificial insemination (AI), and human male-factor infertility diagnostics.

Semen and reproductive hormone parameters in fertile men with and without varicocele.

Although varicoceles are a widely accepted identifiable male factor in infertile couples, the benefit of varicocele repair in improving pregnancy and live birth rates remains uncertain. The Study for Future Families obtained semen and reproductive hormone samples from US men whose partners were currently pregnant. In our analysis cohort of 709 men, a varicocele was detected by clinical examination in 56 (8%) of men. Men with varicocele had smaller left testis, and lower total and total motile sperm counts than men without varicocele. Gonadotropin levels were higher as well in men with varicocele. Interestingly, testosterone levels were also slightly higher in men with varicocele. Despite these differences, there was no difference between the groups in the time to achieve the study pregnancy or percentage of men with a previous pregnancy. We conclude that even in fertile men, varicoceles are associated with some degree of testicular hypofunction. This would support current recommendations to consider varicocele repair in male partners in infertile couples who demonstrate both a varicocele and abnormal semen parameters and after evaluation for treatable female factors.

The activation of the chymotrypsin-like activity of the proteasome is regulated by soluble adenyl cyclase/cAMP/protein kinase A pathway and required for human sperm capacitation.

One of the first events of mammalian sperm capacitation is the activation of the soluble adenyl cyclase/cAMP/protein kinase A (SACY/cAMP/PKA) pathway. Here, we evaluated whether the increase in PKA activity at the onset of human sperm capacitation is responsible for the activation of the sperm proteasome and whether this activation is required for capacitation progress. Viable human sperm were incubated with inhibitors of the SACY/cAMP/PKA pathway. The chymotrypsin-like activity of the sperm proteasome was evaluated using a fluorogenic substrate. Sperm capacitation status was evaluated using the chlortetracycline assay and tyrosine phosphorylation. To determine whether proteasomal subunits were phosphorylated by PKA, the proteasome was immunoprecipitated and tested on a western blot using an antibody against phosphorylated PKA substrates. Immunofluorescence microscopy analysis and co-immunoprecipitation (IPP) were used to investigate an association between the catalytic subunit alpha of PKA (PKA-Cα) and the proteasome. The chymotrypsin-like activity of the sperm proteasome significantly increased after 5 min of capacitation (P < 0.001) and remained high for the remaining incubation time. Treatment with H89, KT5720 or KH7 significantly decreased the chymotrypsin-like activity of the proteasome (P < 0.001). IPP experiments indicated that PKA inhibition significantly modified phosphorylation of proteasome subunits. In addition, PKA-Cα colocalized with the proteasome in the equatorial segment and in the connecting piece, and co-immunoprecipitated with the proteasome. This is the first demonstration of sperm proteasome activity being directly regulated by SACY/PKA-Cα. This novel discovery extends our current knowledge of sperm physiology and may be used to manage sperm capacitation during assisted reproductive technology procedures.

Cervical and systemic concentrations of long acting hormonal contraceptive (LARC) progestins depend on delivery method: Implications for the study of HIV transmission.

Progestin-only long-acting reversible contraceptives (LARCs) are increasingly popular among women seeking contraception; however, recent epidemiological studies suggest that systemically administered medroxyprogesterone acetate (MPA) may increase HIV acquisition. In order to determine the exact mechanisms underlying increases in transmission specific to MPA use and to test safer, alternative contraceptive progestin types and delivery methods, in vitro modeling studies must be performed. To achieve this, it is imperative that accurate hormone concentrations be utilized when modeling progestin-mediated outcomes, as the down-stream effects are dose-dependent. The local concentrations of progestins to which the lower female genital tract tissues are exposed after initiation of LARCs are unknown, but they likely differ from peripheral concentrations, dependent upon the progestin type and delivery method. Here, we measured in vivo endocervical and plasma concentrations of (1) systemically-delivered depo MPA (DMPA), (2) levonorgestrel (LNG) delivered via intrauterine system (IUS) and (3) etonogestrel (ETG) delivered via vaginal ring in women who recently initiated contraception treatment. Levels of ETG and LNG in cervical secretions were 100-200 fold higher than plasma levels. In contrast, measurable MPA levels were approximately 10-fold higher in plasma compared to cervical secretions. These results will inform the design of accurate in vitro studies on the influence of progestins on epithelial cells, tissue explants, and peripheral blood cells, to be able to better predict in vivo outcomes. Subsequent observations will aid in determining how MPA might influence HIV acquisition and may facilitate identification of optimal progestin-containing LARC alternatives for women at high risk for HIV infection.

Effects of three long-acting reversible contraceptive methods on HIV target cells in the human uterine cervix and peripheral blood.

BACKGROUND: Hormonal contraceptives, particularly depot medroxyprogesterone acetate (DMPA), have been reported to be associated with substantially enhanced HIV acquisition; however, the biological mechanisms of this risk remain poorly understood. We aimed to investigate the effects of different hormonal contraceptives on the expression of the HIV co-receptors, CXCR4 and CCR5, on female endocervical and peripheral blood T cells. METHODS: A total of 59 HIV-negative women were enrolled, including 15 initiating DMPA, 28 initiating a levonorgestrel-releasing intrauterine device (LNG-IUD) and 16 initiating an etonogestrel (ETG)-delivering vaginal ring. Peripheral blood and endocervical cytobrush specimens were collected at enrollment and 3-4 weeks after contraception initiation to analyze the expression of CXCR4 and CCR5, on CD4+ and CD8+ T cells using flow cytometry. RESULTS: Administration of DMPA increased the percentages of CD4+ and CD8+ T cells expressing CCR5 in the endocervix but not in the peripheral blood. Administration of the LNG-IUD or the ETG vaginal ring did not affect the percentages of T lymphocytes expressing CXCR4 or CCR5 in the female cervix or peripheral blood. CONCLUSIONS: Increase in the percentage of endocervical T cells expressing CCR5 upon DMPA exposure provides a plausible biological explanation for the association between DMPA use and an elevated risk of HIV infection.

Intravaginal Diazepam for the Treatment of Pelvic Floor Hypertonic Disorder: A Double-Blind, Randomized, Placebo-Controlled Trial.

OBJECTIVES: Pelvic floor hypertonic disorder is characterized by an involuntary spasm of the levator ani muscles and is associated with several clinical syndromes. Several treatment options have been described; however, treatment efficacy data are limited. The objective of this study was to determine the efficacy of intravaginal diazepam for the treatment of pelvic pain secondary to levator ani muscle spasm in comparison to placebo. METHODS: Adult women with complaints of pelvic pain, who were noted to have levator ani muscle spasm on physical examination, were approached for enrollment in a double-blind, placebo-controlled, randomized clinical trial. Eligible participants were randomized to receive 10-mg diazepam capsules or identical-appearing placebo capsules. The primary outcome was the change in pain scores measured by a 100-mm visual analog scale at 4 weeks. Several validated questionnaires were similarly assessed as secondary outcomes. RESULTS: In total, 49 women were randomized (25 in the diazepam arm and 24 in the placebo arm). At 4 weeks, 35 women returned for follow-up and had complete data available analysis. There was no difference in visual analog scale scores between the treatment groups after 4 weeks (50 vs 39 mm, for diazepam and placebo, respectively; P = 0.36). There were also no differences noted in the questionnaire scores. CONCLUSIONS: It is unlikely that self-administered intravaginal diazepam suppositories promote an improvement in the 100-mm visual analog scale of 20 mm or more or other substantial symptom improvement in women with pelvic floor hypertonic disorder.

Zinc ion flux during mammalian sperm capacitation.

Sperm capacitation, the ultimate maturation event preparing mammalian spermatozoa for fertilization, was first described in 1951, yet its regulatory mechanisms remain poorly understood. The capacitation process encompasses an influx of bicarbonate and calcium ions, removal of decapacitating factors, changes of pH and sperm proteasomal activities, and the increased protein tyrosine phosphorylation. Here, we document a novel biological phenomenon of a unique zinc (Zn2+) ion redistribution associated with mammalian sperm in vitro capacitation (IVC). Using image-based flow cytometry (IBFC), we identified four distinct types of sperm zinc ion distribution patterns (further zinc signature) and their changes during IVC. The zinc signature was altered after sperm capacitation, reduced by proteasomal inhibitors, removed by zinc chelators, and maintained with addition of external ZnCl2. These findings represent a fundamental shift in the understanding of mammalian fertilization, paving the way for improved semen analysis, in vitro fertilization (IVF), and artificial insemination (AI).

Non-indicated use of prophylactic antibiotics in gynaecological surgery at an academic tertiary medical centre.

Surgical site infections (SSI) are the most common surgical complication. Perioperative antibiotics can reduce SSI when used properly. Despite guidelines from The American College of Obstetrics and Gynecology, non-indicated antibiotic use is widespread which exposes women to unnecessary risks. This study represents a quality improvement analysis assessing surgeon compliance with established guidelines regarding antibiotic use in gynaecological surgery. This is a single centre, retrospective study examining gynaecological procedures over two years. Cases were identified using Current Procedure Terminology codes. Perioperative antibiotics were used contrary to published guidelines in 199 of 1046 cases. Three variables were independently associated with inappropriate administration of perioperative antibiotics: entrance into abdominal cavity, higher EBL, and longer procedures. Impact statement Overuse of antibiotics has unintended consequences including allergic sequelae, extended length of hospital stay, increased healthcare costs, and the formation of antibiotic-resistant organisms. Antibiotic stewardship programmes have been shown to reduce the number of resistant pathogens, decrease incidence of Clostridium difficile colitis, and decrease length of hospital stay without increasing infection rates. Further outcomes-based research is needed regarding the use of antibiotic stewardship programmes in gynaecological surgery.

Introduction to Medication Effects on Male Reproduction.

The over-arching goal of this volume is to help infertility practitioners evaluate and manage their patients with poor semen quality. Medications can negatively impact on male reproduction and these effects are of increasing concern. People world-wide are using more medications than in the past, including men of childbearing age. In addition, men are fathering children later in life than previously, which is associated with greater medication use in the reproductive population. Finally, people are experiencing more chronic disease at earlier ages, particularly in developed countries. Taken together, these factors have increased the number of prescribed and over-the-counter (OTC) drugs being taken by men attempting fatherhood. There is some evidence in the literature that medications, even some common OTC medications, can negatively impact male reproduction, and yet, medication use is inadequately addressed in the evaluation of male infertility and fertility plans are rarely considered by providers before prescribing medications. In this volume, we systematically consider medications being used world-wide, focusing on those that might cause poor semen quality in men with otherwise idiopathic infertility. Extensive tables are provided in this volume that summarize the research for each specific medication, and it is our hope that these tables will be useful in day-to-day counseling of infertility patients and of men desiring fertility. Although some specialist practitioners are aware that there are pharmacological negative effects on male fertility, most practitioners are not, and the published evidence is surprisingly sparse. We hope that this volume will encourage our readers to conduct robust, well-designed studies to inform clinical practice.

Challenges of Obtaining Evidence-Based Information Regarding Medications and Male Fertility.

In the clinic, the existing literature is insufficient to counsel our infertile men on medication use. Most studies have flaws that limit their application to evidence-based practice. In this chapter, we discuss the limitations of the current literature and the challenges to designing more useful studies. Among the most important weaknesses of existing studies is lack of power; that is, too few men are included to draw conclusions about the existence and size of medication effects. Adequate power is particularly important when confirming an absence of medication effect. Bias is also a problem in most studies. Early studies were rarely randomized, placebo-controlled, or blinded; a common example is patients receiving different medication regimes based on the severity of their symptoms-making it impossible to attribute differences between treated and untreated men to the medications. Additional bias is introduced by failing to include other factors that influence the outcome in the experimental design. A uniform population amenable to randomization and placebo-control are experimental species, and useful information has been gained from these models. However, application to humans is limited by differences from other species in route of drug administration, absorption of the drug, concentration in the male genital tract tissues, and genital tract physiology. To a lesser degree, there is variation among individual men in their response to drugs. In addition, drugs in the same class may have different effects, limiting the applicability of data across drugs of a single class. Complicating matters further, a toxic medication may seem to improve fertility endpoints by improving a disease condition that diminishes fertility. Finally, drug interactions have not been studied, and actual fertility data (pregnancy/fecundity) in humans are rare. A healthy dose of skepticism is warranted when evaluating studies of medications and male reproductive health.

Male Reproductive Functions Disrupted by Pharmacological Agents.

In this chapter, we review the male reproductive functions disrupted by medications. Medications can affect the hypothalamic-pituitary-gonad axis, acting as endocrine disrupting chemicals (EDCs). Disturbances may be directly at androgen receptors, modifying the activity of endogenous androgens at the target tissue, or may disrupt feedback loops at the hypothalamus or pituitary resulting in modification of gonadotropin release. Impaired testosterone production and/or spermatogenesis result. Other EDC activities can be indirect via effects on levels of prolactin (PRL), estrogen, cortisol, thyroid hormone, or sex hormone binding globulin (SHBG). Appropriate regulation of these hormones and SHBG are essential for normal reproductive function. An increase in circulating PRL levels is a common adverse medication effect. The consequence is lower gonadotropin and testosterone secretion. Drugs can also have direct toxicity on the seminiferous tubule epithelium, including effects on Leydig cells, Sertoli cells, or germ cells. In some cases, spermatogenesis is severely impaired. After leaving the testis, sperm spend a week or more in the epididymis. It is clear from the timing of some drug effects that sperm are damaged during epididymal transit. There can also be impairment of the ejaculatory reflex, resulting in alterations of emission or expulsion of semen. Even after ejaculation, exposure to seminal plasma can alter sperm function, and some drugs may affect sperm at this stage. The most critical effects on male reproduction are decreased fertility and/or health effects on offspring. These endpoints have received little research attention. Another consideration is the metabolism of drugs. Medications may become more toxic if metabolic systems are suboptimal due to comorbid conditions.

Exogenous Androgens and Male Reproduction.

Due in part to aggressive marketing, the prevalence of exogenous androgen use has increased to disturbing levels. Prescribing practitioners are often unaware of the severity of the anti-fertility effects. Exogenous androgens should only be prescribed if hypogonadism has been established by appropriate investigation, and preferably the patient does not intend to father a child. There are alternative medications, or combinations of medications, that can be used if hypogonadism is present and fertility is desired.It is somewhat counterintuitive that testosterone treatment will decrease or abolish fertility. Exogenous testosterone inhibits spermatogenesis by removing the feedback response to low testosterone at the hypothalamus and pituitary. This results in reduced synthesis and secretion of gonadotropins required to stimulate endogenous testosterone production and to support spermatogenesis. It is important to realize that the normal testicular levels of testosterone are approximately 100 times the concentration in circulation. These high levels are required locally to support spermatogenesis. So even with circulating androgen levels within the normal range, spermatogenesis fails due to insufficient gonadotropin and local testosterone support. Androgenic herbal supplements and illicit use of anabolic steroids have contributed to this serious challenge in the treatment of infertile men. Most men will recover normal spermatogenesis after cessation of exogenous testosterone treatment, but this requires 6 months or more in most men. In rare cases fertility is permanently impaired.

Phosphodiesterase Inhibitors (PDE Inhibitors) and Male Reproduction.

The nonspecific PDE inhibitors, particularly the methylxanthines: caffeine, pentoxifylline (PTX), and theophylline, are known to stimulate sperm motility in vitro and have been used to treat sperm prior to insemination. The in vivo effects are less dramatic. A beneficial effect of caffeine, which is a constituent of some medications, remains controversial. Very high doses of caffeine do have negative effects on fertility endpoints in men and experimental species. The specific PDE5 inhibitors, particularly sildenafil and tadalafil, are prescribed for erectile dysfunction, as well as pulmonary hypertension, lower urinary tract symptoms, and premature ejaculation. PDE5 is expressed throughout the contractile tissues of the male reproductive tract, generally increasing contractility. Some PDE5 inhibitors tend to increase circulating testosterone levels somewhat. For short-term exposure consistent with use prior to intercourse, there appears to be minimal effects on semen quality. Several large, randomized controlled trials (RCTs) in healthy men have not found adverse effects of long-term use of these drugs on semen quality. RCTs in infertile men have demonstrated a modest increase in semen quality. Animal studies at human equivalent doses (HED) have produced similar results in young males, but a study in aging male rats found progressive decreases in epididymal sperm quality accompanied by consistent degeneration of the seminal tubules suggesting that studies in older men might be warranted. A concerning study in mice found lower fertilization rates in males treated with HED of sildenafil and mated the next day to untreated females than for control males. Fertility studies in humans are needed.

Pain Medications and Male Reproduction.

The increasing use of opioid medications has become a crisis in developed countries. The profound negative effects of opioids on male reproduction are well known, but this topic is absent from the current conversations about these medications. In the fertility clinic, a significant proportion of our patients are using opioids for pain management, and the options for these men are unclear. Opioids exert their negative effects by a variety of mechanisms. At high doses, testosterone levels fall significantly and hypogonadism is seen. In part, this results from increased prolactin and inhibition of gonadotropin production/secretion by the pituitary. However, negative effects on the testis are seen even in the absence of decreased androgen levels. As we review in this chapter, Leydig and germ cells produce endogenous opioids, and receptors for these substances are present throughout the testis. For example, endogenous opioids produced by Leydig and germ cells provide paracrine inhibition at Sertoli cell receptors, decreasing the production of androgen binding protein, which is required for intra-testis transport of androgens. Morphine also increases the expression of aromatase in the brain and testis and acts directly on the testis and germ cells to decrease testicular function. Exogenous opioids in men reduce semen quality, including increased DNA fragmentation. All opioids have these effects, but less damage is caused by lower doses, shorter-acting opioids, and by some drugs with mixed receptor activity, such as tramadol and tapentadol. The non-steroid anti-inflammatory drugs (NSAIDS) have much less effect on the male reproductive system, although there is a paucity of human studies. Paracetamol has been shown to cause sperm abnormalities, including DNA fragmentation, and to increase time to pregnancy and may prove to be of greater concern. In rodents, paracetamol has negative impacts on seminiferous tubule histology and fertility. Robust, well-designed studies in humans are needed.

5α-Reductase Inhibitors (5ARIs) and Male Reproduction.

The 5ARIs, finasteride and dutasteride, are used to treat benign prostate hyperplasia and lower urinary tract symptoms. At much lower doses, 5ARI treatment reduces male hair loss. These drugs inhibit the conversion of testosterone to the more active dihydrotestosterone (DHT). In men taking these medications, DHT levels are reduced by some 90% while testosterone levels remain relatively stable. Well known for their negative effects on libido and erectile function, 5ARIs also cause ejaculatory dysfunction in some men, having the potential to decrease semen quality. In fact, some studies of men treated with these drugs have reported lower total sperm count, along with lower sperm motility, although the changes are probably insufficient to reduce fertility in men with normal semen before treatment. There is a population of men with more severely decreased sperm numbers; as low as 10% of pretreatment values. Fewer studies have looked at the lower doses used for male alopecia, indicating little affect in men with normal semen quality, but a negative effect on sperm numbers in men with oligozoospermia. There have been no studies looking at fertility endpoints for these medications.