The evolving prevalence of anabolic androgenic steroids (AAS) abuse among nonathletes is alarming because of the known harm to an individual's health. Among the adverse effects of AAS abuse, male infertility and sexual dysfunction have been often reported in the literature, but little is known regarding its actual prevalence, possible underpinning mechanisms, and potential treatments either during or post-AAS usage. Thus, the current narrative review summarizes the state-of-art regarding the effects of AAS on male fertility and sexual function. Evidence was gathered from the latest reviews and recent original studies, specifically from prospective cohorts and clinical trials, ultimately resulting in five main topics of discussion. First, AAS usage is briefly characterized by its historical background, main physiological mechanisms, and the most frequently used AAS substances. Second, data on the prevalence of AAS-induced male infertility and sexual dysfunction are described. Third, some new insights on possible underpinning mechanisms of AAS-induced male infertility and sexual dysfunction are thoroughly discussed, with particular attention to histological data derived from animal models and the latest insights from prospective cohorts in humans. Fourth, the potential treatments during and after the AAS usage are presented, highlighting the odds of resolving male infertility and sexual dysfunction. Fifth, future directions on this topic are discussed, focusing on the methodological robustness of scientific studies.
BACKGROUND: Severe acute syndrome coronavirus 2 can invade a variety of tissues, including the testis. Even though this virus is scarcely found in human semen polymerase chain reaction tests, autopsy studies confirm the viral presence in all testicular cell types, including spermatozoa and spermatids. OBJECTIVE: To investigate whether the severe acute syndrome coronavirus 2 is present inside the spermatozoa of negative polymerase chain reaction-infected men up to 3 months after hospital discharge. MATERIALS AND METHODS: This cross-sectional study included 13 confirmed moderate-to-severe COVID-19 patients enrolled 30-90 days after the diagnosis. Semen samples were obtained and examined with real-time polymerase chain reaction for RNA detection and by transmission electron microscopy. RESULTS: In moderate-to-severe clinical scenarios, we identified the severe acute syndrome coronavirus 2 inside spermatozoa in nine of 13 patients up to 90 days after discharge from the hospital. Moreover, some DNA-based extracellular traps were reported in all studied specimens. DISCUSSION AND CONCLUSION: Although severe acute syndrome coronavirus 2 was not present in the infected men's semen, it was intracellularly present in the spermatozoa till 3 months after hospital discharge. The Electron microscopy (EM) findings also suggest that spermatozoa produce nuclear DNA-based extracellular traps, probably in a cell-free DNA-dependent manner, similar to those previously described in the systemic inflammatory response to COVID-19. In moderate-to-severe cases, the blood-testes barrier grants little defence against different pathogenic viruses, including the severe acute syndrome coronavirus 2. The virus could also use the epididymis as a post-testicular route to bind and fuse to the mature spermatozoon and possibly accomplish the reverse transcription of the single-stranded viral RNA into proviral DNA. These mechanisms can elicit extracellular cell-free DNA formation. The potential implications of our findings for assisted conception must be addressed, and the evolutionary history of DNA-based extracellular traps as preserved ammunition in animals' innate defence might improve our understanding of the severe acute syndrome coronavirus 2 pathophysiology in the testis and spermatozoa.
BACKGROUND: Sperm DNA integrity is increasingly seen as a critical characteristic determining reproductive success, both in natural reproduction and in assisted reproductive technologies (ART). Despite this awareness, sperm DNA and nuclear integrity tests are still not part of routine examinations for either infertile men or fertile men wishing to assess their reproductive capacity. This is not due to the unavailability of DNA and sperm nuclear integrity tests. On the contrary, several relevant but distinct tests are available and have been used in many clinical trials, which has led to conflicting results and confusion. The reasons for this are mainly the lack of standardization between different clinics and between the tests themselves. In addition, the small number of samples analyzed in these trials has often weakened the value of the analyses performed. In the present work, we used a large cohort of semen samples, covering a wide age range, which were simultaneously evaluated for sperm DNA fragmentation (SDF) using two of the most frequently used SDF assays, namely the TUNEL assay and the sperm chromatin structure assay (SCSA®). At the same time, as standard seminal parameters (sperm motility, sperm morphology, sperm count) were available for these samples, correlations between age, SDF and conventional seminal parameters were analyzed. RESULTS: We show that the SCSA® and TUNEL assessments of SDF produce concordant data. However, the SDF assessed by TUNEL is systematically lower than that assessed by SCSA®. Regardless of the test used, the SDF increases steadily during aging, while the HDS parameter (High DNA stainability assessed via SCSA®) remains unchanged. In the cohort analyzed, conventional sperm parameters do not seem to discriminate with aging. Only sperm volume and motility were significantly lower in the oldest age group analyzed [50-59 years of age]. CONCLUSIONS: In the large cohort analyzed, SDF is an age-dependent parameter, increasing linearly with aging. The SCSA® assessment of SDF and the flow cytometry-assisted TUNEL assessment are well correlated, although TUNEL is less sensitive than SCSA®. This difference in sensitivity should be taken into account in the final assessment of the true level of fragmentation of the sperm nucleus of a given sample. The classical sperm parameters (motility, morphology, sperm count) do not change dramatically with age, making them inadequate to assess the fertility potential of an individual.
RéSUMé: CONTEXTE: l'intégrité de l'ADN des spermatozoïdes est de plus en plus considérée comme une caractéristique essentielle déterminant le succès de la reproduction, tant dans la reproduction naturelle que dans les techniques de reproduction assistée (AMP). Malgré cette prise de conscience, les tests d'intégrité nucléaire des spermatozoïdes ne font toujours pas partie des examens de routine pour les hommes infertiles ou fertiles souhaitant évaluer leur capacité de reproduction. Cette situation n'est pas due à l'indisponibilité des tests. Au contraire, plusieurs tests pertinents mais distincts sont disponibles et ont été utilisés dans de nombreux essais cliniques, ce qui a donné lieu à des résultats contradictoires et à une certaine confusion. Les raisons en sont principalement le manque de normalisation entre les différentes cliniques et entre les tests eux-mêmes. En outre, le petit nombre d'échantillons analysés dans ces essais a souvent affaibli la valeur des analyses effectuées. Dans le présent travail, nous avons utilisé une vaste cohorte d'échantillons, couvrant une large tranche d'âge, évalués simultanément pour la fragmentation de l'ADN des spermatozoïdes à l'aide de deux des tests les plus fréquemment utilisés, à savoir le test TUNEL et le test de la structure de la chromatine des spermatozoïdes (SCSA®). Parallèlement, comme les paramètres séminaux standard (motilité, morphologie, numération) étaient disponibles pour ces échantillons, les corrélations entre l'âge, le niveau de fragmentation et les paramètres séminaux conventionnels ont été analysées. RéSULTATS: Nous montrons que les évaluations SCSA® et TUNEL produisent des données concordantes. Cependant, le SDF évalué par TUNEL est systématiquement plus faible que celui évalué par SCSA®. Quel que soit le test utilisé, la fragmentation augmente régulièrement au cours du vieillissement, alors que le paramètre HDS (« High DNA stainability¼ évalué par le test SCSA®) reste inchangé. Dans la cohorte analysée, les paramètres spermatiques conventionnels ne semblent pas varier avec le vieillissement. Seuls le volume et la mobilité des spermatozoïdes étaient significativement plus faibles dans le groupe d'âge le plus élevé analysé [5059 ans]. CONCLUSIONS: Dans la grande cohorte analysée, la fragmentation de l'ADN spermatique est un paramètre dépendant de l'âge, augmentant linéairement avec le vieillissement. L'évaluation du SDF par SCSA® et l'évaluation via le test TUNEL assistée par cytométrie de flux sont bien corrélées, bien que le TUNEL soit moins sensible que le SCSA®. Cette différence de sensibilité doit être prise en compte dans l'évaluation finale du niveau réel de fragmentation du noyau des spermatozoïdes d'un échantillon donné. Les paramètres classiques du sperme (motilité, morphologie, nombre de spermatozoïdes) ne changent pas de façon spectaculaire avec l'âge, ce qui les rend inadéquats pour évaluer le potentiel de fertilité d'un individu.
Background: Sertoli cell-only syndrome (SCOS) or germ cell aplasia is one of the most serious histopathological subtypes within the scope of non-obstructive azoospermia (NOA). Understanding the molecular mechanism of SCOS and identifying new non-invasive markers for clinical application is crucial to guide proper sperm procurement and avoid unnecessary interventions. This study sought to identify the differentially expressed genes (DEGs) of SCOS by using gene sequencing identity and verify the key marker genes to provide basic data for subsequent research on SCOS. Methods: A total of 50 testicular samples were collected in this study from 25 patients with SCOS and 25 patients with normal spermatogenesis. In total, 5 pairs of testis samples were used for the RNA-sequencing (RNA-seq). We identified the DEGs between the SCOS and normal spermatogenesis patients and conducted a Gene Ontology (GO) analysis and a Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis. The expression of the main target gene phosducin-like 2 (PDCL2) was examined by quantitative real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry (IHC). Results: In total, 3,133 upregulated DEGs and 1,406 downregulated DEGs were identified by the RNA-seq. The highly enriched processes involved in spermatogenesis included the mitotic cell cycle, cell cycle, and oocyte maturation. The expression of PDCL2 was verified as a downregulation marker in SCOS by qRT-PCR and IHC. Conclusions: This study identified the DEGs of SCOS, and the bioinformatics analysis results identified the potential target key genes and pathways for SCOS. PDCL2 is a key gene involved in SCOS and may serve as a non-invasive downregulation marker of SCOS.
PURPOSE: Several clinical scenarios regulate the final ejaculated semen, which is pivotal to reproductive success. Sperm motility and plasma membrane fusogenic activity primarily rely on the peculiar sperm lipid composition, influenced by the patient's metabolism, genetics, nutritional, environmental status, and concomitant clinical entities such as varicocele. This study aimed to determine the relationship between serum lipid profile and testicular function (semen quality and testosterone levels). METHODS: This retrospective study uses medical charts of 278 infertile men who attended andrological care between 2000 and 2019. Seminal analysis data, lipid profile, and total serum testosterone were collected. A multiple linear regression analysis was performed to evaluate the influence of the lipid parameters on the seminal variables. Statistical analyses were carried out with p ≤ 0.05 considered statistically significant. RESULTS: Seminal creatine kinase activity (p = 0.024) is negatively related to HDL (p = 0.032) and triglycerides (p = 0.037), while total testosterone (p < 0.0001) and seminal volume (p = 0.046) appeared both to be negatively related to triglycerides (p = 0.030 and p = 0.033, respectively). CONCLUSION: Medical advice commonly advocated to prevent endothelial dysfunction and cardiovascular disease and improve HDL-cholesterol and triglyceride levels in dyslipidemic patients should also be given to infertile men. Physicians should give patients a thorough assessment, including the blood lipid profile, hormonal status, and routine seminal examinations. We propose a more comprehensive men´s health check-up for the infertile male population, not limited to a simple evaluation of basic sperm parameters.
Infertility, Male , Semen Analysis , Male , Humans , Semen , Men's Health , Sperm Count , Retrospective Studies , Sperm Motility/physiology , Lipids , Triglycerides , Testosterone
Intracytoplasmic sperm injection (ICSI) using surgically retrieved spermatozoa outside the classic context of azoospermia has been increasingly used to overcome infertility. The primary indications include high levels of sperm DNA damage in ejaculated spermatozoa and severe oligozoospermia or cryptozoospermia, particularly in couples with ICSI failure for no apparent reason. Current evidence suggests that surgically retrieved spermatozoa for ICSI in the above context improves outcomes, mainly concerning pregnancy and miscarriage rates. The reasons are not fully understood but may be related to the lower levels of DNA damage in spermatozoa retrieved from the testis compared with ejaculated counterparts. These findings are consistent with the notion that excessive sperm DNA damage can be a limiting factor responsible for the failure to conceive. Using testicular in preference of low-quality ejaculated spermatozoa bypasses post-testicular sperm DNA damage caused primarily by oxidative stress, thus increasing the likelihood of oocyte fertilization by genomically intact spermatozoa. Despite the overall favorable results, data remain limited, and mainly concern males with confirmed sperm DNA damage in the ejaculate. Additionally, information regarding the health of ICSI offspring resulting from the use of surgically retrieved spermatoa of non-azoospermic males is still lacking. Efforts should be made to improve the male partner's reproductive health for safer ICSI utilization. A comprehensive andrological evaluation aiming to identify and treat the underlying male infertility factor contributing to sperm DNA damage is essential for achieving this goal.
Infertility, Male , Semen , Pregnancy , Female , Male , Humans , Sperm Injections, Intracytoplasmic/methods , DNA Fragmentation , Spermatozoa , Testis , Infertility, Male/therapy , Pregnancy Rate , Sperm Retrieval , Retrospective Studies
Marijuana is one of the most consumed drugs worldwide. There is increasing evidence of an association between marijuana and male infertility. This study intends to assess the repercussion of marijuana smoking and other habits (sedentary lifestyle, alcohol, and tobacco use) in the testicular function of infertile men seeking andrological evaluation. A retrospective study was performed using medical records data of men aged 18-59 years from 2009 to 2017. Complete semen analyses, sperm functional tests, SHBG, and hormonal levels, testosterone-to-estradiol ratio (T/E2), and testis volume were evaluated. Exclusion criteria included cryptorchidism, infertility caused by genetic or infectious diseases, and cancer. A multiple linear regression analysis was performed to investigate which habit could predict certain parameters using the software SPSS 23.0 (P < 0.05). In a sample of 153 men, semen parameters, testosterone levels, and testis volume were not significantly influenced. Marijuana use had the broader hormonal changes since it influences estradiol (P = 0.000; B = -11.616), prolactin (P = 0.000; B = 3.211), SHBG levels (P = 0.017; B = 7.489), and T/E2 (P = 0.004; B = 14.030). Sedentary lifestyle (P = 0.028; B = 1.279) and tobacco smoking (P = 0.031; B = -2.401) influenced the prolactin levels. Marijuana is associated with hormonal imbalance in this infertile cohort by lowering estradiol levels and inhibiting aromatase function.
Objectives: To determine the role of the male sex as a risk factor for coronavirus disease deaths in Sao Paulo and to what extent socioeconomic vulnerability and individual health issues can interfere in such risk. Methods: The primary cause of death, age, sex, comorbidities, and code of the Human Development Units of the residence of 37,583 individuals in Sao Paulo, Brazil, were obtained from the records on confirmed coronavirus disease resident hospitalizations of the city of Sao Paulo from the National Influenza Surveillance Information System. A social vulnerability index was assigned to each Human Development Unit. Using "death" as the outcome variable and sex, admission to the intensive care unit, obesity, renal and heart diseases, diabetes, and social vulnerability as confounders, the odds of death for males and females were compared via logistic regression. Results: The odds of death for males were 1.242 (confidence interval 95% = 1.237, 1.247) times the corresponding odds for females with the same values for all confounders. We estimated the odds of death for patients living in regions with high social vulnerability as 2.243 (CI 95% = 2.151, 2.339) times the corresponding odds of patients living in regions with very low social vulnerability with the same values of the remaining variables. Conclusion: The male:female death ratio by severe acute respiratory syndrome coronavirus 2 infection in Sao Paulo cannot be attributed only to comorbidities or social vulnerabilities. Our results suggest that the male sex is an independent biological risk factor for coronavirus disease death. Besides sex-specific factors, further research should focus on crucial biological factors in male sex coronavirus disease mortality.
The ongoing COVID-19 pandemic represents an extra burden in the majority of public and private health systems worldwide beyond the most pessimistic expectations, driving an urgent rush to develop effective vaccines and effective medical treatments against the SARS-CoV-2 pandemic. The Nucleocapsid structural viral protein is remarkably immunogenic and hugely expressed during infection. High IgG antibodies against Nucleocapsid protein (N protein) levels were detected in the serum of COVID-19 patients, confirming its pivotal antigen role for a T lymphocyte response in a vaccine microenvironment. Currently, adverse events associated with immunizations have raised some degree of concern, irrespective of its huge benefits in dealing with disease severity and decreasing mortality and morbidity. This hitherto study evaluates histological changes in rats' testes, epididymis, prostate, and seminal vesicles and analyzes hormone levels after solely N protein inoculation. Therefore, we exposed a group of Lewis rats to weekly injections of the recombinant N protein for 28 days, while a control group was inoculated with a buffer solution. The N group revealed a more significant number of spermatozoa. Spermatozoa in the seminiferous tubules were counted in twenty 400 × microscopy fields (mean of 9.2 vs. 4.6 in the control group; p < 0,01), but significantly lower testosterone levels (mean of 125.70 ng/dl vs. 309,00 ng/dl in the control group; p < 0,05) were found. No other histological and biochemical changes were displayed. Conclusively, these data suggest testicular hormonal imbalance mediated by the SARS-CoV-2 N protein that could be linked to reported post-COVID-19 syndrome hypogonadism. More relevant research might be performed to confirm this viral antigen's deleterious mechanism in the human testicular microenvironment, particular in Leydig cell function.
Standard protocols for clinical in vitro fertilization (IVF) laboratories recommend incubating semen at 37°C in 5% CO2 without strictly specifying which medium should be used or for how long. This study aimed to test the most common different incubation media used in Latin American andrology and micromanipulation laboratories and verify which, if any, is the most appropriate medium to improve asthenozoospermic semen samples' motility in the infertile male population. Ejaculates (136) collected from asthenozoospermic men were divided into two cohorts with similar characteristics (cohort 1; n = 28 and cohort 2; n = 108). Cohort 1 was used to evaluate the optimal incubation time with regard to unprepared asthenozoospermic sample sperm motility. After defining an optimal incubation period of 2 h, cohort 2 was used to evaluate which of the four media commonly used in IVF clinics (continuous single culture medium = CSCM®; SpermRinse medium = SR®; in vitro fertilization medium = G-IVF® and human tubal fluid medium = HTF®) was preferred for semen samples from asthenozoospermic patients. Overall, it was determined that a 2-h incubation in CSCM® medium led to the highest asthenozoospermic sperm motility. Thus, this simple, cost-effective, easily reproducible protocol could prove extremely useful for andrology laboratories working with IVF clinics dealing with asthenozoospermic semen specimens. This is particularly relevant since the incidence of the latter is on the rise as semen quality decreases around the globe.Abbreviations: ANOVA: Analysis of variance; ARTs: Assisted reproductive techniques; BWW: Biggers, Whitten, and Whittingham; CO2: Carbon dioxide; CPM: counted per minute; CSCM: Continuous Single Culture Medium; DAB: 3.3'- diaminobenzidine; DFI: DNA Fragmentation Index; DMSO: Dimethyl sulfoxide; G-IVF: In Vitro Fertilization Medium; GSH: Glutathione; GPx: glutathione peroxidase; HDS: High DNA Stainability; HSA: Human Serum Albumin; HTF: Human Tubal Fluid; HYP: Hyperactivity; ICSI: Intracytoplasmic sperm injection; IUI: Intrauterine insemination; IVF: in vitro fertilization; LIN: Linearity; ROS: Reactive Oxygen Species-level; SC: Sperm concentration; SCA: Sperm Computer Analysis; SCSA: Sperm Chromatin Structural Assay; SR: SpermRinse medium; SSS: Synthetic Serum Substitute; STR: Straightness; SOD: superoxide dismutase; TNE: Tris-Borate-EDTA; TSC: Total sperm count; VAP: Mean velocity; VCL: Curvilinear velocity; VSL: Linear velocity; WHO: World Health Organization; WOB: Wobble; spz: spermatozoa; AO: antioxidant.
Asthenozoospermia , Sperm Motility , Humans , Male , Semen , Semen Analysis , Spermatozoa
BACKGROUND: Multi-organ damage is a common feature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, going beyond the initially observed severe pneumonia. Evidence that the testis is also compromised is growing. OBJECTIVE: To describe the pathological findings in testes from fatal cases of COVID-19, including the detection of viral particles and antigens, and inflammatory cell subsets. MATERIALS AND METHODS: Postmortem testicular samples were obtained by percutaneous puncture from 11 deceased men and examined by reverse-transcription polymerase chain reaction (RT-PCR) for RNA detection and by light and electron microscopy (EM) for SARS-CoV-2. Immunohistochemistry (IHC) for the SARS-CoV-2 N-protein and lymphocytic and histiocytic markers was also performed. RESULTS: Eight patients had mild interstitial orchitis, composed mainly of CD68+ and TCD8+ cells. Fibrin thrombi were detected in five cases. All cases presented congestion, interstitial edema, thickening of the tubular basal membrane, decreased Leydig and Sertoli cells with reduced spermatogenesis, and strong expression of vascular cell adhesion molecule (VCAM) in vessels. IHC detected SARS-Cov-2 antigen in Leydig cells, Sertoli cells, spermatogonia, and fibroblasts in all cases. EM detected viral particles in the cytoplasm of fibroblasts, endothelium, Sertoli and Leydig cells, spermatids, and epithelial cells of the rete testis in four cases, while RT-PCR detected SARS-CoV-2 RNA in three cases. DISCUSSION AND CONCLUSION: The COVID-19-associated testicular lesion revealed a combination of orchitis, vascular changes, basal membrane thickening, Leydig and Sertoli cell scarcity, and reduced spermatogenesis associated with SARS-CoV-2 local infection that may impair hormonal function and fertility in men.
COVID-19/complications , Orchitis/pathology , Orchitis/virology , Testis/pathology , Adult , Aged , Aged, 80 and over , Autopsy , Humans , Male , Middle Aged , SARS-CoV-2
Significance: Among the 200 or so cell types that comprise mammals, spermatozoa have an ambiguous relationship with the reactive oxygen species (ROS) inherent in the consumption of oxygen that supports aerobic metabolism. Recent Advances: In this review, we shall see that spermatozoa need the action of ROS to reach their structural and functional maturity, but that due to intrinsic unique characteristics, they are, perhaps more than any other cell type, susceptible to oxidative damage. Recent studies have improved our knowledge of how oxidative damage affects sperm structures and functions. The focus of this review will be on how genetic and epigenetic oxidative alterations to spermatozoa can have dramatic unintended consequences in terms of both the support and the suppression of sperm function. Critical Issues: Oxidative stress can have dramatic consequences not only for the spermatozoon itself, but also, and above all, on its primary objective, which is to carry out fertilization and to ensure, in part, that the embryonic development program should lead to a healthy progeny. Future Directions: Sperm oxidative DNA damage largely affects the integrity of the paternal genetic material to such an extent that the oocyte may have difficulties in correcting it. Diagnostic and therapeutic actions should be considered more systematically, especially in men with difficulties to conceive. Research is underway to determine whether the epigenetic information carried by spermatozoa is also subject to changes mediated by pro-oxidative situations. Antioxid. Redox Signal. 37, 481-500.
Semen , Spermatozoa , Animals , Female , Humans , Male , Mammals/metabolism , Oxidative Stress , Pregnancy , Reactive Oxygen Species/metabolism , Semen/metabolism , Spermatozoa/metabolism
INTRODUCTION: The pandemic caused by the COVID-19 resulted in worldwide social isolation and leading to significant personal distress, particularly among health professionals on the front lines. Those factors' relevance and their impact on sexual function in this population have not yet been established. AIM: To evaluate the impact of the pandemic on sexual function in healthcare professionals and medical students at a reference center in the treatment of COVID-19 in Brazil. METHODS: A cross-sectional analysis with online questionnaires about sexual function was sent to health professionals and medical students from the HC-FMUSP medical complex. The questionnaire evaluated Total Sexual and Masturbatory Frequency prior and during the pandemic, libido and sexual satisfaction changes with a detailed inquire about demographics and personal factors. An objective assessment of sexual function was also made using the validated sexual quotient questionnaires. MAIN OUTCOME MEASURES: Differences in intercourse frequency, libido, and overall sexual satisfaction, in a sample of healthcare professionals particularly vulnerable to the pandemic effects. RESULTS: A total of 1,314 responses were available with a mean age of 37 years. Worsening of sexual satisfaction was reported by 44.5% of the participants, with the following associated factors: Lower libido, missing Nightlife, Higher Masturbatory Frequency, and isolation from the partner. Remaning sexualy actively and having higher sexual frequency appear to decrease the chance of worsening sexual function. Worsening of Libido was reported by 37% and had several associated factors, including missing of Nightlife, older age, isolation from the partner among others. Being male and sexually active was associated with a smaller chance of reporting lower libido. CONCLUSION: We were able to observe a sharp drop in Libido and General Sexual Satisfaction. Although an increase in pornography consumption and masturbatory frequency did occur, these factors were not associated with greater sexual satisfaction. The impact of COVID-19 on this population's sexual health is not to be underestimated and should be further studied in the follow-up of the pandemic. Neto RP, Nascimento BCG, Carvalho dos Anjos Silva G, et al. Impact of COVID-19 Pandemic on the Sexual Function of Health Professionals From an Epicenter in Brazil. Sex Med 2021;9:100408.
