Effects of nanotubes on semen quality and fertility in humans: A systematic review of literature.

BACKGROUND: In the medical field, it is increasingly common to observe the use of nanotubes, for example, in the administration of drugs. However, nanotubes raise concerns for male fertility due to potential effects on hormone levels and sperm quality observed in animal studies. In addition, animal exposure to multi-walled carbon nanotube models found alterations in hormone levels, sperm motility, and sperm count. Limited evidence in humans suggests no adverse effects, but further research is needed. This study aimed to perform a systematic review to assess the in vitro effects of nanotubes on semen and fertility in humans. METHODS: We included all published in vitro studies about semen or sperm or male fertility and nanotubes in humans. A search was conducted in LILACS, PubMed, and SCOPUS as of May 2023. The risk of bias was assessed using the QUIN tool. RESULTS: Four studies using nanotubes on human sperm were included, nanotubes exposure appears not to affect sperm viability; however, some alterations to motility, velocity and production of reactive oxygen species were reported. Limited evidence is provided because of the small quantity of publications. CONCLUSIONS: Nanotubes appear to have no adverse effects on human sperm.

Could exposure to spaceflight cause mutations in genes that affect male fertility?

Recently, a study reported that upon analyzing blood samples from 14 astronauts that flew Space Transportation System missions between 1998 and 2001, 34 somatic nonsynonymous single nucleotide variants were detected in 17 CH-driver genes. Of interest is that the cohort consisted of relatively young astronauts, 85% of which were males of reproductive age. Having investigated the genes with nonsynonymous substitutes from the literature, it was found that twelve of these 17 genes appear to play essential roles in male reproduction. Changes in telomere length and gene regulation were also reported in another study conducted on an astronaut during a long duration stay on the International Space Station. Realizing the impact of spaceflight on gene sequence with potential influence on male fertility, it is important that more studies are conducted in this field. Specifically, in light of ultimately colonizing space, multi-generational survival is crucial and strategies to mitigate or counteract such effects should be explored.

Biological sex and age-related differences shape the antiviral response to SARS-CoV-2 infection.

For the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, clinical manifestations are broad and highly heterogeneous for both sexes. We aimed to determine how biological sex and age impact immune gene expression, particularly influencing the humoral neutralizing antibody (NAb) response and the cytokine production in coronavirus disease 2019 (COVID-19) subjects. The immune gene expression, according to biological sex and age, was assessed using the genome wide expression profile of blood proteins from healthy individuals using the Genotype Tissue Expression (GTEx) database. Moreover, anti-SARS-CoV-2 neutralizing antibody titers and cytokine levels were determined in blood samples from 141 COVID-19 individuals from Medellín, Colombia. Among subjects with COVID-19, males had statistically significantly higher median NAb titers and serum concentrations of interleukin-6 and CC chemokine ligand 3 than females. Overall, our findings point out a more robust innate immune response in women that could help recognize and restrain the virus faster than in men.

Testicular and epididymal dysfunctions: searching a new index for the differential diagnosis / Disfunciones testiculares y epididimarias: búsqueda de un nuevo índice para el diagnóstico diferencial

Objective: This proof-of-principle aims to develop an index to aid the differential diagnosis of disorders affecting testicular and/or epididymis. A total of 202 subject data were evaluated in two groups: fertile men with children naturally conceived within 1 year of unprotected intercourse (n = 36) and infertile men (n = 166) who had attempted a pregnancy more than 1 year with unprotected intercourse. Materials and methods: Semen parameters (sperm count, vitality, motility, morphology, and hypoosmotic swelling test [HOST]) were evaluated. The index was calculated by dividing the percentage HOST by the percentage of sperm progressive motility in the fertile group (n = 36). Results: A normal range from 1.23 to 1.53 was determined. Using this index, the outcomes of semen analysis from infertile men were grouped in three study groups: below 1.23 (n = 24), normal (n = 44), and higher than 1.53 (n = 98). These parameters were significantly decreased in semen with normal range (p < 0.01) and in indexes higher than 1.53 (p < 0.0001). Receiver operating characteristic curves compared progressive motility and morphology in infertile men with indexes higher than 1.53 shows that semen samples with normal sperm progressive motility and morphology did not suggest dysfunctions in testis and epididymis. Semen samples with asthenozoospermia suggested epididymal dysfunction (area under the curve [AUC] 0.889, confidence interval [CI] 0.783-1), whereas semen samples with teratoasthenozoospermia suggested dysfunction in both testicles and epididymis (AUC 0.891, CI 0.77-1). Conclusions: The current index proof-of-principle of the success of such a strategy provides valuable information about whether a disorder individually affects testicular and/or epididymal function.

Objetivo: Esta prueba de principio tiene como objetivo desarrollar un índice que ayude al diagnóstico diferencial de los trastornos testiculares y/o epidídimales. Métodos: Se evaluaron 202 individuos divididos en dos grupos: hombres fértiles con hijos concebidos de forma natural en el plazo no mayor a un año (n = 36) y hombres infértiles (n = 166), los cuales habían intentado un embarazo por más de un año. Se evaluaron los parámetros seminales (concentración, viabilidad, movilidad, morfología y prueba de hinchazón hipoosmótica [HOST]). El índice se calculó dividiendo el porcentaje de HOST por el porcentaje de movilidad espermática progresiva en el grupo fértil (n = 36). Resultados: Se determinó un rango normal de 1,23 a 1,53. Utilizando este índice, los resultados del análisis del semen de los hombres infértiles se agruparon en tres grupos de estudio: por debajo de 1,23 (n = 24), normal (n = 44) y superior a 1,53 (n = 98). En contraste, estos parámetros disminuyeron significativamente en el semen de rango normal (p < 0,01) y en los índices superiores a 1,53 (p < 0,0001). Las curvas ROC comparadas con la movilidad espermática progresiva y la morfología en los hombres infértiles con índices superiores a 1,53 muestran que las muestras de semen con movilidad progresiva y morfología normales no sugieren disfunciones en los testículos y epidídimos. Las muestras de semen con astenozoospermia sugerirían una disfunción del epidídimo (AUC 0,889, IC 0,783-1), mientras que las muestra de semen que presentaban teratoastenozoospermia sugerirían una disfunción tanto en los testículos como en el epidídimo (AUC 0,891, IC 0,77-1).

Increased exfoliation of immature germ cells detected in semen analysis routine and its clinical significance.

To the Editor, Currently, semen analysis is the unique test to evaluate men's fertility potential. Semen analysis provides valuable information on sperm production and quality. In addition to the conventional assessment of the sperm characteristics in a basic semen analysis routine, performing a differential diagnosis of leukocytes and sperm precursors immature germ cells (IGC) is also pivotal, due to adding valuable and clinically suitable information to the semen report [...].

SARS-CoV-2 Vaccine Effects on Semen Parameters: A Systematic Review and Meta-Analysis

Objective: Vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epitomizes the best preventative SARS-CoV-2 infection strategy to counteract the severe consequences of infection. However, concerns have been raised that the vaccines could have an adverse effect on sperm function and overall reproductive health. This combined systematic review and meta-analysis aimed to investigate the effects of different available SARS-CoV-2 vaccines on semen parameters. Methods: A systematic PubMed, Scopus, Google Scholar, Science Direct, LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), and Scilit database literature search until mid-June 2022 was conducted. Prospective and retrospective studies were eligible. No limitation was placed on language. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were thereafter obtained.Results: Upon search completion, 122 studies were identified and retrieved and 110 were excluded, while the remaining 12 independent studies evaluating the effects of coronavirus disease 2019 (COVID-19) vaccines on semen parameters were included in this review. The total number of men included was 1551, aged 22.4–48 years. Following meta-analysis, the SMD summary measure with 95% CI for each semen parameter included a concentration of 0.22 (0–0.22); Total sperm count of 0.11 (0.18–0.24);Total motility of 0.02 (0.05–0.09); Volume of 0.02 (–0.1–0.14); Vitality of 0.55 (–0.19–0.29), progressive motility of –0.43 (–0.54 to–0.32); Total motile sperm count of –0.38 (–0.44 to –0.31); And normal morphology of 0.42 (–0.54 to –0.3). In brief, the total sperm count was slightly increased post-vaccination, while progressive motility, total motile sperm count, and normal morphology were marginally reduced post-vaccination, according to the meta- analysis. (AU)

The relationship between sexually transmitted microorganisms and seminal quality in asymptomatic men.

Objective: To detect DNA of different microorganisms, in semen samples from apparently healthy men and correlate their presence with seminal quality. Methods: Semen samples from 81 healthy volunteers were collected, and semen parameters were analyzed. DNA extraction was performed using the phenol-chloroform technique, and the microorganisms were detected by the amplification of specific primers using polymerase chain reaction. Results: DNA from at least one of the microorganisms was detected in 78 samples. The most frequent microorganism found in semen were: Lactobacillus spp. (70%), Neisseria gonorrhoeae (N. gonorrhoeae) (36%), Streptococcus epidermidis (64%), Klebsiella pneumoniae (56%), Staphylococcus aureus (32%), Chlamydia trachomatis (C. trachomatis) (28%), Pseudomonas aeruginosa (27%). The seminal parameters of all semen samples were over the lower reference values for normal semen analysis. To compare with negative samples, seminal volume was higher for the Escherichia coli positive samples and lower for Pseudomonas aeruginosa positive samples. Semen samples positive for Staphylococcus aureus had worse sperm morphology. The frequency of progressive motility was higher in positive samples for N. gonorrhoeae and C. trachomatis. Positive semen samples for C. trachomatis had a higher concentration per milliliter. Conclusion: It is common to find microorganisms in semen of asymptomatic men, including those responsible for sexually transmitted infections. Antimicrobial treatment is recommended only in those individuals with a sexually transmitted infection (C. trachomatis and N. gonorrhoeae) and always promote condom use.

Mechanisms of SARS-CoV-2 and Male Infertility: Could Connexin and Pannexin Play a Role?

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on male infertility has lately received significant attention. SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) in humans, has been shown to impose adverse effects on both the structural components and function of the testis, which potentially impact spermatogenesis. These adverse effects are partially explained by fever, systemic inflammation, oxidative stress, and an increased immune response leading to impaired blood-testis barrier. It has been well established that efficient cellular communication via gap junctions or functional channels is required for tissue homeostasis. Connexins and pannexins are two protein families that mediate autocrine and paracrine signaling between the cells and the extracellular environment. These channel-forming proteins have been shown to play a role in coordinating cellular communication in the testis and epididymis. Despite their role in maintaining a proper male reproductive milieu, their function is disrupted under pathological conditions. The involvement of these channels has been well documented in several physiological and pathological conditions and their designated function in infectious diseases. However, their role in COVID-19 and their meaningful contribution to male infertility remains to be elucidated. Therefore, this review highlights the multivariate pathophysiological mechanisms of SARS-CoV-2 involvement in male reproduction. It also aims to shed light on the role of connexin and pannexin channels in disease progression, emphasizing their unexplored role and regulation of SARS-CoV-2 pathophysiology. Finally, we hypothesize the possible involvement of connexins and pannexins in SARS-CoV-2 inducing male infertility to assist future research ideas targeting therapeutic approaches.

En búsqueda de la fertilidad, tratamiento con antibiótico resuelve el problema de una pareja infértil / Reaching fertility, an antibiotic treatment solves the problem of an infertile couple:

Resumen Introducción: La presencia de bacterias en semen (bacteriospermia) es una condición patológica asociada con infertilidad y con prevalencia de hasta el 35%. Objetivo: Reportar el caso de un paciente con oligoastenozoospermia manejado en la consulta de infertilidad. Caso: Paciente masculino de 33 años de edad con historia de dificultad para la concepción, antecedente de orquiectomía por torsión testicular a los 16 años, infección por Chlamydia trachomatis a los 20 años. Examen físico normal, ecografía doppler testicular con varicocele izquierdo leve. Espermograma con oligoastenozoospermia y espermocultivo en agar sangre positivo para Streptococcus spp y agar chocolate para Streptococcus spp. Se inició manejo con ampicilina Sulbactam durante 14 días y control a los 3 meses con nuevo espermograma con mejoría marcada de la concentración y la movilidad progresiva espermática. Resultado: La pareja logro un embarazo exitoso con bebe vivo en casa. Conclusión: La colonización bacteriana del semen contribuye a alteraciones de la calidad seminal, por lo tanto, determinar la presencia de bacterias en las parejas infértiles podría ser de utilidad para el mejoramiento de los parámetros seminales y lograr un embarazo exitoso.

Abstract The presence of bacteria in semen -bacteriospermia- is a pathological condition associated with infertility, which presents a prevalence of up to 35%. We describe the successful management during infertility consultation of a patient suffering from oligoasthenozoospermia. A 33-year-old male patient with a history of difficulty conceiving, a history of orchiectomy due to testicular torsion at 16 years of age, and Chlamydia trachomatis infection at 20 years of age. The physical examination showed normal results, and testicular Doppler ultrasonography presented mild left varicocele. The semen analysis reported oligoasthenozoospermia, positive semen culture on blood agar for Streptococcus spp, and positive chocolate agar for Streptococcus spp. The treatment started with ampicillin-sulbactam administration for 14 days and a check-up after three months with a new semen analysis which showed an improved concentration and progressive sperm motility. Finally, the couple achieved a successful pregnancy. Bacterial colonization of semen contributes to seminal quality alterations; therefore, determining bacteria's presence in infertile couples could help improve seminal parameters and achieve a successful pregnancy.

Functional Profile of CD8+ T-Cells in Response to HLA-A*02:01-Restricted Mutated Epitopes Derived from the Gag Protein of Circulating HIV-1 Strains from Medellín, Colombia.

CD8+ T-cells play a crucial role in the control of HIV replication. HIV-specific CD8+ T-cell responses rapidly expand since the acute phase of the infection, and it has been observed that HIV controllers harbor CD8+ T-cells with potent anti-HIV capacity. The development of CD8+ T-cell-based vaccine against HIV-1 has focused on searching for immunodominant epitopes. However, the strong immune pressure of CD8+ T-cells causes the selection of viral variants with mutations in immunodominant epitopes. Since HIV-1 mutations are selected under the context of a specific HLA-I, the circulation of viral variants with these mutations is highly predictable based on the most prevalent HLA-I within a population. We previously demonstrated the adaptation of circulating strains of HIV-1 to the HLA-A*02 molecule by identifying mutations under positive selection located in GC9 and SL9 epitopes derived from the Gag protein. Also, we used an in silico prediction approach and evaluated whether the mutations found had a higher or lower affinity to the HLA-A*02. Although this strategy allowed predicting the interaction between mutated peptides and HLA-I, the functional response of CD8+ T-cells that these peptides induce is unknown. In the present work, peripheral blood mononuclear cells from 12 HIV-1+ HLA-A*02:01+ individuals were stimulated with the mutated and wild-type peptides derived from the GC9 and SL9 epitopes. The functional profile of CD8+ T-cells was evaluated using flow cytometry, and the frequency of subpopulations was determined according to their number of functions and the polyfunctionality index. The results suggest that the quality of the response (polyfunctionality) could be associated with the binding affinity of the peptide to the HLA molecule, and the functional profile of specific CD8+ T-cells to mutated epitopes in individuals under cART is maintained.

Implicaciones de los virus Zika y Chikungunya en el semen durante la transmisión sexual / Implications of Zika and Chikungunya viruses in semen during sexual transmission

Introducción: Los brotes de enfermedades causados por los virus Zika (VZIK) y Chikungunya (VCHIK) representan un problema de salud pública para muchos países tropicales y subtropicales. Objetivo: Discutir las implicaciones del hallazgo del VZIK y del VCHIK en el semen, y su relación con la transmisión sexual y la fertilidad masculina. Métodos: Se realizó una revisión narrativa de la literatura usando artículos indexados en PubMed (Medline), Embase y Scopus. Información, análisis y síntesis: Si bien los mosquitos del género Aedes son el vector principal y transmiten ambos virus, la transmisión sexual es una vía de infección significativa del VZIK y una posible ruta alterna para el VCHIK. La diseminación de estas arbovirosis vía linfática y sanguínea contribuye a la infección de diversos tejidos, incluyendo el tracto reproductivo masculino, donde el VZIK puede persistir. La infección de los testículos y quizás también de las glándulas accesorias del sistema reproductor masculino, se asocia con síntomas genitourinarios o alteraciones espermáticas, relacionadas con la detección del virus por largos periodos. Aunque no hay evidencia contundente sobre la presencia del VCHIK en el tracto genital masculino, se ha hallado en orina y semen. Además, se ha sugerido una posible persistencia en macrófagos que pueden infiltrar diferentes tejidos periféricos y cumplir una función de reservorio. Conclusiones: Hay presencia y persistencia de los virus Zika y Chikungunya en el tracto reproductor masculino. La infección en el semen se asocia con la transmisión sexual del virus, y con la alteración en la producción y calidad de los espermatozoides, con consecuencias clínicas graves en la salud sexual y reproductiva de los hombres infectados(AU)

Introduction: Disease outbreaks caused by Zika (ZIKV) and Chikungunya (CHIKV) viruses represent a public health problem for many tropical and subtropical countries. Objective: To discuss the implications of finding ZIKV and CHIKV in semen, and their relationship to sexual transmission and male fertility. Methods: A narrative review of the literature was carried out using articles indexed in PubMed (Medline), Embase and Scopus. Information, Analysis and Synthesis: Although Aedes mosquitoes are the primary vector and transmit both viruses, sexual transmission is a significant route of infection for ZIKV and a possible alternate route for CHIKV. Spread of these arboviruses via lymphatic and blood routes contributes to infection of various tissues, including the male reproductive tract, where ZIKV may persist. Infection of the testes and probably of the accessory glands of the male reproductive system is associated with genitourinary symptoms or sperm alterations, related to the detection of the virus for long periods. Although there is no conclusive evidence of the presence of CHIKV in the male genital tract, it has been found in urine and semen. In addition, a possible persistence in macrophages that can infiltrate different peripheral tissues and function as reservoir has been suggested. Conclusions: Zika and Chikungunya viruses can be present and persist in the male reproductive tract. Infection in semen is associated with sexual transmission of the virus and with alterations in the production and quality of spermatozoa, with serious clinical consequences in the sexual and reproductive health of infected men(AU)

SARS-CoV-2 Vaccine Effects on Semen Parameters: A Systematic Review and Meta-Analysis.

OBJECTIVE: Vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epitomizes the best preventative SARS-CoV-2 infection strategy to counteract the severe consequences of infection. However, concerns have been raised that the vaccines could have an adverse effect on sperm function and overall reproductive health. This combined systematic review and meta-analysis aimed to investigate the effects of different available SARS-CoV-2 vaccines on semen parameters. METHODS: A systematic PubMed, Scopus, Google Scholar, ScienceDirect, LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), and Scilit database literature search until mid-June 2022 was conducted. Prospective and retrospective studies were eligible. No limitation was placed on language. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were thereafter obtained. RESULTS: Upon search completion, 122 studies were identified and retrieved and 110 were excluded, while the remaining 12 independent studies evaluating the effects of coronavirus disease 2019 (COVID-19) vaccines on semen parameters were included in this review. The total number of men included was 1551, aged 22.4-48 years. Following meta-analysis, the SMD summary measure with 95% CI for each semen parameter included a concentration of 0.22 (0-0.22); Total sperm count of 0.11 (0.18-0.24); Total motility of 0.02 (0.05-0.09); Volume of 0.02 (-0.1-0.14); Vitality of 0.55 (-0.19-0.29), progressive motility of -0.43 (-0.54 to -0.32); Total motile sperm count of -0.38 (-0.44 to -0.31); And normal morphology of 0.42 (-0.54 to -0.3). In brief, the total sperm count was slightly increased post-vaccination, while progressive motility, total motile sperm count, and normal morphology were marginally reduced post-vaccination, according to the meta-analysis. CONCLUSIONS: No effects were observed regarding sperm viability and semen volume since the results of all the studies crossed the line of no effect. All seminal parameters analyzed showed a negligible or small change in relation to the vaccination effect. Furthermore, the parameters remained within the normal World Health Organization reference ranges, making the clinical significance unclear. Therefore, based on these results, it appears that vaccination does not have negative effects on semen quality. The individual study findings suggested that COVID-19 vaccines are not associated with decreased semen parameters.

Efecto del consumo de marihuana sobre los parámetros espermáticos humanos: Aproximación in vivo / Effect of Marijuana Use on Human Semen Parameters: In Vivo Approach

La evidencia sugiere que la exposición a sustancias psicoactivas se relaciona con alteraciones en la espermatogénesis que afectan la calidad espermática. El objetivo de este trabajo fue determinar los parámetros espermáticos en consumidores habituales de cigarrillos de marihuana. Se analizaron muestras seminales de 42 consumidores activos de cigarrillos de marihuana y de 16 voluntarios no consumidores de marihuana. Mediante un análisis de semen, se determinaron los parámetros seminales convencionales (viabilidad, movilidad, morfología, y concentración de los espermatozoides) siguiendo los lineamientos establecidos por la Organización Mundial de la Salud (OMS). Adicionalmente, se evaluó la capacidad antioxidante del plasma seminal mediante la determinación del porcentaje de inhibición del radical estable 1,1-difenil-2-picril-hidracilo. Los valores de la mediana de los consumidores respecto al grupo control fueron: volumen ­ 2,98 mL versus 3,95 mL (p = 0,0221); concentración total ­ 189 millones/mL versus 291,1 millones/mL (p = 0,0636); movilidad progresiva ­ 50% versus 56,5% (p = 0,0052); viabilidad ­ 65,3% versus 73,1% (p = 0,0732); y morfología normal ­ 5% versus 7% (p = 0,0167), respectivamente. Los resultados obtenidos en este estudio indican que el consumo de cigarrillos de marihuana afecta negativamente la movilidad progresiva, la morfología normal y la concentración total de espermatozoides; además, la concentración total de espermatozoides está afectada por la frecuencia del consumo de cigarrillos de marihuana.

Evidence suggests that exposure to psychoactive substances is related to spermatogenesis alterations that affect sperm quality. The objective of the present work was to determine sperm parameters in regular users of marijuana cigarettes. Seminal samples from 42 active consumers of marijuana cigarettes and 16 volunteer non-marijuana users were analyzed. Through a semen analysis, we identify conventional seminal parameters (viability, motility, morphology, and sperm concentration) according to the guidelines established by the World Health Organization (WHO). The antioxidant effect of the seminal plasma was evaluated through the determination of the percentage of inhibition of the stable radical 1,1-diphenyl-2-picrylhydrazyl. The median values of consumers with respect to the control group were respectively: volume ­ 2.98 mL versus 3.95 mL (p = 0.0221); total concentration ­ 189 million/mL versus 291.1 million/mL (p = 0.0636); progressive motility ­ 50% versus 56.5% (p = 0.0052); viability ­ 65.3% versus 73.1% (p = 0.0732); and normal morphology ­ 5% versus 7% (p = 0.0167). The results obtained in the present study indicate that the consumption of marijuana cigarettes negatively affects progressive motility, normal morphology, and total sperm concentration. In addition, the total sperm concentration is affected by the frequency of consumption of marijuana cigarettes

In Silico Analysis of Sperm From Ejaculates with Different Semen Characteristics.

BACKGROUND: Male infertility is associated with altered characteristics of the sperm within the ejaculate. It is possible to find molecular explanations for the observed phenotypes and their consequences. This study aimed to analyze, using a specialized software, a gene set of transcriptomic data from different types of ejaculates. METHODS: Data from ejaculate samples categorized as normal, oligospermia, and teratozoospermia were obtained from Gene Expression Omnibus (GEO). After normalization, the data average for each sample category was calculated and analyzed independently using Ingenuity Pathway Analysis (IPA). RESULTS: Five important canonical pathways are involved in normal and altered semen samples (Oligospermia and teratozoospermia) except sirtuin signaling and mitochondrial dysfunction pathways. The five most important biological processes are identified in all semen phenotypes, but the only difference is the genes connected with initiation of RNA transcription in oligospermic and asthenospermic samples. CONCLUSION: Surprisingly, different types of ejaculates share many pathways and biological processes; sperm proteomics as a new global approach gives clues for the development of strategies to explain the reason for observed phenotypes of ejaculated spermatozoa, their possible effect on fertility, and for implementing research strategies in the context of infertility diagnosis and treatment.