Male immunity to the chlamydial 60 kDa heat shock protein (HSP 60) - associated with semen quality?

The role of Chlamydia trachomatis for male infertility is a matter of constant debate. It is assumed that in its persistent form this pathogen may produce high levels of 60 kD heat shock protein (Chlam HSP60). Cross-reactivity between epitopes of the bacterial and human HSPs, involved in many steps of the reproductive process, might induce an autoimmune response with potential impairment of semen quality and sperm fertilising capacity. This prospective study included asymptomatic males of a total of 128 unselected subfertile couples (median duration of infertility 3 years) to determine the clinical relevance of male immunity to Chlam HSP60 during infertility investigation. After medical history and clinical examination of both partners, serum antibodies (Ab) to Chlam HSP60 were determined. Same day semen quality evaluation included microscopical standard sperm analysis, determination of seminal white blood cells (WBC) and of antisperm Ab (ASA) of the Ig G- and Ig-A class (mixed antiglobulin reaction, MAR), microbial screening and examination of sperm functional capacity. Sperm/mucus interaction was tested in vitro and in vivo. Simultaneously, patients' female partners were tested for Chlam HSP60 Ab and results were compared with a standard serology evaluation for antichlamydial IgG Ab. The presence of ChlamHSP60 Ab (positive in 24% of males) was not significantly associated with semen quality, seminal WBC and antisperm AB of the IgG- or Ig A-class, the outcome of the microbial screening nor with sperm functional capacity and results of sperm/mucus interaction testing in vitro and in vivo. Chlam HSP60 Ab were significantly more frequent in female partners of Chlam HSP60 Ab-positive men, and results correlated with the outcome of standard chlamydial serology evaluation. In conclusion, when serum Chlam HSP60 Ab are used as marker, male immunity to the chlamydial 60 kD heat shock protein is not associated with semen quality, sperm functional capacity and other clinically relevant parameters of male fertility.

Presence of DNA of adeno-associated virus in subfertile couples, but no association with fertility factors.

BACKGROUND: Based on previous reports suggesting a role of adeno-associated virus (AAV) in miscarriage, the prevalence of AAV DNA in genital tracts of male and female partners of subfertile couples was determined to assess a potential association of AAV infection with clinically relevant parameters of male and female fertility. METHODS: A prospective study was performed in the outpatient infertility clinic of a university-based hospital. Semen samples and endocervical material obtained from 146 male and 134 female partners of asymptomatic subfertile couples were analyzed for the presence of AAV DNA (using nested PCR). Patients' medical histories and details of clinical examinations were recorded. Semen quality, including sperm functional capacity and the presence of antisperm antibodies (ASA) and seminal white blood cells (WBC), was assessed in aliquots of the same ejaculate. Detailed examinations of the cervical factor and other variables of female subfertility were performed. Both partners were screened for bacterial infection. RESULTS: The presence of AAV DNA in semen was not significantly related to semen quality, including sperm functional capacity or local ASA, nor was it coupled to the presence of AAV in the endocervical material of female partners. The presence of AAV DNA was not associated with the presence of other micro-organisms of the lower genital tract or with seminal WBC in men. AAV DNA in endocervical material was not related to a reduced quality of cervical mucus or to other female infertility factors. CONCLUSIONS: The presence of AAV DNA in semen samples or endocervical swabs showed no significant association with clinically relevant infertility factors. However, longitudinal studies may clarify previous suggestions of an influence of AAV infection on early pregnancy problems.

Clinical relevance of polymorphonuclear (PMN-) elastase determination in semen and serum during infertility investigation.

The polymorphonuclear (PMN) elastase is secreted by activated granulocytes and is widely used as a marker of male accessory gland infection. However, the clinical value of routine determination of seminal plasma (SP) PMN elastase in asymptomatic patients during infertility investigation has not clearly been established and not much is known about the significance of PMN-elastase levels in serum as a potential biochemical determinant associated with infection/inflammation of the male genital tract. This prospective study included a total of 221 asymptomatic males from unselected subfertile couples, to evaluate the relationship of (i) serum and (ii) same-day SP PMN elastase concentrations with established semen quality parameters, including sperm functional capacity, local antisperm antibodies (ASA), seminal leucocytes, and the outcome of semen cultures including typical sexually transmitted disease pathogens, and a potential association with patients' medical history and results of clinical andrological examination. Furthermore, couples were followed up for subsequent fertility (controlled for female infertility factors). The concentrations of PMN elastase in serum and in SP were not significantly related to semen quality [with regard to microscopic (e.g. count, motility, morphology) as well as biochemical parameters, and also to local ASA of the IgG- or IgA-class]. There was no strong relationship with sperm functional capacity. No significant relationship with the outcome of the microbial screening was found. PMN-elastase levels in serum and SP were not significantly correlated and there was no association with subsequent fertility. Therefore, the value of routine determination of PMN elastase in semen and/or serum samples, particularly when used as a single parameter to screen for subclinical infection/inflammation in males under infertility investigation is limited.

Chlamydial infection--a female and/or male infertility factor?

After screening a large series (n = 491) of asymptomatic males of infertile partnerships for chlamydial immunoglobulin (Ig) G antibodies (Chlam AB), no significant influence of past chlamydial infection was found with regard to semen analysis, postcoital testing, in vitro sperm-cervical mucus penetration tests with hormonally standardized cervical mucus, circulating antisperm antibodies (detected with three different methods), local IgG and IgA antibodies (detected by means of the mixed antiglobulin reaction test) on the sperm surface, the sperm-cervical mucus contact test, and a microbial screening of semen samples for mycoplasmas and other potentially pathogenic micro-organisms. However, when the findings were correlated with infertility factors of patients' female partners and the subsequent pregnancy rate in a prospective study, a significant positive correlation of male Chlam AB with a tubal factor in their wives as cause of the couple's infertility was found. The results suggest that the main influence of Chlamydia trachomatis on male fertility is based on sexual transmission and negative influence on tubal function of female partners, but not on reduced sperm functional capacity.

Clinical significance of crossed in vitro sperm-cervical mucus penetration test in infertility investigation.

To evaluate the clinical significance of in vivo and in vitro testing of sperm ability to penetrate cervical mucus (CM), postcoital testing (PCT) and in vitro sperm-cervical mucus penetration testing were compared in a prospective study. Both in vivo and in vitro tests were standardized and performed after an oral course of estrogen therapy. Crossed in vitro sperm-cervical mucus penetration test, evaluated in 277 couples with CM of patients' wives and additionally with CM and semen of fertile donors, revealed that the male factor contributed to a significantly higher extent to deficient sperm-mucus interaction than the cervical factor. The overall pregnancy rate after 6 months was 23% (64/277). Whereas the outcome of PCT did not significantly predict subsequent fertility (PCT good pregnancy rate 24%/PCT poor 20%), significant differences were found for the sperm-cervical mucus penetration test with CM of patients' wives (pregnancy rate, 30.5% versus 8.5%) and for in vitro testing with donors' CM, but not for the mucus penetration test with donors' spermatozoa. Routine sperm analysis did not prove to be of prognostic value for a subsequent pregnancy. The results suggest that the in vitro sperm-cervical mucus penetration test is a good parameter of sperm function and, in particular, when performed as a cross-matching penetrability test, a valuable adjunct to PCT with regard to fertility prognosis.

Prognostic value of in vitro sperm penetration into hormonally standardized human cervical mucus.

To analyze the prognostic value of the sperm cervical mucus penetration test (SCMPT), fresh semen samples of 99 male patients under infertility investigation were exposed to capillary tubes filled with freshly obtained cervical mucus (CM) of the patients' wives (WCM), fertile donors (DCM), and bovine CM (BCM). The quality of the human CM was standardized by oral administration of estrogens. The overall pregnancy rate after 6 months was 17.2% (17/99), and was significantly different in couples with poor and good SCMPT with WCM (1/44, 2.3% versus 16/55, 29%; P less than 0.001) in a prospective study. Human CM was superior to BCM as a penetration medium in providing more information about sperm function. The results suggest that in vitro sperm penetration testing with hormonally standardized CM of female partners adds an important dimension to sperm analysis with regard to fertility prognosis.

Differentiation of round cells in semen by means of monoclonal antibodies and relationship with male fertility.

OBJECTIVE: To differentiate round cells in semen samples of subfertile men and evaluate the clinical significance during infertility investigation. PATIENTS: One hundred and eight randomly chosen couples with a median duration of infertility of 4 (range, 1 to 20) years presenting at the outpatient infertility clinic of the University of Heidelberg, Germany. MAIN OUTCOME MEASURES: Differentiation of round cells in semen by means of monoclonal antibodies (mABs) and a streptavidin-biotin system for staining. Correlation of results with medical history, outcome of clinical examination, sperm analysis, microbial screening of both partners, evaluation of sperm functional capacity in vivo by means of the postcoital test (PCT) and in vitro with the standardized crossed sperm-cervical mucus penetration test (SCMPT) and the subsequent fertility in a prospective study. RESULTS: The method used for differentiation of round cells proved to be practical and suitable for routine use. The percentage of leukocytes ranged from 0% to 58% with a median of 3%. Number of round cells and percentage of leukocytes did not differ markedly with regard to andrologic history, clinical findings, for example, varicocele, results of standard sperm analysis, and microbial colonization of semen samples. However, high rates of leukocytes of the round cells correlated with reduced sperm count and morphology and results of PCT. Leukocyte-positive (> 15% leukocytes) specimens were also significantly more frequent in case of inadequate SCMPT and reduced sperm penetration ability in vitro. CONCLUSIONS: In asymptomatic patients (in terms of genital tract infection), the majority of round cells consist of immature germ cells and < 5% are white blood cells. The streptavidin-biotin system and the mABs used in this study proved to be useful to identify patients with elevated rates of leukocytes in semen possibly reflecting subclinical genital tract infection with influence on sperm functional capacity and subsequent fertility. Thus the procedure can be recommended to be included in a comprehensive evaluation of male fertility.

Screening for subclinical inflammation in ejaculates.

OBJECTIVE: To determine the clinical significance of albumin determination in ejaculates by means of an easy office test to screen semen samples for subclinical infection-inflammation. PATIENTS: One hundred fifty-nine randomly chosen males of couples with longstanding infertility (median duration of infertility 4 years (range 1 to 19 years) without clinical signs or symptoms of genital tract infection. SETTING: Outpatient Infertility Clinic of the University of Heidelberg, Germany. MAIN OUTCOME MEASURES: Screening of ejaculates for subclinical infection-inflammation by means of a ready-to-use kit for semiquantitative detection of albumin in addition to determination of leukocytes rates by means of monoclonal antibodies for differentiation of round cells and measurement of granulocyte elastase concentration in semen samples. Evaluation of sperm quality by means of standard sperm analysis including determination of local antisperm antibodies with the mixed antiglobulin reaction, evaluation of sperm functional capacity in vitro with the standardized sperm-cervical mucus (CM) penetration test, and semen cultures. All tests were performed from aliquots of the same ejaculates. RESULTS: Screening of semen samples for elevated albumin with the modified paper strips proved to be very easy, quick, and suitable for routine use. Positive results were not related markedly to medical history and outcome of clinical examination as well as to standard parameters of sperm analysis and were not influenced by local antisperm antibodies of the immunoglobulin (Ig)G and/or IgA class and microbial colonization. However, albumin-positive semen samples were significantly less frequent in case of very good outcome of the sperm-CM penetration test. A significant relationship was found with high rates of leukocytes of the round cells in semen samples (total range 0% to 96%) and the concentration of granulocyte elastase (total range 1 to 880 micrograms/L). CONCLUSIONS: The results of this prospective study suggest that the determination of albumin in semen samples with ready-to-use test kits might be a valuable additional marker for subclinical infection-inflammation of the male genital tract and therefore suitable for screening during infertility investigation.

Induction of immunoresponse by subclinical male genital tract infection?

OBJECTIVE: To determine the relationship of subclinical infection or inflammation of the male genital tract, as evaluated with seminal markers, with local antisperm antibodies as potential parameter of immunoresponse. PATIENTS: One hundred ninety-one randomly chosen males of subfertile couples who were asymptomatic in terms of genital tract infection. SETTING: Outpatient Infertility Clinic of the University of Heidelberg, Germany. MAIN OUTCOME MEASURES: Determination of leukocytes rates in semen using an immunocytochemical method for differentiation of round cells and measurement of polymorphonuclear (PMN) granulocyte elastase concentration in seminal plasma in addition to semen cultures as screening for subclinical infection of the male genital tract. Determination of local antisperm antibodies (Ab) with the mixed antiglobulin reaction ([MAR] immunoglobulin [Ig] G and IgA) in aliquots of the same ejaculates. RESULTS: Leukocyte rates of the round cells ranged from 0% to 93%, leukocytospermia was found in 6.8%. This was not related significantly to the presence of local antisperm antibodies of the IgG or IgA class. There was also no significant association of antisperm Ab with the concentration of PMN granulocyte elastase in seminal plasma and the outcome of semen cultures. CONCLUSIONS: The results of this prospective study suggest that when the rate or number of leukocytes or the concentration of PMN elastase in semen are taken as markers for subclinical infection or inflammation of the male genital tract, this is not associated significantly with the production of local antisperm Ab of the IgG or IgA class as indicator of immunoreaction.

The pH as an important determinant of sperm-mucus interaction.

OBJECTIVE: To determine the clinical significance of endocervical mucus pH on sperm-mucus interaction during infertility investigation. PATIENTS AND MATERIAL: Two hundred sixteen couples with a median duration of infertility of 4 years (range, 1 to 19 years) presenting at the infertility unit of the Women's University Hospital of Heidelberg, Germany. MAIN OUTCOME MEASURES: Determination of endocervical pH by colorimetric and electrometric measurement and correlation of results with the outcome of postcoital testing (PCT) and other parameters of infertility investigation (semen and cervical mucus [CM] quality, microbial colonization of cervix and ejaculates, medical history, hormonal status, and specific medication) and the subsequent fertility in a prospective study. In vitro experiments with the sperm-cervical mucus penetration test (SCMPT) used as biological model. RESULTS: The colorimetric determination of endocervical mucus pH is an easy method, suitable for routine clinical use, correlating significantly with electrometric measurement of pH. Median pH was 7.0 (range, 5.4 to 8.2). The mucus pH was significantly related with the results of PCT, even when mucus and semen variables were taken into account. No significant relationship was seen between the cervical index and mucus pH and the microbial colonization of cervix and ejaculates. The pH of endocervical secretions correlated with the peripheral hormonal status: low pH levels were significantly more frequent in patients with hyperandrogenemia, indicated by high testosterone and/or dehydroepiandrosterone sulfate levels before medication was started, and in hyperandrogenemic patients treated with dexamethasone than in the other women. Oral administration of estrogens led to a subtle alkalinization of the CM. With regard to subsequent fertility 6 months after pH testing, the pregnancy rate was significantly lower in women offering reduced mucus pH on occasion of the PCT in the group of couples with primary infertility and in couples with oligozoospermia of the male partner. The significant influence of pH on sperm-mucus interaction was confirmed in vitro with the SCMPT. CONCLUSIONS: The results indicate that the pH of the CM, easily determined with pH indicator paper, is an important parameter of mucus quality with significant influence on spermatozoal viability in CM, which correlates with peripheral hormonal status and can be affected by oral medication with estrogens. Therefore the routine determination of pH on occasion of the PCT is recommended during infertility investigation.

Evaluation of polyacrylamide gel as substitute for human cervical mucus in the sperm penetration test.

OBJECTIVE: To compare polyacrylamide gel as synthetic medium with human cervical mucus (CM) for the in vitro sperm-penetration test during infertility investigation. PATIENTS: One hundred sixty-nine randomly chosen couples with a median duration of infertility of 4 (range, 1 to 16) years presenting at the infertility unit of the Women's University Hospital of Heidelberg, Germany. MAIN OUTCOME MEASURES: Evaluation of sperm migration in polyacrylamide gel used in four different concentrations (1.5%, 1.6%, 1.7%, 1.8%) in the capillary tube test in parallel with CM of patients' female partners and CM of fertile donors, obtained under standardized conditions. Correlation of migration test results with outcome of semen analysis including microbial cultures and testing for local antisperm antibodies by means of the mixed antiglobulin reaction, postcoital testing, and the subsequent pregnancy rate after control for female infertility factors in a prospective study. RESULTS: Sperm ability to penetrate the synthetic medium (concerning all concentrations) correlated significantly with the penetration of human CM, although polyacrylamide proved to be a stronger barrier. Sperm velocity and duration of progressive motility were markedly reduced in polyacrylamide. Polyacrylamide results correlated with the outcome of standard sperm analyses but not with sperm antibody testing. No clear differentiation was obtained with regard to subsequent fertility (19% after 6 months), although adequate sperm migration in polyacrylamide 1.8% was significantly more frequent in the fertile group. CONCLUSIONS: In analyzing the intrinsic motility, penetration testing with polyacrylamide gel provides important information not obtained by routine sperm analysis. However, particularly with regard to immunological factors and fertility prognosis, human CM should be preferred whenever possible.

Herpes simplex virus infection of the uterine cervix--relationship with a cervical factor?

OBJECTIVE: To determine the prevalence of genital herpes simplex virus (HSV) in women of reproductive age and to evaluate a potential relation of asymptomatic HSV shedding with a cervical factor. DESIGN: Prospective study. SETTING: Outpatient infertility clinic of a university hospital. PATIENT(S): Randomly chosen asymptomatic women (n = 1,262) with a median age of 30 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Prevalence of cervical HSV, cervical index parameters, and other variables of CM quality, including CM penetrability in vivo and in vitro. RESULT(S): The prevalence of HSV infection of the uterine cervix was 5.2% (identified with cell culture). There was a tendency toward increased viscosity of the CM in HSV-positive women, but no significant relation with the other variables of CM quality (amount, spinnbarkeit, ferning, cervical appearance, and cellularity of the CM), or with the summarized Insler score or the cervical index according to World Health Organization guidelines. Postcoital testing and the in vitro penetration test, using either partners' or donors' semen, showed that the penetrability of the CM did not differ significantly between women with and without cervical HSV shedding. Asymptomatic cervical HSV infection was not significantly associated with bacterial colonization of the lower genital tract, with leukocyte counts in cervical secretions, with the pH of the CM or the vaginal fluid, or with antisperm antibodies in the CM. CONCLUSION(S): The results suggest that in asymptomatic women under controlled endocrine conditions, cervical HSV infection is not a significant cause of impaired quality and penetrability of the CM.

Clinical relevance of sperm morphology assessment using strict criteria and relationship with sperm-mucus interaction in vivo and in vitro.

OBJECTIVE: To determine the relationship of the differentiated morphological pattern of semen samples according to strict criteria and sperm-mucus interaction in vivo and in vitro. PATIENTS: One hundred sixty-three randomly chosen couples with long-standing infertility (median duration of infertility 4 years, range 1 to 19 years). SETTING: Outpatient clinic of the fertility unit at the Women's University Hospital of the University of Heidelberg, Heidelberg, Germany. MAIN OUTCOME MEASURES: Sperm morphology assessment using strict criteria (Tygerberg or Norfolk classification) parallel to standard methods of sperm analysis: Evaluation of the cervical factor of patients' female partners, including a microbial screening of genital secretions of both partners; Examination of sperm migration ability in vivo under hormonally controlled conditions for the cervical mucus (CM) quality and in vitro with the crossed sperm-CM penetration test performed with CM of patients' partners, as well as with CM and spermatozoa of donors; Determination of the selection capacity of CM with regard to sperm morphology by means of a biological model; Prospective analysis of the differentiated morphological pattern with respect to couples' subsequent fertility within 6 months. RESULTS: Using stict criteria, amorphous sperm heads were the most frequently found sperm anomaly (severely amorphous forms: median, 28%; range, 4% to 62%). The morphology index offered a median of 45% (range, 7% to 80%). Results correlated significantly with routine sperm analysis, including standard morphology. The morphological pattern differed significantly in samples offering adequate or inadequate ability to penetrate CM in the standardized sperm-CM penetration test or in the postcoital test, with the percent of severely amorphous heads as the most important parameter. Neck and tail defects did not play an important role. During passage of mucus columns in vitro, the rate of pathological spermatozoal forms was reduced significantly, from a median of 65% to a median of 38%. Better functional capacity of spermatozoa with normal head morphology also was reflected by a significantly higher pregnancy rate under natural conditions of conception. CONCLUSIONS: Sperm morphological properties, determined with strict criteria, are important factors for sperm ability to penetrate the mucus barrier at the uterine cervix before reaching the site of fertilization, but sperm morphology is only one among other parameters determining the complex phenomenon of sperm-mucus interaction.

Chlamydia trachomatis: impact on human reproduction.

Chlamydia trachomatis infections are the most prevalent bacterial sexually transmitted infections (STI) recognized throughout the world. Worldwide, the magnitude of morbidity associated with sexually transmitted chlamydial infections is enormous. C.trachomatis is a common cause of urethritis and cervicitis, and sequelae include pelvic inflammatory disease (PID), ectopic pregnancy, tubal factor infertility, epididymitis, proctitis and reactive arthritis. The sharp worldwide increase in the incidence of PID during the past two decades has led to the secondary epidemics of tubal factor infertility and ectopic pregnancy. Chlamydial PID is the most important preventable cause of infertility and adverse pregnancy outcome. Chlamydial infections, like STI in general, are primarily a woman's health care issue since the manifestations and consequences are more damaging to the reproductive health in women than in men. Based on the available evidence, approximately 20% of women with chlamydial lower genital tract infection will develop PID, approximately 4% develop chronic pelvic pain, 3% infertility, and 2% adverse pregnancy outcome. However, these estimates are based on relatively weak evidence. Research on the link between C.trachomatis and male aspects of infertility has been much more limited. Currently recommended treatment regimens include azithromycin in a single dose or doxycycline for 7 days. These therapies are highly efficacious. Timely management of sex partners is essential for decreasing the risk for re-infection. Immunopathogenesis of C.trachomatis infection is one of the main focal points of current research into Chlamydia. Chlamydial infection fills the general prerequisites for disease prevention by screening, i.e. chlamydial infections are highly prevalent, usually asymptomatic, are associated with significant morbidity, can be reliably diagnosed, and are treatable. Screening programmes for C.trachomatis will be of paramount importance in the prevention of long-term sequelae. The cost of screening is only a fraction of the health care costs incurred due to complications resulting from undiagnosed and untreated chlamydial infections. Current strategies to control C.trachomatis still largely depend on clinic-based screening of symptomatic patients, and have not been successful. The development of highly sensitive and specific nucleic acid amplification tests for the diagnosis of chlamydial infections has been an important advance in the ability to conduct population-based screening programmes to prevent complications. Thus, the case for screening is clearly made, but much detail remains to be worked out.

Determination of antisperm antibodies in serum samples by means of enzyme-linked immunosorbent assay--a procedure to be recommended during infertility investigation?

The clinical significance of antispermatozoal antibody (ASA) testing in serum samples with an enzyme-linked immunosorbent (ELISA) technique using a commercially available kit was evaluated in 95 randomly chosen couples under infertility investigation. Results were related to many other parameters of male and female fertility, e.g. outcome of sperm analysis, testing of sperm functional capacity including the crossed in-vitro sperm-cervical mucus penetration test (SCMPT), results of a microbial screening in genital secretions, testing for local IgG- and IgA-class sperm antibodies in semen by means of the mixed antiglobulin reaction (MAR) and the subsequent pregnancy rate in a prospective study. Results of ASA testing did not show any relationship with medical history and results of clinical examination, the semen quality including sperm function tests and seminal cultures, outcome of the crossed SCMPT, and local ASA. All patients with MAR (IgG or IgA) positive ejaculates were ELISA negative in serum samples. No significant difference with regard to circulating ASA (ELISA) was found in couples with and without a subsequent pregnancy. Furthermore there was no significant difference of antibody levels in subfertile female patients, virgins (n = 36), 'normal' pregnant women (n = 39) and prostitutes (n = 40). In summary, the results of this study clearly demonstrate that the use of this method for detection of antisperm antibodies during infertility investigation cannot be recommended.

[Topical one-time therapy with ketoconazole: a double-blind randomized study in vaginal mycosis]. / Topische Einmaltherapie mit Ketoconazol: Eine doppelblind randomisierte Studie bei Vaginalmykose.

In a double-blind clinical study 90 women with vaginal candidosis were randomly assigned to treatment with either single-dose ketoconazole (400 mg or 800 mg) or placebo vaginal suppositories. Microscope checks of vaginal fluid and mycological cultures were performed one week and four weeks after the treatment. The four weeks observation period gave no evidence for any significant differences among the three groups regarding symptoms reported as well as clinical picture and microscopy findings. Cure rate after one week, as determined by fungal cultures, was significantly lower in the placebo group (43%) than in the 400 mg (60%) and 800 mg groups (76%; p = 0.031). The mycological cure rate after four weeks did no longer show a significant difference between the groups tested, being 47% in the placebo group and 67% in each of the ketoconazole groups. Treatment of the sexual partner as well as predisposing factors did not influence the therapeutic effect. Due to the low ketoconazole serum concentrations after absorption of single vaginal doses, topical ketoconazole treatment can be applied in pregnancy. It remains to be tested, however, whether repeated vaginal application over three to five days will render higher and longer-lasting cure rates.

Effects of kallikrein on sperm motility, capillary tube test, and pregnancy rate in an AIH program.

From 1984 to 1986, 172 couples were enrolled in an artificial insemination homologous (AIH) program, because of negative postcoital test, fair PT, positive PT with unexplained infertility, and impotentia coeundi. Patients were randomly assigned to the following procedures: AIH with native semen (N, n = 68), washed sperm (V, n = 50), semen mixed with kallikrein (K, 5 IE/ml semen, n = 45), and timed intercourse. The overall pregnancy rate (PR) was 22% per couple (13% inseminations, 9% spontaneous). PR from insemination (spontaneous) was 13% (8), 13% (13), 23% (0) in PT negative, fair, and positive patients, respectively, and 18% (9), 13% (7), and 11% (9) in AIH groups N, V, and K. Among in vitro studies with K added semen, an improvement of sperm motility was demonstrated in half of the specimens. In the capillary tube test (CTT), with wives' cervical mucus, a deterioration was more frequently seen than an improvement after 2 h, independent of the early effect of K in semen, K induced changes of CTT were less pronounced when donors' cervical mucus was used. The results of the in vitro studies offer an explanation for the low PR in the AIH program with K.

The use of hens' egg white as a substitute for human cervical mucus in assessing human infertility.

Semen samples from 179 patients with longstanding infertility were allowed to penetrate capillaries filled with a fraction of fresh hens' egg white (HEW) as a substitute for cervical mucus (CM) for the in-vitro sperm-cervical mucus penetration test (SCPMT). Results were correlated with those obtained from human CM (HCM) used in parallel on the same semen sample, compared to results of sperm analysis and post-coital testing (PCT) and analysed for their prognostic value for a subsequent pregnancy in a prospective study. The overall pregnancy rate after 6 months was 26.3% (47/179). Whereas routine semen analysis (semen volume, pH, sperm count, progressive motility, morphology and fructose concentration) did not differentiate between patients who achieved pregnancy and those who did not, significant differences were found for the penetration distance (P less than 0.02) and the motility grade of sperm in HEW (P less than 0.02). Although the mean sperm velocity in HEW was reduced compared to HCM, a close positive correlation was found between the sperm density and the penetration distance (P less than 0.001). The percentage of samples with good HEW penetration increased significantly in parallel with better results of post-coital testing (P less than 0.001). The results indicate that, when fresh human CM is not available, HEW can be used as a medium for the SCPMT as a valuable adjunct to semen analysis which provides information about sperm functional capacity.

Clinical data which influence semen parameters in infertile men.

Spermiograms, Sims-Huhner postcoital tests, in-vitro sperm penetration tests and hormone stimulation tests, including gonadotrophin-releasing hormone, thyrotrophin-releasing hormone and the adrenocorticotrophic hormone (ACTH) test, were obtained in 225 infertile men. The present paper deals with the influence which anamnestic factors have on the spermiogram and on hormone levels. Adrenocortical function decreased with age. Blue-collar workers had poorer sperm parameters than white-collar workers. Smokers exhibited hormone alterations without significant changes in the spermiogram. Regular alcohol consumption was associated with elevated dehydroepiandrosterone-sulphate and oestradiol concentrations and poor postcoital test results. Emotional stress had a negative influence on sperm parameters. Environmental influences warrant additional attention in the evaluation of men with abnormal spermiograms.

Double-blind controlled trial of progesterone substitution in threatened abortion.

Between 1983 and 1984 a double-blind randomized study with progesterone substitution in threatened abortion was carried out. Fifty-six patients with vaginal bleeding during the first trimester of pregnancy, the internal cervical os being closed, were referred to the hospital. Twenty-five women (5th and 6th week of gestation) with positive serum concentrations of beta-hCG were admitted to the study without regard to sonogram results. In other 25 women (7th-10th week of pregnancy) and 6 women (greater than or equal to 11th week of pregnancy) fetal heart action and movement could be demonstrated by ultrasound. The patients were prescribed bed rest and vaginal suppositories twice daily, containing either 25 mg progesterone or only polyethylene glycol. The code was not broken until after completion of the study. Serial serum determinations of beta-hCG, estradiol-17 beta (E2), progesterone, and ultrasound were performed. Four patients had to be omitted from final analysis (two tubal pregnancies, one intrauterine infection, one sectio parva). Three of 26 patients progesterone (11%) and five of 26 patients with placebo (19%) had an abortion, which represented no significant difference. Frequency of abortion was increased in women more than 30 years old, in women with previous abortions and after ovulation induction. Progesterone treatment resulted in a significant elevation of serum progesterone concentrations (p less than 0.01), while beta-hCG and E2 were unchanged. The results of this study confirm that pregnancy outcome is favorable in women with bleeding and normal hormone concentrations without hormonal treatment and unfavorable in women with reduced beta-hCG and E2-concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)