Male factors in rpl

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Dr Mangala Devi Smile baby IVF

MALE FACTORS IN RPL

www.smilebabyivfs.in

How much can be attributed to the male?etiology female..


The word miscarriage is misleading, because it seems that only females are involved in its nature. But it is well recognized that both couples are involved since male gamete contributes one-half of the genome content to the embryo



The obvious situation in which the male can contribute to recurrent early pregnancy loss is when the genetic aspect of the speerm is deranged like aneuploidy or he is the carrier of a balanced chromosomal rearrangement, such as a, in which he has the correctamount of genetic material but has a high risk of making sperm that have an incorrect amount and we have discussed this situation in previous posts. Too much or too little genetic material usually results in early miscarriage

Abnormal sperm morphology,leucocytospermia

Abnormal sperm functions

Abnormal Sperm DNA

Advanced paternal age

Infections: Listeria,toxoplasma,CMV,HSV

Varicocoele

Paternal HLA sharing not related to RPL

Male factors


Age of male

Males above 35 y are at increased risk of RPL, a decrease in conception rate, an increase in autosomal dominant diseases

Increased chance for mutation or aneuploid during the maturation of male germ cells

Decrease in sperm quality particularly motility

May have an impact on implantation, placental proliferation, and placenta quality

amount of DNA damage in sperms of men aged 3657 is three times that of men 35 year

Puscheck and Jeyendran 2007, Aitken and Baker 2006


VARICOCOELE

DNA damage can occur in men with varicocele due to excessive sperm oxidative DNA damage which is associated with a reduction in some fertility indices.

The risk of child loss decreased significantly with varicocelectomy

(Wang et al. 2012; (Agarwal et al. 2009; Iselin et al. 2010; Wang et al. 2012),


Semen analysis:concentration,motility,morphology,viability,leucocytes

Sperm function tests: HOST, acrosomal status, TUNELLipid peroxidation

Antioxidant capacity of seminal plasma,estimation of ROS

Sperm DNA packaging: TUNEL;%DFI,TBARS production

Genetic factors play an important role in recurrent abortion

Evaluation of Male factor


Decreased percentage of morphologically normal sperm in the recurrent pregnancy loss patients compared with both the general population, control group and the donors.

Few IVF studies showed association of high abnormal sperm morphology with embryo failure at an early cleavage stage .

Recent study reported significant difference in sperm morphology and motility between RPL and control group.

Carrell et al., Absalan et al.,

Sperm Morphology


. The relation between standard semen parameters and recurrent pregnancy loss has been controversial subject [22]. Few researchers did not find any significant difference in the semen parameters like count, motility and morphology between recurrent spontaneous abortion and control group Kobayashi and colleaguesdemonstrated infertilization cycles that low percentages of normal sperm morphology were associated not only with lower successful fertilization rates and pregnancy rates per cycle, but also with a greater risk foreven if embryo transfer was successfulCarrell et al., [24] reported decreased percentage of morphologically normal sperm in the recurrent pregnancy loss patients compared with both the general population, control group and the donors.. Few IVF studies showed association of high abnormal sperm morphology with embryo failure at an early cleavage stage [26,27]. Recent study by Absalan et al., [28] reported significant difference in sperm morphology and motility between RPL and control group.


Saxena et al., reported mean less scores for all the three function tests in RPL group when compared to controls.

The pilot study carried out by Chaithra et al., reported significantly lower scores for semen profile and sperm function tests in the RPL group when compared to the control group. This study strengthens the current literature associating sperm quality with RPL, and emphasizes evaluating male factor by sperm function tests along with conventional semen parameters

Though individual has normal sperm count, motility and morphology but the sperm function tests exhibit sub normal scores which may be the possible aetiology for RPL.

Sperm function tests


Acrosin and Hyaluronidase are the two main acrosomal enzymes (proteases), which plays an important role in penetration of spermatozoa through outer membrane of oocyte. In our study mean AIT scores were observed to be within normal range in both RPL and control group. Subnormal scores were observed in 14(15%) individuals of RPL group. Saxena et al., [29] reported mean less scores for all the three function tests in RPL group when compared to controls. The pilot study carried out by Chaithra et al., [30] reported significantly lower scores for semen profile and sperm function tests in the RPL group when compared to the control group. This study strengthens the current literature associating sperm quality with RPL, and emphasizes evaluating male factor by sperm function tests along with conventional semen parametersour data suggest that though individual has normal sperm count, motility and morphology but the sperm function tests exhibit sub normal scores which may be the possible aetiology for RPL. Hence, we recommend screening of both partners simultaneously in RPL case to achieve desirable outcome. It might also assist in the selection of functionally superior sperm of such male partners who opt for assisted reproductive techniques like intra-cytoplasmic sperm injection (ICSI) or in vitro fertilization (IVF).




The intactness of the plasma membrane,its physical and chemical intergrity was evaluated by HOS test.

Normal values :> 60% with coiled tail

In Several studies, RPL group had low scores for HOS

Buckett et al

Hyper Osmotic Swelling Test


Buckett et al., [23] showed correlation with HOS test in recurrent miscarriage group and also showed the viability and quality of the sperm may have an impact on conception and miscarriage rates. The intactness of the plasma membrane was evaluated by HOS test. It is not only an indicator of the chemical integrity of the plasma membrane but also its physical integrity. Buckett et al., [23] showed correlation with HOS test in recurrent miscarriage group. Twenty two (23%) individual in RPL group had low scores for HOS and the mean scores of both the groups were within the normal range.

Buckett et al., [23] showed correlation with HOS test in recurrent miscarriage group and also showed the viability and quality of the sperm may have an impact on conception and miscarriage rates. The intactness of the plasma membrane was evaluated by HOS test. It is not only an indicator of the chemical integrity of the plasma membrane but also its physical integrity. Buckett et al., [23] showed correlation with HOS test in recurrent miscarriage group. Twenty two (23%) individual in RPL group had low scores for HOS and the mean scores of both the groups were within the normal range.



500 micro litre of HOS solution in atest tube,add 50 Ul of liquified semen sample to it and incubate.Observe a small drop on slide with cpoverslip and Count % of sperm with bent tail,.Normal >60% with bent tail

Nuclear chromatin Decondensation test

Normal value: >70% swelled head


Acrosome reaction and function

Normal range:>50% with halos


Interpretation of results

DFI < 15% : Low

DFI between 15-30%: medium

DFI > 30% : High

Several DFI assays available:1. sperm chromatin structure assay (SCSA) is commercially available2. Terminal deoxynucleotidyl transferase (TdT) dUTP Nick-End Labeling (TUNEL) assay

3.Halo test4. Comet assay .


In particular, men with normal semen parameters are often ignored because the bulk semen parameters appear normal [1]. Despite normal semen parameters, male partners in couples with RPL or recurrent implantation failure could have underlying genetic abnormalities in sperm DNA that can be identified. There are a couple of diagnostic tests that we recommend in the evaluation of these men, the first being DNA Fragmentation Index (DFI) and the second, fluorescence in situ hybridization (FISH) for evaluating sperm aneuploidyNCD of spermatozoa and subsequent male pronucleus formation is essential for fertilization and normal embryonic development. The failure of sperm decondensation in the oocytes may be a consequence of a subtle sperm abnormality like structural or biochemical defects associated with chromatin packaging or organization during spermatogenesis [29]. Chromatin damage precedes the loss of fertilization potential and poor embryo quality, resulting in pregnancy loss. The mean score for NCD test are subnormal in RPL group and 56 (58.9%) individual in RPL group had lesser score. Absalan et al., [28] tested the sperm DNA fragmentation by sperm chromatin depression (SCD) test and they observed significant difference between RPL and control group

Sperm aneuploidy testing: clinical testing of sperm aneuploidy has centered on those compatible with survival, namely trisomy 13, 18, 21, X monosomy and Klinefelter (XXY-XXXXY)

Sperm FISH : cytogenic assay that measures the frequency of chromosomal abnormalities by measuring sperm aneuploidy. Effective in identifying abnormal sperm aneuploidy in men with RPL and normal sperm parameters.

FISH/Aneuploidy testing


especially men with reciprocal translocations who had a higher rate of abortion compared with men with Robertsonian translocations who are complaining mainly of infertility and finally those with inversions. This has been explained as that reciprocal translocations do not affect sperm production and sperm parameters which occur in Robertsonian translocations and in turn lead to men infertility (Gualandi et al. 2000; Sugiura-Ogasawara et al. 2004). Also there is an increased rate of sperms aneuploidy for chromosomes 13, 18, 21, X, and Y detected by fluoresence in situ hybridization in the sperms of men who had history of unexplained recurrent miscarriage especialy with increase paternal age (Borini et al. 2006

Anti oxidants: Fruits/vegetables/multivitamins

Reduce ROS, reduced damage to DNA

Use of Migration-sedimentation/Density Gradient method of sperm preparation: recover sperm of high quality

A new sperm selection device, the PICSI dish: for use during IVF/ICSI allows selection of more genetically normal sperm.

Use of intrauterine insemination (IUI) : to select more normal sperm and subsequently improve pregnancy outcomes in RPL patients with associated male factor

Also IVF with prenatal genetic diagnosis (PGD), may be helpful in case of recurrent aneuploidy or a known balanced carrier parent

Treatment


Men with increased DFI in ejaculated sperm may be counselled for a testicular biopsy in combination with ICSI

Genetic counselling can be helpful in providing information about the risk of future miscarriage or live born offspring with an unbalanced karyotype which varies with the size and location of the chromosomal rearrangement

Treatment options


In particular, there are no repair mechanisms that occur once sperm are transported to the epididymis or post ejaculation [3]. High DNA damage as demonstrated by increased DFI is associated with recurrent pregnancy loss, recurrent IVF failure, and increased congenital abnormalities [4,5]. Therefore, men with abnormally elevated DFI can undergo testicular biopsy for sperm retrieval and use with intracytoplasmic sperm injection (ICSI) because DFI in testicular sperm is significantly lower compared to DFI in ejaculated sperm [6

Studies show significantly lower scores for semen profile and sperm function tests in the RPL group when compared to the control group. Evaluating male factor by sperm function tests along with conventional semen parameters is therefore important.

Hence, we recommend screening of both partners simultaneously in RPL case to achieve desirable outcome. It might also assist in the selection of functionally superior sperm of such male partners who opt for assisted reproductive techniques like intra-cytoplasmic sperm injection (ICSI) or in vitro fertilization (IVF).

Conclusion


whenthe male can contribute to recurrent early pregnancy loss is when he is the carrier of a balanced chromosomal rearrangement, such as a, in which he has the correctamount of genetic material but has a high risk of making sperm that have an incorrect amount and we have discussed this situation in previous posts. Too much or too little genetic material usually results in early miscarriage

.Egozcue and colleaguesreported that among infertile couples in which the males were chromosomallyand there was no identifiable source of infertility in the females, there were greater frequencies of chromosomallyproduced by the males as the result of meiotic disorders meiosis being the final stage of sperm production in which the normal chromosomal complement of 46 (23 pairs) is supposed to be halved to just 23 different chromosomes. Among these males they found a greater percentage of sperm with two copies (or none) of single chromosomes, such as chromosome 21 or other autosomes (non-sex chromosomes), two copies (or none) of sex chromosomes (rather than just one X or Y), and sperm that were still diploid, containing 46 chromosomes rather than 23. Obviously, under any of these circumstances, if these abnormal sperm got together with an egg that had a normal number of 23 chromosomes, the resulting baby would end up with too many or too few and the likelihood of miscarriage in early pregnancy would be high.The results and conclusions of this study were supported by Carrell and colleagueswho found the sperm aneuploidy (chromosomal abnormalities) rate in couples with recurrent pregnancy loss to be about twice that of the general population and this was accompanied by diminished percentages of sperm with normal morphology.

Bernadini and colleaguesreported that among men with recurrent pregnancy loss and poor semen quality, elevated frequencies of sperm aneuploidy were found in about 10% of these men who had, individually, sperm aneuploidy rates between 30-34%. In some instances, the high aneuploidy rate may be related to mosaicism (separate populations of cells, one chromosomally normal and the other chromosomally abnormal) that is confined to the germ lines (sperm-producing cells) in the testes. Such individuals would appear to be chromosomally normal except where it counts!In addition to sperm aneuploidy

Puscheck and Jeyendran 2007).

Sperm genetics



Male factors in rpl

Health & Medicine

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