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ORIGINAL ARTICLE
Year : 2001  |  Volume : 17  |  Issue : 2  |  Page : 152-155
 

Effects of steroid therapy in subfertile men with antisperm antibodies


Departments of Urology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India

Correspondence Address:
Sulabha Punekar
Department of Urology, K.E.M. Hospital, Parel, Mumbai - 400 012
India
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Keywords: Infertility; Antibodies


How to cite this article:
Punekar S, Ridhorkar V, Rao S, Soni A, Swami G, Kinne J S, Samtani J R. Effects of steroid therapy in subfertile men with antisperm antibodies. Indian J Urol 2001;17:152-5

How to cite this URL:
Punekar S, Ridhorkar V, Rao S, Soni A, Swami G, Kinne J S, Samtani J R. Effects of steroid therapy in subfertile men with antisperm antibodies. Indian J Urol [serial online] 2001 [cited 2014 Dec 19];17:152-5. Available from: http://www.indianjurol.com/text.asp?2001/17/2/152/21046



   Introduction Top


The problem of infertility has troubled mankind since ages. The concept of immunological infertility introduced in the fifties is now a well accepted entity. As our under­standing of antisperm antibodies improves, there is a cor­responding increase in the intensity of our search for effective and rational therapy. However a review of litera­ture reveals no standardization of therapeutic strategies.


   Aims and Objectives Top


We wanted to assess the effects of steroid suppression therapy on antisperm antibody status, seminal parameters and pregnancy rates and also the role of Intrauterine In­semination (IUI) in the management of patients with ASA.


   Materials and Methods Top


45 male patients diagnosed to have antisperm anti­bodies by the Direct Sperm Mar IgG Test were included in this study after excluding female factor infertility by examination and necessary investigation in the Obstet­rics & Gynecology department of our hospital.

These 45 patients were then started on intermediate dose steroid-suppression therapy. Patients were given oral pred­nisolone 20 mg twice daily from the first to the tenth day of the wife's cycle and 5 mg once daily on days 11 & 12. This regime was given for 6 consecutive cycles and pregnancies if any recorded. The patients were regularly followed up in this period to monitor the adverse effects of steroid therapy. Semen analysis was performed every 2 months to assess the change in seminal parameters. The Sperm Mar IgG test was repeated after 6 cycles and pregnancies if any noted. A posi­tive response to steroids meant absence of antisperm anti­bodies by Sperm Mar IgG test in patients who had originally tested positive for ASA. Those patients who did not respond to steroids were sent for AIH as also those patients who responded, but could not achieve pregnancy.


   Results Top


Of the 45 patients, 12 were patients with idiopathic infer­tility (Group A) and 33 were patients with correction of known risk factors for infertility such as varicocele, testicu­lar obstruction, infection and undescended testis (Group B). 5 of 12 patients in Group A (41.66%) had a negative Sperm Mar Test after 6 weeks of steroid suppression therapy while the remaining 7 (58.33%) remained persistently positive. 12 of 33 patients in Group B (36.72%) had a negative test while 21 (63.28%) remained positive [Table - 1].

In both groups, there was a marginal improvement in sperm count and motility index among both responders and non-responders. However, this was not statistically signifi­cant. The only parameter to change significantly in both groups was spontaneous agglutination. In responders from both groups semen showed absence of spontaneous aggluti­nation [Table - 2]. Spontaneous autoagglutination persisted in the non-responders of both groups.

Pregnancy rates were noted after steroid therapy. Only I of 5 responders from Group A and 3 of 12 responders from Group B achieved pregnancy. Pregnancy rates among non­responders in both groups was nil [Table - 3]. Thus the total pregnancy rate after steroids was 4 out of 45 (8.88%).

Non-responders and those responders who did not achieve pregnancy were sent for IUI. No patient from Group B achieved conception [Table - 4].

2 non-responders and 1 responder from Group A achieved pregnancy. Thus a total 7 of 45 patients (15.5%) achieved pregnancy [Table - 5].


   Discussion Top


Since the formation of antisperm antibodies is an immune mediated phenomenon, it should logically be suppressed by ster­oids. [1],[2] However review of literature reveals that there is no con­sensus regarding the route, dosage or interval of steroid administration. The pendulum of opinion has swung from high dose cyclic therapy to low dose long-term therapy. The intro­duction of an intermediate dose cyclic regimen marks an at­tempt at maintaining efficacy while decreasing toxicity. [3]

Hendry et al [4] reported a pregnancy rate of 14% using low dose continuous therapy, i.e., 5 mg of oral prednisolone three times daily for 3 to 12 months. He found that though there was improvement in sperm counts, serum antibody titres remained significant. De Almeida and Jouanuet[3] used 2-3 mg of dexamethasone daily over several weeks with gradual tapering and demonstrated a decrease in both se­rum and seminal antibodies during therapy. They reported an overall pregnancy rate of 21 % with all these patients showing disappearance of seminal antibodies. This was accompanied by increased sperm motility and decreased agglutination in responders and improved counts in pa­tients with initial oligospermia. Using high dose cyclic regimen, where patients were treated with 32 mg of oral methyl prednisolone 3 times daily on days 21 to 28 of the wife's cycle, Hendry reported a pregnancy rate of 31%. [5] Shulman & Shulman reported a pregnancy rate of 44% in 71 patients treated with a similar regimen.

We found a marginal improvement in both mean sperm count and motility index in both groups. which was not statistically significant. The only seminal parameter to show significant change was spontaneous agglutination, which became negative in all responders of both Groups A & B and persisted in the non-responders. Thus sponta­neous agglutination is a good indication of the presence of ASA in the semen sample [6],[7],[8] and may be the only semi­nal parameter predictive of ASA status. [6]

With use of steroids only, 4 patients (8.88%) achieved pregnancy at the end of 6 months. Hendry et al [9] using a similar intermediate dose cyclic regimen has reported a preg­nancy rate of 31 % at the end of 18 months. Cookson & Witt [3] reported that steroid induced suppression of antibody requires longer than 3 months. Hendry et al [9] reported a sta­tistically improved pregnancy rate after 18 months of ste­roid therapy. The modest pregnancy rate in this study could be due to the fact that the follow-up period was short.

In group B, 3 of the 12 responders reported pregnancy of which 1 was a case of operated varicocele and 2 were pa­tients with treated infection. These 2 groups in general had higher sperm densities when compared to the other risk factor groups. Moreover these 3 patients in particular had nor­mal sperm counts following treatment. Cookson & Witt [3] have concluded that in patients with immune-mediated in­fertility, steroid therapy is only moderately successful and the pregnancy normally occurs in spouses of men with nor­mal sperm densities and short duration of untreated infer­tility. After treatment of the primary pathology, very little can be offered to these patients with known risk factors.

Antisperm antibodies can severely inhibit sperm pen­etration into cervical mucus and subsequent migration into the  Fallopian tube More Details. [3] The damaging effects of ASA-bound sperm cervical mucus interaction must be bypassed in addition to suppressing ASA formation. One such tech­nique is Intrauterine Insemination (IUI). We referred all cases from both groups who had not conceived for IUI. This resulted in 3 pregnancies from group A and none from group B. Haas [10] after combining several different series has quoted a pregnancy rate of 16% while Kremer [3] has reported a pregnancy rate of 20%. These modest rates are probably due to the fact that ASA block reproduction at different steps of the cycle in addition to the sperm cer­vical mucus barrier which is bypassed by IUI.


   Conclusion Top


Along with increased detection of ASA, there is an in­creased demand for effective treatment of immunological infertility. The beneficial role of steroids is undoubted, regardless of the regimen followed. The only seminal pa­rameter showing significant response to steroids is spon­taneous autoagglutination which disappears or decreases in the responders. Modest pregnancy rates were achieved with short-term therapy and probably a longer duration of treatment would yield better results. With the advent of assisted reproductive techniques such as ICSI, which is capable of bypassing most barriers to transport, the future seems promising for these patients.


   Acknowledgement Top


We wish to thank Dr. P.M. Pai, the Dean of Seth G.S. Medical College and King Edward Memorial Hospital, Mumbai for permission and Mrs. Namrata P. Parab for the secretarial help.

 
   References Top

1.Sigman M. Howards SS. Male Infertility. In: Walsh PC, Retik AB, Stamey TA et al (eds.): Campbell's Urology 6 th ed. Saunders, Phila­delphia, 1992; 661.  Back to cited text no. 1    
2.Weese DL, Zimmern PE. Sperm antibodies in infertility and how to surmount them. Contemp Urol 1992; 19: 68.  Back to cited text no. 2    
3.Mosby Editors, Lytton B. Catalona WI, Lipshultz LL McGuire EJ: Adva Urol 1994; 7.  Back to cited text no. 3    
4.Hendry WF, Stedronska J, Hughes L et al. Steroid treatment of male subfertility caused by antisperm antibodies. Lancet 1979; 2: 498.  Back to cited text no. 4    
5.Hendry WE The diagnosis and treatment of antisperm antibodies in subfertile males. In: Recent Adv Urol/Androl. Churchill Living stone, Edinburgh. 1981: 3: 339.  Back to cited text no. 5    
6.Jarow JP, Sanzone JJ. Risk factors for male partner antispertn anti­bodies. J Urol 1992: 148: 1805-1807.  Back to cited text no. 6    
7.Cerasaro M, Valenti M. Massacesi A et al. Correlation between the direct IgG Mar Test (mixed antiglobulin reaction test) and seminal analysis in men from infertile couples. Fertil Steril 1985; 44: 390.  Back to cited text no. 7    
8.Kremer J, Jagor S. The sperm cervical mucus contact test: a pre­liminary report. Fertil Steril 1976; 27: 335-340.  Back to cited text no. 8    
9.Hendry WE Hughes L. Scammel G et al. Comparison of pred­nisolone and placebo in subfertile men with antibodies to sperma­tozoa. Lancet 1990: 335: 85.  Back to cited text no. 9    
10.Haas GG. Male fertility and immunity. In: Lipshultz LJ, Howards SH (eds.): Infertility in the Male. Churchill Livingstone, New York, 1991; 227.  Back to cited text no. 10    



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]



 

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    Introduction
    Aims and Objectives
    Materials and Me...
    Results
    Discussion
    Conclusion
    Acknowledgement
    References
    Article Tables

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