|Year : 2001 | Volume
| Issue : 2 | Page : 152-155
Effects of steroid therapy in subfertile men with antisperm antibodies
Sulabha Punekar, Vasudeo Ridhorkar, Sandhya Rao, Atul Soni, G Swami, JS Kinne, JR Samtani
Departments of Urology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
Department of Urology, K.E.M. Hospital, Parel, Mumbai - 400 012
Source of Support: None, Conflict of Interest: None
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 2015 Jul 5];17:152-5. Available from: http://www.indianjurol.com/text.asp?2001/17/2/152/21046
| Introduction|| |
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|| |
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|| |
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|| |
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|| |
Since the formation of antisperm antibodies is an immune mediated phenomenon, it should logically be suppressed by steroids. , 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. 
Hendry et al  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 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%.  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 ,, and may be the only seminal parameter predictive of ASA status. 
With use of steroids only, 4 patients (8.88%) achieved pregnancy at the end of 6 months. Hendry et al  using a similar intermediate dose cyclic regimen has reported a pregnancy rate of 31 % at the end of 18 months. Cookson & Witt  reported that steroid induced suppression of antibody requires longer than 3 months. Hendry et al  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  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.  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  after combining several different series has quoted a pregnancy rate of 16% while Kremer  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|| |
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|| |
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|| |
|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. |
|2.||Weese DL, Zimmern PE. Sperm antibodies in infertility and how to surmount them. Contemp Urol 1992; 19: 68. |
|3.||Mosby Editors, Lytton B. Catalona WI, Lipshultz LL McGuire EJ: Adva Urol 1994; 7. |
|4.||Hendry WF, Stedronska J, Hughes L et al. Steroid treatment of male subfertility caused by antisperm antibodies. Lancet 1979; 2: 498. |
|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. |
|6.||Jarow JP, Sanzone JJ. Risk factors for male partner antispertn antibodies. J Urol 1992: 148: 1805-1807. |
|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. |
|8.||Kremer J, Jagor S. The sperm cervical mucus contact test: a preliminary report. Fertil Steril 1976; 27: 335-340. |
|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. |
|10.||Haas GG. Male fertility and immunity. In: Lipshultz LJ, Howards SH (eds.): Infertility in the Male. Churchill Livingstone, New York, 1991; 227. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]