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Male accessory gland infection and subfertility: a diagnostic challenge
Trum, J.W.
Publication date
1999
Link to publication
Citation for published version (APA):
Trum, J. W. (1999). Male accessory gland infection and subfertility: a diagnostic challenge.
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Chapter
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JWTrum, BWJ Mol, Y Pannekoek, L Spanjaard, P Wertheim, OP Bleker, F van der Veen.
Objectives: To evaluate whethet detection of leukocytospetmia in a routine semen analysis
is of diagnostic value in selecting men with an 'actual' microbial infection and to assess the association between leukocytospermia and a history of bacterial and viral infections.
Design: Prospective clinical study.
Setting: Infertility clinic at the Center for Reproductive Medicine: Academic Medical
Center, Amsterdam, the Netherlands.
Patients: One hundred andeighty-four men among subfertile couples attending our infertility
clinic.
Intervention(s): The number of leukocytes was assessed in three semensamples. Serologic
tests were performed, as was transurethral culture after digital prostatic massage.
Main Outcome Measures: Diagnosis of actual bacterial and viral infections in relation to
seminal leukocyte concentrations. The association of a history of sexually transmitted diseases with seminal leukocyte concentration.
Results: An actual bacterial infection was present in 39% of men and 1 1 % of men had
an actual viral infection. The area under the receiver operating curve, which was used to determine whether detection of leukocytospermia was of diagnostic value in identifying men with actual bacterial or viral infections, was 0.55 and 0.56 for bacterial and viral infection, respectively.
A past infection with N. gonorrhoeae was associated with the presence of leukocytosper-mia. A past viral infection was not associated with leukocytospermia .
Conclusion(s): Detection of leukocytospermia appears to be of no diagnostic value for
selecting men with actual microbial infections, but leukocytospermia is associated with a history of gonorrhoea.
Key Words: Leukocytospermia, genital tract infection, STD's, bacterial infections, viral infections, semenanalysis.
Introduction
Leukocytospermia, defined by the World Health Organization as > 1. 106 white
blood cells (WBCs)per mL of semen, has traditionally been associated with subclinical genital tract infection (1-4). Microorganisms that may lead to subclinical genital tract infection that induces urethritis, prostatovesiculitis, and epididymitis are Ureaplasma
urea-lyticum, Mycoplasma hominis, and Chlamydia trachomatis (5-7). The most reliable way to
detect these organisms is by culturing a urethral swab after digital prostatic massage (8,9). However this test is expensive and time consuming and is reported as a negative experience by most men.
To our knowledge, only one study has examined the relationship between genital tract infection and leukocytospermia to assess whether detecting leukocytospermia is of diagnostic value for determining active microbial infection (10). This preliminary study among potential semen donors concluded that seminal peroxidase- positive cells are not an adequate indicator of asymptomatic urethral gland infection . However, there was only a small number of subjects with > 1.106 WBC/mL of semen. The possibility that
leukocy-tospermia may be caused by sexually transmissible viruses other than human immunodefi-ciency virus and hepatitis B virus has never been studied (11).
The purpose of this study was to evaluate whether detection of WBCs in routine semen analyses could be used as a diagnostic test for selecting men with a positive bacterial culture or viral infection; men with bacterial infections could then be treated. We also eva-luated whether leukocytospermia can be regarded as a chronic inflammatory response in patients with a history of sexually transmitted diseases (STD's).
Materials and Methods
Between April 1994 and September 1996, 200 randomly chosen men who were > 18 years of age and who presented to the Center for Reproductive Medicine at the Academic Medical Center in Amsterdam were asked to participate in the study. Couples were referred because of primary or secondary infertility. The study was approved by our hospital's Institutional Review Board.
After patients had given informed consent, a detailed history of STDs was taken. Three semen samples were obtained from all men; there was an interval of at least 2 weeks between each sample. Semen was collected by masturbation after at least 72 hours of absti-nence. Semen samples were assessed with use of standardized techniques and the results were analyzed according to W H O criteria for the following parameters: volume, acidity, concentration, motility, morphology, fructose, and antisperm antibodies (1).
The number of leukocytes in each semen sample was assessed with the peroxidase assay (12). Brown staining round cells were classified as peroxidase positive. The number of WBCs was calculated by multiplying the number of round cells by the percentage of peroxidase positive cells.
All men underwent digital prostatic massage, after which two cotton urethral swab specimens were obtained; standard methods were used to determine whether bacteria were present. A gram stain of a urethral smear was examined for the presence of Neisseria
gonorrhoeae. One cotton swab was placed in a Stuart medium and used for bacterial
cultu-re. Culture for N. gonorrhoeae was done using a modified Thayer-Martin plate. In addi-tion a chocolate agar plate was used for routine culture. Culture of U. urealyticum and M.
hominis was performed with use of a Shepard broth and a Shepard plate. The presence of
•'••.-__
C. trachomatis was investigated with DNA-RNA hybridization (Genprobe Inc., San Diego,
CA). A positive bacterial culture or chemiluminescence signal was considered to indicate bacterial infection.
To detect an active or previous Cytomegalovirus (CMV), Ebstein-Barr virus (EBV), hepatitis B virus (HBV) and a past C. trachomatis, serumplasma was tested for the presence of antibodies. IgG and IgM antibodies to CMV were detected with the ImX system (Abbott, USA). IgM positive sera were confirmed in the Vidas system (bioMerieux, Marcy l'Etoile, France). Antibodies to EBV were detected by indirect immunofluorescence with use of IgG and IgM antibodies to EBV viral capsid antigen and by anti complement immunofluorescence with use of the Epstein-Barr virus associated nuclear antigen (Gull laboratories, Inc, Salt Lake City, USA). Serology for HBV (hepatitis B surface antigen, antibodies to hepatitis B core antigen, and if appropriate, hepatitis B e antigen) was perfor-med with the ImX system. IgG and IgA antibodies to C. trachomatis were detected with use of an enzyme immuno-assay from Lab Systems (Finland) based on a species-specific synthetic peptide. This test allows the screening and diagnosing of C. trachomatis infecti-ons without interference of C.pneumoniae antibodies.
Actual infections were diagnosed by high titers of IgM to CMV, high titer of IgM to EBV in the absence of antibodies to Epstein-Barr virus associated nuclear antigen, and the presence of hepatitis B surface antigen and hepatitis B e antigen. Past infections with CMV and EBV were diagnosed by positive IgG and negative IgM serology. Past HBV was diagnosed by detection of antibody to hepatitis B core antigen without detection of hepa-titis surface antigen. Past C. trachomatis was diagnosed by a positive IgG and/or IgA sero-logy.
.^jSM^m;-Statistical Analysis
The concentration of leukocytes in the first and second semen sample were com-pared by calculating an intra class correlation coefficient.
Differences in the number of leukocytes in sperm between patients with positive and nega-tive history of bacterial or viral infections and serologic findings of a previous bacterial or viral infection were assessed with use of the Mann-Whitney U test. A P-value < 0.05 was defined as statistically significant.
The diagnostic value of detecting leukocytes in sperm for identifying men with a positive culture for C. trachomatis, U. urealyticum and M. hominis was assessed with a receiver operating characteristic (ROC) curve. We assessed the diagnostic performance of leukocytes in two ways. First, we determined the concentration of leukocytes in the first sample that indicated an active bacterial infection. Second, the highest leukocyte concen-tration that was determined in the three samples was assessed. The area under the ROC-curve, which was used to determine the performance of the test, was calculated. The same was done to identify men whose positive serology indicated an active CMV, EBV or HBV infection.
Results
Of the 200 men that were asked to participate in the study, 12 men refused parti-cipation and 4 men were excluded because of hypergonadotrope hypogonadism. Therefore
184 men were available for analysis. The mean age ( ± SD) was 34.7 years ±6.7 years. One hundred and thirty-five patients (74%) had primary infertility. One hundred and thirty six patients (74%) had oligo-astheno-terato-zoospermia.
Seven female partners (3.8%) had subfertility due to a tubal factor, whereas two female partners (1.1%) had polycystic ovary syndrome.
At the first semen analysis 53 men had a WBC count of >1.106 /mL. Among
these 53 men, 36 (68%) had a WBC count of >1.106 /mL at the second analysis. Of the
131 men with a WBC count of <1.106 /mL at first analysis, 22 had a WBC count of
1.106 /mL at the second analysis. The intra class correlation coefficient for the number of
WBCs in the first and the second semensample was 0.38 (95%CI 0.27 to 0.55). Since the intra class correlation coefficient between the number of WBCs in the first and second semen sample was low, the WBC concentration in the third sample was not taken into account.
The prevalences of actual bacterial and viral infections in the male genital tract are shown in table I.
Table I. Prevalence of active bacterial and viral genital tract infections in 184 men
No of Prevalence
Organisms infections (%)
Ureaplasma urealyticum 67 36%
Mycoplasma hominis 14 7.6%
Chlamydia trachomatis 1 0.5%
any bacterial infection 72 39%
Cytomegalo Virus 16 8.7%
Ebstein Barr Virus 1 0.5%
Hepatitis B Virus 4 2.2%
The association between a positive history for gonorrhoea, C. trachomatis- and Treponema
pallidum infection and leukocytospermia is shown in table II. The concentration of
leuko-cytes in the first semensample was significantly higher in patients with a history of gonorr-hoea than in patients without a history of gonorrgonorr-hoea (P=0.001).
Table II Association between history of a past STD and leukocytospermia.
History of STD pos L* neg L* P value N. gonorrhoeae infection 26 2 (0-13)
C. trachomatis infection 15 0.5 (0- 7) T. pallidum infection 2 0.5 (0- 1) * mean number of leukocytes x 1 0 /ml in the first semen sample
158 0.5 (0-40) 0.0013 169 0.5 (0-40) 0.42 182 0.5 (0-40) 0.38
The association between a positive serology indicating a previous infection with CMV, EBV, HBV or C. trachomatis and leukocytospermia is shown in table III. Previous viral infections were not associated with the concentration of WBCs in semen (P>0.05). Serologic markers indicating a past C. trachomatis infection were not associated with the concentration of WBCs in semen (P>0.05).
=
Table III Association between a positive serology indicating a previous STD and leukocytospermia
PositiveSerology No. of WBCs* No. of WBCs*
men pos (range) men neg (range) P value
Ebstein-Barr Virus 178 0.5 (0-40) 6 0 (0- 2) 0.64
Cytomegalo Virus 87 0.5 (0-20) 97 0.5 (0-40) 0.39
Hepatitis B Virus 22 0.5 (0- 7) 162 0.5 (0-40) 0.34
Chlamydia trachomatis 64 0.5 (0-13) 120 0.5 (0-40) 0.38
mean number of white blood cells x l O /ml in the first semensample
The ROC-curves for the number of WBCs in sperm that were indicative of an actual bac-terial or viral infection are shown in Figurel. The area under the ROC-curve was 0.55 (95%CI 0.46-0.63), for a positive culture indicating an actual bacterial genital tract infec-tion. The area under the ROC-curve was 0.56 (95%CI 0.44-0.78), for a positive serology indicating an actual viral genital tract infection. The sensitivity and specificity of leukocy-tospermia for detecting M. hominis infection were 9 3 % (95%CI, 88-97) and 10% (95%CI, 4-21), respectively.
The sensitivity and specificity of leukocytospermia for detecting U. urealyticum infection were 6 5 % (95%CI, 57-74) and 40% (95%CI, 28-54), respectively. The sensitivity and specificity of leukocytospermia for detecting C. trachomatis infection could not be calcula-ted because of the low prevalence of this organism.
Figure 1 Roc curves for varying seminal leukocyte concentrations with either an active bacterial genital tract infection ( ) or active viral genital tract infection (—) as criterium for disease.
09 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0
Discussion
This study shows that leukocytospermia is of no diagnostic value in selecting patients with an actual bacterial or viral infection or colonization of the genital tract.
In this infertility cohort, the overall prevalence of silent genital tract infections due to U. urealyticum, M. hominis, or C. trachomatis was 39%. The overall prevalence of infec-tions with CMV, EBV and HBV was 1 1 % . It is not clear whether serologic evidence of a recent infection reflects the presence of these viruses in the genital tract.
Detection of sexually transmitted bacterial genital tract infections in men is important, because these infections like C. trachomatis infection, may cause severe damage in the genital tract of their female partners (13). There have been few studies on the long-term consequences of persistent U. urealyticum, M. hominis or C. trachomatis infections of the male genital tract suggesting that these infections may lead to subfertility (14-16). Studies should be performed to determine whether the presence of U. urealyticum and
M. hominis in bacterial cultures reflects colonization of the distal urethra rather than an
active infection. In view of the above and considering the fact that there is no relation bet-ween leukocytospermia and actual bacterial infection, cultures should be performed for detection of genital infections.
Most men who have a transurethral swab test after digital prostatic massage report that it is a negative experience. Since U. urealyticum, M. hominis and C. trachomatis are sexually transmitted, obtaining a cervical swab specimen for culture from their female partners as part of the routine fertility work-up may be a suitable alternative for diagnosing a silent genital tract infection in men.
Apart from the poor correlation between leukocytospermia and genital tract infec-tion, leukocytospermia itself is episodic and disappearing over time, as is demonstrated by an ICC of only 0.38 (95%CI:0.27 to 0.55) between the number of WBCs in the first and second semen sample.
In contrast with other investigators (10), we found an association between a histo-ry of gonorrhoea and peroxidase-positive cells. Further research must elucidate the role of these WBCs in the reproductive process.
In conclusion: silent genital tract infection or colonization with U. urealyticum and M. hominis is a frequent finding in populations of infertile men. The quantification of WBCs in semen is of no diagnostic value in selecting patients with an active genital tract infection and therefore cannot replace culture. The role of WBCs in predicting reproducti-ve performance warrants further study.
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