Lahteenmaki-142-7

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Human Reproduction

vol.10 no.l pp.142-147, 1995

Intra-uterine insemination versus cyclic, low-dose

prednisolone in couples with male antisperm antibodies

A.Lahteenmaki

1

'

2

, J.Veilahti

3

and O.Hovatta

1

'infertility Clinic, The Family Federation of Finland, Kalevankatu

16 B, 00100 Helsinki and department of Biomedicine, University

of Helsinki, Siltavuorenpenger 20 J, 00170 Helsinki, Finland

2

To whom correspondence should be addressed

A total of 46 couples with male immunological infertility

entered the trial at the infertility clinic of the Family

Federation of Finland. The men all showed a positive mixed

antiglobulin reaction to immunoglobulin G in their semen;

31 men were also tested for sperm-bound IgA inimuno-

globulins by flow cytometry. Serum antisperm antibodies

were checked in a tray agglutination test. The women

showed normal reproductive endocrinology and at least

one patent Fallopian tube. The couples were randomized

to undergo either up to three intra-uterine inseminations

IUI),

or timed intercourse with cyclic, low-dose 20 mg)

prednisolone therapy of the men. Cross-over was carried

out if no pregnancy occurred in the first stage. Timing of

ovulation was based on urinary luteinizing hormone assay

and transvaginal ultrasonographic measurements. In all,

40 couples either completed the study or the female partner

conceived. IUI was significantly better

P

= 0.04) with nine

pregna ncies than timed intercourse with prednisolone one

pregnancy). There were no significant associations between

antibody levels, sperm count or motility versus the incidence

of pregnancy. In male immunological infertility, well-timed

IUI is an effective treatment method: results are obtained

rapidly and steroidal side-effects can be avoided.

Key words:

antisperm antibodies/intra-uterine insemination/

prednisolone

Introduction

It is known that auto-antibodies to spermatozoa impair fertility.

Those bound to the sperm surface are considered to be

especially important (Eggert-Kruse

et ai,

1991). The presence

of such antibodies in men has been shown to be associated

with genital infections, vasectom y, trauma or certain anatomical

abnormalities (for a review see Isidori

et ai,

1988). The effects

that male antisperm antibodies have on fertility are still not

very well known, which is reflected in the various treatment

modalities. In addition, the results of these treatments are

sometimes difficult to interpret because this condition is

anything but absolute. Spontaneous pregnancies occur,

although long periods are often involved (Shulman, 1986).

However, couples that have been trying to achieve a pregnancy

for several years are anxious for assistance.

Assisted reproductive techniques have been employed to

achieve pregnancy, with variable success rates. Intra-uterine

insemination (IUI) with washed spermatozoa has been used to

bypass the cervix, one of the possible sites of action of

antisperm antibodies (Mahony and Alexander, 1991). Better

results have been achieved by in-vitro fertilization (IVF)

treatment (Clarke

etai,

1985). Imm unosuppression by cortico-

steroids, introduced by Shulman in 1976, has been used with

various regimens. However, the results are inconclusive. In

this study we compared the efficacy of oral, low-dose cyclic

prednisolone with IUI, when the male partners had various

levels of sperm-bound antibodies in their semen.

Materials and methods

Patients

A total of 46 couples, who had been trying to achieve

pregnancy for at least a year, entered the trial between

September 1989 and October 1993 at the infertility clinic of the

Family Federation of Finland, Helsinki, after giving informed

consent. M ale partners had to show a positive m ixed antiglobu-

lin reaction (MAR) to immu noglobulin G (IgG) in their semen.

The men all had sufficient spermatozoa in their semen, so that

at baseline there were at least 1X10

6

spermatozoa with mean

progressive motility of 72% (range 19-99) after preparation.

A tray agglutination test (TAT), for detecting the presence of

circulating antisperm antibodies, was also carried out before

the trial. A sub-group of men

(n =

31) was checked by flow

cytometry for IgA antibodies in their semen. The men were

healthy, except for one man who had diabetes. He was under

medical surveillance during the study. No X-ray examinations

were performed, since the prevalence of tuberculosis at present

is very small in the Finnish population.

The female partners had to be <40 years old and in good

general condition. Serum antibodies were also checked in the

women, and four women had a slightly elevated titre (TAT

1:16), which we considered to be insignificant. Tubal patency

was assessed by laparoscopic chromopertubation (41 women)

or hysterosalpingography (four women). One woman was not

assessed by either method as she had two children from her

previous marriage. Two women showed some pathological

results in their left Fallopian tubes, and one in the right

tube but no other abnormalities w ere seen. Ovulation and

reproductive endocrinology were assessed before the start of

the study. Oligo-ovulation occurred in five women. Serum

142

© Oxford University Press





A.Lahteenmaki, J.Veilahti and O.Hovatta

Results

In all, 40 couples either completed the study or the female

partner conceived and treatment was stopped. The reasons for

withdrawal of six couples are given in Table I. None of

them withdrew because of steroidal side-effects. One- man

complained of mild dyspepsia; two others of erythema on the

face and chest. No sleeplessness or irritability was reported.

Of the 40 men above, 19 (48%) had had some predisposing

factors for antisperm antibodies in their past: eight men had

had genital tract infections, five had had operations because

of inguinal hernias, three had suffered from cryptorchidism

and two from left-sided varicocele. One man had a unilateral

obstruction of the epididymis as a result of surgery. Interes-

tingly, operated inguinal hernias predisposed the subjects to

very strong IgG-MAR positivity (>90%), whereas the other

factors were associated with more variable MAR values. In

these five men, serum TAT results were also clearly positive

(1:64-1:1024) .

The mean duration of infertility in these couples up to the

start of the study was 5.3 years (SD 3.4; range 1-18). Infertility

was primary in 32 couples (80%). Previous fertility of the

female partner was not a significant predictor of pregnancy,

even though a slight association was noted (P = 0.09). A total

of 10 pregnancies resulted: nine from IUI cycles, and one

from the timed intercourse regime during which the men had

prednisolone therapy. Numbers of couples starting the study

with IUI and with timed intercourse were 19 and 21 respect-

ively. There were no significant differences in semen para-

meters, antibody levels or duration of infertility between these

groups (Table II). Before cross-over, the pregnancy rate after

three cycles of IUI was 16.7% (8/48), whereas no p regnancies

occurred in 63 timed intercourse cycles. The difference in

pregnancy rates per couple was highly significant

(P =

0.001),

and remained also after cross-over (P = 0.04 for the whole

study), when two more pregnancies occurred, one in both

groups. The results of these treatments are shown in Table III.

Six IUI pregnancies resulted from 67 clomiphene citrate-

induced cycles (9%) and three from 41 natural cycles (7%).

Clomiphene citrate was not used in those 44 timed intercourse

cycles which resulted in one pregnancy (2%).

There were no significant differences in IgG-MAR or TAT

values before and after three cycles of IUI. This was also the

case with IgG-MAR after three-cycle steroid therapy. However,

a reduction in serum TAT values (P = 0.03) was noticed after

the prednisolone treatment, although total disappearance of

antibody was not observed. This fall in serum antibody levels

Table I.

Reason for withdrawal of six couples and some immunological characteristics of the men

Patient no.

Reason for withdrawal Randomized

to start with

No .

of treated

cycles

IgG

a

IgA

b

TAT

28

40

41

43

45

46

spontaneous pregnancy after the

first IUI

endometrial polyps discovered during

the study; later IUI pregnancy

male partner could not produce semen

samples for IUI

ovarian endometrioma discovered

during the study; later IVF

pregnancy

no longer wished to participate in the

study; later pregnancy with

prednisolone

no longer wished to participate in the

study

IUI

IUI

IUI

TI

1

0

0

3

TI

IUI

100

76

95

70

98

95

ND

ND

ND

9

89

64

1:256

1:64

1:64

1:128

1:512

1:128

Ig = immunoglobulin; TAT = tray agglutination test; IUI = intra-uterine insemination; TI = timed intercourse;

ND = not done

a

Direct mixed antiglobulin reaction (MAR) test.

b

Flow cytometry.

Table

II. Comparison of initial semen parameters, antibody levels and duration of infertility in couples who first started with intra-uterine insemination (IUI),

with those starting with timed intercourse (TI)

a

Ig G

b

(%)

Ig A

c

(%)

Total sperm count per ejaculate (X10

6

)

Progressive motility (%)

Duration of infertility (years)

a

Values are mean ± SD.

• Direct mixed antiglobulin reaction (MAR) test.

c

Flow cytometry.

d

n =

14.

e

« = 17.

IUI first

(n =

19)

82 ± 25

38 ± 9

d

258 ± 248

57 ± 19

5.2 ± 4.4

TI first (n = 21)

80 ± 27

51 ± T

174 ± 127

46 ± 21

5.4 ± 3.6

P

0.9

0.3

0.5

0.05

0.8

144



IUI versus prednisolone in male immunological infertility

Table III. Pregnancies

IUI

Prednisolone + TI

per cycle and couple before

Before cross-over

Per cycle

(%)

8/48 (17)

0/63 (0)

cross-over and for the whole study

Per couple

(%)

8/19 (42)

a

0/21 (0)

The whole study

Per cycle

(%)

9/108 (8)

1/96 1)

Per couple

(%)

9/40 (23)

b

1/32 (3)

IUI = intra-uterine insemination; TI = timed intercourse.

P = 0.001.

b

P = 0.04.

was not associated with the occurrence of pregnancy. The total

count and progressive motility of spermatozoa remained almost

unchanged after steroid therapy.

Table IV illustrates some antisperm antibody characteristics

of those men whose partners conceived during the study

period. There were no significant differences in sperm-bound

IgG or humoral antibody levels between pregnant and non-

pregnant couples. The man undergoing steroid treatment whose

partner conceived had minimal amounts of seminal and serum

antibodies (MAR 10%, TAT

1:16).

Of the IUI pregnancies,

five occurred in IgA-positive cases and one in an IgA-negative

case. Of the 31 cases tested for IgA, 26 were positive and five

were negative. The difference in IgA antibody levels between

pregnant and non-pregnant couples was not significant.

The semen parameters, i.e. total count and progressive

motility before and after w ashing, were analysed in the partners

of those women who first started with IUI (n = 19). This was

done because motility in native semen was slightly but not

significantly better in these men compared with those who

started with timed intercourse. However, there was no signific-

ant difference in sperm motility in IUI between pregnant and

non-pregnant couples. As Table III shows, most pregnancies

(n = 8) occurred in the IUI cycles before cross-over. Thus,

we also analysed the semen parameters in the IUI cycles after

cross-over. These cycles did not differ as regards sperm count

and progressive motility, although initially the difference in

progressive motility was close to significance (Table II).

Overall, the IUI cycles that led to a pregnancy were slightly

better as regards washed sperm prog ressive motility (mean ±

SD ;

83 ± 17%) than those which did not (mean ± SD ; 73 ±

19%, P = 0.08). Sperm preparation with Percoll gradients

produced relatively more pregnancies than swim-up, 5/16 and

4/24 respectively.

After the study period, one spontaneous pregnancy occurred

within 3 months. In this specific case, the man showed strong

IgG-MAR positivity (100%), and also by flow cytometry

clearly positive IgG (92%) and IgA (93%) antibody values.

Later, two more spontaneous pregnancies occurred.

Discussion

In the present study, IUI proved to be superior to low-dose,

cyclic prednisolone therapy with timed intercourse when the

male partner had sperm-associated IgG and/or IgA immuno-

globulins. Limited success with IUI has been reported by

Kremer et al. (1978). On the other hand, Francavilla et al.

Table

IV. Immunological characteristics of the men whose female partner

conceived

Method

IgG

a

Ig A

b

TAT

Prednisolone + TI

IUI

IUI

IUI

IUI

IUI

IUI

IUI

IUI

IUI

10

98

94

63

97

100

95

55

77

95

ND

ND

24

34

13

51

ND

ND

73

0

:16

128

:1024

:64

:64

128

:16

128

:256

128

Ig = immunoglobulin; TAT = tray agglutination test; TI = timed intercourse;

IUI = intra-uterine insemination;

ND = not done

Direct mixed antiglobulin reaction (MAR) test.

b

Flow cytometry.

(1992) failed to obtain pregnancies by IUI when all spermato-

zoa were IgG and/or IgA antibody-coated, irrespective of the

other semen parameters. In our study, timing of ovulation

was based on urinary LH rise and checked by transvaginal

ultrasonography, thus optimizing the timing of insemination.

When monitoring the female partner during these cycles, it is

possible to recognize and avoid problems that may be involved.

The importance of adequate ovulation has been reported by

Margalioth et al. (1988), who had some success with IUI,

especially when gonadotrophin stimulation of the female

partner was employed.

IUI may be of help if the primary obstacle to fertility is

sperm penetration through the cervical mucus, as suggested

with regard to locally produced IgA antibody (Jager et al.,

1980). The benefit of IUI may also be in overcoming problems

in sperm capacitation and acrosome reaction. As Lansford

et al. (1990) showed, premature acrosomal loss shortly after

ejaculation may be associated with sperm-bound antibodies.

If the lifespan of these spermatozoa is decreased, IUI with

appropriate timing has to be performed to enhance the probabil-

ity of achieving pregnancy.

The effect of semen preparation on sperm-associated

immunoglobulins is interesting. Simply centrifuging and resus-

pending specimens has been considered to be inadequate in

separating antibodies from the sperm surface. This has been

shown by Haas

et al.

(1988), who used a radioimmunoassay

method to measure antibody levels after multiple washings.

However, flow cytometric data suggest that the first wash

145



A.Lahteenmaki, J.Veilahti and O.Hovatta

separates loosely bound antibodies but further washings have

no further beneficial effect (Rasanen et al, 1994). In the

present study, sperm preparation with Percoll gradients seemed

to be relatively more effective than swim-up, although with

the present number of couples this difference did not reach

significance. Almagor

et al.

(1992) showed that some of the

head-attached an tibodies are removed from spermatozoa during

Percoll processing. These observations need to be investi-

gated further.

The mechanism of corticosteroid action on immunological

infertility is still unclear. With our low-dose cyclic regimen,

no significant fluctuation in sperm-bound antibody levels was

observed, although a fall in serum TAT titres after the steroid

therapy was noted. As also reported by Hendry et

al.

(1990),

this was not correlated with the occurrence of pregnancy. They

found that a fall in seminal plasma antibody titres was

associated with successful outcome. On the other hand, there

was substantial spontaneous variation in antibody levels even

during placebo treatment. A favourable effect of corticosteroid

on IgG, but not on IgA, levels was reported by Haas and

Manganiello (1987). They explained the finding by a differen-

tial effect of the steroid on systemic versus local immune

systems. When the circulating concentrations of IgG antibody

fall,

then the seminal plasma antibodies derived from the

circulation would also decline. Hence the amounts of sperm-

associated IgG would diminish. However, this change was

not significantly associated with increased pregnancy rates.

Moreover, seminal plasma antibodies may not be identical to

those bound to the sperm surface (Bronson et al, 1987).

The man undergoing steroid treatment whose partner con-

ceived during this study had minimal amounts of seminal and

serum antibodies. However, analysing IUI results, we found

no prognostic factors, either in antibody levels or in the semen

parameters we studied. In addition, spontaneous and assisted

pregnancies occurred during and after the study (Table I). On

the other hand, Francavilla et al. (1992) were unable to bring

about pregnancy in cases of severe immunological infertility.

However, they did not include in their study men with low

and modera te antibody positivity. Barratt et

al.

(1992) reported

poor prognostic values of low to moderate levels of sperm-

bound antibodies on conception rates. The heterogeneity of

sperm surface antigens that may be involved in antisperm

immune responses poses clinical problems. Variable success

rates in different studies may indicate that quantitative analysis

of antibody levels is not enough. M easuring the sperm antibody

load, for example, may give more precision (Rasanen et al,

1994).

As infertility due to antisperm antibodies is incomplete

(Hendry et al, 1990), succes s may be time-related. Additional

time to achieve a pregnancy may also be required with

corticosteroid therapy. No results have been achieved with 40

mg of prednisolone over a three-cycle period (Bals-Pratsch

et al,

1992). Hendry

et al

(1990) reported a significant

difference between prednisolone and placebo in production of

pregnancies after 6 months of treatment. However, after three

cycles the dose was doubled. In this context, our low-dose

regimen was not new, but IUI was shown to be a faster way

to obtain results. In this small study population the relatively

poor pregnancy results in the whole study compared with the

before cross-over groups for IUI is likely to reflect intra-

individual variation rather than a negative effect of corticos-

teroid.

Even though previous fertility of the female partner and

duration of the couple's infertility were not significant pre-

dictors of pregnancy in this study, a weak association was

noted. This has been shown by Duleba et al (1992), who

analysed couples with m ale factor infertility. As they explained,

there is a chance of including a sub-fertile female population

which may not be identified in a standard infertility study. In

addition, H endry etal. (1986) found that in male immunological

infertility, there was a preponderance of successful couples

amo ng those whose duration of infertility was < 2 ye ars.

In conclusion, our results show that IUI is an effective

method for couples with male antisperm antibodies. The

method used for sperm preparation may be important. Slightly

better pregnancy rates achieved with a discontinuous Percoll

gradient than with swim-up suggest that the former technique

may remove some surface-bound antibodies on spermatozoa.

Monitoring the LH surge and checking ovulation by transva-

ginal ultrasonography makes it possible to exclude ovulatory

problems. As the majority of pregnancies usually occur within

the first two or three well-timed IUI cycles (te Velde et al,

1989),

corticosteroid therapy and the steroidal side-effects that

may appear even with low doses (Spector and Sambrook,

1993) can be avoided.

Acknowledgements

We thank Dr Pekka Lahteenmaki for his critical review of the

manuscript, Dr Marita Rasanen for the flow cytometric analyses of

IgA antibodies and Dr Nicholas Bolton for revising the language.

The nursing assistance of Ms Ulla-Riitta Ripatti, the technical

assistance of Ms Kisse Johansson and Ms Kaisu Lavikka and the

secretarial assistance of Miss Anne Kaljunen are greatly appreciated.

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Lahteenmaki-142-7