F'ERTH.lTY AND STERn.ITY Copyright' 1971 by The Williams & Wilkins Co. Vol. 22, No.5, May 1971 Printed in U.S.A. SPERM ANTIBODIES IN INFERTILE COUPLES*,t Rum ANSBACHER, M.D., M.S.,:j:SOL MANARANG-PANGAN, M.D., M.S., AND SABIANG SRIVANNABOON, M.D.~ Center for Research in Reproductive Biology, Department of Obstetrics and Gynecology, The University of Michigan Medical Center, Ann Arbor, Michigan The report by Franklin and Dukes! in 1964 described an antispermatozoal antibody in 78.9% of their patients with unexplained infertility. Since then, controversy developed about the incidence of infertility caused by immunologic factors. Schwimmer, Ustay, and Behrman 2,3 in 1967 reported that 47.9% of their infertile couples possessed sperm-agglutinating, whereas in a group of prostitutes the incidence was 72.9%. These investigators found no correlation between the postcoital test and positive microagglutination tests in 62 couples with primary infertility. A reduction in cervical mucus penetration by spermatozoa treated with antispermatozoal from either rabbit or man has been demonstrated by FjB'llbrant,4 and he suggested that this was the likely mechanism involved in the sterility of men with sperm. The antigenicity of spermatozoa was first demonstrated in 1899 by Landsteiner5 and independently by Metchnikoff.6 ill the past 50 years numerous methods have been utilized to induce antisperm antibody production, but the basic questions * This work was supported by a Ford Foundation Research Grant 37482. t Presented at the Nineteenth Annual Armed Forces Obstetrics and Gynecology Seminar and the Ninth Annual Armed Forces District Meeting of the American College of Obstetricians and Gynecologists held at Las Vegas, Nevada, October 19-23, 1970. :j: U. S. Army sponsored Research Fellow. Aid to International Development Research Fellow. ~ Present address: University of Medical Sciences, Siriraj Hospital, Bangkok, Thailand. 298 whether and how these cause sterility remain unanswered. Our study is an ~xtension of the work reported by Behrman 7 in 1968, and is directed toward the clinical correlation of cervical mucus sperm penetration with the demonstration of either sperm-agglutinating or sperm-immobilizing in infertile couples. METHODS illfertile couples were referred to our laboratory after routine infertility testing was accomplished. This report covers.two time intervals: October 1, 1967 to May 31, 1969, under the direction of the junior author (S. S.) when 227 couples were evaluated; and October 1, 1969 to August 31, 1970, under the direction of the senior author (R. A.) when an additional 150 couples were studied. During the first period the following examinations were performed: (a) whole semen analysis comprising specimen volume, sperm count, motility, morphology, liquefaction time, and the presence of spontaneous agglutination and white blood cells on microscopic examination; (b) the macroscopic gelatin sperm-agglutination test of Kibrick, Belding, and Merrill 8 ; (c) the sperm immobilization test of Isojima, Li, and Ashitaka. 9 Tests band c were performed on both the wife's and the husband's sera to demonstrate the presence of sperm. ill the later series two additional examinations were correlated with the above:.,.
f May 1971 SPERM ANTIBODIES 299 TABLE 1. Sperm-Agglutination and Sperm-Immobilization Tests on Infertile Couples Study period Oct. 1, 1967 to May 31, 1969 Oct. 1, 1969 to Aug. 31, 1970 No. of couples studied Negative tests 227 185 (81. 5;c) 150 127 (84.7;c) Wife Positive tests Husband Total positive tests 31 11 42 (13_ 7':C) (4.890) (18. 5~o) 12 11 23 (8.0;0) (7.3)0) (15.3%) Total 377 312 (82.8;0) 43 22 65 (11.4;0) (5.8%) (17.2%) TABLE 2. Sperm Antibodies in Primary and Secondary Infertile Couples Study period Couples with primary infertility Total no. Couples with secondary infertility No. with Total No. with sperm no. sperm Oct. 1, 1967 181 40 46 to May 31, 1969 (22. Fe) (4.3';) Oct. 1, 1969 113 20 37 3 to Aug. 31, 1970 (17,7';) (8.l'd Total 294 60 83 (20.4';) (6.0',) (d) characterization of the preovulatory cervical mucus with respect to color, opacity, viscosity, ph, ferning pattern, and spinnbarkeit; (e) the Kremer!O cervical mucus sperm penetration test as modified by Fjallbrant. 11 RESULTS Sperm antibody test results within the 3-year period are presented in Table 1. Over-all, 17.290 of the couples were positive, 11.4% of the wives and 5.8% of the husbands. In no instance have we found both the wife and the husband positive. Primary and secondary infertility couples are compared in Table 2. Of the couples, 20.4% with primary infertility showed sperm, whereas only 6% of couples with secondary infertility were positive. In Table 3 the positive sera found from October 1, 1969-August 31, 1970 are grouped according to the type of reaction TABLE 3. Results of Therapy in 23 Couples with Sperm Antibodies No. of Test No. of I No. of wives on No. of husbands wives condom pregnancies therapy Positive sperm-agglutination test Positive sperm-immobilization test 2 Positive sperm-agglutination and Total 11 12 present, i.e., sperm agglutination, sperm immobilization, or both. After women demonstrating to spermatozoa become negative by condom-protected coitus, intercourse without the condom was advocated for the time of expected ovulation. Table 3 shows 12 positive women, 7 of whom have become negative after 3-6 months of condom therapy. Two of these became pregnant: 1 aborted at 6 weeks of gestation and the other is presently in her 5th month of pregnancy. Sperm were demonstrated in the sera of 22 husbands; 21 of them were in the primary infertility group and were advised that no therapy is available at present. One husband possessed spermagglutinating 5 years after bilateral vasectomy and subsequent reanastomosis. Further studies concerning the development of to spermatozoa in vas-ligated men is being performed. Cervical mucus sperm-penetration tests on 83 wives and 91 husbands were compared in patients with and without demonstrable (Table 4). Fresh donor 7 4 12 1 o
300 ANSBACHER ET AL. Vol. 22 TABLE 4. 'Cervical Mucus Sperm-Penetration Tests Degree of mucus penetration* Sample tested Sperm Total.. Wife's cervical mucus Wife positive 3 3 and donor's sperm Wife negative 16 23 37 Donor's cervical mucus Husband positive 3 2 3 and husband's sperm Husband negative 9 44 30 * After 3 hours:., sperm penetration of cervical mucus less than 5 mm.; "', sperm penetration of cervical mucus between 6 and 29 mm.;., sperm penetration of cervical mucus 30 mm. or more. 7 76 8 83 TABLE 5. Cervical Mucus Sperm-Penetration Tests on 12 Wives with Sperm Antibodies TABLE 6. Cervical Mucus Sperm-Penetration Tests on 11 Husbands with Sperm Antibodies Test Positive agglutination test Positive immobilization test Positive agglutination and positive Degree of rr\ucus penetration* Not tested Test Positive agglutination test Positive immobilization test Positive agglutination and positive Degree of mucus penetration * Not tested * After 3 hours:., sperm penetration of cervical mucus less than 5 mm.;..., sperm penetration of cervical mucus between 6 and 29 mm.;. sperm penetration of cervical mucus 30 mm. or more. * After 3 hours:., sperm penetration of cervical mucus less than 5 mm.; A, sperm penetration of cervical mucus between 6 and 29 mm.; e, sperm penetration of cervical mucus 30 mm. or more. spermatozoa were used to determine the penetrability of the wife's midcycle mucus. Donor cervical mucus, previously tested by penetration of donor spermatozoa, was utilized to determine the penetration of the husband's spermatozoa. The husband's spermatozoa were also evaluated in his wife's cervical mucus. The presence of sperm-immobilizing promotes a definite trend toward poor or no penetration of the cervical mucus by spermatozoa (Tables 5 and 6), but this observation remains to be confirmed. Eleven of the 150 women (7.3%) in the present study group had a cervical mucus ph of 5.5 or less. No demonstrable penetration of their cervical mucus by normal donor spermatozoa was observed despite excellent ferning and spinnbarkeit of the mucus. These patients were placed on precoital alkaline douches at the expected time of ovulation. Other factors which appear to.iftffect sperm penetration are thick, viscous cer- Sperm coupt TABLE 7. Sperm Count Profile :--10. of husbands c, :S-o. with sperm Azoospermic 2 1.3 1 2-10 million/m!' 6 4.0 2 11-20 million/m!' 14 9.3 0 21-40 million/m!. 15 10.0 1 More than 40 113 75.3 7 million/m!' Total 150 99.9 11 vical mucus, and cervical mucus with poor feming or spinnbarkeit characteristics. Semen samples with prolonged liquefaction times were found in 8 males (6~c) of the later study group. Further evaluation of this finding is underway. The presence of varying degrees of sperm agglutination as ascertained by microscopic examination of semen samples did not correlate with the presence of sperm-autoagglutinating or sperm-autoimmobilizing in the serum, but..
May 1971 SPERM ANTIBODIES 301... correlation was more prominent in samples containing white blood cells or debris. The sperm count profile of the most recent 150 husbands is given in Table 7. One cannot pinpoint the male with auto by routine semen analysis and sperm count. DISCUSSION Our results indicate that the occurrence of sperm-agglutinating or sperm-immobilizing antobodies in infertile couples is not as high as was reported. 1. 2. 9 The couples tested had an over-all incidence of 17.2%, which compares favorably with that reported by Behrman. 7 This percentage is probably closer to the true incidence seen in a general infertility clinic, since these tests for sperm are performed as part of the routine infertility investigation in our center. Antibodies were present in 20.4% of our primary infertility cases, three times higher than that of secondary infertility couples. The presence of auto in 5.8% of the husbands studied is similar to that reported by Rumke and Hellinga 12 and by Fjallbrant. 13 Low cervical mucus ph and poor liquefaction of the semen sample are factors which may contribute to the infertile state, and should be corrected when uncovered. It is apparent that multiple factors may play a significant role when assessing the immunologic basis of infertility. The type of antibody present, the titer of the antibody, the presence of the antibody in the wife, in the husband, or in both, and the relation of demonstrable antibody with poor cervical mucus sperm penetration must be correlated before more definitive statements can be made concerning the etiology of infertility on an immunologic basis. The probable role of immunology in infertility does not seem to be as significant as was first reported by Franklin and Dukes 1 six years ago. However, the presence of sperm-agglutinating and spermimmobilizing may be implicated as a cause of sterility in some couples. An abnormal Sims-Hubner postcoital test, with the finding of immobile or agglutinated spermatozoa, with poor penetration of the cervical mucus by spermatozoa, should alert the clinician to the possibility that sperm are present. Our laboratory procedures should be helpful in determining the etiology of infertility in these cases. SUMMARY From October 1, 1967 to August 31, 1970, 377 infertile couples were tested for sperm utilizing both spermagglutination and sperm-immobilization technics. Of the couples, 17.2~c possessed sperm, of which 11.4% were demonstrated in the wife and 5.8% in the husband. Sperm were present in 20.4% of the primary infertility cases, which was three times higher than the rate in secondary infertility. Factors contributing to infertility in the most recent series of 150 cases were low cervical mucus ph, poor liquefaction of the semen sample, and poor cervical mucus sperm penetration. The presence of auto in the male cannot be determined by routine semen analysis and sperm count. REFERENCES 1. FRANKLIN, R. R., AND DUKES, C. D. Antispermatozoal activity and unexplained infertility. Amer J Obstet Gynec 89:6, 1964. 2. SCHWIMMER, W. B., USTAY, K. A., AND BEHRMAN, S. J. An evaluation of immunologic factors in infertility. Fertil Steril18:167, 1967. 3. SCHWIMMER, W. B., USTAY, K. A., AND BEHRMAN, S. J. Sperm-agglutinating and decreased fertility in prostitutes. Obstet Gynec 30: 192, 1967. 4. FJALLBRANT, B. Cervical mucus penetration by
1-302 ANSBACHER ET AL. Vol. 22 human spermatozoa treated with anti-spermatozoal from rabbit and man. Acta Obstet Gynec! Scand 48:71, 1969. 5. LANDSTEINER, K. Zur Kenntnis der spezifisch auf Blutkorperchen wirkenden Sera. Zbl Bakt [Origj 25:546, 1899. 6. METCHNIKOFF, E. Etudes sur la resorption des cellules. Ann Inst Pasteur (Paris) 13:737, 1899. 7. BEHRMAN, S. J. "The immune response and infertility: experimental evidence." In Progress in Infertility, Behrman, S. J., and Kistner, R. W., Eds., Little, Boston, 1968, p. 675. 8. KmRlcK, S., BELDING, D. L., AND MERRILL, B. Methods for the detection of against mammalian spermatozoa. II. A gelatin agglutination test. Fertil Steril 3:430, 1952. 9. IsOJIMA, S., LI, T. S., AND AsHITAKA, Y. hnmunologic analysis of sperm-immobilizing factor found in sera of women with unexplained sterility. Amer J Obstet Gynec 101:677, 1968. 10. KREMER, J. A simple sperm penetration test. Int J Fertil 10:209, 1965. 11. FJALLBRANT, B. Interrelation between high levels of sperm, reduced penetration of cervical mucus by spermatozoa, and sterility in men. Acta Obstet Gynec Scand 47:102, 1968. 12. RUMKE, P., AND HELLINGA, G. Auto against spermatozoa in sterile men. Amer J Clin Path 32:357, 1959. 13. FJALLBRANT, B. Sperm agglutinins in sterile and fertile men. Acta Obstet Gynec Scand 47:89, 1968.