About a century ago the ability of sperm to induce an immune response was determined. Since then, understanding of the immune system's interplay with fertility has expanded significantly. In this article, the normal functions of the immune system will first be briefly described to provide context for the rest of the article, which will cover the pathophysiology, diagnostics, and management of immune infertility.

Background Disease-modifying anti-rheumatic drugs (DMARDs) are used in the management of rheumatoid arthritis (RA) and are classified as conventional DMARDs and biologic agents. A concern with DMARDs is the increased risk of infection after surgery. A practice advisory from the American Society of Anesthesiologists recommend alternatives to neuraxial injections in patients who are immunocompromized. We describe a patient who was on several DMARDs and developed inflammatory reactions in her bilateral paraspinal muscles and lumbar spine after an epidural steroid injection (ESI). Case presentation The patient was a 79-year-old woman; she was taking methotrexate, adalimumab and prednisone for her RA. She had a left L5-S1 paramedian ESI for her L5 radiculitis. After relief of her back and radicular pain for 5 weeks, she had an acute exacerbation of her back pain. MRI showed bilateral paraspinal fluid accumulations and enhancement in her ligamentum flavum. Cultures of the aspirated fluid and biopsy specimens were negative for fungal, aerobic and anaerobic organisms. A repeat MRI 2 months later showed diminution of the fluid collection but with a new fluid accumulation near the left L4-5 facet and left L4 pedicle. Repeat cultures and gram stain of the specimens taken from the pedicle and the paraspinal muscles were negative. The patient was followed by her rheumatologist and in the pain clinic until resolution of her symptoms. Conclusions Several society guidelines recommend the continuation of methotrexate but stoppage of the biologic DMARDS before surgery. The occurrence of an intense inflammatory reaction after an ESI in our patient calls for additional research on the subject and shared decision-making between the pain physician, patient and rheumatologist especially in patients on several DMARDs.

Abstract Background Adult men with autoimmune conditions are commonly prescribed anti-tumor necrosis factor (anti-TNF) agents; however, there is a paucity of quality evidence as to their effect on male fertility (e.g. semen parameters and sperm quality). Our objective was to determine if men with autoimmune conditions are being counseled regarding the unknown reproductive effects of anti-TNF agents prior to initiation of therapy. Methods A retrospective analysis of 1010 male patients age 18–45 who were prescribed an anti-TNF agent were assessed for (1) receipt of counseling regarding potential reproductive effects; (2) screening for anatomic or laboratory abnormalities associated with infertility; (3) election for sperm cryopreservation. Results Only 10.3% of men received counseling, and this was not associated with age (p = 0.77). Those who received counseling were significantly more likely to have a genitourinary exam performed, be assessed for presence of a varicocele, be asked about or endorse low libido or erectile dysfunction, have a testosterone, LH, FSH, or prolactin level checked, and have a semen analysis performed (all, p < 0.0001). Rates of sperm cryopreservation were low, but statistically higher in men who received counseling (5.77% (+) counseling, 1.10% (−) counseling) (p = 0.002). Conclusions The limited current literature lacks a consensus regarding the short- and long-term male reproductive effects of anti-TNF therapy. Despite this lack of clarity, rates of pre-initiation counseling were low. Rates of sperm cryopreservation, while improved in the counseled group remained low, suggesting prescribing physicians may be unaware of this option for patients.

OBJECTIVE To determine the percentage of laboratories in the United States that have adopted the World Health Organization 2010 (WHO5) semen analysis (SA) reference values 6 years after their publication. METHODS Laboratories were identified via 3 approaches: using the Clinical Laboratory Improvement Amendments (CLIA) website, the CDC's 2015 Assisted Reproductive Technology Fertility Clinical Success Rate Report, and automated web searches. Laboratories were contacted by phone or email to obtain de-identified SA reports and reference ranges. RESULTS We contacted 617 laboratories in 46 states, of which 208 (26.7%) laboratories in 45 states were included in our analysis. 132 (63.5%) laboratories used WHO 5 criteria, 57 (27.4%) used WHO 4 criteria, and 19 (9.1%) used other criteria. WHO 5 criteria adoption rates varied by geographic region, ranging from 87.5% (35/40) in the Midwest to 50.0% (33/66) in the West. There was a greater adoption rate of WHO 5 reference values in academic affiliated (23/26, 88.5%) compared to non-academic affiliated laboratories (110/182, 60.4%) (P = .028). CONCLUSION While the majority of laboratories have adopted WHO 5 criteria following its release 6 years ago, a large percentage (36.5%) use what is now considered outdated criteria. This variability could result in the characterization of a male's semen values as being "within reference range" at one center and "outside of reference range" at another. This inconsistency in classification may result in confusion for the both patient and physician and potentially shift the burden of infertility evaluation and treatment to the female partner. Published by Elsevier Inc.

Male infertility is a common condition that often negatively impacts patients socially, psychologically, and financially. This article will provide an overview on the various diseases, medications, procedures, and environmental factors that can lead to male infertility. The mechanism through which these triggers damage male reproductive health will be discussed, as well as the treatment options for patients afflicted by different forms of infertility.

You have accessJournal of UrologyInfertility: Epidemiology & Evaluation II1 Apr 2018MP19-13 UNCERTAIN IMPACT OF ANTI-TNF AGENTS ON MALE FERTILITY: ARE MEN BEING COUNSELED? Lauren F. Cooley, Isaac Lam, James Wren, Nelson Bennett, and Robert Brannigan Lauren F. CooleyLauren F. Cooley More articles by this author , Isaac LamIsaac Lam More articles by this author , James WrenJames Wren More articles by this author , Nelson BennettNelson Bennett More articles by this author , and Robert BranniganRobert Brannigan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.662AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Adult men with autoimmune conditions are commonly prescribed anti-TNF agents. Literature on the effect of anti-TNF agents on male fertility is sparse, under-powered and with mixed results; but, some studies have reported adverse effects on semen parameters and sperm quality. Given this lack of clear evidence, our objective was to see if men receiving anti-TNF agents are being (1) counseled regarding potential adverse reproductive effects, (2) screened for anatomic or laboratory abnormalities associated with infertility and (3) offered sperm cryopreservation. METHODS A single-center, retrospective analysis of 1012 male patients prescribed an anti-TNF agent between ages 18-45 from 1/1/2008 to 8/1/2017. Our retrospective database review determined if men received (1) counseling regarding risk to fertility, (2) a genitourinary exam (penis, urethra, testicles), (3) screening for varicocele, (4) diagnosis or assessment for low libido or ED, (5) testosterone level, (6) semen analysis, (7) sperm cryopreservation. Chi square test compared proportions between those who did and did not receive counseling. p<0.05=significant. RESULTS Of 1012 men started on anti-TNF agents, only 10.2% received counseling regarding the potential adverse effect of these agents on fertility. Age was not a statistically significant factor related to likelihood to receive counseling (p=0.77). Those who received counseling were significantly more likely to have a genitourinary exam performed, be assessed for presence of a varicocele, be asked about or endorse low libido or ED, have a testosterone level checked, and have a semen analysis performed before or during treatment (all, p<0.0001). There was no statistical difference found between rates of sperm cryopreservation between those who did or did not receive counseling (p=0.7923) and overall rates of cryopreservation were low: 3.4% (no counseling) and 3.9% (counseling). CONCLUSIONS The impact of anti-TNF agents on male fertility is unknown. Our study is the first to demonstrate the lack of patient education regarding the potential for adverse reproductive effects with only 10.2% of men receiving counseling. Those who were counseled were more likely to be screened for anatomic, hormonal, and semen analysis parameters that could impact fertility. Lastly, sperm cryopreservation was rarely offered suggesting prescribing physicians may be unaware of this option for patients. Until a prospective trial is performed to better understand the impact of anti-TNF agents on male fertility, men should be counseled about the possible risk and fertility preservation. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e249 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Lauren F. Cooley More articles by this author Isaac Lam More articles by this author James Wren More articles by this author Nelson Bennett More articles by this author Robert Brannigan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...