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Introduction
The infertility is common clinical problem. Sixty percent
of patients treated with assisted reproductive technology
(ART) had suffered inflammation or infection. There is
direct relation between male infertility and genital tract
infection, this relation represents important problem in
contemporary andrology (1).
The bacteria responsible for semen infection may
originate from the urinary tract or be sexually transmitted
(1). The unhygienic sex represents important way for
permeation of such these bacteria to genital tract.
The male reproductive system includes 2 testicles,
accessory reproductive ducts and secretory glands
(seminal vesicles and prostate gland). Testicles are
components of reproductive and the endocrine system.
Therefore, the 2 main functions of the testicles are:
producing sperm (approximately 1 million per hour) and
male sex hormones (e.g. testosterone) (2).
Spermatogenesis occurs within the seminiferous
epithelium on the surface of the sertoli cells. Sperm pass
in different stages of maturation before a gamete can leave
the testis. These processes include mitotic multi plication
and propagation of the spermatogonial stem cells (SSCs),
meiotic division of genetic material and maturation of
spermatozoa (3).
Human normal semen consists of sperm and fluids from
each of the vas deferens, the seminal vesicles, the prostate
gland and the mucous glands, especially the bulb urethral
glands. Seminal vesicle fluid represents 60% of the semen
where serves to wash the sperm out of the ejaculatory duct
and urethra (4).
According to the fifth edition of manual for semen
analysis of WHO, 2010 (5), the normal values of semen
determined as follow:
sperm concentration is ≥15 × 106/mL and the total
sperm count is ≥39 × 106/ejaculate, ≥40% motility, 32%
progressive motility, ≥4% normal forms and white cell
count, <106/ml of ejaculate.
Sperm Chromatin and Nuclear Protein
Normally, the sperm chromatin is a highly compact
structure consisting of DNA and heterogeneous
nucleoproteins. It is compacted and insoluble in order
to protect DNA and facilitate transport of the paternal
genome through the male and female reproductive tracts
(6).
Sperm chromatin differs from somatic cells in both
constituents and arrangement. Human sperm nuclei
contain approximately 85% protamines and 15% histones
in their nucleoprotein component, (7). Protamines, which
Abstract
Male urogenital tract infection (UTI) is one of the most important causes of male infertility, being associated with 8%-35% of
male infertility. Pathogenic bacteria may interfere with infertility treatment involving the application of in vitro fertilization.
Microorganisms might affect the spermatozoa function in different ways: (a) By direct contact on sperm cells; by the help of some
organelles such as pili; causing agglutination of motile sperm, reducing ability of the acrosome reaction, and also causing alterations
in cell morphology. (b) Trigger a local inflammatory reaction leading to increase in reactive oxygen species (ROS). (c) Induction
of sperm autoantibodies. (d) Production of cytotoxic factors. (e) Infection treatment with antibiotics for long time may lead to
defect in the sperm. The most frequently isolated bacteria from semen samples include Staphylococcus aureus, Escherichia coli,
Streptococci, Klebsiella sp, Mycoplasma hominis, Chlamydia trachomatis and Enterococcus faecalis. The infection with these bacteria
has significantly negative effect on sperm parameters and DNA integrity. DNA fragmentation may cause infertility, miscarriage, and
birth defects in offspring. Therefore it may be a more objective marker of sperm function. The exact molecular mechanism of how
bacteria affect chromatin and sperm nuclear protein still unknown. The bacterial infections lead to premature emergence of histone
H3 methylation at lysine 79 (trimethylated H3K79) and hyperacetylated H4 which simultaneously occurred with transition protein
TNP1. In mammals, reduced levels of histone H4 hyperacetylation correlates with impaired fertility. Further researches on this topic
are necessary.
Keywords: Bacterial Infection, Sperm proteins, PRM1/PRM2 ratios
The Impact of Bacterial Infections on Human
Spermatozoa
Ali Zeyad1, Houda Amor1, and Mohamad Eid Hammadeh1*
Open Access Review
International Journal of Women’s Health and Reproduction Sciences
Vol. 5, No. 4, October 2017, 243–252
http://www.ijwhr.net doi 10.15296/ijwhr.2017.43
ISSN 2330- 4456
Received 16 November 2016, Accepted 25 April 2017, Available online 4 June 2017
1Department of Obstetrics and Gynaecology, IVF & Andrology Laboratory, University of the Saarland, Homburg/Saar, Germany University of the
Saarland, Homburg/Saar, Germany.
*Corresponding Author: Mohammad Eid Hammadeh, Tel: +49-68411628117, Fax: +49-68411628443, Emails: mehammadeh@yahoo.de,
mohamad.eid.hammadeh@uks.eu
Introduction
Throughout the history of the world, the ones who had
confronted the bitterest face of poverty and war had al-
ways been the women. As known poverty and war affects
human health either directly or indirectly, the effects of
this condition on health and status of women in the so-
ciety should not be ignored. This study intends to cast
light on the effects of war and poverty on the reproductive
health of women. For this purpose, the face of war affect-
ing the women, the problem of immigration, inequalities
in distribution of income based on gender and the effects
of all these on the reproductive health of women will be
addressed.
War and Women’s Health
Famine, synonymous with war and poverty, is clearer for
women; war means deep disadvantages such as full de-
struction, loss of future and uncertainty for women. Wars
are conflicts that destroy families, societies and cultures
that negatively affect the health of community and cause
violation of human rights. According to the data of World
Health Organization (WHO) and World Bank, in 2002
wars had been among the first ten reasons which killed
the most and caused disabilities. Civil losses are at the rate
of 90% within all losses (1).
War has many negative effects on human health. One of
these is its effect of shortening the average human life.
According to the data of WHO, the average human life is
68.1 years for males and 72.7 years for females. It is being
thought that severe military conflicts in Africa shorten
the expected lifetime for more than 2 years. In general,
WHO had calculated that 269 thousand people had died
in 1999 due to the effect of wars and that loss of 8.44 mil-
lion healthy years of life had occurred (2,3).
Wars negatively affect the provision of health services.
Health institutions such as hospitals, laboratories and
health centers are direct targets of war. Moreover, the wars
cause the migration of qualified health employees, and
thus the health services hitches. Assessments made indi-
cate that the effect of destruction in the infrastructure of
health continues for 5-10 years even after the finalization
of conflicts (3). Due to resource requirements in the re-
structuring investments after war, the share allocated to
health has decreased (1).
Mortalities and Morbidities
The ones who are most affected from wars are women and
children. While deaths depending on direct violence af-
fect the male population, the indirect deaths kill children,
women and elders more. In Iraq between 1990-1994, in-
fant deaths had shown this reality in its more bare form
with an increase of 600% (4). The war taking five years
increases the child deaths under age of 5 by 13%. Also 47%
of all the refugees in the world and 50% of asylum seekers
and displaced people are women and girls and 44% ref-
ugees and asylum seekers are children under the age of
18 (5).
As the result of wars and armed conflicts, women are
Abstract
War and poverty are ‘extraordinary conditions created by human intervention’ and ‘preventable public health problems.’ War and
poverty have many negative effects on human health, especially women’s health. Health problems arising due to war and poverty are
being observed as sexual abuse and rape, all kinds of violence and subsequent gynecologic and obstetrics problems with physiological
and psychological courses, and pregnancies as the result of undesired but forced or obliged marriages and even rapes. Certainly,
unjust treatment such as being unable to gain footing on the land it is lived (asylum seeker, refugee, etc.) and being deprived of
social security, citizenship rights and human rights brings about the deprivation of access to health services and of provision of
service intended for gynecology and obstetrics. The purpose of this article is to address effects of war and poverty on the health of
reproduction of women and to offer scientific contribution and solutions.
Keywords: Poverty, Reproductive health, War
Women on the Other Side of War and Poverty: Its Effect
on the Health of Reproduction
Ayse Cevirme1, Yasemin Hamlaci2*, Kevser Ozdemir2
Open Access Review
International Journal of Women’s Health and Reproduction Sciences
Vol. 3, No. 3, July 2015, 126–131
Received 12 December 2014, Accepted 25 April 2015, Available online 1 July 2015
1Department of Nursing, Sakarya University, Sakarya, Turkey. 2Department of Midwifery, Sakarya University, Sakarya, Turkey.
*Corresponding author: Yasemin Hamlaci, Department of Midwifery, Sakarya University, Sakarya, Turkey. Tel: +905556080628,
Email: yaseminhamlaci@gmail.com
http://www.ijwhr.net doi 10.15296/ijwhr.2015.27
ISSN 2330- 4456
Zeyad et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 4, October 2017
244
are half the size of histones, replace the most of histone
during maturation process and the chromatin becomes
condensed unique supercoiled structure named toroids
(8). Protamine 1 and 2 (P1&P2) are the most nuclear
proteins in human sperm nucleus packaging the sperm
DNA, where P1 is produced as a mature protein while P2
is produced as a precursor protein (9).
The retained histones may be associated with telomeric
sequences and these are the first structures in the sperm
nucleus which act as a trigger to oocyte for pronucleus
formation to achieve the process of fertilization and early
embryo development (10,11).
Protamines are small size proteins contain a lot of
positively charged amino acids, especially arginine. This
positive charge allows the formation of a highly condensed
complex with the paternal genomic DNA, which has a
strong negative charge (12).
Protamines size ranging between 4000-12 000 Da,
are composed of more than 50% arginine (13). There
are 2 types of protamines, namely protamine 1 (P1) and
protamine 2 (P2). The incorporation of these 2 proteins
into the sperm chromatin is strictly regulated, resulting in
specific P1/P2 ratio (14).
In human sperm, P1/P2 ratio is approximately 1 in
fertile men (15,16). The P1 of the mammalian placenta
is exactly 49 or 50 amino acids long (17). P2 is slightly
larger than P1, where contains about 63 amino acids, and
is the predominant form of P2 in the mature sperm head.
In human sperm, there are 2 differently processed forms
of protamine 2; P2 and P3. The 2 forms of the P2 protein
differ only in their three amino-terminal amino acids - P3
is 3 amino acids shorter (at 54 amino-acid residues) than
P2 (57 amino acids), and they encode by the same gene
(PRM2 gene) (17). P2 also differs from P1 in that P2 binds
zinc, in human and other mammalian species coordinate
one zinc atom per molecule of P2 (18).
Disulfide cross-links between the cysteine-rich
protamines are responsible for further compaction and
stabilization of the sperm nucleus (19,20).
During spermiogenesis, the majority of nucleosomal
histones are replaced by protamines in a multi-step process
resulting in intensive chromatin (21). First, the somatic
histones are replaced by testis-specific histone variants,
followed by the replacement of these by transition proteins
(transition protein 1 and 2). Finally, transition proteins are
replaced by protamines during the spermatid elongation
process (15,16).
The deficiency of protamine replacement may not only
be a marker of abnormal spermiogenesis, but may also
affect the function of the paternal genome contribution
during embryogenesis. It may result in suboptimal
embryogenesis and/or increased risk of mutations to the
offspring (21)
The exact mechanism by which DNA damage arises
in human spermatozoa is not clearly understood and
three mechanisms have been proposed: defective sperm
chromatin packaging, apoptosis, and oxidative stress (22).
Sperm DNA Fragmentation
Fertilization is the process of penetration of sperm into
oocyte. The achievement of this process as well as embryo
development depends on the DNA integrity of the sperm
(23).
Male infertility has classically been diagnosed by
microscopic assessment of concentration, motility and
morphology of the sperm in the ejaculate. These tests
are essential to provide the basic information of the
sperm quality. Sperm DNA fragmentation (SDF) tests
can differentiate fertile from infertile males, high levels of
SDF are positively correlated with lower fertilization rates
in IVF (in vitro fertilization), impaired the implantation
rates and an increased abortion incidence (24).
Sperm DNA fragmentation may cause infertility,
miscarriage, and birth defects in offspring (25). There are
2 types of factors may cause sperm DNA damage:
1) Intrinsic factors including in the ejaculates such as
oxidative stress, apoptosis and failure in the histone-
protamine replacement (26,27). Sperm DNA becomes
exposure to damage if chromatin packing is not completed
during sperm maturation (24).
DNA fragmentation may also occur during
spermiogenesis by endonucleases (topoisomerases), this
enzyme act to relieve the increased DNA torsional stress
during the DNA condensing and packaging into the
differentiating sperm head (28).
2) Extrinsic factors such as storage temperatures,
handling conditions, lapse of time after ejaculation,
infections, reaction to medicines, or post-testicular
oxidative stress (24).
Sperm DNA damage may affect the early post
implantation embryo development in ART and thus
decrease the fertility and pregnancy rate (29).
Some reports have indicated that when >30% of sperm
DNA is damaged, natural pregnancy is not possible (30).
Also, it has been proposed that the sperm DNA integrity
may be a more objective marker of sperm function as
opposed to the standard semen analysis (30).
Hofmann and Hilscher (31) mentioned that various
nuclear alterations including an abnormal chromatin
structure, chromosomes with microdeletions,
aneuploidies and DNA strand breaks can be detected
in infertile men. Damaged DNA has been observed in
testicular, epididymal and ejaculated sperm (24).
DNA repair process occurs in developing sperm but
it is terminated as transcription and translation stops
post-spermiogenesis. So that mature sperms do not
have mechanism to repair DNA abnormality that occurs
during their transit and storage in the epididymis or post-
ejaculation. However, ocytes and early embryos have been
shown to repair some types of sperm DNA breakage.
Consequently, the biological effect of damaged sperm
chromatin structure depends on the combined effects of
level and type of sperm chromatin damage and the ability
of the oocyte to repair it (24).
In mammalian sperms, DNA fragmentations can occur
in 2 forms: single (SSB) and double DNA strand breaks
Zeyad et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 4, October 2017 245
(DSBs), and it is particularly frequent in the ejaculates of
subfertile males (32).
The sperm DNA fragmentation could be induced by
oxidative attacks like the hydroxyl radical and ionizing
radiation results in the formation of 8-OH-guanine and
8-OH-20-deoxyguanosine (8-OHdG) at a first stage and
single-stranded DNA fragmentation. Hydroxyl radical
formation may result in the indirect induction of double-
stranded sperm DNA damage through the activation of
sperm caspases and endonucleases (33).
DNA double-strand breaks are extremely harmful
lesions that can lead to genomic instability and cell death.
There are several possibilities for a cell that is facing
DNA damage: despite DNA damage it may be repaired,
fertilization of an oocyte by a spermatozoon with double-
stranded DNA fragmentation could happen without
repairing the DNA and result in abnormal embryo and
abnormal fetal development (34).
Genome integrity controlled by means of complicated
cellular network. Nevertheless, during initiation of DNA
damage by genotoxic stress, series of proteins, in response,
are immobilized. There are some proteins complexes act
as sensors, transducers and effectors of DNA damage
which induced by Double strand breaks DSBs (35).
However if un-repaired DSBs persist, cells can undergo
apoptosis to prevent the accumulation of potentially
tumorigenic mutations. If all the damage responses fail, de
novo mutations will appear (36).
Male Genital Tract Infection and Bacteriospermia
Male Urogenital Tract Infection
Male genital tract infection is one of the most important
causes of male infertility worldwide. Invasion of bacteria
into the male genital tract has been frequently shown
to be associated with impaired sperm function, leading
to infertility (37). Male urogenital tract infections
(UTIs) play an important role in male infertility, being
associated with 8%-35% of male infertility. Asymptomatic
bacteriospermia play a major role (37,38). A recent study
mentioned that UTIs are associated with about 15% of
male infertility (1).
It has been observed that the presence of pathogenic
organisms may interfere with infertility treatment involving
the application of IVF and intra-uterine insemination (39).
Pathogenic bacteria such as streptococci, staphylococci,
Mycoplasma, Chlamydia and Ureaplasma produce an
acute inflammatory response with a flow of leucocytes
into the genital tract leading to increase the level of
reactive oxygen species (ROS) production (29,40-42).
Excessive like these substances have negative effects on
sperm parameters (43). Hammadeh et al (44) reported
that the increase of ROS concentration in seminal plasma
has negative effects on sperm vitality, membrane integrity,
sperm density, chromatin condensation, and DNA single
stand breaks.
Cunningham and Beagley (45) referred to some
pathogenic bacterial species that well-known as causative
pathogens of genitourinary infections and can interact
with spermatozoa such as Escherichia coli, Ureaplasma
urealyticum, Mycoplasma hominis and Chlamydia
trachomatis. Mehta et al (46) isolated some pathogenic
bacteria from semen samples of male partners in infertile
couples, including Enterococcus faecalis, micrococci, and
alpha-haemolytic streptococci. Other studies mentioned
that the contamination and colonization of some bacteria
in the male urogenital tract, rather than infection, could
also contribute to the decrease in sperm quality (47,48).
Asymptomatic Bacteriospermia
Asymptomatic bacteriospermia (ABS) is an invisible
infection in the male genital tract and considered as a
major cause of male infertility (49).
The passive or active invasion of these bacterial strains
induce a generalized or local reaction in the urogenital
tract and is often observed as an asymptomatic subclinical
inflammation caused by pathogens (50,51).
Khalili and Sharifi-Yazdi (52) isolated different bacterial
species from 34.4% of semen samples, like Streptococci
pyogenes, Enetrococci, E. coli and staphylococci. These
bacteria had negative effects on the morphology and the
motility of sperms.
Fraczek et al (53) concluded that the incubation of
sperm with bacteria and/or leukocytes was associated
with reduction of their fertilization potentials resulting
in the negative impact of bacteria and white blood cells
(WBCs) on the sperm motility and sperm membrane lipid
bilayers.
In Iran, Golshani et al (49) found that 35.22% of infertile
men showed at least 1 pathogen. E. coli, Coagulase-negative
staphylococci (saprophyticus), group B streptococci, 5.88%
enterococci, Candida sp., gonococci, Staphylococcus
aureus, Klebsiella sp. and Providencia sp. were isolated.
Also, there was a significant (P<0.001) positive relation
between the bacteriospermia and immotile sperm rat and
abnormality of sperm morphology.
Leukocytospermia
A high concentration of WBCs (≥1 × 106/mL) in semen
samples is a marker of microbial inflammation (54). Male
accessory gland infections which produced leukocytes
was a condition frequently detected in infertile patients
(55,56). Leukocytes appear in semen as the addition to
bacteriospermia at the second stage of the UTI, and remain
present in semen for some period of time following the
elimination of the bacteria in the third stage (1).
In vitro studies have shown significant positive
correlations between WBCs in semen and deterioration
in total sperm count (50), motility (53,57), morphology
(50,57,58) and sperm viability (57).
Many authors have concluded that the leukocytospermia
has a negative impact on semen quality due to the
production of reactive oxygen species (ROS) (59-61). The
ROS produced by leukocytes increase the apoptosis in
mature human spermatozoa (29). Other authors reported
that semen samples with leukocytospermia are more likely
to evidence sperm with DNA fragmentation (58,62).
Zeyad et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 4, October 2017
246
On the other hand, some investigators reported that
the final effects of the cells of the immune system on
spermatozoa may depend on their activity, regardless
of the number of leukocytes in the semen (63-65).
However, Golshani (49) mentioned that the presence of
bacteriospermia and leukocytospermia did not correlate
with each other. It seems that leukocytospermia is a poor
marker to predict bacteriospermia.
The Effects of Bacterial Infection on Sperm Parameters
The presence of bacteria might alter the sperm quality
(48).
Microbial infections have been reported to reduce
sperm viability (66). Microorganisms might affect the
male reproductive function in different ways:
1) Some pathogenic bacterial strains present in semen
may act directly on sperm cells causing the agglutination
of motile sperm, reducing the ability for the acrosome
reaction, and also causing alterations in cell morphology
(67). For example E. coli strains are known for their
ability to immobilize and damage the morphology of
spermatozoa by direct contact, mediated by attachment
organelles such as pili or type-1 fimbriae (projections)
and mannose receptor-dependent interactions (68). Also,
the sperm surface is rich in glycoproteins and is therefore
susceptible to the nitration of bacteria such as E. coli, C.
trachomatis, U. urealyticum, Staphylococcus haemolyticus
and Bacteroides ureolyticus with spermatozoa leading to
the loss of sperm motility and normal morphology (1).
Some researchers were isolated the spermagglutination
factor from S. aureus, which showed spermagglutinating
and spermicidal properties in vitro (69).
2) Microorganisms trigger a local inflammatory
reaction. The inflammatory response of the
genitourinary tract to the invasion of microorganisms
and inflammation is considered to be extremely similar
to the reaction observed in other sites of the body (70).
This physiological response activates leukocytes and
inflammatory mediators such as cytokines and reactive-
oxygen species (ROS) which are known to play important
roles in sperm DNA fragmentation and male infertility
(67). The inflammatory process caused by pathogenic
bacteria in the genital tract may lead to a deterioration
of spermatogenesis and obstruction of the seminal tract
(71). The induction all of the inflammatory reactions in
the seminal tract through the activation of neutrophils
and macrophages may indirectly exert a deleterious effect
on male fertility, where most of the leukocytes attracted to
the semen during bacterial semen infection are phagocytic
cells such as polymorphonuclear granulocytes (PMNs)
and macrophages. The tight adhesion of neutrophils,
and macrophages to the surface of the sperm results in
phagocytic process (1) (Figure 1). The sperm abnormal
form associated with elongation and reduced acrosomal
inducibility have been found in men with inflammatory
chronic prostatitis and these changes were attributed to
leukocytes (72).
3) Induction of sperm autoantibodies (73).
Figure 1. Mechanisms of the Negatively Effect of Bacteriospermia
on Human Spermatozoa. (1) Bacteria and their toxins trigger the
inltration of immune cells connected with (2) the production
and release of ROS by neutrophils and macrophages as well
as (3) immune regulatory factors; cytokines, chemokines and
growth factors from macrophages, lymphocytes, monocytes, and
dendritic cells leading to (4) oxidative stress (5) oxidative stress
induces lipid sperm membrane peroxidation and leads to decrease
sperm fertility potentials and thus sperm DNA fragmentation and
sperm death. (6) Damaged and dead spermatozoa can occur by
traditional phagocytosis; or by (7) direct adhering of bacteria to
spermatozoa. Adapted from Fraczek and Kurpisz (1).
4) Some microbial pathogens may affect the sperm,
resulting in the expression of some surface virulent factors
such as lipopolysaccharides (LPS), cytotoxic necrotising
factor, α-haemolysins and ß-haemolysins, and from the
release of soluble spermatotoxic factors such as sperm
immobilisation factor (SIF) (74,75).
A single incubation with E. faecalis, E. coli and S.
aureus induced apoptosis in human sperm with two
possible, putative mechanisms: a direct cytotoxic activity
of bacterial toxins and the contact with pili and flagella.
It has also been demonstrated that E. coli can start the
apoptotic process by activating several caspases, proteases
responsible for mitochondrial changes, alterations in
membrane symmetry, and DNA fragmentation (48).
Other study revealed that the E. coli showed a significant
increase in apoptosis in sperm, and the bacterial infection
Zeyad et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 4, October 2017 247
of male genital tract decrease the motility and increase
in non-viable sperm, as well as causing sperm DNA
fragmentation (29).
Escherichia is the most extensively studied
microorganism in relation to infertility as a result of
interaction with spermatozoa (76). It is also the primary
bacteria associated with prostatitis and epididymitis
(77). E. coli has a passive effect on sperm motility and
acrosomal function (48). Several authors were described
spermagglutination and immobilization by E. coli (52,78).
In rats, infection with uropathogenic E. coli (UPEC)
results in severely impaired spermatogenesis, characterized
by, for example hypospermatogenesis, germ cell loss
and reduced sperm number (79). Kaur and Prabha (69)
isolated Sperm agglutination factor from S. aureus which
showed sperm agglutinating and spermicidal properties
in vitro.
In human, E. coli and S. aureus are the predominant
flora in infertile men (80). Other authors reported that
these species of bacteria can cause a significant decrease
in sperm motility (81). Emokpae et al (82) studied the
contribution of seminal tract infection to sperm density,
asthenozoospermia and teratozoospermia, where they
observed S. aureus as the causative organism accounting
for 68.2% of seminal infections. S. aureus is known to
produce various toxins and enzymes that may exert a
damaging effect on human sperm.
The increased prevalence of genital tract infections
caused by E. faecalis is associated with a deterioration
of semen quality in terms of sperm concentration and
morphology. Also the presence of micrococci and alpha-
haemolytic streptococci does not appear to exert any
detrimental effect on sperm quality (46).
Although no significant depressor effect of enterococci
on sperm motility was observed (48), some researchers
described, in an in vitro study, a negative influence on
membrane integrity of human sperm head, neck and
mid-piece (83), probably mediated by haemolysin, a well-
known virulence factor of enterococci.
5) Infection treatment with antibiotics
In spite of the sperm parameters being improved after
the treatment of UTIs (84), antibiotics have negative
effects on sperm motility and morphology (67).
The Effects of Bacterial Infection on Sperm Chromatin
Condensation and DNA Integrity
Different bacterial species such as S. aureus, E. coli, P.
aeruginosa can cause sperm DNA fragmentation (29).
The effect of the male genital tract infection depends on
the pathogen type, acute or chronic condition as well as
the site of infection, where the inflammation can occur
in the epididymis, prostate gland or seminal vesicles (66).
In certain situation the genital tract inflammation become
difficult to diagnose because the symptoms may not be
apparent (Asymptomatic infection) and the patients only
suffering from some local discomfort (85).
Human patients infected with C. trachomatis and
Mycoplasma had a significant (P < 0.05) increased of
sperm DNA damage compared to control individuals (86).
This effect has also been seen in other animal species (87).
However, Rybar et al concluded that the contaminated
semen with C. trachomatis, Ureaplasma and Mycoplasma
spp. were not associated with sperm DNA fragmentation
(85).
The exact molecular mechanism of how bacteria
infections affect chromatin and sperm nuclear protein
still unknown. In mammals, postmeiotic spermatogenesis
is characterized by a dramatic reorganization and
compaction of the chromatin. The nucleosomal histone-
based structure is largely replaced by a transition protein-
based structure and eventually by a protamine-based
structure (88-91).
Dottermusch-Heidel et al (92) reported that the
bacterial infections lead to the premature emergence of
trimethylated H3K79 and hyperacetylated H4, which
simultaneously occur with the transition protein TNP1.
In contrast, they were never observed in the spermatids
of infected rats. Furthermore, upon bacterial infection,
only histone-based spermatid chromatin showed
abnormalities; whereas protamine compacted chromatin
seemed to be unaffected.
Hyperacetylation of histone H4 occurs during the
histone-to-protamine transition, perhaps causing a more
open chromatin structure to facilitate histone replacement
(93-96) and serving as a signal for the bromodomain
protein BRDT to initiate the histone-to-protamine
transition (97). In mammals, reduced levels of histone H4
hyperacetylation correlates with impaired fertility (95,98).
Many researchers found that there are different bacteria
species can affect sperm DNA integrity for examples: S.
aureus, E. coli, Pseudomonas aeruginosa, C. trachomatis,
U. urealyticum, Mycoplasma spp. and C. albicans. They
can induce the expression of apoptosis in the male genital
tract during inflammatory processes (68).
The increased sperm DNA fragmentation in an
infertile patient with the male accessory gland infection
is due to influence of reactive oxygen species produced
by activated leukocytes at the level of apoptosis in mature
human spermatozoa, E. coli showed significant increase
in apoptosis on spermatozoa as will as cause alteration of
human sperms (29).
Gallegos et al (86) demonstrated that human patients
infected with C. trachomatis and Mycoplasma have
increased values of sperm DNA damage compared to
control individuals.
Burrello et al (99) reported that the male accessory
gland infection with C. albicans increased sperm DNA
fragmentation and sperm chromatin packaging damage.
Pathogenicity of Some Bacterial Species on Sperm
Some gram-negative Enterobacteriaceae such as E. coli,
Klebsiella spp., Proteus, Serratia, Pseudomonas spp., etc are
considered pathogens for the urogenital system (100). The
major difficulty in interpreting microbiological findings
is the presence of contaminating, indig enous microbiota,
or of inhibitory substances known to be present in
Zeyad et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 4, October 2017
248
the prostate secretions, as well as previous courses of
antibiotics (77). The diagnosis of semen bacterial infection
may be confirmed by semen quantitative bacteriological
cultures. The semen cultures were considered positive
when the number of bacteria colonies was >103 CFU/mL,
according to Domes et al (58).
Several of the bacterial species have negative effects on
sperm conventional parameters, chromatin condensation
and DNA integrity (100). In the experimental infection
module, the incubation of human sperm with suspensions
of some bacterial species such as E. coli, S. haemolyticus,
and B. ureolyticus resulted in a reduction of sperm
motility (53).
Staphylococcus aureus
Staphylococcus aureus is one of the most pathogenic
bacteria as it can infect various organs in the body
(101). Various studies revealed that S. aureus was the
most common isolated bacterial species from seminal
fluid samples. Prabha et al (102) found that 51.85% of
seminal fluid samples were contaminated with S. aureus.
Additionally, Emokpae et al (82) detected S. aureus in
68.2% of the seminal fluid. Contamination of seminal fluid
with S. aureus significantly increased the risk of recurrent
pregnancy abortion (103). S. aureus produces a protein
molecule (MW = 20 kDa) called SIF. It was isolated and
purified by Prabha et al (104), where they reported that
SIF can lead to complete immobilization of spermatozoa
at a concentration of 150 mg/ml; whereas 200 mg/mL of
this factor is required to kill spermatozoa.
Escherichia coli
There were several investigations that have described the
harmful effects of E. coli on sperm fertilization potentials.
Fraczek et al (53) concluded that E. coli and serotype
O75:HNT have a negative effect on human sperm motility.
An inhibitory effect of E. coli, serotype 06, on sperm
motility has been investigated by some authors (105).
Sperm incubated with E. coli demonstrated significant
alterations in motility (78,106). Some investigators
revealed that the immobilization of spermatozoa may
occur as a result of direct contact of the sperm with
bacterial cells (105,107).
Villegas et al (68) concluded that the direct exposure
of spermatozoa to E. coli is enough to decrease sperm
quality. They noticed that the early apoptosis incident
(phosphatidyl serine [PS] externalization) was significantly
increased in spermatozoa after incubation with E. coli
alone. Other in vitro studies demonstrated that the soluble
products of E. coli decreased sperm motility by causing
defects in the sperm’s mitochondrial function (108,109).
SIF was isolated from E. coli by Prabha et al (110), where
they reported that the incubation of spermatozoa with SIF
causes sperm immobilization and structural modification.
Escherichia coli have certain virulence characteristics
and have the ability to adhere to sperm cells and to
colonize tissues of the male genital tract, thereby causing
asymptomatic male infertility (76).
Neisseria gonorrhoeae
Neisseria gonorrhoeae is diplococcus bacteria, which
infect men and women alike, causing gonorrhea (111).
The seminal fluid acts as a mediator triggering the
motility of N. gonorrhoeae and microcolony formation via
an increase in the number of pili on the bacterial surface
(112). N. gonorrhoeae may attach to the spermatozoa by
pili as T1 gonococci or by direct contact as T4 gonococci
(113). Gonococcal infection caused by N. gonorrhoeae
triggers the flow of PMNs into the infected tissue (114).
As mentioned previously, the presence of leucocytes in
the genital tract can increase the level of reactive oxygen
species which have harmful effects on spermatozoa
(40,42). On the contrary, Liu et al (115), did not find
any effects on the sperm by N. gonorrhoeae after in vitro
incubation.
Ureaplasma urealyticum
Ureaplasma urealyticum is a common bacteria present
in the genitourinary tract and it is more prevalent
in infertile men, where it has the ability to affect the
sperm morphology (116). Various authors noted that
there was a significant correlation between lower sperm
concentration and the presence of U. urealyticum in the
male genital tract (100). Furthermore, one study revealed
that infected patients with U. urealyticum showed a
significant impairment of sperm concentration, motility,
and vitality. The authors found that the seminal plasma
alpha-glucosidase decreased in the infected patients when
compared with in the non-infected patients (117). Kohn
el al (118) studied the effect of U. urealyticum on human
sperm. It was noticed that 69% of infected patients with U.
urealyticum had a decreased capacity of sperm acrosome
reaction.
Chlamydia trachomatis
Chlamydial infection is a popular sexually transmitted
disease that is caused by C. trachomatis. It affects
approximately 90 million people yearly worldwide
(51). C. trachomatis infection has a positive correlation
with apoptosis rate in the human spermatozoa (119).
Furthermore, Gallegos et al (86) demonstrated the
negative effect of chlamydial infection on the sperm DNA.
Kokab et al (51) found a significant relationship between
chlamydial infections and an increase the level of IL-8
and seminal leukocytes. While the progressively motile
sperm decreased in infected patients with C. trachomatis,
another bacterial species had a negative effect on sperm
parameters. E. faecalis, for instance, had negative effects
on sperm motility and morphology (46). The results
of another study clearly showed a spermicidal activity
of Streptococcus anginosus, thereby, affecting sperm
concentration and triggering necrosis. Additionally,
Staphylococcus epidermidis had negative effects on sperm
concentration and progressive motility (48).
In an in vitro study, the incubation of spermatozoa
with Mycoplasma hominis reduced sperm motility and
acrosome reaction property (118). Moreover, Mycoplasma
Zeyad et al
International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 4, October 2017 249
had a negative effect on sperm DNA integrity (86). The
positive correlation between Klebsiella spp. infection
and morphologically abnormal spermatozoa were also
reported (120).
Conclusion
The bacteria in semen samples have negative effects
on sperm parameters and may be an important factor
negatively influencing fertility status and worsening
reproductive potential (53).
The molecular mechanism of how bacteria affect
chromatin and sperm nuclear protein still unknown
exactly. The bacterial infection should be treated with
care, especially in patients consulting for infertility and
advising for assisted reproduction techniques.
Ethical Issues
Not Applicable.
Conict of Interests
e authors declare no conicts of interests.
Financial Support
is study received no funding.
Acknowledgments
I am grateful to thank, Dr. Majed Alhudhud, Consultant
Obstetrician and Gynaecologist, UK for revising the text
language.
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