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Annals of Ayurvedic Medicine Vol-9 Issue-3 Jul.-Sep., 2020 230
Case Report
Case report on the effect of Virechana and Chatuhprasritik Basti in
Achala R Kumawat
, Gopesh Mangal
PG Department of Panchakarma, National Institute of Ayurveda , Jaipur, India .
Corresponding Author’s Email:
Date of Submission: 4 May 2019|| Date of Acceptance : 12 July 2020
Context: The urge for fatherhood can be biologically as strong as the urge for motherhood. Male infertility is directly
related to impairment in the quality of semen. Complete asthenozoospermia (loss of motility) and necrozoospermia (non-
viable sperms) are potential causes of male infertility. Necrozoospermia or necrospermia accounts for 0.2% to 0.5% of
male infertility. In Ayurveda, these could be considered Kshina Shukra, one of the “Shukradushti” (~vitiation of sperm)
where Shukra Dhatu (~reproductive tissue) is of poor quality. Methodology: A 36-year-old patient presented with complaints
of having no children in the last 7 years of active married life. Based on laboratory examination, his diagnosis was
confirmed as necrozoospermia. The study intervention included, Virechana Karma (~therapeutic purgation) as per the
classical textbook guidelines, followed by Chatuhprasrtik Basti (~therapeutic enema) for 16 days. Results: At the end of
therapy, semen analysis showed marked improvement in sperm count, increase in sperm motility and normal forms. The
positive changes in semen analysis after Virechana Karma match the textbook descriptions of the benefits of Virechana
Karma for Shukradushti. Conclusion: Classical Virechana followed by Chatuhprasritik Basti may be effective in improving
the seminal characteristics in Necrozoospermia. The present findings with no adverse effects indicate the promising scope
of traditional medicine in male infertility disorders.
Keywords: Asthenozoospermia, Chatuhprasritik Basti, Male Infertility, Necrozoospermia, Shukradushti, Virechana.
Annals Ayurvedic Med.2020 ;9 ( 3) 230-236
Introduction: WHO defines infertility as the inability of
a sexually active, non-contracepting couple to achieve
pregnancy in one yea r.
In male infertility, total
spermatozoa count, motility, morphology, and viability of
the spermatozoa are considered as important factors. The
effective passage of spermatozoa through the cervical
mucus is dependent on their rapid progressive motility. A
non-motile sperm cannot pass through the cervical mucus
to fertilize the egg. Absolute asthenozoospermia (the
condition in which only immotile spermatozoa are
retrieved) is reported at a frequency of 1 in 5000 men and
it implies a very poor fertility prognosis.
Sperm viability
testing is indicated when sperm motility is less than 5-
Necrospermia is characterized by usually less than
20% to 30% total motility, less than 5% progressive
motility, and a viability test less than 30% to 40%,
indicating a high proportion of dead sperm.
It is a rare
condition with a reported prevalence of 0.2-0.48% in
infe rt ile subjects.
Bo th asthenozoo sp ermia and
necrozoospermia are potential causes of male infertility.
There are usually no external symptoms. The only way to
diagnose the problem is with a semen analysis.
The rate
for natural conception in cases of necrozoospermia are
5% with medical Intervention.
In Ayurveda, necrozoospermia can be considered as Kshina
Shukra, one of the Shukra dushti as per Acharya Sushruta.
The line of treatment for Shukra Dosha (~defective sperm)
as mentioned in Ayurvedic texts are Snehana (~therapeutic
oleation), Vamana (~therapeutic emesis), Virechana,
Niruha Basti (~therapeutic enema with decoction)
Anuvasana Basti (~therapeutic enema with oil) and
Annals of Ayurvedic Medicine Vol-9 Issue-3 Jul.-Sep., 2020 231
Shamana Aushadhi (~palliative therapy) depending on the
Vata (Dosha responsible for movement and
cognition) and Pitta (Dosha responsible for regulating
metabolic activities) imbalance is predominant in Kshina
Shukra., Therefore, Virechana and Basti are considered
important in the treatment protocol. Acharya Charaka
suggested Chatuhprasrtik Basti as the best enhancer of
, be it in quality or quantity. The purpose of this
article is to demonstrate the usefulness of Virechana
followed by Chatuhprasrtik Basti for 16 days in improving
the sperm quality in a patient with necrozoospermia.
Case History
A 36-year-old male patient presented to the outpatient
department of Panchakarma, with the complaint of no
children after 7 years of active married life. He had had
several semen analyses carried out at intervals of 3-4
months. Latest report, carried out one month ago, showed
100% non-motile sperms despit e sufficient sperm
concentration [Table 6]. His previous reports carried out
four months ago revealed 100% immotile and non-viable
sperms. Based on the latest report that showed 100%
immotile and non-viable spermatozoa, the patient was
diagnosed with necrozoospermia.
The patient did not
report any problems with erection or ejaculation, or any
other complaints related to sexual performance. There was
no history of sexually transmitted disease, mumps,
herniorrhaphy/herniotomy, or urogenital infections or other
significant past medical history. No relevant family history
was also noted. He worked as a nursing staff in one of the
medical colleges and, thus had a history of night awakening
and daytime sleep. He had irregular dietary habits. Sexual
life was reported as satisfactory per the patient with a
frequency of having intercourse 2-3 times a week. He was
addicted to tobacco chewing (Gutka) for more than 20
years and smoking (4-5 Beedi/day) for 7-8 years. History
revealed occasional alcohol intake for 12 years. Stress was
present due to his job schedule which included working
for more than 12 hours at times. Inability to reproduce in
7 years of active married life added to the existing stress.
He sought treatment from various allopathic doctors in
the past 3-4 years, and underwent Homeopathic treatment
also for few months, but was not satisfied and therefore
approached us for Ayurveda care. As the patient could not
afford, other investigations such as antisperm antibodies
could not be carried out. Fructose test was also not done.
Semen Analysis was not repeated because of several past
reports showing either decreased motility or total
immotility. As mentioned above, the patient was diagnosed
as Kshina Shukra based on is latest semen analysis report.
Firstly, the patient was counseled and explained about the
significance of Virechana Karma (purgation therapy). He
was later admitted in the Indoor Patient Department of
Panchakarma. His clinical examination did not reveal any
abnormality. Patient was of Vatakaphaja Prakriti (type
of body constitution attained at the time of conception),
Madhyama Samhanana (Moderate physique), Madhyama
Pramana (well-proportioned body), and Madhyama
Koshtha (normal bowel habits). Considering his history
of Tobacco use and Alcohol intake, and Vata Pitta
association of the disease, classical Virechana Karma was
advised followed by Chatuhprasritik Basti based on the
Ayurvedic principles for the treatment of Kshina Shukra.
Treatment Plan
Virechana Karma was carried out as per classical method
[Table 1] followed by administration of Chatuhprasritik
Basti for 16 days starting from 9
day of Virechana as
stated in classics.
Before administration of Basti, local
Abhyanga (~therapeutic massage) at lower back, abdomen,
and legs with Dashmoola Taila (~medicated oil) & Bashpa
Swedana (~therapeutic steam bath) with Dashmoola
Kw at ha (decoction) wa s do ne for 15 minutes.
Chatuhprasritik Bastidrava was prepared as per classical
method [Table 2]. The patient was not taking any other
concurrent treatments during this period.
Preparation of Bastidrava
(~Therapeutic enema liquid): Madhu (Honey) (100 ml)
and Saindhava (Rock salt) (5 gm) were mixed well using
a porcelain pestle and mortar. To this combination, 100ml
of Goghrita (Cow’s ghee) and 100ml of Tila Taila (Sesame
oil) were added and to this mixture 11 gm of Hapusha
Kalka (Paste of Juniperus communis Linn.) and 100ml of
Kumawat AR., Mangal G. : Cases report on the effect of Virechana and Chatuhprasritik....
Annals of Ayurvedic Medicine Vol-9 Issue-3 Jul.-Sep., 2020 232
Godugdha (Cow’s milk) were added and stirred well. As
a result, the total quantity of about 400 ml of
Chatuhprasritik Bastidrava (enema liquid) was prepared.
Administration of Basti
Patient was advised to lie down in the left lateral position
on a table of knee height, with left lower limb in extended
position over the table while the right lower limb flexed at
knee and hip joint, close to chest.
Basti Netra (~Basti
nozzle) and anal region of the patient were lubricated with
oil prior to insertion of Netra into the anal canal.
other end of Basti Netra was tied to the Bastiputaka
(~Enema pot), filled with Basti Drava (400 ml). Then Basti
Netra was inserted slowly and steadily parallel to the
vertebral column and the Bastiputaka was pressed gently
and uniformly. After confirming that, some Bastidrava
remained in Bastiputaka, the Basti Netra was gently
removed from the anal canal and the patient was advised
to relax in the supine position. Gentle tapping was done
on the buttocks, hips, and soles for proper distribution of
Bastidrava. Time of administration of Basti was recorded.
Patient could leave after 5 minutes and was advised to
note down the time of Pratyagamana (~evacuation) of
Basti. The patient was advised to take bath with lukewarm
water once the Basti is completely evacuated followed by
intake of hot soup made with green gram (split mung
Pathyaapathya (Dietary restrictions)
Patient was advised to avoid sour, salty, spicy, and fried
items in his routine diet- Curd, Lemon, Pickles, junk
food etc.
Any sort of physical or mental exertion was advised to
be avoided.
Sexual activity was also restricted during the treatment
After completion of Basti regimen patient was advised
to follow the same dietary pattern and routine for at
least twice the duration as Basti administered i.e. 32
Additionally, the patient was advised use of Godugdha,
Masha etc.. He was also advised to limit the intake of
alcohol and smoking and to avoid Gutka intake too.
Outcomes Assessment
Semen analysis were repeated after Virechana (after
completion of post purificatory regimen) on 21
day and
after completion of course of Basti i.e. on 41
day of
admission. Sperm concentration was analyzed using
volumetric dilution and hemocytometry. Morphological
analysis was carried out using Kruger’s strict criteria for
classification, and simple classification system was used
for motility assessment.
Observations & Results
Observations on Virechana Karma and Basti: Total
number of Vega (~number of movements) observed during
Virechana were 15. Kaphanta Shuddhi (~appearance of
mucus during the last Vega) was achieved. Samsarjana
Krama (post purificatory dietary regimen) was advised
for 5 days based on the Vaigiki Shuddhi (~purification
based on frequency of defecation) of 15 Vega. The average
Basti administration and retention time were 2 minutes
and 25 minutes, respectively.
Observation on semen analysis: There was no difference
found in Physical examination i.e. pH and liquefaction
time in semen analysis report [Table 3] except that volume
of semen before treatment was 1.5 ml, after Virechana it
was 2.5 ml and after Basti it reduced to 1ml. This decrease
in volume of semen after Basti was due to mishandling (fall)
of the container containing semen by patient, which he
reported after sampling. Thus, the difference in volume of
semen was not taken into consideration. A significant
increase in total spermatozoa concentration, motility,
morphology, and vitality of the spermatozoa was found after
Virechana, which further improved after Basti [Table 3].
Only Shuddha Shukra (~healthy sperm) is capable of
Kumawat AR., Mangal G. : Cases report on the effect of Virechana and Chatuhprasritik....
Annals of Ayurvedic Medicine Vol-9 Issue-3 Jul.-Sep., 2020 233
fertilization which can be thought of as Spermatozoa
present in optimum quantity with optimum motility and
morphology that is required to achieve fertilization.
Completely Immotile sperms or Non-viable sperms lack
the ability to permeate the cervical mucus and fertilize the
egg, and thus is a form of Shukradosha, more precisely
Kshina Shukra. The word Kshina is a broader term. When
used in context of Alpa (scanty), it indicates reduction in
quantity of ejaculated sperm i.e. low sperm count or
oligospermia. In context of power, Kshina Shukra refers
to Asthenozoospermia, where the motility of spermatozoa
is greatly reduced and Teratozoospermia (Abnormal forms
of sperms), where owing to the abnormal form, the
fertilizatio n cap acity of sper m is reduced. Thus,
As th en ozoospermia , Teratozoo sp er mia and
Necrozoospermia can be considered as Kshina Shukra.
Patient was working as a nursing staff in a government
hospital with long standing hours, disturbed eating habits
and sleeping schedule. Infertility has been linked to several
emotional, physical, and sociocultural problems.
was a major factor in the present case arising out of his
job schedule and inability to reproduce added to it. Irregular
dietary habits, as in this patient’s case, create Agnimandya
(diminution of digestive/ metabolic factors). Ayurveda
considers Agnimandya as the root cause of all ailments
Jatharagnimandya (diminution of metabolic factors
located in digestive tract), if left untreated may lead to
Dhatwagnimandya (diminution of metabolic factors
located in Dhatu), which may further lead to other diseases.
Diminution of agni produces ama (~undigested food
residue). This ama may vitiate Kapha and may increase
the Picchila Guna (~slimy property) of Kapha, which may
cause the obstruction in the micro circulatory channels.
Thus, proper nutrition to the Dhatu is affected and as a
result, their normal functions are also affected. Shukra
(~reproductive element) is the last Dhatu and is said to be
the essence of Ahara (food).
An imbalance of the
preceding Dhatu invariably leads to unhealthy Shukra
which is incapable of fertilization. The obstruction in the
microchannels of Shukra Dhatu may be attributed as a
cause for totally immotile and non-viable sperms. However,
the exact cause for immotility and non-vitality of sperms
was not clear in the present case.
The ama created by improper nutrition and metabolism is
equivalent to the free radicals, a kind of Reactive oxygen
Reactive oxygen species (ROS) are formed from
oxygen as a natural byproduct during metabolism.
Though certain level of ROS are necessary for maturation
of spermatozoa, capacitation, acrosome reaction etc.,
increased ROS along with decrease antioxidant defense
results in oxidative stress which hampers the motility of
Abundance of polyunsaturated fatty acids
in plasma membrane and cytoplasm of sperm cells make
them vulnerable to ROS.
Extrinsic factors such as
smoking, and alcohol intake have been associated with
increased ROS and male infertility.
Smoking has been
associated with reduced sperm concentration, motility, and
altered morphology.
Evidence suggests, tobacco chewing
is strongly associated with a decrease in sperm quality.
Similarly, the excess Kashaya Rasa intake due to Gutka/
Tobacco abuse might have also contributed to the
Excess intake of Kashaya Rasa may cause
Stambhana, which leads to obstruction in the Srotas and
aggravates Vata. This obstruction in the Shukravaha Srotas
(~circulatory channels in reproductive tissue) might impede
the nutritional factors to sperm hampering their motility
and morphology. Such a pathomechanism of Shukradushti
signifies Ama elimination in our patient with a longstanding
history of tobacco use and alcohol intake.
The treatment protocol was planned to address the stress
factor, Agnimandya, Ama, Srotavarodha (Obstruction in
the mi cr o ci rc ulatory channels) and subsequen t
Shukradushti. Acharya Charaka recommends Virechana
for Shukradushti. Virechana is indicated to cause
Kayagnideepana (increase in factors responsible for
digestion and metabolism / transformation), Manah
Prasadana (cheers mind), acts as an aphrodisiac (Vrishta
Chasya Jayate).
Virechana is one of the removal methods
for oxidative stress due to ROS.
By means of Snehana
(Oleation) and Swedana (fomentation), the Ama from all
over the body is brought to the gastrointestinal tract and
then expelled out through Virechana.
Kumawat AR., Mangal G. : Cases report on the effect of Virechana and Chatuhprasritik....
Annals of Ayurvedic Medicine Vol-9 Issue-3 Jul.-Sep., 2020 234
In the present case, Ama digestion, elimination and
Srotoshuddhi (removal of obstruction) might have occurred
with Virechana Karma, thus improving Agni, and restoring
the nutritional pathways to Shukra Dhatu. Decrease in
oxidative stress due to ROS might have improved motility
and normal forms of spermatozoa. Virechana might have
produced Manah Prasadana (happiness) by relieving
stress, which possesses major role in fertili zation
(Saumanasya Garbhajananam).
. The mechanism of
actions of Virechana Karma includes clearing the
occlusions in a channel and enhances better absorption of
oral herbal therapies,
and produce Vatanulomana
(~downward movement of Vata) required to balance Vyana
(a subtype of Vata, that is seated in Hridaya) and Apana
(a subtype of Vata, that is seated in pelvic region) in
The positive changes in semen analysis in
our patient after Virechana Karma match the textbook
descriptions of the benefits of Virechana Karma for
Similarly, Basti is said to be the best Karma for treatment
of Shukra Dosha
as it enhances the low level of Shukra,
vi ri li ty, vigor, and life span of an in di vidual.
Chatuhprasritik Basti was selected in the present case as
it is an appropriate therapy for Brimhana after Shodhana
and is known to improve the quality of Sperm.
ingredients in this type of Basti support the improvement
in the semen quantity and quality. Tila Taila is Balya,
Uttama Vataghna
and Vrishya (~aphrodisiac)
possesses Balya properties
Godugdha acquires
Jeevaniya (vitalizer) property.
Basti also acts as Vajikara
if prepared with Vaj ikarana drugs like Ksheera,
Mamsarasa, Ghrita, etc. in the form of Yapana Basti.
Aphrodisiac nature of Basti might have enhanced the
therapeutic efficacy of Virechana. It is important to note
that the overall improvement in the semen characteristics
in our patient supports the classical approach of treating
Shukradushti, which utilizes Virechana followed by
Chatuhprasritik Basti.
The patient was followed up for another 4 months. During
this time, the patient reported that his wife conceived after
2 months of cessation of our cleansing treatments, which
indicated that the improvement in semen characteristics
lasted for more than two months and also addressed his
long-standing infertility. Despite the successful outcome
in this case, these findings are still in a single case study
and must be interpreted with caution and one cannot make
generalizations of these results without replicating these
findings in a larger sample using a much rigorous design.
Nevertheless, it provides a promising protocol that requires
further exploration.
Classical Virechana Karma followed by Chatuhprasritik
Basti may be effective in correcting the motility and
vi ab il it y of s perms in asthenozoo sp er mia and
necrozoospermia and addressing male infertility. The
results obtained in this single case study were encouraging
and require further exploration of these approaches as an
option to treat male infertility. We recommend more
extensive studies with longer follow up period to validate
our findings.
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Source of Support : Nil
Conflict of Interest : None
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"Case report on the effect of virechan and chatuhprasritik basti in necrozoospermia."
Full-text available
Current evidence links oxidative stress (OS) to male infertility, reduced sperm motility, sperm DNA damage and increased risk of recurrent abortions and genetic diseases. A review of PubMed, Medline, Google Scholar, and Cochrane review databases of published articles from years 2000–2018 was performed focusing on physiological and pathological consequences of reactive oxygen species (ROS), sperm DNA damage, OS tests, and the association between OS and male infertility, pregnancy and assisted reproductive techniques outcomes. Generation of ROS is essential for reproductive function, but OS is detrimental to fertility, pregnancy, and genetic status of the newborns. Further, there is a lack of consensus on selecting OS test, type, and duration of antioxidants treatment as well as on the target patients group. Developing advanced diagnostic and therapeutic options for OS is essential to improve fertility potential and limit genetic diseases transmitted to offspring.
Full-text available
DNA damage, largely owing to oxidative stress, is a leading cause of defective sperm function. High levels of oxidative stress result in damage to sperm DNA, RNA transcripts, and telomeres and, therefore might provide a common underlying aetiology of male infertility and recurrent pregnancy loss, in addition to congenital malformations, complex neuropsychiatric disorders, and childhood cancers in children fathered by men with defective sperm cells. Spermatozoa are highly vulnerable to oxidative stress owing to limited levels of antioxidant defence and a single, limited DNA-damage detection and repair mechanism. Oxidative stress is predominantly caused by a host of lifestyle-related factors, the majority of which are modifiable. Antioxidant regimens and lifestyle modifications could both be plausible therapeutic approaches that enable the burden of oxidative-stress-induced male factor infertility to be overcome. Lifestyle interventions including yoga and meditation can substantially improve the integrity of sperm DNA by reducing levels of oxidative DNA damage, regulating oxidative stress and by increasing the expression of genes responsible for DNA repair, cell-cycle control and anti-inflammatory effects. Oxidative stress is caused by various modifiable factors, and the use of simple interventions can decrease levels of oxidative stress, and therefore reduce the incidence of both infertility and complex diseases in the resultant offspring.
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Background Tobacco smoking is a public health issue and has been implicated in adverse reproductive outcomes including semen quality. Available data however provides conflicting findings. The objective of this study was to evaluate the effect of tobacco smoking on semen quality among men in Ghana. Methods In this study, a total of 140 subjects were recruited, comprising 95 smokers and 45 non-smokers. Smokers were further categorized into mild, moderate and heavy smokers. Semen parameters such as sperm concentration, motility, viability and normal morphology were measured according to the World Health Organisation criteria. ResultsThe study showed that smokers had significantly lower semen volume, sperm concentration, sperm motility, total sperm count, sperm morphology, free testosterone and follicle stimulating hormone (p <0.05 respectively), compared with non-smokers. Smokers were at a higher risk of developing oligospermia, asthenozoospermia and teratozoospermia (OR = 3.1, 4.2 and, 4.7; p <0.05) than non-smokers. Conclusion Results demonstrated a decline in semen quality in a dose dependent tobacco smoking manner.
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Sperm is particularly susceptible to reactive oxygen species (ROS) during critical phases of spermiogenesis. However, the level of seminal ROS is restricted by seminal antioxidants which have beneficial effects on sperm parameters and developmental potentials. Mitochondria and sperm plasma membrane are two major sites of ROS generation in sperm cells. Besides, leukocytes including polymer phonuclear (PMN) leukocytes and macrophages produce broad category of molecules including oxygen free radicals, non-radical species and reactive nitrogen species. Physiological role of ROS increase the intracellular cAMP which then activate protein kinase in male reproductive system. This indicates that spermatozoa need small amounts of ROS to acquire the ability of nuclear maturation regulation and condensation to fertilize the oocyte. There is a long list of intrinsic and extrinsic factors which can induce oxidative stress to interact with lipids, proteins and DNA molecules. As a result, we have lipid peroxidation, DNA fragmentation, axonemal damage, denaturation of the enzymes, over generation of superoxide in the mitochondria, lower antioxidant activity and finally abnormal spermatogenesis. If oxidative stress is considered as one of the main cause of DNA damage in the germ cells, then there should be good reason for antioxidant therapy in these conditions.
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Semen analysis as an integral part of infertility investigations is taken as a surrogate measure for male fecundity in clinical andrology, male fertility, and pregnancy risk assessments. Clearly, laboratory seminology is still very much in its infancy. In as much as the creation of a conventional semen profile will always represent the foundations of male fertility evaluation, the 5th edition of the World Health Organization (WHO) manual is a definitive statement on how such assessments should be carried out and how the quality should be controlled. A major advance in this new edition of the WHO manual, resolving the most salient critique of previous editions, is the development of the first well-defined reference ranges for semen analysis based on the analysis of over 1900 recent fathers. The methodology used in the assessment of the usual variables in semen analysis is described, as are many of the less common, but very valuable, sperm function tests. Sperm function testing is used to determine if the sperm have the biologic capacity to perform the tasks necessary to reach and fertilize ova and ultimately result in live births. A variety of tests are available to evaluate different aspects of these functions. To accurately use these functional assays, the clinician must understand what the tests measure, what the indications are for the assays, and how to interpret the results to direct further testing or patient management.
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A model suggesting that high perception of stigma is associated with reduced disclosure to others, leading to lower social support and higher distress in new attendees at an infertility clinic is tested. Questionnaires measuring stigmatization (Stigma consciousness questionnaire), disclosure of fertility difficulties (Disclosure questionnaire), social support (Duke-UNC Functional Social Support Questionnaire) and fertility-related [Fertility Problem Inventory (FPI)] and generic distress [Hospital Anxiety and Depression Scale (HADS)] were completed by 87 women and 64 men. Data were analysed by gender comparisons, correlations and path analysis. Women reported higher stigma and disclosure than men. For women, stigma and disclosure were unrelated but in men higher stigma was associated with lower disclosure. Perceptions of stigma were related to low social support for both genders. Social support was negatively related to anxiety, depression and overall infertility distress and showed greater predictive capacity than satisfaction with partner relationship. Testing the model showed that, for men, stigma was linked to lower disclosure and support and higher fertility-related and generic distress. Disclosure itself did not link to support. For women, greater disclosure linked only to higher generic distress. Stigma was directly linked to fertility-related distress and to low perceived support which mediated a relationship with generic distress. Stigma and the wider social context should be considered when supporting people with fertility problems. Greater disclosure may be associated with higher distress in women.
Objective Approximately 37% of men of reproductive age smoke cigarettes, with Europe having the highest tobacco use among all the World Health Organization (WHO) regions. Toxins from tobacco smoking can potentially affect sperm development and function, with a negative effect on semen parameters. Given the high prevalence of smoking and recent changes in the WHO laboratory methods for the examination of human semen, the role of this exposure in face of new WHO methods needs to be clarified. Evidence acquisition We conducted a systematic review, followed by a meta-analysis, to determine whether cigarette smoking affects human semen parameters. PubMed, Saint Joseph's University Discover, and Google Scholar were used to identify relevant studies published after release of the latest WHO methods for laboratory evaluation of human semen. Participants were from fertility/urologic clinics and andrology laboratories. The outcome measures were semen volume, sperm concentration, motility, and morphology, the parameters usually used in clinical settings to assess fertility. Evidence synthesis Twenty studies with 5865 participants were included in the meta-analysis. Exposure to cigarette smoking was associated with reduced sperm count (mean difference [MD]: −9.72×10 6 /ml; 95% confidence interval [CI], −13.32 to −6.12), motility (MD: −3.48%; 95% CI, −5.53 to −1.44), and morphology (MD: −1.37%; 95% CI, −2.63 to −0.11). Subgroup analyses indicated that effect size was higher in infertile men than in the general population and in moderate/heavy smokers than in mild smokers. The overall effect size on semen volume, sperm count, and motility remained similar when 2010 and earlier WHO manuals were used for semen analysis but was lower with regard to sperm morphology. Conclusions Our results suggest that cigarette smoking has an overall negative effect on semen parameters. The latest WHO laboratory methods for the examination of human semen had a minimal impact on the magnitude of effect size, thus confirming the observed negative effect of smoking on conventional semen parameters. Patient summary A new systematic review and meta-analysis comprising 5865 men shows that cigarette smoking is associated with reduced sperm count and motility. Deterioration of semen quality is more pronounced in moderate and heavy smokers.
DNA fragmentation is an important factor in the aetiology of male infertility. However, it is still underevaluated and its inclusion in routine semen analysis is debated. DNA fragmentation has been shown to be a robust indicator of fertility potential, more so than conventional semen parameters. Men with high DNA fragmentation levels have significantly lower odds of conceiving, naturally or through procedures such as intrauterine insemination and IVF. Couples may be counselled to proceed directly to intracytoplasmic sperm injection as it is more successful in this group, avoiding costly procedures, recurrent failures or pregnancy losses; however, this treatment is not without limitations or risks. Ideally DNA fragmentation should be minimized where possible. Oxidative stress is the major cause of DNA fragmentation in spermatozoa. Endogenous and exogenous factors that contribute to oxidative stress are discussed, and in many cases are shown to be easily modifiable. Antioxidants play a protective role, although a delicate balance of reduction and oxidation is required for essential functions, including fertilization. Reducing oxidative stress may improve a couple’s chances of conception either naturally or via assisted reproduction. Sources of oxidative stress therefore should be thoroughly examined in men with high levels of DNA fragmentation and modified where possible.
Significance: Functional stem cell decline has been postulated to result in loss of maintenance of tissue homeostasis leading to organismal decline and diseases of aging. Recent advances: Recent findings implicate redox metabolism in the control of stem cell pool and stem cell aging. Although reactive oxygen species (ROS) are better known for their damaging properties to DNA, proteins and lipids, recent findings suggest that ROS may also be an integral physiological mediator of cellular signaling in primary cells. Critical issues: Here we review recent published work on major signaling pathways and transcription factors that are regulated by ROS and mediate ROS regulation of stem cell fate. We will specifically focus on how alterations in this regulation may be implicated in disease and particularly in diseases of stem cell aging. In general, based on the work described here we propose a model in which ROS function as stem cell rheostat. Future directions: Future work in elucidating how ROS control stem cell cycling, apoptotic machinery, and lineage determination should shed light on mechanisms whereby ROS may control stem cell aging.
Four patients with persistent oligospermia and necrospermia were found to have severely degenerated sperm in the ejaculate. However, in those examined, testicular sperm were ultrastructurally normal, indicating that sperm degeneration and death was occurring during epididymal passage or storage or both or upon mixing with the seminal plasma at ejaculation. Seminal plasma was found to be nontoxic to normal donor sperm. In three patients, frequent ejaculation (two ejaculates per day for 4 or 5 days) was used to deplete epididymal sperm reserves and reduce the period spent in the epididymis. This resulted in a threefold to sevenfold increase in percentage of motile sperm in the ejaculate and a similar increase in sperm motility index. The authors propose the term "epididymal necrospermia" to describe this previously undefined type of male infertility.