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Genitourinary Bacterial Infection: a Cause of Infertility in Men?

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Genitourinary Bacterial Infection: a Cause of Infertility in Men? Acta Marisiensis - Seria Medica 2020;66(3):116-120 DOI: 10.2478/amma-2020-0024 CASE REPORT Genitourinary Bacterial Infection: a Cause of Infertility in Men? A Cases Series and Short Review of Literature Răzvan Lucian Coșeriu1, Camelia Vintilă1*, Bianca Irina Kosovski2, Anca Delia Mare3, Cristina Nicoleta Ciurea3 1. Department of Immunology, Mures County Clinical Hospital - Infectious Diseases Laboratory, Targu Mures, Romania 2. Department of Physiopathology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania 3. Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania Introduction: The role of bacterial infections on the onset and the development of male infertility is still highly controversial, as the clinical cases have different outcomes and the practitioners have no guidelines that will help them select the cases that could better benefit from antibiotic treatment. Case presentation: Four case reports are presented in order to emphasize the possible clinical implications of genitourinary bacte- rial infections on male infertility. The first patient had two bacterial strains isolated from the semen culture, Escherichia coli, and then Entero- coccus faecalis. The antibiotic treatment was not effective. The second patient had a semen culture positive with Enterococcus faecalis. The treatment was successful: the bacteria were eradicated and the patient was able to conceive a baby. Enterococcus faecalis was also identi- fied in the third and the fourth case. These patients were able to conceive, despite the different clinical management strategies of the cases. Conclusion: Bacterial prostatitis might play a role in male infertility, but the clinical cases are still highly unpredictable. Every case presents a different viewpoint and raises awareness of the complexity of the problem. Keywords: Enterococcus faecalis, spermatozoa, azoospermia, male infertility, sperm count Received 24 August 2020 / Accepted 4 September 2020 Introduction quality of spermatozoa are Enterococcus faecalis (32.1%), At least 30 million men are infertile around the globe, Escherichia coli (20.1%), Streptococcus agalactiae (13.4%), making male infertility a subject of real concern [1]. The and Ureaplasma urealyticum (11.8%) [6]. complex etiology of the problem, combined with the Sperm quality is closely linked with infertility, although public stigma that might come from acknowledging and not exclusively. Urogenital bacterial infections are respon- addressing this problem, makes this a sensitive issue. A sible for 15% of the male infertility cases and some authors meta-analysis targeting men from Europe, North America, consider that the presence of bacteria in semen may affect and Australia reported a 50-60% decline in sperm quality the quality of spermatozoa [7], but there are still many un- during 1973-2011, with vast implications on men’s health answered questions on this topic. [2]. The main reason for this mini-series of case reports is Globally, 15% of couples are affected by infertility, 20- to present the possible different evolution of genitourinary 30% of which are due solely to male infertility, while 50% tract infections and the possible impact that bacterial pros- are due to causes that involve both partners [1, 3, 4]. The tatitis might have on the quality of the semen. highest infertility rates were reported in Africa and Cen- tral/Eastern Europe [1]. Materials and methods According to De Kretser and Baker, the male infertil- Prior to harvesting the clinical sample, all four patients fol- ity etiological factors are classified into 3 categories: pre- lowed the World Health Organization 2010 protocol: 3 to testicular (endocrine disorders, coital disorders, or ejacu- 7 days of abstinence, proper hygiene before collecting the latory failure), testicular (infective pathologies, genetic or specimen and transportation time to the laboratory of less congenital disorders), and post-testicular (genital tracts than 30 minutes. After receiving the samples in the labora- obstructions or accessory gland infections). Even though tory, these were incubated at 37oC for up to one hour, to this classification was published in 1999, it is still wildly establish the liquefaction time. used [5]. The motility, viability of spermatozoa, the presence of Bacterial infections might play a role in male infertility. bacteria or leukocytes were evaluated by wet mounts. To A study published in 2009 by Moretti et al, showed that count the number of spermatozoa, we used solutions con- the most frequently isolated bacteria that might affect the taining water and formaldehyde in a ratio of 9:1. The spermatozoa morphology was evaluated by Giemsa * Correspondence to: Camelia Vintilă staining. E-mail: [email protected] Acta Marisiensis - Seria Medica 2020;66(3) 117 The bacterial cultures and antibiotic susceptibility test- sample, the microscopy revealed 15 spermatozoa/field with ing were performed following the current protocols that are grades A and B motility, frequent bacteria, and PMN leu- used in the laboratory. Shortly after their arrival, the sam- kocytes. A pure culture of E. faecalis was again identified. ples were inoculated on specific culture media, incubated, The patient’s wife had E. faecalis in her vaginal secretion. and the colonies bacterial strains were identified based on Treatment with 1 gram of ampicillin per day for 30 days their biochemical characters. The antibiotic susceptibility was suggested, alongside anti-mycotic prophylaxis with was performed following EUCAST standard. 150 mg of fluconazole every 4 days. The study was approved by the Medical College of Ro- At revaluation in January 2019, after the patient finished mania (decision no.3374/28.07.2020). the treatment, the sperm count showed 6-8 spermatozoa per microscope field (motility grade B, C, D, and rarely, Presentation of case series grade A). E. faecalis, susceptible to all tested antibiotics was again isolated. The difference between this sample and the Case 1 previous ones consisted of the lack of inflammatory cells. A 28-years-old patient presented to the medical laboratory A standard dosage of hormones, spermatozoa antibod- in March 2018 for a semen analysis. The patient and his ies, and a testicular echography for a possible varicocele wife confirmed that they were trying without success to was recommended. The FSH and testosterone values were have a baby for longer than 6 months. The wife’s labora- out of range, so the patient was referred to the Endocri- tory tests and her gynecological consult were in the normal nology Department where a treatment was prescribed. The range. treatment did not improve the patient’s fertility status. The Family Practitioner recommended the husband to In April 2019, the following were observed on the se- perform a sperm count. The patient denied any other ill- men analysis: high viscosity, a volume of 4 ml, 4-5 sper- nesses. Before the sperm count, the patient complied with matozoa per microscope field with grade B motility, and a all the pre-analytical requirements established by the labo- high inflammatory response. In the semen culture, a strain ratory. The sample volume was 3.1 ml, the viscosity and of E. faecalis with the same susceptibility to antibiotics was the appearance were both in the normal range, the lique- identified. faction occurred at 25 minutes and the pH was 8.5. The microscopical examination showed no spermatozoa Case 2 but a field full of bacteria, polymorphonuclear (PMN) leu- A 32-years-old patient presented to the Medical Labora- kocytes, and few red blood cells. Semen culture showed a tory for performing a semen analysis and a semen culture. pure and rich culture of E. coli, and the isolated strain was He declared that he and his wife were trying to conceive susceptible to all tested antibiotics. without success for more than 1 year. On semen count, The patient was reassessed after two months. At that azoospermia was observed, as well as bacteria and inflam- time, he was following the treatment with gentamicin, tri- matory cells. The sample volume was low, with a high pH. methoprim - sulfamethoxazole and nystatin for 7 days, as A pure culture of E. faecalis was noted. The patient fol- prescribed by his urologist. lowed a treatment with levofloxacin 500 mg for 30 days, The semen analysis showed the following: a volume of and diclofenac suppository for 7 days. The patient turned 2.5 ml, a viscosity and pH similar values as in the first back after he finished the treatment. The sperm count was sample, 2-3 viable spermatozoa per microscopic field with in the normal range, passing from azoospermia to normo- grade B motility. Also, the sample contained numerous zoospermia with over 45 million spermatozoa. No bacte- sperm precursor cells, PMN leukocytes, and bacteria. No rial growth was observed. Following this, the couple man- bacterial culture was performed, as the patient was already aged to conceive a child. following antibiotic therapy. The prolongation of the treat- ment for up to 21-30 days was recommended, but not pre- Case 3 scribed. A 29-year-old patient presented at the Medical Laboratory After finishing the antibiotic treatment, the patient for a semen analysis and a semen culture on his own will. followed a complementary treatment with an amino-ac- The reason he wanted to take the test was the low volume ids-containing drug that enhances the fertility rate. The of ejaculate during intercourse. The urologist discovered patient returned to the laboratory for reevaluation, but a severe prostate inflammation and calcification of some no improvement in the quality of the semen was noticed. prostate zones. The sperm analysis showed a low sample Only 2-3 viable spermatozoa with grade A and B motility volume (1.8 ml), with high viscosity and normal pH. Mi- were observed per microscopical field, along with bacteria, croscopy showed 14.6 million/ml highly mobile sperma- PMN leukocytes, and sperm precursor cells. The bacterial tozoa with grade A and B motility.
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