Do Bacteria in the Sperm of an Asymptomatic Man Play a Role in TFI in His Partner?

More than 40 years of experience in my field convinced me that bacteria of an asymptomatic man can have serious adverse effects on the reproductive performance of his partner. To clearly demonstrate this, we will have to use  the most modern molecular technology to research the bacterial flora of the semen. These tests, like broad range PCR and pyrosequencing, could then identify bacterial DNA in the semen. The results would give strong evidence for the presence of a broad range of bacteria in the sperm. Even when only bacteria that represent 10% or more of the total are considered, these tests usually confirm the presence of at least 10-30 different bacterial species. While the so-called sexually transmitted bacteria, like chlamydia, gonorrhea, mycoplasma etc., usually cause symptoms, these other bacteria exist in asymptomatic men and we do not know if they are sexually transmissible. 

Tubal Factor Infertility (TFI) is one of the most important sequelae of Pelvic Inflammatory Disease (PID), which is a multi-bacterial infection caused by a multitude of different bacteria. In addition to sexually transmitted bacteria, anaerobes like Bacterioides fragilis and Anaerobe Strep play leading roles. These bacteria are not causing any symptoms most of the time, and women with TFI, like their partners, are not aware of the infection.

We urgently need to find the answer to the following questions:

     1. Why don't most women with tubal factor infertility find out about their condition until they finally see a fertility specialist?  

     2. Why must it take years of unsuccessful trying for a pregnancy before the damaging nature of this infection is uncovered?

I believe that bacteria, carried by asymptomatic males, are the cause of tubal factor infertility. Germs like chlamydia trachomatis frequently colonize the prostate of asymptomatic men. It can invade the uterine lining (endometrium) with intercourse. Chlamydia can cause irreversible tissue damage to the female reproductive tract either directly, through its toxic “heat shock proteins”, or indirectly, by modulating the immune system. But other bacteria may have a similarly important role as well.

Let's briefly review the facts to understand why it is so important to explore the male bacterial flora in its entirety.

Infertility is a unique medical condition of a couple that cannot conceive after 12 months of regular, unprotected intercourse in women younger than 35 years of age. Because fertility naturally declines after age 33-35, women age 35 or older should be evaluated after six months. 80-90% of healthy couples will eventually achieve pregnancy within one year of trying.

Infertility is a multidimensional disruptive condition with serious consequences for the family and society. Based on WHO data obtained from 85,000 infertile couples, the medical conditions contributing to infertility can be divided into three groups: female factor infertility (37%), male factor infertility (8%), and both female and male factor infertility (35%) of couples. Female factors, in order of importance, are: ovulatory dysfunction, tubal damage and adhesions, endometriosis, uterine factors, coital problems, cervical factors and finally, unexplained infertility.

The causes of male infertility can be divided into four categories: testicular defects of spermatogenesis (60-80%), endocrine and systemic disorders that cause hypogonadotropic hypogonadism (5%), sperm transfer disorders (5%) and idiopathic male infertility (10-20%).

The role of infection: The long-term consequences of sexually transmitted infections (STIs), most importantly chlamydia and gonorrhea, are fundamentally different in men and women. In the male, the bacteria cause sperm abnormalities, including fewer motile forms and premature sperm death. However, these changes are temporary and do not affect the newly formed sperm that is produced a few weeks later. Prostate hypertrophy may develop at a more advanced age, but it does not have any adverse effect on spermatogenesis.

A few years ago, using immune histo-chemistry in a small study, we found chlamydia antigenic material in 30% of the prostate hypertrophy specimens.  None of these men had fertility problems. Also, men with prostate hypertrophy frequently are culture negative on routine testing, but can have leukospermia (white blood cells in the sperm). The treatment of this condition is controversial, especially in asymptomatic men. A small study from the Cleveland Clinic showed improved pregnancy outcome after both partners were treated with doxycycline. The condition in itself does not have any effect on ejaculate variables.

By contrast, acute epididymitis is a more serious complication of an STD. Ten percent of patients will develop azoospermia after the disease, and 30% will have oligozoospermia.

No data are available on the effect of male bacterospermia on the upper genital tract of the female sexual partner, but many experts would recommend treatment for leukospermia. In summary: male infertility treatment is focused on restoring/preserving normal sperm quantity and quality, while bacterospermia and leukospermia remain enigmas.  In addition, assisted reproductive technology (ART) uses sperm that is always washed free of contaminants and bacteria. For these reasons, routine bacterial culture of the semen is not currently included in the work-up of the infertile couple. 

In the female: Pelvic inflammatory disease, or the infection of the female upper genital tract, is the most serious consequence of STDs. It is a polymicrobial infection that may be asymptomatic in more than half of the cases.

Tubal scarring or occlusion is one of the most common complications of the disease. A woman who cannot conceive has a 30% chance of having tubal factor infertility. During her work-up she will find out the first time that she has pelvic inflammatory disease that destroyed her tubes.

Because of recent advances in ARTs she will still be able to conceive using IVF to bypass the tubes.

There is urgent need to study the bacterial flora of the sperm in the asymptomatic male partners of infertile couples.

Doing a study in the context of infertility will help us understand the role of bacterospermia in the etiology of the fertility problem. Additionally, these women will have been exposed to the bacterial flora of their partners for a minimum a year or more. It is possible  that the same bacteria can be found in their endometria (the lining of the uterus).

Finally, a recent study from Spain showed that the endometrium of a women with TFI harbor several bacteria. Lactobacilli are the most common among several others. Once the Lactobacillus level goes below 80%, there is a very high risk for recurrent IVF failure. It is possible that the male flora that ascends to the endometrium is responsible for the decline in Lactobacilli.

In conclusion: Molecular testing of the sperm in infertile couples can find the association between the type and duration of infertility (TFI) and the bacterial flora of the man. It may help to identify previously unrecognized symptoms in the female that are warning signs of an impending tubal damage. The information will then assist to find the necessary and most effective early intervention to avoid the development of an irreversible tubal damage that destroys the reproductive capacity of the woman.