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Correction to Howards, N Engl J Med 332(5):312-317 February 2, 1995.

Correspondence
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Volume 332:1790-1791 June 29, 1995 Number 26
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Male Infertility

 

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To the Editor: There are misleading recommendations in the Current Concepts article entitled "Treatment of Male Infertility," by Stuart S. Howards (Feb. 2 issue).1 Dr. Howards recommends the use of an inappropriate dosage of metronidazole to treat trichomonas infections. The article states that 2 g of metronidazole should be administered orally four times a day for 10 days. In fact, the recommended dose for trichomonas infections in both men and women is either a single oral dose of 2 g or a dose of 500 mg orally two times a day for seven days.2 In addition, the final sentence of the section entitled "Infection" can be easily misinterpreted. As the sentence reads currently, either doxycycline or metronidazole is recommended for mycoplasma, ureaplasma, or trichomonas infections. In fact, the treatment for mycoplasma or ureaplasma is indeed doxycycline, and the treatment for trichomonas is metronidazole. Doxycycline is not recommended for trichomonas infections.

Aside from these two issues, I found Dr. Howards's article quite informative.


Harold C. Wiesenfeld, M.D., C.M.
Magee–Womens Hospital
Pittsburgh, PA 15213-3180

References

  1. Howards SS. Treatment of male infertility. N Engl J Med 1995;332:312-317. [Free Full Text]
  2. 1993 Sexually transmitted diseases treatment guidelines. MMWR Morb Mortal Wkly Rep 1993;42:1-102. [Medline]
 
To the Editor: In discussing abnormalities of semen, Dr. Howards erroneously states that the normal ejaculate is liquefied within 20 minutes by proteolytic enzymes secreted by the seminal vesicles. In fact, the seminal vesicles provide the substrate for seminal coagulation. The proteolytic enzyme causing sequential liquefaction comes from the prostate.1 This proteolytic agent has recently been identified as prostate-specific antigen, a glycoprotein kallikrein-like serine protease derived from the secretory layer of prostatic epithelium.2 Prostate-specific antigen is also found in high concentrations in specimens of human semen.


Richard D. Amelar, M.D.
Lawrence Dubin, M.D.
Cy Schoenfeld, Ph.D.
New York University Medical Center
New York, NY 10016

References

  1. Amelar RD. Coagulation, liquefaction and viscosity of human semen. J Urol 1962;87:187-190. [Medline]
  2. Oesterling JE. Prostate specific antigen: a critical assessment of the most useful tumor marker for adenocarcinoma of the prostate. J Urol 1991;145:907-923. [Medline]
 
To the Editor: In men with normospermia, sperm counts decrease significantly with frequent ejaculation. In men with oligospermia or asthenospermia, the effect of sequential ejaculation was generally assumed to be similar or even greater. Thus, in order to "save up sperm," the usual recommendation to couples trying to conceive was to have intercourse every 48 hours during the time of expected ovulation, as stated by Howards in his recent review of the treatment of male infertility.

However, recent results from different laboratories suggest that this is a myth.1,2,3,4 We recently demonstrated in a cohort of 576 men that, in contrast to men with normospermia, most men with oligospermia or asthenospermia have a different response to sequential ejaculation.4 As compared with the first ejaculate, in most of these men the second successive ejaculate, obtained after an interval of 1 to 4 or 24 hours, contained a similar or an even greater number of motile sperm. Therefore, pooling sequential ejaculates can significantly increase the total motile-sperm count by 67 to 233 percent of that of the first ejaculate.

The current trend in the management of severe male infertility is to use assisted-reproduction techniques with or without gamete micromanipulation. These procedures involve some risks, are psychologically stressful to patients, and are expensive and time consuming. Although it is not clear how many sperm are needed for a man to be fertile, higher sperm counts are associated with an increased chance that an infertile couple will conceive and with increased success rates of in vitro fertilization. On the basis of these recent studies,1,2,3,4 we suggest changing the usual recommendation made to infertile men who try to conceive.4,5 Men with oligospermia or asthenospermia may increase their fertility potential, as assessed by the total motile-sperm count, by having timed intercourse every day or even twice a day at the time of expected ovulation.


Ilan Tur-Kaspa, M.D.
Yasmin Maor, M.D.
Jehoshua Dor, M.D.
Chaim Sheba Medical Center
Tel Hashomer 52621, Israel

References

  1. Tur-Kaspa I, Dudkiewicz A, Confino E, Gleicher N. Pooled sequential ejaculates: a way to increase the total number of motile sperm from oligozoospermic men. Fertil Steril 1990;54:906-909. [Medline]
  2. Hornstein MD, Cohen JN, Thomas PP, Gleason RE, Friedman AJ, Mutter GL. The effect of consecutive day inseminations on semen characteristics in an intrauterine insemination program. Fertil Steril 1992;58:433-435. [Medline]
  3. Matilsky M, Battino S, Ben-Ami M, Geslevich Y, Eyali V, Shalev E. The effect of ejaculatory frequency on semen characteristics of normozoospermic and oligozoospermic men from an infertile population. Hum Reprod 1993;8:71-73. [Free Full Text]
  4. Tur-Kaspa I, Maor Y, Levran D, Yonish M, Mashiach S, Dor J. How often should infertile men have intercourse to achieve conception? Fertil Steril 1994;62:370-375. [Medline]
  5. Tur-Kaspa I, Maor Y, Dor J, Mashiach S. Frequency of intercourse for couples trying to conceive. Lancet 1994;344:766-766. [Medline]
 
Dr. Howards replies:

To the Editor: I thank Amelar et al. for correcting the error in my discussion of the source of proteolytic enzymes in the semen. I also thank Dr. Wiesenfeld for his appropriate corrections of the dose and use of metronidazole. Finally, it is possible that Tur-Kaspa et al. are correct, and their conclusions are certainly consistent with their referenced work. However, uncertainty remains about how often infertile men should have intercourse to maximize the chance of conception. Their study1 by no means offers enough data to be certain about this point. There is no consensus whether their approach or the one I recommended is correct.


Stuart S. Howards, M.D.
University of Virginia Health Sciences Center
Charlottesville, VA 22908

References

  1. Tur-Kaspa I, Maor Y, Levran D, Yonish M, Mashiach S, Dor J. How often should infertile men have intercourse to achieve conception? Fertil Steril 1994;62:370-375.
 


 

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