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DIAGNOSIS AND TREATMENT OF PATIENTS WITH INFERTILITY DEVELOPED
AGAINST THE BACKGROUND OF CHRONIC PROSTATITIS
Gafurov B.K.,
Mirzarakhimov Kh.A.,
Sabirov A.A.,
Kupaysinov B.B.*
*Lecturer at the Department of General Surgery of
the Chirchik branch of the Tashkent Medical
Introduction
According to the WHO definition, male infertility is a disorder of male reproductive function,
which is expressed in quantitative or qualitative changes in spermatozoa. Male infertility can be
a clinical manifestation of many different pathological conditions affecting both the reproductive
and other div systems. A significant share of the diversity of forms of male infertility is made
up of violations of the qualitative characteristics of the ejaculate. In particular, it is known that
physicochemical changes in the tissue of the prostate gland that occur during its inflammation
lead to a change in the quality of sperm [1–3]. The issues of the etiology and pathogenesis of
fertile dysfunction in chronic prostatitis remain the subject of serious discussions and
disagreements. Despite many published works, this condition remains insufficiently studied and
difficult to treat [4, 5]. Although abacterial prostatitis is recognized as an independent disease, it
remains unclear whether it is a stage in the development of bacterial prostatitis. It has been
suggested that primary infectious prostatitis does not exist, but only secondary infectious
prostatitis, which occurs as a result of morphological changes or dysfunction of the prostate
gland [6, 7]. Oxidative stress, which occurs under conditions of the inflammatory process,
negatively affects the testicular microenvironment and disrupts spermatogenesis, damages DNA,
reduces motility and changes the morphology of spermatozoa. Many aspects of oxidative stress
are caused by damage to mitochondria, the energy potential of which is regulated, in particular,
by inositols [8–10]. One of the reasons for the deterioration of fertility in patients with chronic
prostatitis is a decrease in the concentration of testosterone in the blood serum. Thus, a direct
correlation was established between the level of sex hormones and the severity of sexual
dysfunction in men. These data indicate the important role of non-testicular androgens in
regulating male sexual function [11–13]. The prostate gland and testicle are in a positive
correlative relationship, and if one organ is dysfunctional, the other suffers. At the same time, the
prostate gland is an organ responsible for the metabolism of sex hormones, and its disease leads
to a disruption of this metabolism [14, 15]. Unfortunately, the etiology and pathogenesis, timely
diagnosis of chronic prostatitis, its characteristic infertility, and therapeutic approaches to its
treatment are all issues that are far from being resolved today. Despite the widespread prevalence
of male infertility in patients with chronic prostatitis, the role of this disease in the genesis of
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infertility remains controversial.
Purpose of the study:
to evaluate the impairment of sperm quality and prostate secretion in
patients with infertility and chronic prostatitis, and to compare the effectiveness of various
treatment regimens for this pathology.
Material and methods
A retrospective analysis of the treatment results of patients with infertility and chronic prostatitis
was performed. The reason for seeking medical help from a urologist was an infertile marriage.
As a result of a comprehensive examination of patients, chronic prostatitis was verified in some
patients, which had not previously manifested clinically, in some patients the presence of chronic
prostatitis was confirmed anamnestically. The study included only patients who first sought
medical help with problems of conception and had not previously received specific treatment.
The data of laboratory examination and treatment of patients were obtained from the medical
records of outpatients (form No. 025 / U-87) by the copying method.
Our analysis included 50 men of reproductive age from 18 to 36 years (mean age was 26.6±2.2
years) with chronic prostatitis, having various manifestations of pathospermia. In the 1st group
(n=25), patients along with standard therapy for chronic prostatitis received a complex
biologically active supplement (BAS) Aktifert-Andro according to the standard scheme (1 tablet
1 time per day for 3 months in a continuous course), in the 2nd group (n=25) - only standard
drug therapy for chronic prostatitis: anti-inflammatory, antibacterial, prostatotropic, anti-
edematous, improving microcirculation.
General clinical, laboratory and ultrasound examination methods were used according to
generally accepted standards. All patients underwent physical examination of the prostate gland
per rectum. Laboratory methods included spermogram, bacteriological examination of ejaculate
samples, microscopy of prostate secretion. When conducting bacteriological analysis, a bacterial
titer of at least 10 was considered diagnostically significant.
4
CFU/ml.
The prostate gland secretion was obtained after digital massage of the prostate through the
rectum. The norm was taken to be no more than 10 leukocytes per field of vision in the prostate
secretion, a large number of lecithin grains and the absence of erythrocytes. The ejaculate was
analyzed according to the 2010 WHO recommendations. The MarScreen method was used to
detect antisperm antibodies (IgA, IgG) on the surface of spermatozoa (MAR test). Laboratory
studies were performed before the start of treatment and 3 months after the start of treatment.
Chronic prostatitis was diagnosed according to generally accepted criteria and standards, using
the Index of the Chronic Prostatitis and Pelvic Pain Syndrome Symptom Scale in Men according
to the US National Institutes of Health (NIH-CPSI).
Transrectal ultrasound of the prostate gland determined the size and volume of the prostate, its
structure, symmetry, presence of additional formations, foci of increased and decreased
echogenicity, calcifications and fibrosis. Statistical processing of the obtained results was carried
out using the Microsoft Excel, Statistica, v. 12.6 for Windows (2015) software package with an
assessment of the nature of the distribution. The reliability of differences was assessed using the
Student criterion.
Results and discussion
The age structure of the patients we examined was as follows: 8 (16%) patients were under 20
years old, 15 (30%) were between 20 and 30 years old, and 27 (54%) were over 30 years old.
That is, the incidence of chronic bacterial prostatitis increases with age.
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Normal prostate size (less than 20 cm
3
) were determined in 26% of patients, moderately enlarged
(20–30 cm
3
) - in 56%, significantly enlarged (more than 30 cm
3
) — in 18%. Initially, the groups
were comparable in terms of the laboratory parameters studied.
According to the results of bacteriological analysis of ejaculate, in 39 patients the titer of bacteria
in the culture exceeded 10
4
CFU/ml, in 11 patients the growth of microflora was not detected or
was detected in a clinically insignificant titer (less than 10
4
CFU/ml).
When comparing laboratory parameters of prostate secretion and ejaculate in different age
groups of patients, the following trend was noted: the most pronounced inflammatory changes in
the ejaculate were detected in patients aged 20–30 years; in patients younger than 20 years,
inflammatory changes were slightly less pronounced and occurred less frequently; and in the
group older than 30 years, inflammatory disorders were most common, but their severity
corresponded
to
the
average
level
(Table
1).
Changes of an inflammatory nature in the prostate secretion were most pronounced in young
patients (under 20 years old); at an older age (20–30 years old), the activity of inflammatory
changes somewhat decreased, reaching its minimum in patients over 30 years old. A similar
trend was maintained when evaluating the MAR test: its indicator decreased from 74.6% (in the
group under 20 years old) to 42.1% (in the group over 30 years old).
With increasing age, the frequency and prevalence of detected deviations in laboratory
parameters increased, but their activity and severity tended to decrease. The detected changes
allow us to conclude that the number of leukocytes in the prostate secretion and ejaculate does
not fully reflect the state of the prostate gland and does not provide complete information for
understanding the nature of the current inflammatory process. The fact is that when collecting
biological material for these tests, only part of the prostate acini is emptied, which cannot give a
complete picture of the inflammatory process in the gland, but characterizes the state of a limited
area of the organ.
Despite the lack of clear patterns in the combination of microbiological, immunological and
spermatological changes in prostate secretion and ejaculate, these methods are the “gold
standard” for diagnosing pathological conditions of the reproductive system due to their low cost,
availability and speed of execution.
An assessment of the relationship between inflammatory disorders (according to laboratory tests)
and structural changes in the prostate gland revealed the following patterns. With an increase in
the size of the prostate in patients with chronic prostatitis, a decrease in the severity of
inflammatory changes in the prostate secretion and ejaculate is noted, which may be due to the
replacement of gland tissue with connective tissue during a chronic inflammatory process in the
tissue of the organ itself. It is known that a moderate increase in the prostate indicates its edema,
which is a sign of an inflammatory process and the activity of which is characterized by
inflammatory abnormalities in laboratory tests. A significant increase in the size of the prostate
gland is caused not by edema of the organ, but by cicatricial structural changes in the tissue of
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the gland itself, which is a sign of a chronic sluggish process without exacerbations. This is
reflected in a decrease in the severity of inflammatory changes in the prostate secretion and
ejaculate with an increase in the size of the gland.
Initially, oligoasthenozoospermia was detected in 18 patients (72%) in the 1st group, and in 20
patients (80%) in the 2nd group. The patient groups were compared mainly by the severity of
inflammatory changes in the prostatic secretion and ejaculate. After a three-month course of
treatment, leukospermia and erythrocytes were absent in the ejaculate of 52% of patients in both
groups. The level of inflammatory abnormalities was minimal in the remaining men (weak
leuko- and erythrospermia were detected). In the 1st group, the general parameters (viscosity,
liquefaction time, color, impurities) were normal in almost all patients, as well as the
morphology and viability of spermatozoa (Table 2). Mild agglutination of spermatozoa was
detected in 6 cases, mild asthenozoospermia was present, aggregation was absent, and the MAR
test was negative. The severity of inflammatory changes in the prostate secretion was minimal.
Only isolated cases of severe (more than 50 leukocytes in the field of vision) — in 1 (4%) person
and moderate (10–50 leukocytes in the field of vision) — in 3 (12%) people of inflammatory
changes in the prostate secretion were revealed. In other cases, the indicator corresponded to the
norm. Among the patients of the 2nd group, the presence of mucus in the ejaculate and a shift in
the pH of the ejaculate, an increase in the viscosity of the sperm and an increase in the time of its
liquefaction were more often noted (see Table 2).
Asthenozoospermia was also more pronounced, in some cases oligoastheno- and
teratozoospermia were detected, agglutination and aggregation of spermatozoa, weakly positive
(50-60%) MAR-test were recorded more often. The differences were statistically significant
(p<0.05). Inflammatory phenomena (0.5-6 million leukocytes in 1 ml of ejaculate) were detected
in the spermogram of 7 patients, accompanied by pathospermia and asthenozoospermia, mucus
admixture and shift in pH of the ejaculate, the MAR-test was at the level of 50%. Inflammatory
changes and microbiological abnormalities in laboratory tests of prostate secretion in the 2nd
group were significantly more common than in the 1st group (p<0.05). Pronounced
inflammatory changes in the prostate secretion were detected in 5 (20%) patients, moderate ones
- in 7 (28%). In other cases, no deviations of this indicator were detected.
As can be seen from the presented data, the complex dietary supplement Aktifert-Andro
contributed to the improvement of the qualitative and quantitative parameters of the ejaculate, as
well as to the improvement of the sperm quality. The components included in Aktifert-Andro
(myo-inositol, carnitine, arginine, cysteine, selenium, zinc, vitamin E and folic acid) help to
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reduce the viscosity of the ejaculate, increase the activity and motility of sperm. Myo-inositol is
involved in the synthesis of proteins necessary for the maturation of sperm. In addition, it
regulates the osmolarity and volume of seminal fluid, increasing the motility of sperm. The
complex effect on the reproductive function of men, the ability to eliminate existing fertile
disorders provide grounds for the use of this drug on a planned basis for the purpose of pre-
gravid preparation, including in men with chronic prostatitis. Inositols are traditionally used as a
means of treating female infertility associated with insulin resistance. However, recently there is
evidence of their use in the treatment of male infertility. In particular, clinical algorithms are
proposed for patients with asthenozoospermia [16]. In European studies, an improvement in
sperm motility was noted in 85.3% of patients after a three-month course of treatment with myo-
inositol-based drugs with minerals and vitamins [17]. This component is a sugar-like molecule
and is one of the precursors for the synthesis of phosphatidylinositol polyphosphates, key
biomolecules belonging to the signaling system of several cellular functions. Myo-inositol
normalizes the metabolic profile of patients, increasing insulin sensitivity, improves sperm
characteristics such as sperm concentration, motility and morphology, i.e. it can be used in the
treatment of spermatological and metabolic disorders responsible for male infertility [18].
Conclusion
Chronic prostatitis complicated by infertility is most common in the age group over 30 years,
while the activity of the inflammatory process is more pronounced at a young age of up to 20
years. The study revealed that with an increase in the size of the prostate gland, the severity of
inflammatory changes in the prostate secretion and spermogram decreases, which may be due to
a change in the structure of the organ and the replacement of glandular tissue with connective
tissue. The detected microbiological and spermatological changes in the prostate secretion and
ejaculate in different age groups in patients with chronic prostatitis and infertility are of the same
type. Inclusion of the Aktifert-Andro complex in the complex therapy of male infertility
developed against the background of chronic prostatitis allows affecting various links in
spermatogenesis disorders, which is especially important given the polyetiology of this
pathology.
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