1

RBMO VOLUME 00 ISSUE 0 2018

Anti-sperm antibodies detection by a

modified MAR test: Towards a better
definition of its indications
BIOGRAPHY
Nicolas Gatimel has been working as an embryologist at CHU Toulouse’s assisted
reproduction unit since 2011. He obtained a specialist degree in medical biology after a
4-year residency in medical biology, specializing in assisted reproductive technologies. His
PhD thesis was on the interest of human sperm morphology assessment.

Nicolas Gatimel1,2,*, Jessika Moreau1,2, François Isus1,2, Nathalie Moinard1,2,

Jean Parinaud1,2, Roger D. Leandri1,2

KEY MESSAGE
Anti-sperm antibodies detection should not be systematically recommended in investigations of fertility status
and before assisted reproductive technology treatment, but reserved for when sperm agglutination is found
during conventional sperm examination or if the patient has a history of scrotal trauma or of inguinal surgery.

ABSTRACT
Research question: Anti-sperm antibodies (ASA) have been shown to reduce male fertility but consensus about
the precise situations in which tests should be carried out are lacking. In infertility investigations, should the
mixed antiglobulin reaction (MAR) test be a first-line test? Should it be carried out systematically before assisted
reproductive technology (ART)? What are the risk factors for ASA?

Design: All infertile patients (n = 1364) were tested with SpermMar (modified MAR test) between July 2013 and
June 2017. Intra-patient variability of the MAR test was also assesed by comparing two tests within the same year in
selected patients (n = 101).

Results: The main factor that influenced the percentage of ASA was the presence or absence of sperm agglutination.
In the presence of agglutinations, 27 out of 72 (37.5%) patients were positive for ASA compared with 33 out of
1292 (2.6%) in the absence of agglutinations (P < 0.0001). When one risk factor was present (spontaneous sperm
agglutination, history of scrotal trauma or inguinal surgery), 33 out of 179 (18.44%) tests were positive for ASA (≥50%
coated spermatozoa), whereas only 27 out of 1242 (2.2%) were positive when no risk factor was present (P < 0.0001).

Conclusions: ASA detection should not be systematically recommended in investigations of fertility status and before
ART but reserved for when sperm agglutination is found during conventional sperm examination, or if the patient has
a history of scrotal trauma or has undergone inguinal surgery.

KEY WORDS
1  Servicede Médecine de la Reproduction, Hôpital Paule de Viguier, CHU Toulouse, 330 avenue de Grande Bretagne,
Toulouse 31059, France
2  Université Paul Sabatier Toulouse-III, Groupe de Recherche en Fertilité Humaine (EA 31694, Human Fertility Research
ART
Anti-sperm antibodies
Group), 330 avenue de Grande Bretagne, Toulouse 31059, France
Infertility
© 2018 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. Prevalence
*Corresponding author. E-mail address: gatimel.n@chu-toulouse.fr (N Gatimel). https://doi.org/10.1016/j.rbmo.2018.09.011
1472-6483/© 2018 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
Declaration: The authors report no financial or commerical conflicts of interest.
2 RBMO VOLUME 00 ISSUE 0 2018
INTRODUCTION
T
he presence of anti-sperm
antibodies (ASA) in human
semen can reduce fecundity
(Ayvaliotis et al., 1985).
Diverse ASA bind to the sperm surface,
and their effect on fertilization may
differ. Some sperm-bound antibodies
are related to inhibitory effects on
fertilization (Shibahara and Koriyama,
2013), but not all ASA cause infertility.
The main immunoglobulin classes for
ASA are immunoglobulin G (IgG) and
immunoglobulin A (IgA) (Mazumdar and
Levine, 1998). It has been assumed that
immunoglobulin M (IgM) would only be
found in rare situations as it is a large
molecule. Several investigators have
found a decreased fertilization rate when
more than 80% of the sperm head was
coated with IgA or IgG (Clarke et al.,
1985b; Pattinson and Mortimer, 1987).
Also, no consensus has been reached on
the importance of the location of IgG or
IgA and sperm function (Mandelbaum
et al., 1987b; Sukcharoen and Keith,
1995; Chiu and Chamley, 2004).
The value of data on the frequency
of ASA in infertile men may depend
on the testing method used (Clarke
et al., 1985a; Cerasaro et al., 1985;
Kamieniczna et al., 2003). In a
population of infertile men (without
exclusion criteria and without a clear
description of semen parameters), ASA
was detected with the MAR test on more
than 40% of the motile spermatozoa in
about 13% of men (Sinisi et al., 1993).
Various pathogeneses explain why ASA
may lead to infertility. The presence of
ASA decreases sperm penetration in
cervical mucus (De Almeida et al., 1986;
Menge and Beitner, 1989). Some ASA
can reduce the ability of spermatozoa
to undergo capacitation or acrosome
reaction through inhibition of changes in
the sperm membrane (Fusi and Bronson,
1990). Moreover, the proportion of
spermatozoa bound with ASA has been
shown to be related to the fertilization
ability of sperm. Among IVF trials
assessing the effect of ASA on fertilization
(detected by the MAR test), six out of
seven trials showed a decrease in the
fertilization rate (Chiu and Chamley,
2004). The effect of ASA on sperm–
oocyte fusion is still under debate,
as shown in studies on binding and
penetration of hamster zona-free eggs
(Primakoff and Hyatt, 1986; Aitken et al.,
1988; Shibahara et al., 1996). Some (but
not all) of the ASA have been shown
to decrease fertilization ability. Other
studies suggest ASA could act directly on
antigen sperm surface antigens, or have
an indirect action mediating the release
of cytokines that affect sperm function
(Mazumdar and Levine, 1998; Lombardo
et al., 2001). The deleterious effect of
ASA on embryo implantation has been
shown in a few studies (Witkin and
Chaudhry, 1989; Check et al., 2000),
but the mechanism by which ASA could
interfere with embryo implantation is not
clear.
Commonly used tests to detect
seminal ASA are the mixed antiglobulin
reaction test (MAR) and immunobead
test. Current tests, however, cannot
differentiate ASA that cause infertility
from those that do not. A commercially
available modified MAR test (SpermMar,
FertiPro, Beernem, Belgium) is widely
used during routine semen analysis
in andrologic laboratories because of
its technical advantages, such as the
application of unwashed fresh semen and
its rapidity.
Even if indirect tests to detect ASA
in serum have good sensitivity and
specificity (Mazumdar and Levine,
1998), they are increasingly neglected in
routine practice in favour of quicker and
cheaper direct tests. The MAR test has
been routinely used for several decades;
however, its indications are not well
defined. The World Health Organization
(WHO) laboratory manual for the
examination and processing of human
semen includes the testing for antibody
coating of spermatozoa in its ‘Standard
Procedures’ chapter not in its ‘Optional
Procedures’ (WHO, 2010). Introducing
this testing, the manual stipulates that ‘If
spermatozoa demonstrate agglutination
… the presence of sperm antibodies may
be the cause.’ Immediately after, it states
that ‘Sperm antibodies can be present
without sperm agglutination’. Therefore,
we examined the application of routine
testing for ASA as a first-line test in an
infertility investigation, and for risk factors
for ASA, by systematically testing all men
in an infertile couple with SpermMar
who were seen in our centre between
July 2013 and June 2017. The aim of this
study was to explore whether SpermMar
should be carried out systematically
in infertility investigations and before
assisted reproductive technology and
to detect any risk factors for ASA.
Furthermore, because it has been poorly
assessed previously, we tested for the
intra-patient variability in the MAR test
results over time.
MATERIALS AND METHODS
Study population
Infertile men were defined as men in
a relationship who failed to achieve a
pregnancy after 12 months or more of
regular unprotected sexual intercourse.
All infertile men (n = 1364) who were
seen in our centre between July 2013
and June 2017 were tested for the
presence of ASA, except in cases of
severe oligoasthenozoospermia, defined
as a sperm concentration below 1.106/ml
or progressive motility less than 10%. All
patients were asked about their medical,
surgical and andrologic history by an
andrologist physician in our fertility
centre. Andrologic history includes
history of scrotal trauma, scrotal or
inguinal surgery, genital infectious disease
such as epididymo-orchitis and history of
prostatitis. No men who had undergone
a vasectomy reversal were included in
this study, as vasectomy in France is not
current practice compared with other
countries.
To assess intra-patient variability, we
conducted a second analysis comparing
the results of two MAR tests conducted
in the same year in 101 patients who
planned to return to the centre for
other consultations or examinations. The
patients had no medical, andrologic or
surgical treatment history between the
two assessments.
Anti-sperm antibody detection
Determination of ASA was carried
out directly after complete semen
liquefaction for 15–60 min at 37°C
using the SpermMar IgG kit ® (FertiPro,
Beernem, Belgium). This method is
based on the binding reaction of latex
particles sensitized with human IgG to
live spermatozoa in the presence of
an antiserum against the Fc fragment
of human IgG. Ten microlitres of fresh
untreated semen, 10 µL of SpermMar
Test IgG Latex Particles and 10 µL of
SpermMar Test IgG Antiserum were
placed separate to each other on a
microscope slide. The sample and the
latex reagent were mixed five times with
the edge of a cover glass and then the
antiserum was mixed with the previous
mixture. The cover glass was placed
on the final mixture and the mixture

was observed under a light microscope
(x400 magnification at phase contrast).
The results were read after 3 min. One
hundred spermatozoa were counted to
determine the percentage of reactive
spermatozoa (two or more latex particles
attached to motile spermatozoa). If no
bead attachment to spermatozoa was
observed, the slide was read again after
10 min. According to WHO guidelines
(WHO, 2010), the test is considered
positive if at least 50% of spermatozoa
are coated with antibodies. As the
proportion of patients with a positive
reaction in the SpermMar Test IgA in the
absence of any reaction in the SpermMar
Test IgG is rare (Mazumdar and Levine,
1998), we decided to routinely use only
the IgG-class kit in our centre.
Semen analysis
Semen analyses were conducted by four
technicians from the same laboratory.
Briefly, analyses were carried out after 15–
60-min liquefaction. An initial microscopic
examination of the sample at phase
contrast with a x20 objective was carried
out to detect agglutination. The difference
between agglutination (=spontaneous
agglutination) and aggregation was noted.
As stated in the WHO 2010 guidelines,
agglutination specifically refers to motile
spermatozoa sticking to each other,
head-to-head, tail-to-tail or in a mixed
way with a shaking motion in most
cases. The adherence either of immotile
spermatozoa to each other or of motile
spermatozoa to mucus strands, non-
FIGURE 1  Distribution of percentage of anti-sperm antibodies coated spermatozoa in a population of 1364 infertile men.
sperm cells or debris is considered to be
aggregation (WHO, 2010).
Semen volume was measured by
a graduated pipette (in laboratory
validated technique after comparison
to the reference method by weighing;
data not published). Spermatozoa were
counted on two replicates (at least
200 spermatozoa per replicate) in a
Malassez chamber. Sperm motility was
measured using phase-contrast optics
at x400 magnification and expressed
as percentage progressive motility.
Sperm viability was assessed by nigrosin
and eosin staining (Sigma Aldrich) and
expressed as percentage viability.
Statistical analysis
Data were extracted from the Gynelog
clinical database used in our department.
StatView software (Abacus Concepts
Inc., Berkeley, CA) was used for statistical
analyses. Data were presented as means
± SD. Percentages were compared using
chi-squared test. Means were compared
using Student’s t-test or the Mann–
Whitney test according to the normality
of data distribution. P < 0.05 was
considered statistically significant.
Ethical approval
Data were extracted from the ART
centre patient database. This database
was approved by the French National
Commission for Information Technology
and Civil Liberties to be used for clinical
research. Patients are aware that their
RBMO VOLUME 00 ISSUE 0 2018 3
data can be used for anonymous clinical
studies unless they specifically state
otherwise. According to new French law
(2016-1537), non-interventional studies,
such as from clinical databases, do
not need to be submitted to an ethical
committee.
RESULTS
The total prevalence of positive ASA
(≥ 50%) in our population was 60
out of 1364 (4.4%); 35 out of 1364
(2.6%) patients had a high percentage
of coated spermatozoa (≥75%); 637
out of 1364 (46.7%) had 0% of ASA;
626 out of 1364 (45.9%) had 1–24% of
ASA-coated spermatozoa; and 41 out of
1364 (3.0%) had 25–49% ASA-coated
spermatozoa (FIGURE 1). The conventional
semen parameters were not significantly
different according to the percentage
of spermatozoa coated with antibodies
(TABLE 1).
The clinical factors and the presence
or absence of spontaneous sperm
agglutination according to the proportion
of ASA-coated spermatozoa are
presented in TABLE 2. The main factor
that influences the percentage of ASA
is the presence or absence of sperm
agglutination. Applying the threshold
(>50%) for a positive detection in the
presence of agglutination, as defined
by WHO (2010), 27 out of 72 (37.5%)
patients were positive for ASA compared
with 33 out of 1292 (2.5%) patients
4 RBMO VOLUME 00 ISSUE 0 2018

TABLE 1  COMPARISON OF CONVENTIONAL SEMEN PARAMETERS ACCORDING TO THE PERCENTAGE OF ANTIBODIES

COATED SPERMATOZOA a

Percentage of antibodies coated spermatozoa ± SD

<50%; n = 1304 ≥50%; n = 60
Age (years) 35.2 ± 6.2 35.4 ± 6.1
Volume (ml) 3.4 ± 1.7 3.2 ± 1.6
Sperm concentration (106/ml) 51.5 ± 56.0 40.5 ± 38.1
Total sperm count (106 per ejaculate) 156.9 ± 172.8 127.9 ± 133.6
Progressive motility (%) 34 ± 12 33 ± 12
Vitality (%) 70 ± 13 69 ± 14
a
  No statistically significant differences were observed between the two groups for all parameters.

when no agglutination was present
(P < 0.0001). When at least one of
the three risk factors were present
(spontaneous sperm agglutination or
history of scrotal trauma or of inguinal
surgery), 33 out of 179 (18.4%) tests were
positive, whereas only 27 out of 1185
(2.3%) were positive when no risk factor
was present (P < 0.0001).
In assessing intra-patient variability
(TABLE 3), when the tests were repeated
a second time in the same year in the
same patient, of the 79 patients who
were found to be negative in the first
test, three (3.8%) were found to be
positive in the second test (TABLE 3),
whereas, of the 22 patients who were
found to be positive in the first test, 10
(45%) were found to be negative in the
second test.
DISCUSSION
Some investigators have argued in
favour of an association between ASA
and reduced male fertility potential
(Mazumdar and Levine, 1998; Lombardo
et al., 2001; Chiu and Chamley, 2004).
Good evidence has also shown that
prevalence of ASA is higher in infertile
men than in fertile men (Sinisi et al.,
1993). Although these in-vitro studies
have shown that ASA can impair various
mechanisms, such as motility, sperm-
oocyte fusion or acrosome reaction,
the relationship between the presence
of ASA and spontaneous fertility is not
clear. In the study by Ayvaliotis et al.
(1985), the spontaneous pregnancy rate
for couples whose male partners had
more than 50% sperm-bound antibodies

TABLE 2  FACTORS INFLUENCING THE PERCENTAGE OF SPERMATOZOA COATED IN ANTIBODIES

Spermatozoa coated in antibodies (%) Statistical comparisona

0 1–24% 25–49% 50–74% ≥75%
Spontaneous sperm agglutination, n (%)
Yes (n = 72) 12 (16.7) 22 (30.6) 11(15.3) 9 (12.5) 18 (25.0) P < 0.0001
No (n = 1292) 625 (48.4) 604 (46.7) 30 (2.3) 16 (1.2) 17 (1.3)
History of scrotal trauma, n (%)
Yes (n = 54) 23 (42.6) 22 (40.7) 3 (5.6) 3 (5.6) 3 (5.6) NS
No (n = 1310) 614 (46.9) 604 (46.2) 38 (2.9) 22 (1.7) 32 (2.4)
History of epididymo-orchitis, n (%)
Yes (n = 8) 3 (37.5) 2 (25.0) 2 (25.0) 1 (12.5) 0 (0) NS
No (n = 1356) 634 (46.7) 624 (46.0) 39 (2.9) 24 (1.7) 35 (2.5)
History of scrotal surgery, n (%)
Yes (n = 52) 21 (40.4) 26 (50.0) 1 (1.9) 2 (3.8) 2 (3.8) NS
No (n = 1312) 616 (47.0) 600 (45.7) 40 (3.1) 23 (1.8) 33 (2.5)
History of inguinal surgery, n (%)
Yes (n = 62) 17 (27.4) 35 (56.5) 3 (4.8) 2 (3.2) 5 (8.1) P = 0.008
No (n = 1302) 620 (47.6) 591 (45.4) 38 (2.9) 23 (1.8) 30 (2.3)
History of prostatitis, n (%)
Yes (n = 17) 8 (47.1) 9 (52.9) 0 (0) 0 (0) 0 (0) NS
No (n = 1347) 629 (46.7) 617 (45.8) 41 (3.0) 25 (1.9) 35 (2.6)
Spermatozoa agglutination or history of scrotal
trauma or of inguinal surgery, n (%)
Yes (n = 179) 52 (29.1) 78 (43.6) 16 (8.9) 13 (7.3) 20 (11.2) P < 0.0001
No (n = 1185) 585 (49.4) 548 (46.2) 25 (2.1) 12 (1.0) 15 (1.3)
a
  Comparing all groups using the chi-squared test.

TABLE 3  RESULTS OF A SECOND ANTI-SPERM ANTIBODIES TEST AS A FUNCTION OF THE FIRST TESTa
First test
0% (n = 41)
1–24% (n = 33)
25–49% (n = 5)
50–74% (n = 12)
≥79% (n = 10)
a  Distribution of percentage of anti-sperm spermatozoa coated in antibodies in two tests carried out within the same year. Significance is P < 0.0001, comparing all groups
using the chi-squared test.
was significantly decreased (15.3%
versus 66.7%; P < 0.005). The results
of studies evaluating the effect of ASA
on reproductive outcomes, however,
are somewhat controversial (Chiu and
Chamley, 2004).
The MAR test is currently a rapid
(3–10 min), easy to perform diagnostic
test on unwashed fresh semen. One
limitation is that it can only be carried
out if motile spermatozoa are present
in the semen, as samples with poor
motility may have false negative results.
In cases of severe impairment in sperm
parameters, determination of ASA is
not contributive, either for the diagnosis
of infertility or for treatment (choice
of ART technique). In the present
study, we found that 4.4% of infertile
patients had positive ASA (≥50%
coated spermatozoa) using SpermMar
test. Our results are similar to those of
Sinisi et al. (1993), who detected IgG
bound to spermatozoa (with >40%
ASA binding threshold) in 6.2% of
infertile men. In a study using serum
assays, Collins et al. (1993) found ASA
in 8.1% of infertile men. Studies using
indirect assays, however, should be
interpreted with caution because they
may not reflect the presence of ASA
on spermatozoa (Bronson et al., 1987).
On the other hand, ASA detected by
SpermMar are present in 0.9% of fertile
men (Sinisi et al., 1993). Immunobead
tests for IgG, IgA, and IgM were carried
out by Pattinson and Mortimer (1987)
on 300 sperm samples from infertile
men. Thirty-two (10.7%) showed positive
results (using a threshold >10% of
coated spermatozoa). These latter results
should be interpreted with caution
because, as demonstrated by Barratt et
al. (1989), low to moderate levels of ASA
have a poor prognostic value.
In the present study, the main factor
that influenced the percentage of ASA
Second test, n (%)
0% 1–24%
23 (56.1) 16 (39.0)
8 (24.2) 23 (69.7)
0 3 (60.0)
0 4 (33.3)
1 (10.0) 1 (10.0)
is the presence or absence of sperm
agglutination. The association between
the presence of ASA and agglutination
was demonstrated over 40 years
ago (1974) and, since then, by others
(Kunathikom et al., 1995). In this latter
study, the incidence of positive MAR
results in samples with and without
spontaneous sperm agglutination was
15 and 0%, respectively (P < 0.05);
however, the prevalence of spontaneous
agglutination was high in this study
(80/160). Our results highlight the
importance of agglutination evaluation
on fresh semen during the assessment
of conventional sperm parameters.
Sperm antibodies, however, can be
present without sperm agglutination, and
agglutination can be caused by factors
other than sperm antibodies, such as
bacterial infections or some antibiotic
therapies (Carranza-Lira et al., 1998;
Kaur and Prabha, 2013).
In relation to andrologic factors that
could influence the presence of
ASA, we did not find an association
between a history of prostatitis and
the presence of ASA. These results
are not in agreement with the meta-
analysis by Jiang et al. (2016). The
investigators of this meta-analysis found
a combined odds ratio of the ASA-
positive rate in patients with chronic
prostatitis and normal controls of 3.26
(95% CI 1.86 to 5.71). An immune
pathogenicity for chronic prostatitis has
been suspected. It may be mediated by
lymphocyte infiltration in the semen of
patients with autoimmune prostatitis,
or by a semen prostatic liquid reflux
phenomenon (Batstone et al., 2002;
Ausmees et al., 2013; Jiang et al., 2016).
The absence of correlation between
chronic prostatitis and ASA in our study
could be due to the small number of
patients with chronic prostatitis. In
agreement with some studies (Marconi
et al., 2009), we found no effect of
RBMO VOLUME 00 ISSUE 0 2018 5
25–49% 50–74% ≥75%
0 1 (2.4) 1 (2.4)
1 (3.0) 0 1 (3.0)
2 (40.0) 0 0
4 (33.3) 2 (16.7) 2 (16.)
0 2 (20.0) 6 (60.0)
history of epididymo-orchitis on ASA
formation: however, our results are
not in accordance with others studies
that showed a correlation between
some inflammation, infection situations
(as acute epididimytis), or both, and
presence of ASA (Ingerslev et al., 1986;
Heidenreich et al., 1994). We found that
testis trauma is associated with a trend
of more frequent ASA-positive semen.
During testis trauma, the breaching of
the blood–testis barrier may induce
an exposure of immunogenic sperm
antigens to the immune system, resulting
in ASA formation (Mandelbaum et al.,
1987a; Mazumdar and Levine, 1998;
Bohring and Krause, 2003). The
occurrence of these testis traumas must
be systematically sought and, even in
early childhood, because ASA may be
produced in children during puberty
despite ‘quiescent’ spermatogenesis
(Domagala et al., 2006). Childhood
inguinal herniorrhaphy with vas-deferens
obstruction has also been reported to
be associated with ASA (Matsuda et al.,
1993). In the present study, we found a
significantly higher prevalence of ASA
in patients who had undergone inguinal
surgery. Applying the threshold (>50%)
for a positive detection, in the presence
of a history of inguinal surgery, seven
out of 62 (11.3%) patients were positive
for ASA compared with 53 out of 1302
(4.1%) patients when no history of
inguinal surgery was present (P = 0.008).
Vasectomy has been reported to induce
ASA (Awsare et al., 2005). As vasectomy
is not current practice in France
compared with other countries, we were
not able to determine the prevalence of
these antibodies in men after vasectomy
reversal.
Our results show that the presence of
at least one of the three risk factors
(spontaneous sperm agglutination or
history of scrotal trauma or of inguinal
6 RBMO VOLUME 00 ISSUE 0 2018
surgery) significantly increased the
probability of positive test for ASA.
Finally, in assessing intra-patient variability
in ASA detection using the SperMar
test, our results (TABLE 3) suggest that
it is not necessary to repeat the test a
second time if it is negative on the first
determination. This is in accordance with
a previous study on a smaller population
showing that among 29 patients first
tested as negative (ASA threshold
≤40%); all of them were still negative
in two supplementary tests, carried out
respectively with a mean interval of 4 and
10 months after the first test (Paschke
et al., 1994). On the other hand, we
show that if a first test is positive, 45%
of those patients are detected negative
within a year. This is also in agreement
with the study y Paschke (1994) in
which 25 patients that first tested as
positive, nine (36%) became negative
on the following tests. No data have
been published on how to manage
such patients. It would be of interest to
assess the clinical effect of ASA in these
patients.
A routine diagnostic test for immunologic
infertility does not assess the specificity
of the antibodies, nor does it provide
information on the proportion of ASA
bound to clinically relevant antigens. As
stated by WHO guidelines, fifth edition
(WHO, 2010), ‘The mere presence
of sperm antibodies is insufficient for
a diagnosis of sperm immunologic
infertility. It is necessary to demonstrate
that the antibodies severely interfere
with sperm function’. A sperm–mucus
penetration test has typically been used
for this. Unfortunately, these sperm–
mucus penetration tests should no
longer be carried out, given their lack of
clinical relevance and analytical reliability,
as recommended by learned societies
(Crosignani and Rubin, 2000; Smith
et al., 2003).
In 2018, it is still difficult to know the
clinical value of ASA determination
before ART treatment. In relation to the
effect of ASA on ART outcomes, the
results have been heterogeneous. Some
studies report that ASA are associated
with a reduced probability of pregnancy
after intrauterine insemination (Check
and Bollendorf, 1992; van Weert et al.,
2005). A more recent study reported
pregnancy rates of 18.4% (seven out of
38) after intrauterine insemination, with
or without ovarian stimulation in cases
of immunologic male subfertility (with
>90% antibody-coated spermatozoa),
suggesting that the ASA clinical
interference with fertility could be
overcome by bypassing the cervical
mucus (Francavilla et al., 2009). Studies
assessing the effect of ASA on fertilization
and pregnancy rates after conventional
IVF have reported contradictory results
(Junk et al., 1986; de Almeida et al.,
1989; Ford et al., 1996; Culligan et al.,
1998; Rajah et al., 1993; Vujisic et al.,
2005). In other studies that examined
the effect of ASA on ICSI outcomes,
ASA was shown to have no influence
on intracytoplasmic sperm injection
(ICSI) pregnancy rates (Lahteenmaki
et al., 1995; Mazumdar and Levine,
1998; Check et al., 2000). As far as we
know, however, no comparative study
of different ART in patients with ASA
has been published (probably due to
the difficulty of recruiting patients with
an ASA-positive test). On the basis of
published research, ASA alone has a
poor correlation with conventional IVF
or ICSI outcomes. In previously cited
studies on the effect of ASA on ART
outcomes, however, the cut-off value
for an ASA positive test varied from 1 to
80%. A systematic review and meta-
analysis indicated that ASA are not
related to pregnancy rates after IVF or
ICSI (Zini et al., 2011). Our results do
not assess the effect of ASA on clinical
outcomes in ART; however, in view of the
low prevalence of ASA in our study in the
absence of a risk factor, and of literature
data demonstrating controversy about
the efect of ASA on clinical outcomes,
we do not recommend systematic
determination of ASA before ART.
In conclusion, routine direct assays to
detect ASA in spermatozoa have been
used for several decades and are easy to
use; however, their indications are still
not well defined. We conclude that ASA
detection should not be recommended
as a systematic test for the investigation
of fertility status and before ART, unless
sperm agglutinations are found during
conventional sperm examination, or if
there is a history of scrotal trauma or of
inguinal surgery. This study, however, has
been conducted using the SperMar test
and results obtained using a different
technique, such as the immunobead test,
may not be comparable.
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