Zentralbl Gynakol 122 (2000) 495 499

Effect of corticosteroids on sperm antibody concentration in different

biological fluids and on pregnancy outcome in immunologic infertility
Zdenka Ulcova-Gallova, V. Bouse, Z. Rokyta, K. Krizanovska

Summary: Objective: In the last fourteen years, detection of

free spermagglutinating antibodies has been performed by tray
agglutination test (TAT) and by direct/indirect mixed antiglobulin reaction test (MAR) in 696 infertile couples aged 2342 years
(female) and 2652 years (male) with previously undiagnosed
infertility. Material and methods: Oral decreasing doses of
prednisone or dexamethasone for three months in the case of serum or seminal plasma spermantibodies, plasmapheresis in one
patient with serum spermantibodies were used. Hydrocortisone
to the ectocervix was applicated in patients with spermagglutinating antibodies in cervical ovulatory mucus. Results: Serum IgG
spermagglutinating antibodies totally disappeared in 3 out of
11 men, and four out of 15 women. But serum IgM sperm antibodies persisted. One female patient was treated with corticosteroids and also with plasmapheresis. Seminal plasma IgG spermagglutinating antibodies were greatly influenced in 57.8 % of

the patients, IgA in 38.9 % and each case by oral corticosteroids.

A decrease of IgG and IgA spermagglutinating antibodies in
ovulatory cervical mucus during hydrocortisone local application was registered in 61.3 %, IgG in 50.7 %, and IgA in 65.9 %.
Levels of IgM spermagglutinating antibodies in cervical ovulatory mucus were not influenced, spermantibodies in IgA and
IgE were affected very little. Conclusion: The corticosteroid influence of immunocompetent cells in each case must be chosen
individually with regard to the localisation of spermantibodies.
We often combine the long lasting corticosteroids treatment with
in vitro fertilization. The therapy seems to be very promising for
the improvement of immunological causes of infertility.
Key words: Infertility sperm antibodies local hydrocortisone
oral prednisone dexamethasone plasmapheresis serum
ovulatory mucus

Einflu von Kortikosteroiden auf die Sperma-Antikorper-Konzentration

in verschiedenen Korperflussigkeiten sowie auf die Schwangerschaftsrate
bei immunologisch bedingter Infertilitat
Zusammenfassung: Fragestellung: In den vergangenen 14 Jahren erfolgte der Nachweis freier spermagglutinierender Antikorper durch den Agglutinationstest (TAT) und den direkten/indirekten Antiglobulin Test (MAR) bei 696 infertilen Paaren im Alter von 2342 Jahren (Frauen) und 2652 Jahren (Manner) bei
vorher nicht diagnostizierter Infertilitat. Material und Methoden: ber 3 Monate wurden oral bei Patienten mit Serum oder
Plasma Sperma-Antikorpern abnehmende Dosen von Prednisone
oder Dexamethasone verabreicht, bei einem Patienten mit Serum
Sperma-Antikorpern wurde eine Plasmapherese durchgefuhrt.
Bei Patienten mit spermagglutinierenden Antikorpern in der zervikalen ovulatorischen Mukosa wurde Hydrokortison in die Ektozervix verabreicht. Ergebnisse: In 3 von 11 Mannern und 4
von 15 Frauen waren keine Serum IgG spermagglutinierende
Antikorper mehr nachzuweisen, wohingegen Serum IgM Sperma-Antikorper weiterhin nachweisbar blieben. Eine Patientin
wurde sowohl mit Kortikosteroiden behandelt als auch eine Plasmapherese durchgefuhrt. In 57,8 % aller Patienten wurde die
Plasma IgG spermagglutinierenden Antikorper und in 38,9 %
die IgA stark beeinflut. Jeder Fall wurde beeinflut durch die

Gabe oraler Kortikosteroide. Eine Abnahme von IgG und IgA

spermagglutinierenden Antikorpern in der zervikalen ovulatorischen Mukosa durch lokaler Hydrokortison Applikation wurde
in 61,3 %, bei IgG in 50,7 % und IgA in 65,9 % der Falle verzeichnet. Die Werte der IgM spermagglutinierenden Antikorper
in der zervikalen ovulatorischen Mukosa wurden nicht beeinflut, Sperma-Antikorper IgA und IgE zusammen nur wenig.
Schlufolgerung: Der Einflu von Kortikosteroiden auf immunkompetente Zellen mu in jedem Fall individuell betrachtet werden im Hinblick auf die Lokalisation der Sperma-Antikorper.
Wir kombinieren haufig die langandauernde Kortikosteroidbehandlung mit IVF. Diese Therapie erscheint vielversprechend
zu sein fur die Behandlung immunologischer Ursachen der Infertilitat.
Schlusselworter: Infertilitat Sperma-Antikorper Hydrokortison
MeSH: E5.820.490 fertilization in vitro

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Department of Gynecology and Obstetrics, Charles University and Medical Faculty Hospital, Pilsen/Czech Republic
(Head: doc. MUDr. Z. Rokyta, CSc.)

496

Zentralbl Gynakol 122 (2000) 9

Immunological infertility in previously undiagnosed infertile couples has been very often combined with sperm
auto/iso antibodies in serum, in seminal plasma, and in
cervical ovulatory mucus. Inhibition of fertilization due
to spermagglutinating, spermimmobilizating or cytotoxic
antibodies has already been explained f. e. [2, 5, 6, 9, 11].
The role of spermagglutinating antibodies is to inhibit
sperm penetration into cervical ovulatory mucus through
the zona pellucida, or to stop the fusion of the sperm plasma membrane with the vitelline membrane of the oocyte.
Spermantibodies may also block the implantation or the
development of embryos [6]. The detection of free antisperm antibodies on the surface of sperm antigens is performed by different accesses [9], immunocompetent cells
are influenced by various courses for corticosteroids.
Fourteen years of experience with new possibilities in
the treatment of immunological infertility in 696 immunologically infertile couples will be described.
Material and methods
Patients
Six hundred ninety-six previously undiagnosed infertile patients with spermagglutinating antibodies, aged 23
42 years (women), and 2652 years (men) were chosen for
this study. Conditions for the selection of couples were normal: gynecologically, endocrinologically, laparoscopically,
hysterosalpingrographically, genetically, and bacteriologically vaginal findings, and semen analysis was normal.

Fifty microlitres of serum (bromeline-treated mucus)

and 50 ml of washed spermatozoa in concetration of
40 106 sperm/ml were incubated at 37 C for 1 hr. Fresh
partner sperm-serum (ovulatory mucus) suspension was
used for indirect MAR-test: 1 ml of sperm suspension
senzitized in the serum (ovulatory mucus) and 1 ml of
glutaraldehyde-fixed sheep erythrocytes coated with human IgA, IgA, IgM, and IgE and finally adding 1 ml of
the corresponding antiserum anti-IgG, anti-IgA, anti-IgM
(rabbit anti-human sera from Behring, anti-IgE-SwAHu/
IgE-Sevac. Note: anti-IgE was purified on Ultrogel
AcA34, a gammaglobulin fraction was collected and was
concentrated 15 times). The mixture was covered with a
coverslip and incubated in humid Petri chamber for 3
10 min. The results of immunologic reaction were observed under the inverted Zeiss Jena microscope at 200300
magnification. Microscopic results were taken as a percentage of motile spermatozoa involved in mixed agglutinates with one or more sheep coated erythrocytes
(MAR %). Good positivity in the MAR-test are defined
by more than 41 % motile spermatozoa involved in mixed
agglutinates (spermatozoa and sheep erythrocytes coated
by a corresponding immunoglobulin).
Local hydrocortisone treatment
Local immunosupression in women having sperm agglutinating antibodies in cervical ovulatory mucus was referred to two years before [14]. Briefly, hydrocortisone gel
is used locally at a dose of 20 mg for four days, 10 mg
for the next 7 days, than 5 mg daily until menstruation.
Oral prednisone administration

Tray agglutination test (TAT) [7, 13]

Tray microagglutination-testing was used as a screening
method for detection of serum, seminal plasma and cervical ovulatory mucus spermagglutinating antibodies. The
above mentioned biological secretion (f. e. after special
preparation of bromeline-treated cervical ovulatory mucus), five microlitres of supernatant and 1 ml of treated
motile donor sperm isolated by the swim-up technique.
In average counts 40 106 /ml were put into microchambers covered by paraffin oil. Backer solution is: CaCl2
50 %, 0.44 g; KCl 0.2 g; MgSO4 0.7 g; glucosum 0.5 g;
phenol red, 8.3 ml, and distilled water, 500 ml. Incubation
time at 37 C was 2 hrs when immunological reaction was
evaluated and observed under an inverted Zeiss Jena microscope at 200 magnification. Agglutination 1 : 16 was
considered as positive result.
Direct (indirect) mixed antiglobulin reaction test (MAR)
[8, 13]
MAR-test was prepared for immunoglobulin G (IgG),
IgA, IgM and IgE.

Oral prednisone administration is seen in table 1. It is

started with relatively high doses of 60 mg per day and
finished with 5 or 2.5 mg per day.
Tab. 1 Scheme for oral prednisone administration (in mg)
weeks

morning

noon

evening

1
20
20
20
2
20
20
10
3
10
10
5
4
10
5
5
5
10
5
5
6
5
5
0
7
5
5
0
8
5
5
0
9
5
0
0
10
0
0
next treatment depends on immunological results
11
5 (2.5)
0
0
12
5 (2.5)
0
0

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Introduction

497

Zdenka Ulcova-Gallova u. a., Kortikosteroiden und Sperma-Antikorper-Konzentration

Tab. 2 Scheme for dexamethasone administration (in mg)
weeks

morning

noon

evening

1
2
3
4
5
6
7
8
9
10
11
12

1
1
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5

0.5
0.5
0.5
0.5
0.5
0.5
0
0
0
0
0
0

0.5
0
0
0
0
0
0
0
0
0
0
0

Tab. 3 Results of direct (In-)-MAR-test percentage (more

41 %) of antisperm activity in serum, ovulatory mucus, and in seminal plasma from 696 infertile couples
agglutinating
antibodies
serum IgG
IgM
ovulat. mucus
IgG + IgA
IgG
IgA
IgM
semin. plasma
IgG + IgE
IgG
IgA
IgM
IgE
IgG + IgA

men

women

number %

number %

11
1

1.6
0.14

3
102
95
6
3
2

0.44
14.66
13.65
0.86
0.43
0.29

15
2

2.15
0.29

124
201
129
2

17.8
28.9
18.5
0.29

Oral dexamethasone treatment

Plasmapheresis [12]
Spermagglutinating antibodies were found in a 30-yearold woman with primary idiopathic infertility in the serum
and ovulatory cervical mucus. The patient was treated
without success by condom for 6 months, by oral corticosteroids for three months, by local hydrocortisone application together, and by insemination at the time of ovulation. Treatment by a membrane separation plasmapheresis
was started during two preovulatory periods. Serum IgM
spermagglutinating antibodies were reduced from the original titre 1 : 1 024 up to 1 : 16. Prednison with plasmapheresis was used at the same time.

Tab. 4 Results of spermagglutinating antibodies in men before

and after the prednisone or dexamethasone treatment
Auto-type of
spermagglut. antibody
serum IgG
IgM
seminal plasma
IgG + IgE
IgG
IgA
IgE
IgG + IgA

TAT-test was used as a screening method for detection of

sperm agglutination in serum, in seminal plasma and in
cervical ovulatory mucus. Positivity of the TAT-test was
1 : 16 and more. When the positive level of the sperm antibodies was reached by TAT, MAR-test was used for a determination of immunoglobulin iso- or auto-typ of an individual antibody activity.
Table 3 shows the results of MAR-test (the percentage
of positivity in serum, seminal plasma and ovulatory cervical mucus) before the treatment in infertile women and
men. Serum antibodies against sperm were in the majority
of infertile couples connected with local findings of antispermimmunity (seminal plasma or cervical ovultarory
mucus).

before

after

11
1

3
0

2
102
95
3
2

2
59 (57.8 %)
37 (38.9 %)
1
1

Tab. 5 Results of spermagglutinating antibodies in women before and after three months of the hydrocortisone, prednisone,
dexamethasone treatment
Iso-type spermalut.
antibody
serum IgG
IgM

Results

number of men treatment

ovulatory mucus
IgG + IgA
IgG
IgA
IgE
IgA + IgE

number of women treatment

before
15
2
124
201
129
0
3

after
4
2 (plasmapheresis
in one woman)
76 (61.3 %)
102 (50.7 %)
85 (65.9 %)

The levels of spermagglutinating antibodies in men

were decreased only in 3 out of 11 patients after oral corticosteroid treatment, antisperm IgM levels were not influenced by oral corticosteroids as shown in table 4.
Long-lasting decreasing doses of prednisone or dexamethasone influenced the creation of IgG levels of sperm

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Dexamethasone was also used for immunosuppression. Its

scheme is shown in table 2. The treatment regimes of
prednison or dexamethasone were applied once a year.
Dosages were chosen according to the experience of rheumatologists and allergologists.

498
antibodies in 57.8 %, IgA in 38.9 %, combination of IgG
and IgE together was not changed in this group of men.
Table 5 analysis results of spermagglutinating antibodies before and after the treatment in women. Serum IgG
sperm antibodies were decreased in 4 of 15 women, IgM
in no patient. One woman with very high levels of spermagglutinating antibodies underwent plasmapheresis. Before, during and after this procedure all immunological
factors were monitored (not only sperm antibodies, but
all specific and non-specific immunological factors were
studied [12]). Levels of spermagglutinating antibodies decreased on the titre of 1 : 16, but after homologous insemination the sperm antibodies immediately increased to the
original levels. Our patient did not become pregnant. The
second separation combined with the first in vitro fertilization during the next ovulation did not lead to pregnancy,
too, but, the second IVF was successful.
Table 5 shows results of local immunosuppression by
hydrocortisone. Levels of the sperm agglutinating antibodies in IgG and IgA together decreased or desappeared in
61.3 %, in IgG in 50.4 %, in IgA in 65.9 %. No effect was
registered in ovulatory mucus with spermagglutinating
antibodies in IgM, and a very poor one in combination of
IgG and IgE.
Discussion
This study concentrated on the influence of the production
of spermantibodies in 696 infertile couples, where immunological problems were detected in one or both partners.
Various effects of local hydrocortisone treatment, oral
prednisone or dexamethasone treatment, and the results
of plasmapheresis were seen. Cortiscosteroids in various
forms focus immunocompetent cells (T-lympholytic effect, the blocking of macrophage phagocytic function, or
the inhibition of sperm antigen modification may be the
mechanism) in no corticosteroid resistant patients. Local
influence of immunocompetent cells seems to be better
than in serum. Good results were obviously achieved in
patients with seminal plasma spermantibodies in IgG or
in IgA, and in women with spermantibodies in ovulatory
mucus in the same isotypes of immunoglobulins.
During all types of corticosteroid treatment patients
must be monitored (levels of sperm antibodies, blood
pressure, body weight). We have to be very careful to
symptoms such as insomnia, improving appetite, oedema
in the face. We have never had serious complications (exacerbation of gasteric or duodenal ulcers, aseptic necrosis
of the hip) as other studies described [1].
We prefer long-lasting and decreasing doses of corticosteroid treatment, rather than short or only preovulation
application of relatively low doses of this treatment. The
reason is, that in practice and our experience a much better response in the immunocompetent cells-blockage of
the creation of spermantibodies is shown and so an increasing chance for future pregnancy. Patients treated with
oral corticosteroids must follow a special regime (exclusion of heavy work, sun-exposure, stress, diet on high calci-

um, etc.) Detailed explanations and advice given to patients must be part of the therapy because its adds to the improvement of the corticosteroid treatment. When we find
corticoid resistance (the second monitoring of spermagglutinating antibodies is on the same level as before the
treatment), we reduce corticosteroid doses consecutively
and relatively quickly to stop this therapy. As to prednisone or dexamethasone efficacy, we do not distinguish differences in the effect on immunocompetent cells, the effect
seems to be almost the same.
Plasmapheresis combined with corticosteroid treatment
is a perfect method for reducing pathological auto- (iso-)
antibodies in various autoimmune diseases (e. g. system
lupus erythematodes, myathenia gravis, etc). Our aim in
plasmapheresis was to reduce levels of spermantibodies,
and to combine it with homologous insemination in two
stimulated cycles. Unfortunately, a strong reboundimmunoglobulin synthesis in the place of immunocompetent cells and sperm antigens contact or postplasmapheretic cummulation of sperm antibodies of external bloodvessel space tissues in the blood appeared. The question
is, how to influence the memory cells in connection with
immunoogical disorders?
Assisted reproduction techniques [3, 10] such as in vitro fertilization are very often combined with immunological induced infertility, not only in cases of presence of
sperm agglutinating antibodies, but with zona pellucida
antibodies, and with antiphospholipid antibodies as well.
Our experience shows that combination of IVF with corticosteroid treatment improves the fertility rate in the
majority of infertile couples.
Finally, fourteen years of analysis also showed, that
64 percent of couples decided to remain without children
owing to being older than 40 years in one of them, minority of questioned couples mentioned a worse economical
situation due to unemployment. The rest, 36 %, are very
happy families (tab. 6).
The ratio of 202 abortions in 411 pregnancies is rather
high. We started to concentrate on the antiphospholipid
antibody levels as well (against mixed antigens such as
cardiolipin, and against phosphatidylserine, phosphatidylinositol, phosphatydylethanolamine, ph-glycerol, phcholine) (e. g. [15]). The majority of women with repeated
spontaneous miscarriages had high levels of antiphospholipid antibodies and HLA-DR specificities (e. g. [5]).
Reproductive immunology is able to influence immunocompetent cells by corticosteroids and IVF. It seems to
be the most effective way for the future.

Tab. 6 Family survey of the children situation in 696 treated

couples
pregnancy in 389 women (achieved 411 )

55.9 %

child birth in 209 women

child adoption in 41 couples
without children 446 couples

30.1 %
5.89 %
64.0 %

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Zentralbl Gynakol 122 (2000) 9

Zdenka Ulcova-Gallova u. a., Kortikosteroiden und Sperma-Antikorper-Konzentration

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Ulcova-Gallova Z, Krauz V, Bouse V, Novotny Z, Rokyta Z,
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Received: 6. 8. 1999
Accepted: 20. 1. 2000
MUDr. Zdenka Ulcova-Gallova, DrSc.
Department of Gynecology and Obstetrics
Charles University and Medical Faculty Hospital
Capkovo nam. 1
30708 Pilsen
Czech Republic
Fax: 00 42/19/7 26 29 01
E-mail: Ulcova@fnplzen.cz

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Acknowledgement. This research was supported by a

grant from Czech Ministry of Health-4294 (96/55) and
Faculty of Medicine of Charles University 1114 00005
(6035).

499