See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/233694670

Mechanisms of obesity-induced male infertility

Article  in  Expert Review of Endocrinology & Metabolism · March 2010

DOI: 10.1586/eem.09.65

CITATIONS READS

20 565

2 authors:

Karen Phillips Nongnuj Tanphaichitr

University of Ottawa The Ottawa Hospital
66 PUBLICATIONS   1,015 CITATIONS    114 PUBLICATIONS   2,542 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Women & Health View project

www.ReproHealthLab.org View project

All content following this page was uploaded by Nongnuj Tanphaichitr on 11 June 2014.

The user has requested enhancement of the downloaded file.

 Review
For reprint orders, please contact reprints@expert-reviews.com

Mechanisms of obesity-induced
male infertility
Expert Rev. Endocrinol. Metab. 5(2), 229–251 (2010)

Karen P Phillips† and
Nongnuj Tanphaichitr
†
Author for correspondence
University of Ottawa,
43 Templeton Street, Room 215,
Ottawa, ON K1N 6N5, Canada
Tel.: + 1 613 562 5800 ext. 8678
karen.phillips@uottawa.ca
Male infertility, characterized by hypogonadism, decreased semen quality or ejaculatory
dysfunction, accounts for approximately 20% of infertility cases. Obesity and metabolic
dysfunction have been identified, among other causal factors, to contribute to male infertility.
In the context of the Western world’s ‘obesity epidemic’, this article discusses three main
biological mechanisms linking obesity to impaired male reproductive function: hypogonadism,
testicular heat stress/hypoxia-induced apoptosis and endocrine disruption by ‘obesogens’.
Among these, obesity-induced hypogonadism is undoubtedly the most clinically significant
and is easily assessed. Rapidly expanding areas of research in this area include leptin modulation
of kisspeptins and hypothalamic–pituitary–testicular hormone pathways, and roles of other
adipocytokines in male infertility, as well as the impact of exposure to obesogens on the quality
of semen.

Keywords : endocrine disrupters • estrogen • hypogonadism • leptin • obesity • obesogens • semen

Approximately 30–40% of infertility cases
can be attributed to problems with the male
partner  [1] . Obesity and related concomitant
metabolic abnormalities are among the pro-
posed causes of male infertility [2] . Metabolic
syndrome has been characterized as a constel-
lation of disorders, including Type 2 diabetes,
coronary heart disease, obesity with visceral
abdominal fat distribution, dyslipidemia, hyper-
tension and impaired glucose metabolism/insu-
lin resistance [3–5] . In the context of the ‘obesity
epidemic’ in the Western world, this paper dis-
cusses three main biological mechanisms linking
obesity to impaired male reproductive function.
These mechanisms include hypogonadism, testi­
cular heat-stress-/hypoxia-induced apoptosis and
endocrine disruption by ‘obesogens’.
Spermatogenesis & the assessment of
male fertility
Testicular function is regulated by the hypo-
thalamic–pituitary–testicular (HPT) axis
(F igur e   1) . Gonadotropin-releasing hormone
(GnRH) is released by hypothalamic neu-
rons and stimulates the release of pituitary
gonadotropins, luteinizing hormone (LH) and
follicle-stimulating hormone (FSH) [2] , both
of which play major roles in the regulation of
testicular steroidogenesis and spermatogenesis,
respectively (Figure 2) . The mature sperm­atozoa
(sperm) are polarized cells, each consisting of a
head, midpiece and tail (Figure 3) . These struc-
tural entities of sperm are used as landmarks
for morphological categorization. Testicular
injury, disease or impairments of the HPT axis
can produce abnormalities of spermatogenesis
with consequences, including the production
of fewer, abnormal or underdeveloped sperm,
characterized by morphological defects or
reduced motility. Further modifications of bio-
chemical and kinetic properties of sperm take
place in the female reproductive tract; a pro-
cess known as capacitation, which includes the
acquisition of hyperactive motility (Figure 4) [6,7] .
Once bound and penetrating the egg zona
pellucida, sperm undergo the zona pellucida-
induced acrosome reaction (Figure 3) , an acro-
somal exocytosis event that involves the release
of hydrolytic acrosomal enzymes, followed by
fusion of one of these acrosome-reacted sperm
with the egg plasma membrane and sperm
incorporation into the egg (fertilization).
The determination of spermatozoa concen-
tration, morphology and motility remains the
primary clinical tool for the assessment of male
infertility [8] . Reproductive hormone profiles
(free and total testosterone, estradiol, LH and
FSH) in addition to semen parameters are typi-
cally used to assess male reproductive function.
Development of clinical assays to delineate new
parameters that better reflect sperm fertilizing
competence are needed.

www.expert-reviews.com 10.1586/EEM.09.65 © 2010 Expert Reviews Ltd ISSN 1744-6651 229

 Review Phillips & Tanphaichitr
Hypothalamus
– GnRH
Pituitary
– FSH, LH
T Testis
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
Figure 1. Hypothalamic–pituitary–testicular axis. Systemic
regulation of testicular function is provided by the hypothalamic–
pituitary–testicular axis. Briefly, the hypothalamus releases GnRH,
which acts on the anterior pituitary to release FSH and LH. FSH
binds to receptors on testicular Sertoli cells to regulate
spermatogenesis. LH binds receptors on testicular Leydig cells.
FSH: Follicle-stimulating hormone; GnRH: Gonadotropin-
releasing hormone; LH: Luteinizing hormone; T: Testosterone.
Adipogenesis & the assessment of obesity
Adipocytes are the main cellular constituents of the adipose tissue
and play an important role in regulating triglyercide and free fatty
acid levels. Adipocytes are derived from multipotent stem cells that
differentiate into preadipocytes and, subsequently, mature adipo-
cytes [9] . Estrogen is a positive regulator of adipogenesis, stimulat-
ing preadipocyte proliferation and growth of mature adipocytes [10] .
By contrast, adipocyte differentiation and maturation is negatively
regulated by androgens such that high androgen levels both drive
differentiation of the multipotent stem cells toward myogenesis,
thereby inhibiting adipogenesis [11] , and inhibit adipogenic differ-
entiation of existing preadipocytes [12] . Adipose tissue has endocrine
function and synthesizes chemical messengers, known as adipocy-
tokines or adipocyte-derived hormones, in addition to the aromati-
zation of androgens to estrogens. Basal aromatase activity decreases
during adipocyte maturation with tenfold less aromatase activity
in mature adipocytes compared to preadipocytes. Aromatase activ-
ity is also site dependent with higher activity in preadiopocytes in
subcutaneous tissue compared with omental cells [13] .
The obese male is generally characterized as having greater than
25% body fat of total body mass with a BMI in excess of 30 kg/m2
[14] . BMI is used as the chief indicator of obesity, with stratified
BMI categories as follows: 18.5–24.9 kg/m2 (normal), 25 kg/m2
and above (overweight) and 30 kg/m2 and above (obese). Other
more accurate methods to assess obesity include measurement of
skinfold thickness [15] , hydrostatic weighing, dual-energy x-ray
absorptiometry (originally designed to measure bone mineral
230
density, this technology differentiates between absorption of
x-rays in bone vs soft tissue) or whole-body adipose tissue com-
puted tomography (CT) and MRI combined with waist:hip ratio
measurements [16] .
Reproductive parameters in obese men
The relationship between semen quality and BMI has been exam-
ined in several observational studies (Table 1 & 2) . Studies set in infer-
tility clinics have the advantage of investigating obesity trends within
infertile populations whereas populations of unselected healthy men
across BMI categories enable evaluation of the association between
obesity and fertility without a preconceived bias. Studies designed to
measure sperm parameters for obese men tended to report a negative
association between semen quality and BMI (Table 1) [17–21] . By con-
trast, the large INUENDO study of European infertility patients
reports no reduction in sperm concentrations or sperm motility in
the obese group, whereas moderately overweight men exhibit a small
decrease in sperm concentrations [22] , which is supported by more
recent studies [23,24] that also report no associations between semen
parameters and BMI. However, time-to-pregnancy studies support
an association between subfecundity and high BMI (Table 1) [25–27] .
Sperm concentration/total sperm count seem most likely to be nega-
tively associated with BMI above 25 kg/m2 (Table 2) [17–18,20,21,28]
with reduced normal sperm morphology and motility less consistent
across studies (Table 2) .
Many population studies are limited by the small sample size of
the obese study population, and tend to report overweight/obese
data as a single group, which would be expected to reduce the
strength of the associations measured. Possible explanations why
these population studies are not more consistent could include lack
of sensitivity of BMI as a measurement of adiposity, presence of sub-
fertility, which may manifest by more subtle changes in testicular/
sperm physiology not captured by traditional semen assessments,
and finally, heterogeneity within the overweight/obese populations.
The association between infertility and obesity has also been
examined using reproductive hormone profiles of infertility
patients across BMI categories. BMI is negatively correlated with
serum testosterone but positively correlated with serum estradiol
in these patients [15,22,28,29] ; consistent with original reports that
visceral obesity in men is associated with decreased free- and total-
testosterone levels [30–32] and with increased estrone and estradiol
levels [9,33–35] . Therefore, it seems likely that important reproduc-
tive features of morbid obesity in men include hypogonadism,
hyperestrogenemia and subfertility (Figure 5) [36] .
Mechanisms of obesity-induced male infertility
Hypogonadism
Hypogonadism in males encompasses disrupted testicular func-
tions, including deficient steroidogenesis and/or spermatogenesis.
Hypogonadism is classified by the origin of dysfunction, either at
the testis or within the HPT axis. Primary hypogonadism results
from a testicular deficit (Figure 6A) and may be caused by genetic dis-
eases, including Klinefelter’s syndrome or 5α-reductase deficiency,
congenital abnormalities, including cryptorchidism or testicular
feminization, or testicular insults, such as trauma, mumps orchitis,
Expert Rev. Endocrinol. Metab. 5(2), (2010)
 Obesity & semen quality Review

radiation or chemotherapy [1] , testicular

heat stress [37] or varicocele (associated with 1
impaired testicular venous drainage) [38] .
Primary testicular deficit is also classified Mitosis
as hypergonadotropic hypogonadism and 2
is clinically characterized by hypogonadism
(low free and/or total testosterone and low Mitosis
sperm production) with increased FSH and 3
LH levels, caused by inadequate testoster-
one levels to provide negative feedback to
the HPT axis. Hypogonadism may also be Meiosis I
4
caused by deficits within the hypothalamus
or pituitary, a so-called secondary hypogo- Meiosis II
nadism, also termed hypogonadotropic 5
hypogonadism (Figure 6B) . This is charac-
terized by low–normal FSH and LH levels
and subsequently low testosterone, and is 6
featured in men with Kallman’s syndrome,
pituitary disorders and serious illnesses,
such as AIDS [39] . We will discuss sev-
7
eral hypogonadal mechanisms with either
testicular or hypothalamic origins that
explain the association between obesity and
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
male hypogonadism.
Figure 2. Mammalian spermatozoa. Spermatogenesis is supported by Sertoli cells
Adipocyte-derived estrogen contained within testicular seminiferous tubules. Spermatogonium (type A) continuously
& hypogonadism replicates by mitosis. Spermatogonium (type B) undergoes mitosis followed by two
rounds of meiosis to produce spermatocytes and spermatids. Round spermatids undergo
Adipocyte-derived estrogens in obese men
differentiation (spermiogenesis) including remodeling of the cytoplasm to form
provide feedback inhibition to the HPT elongated spermatids and ultimately testicular spermatozoa. Major stages include:
axis, modulated by the presence of estro- spermatogonium type A and type B; primary spermatocyte (shown pachytene
gen receptors (ER-α and -b) localized to spermatocyte); secondary spermatocyte; round spermatid; elongated spermatid; and
the hypothalamus and pituitary, shown testicular spermatozoa.
in mouse [40] and rat [41,42] . A plausible
biological mechanism for obesity-induced hypogonadotropic inhibitors, letrozole and anastrozole, can be used to prevent enzy-
hypogonadism may result, in part, from increased feedback inhi- matic conversion of androgens to estrogens in adipocytes and
bition of the HPT axis due to high serum levels of estrogens in other tissues [49,50] , thereby reducing serum estradiol and suppres-
obese males [43] . This may lead to a hypogonadal–obesity cycle sion of the HPT axis by interrupting the hypogonadal–obesity
[44] , wherein an increased adipose tissue mass represents a sig- cycle [46] .
nificant peripheral source of estrogens, which, in turn, suppress
the HPT axis and increase central adiposity (Figure 7) . The sub- Inter-relationship between hypogonadism
sequent reduction in circulating testosterone leads to increased & non-insulin-dependent diabetes mellitus
deposits of visceral/abdominal adipose tissue [45–47] and subfer- Insulin resistance, together with obesity, are cardinal features
tility, whereas the increased production of circulating estrogens of metabolic syndrome [2] . However, it is important to note that
supports differentiation of adipocytes [10] . not all obese individuals will develop non-insulin-dependent dia-
Obesity-induced hypogonadism in males may be treated by betes mellitus (NIDDM) or Type 2 diabetes, a disease that also
weight loss, which should reduce estrogen levels to normal and manifests in normal-weight individuals [51] . Consideration must,
alleviate the HPT feedback inhibition. Roux-en-Y gastric bypass therefore, be granted to the differential impacts of adiposity and
surgery, one option for the treatment of morbid obesity, has been insulin resistance in the context of fertility in the obese male.
shown in one study to seemingly reverse abnormal reproduc- Non-insulin-dependent diabetes mellitus is generally charac-
tive hormonal profiles, such that total testosterone is increased terized by obesity, insulin resistance, hypogonadism, low sex-
and serum estradiol is decreased [48] . Other treatment options hormone binding globulin (SHBG) and reduced free and total
for hypogonadism include supplementation with alternative or testosterone [2,52] . However, it is unclear which of these parameters
recombinant gonadotropins (e.g., human chorionic gonado­tropin are causal factors and which are independent. Hypogonadism,
[hCG] and recombinant FSH), which stimulate testicular func- for example, has been demonstrated in several studies to predict
tion, including testosterone production [49] . Finally, aromatase NIDDM risk (e.g., Multiple Risk Factor Intervention Trial cohort

www.expert-reviews.com 231
 Table 1. Male obesity and infertility: observational studies of sperm parameters and BMI.

232
Study (year) Study design Population (n) Parameters Support relationship between obesity and Ref.
male infertility?
Review

Jensen et al. Cross-sectional 1558 Danish men, Semen volume, sperm concentration, Yes, sperm concentration and total sperm count reduced in [17]
(2004) general population motility, morphology, total sperm underweight men (BMI <20 kg/m2) and in overweight/
count, testis volume, obese men (BMI > 25 kg/m2) compared with normal-weight
reproductive hormones men (BMI: 20–25 kg/m2)
Hammoud Retrospective, 526 male patients attending Sperm concentration, progressive Yes, results support association between obesity and [18]
et al. (2008) cross-sectional US fertility center, motility, morphology, BMI oligospermia, reduced motile sperm count, increased
390 included incidence of abnormal sperm morphology
Kort et al. Cross-sectional 520 men attending Semen volume, sperm concentration, Yes, inverted relationship between BMI and total normal [19]
(2006) US andrology laboratory motility, morphology, sperm motile sperm, obese men have fewer chromatin-intact
chromatin index, BMI normal motile sperm
Phillips & Tanphaichitr

Koloszar et al. Cross-sectional 274 Hungarian Sperm concentration, BMI Yes, results indicate reduced sperm concentration in obese [20]
(2005) normozoospermic group of men (BMI >30.1 kg/m2) compared with
andrology patients underweight, normal-weight and overweight groups
Hofny et al. Prospective 122 obese, Egyptian Total sperm count, sperm motility, Yes, BMI inversely related to sperm concentration, motility [21]
(2009) andrology patients morphology, BMI, reproductive and normal morphology
hormones, leptin
Aggerholm Retrospective, 2139 Danish men, Total sperm count, motility, semen Unclear, results support a slight reduction in total sperm [22]
et al. (2008) cross-sectional 1989 included volume, BMI, reproductive hormones count among overweight men (BMI: 25.1–30 kg/m2)
(INUENDO study) compared with normal weight men; no reduction in sperm
count in obese men
Pauli et al. Prospective 87 US men, included fathers Semen volume, sperm concentration, Unclear, no correlation between semen parameters with [15]
(2008) and men attending motility, BMI, skin-fold thickness, obesity (BMI/skinfold thickness), men unable to conceive,
fertility center testicular volume, had higher body fat (BMI/skinfold measurements) compared
reproductive hormones with men with paternity
Duits et al. Prospective cohort 1466 male patients attending Sperm concentration, motility, No, results did not support association between high BMI [23]
(2009) Dutch fertility center, morphology, total sperm count, and any of the sperm parameters measured
1401 included semen volume, BMI
Nicopoulou Retrospective, 349 Greek andrology patients Total sperm count, BMI No, results did not support a significant association between [24]
et al. (2009) cross-sectional BMI and total sperm count
Fecundity and BMI
Ramlau- Cohort 64,167 pregnant women, BMI (women’s report), Yes, overweight/obese men associated with subfecundity [25]
Hansen et al. (Danish National Birth 47,835 couples included time to pregnancy (time to pregnancy >12 months)
(2007) Cohort)
Sallmén et al. Cohort (Agricultural 52,395 US pesticide BMI (self-report), time to pregnancy Yes, overweight/obese men associated with subfecundity, [26]
(2006) Health Study [US]) applicators, 1329 included dose–response relationship
Nguyen et al. Retrospective cohort 45,132 Norwegian couples, BMI (women’s report, self-report), Yes, risks of infertility associated with underweight [27]
(2007) (Norwegian Mother 26,303 included time to pregnancy (BMI <20 kg/m2), increased risk of infertility with increase
and Child Cohort) in BMI

Expert Rev. Endocrinol. Metab. 5(2), (2010)

 Table 2. Semen quality parameters in overweight/obese men (BMI >25 kg/m2).
Study (year) Obese sample size Population Association with BMI? Ref.
(total sample size [n])
Jensen et al. 299 (1558) Danish men Sperm concentration/total sperm count: yes, BMI >25 kg/m2 group exhibited significantly reduced [17]
(2004) sperm count and reduced sperm concentration; large sample, general population

www.expert-reviews.com
Sperm motility: no association between sperm motility and BMI; large sample, general population;
young population
Sperm morphology: no significant association; large sample, general population, very young (mean
age: 19 years)
Hammoud et al. 296 (390) Fertility patients Sperm concentration/total sperm count: yes, oligospermia associated with increasing BMI; moderate [18]
(2008) sample size, large proportion of overweight/obese men
Sperm motility: yes, increasing BMI associated with low sperm motility; moderate sample size, large
proportion of overweight/obese men
Sperm morphology: yes, reduced in obese group vs others; moderate sample size, large proportion of
overweight/obese men
Koloszár et al. 149 (274) Normo-zoospermic Sperm concentration/total sperm count: yes, sperm concentration significantly reduced in men with [20]
(2005) Infertility patients BMI >30 kg/m2, not in overweight men (BMI: 25.1–30 kg/m2); simple analysis, determined age effect in
obese group, men with abnormalities in reproductive hormones were excluded
Hofny et al. 122 (122) Fertile/oligospermic Sperm concentration/total sperm count: yes, BMI negatively correlated with sperm count; [21]
(2009) andrology patients homogenous sample; BMI >30 kg/m2
Sperm motility: yes, BMI negatively correlated with sperm motility; sperm motility significantly decreased
in oligospermic group. Entire sample had BMI >30 kg/m2, excluded major illness diabetes, hypertension
Sperm morphology: yes, BMI positively correlated with abnormal sperm morphology; entire sample had
BMI >30kg/m2, excluded major illness diabetes, hypertension
Fejes et al. 25 (42) Oligospermic Sperm concentration/total sperm count: yes, reduced sperm concentration vs normal/underweight [28]
(2006) patients men; small sample size, subfertile population
Sperm motility: no difference vs normal/underweight men; small sample size, subfertile population
Sperm morphology: no difference vs normal/underweight men; small sample size, subfertile population
Duits et al. 733 (1401) Fertility patients Sperm concentration/total sperm count: no association with BMI; thorough analysis, large sample, [23]
(2009) reduced semen volume in overweight group
Sperm motility: no association with BMI; thorough analysis, found reduced semen volume in
overweight group
Sperm morphology: no association with BMI; thorough analysis, found reduced semen volume in
overweight group
Pauli et al. Not listed, mean Fathers/infertility Sperm concentration/total sperm count: no association between BMI or skinfold thickness with sperm [15]
(2008) BMI >25 kg/m2 (87) patients concentration; proportion of sample with BMI >30 kg/m2 not identified, small sample
Sperm motility: No association between BMI or skinfold thickness with sperm motility; proportion of
sample with BMI >30 kg/m2 not identified, small sample
Obesity & semen quality

Kort et al. Not listed, mean Andrology patients Sperm motility: yes, BMI negatively correlated with total number of normal motile sperm; [19]
(2006) BMI >25 kg/m2 (520) analysis used normal motile sperm that combines sperm concentration, volume, morphology and motility,
no raw data reported
Review

233
 Review Phillips & Tanphaichitr
Acrosomal
cap region
Head
Nucleus
Mitochondria
Midpiece
Acrosome
reaction
Tail
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
Figure 3. Mature spermatozoon undergoes the acrosome
reaction upon binding to the egg’s extracellular matrix,
the zona pellucida. Featured on the left is a mature
spermatozoon with three morphological structures: head,
midpiece and tail. The head contains the acrosome and the
nucleus. The midpiece is the ‘engine’ of the spermatozoon,
densely packed with mitochondria that power the flagellum or
tail. Spermatozoa initially lack the ability to fertilize an egg,
necessitating further remodeling (capacitation) induced by
contact with the female reproductive tract. Capacitation is
accompanied by cholesterol efflux, protein tyrosine
phosphorylation and rupture of the acrosomal membrane,
releasing acrosomal enzymes (acrosome reaction), as shown on
the right. Acrosome reaction involves fusion of outer acrosomal
membrane with sperm plasma membrane, progressive loss of
outer acrosomal membrane and acrosomal contents and, finally,
exposure of the inner acrosomal membrane.
study [53] , Massachusetts Male Aging Study [54] , Rancho Bernardo
Study [55] , Kuopio Ischaemic Heart Disease Risk Factor Study
[KIHD]  [56–58]). Men with NIDDM are more likely to exhibit
hypogonadism with reduced serum testosterone and SHBG [59–61] .
These studies are consistent with established associations between
obesity and hypogonadism, and between obesity and insulin
resistance. SHBG and testosterone are inversely correlated with
BMI  [17] and insulin [62,63] , such that obese males exhibit high
serum insulin with low SHBG and bioavailable testosterone [52] .
The inverse relationship between total serum testosterone and
insulin appears to be independent of central adiposity, demon-
strated in the Health in Men study [64] . Hyperinsulinemia fea-
tured in NIDDM patients appears to produce hypergonadotropic
hypogonadism by directly reducing testicular testosterone levels.
Pitteloud and colleagues demonstrated a positive correlation
between insulin sensitivity and serum testosterone levels in a
cohort of 60 men, across a broad range of BMI categories [65] .
In a sub­sequent study, Pitteloud’s group reported no correlation
between insulin sensitivity and LH, suggesting no hypothalamic
or pituitary deficit [66] . Instead, insulin resistance, associated with
234
hyperinsulimia, somehow directly suppressed Leydig cell testos-
terone production in a cohort of men with mild-to-moderate
obesity [65] . In vitro, Leydig cells express insulin receptors, and
insulin has been shown to induce testosterone secretion from
Leydig cell cultures [67,68] . The molecular mechanism wherein
insulin modulates Leydig cell steroidogenesis is unknown, with
the possibility that the testis, as with other organs in individuals
with NIDDM, is resistant to insulin signaling [66] .
Non-insulin-dependent diabetes mellitus and, therefore, insulin
resistance, appears to be associated with ‘mixed hypogonadism’,
reflecting the dual actions of insulin resistance at the testis (hyper-
gonadotropic hypogonadism); and the hypothalamus/pituitary
(hypogonadotropic hypogonadism). Insulin is predominantly
stimulatory, acting at hypothalamic neurons to induce GnRH
secretion and gonadotropin secretion from the pituitary gonado-
trophs, demonstrated in vitro [69] . In obese men with NIDDM,
insulin resistance may blunt the normal, insulin stimulation of the
HPT axis [66] . More studies are needed to identify the mechanisms
of HPT insulin signaling and the consequences of insulin resistance
to the normal endocrine function of these glands.
Although reproductive hormonal profiles have been fairly well
established for men with NIDDM, semen quality has been examined
in only a few studies. Generally, sperm count is normal or increased,
with decreases in sperm motility [70] and semen volume  [71] , and
increases in abnormal sperm morphology [72] . Unfortunately, many
published studies of ‘diabetic men’ do not disaggregate the insulin-
dependent diabetes mellitus (IDDM) and NIDDM groups; a criti-
cal reporting gap in the literature as it appears that NIDDM may be
more of a concern with respect to male reproduction. The pathology
of IDDM (autoimmune and insulin deficiency) is different from
NIDDM (insulin resistance). The stimulatory effects of insulin on
the HPT axis in IDDM patients are continued through exogenous
insulin, the standard intervention. Insulin resistance in NIDDM
patients, however, leads to aberrance in testicular cell signaling and
subsequent hypogonadism. With so few studies examining the asso-
ciation between semen quality and insulin resistance, it is impossible
to profile ‘typical’ semen parameters of a NIDDM man. More stud-
ies using NIDDM men and animal models are urgently needed to
verify the causal effect of insulin resistance on hypogonadism, as
well as to discern the molecular mechanisms involved.
Leptin’s roles in hypogonadism
Leptin is a 16-kDa protein hormone, encoded by the ob gene [73]
and secreted by adipocytes. This adipocytokine plays a major role
in energy homeostasis, including neuroendocrine regulation of
bodyweight. Leptin is the endogenous agonist for the leptin recep-
tor (Ob‑R), a member of the class I cytokine receptor superfamily.
Ob‑R is produced as alternatively spliced forms and further classi-
fied as short (Ob-Ra, Ob-Rc, Ob-Rd and Ob-Rf), long (Ob-Rb)
and secreted (Ob-Re) receptor types, all with extracellular, trans-
membrane and variable intracellular domains with the exception of
Ob-Re [74–76] . Ob-Rb has the longest intracellular domain and is the
functional isoform in the hypothalamus, whereas Ob-Ra and Ob-Rc
are proposed to participate in leptin transport across the blood–brain
barrier (BBB) [76,77] . Ob-Re is the putative soluble leptin receptor
Expert Rev. Endocrinol. Metab. 5(2), (2010)
 Obesity & semen quality Review

Cholesterol contrast to the hypogonadism featured in

EGF receptor Leptin efflux congenital leptin deficiency cases, hypo-
gonadism in obese men is associated with
Ob-R
high serum leptin. Altered leptin dynamics
JAK2 SACY may, therefore, contribute to male infertil-
P P ity via at least two mechanisms, both of
Y Y
Na+ which may produce hypogonadism. These
include leptin resistance or leptin insuf-
HCO3- HCO3- Ca2+ ficiency at the hypothalamus and leptin
cAMP
modulation of testicular physiology.
PDE
Leptin resistance or leptin insufficiency at
Ras the hypothalamus
5´AMP
Raf PKA Consider the perplexing presence of the
same phenotype (obesity and hypogonad­
otropic hypogonadism) in individuals with
MEK high serum leptin due to obesity, and in
Tyrosine Sperm-motility activation humans/animals with leptin deficiencies
kinase Hyperactivated sperm motility due to mutations. Leptin resistance has
activation Preparation for acrosome reaction
been proposed to explain this apparent
ERK
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
paradox in the former group, referring to
the inability of leptin to act at the hypo­
Figure 4. Sperm capacitation signaling. The process of capacitation includes changes thalamus, either due to reduced levels of
to the sperm membrane and the acquisition of hyperactive motility. Hallmark
characteristics of sperm capacitation including intracellular increases in cAMP and HCO3-, bioavailable leptin (leptin insufficiency) [95]
cholesterol efflux and tyrosine phosphorylation. Ob-R signal crosstalk is also shown (see or impaired leptin signaling [96] , thereby
text for details). Dotted lines indicate proposed pathways and solid lines indicate mirroring the leptin deficiency present in
established pathways. animal models and congenital genetic con-
cAMP: Cyclic adenosine monophosphate; EGFR: EGF receptor; ERK: Extracellular ditions [97] . There does not appear to be a
signal-regulated kinase; JAK: Nonreceptor tyrosine kinase; MEK: Mitogen-activated
protein kinase; PDE: Phosphodiesterase; PKA: Protein kinase A; SACY: Soluble adenylyl model for central leptin excess, in spite of
cyclase; Y-P: Phosphorylated tyrosine residue. the increased serum leptin levels exhibited
by morbidly obese individuals.
lacking the transmembrane and intracellular domains, and pro- Peripheral adipocyte-derived leptin circulating in the blood-
posed to buffer circulating leptin levels, thereby regulating leptin stream can cross the BBB via a saturable transport system [95]
bioavailability [78] . to act centrally via Ob-Rb in the brain, particularly at the
Leptin was initially characterized in ob/ob mice, which, because
of a natural mutation, possess no ob gene and are, therefore,
leptin deficient [79] . Both male and female ob/ob mice are mor-
bidly obese and infertile [80] . Similar phenotypes are observed
in Ob-R-deficient mice [81] and the Zucker fatty (fa/fa) rat [82] .
Several human families have also been identified with congeni-
tal leptin deficiency owing to recessive mutations in the leptin
Obese male
gene (Delta133G [83] , R105W [84,85] and N103K [86]) or the leptin
receptor [87] . Clinical features of human congenital leptin defi- • BMI >30 kg/m2
ciency  [84–85] include early onset of obesity, hyperphagia (over- • High serum estradiol
• Insulin resistance
eating), hypogonadotropic hypogonadism and delayed pubertal • High serum leptin
onset. Congenital leptin deficiency caused by leptin receptor • Hypogonadism
mutation is associated with a slightly less severe phenotype [87] . • Subfertility
Recombinant leptin administration has been used successfully
to mitigate some of the features of congenital leptin deficiency,
resulting in weight loss and reversal of hypogonadism [83,88,89] .
In healthy men, serum leptin positively correlates with BMI
and adipose mass [90] . A number of studies in overweight and
obese participants report an inverse relationship between serum Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
levels of leptin and testosterone [91–94] but no significant corre-
lation between levels of leptin and the gonadotropins [91,93] . In Figure 5. Endocrine profile of the obese male.

www.expert-reviews.com 235
 Review Phillips & Tanphaichitr

was first considered following reports that the ratios of cerebro-

spinal fluid leptin to plasma leptin are reduced in obese individu-
A
Hypothalamus als compared with lean counterparts [95] . Thus, in spite of large
circulating leptin plasma levels in obese individuals, cerebro-
– GnRH
spinal fluid leptin levels are not proportionately high [95,100] . As
peripheral leptin is ordinarily released in a pulsatile fashion, any
number of factors, including circadian rhythm, meal spacing and
aging could disrupt this initial leptin pulsatile signal and pro-
duce leptin receptor downregulation, thereby attenuating leptin
Pituitary transport at the BBB [101] . Reduced hypothalamic leptin stimu-
lation may produce the morbidly obese phenotype in humans
– FSH, LH ,as these individuals lack leptin-induced suppression of appetite
or stimulation of energy expenditure [81] , thereby producing
a phenotype similar to the ob/ob mouse [102] . The molecular
mechanisms of leptin transport saturation at the BBB are not
Hypergonadotropic
Testicular well characterized; however, triglyceride inhibition/reduction of
hypogonadism
deficit leptin transport at the BBB has been proposed [99] . Alternatively,
leptin resistance, characterized by deficits in Ob-R signaling
Testosterone pathways, may impair leptin regulation of eating and energy
expenditure. Candidate signaling pathways include SOCS3 and
B STAT3, both downstream of Ob-Rb [103] . Although impair-
Hypothalamic
deficit
ments in leptin signaling may well accompany central leptin
insufficiency, perturbed signaling as a basis for leptin resistance
– GnRH remains to be elucidated [101]. As described previously, ob/ob
mice are obese, infertile and exhibit hypogonadism; however,
this phenotype can be reversed, including restoration of fertility,
by treatment with exogenous leptin [102,104,105] . Gonadotropins
Pituitary and sex-steroid hormones are low in ob/ob mice, consistent with
deficit hypogonadotropic hypogonadism and a role for leptin in the
regulation of the HPT axis [102] . Leptin acts indirectly to regu-
– FSH, LH late gonadotropin secretion in the hypothalamus by modulating
kisspeptins in the arcuate nucleus (Figure 8A) [106] . Kisspeptins
are proteins encoded by the Kiss1 gene, transcribed as KiSS1
Hypogonadotropic mRNA and act via a G-protein-coupled receptor (GPR54) [107]
hypogonadism to stimulate GnRH release, thereby triggering the gonadotropin
Testis
cascade [108] . Peripheral leptin, once transported across the BBB
to the hypothalamus, binds leptin receptors in the forebrain.
Testosterone
Arcuate nucleus neurons in the mouse express both Ob-Rb and
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
KiSS-1 mRNA in approximately 40% of cells, suggesting that
Figure 6. Hypogonadism. (A) Hypergonadotropic hypogonadism. so-called KiSS1 neurons (kisspeptins-expressing neurons) are
Also known as primary hypogonadism, reduced testosterone levels direct targets of leptin. Further, the numbers of KiSS1 neurons
and impaired spermatogenesis are caused by testicular deficit. are decreased in the hypothalamus of ob/ob mice, indicating that
Reduced testosterone levels leads to attenuation of the
testosterone-induced negative feedback loop to the secretory
leptin regulates KiSS1 neurons, and indirectly gonadotropin
activities of the hypothalamus and pituitary. Increased amounts of release [108,109] . Modulation of the gonadotropin levels is almost
GnRH and FSH/LH are thus secreted. (B) Hypogonadotropic certainly limited to an indirect role of leptin, since leptin recep-
hypogonadism. Secondary hypogonadism is caused by deficit at the tors are not present on rat GnRH neurons. Supporting these data
hypothalamus and/or pituitary. FSH and LH are, thus, secreted at is the observation of normal fertility in transgenic mice lacking
reduced levels, which also lead to decreased stimulation of Leydig
cells to secrete testosterone.
GnRH neuronal leptin receptors [110] .
FSH: Follicle-stimulating hormone; GnRH: Gonadotropin-releasing Testicular stress induced by leptin-modulated reductions in cir-
hormone; LH: Luteinizing hormone. culating gonadotropins, established antiapoptotic agents [111] , can
induce apoptosis [112] . FSH, a prosurvival factor in rat testis, upreg-
hypothalamus [98,99] . Saturation of this BBB transport system is ulates expression of antiapoptotic protein Bcl-w in rat Sertoli cells,
believed to produce central leptin insufficiency, as leptin is pres- spermatogonia and spermatocytes, but not spermatids, in vitro [113] .
ent in large quantities in plasma without corresponding leptin Germ cell death is a normal event during spermatogenesis and
action at the hypothalamus [97] . Impaired central leptin action may serve to regulate the size of the germ cell population [112,114] ;

236 Expert Rev. Endocrinol. Metab. 5(2), (2010)

 Obesity & semen quality Review

however, in the event of central leptin insuf-

ficiency and reduced gonadotropins release,
testicular apoptosis may be pathological. Hypothalamus
This has been demonstrated in leptin-defi-
cient ob/ob mice that exhibit upregulation of E2
Pituitary
nine testicular pro-apoptotic genes involved
in both intrinsic and extrinsic apoptosis
pathways [115] . Abnormal spermatogenesis
and infertility in these mice is likely due to Abdominal/
inadequate gonadotropin support of sper- visceral
matogenesis and accelerated germ cell death adiposity
by apoptosis [115,116] .
Deficiency in hypothalamic leptin sig- Adipose
T E2
naling resulting in hypogonadotropic aromatase
hypogonadism is observed in ob/ob mice Testis T
and humans with leptin deficiency. It
would appear that central leptin insuffi-
ciency is the causal mechanism of deficient
hypothalamic leptin signaling and, thus, Expert Rev. Endocrinol. Metab. © Future Science Group (2010)

the underlying cause of hypogonadotropic Figure 7. Hypogonadal–obesity cycle: peripheral estrogen synthesis. Adipocytes
hypogonadism (Figure 8B) . The stimulation express the enzyme aromatase that converts androgens (T and androstendione) to
of KiSS1 neurons by leptin provides a link estrogens (17b-E2 and estrone). Adipose tissue represents a rich source of peripheral
between energy homeostasis and repro- estrogens that regulate testicular function. In response to an increased adipose tissue
duction. Moderate elevations in serum mass, peripheral E2 is elevated, which, in turn, modulates the differentiation of
adipocytes and suppresses the Hypothalamus–pituitary–testis axis (hypogonadism).
leptin levels due to seasonal weight gain Reduced T contributes to abdominal adipose tissue distribution.
in response to changing environmental E2: Estradiol; T: Testosterone.
conditions may signal reproductive oppor-
tunity [80] . While moderate fluctuations in leptin may prove cells in the rat [121,126] and human [117] , but not mouse [127] ,
physiologically relevant to seasonal breeders and other animals, express leptin receptors, thus providing a mechanism for direct
high serum leptin levels in the obese human male may be detri- leptin modulation of Leydig cell functions. In rat Leydig cul-
mental, as this leads to saturation of the BBB transport system ture, leptin suppresses hCG-stimulated testosterone secretion,
and central leptin insufficiency. supporting a role for leptin in the negative regulation of steroido-
genesis [126,128,129] . Leydig cells exhibit differential sensitivity
Leptin modulation of testicular physiology to leptin, according to the developmental expression profiles of
Leptin is found in human and rodent Sertoli cells, Leydig cells, Ob-R, such that embryonic and adult but not prepubertal rat
seminiferous tubules and germ cells [117,118] and is able to cross Leydig cells demonstrate leptin suppression of hCG-induced
the testis–blood barrier (TBB) [119] , suggesting both testicular testosterone secretion [121] . In an elegant experiment designed by
and peripheral sources of leptin may be involved in reproduction. Tena-Sempere and colleagues [122] , hCG-stimulated rat testicu-
Unlike the BBB’s saturable transport system for leptin, the TBB lar samples exposed to increasing doses of human recombinant
system is nonsaturable, enabling leptin to ‘leak’ across the barrier leptin decreased expression of steroidogenic enzymes mRNAs
between the blood and the testicular interstitium and traverse the and, subsequently, reduced testosterone secretion. Leptin is also
Sertoli cell barrier, dividing the interstitium from the seminiferous able to decrease hCG-induced expression levels of steroidogenic
tubule fluid. The mechanism at the Sertoli cell barrier has not factor (SF)-1, steroidogenic acute regulatory protein (StAR)
been elucidated as saturable or leakage [119] . Thus, as serum leptin and cytochrome P450 cholesterol side-chain cleavage enzyme
levels increase, intratesticular leptin levels would be expected to (P450scc) in a dose-dependent manner [122] .
similarly increase with leptin action limited by receptor expres- Drawing from the findings reported by the teams of Caprio
sion in the testis. Ob-R have been localized to isolated Sertoli and Tena-Sempere, a model of leptin regulation of Leydig
and Leydig cells, and testicular germ cells in rodents [119–122] , and cell steroidogenesis is proposed (Figure 9) . Leptin signaling via
in seminiferous tubules in humans [117,123,124] . Together, these Ob-R is relatively well characterized [76] and is mediated by the
results strongly suggest that leptin directly modulates testicular JAK–STAT pathway [130–132] , with JAK2 [133] and STAT3, pri-
functions [80,102] . marily described [134] . STAT3 ultimately regulates expression
Leptin is a negative regulator of testicular steroidogenesis; it of steroidogenic genes including SF-1, StAR and P450scc [135] .
acts directly on testicular Leydig cells. In response to LH, Leydig Alternatively, steroidogenic gene expression can be regulated via
cells activate PKA-dependent gene expression, which triggers the PI3K/Akt or MAPK cascades, triggered by leptin binding to
steroidogenesis (i.e., the production of testosterone) [125] . Leydig Ob-R [76] . Leptin’s repression of steroidogenic gene expression,

www.expert-reviews.com 237
 Review Phillips & Tanphaichitr

A Hypothalamus B Hypothalamus
Arc Arc
KiSS KiSS
neurons neurons

GnRH
GnRH
1
Leptin
BBB BBB
resistance
1
Leptin Leptin
Pituitary Pituitary

Adipocytes Adipocytes

FSH, LH FSH, LH
2 2
Leptin Leptin

Testis Testis

X
Testosterone Testosterone
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)

Figure 8. Leptin modulation of hypothalamic–pituitary–testis axis. (A) Normal leptin action. Leptin provides a physiological link
between energy expenditure and reproduction by stimulating expression of KiSS, located in the hypothalamic arcuate nucleus. KiSS
neurons stimulate GnRH release and trigger the gonadotropin cascade and, in turn, testicular steroidogenesis and spermatogenesis.
Leptin may also negatively regulate steroidogenesis through direct actions on Leydig cells. (B) Leptin resistance. In obese men, leptin is
unable to cross the BBB and stimulate release of GnRH via KiSS neurons, thereby resulting in hypogonadism. With insufficient
gonadotropic stimulation, testicular dysfunction occurs. Higher circulating leptin levels may also impair testicular function through
inhibition of steroidogenesis. Dotted lines indicate proposed mechanisms and solid lines indicate established mechanisms.
Arc: Arcuate nucleus; BBB: Blood–brain barrier; FSH: Follicle-stimulating hormone; GnRH: Gonadotropin-releasing hormone;
KiSS: Kisspeptin; LH: Luteinizing hormone; T: Testosterone.

particularly StAR, the rate-limiting step in steroidogenesis [136]
would, therefore, counteract LH-mediated testosterone produc-
tion. Leptin’s negative regulation of steroidogenesis provides
subtle control over reproductive functions and represents yet
another mechanism for leptin in reproduction.
Leptin’s modulation of male infertility also involves direct
action of leptin on the sperm itself. Studies in mice indicate that
leptin and its receptor are expressed in specific types of male germ
cells, implicating leptin in cell proliferation and differentiation.
Leptin protein and mRNA expression are present in gonocytes
from neonatal mice, spermatogonia from 10-day-old mice and
in spermatocytes from adult mice [118] . Neonatal and adult mice
express Ob-Ra, Ob-Rb and Ob-Re in the testes [118,120] , suggest-
ing leptin normally functions in an autocrine or paracrine manner
to regulate spermatogenesis. It remains to be elucidated whether
leptin exclusively acts as a positive or negative regulator of sper-
matogenesis, or whether leptin’s role is more refined, dependent on
the receptor isoforms expressed at different stages of spermagogen-
esis. Leptin signaling via STAT3 suggests a role in the proliferation
of undifferentiated germ cells [120] ; consistent with reports that
stem cell STAT3 phosphorylation prevents differentiation and
enables continuous stem cell renewal [137] . Leptin STAT3 signaling
may enable undifferentiated germ cells to replicate without loss
of potency while triggering later-stage spermatocytes to undergo
development and differentiation [118,120] . In obese males, serum
leptin levels are elevated, which may lead to downregulation of
testicular Ob-R, previously demonstrated in vitro in the rat [138] .
Downregulation of leptin receptor expression would disrupt auto-
crine/paracrine testicular signaling and perhaps spermatogene-
sis. Taken together, the localization studies demonstrating testis
and spermatocyte-specific leptin and leptin receptor expression
[117,123,124] , along with the studies of testicular leptin signaling [122] ,
suggest that elevated serum leptin levels exhibited by obese males
are likely to perturb normal testicular physiology.
Ejaculated sperm are not able to fertilize the egg and must
undergo further structural and functional changes during capaci-
tation (Figure 3 & 4) . The purpose of seminal plasma leptin is still
unclear [117,123,139–143] , and is required to modulate sperm capacita-
tion and the acquisition of hyperactive motility. Human seminal
plasma leptin levels are positively correlated with serum leptin
levels [117,139–141] but inversely correlated with serum testosterone
and normal sperm parameters [123,139,142] . Seminal plasma leptin
levels tend to be disproportiately lower than serum leptin levels
[139] but are still positively correlated [139,142] . Obese men would be
expected to have greatly increased seminal plasma levels of leptin,
relative to their lean counterparts; however, very few studies have

238 Expert Rev. Endocrinol. Metab. 5(2), (2010)

 Obesity & semen quality Review

reported seminal plasma leptin levels in LH

morbidly obese men, and the capacitation/ Leptin
acrosome reaction status of their sperm has
not been investigated. JAK2 JAK2
A role for leptin in sperm capacitation

Ob-Rb
has been proposed by the Aquila research Y Grb2
team, drawing upon their studies in SHP-2
humans and boars. Leptin and leptin recep- Gα
-
tor expression are localized exclusively on Ras Cholesterol StAR Cholesterol
the plasma membrane overlying the acro- Raf -
some in boar sperm, consistent with their STAT3 STAT3 ? P450scc
putative regulations of sperm fertilizing
ability [135,144] . Leptin has been localized to MEK
midpiece/equatorial segment in uncapaci-
PKA
tated human sperm, undergoing an overall
decrease in expression and more uniform ERK Pregnenolone
localization in capacitated sperm [141,145] , -
with leptin receptor confirmed at the tail +
Gene expression - Steroidogenesis
region in ejaculated spermatozoa [145,146] .
StAR
These expression patterns support a physio- SF-1
logical role for leptin, perhaps in the modu- P450scc
Testosterone
lation of human sperm motility. Following
SF-1
acute leptin exposure (30–60 min), unca-
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
pacitated boar and human sperm undergo
leptin-enhanced cholesterol efflux and Figure 9. Model of leptin action in the Leydig cell. In response to LH, Leydig cells
protein tyrosine phosphorylation  [135,141] , activate PKA-dependent gene expression and downstream steroidogenesis pathways,
both hallmark steps in capacitation [143] . including production of testosterone. Leptin-bound Ob-Rb captures JAK2, a non-
receptor tyrosine kinase, which phosphorylates STAT3 and Y on the Ob-Rb.
Furthermore, boar sperm acrosin activity
Phosphorylated STAT3 dimers translocate to the nucleus and negatively regulate
(acrosomal trypsin-like enzyme) is stimu- expression of steroidogenic genes, including SF-1, StAR and P450scc. Leptin-inhibition of
lated by leptin [135] . It is important to note gene expression may also occur via recruitment of SHP-2 to phosphotyrosine residues on
that leptin’s stimulation of these capacita- the Ob-Rb. SHP-2 recruits Grb2 and leads to activation of the MAPK pathway (Ras, Raf,
tion-related events in both studies [135,141] is MEK and ERK). Leptin-dependent reduction of testicular expression of StAR, the
rate-limiting step in steroidogenesis at the mitochondria, would negatively regulate
not dose dependent, with very low concen-
steroidogenesis and, thereby, counteract LH-mediated activation of Leydig cells. Dotted
trations of leptin (0.63 nM human leptin lines indicate proposed pathways and solid lines indicate established pathways.
and 1–10 nM porcine leptin) producing the LH: Luteinizing hormone; Ob-Rb: Leptin receptor; P450scc: Cytochrome P450 cholesterol
greatest response. This may be explained by side-chain cleavage enzyme; SF-1: Steroidogenic factor-1; StAR: Steroidogenic acute
receptor downregulation at higher leptin regulatory protein; Y: Tyrosine residue.
levels [138] and may hold significance for
obese men who would be expected to exhibit seminal plasma In summary, leptin regulation of normal male reproduction
leptin levels in the highest ranges. includes central (HPT) and testicular actions. In morbidly obese
A model of capacitation signaling crosstalk emerges, wherein men, central leptin insufficiency produces hypogonadotropic
leptin signaling via the leptin receptor induces tyrosine phos- hypogonadism, reducing circulating gonadotropins  [95,98,99] ,
phorylation downstream of MAPK pathway activation (Figure 4) . and subsequently inducing testicular apoptosis [111] . It is believed
The process of capacitation includes changes to the sperm mem- that high serum leptin is able to perturb testicular steroidogen-
brane and the acquisition of hyperactivated motility. Molecular esis and spermatocyte differentiation and development [118,120] .
events include HCO3- -dependent increase in intracellular cAMP, It can also be hypothesized that ejaculated sperm from obese
subsequent activation of PKA and, ultimately, tyrosine kinase males exhibit reduced capacitation through leptin receptor
activation and protein tyrosine phosphorylation, necessary for downregulation in response to high seminal plasma leptin [138] .
acquisition of hyperactivated sperm motility [6,7] . Leptin acti- Many knowledge gaps remain to be elucidated, including a
vation of prosurvival pathways may lead to the activation of greater understanding of BBB and TBB leptin transport, the
ERK1/2 signaling [135,140] , representing capacitation signaling differential roles and associated signaling pathways associated
crosstalk. It is intriguing to speculate that acrosomal leptin recep- with soluble and transmembrane leptin receptor isoforms in the
tor expression is associated with cholesterol efflux and acrosome brain, testis and sperm, with further study required to enable
reaction, whereas tail leptin receptor expression in human sperm the characterization of leptin’s modulation for reproduction in
may reflect leptin’s modulation of hyperactivated sperm motility. the obese male.

www.expert-reviews.com 239
 Review Phillips & Tanphaichitr

Research studies using animals provide

Heat-stress better models and opportunity to inves-
hypoxia tigate the biological effects of thermal
P stress on testicular functions and struc-
Caspase-2 p38MAPK
2 Bcl2 ture. Various experimental approaches
1 have been used. One mechanism used to
Disrupted X
Bax:Bcl2 elevate testicular temperatures in rats [153]
and mice [154,155] is transient exposure of
Cytochrome C the animals to temperatures exceeding
Apoptosis 4 3 40°C. Alternatively, surgically induced
cryptorchidism is used in mice to elevate
Caspase-3 testicular temperature to the body tem-
perature [156] . In another design, mice
ICAD 3
are housed at 35–38°C over a period of
several hours to induce thermal stress
HSF1
[157,158] . Major reproductive outcomes
in responses to hyperthermia include
CAD
decreased testicular weights, germ cell
HSE
loss and increased rates of apoptosis.
Testicular heat-stress responses involve
Downregulated Upregulated complex signaling pathways with inter-
DNA repair genes Hif1α
connection among hypoxia, apoptosis,
ICAD HSF1
Hsp70 Testicular antioxidants gene expression and inhibition of DNA
Germ cell antioxidants repair, which eventually culminates in
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
altered spermatogenesis.
Figure 10. Model of testicular heat stress. In response to testicular heat stress, Elevations in temperature and other
apoptosis pathways may be activated through several mechanisms. Caspase-2 perturbs environmental stressors, including oxi-
the ratio of apoptotic proteins Bax:Bcl2 and directly activates apoptosis. p38MAPK (also dative stress and chemical exposures, are
known as MAPK14) phosphorylates Bcl2, thereby removing the inhibitory block to known to trigger intracellular changes in
apoptosis. Caspase-2 and/or caspase-3 degrade ICAD, leading to activation of CAD and
gene expression, resulting in altered cell
DNA fragmentation. Caspase-2 activates HSF1, which downregulates expression of DNA
repair genes, ICAD, Hsp70, germ cell antioxidants, upregulates Hif1a, HSF1 and testicular survival/apoptosis pathways. Heat stress
antioxidants, and induces apoptosis. Dotted lines indicate proposed mechanisms and induces increased expression of a class of
solid lines indicate established mechanisms. 70-kDa heat-shock proteins (Hsp70), a
CAD: Caspase-activated DNase; HSF: Heat-shock factor; Hsp: Heat-shock protein; class of chaperone proteins that help regu-
ICAD: Inhibitor of caspase-activated DNase; P: Phosphorylation
late protein folding and assembly [159,160] .
Hsp70 also play an important role in
Heat stress, hypoxia-induced testicular apoptosis the prevention of apoptosis [161,162] . At least two testis-specific
It is well established that the testis is sensitive to heat, evidenced Hsp70 have been identified. Spermatocyte-specific Hsp70.2
by the approximately 3°C lower temperature of the scrotum com- (mice) is continuously expressed by pachytene spermatocytes
pared with core body temperature, a condition critical for efficient during meiosis and is not heat inducible [159] . Testis-specific
spermatogenesis [147] . Many environmental/lifestyle factors are Hsc70t is similarly expressed in round spermatids. Expression
associated with elevated testicular temperatures including varico- of inducible Hsp70 by germ cells is conflicting. Rockett and
cele [148,149] , tight fitting undergarments, sedentary work positions, colleagues demonstrated upregulation of Hsp70-1 and Hsp70-3
laptop position of portable computers, saunas and occupational in mouse spermatocytes following acute hyperthermia (10 min
heat exposures [37] . Although it is likely that suprapubic and inner at 43°C) [163] . Other researchers reported that testicular heat
thigh adipose tissue in obese males combined with sedentary stress did not increase expression of heat shock genes at the
behaviour increases scrotal temperatures [37] , there are no studies mRNA or protein levels in mouse germ cells [161,164] . Transgenic
that report scrotal temperature measurements in an obese popula- mice designed to express constitutively active heat-shock factor
tion. As increased scrotal temperature during sedentary activities (HSF1) in spermatocytes did not induce Hsp70 gene expres-
is associated with impaired semen quality [150–152] , it follows that sion but did activate caspase-dependent apoptosis pathways in
obese men would be at risk of genital heat stress and infertility. the absence of heat shock [161] . HSF1 is a transcription factor
Testicular scrotal temperature measurements are difficult to obtain activated during stress (hypoxia and hyperthermia); it trimer-
in humans and data regarding duration of sustained sedentary izes, translocates to the nucleus and binds heat-shock response
position is not often collected, underscoring the need for more elements in the promoter regions of HSF1 target genes [165,166].
well-designed testicular thermal stress research studies. Hsp70 does not appear to be sufficient to prevent HSF1-induced

240 Expert Rev. Endocrinol. Metab. 5(2), (2010)


apoptosis as mouse spermatocytes with constitutive expression
of both Hsp70 and HSF1 exhibited characteristic DNA strands
breaks consistent with apoptosis [161] .
The mechanism underlying heat-stress-induced apopto-
sis appears to be primarily regulated by HSF1 (F igur e 10) .
Intriguingly, the endogenously established temperature ‘set-
point’ for HSF1 activation is higher for core somatic tissues
compared with the testis, consistent with external location of
the male reproductive organ in mammalian species. Thus, tes-
ticular tissues are exquisitely sensitive to even mild hyperther-
mia through regulation by HSF1. Persistent testicular HSF1
activation is observed in cryptorchid mice and is associated
with disrupted spermatogenesis [164] . HSF1 may even down-
regulate Hsp70 to ensure unopposed activation of apoptosis
pathways. In early developmental stages of mouse spermato-
cytes that express HSF1, Hsp70.2 protein undergoes trans-
location from the cytoplasm to the nucleus. At later stages of
development, germ cells exhibit HSF1-mediated repression
of Hsp70.2 following hyperthermia. Widlak and colleagues
propose that a reduction in both Hsp70.2 mRNA and protein
levels occurs prior to heat-stress induction of apoptosis, with
both events mediated by HSF1 [167] . Depending on the condi-
tions of experimentally induced testicular heat stress and the
subsequent assays to detect Hsp70, HSF1’s negative regulation
of Hsp70 expression and nuclear translocation may explain the
inconsistencies regarding spermatocyte expression of Hsp70 in
the literature discussed earlier.
Other important changes in testicular cells in response to
heat stress include downregulation of DNA repair pathways
and activation of p38MAPK signaling (Figure 10) . Mouse testis
exposed to acute heat stress (43°C for 10 min) down­regulate
DNA repair genes, including Ogg1 (base excision repair), Xpg
(nucleotide excision repair) and Rad54 (double-strand break
repair) [163] . Decreased expression of poly (ADP-ribose) poly-
merase PARP (base excision repair/nucleotide excision repair
pathways) also occurs in the rat testis in response to heat stress
[168] . With DNA repair pathways disabled, apoptosis is induced
via multiple mechanisms, including direct hyperthermic/
hypoxic stress. Heat stress induces activation of p38MAPK
(also known as MAPK14), which, in turn, phosphorylates
Bcl2, thereby removing the inhibitory block to apoptosis
[169] . Apoptosis is regulated, in part, by the balance between
proapoptotic proteins (e.g., Bax) and antiapoptotic proteins
(e.g., Bcl2). Caspase-2 is proposed to be activated upstream
of p38MAPK by hyperthermia and/or reactive oxygen spe-
cies produced during hypoxia. Caspase-2 may also perturb the
ratio of Bax:Bcl2 [170] and directly activate caspase-3, thereby
promoting apoptosis [170,171] . Finally, heat-stress-induced cleav-
age of inhibitor of caspase-activated DNase (ICAD) via cas-
pase-3 activation [154] or directly via caspase-2 activation [171]
produces the final fragmentation of nuclear DNA. Another
mechanism, yet to be defined, links hyperthermic stress with
induced activation of HSF1, which, in turn, promotes apop-
tosis of pachytene spermatocytes [164] . Testicular heat stress
is accompanied by localized hypoxia that induces oxidative
www.expert-reviews.com
Obesity & semen quality Review
Mitosis Spermatogonia
Susceptibilty to
heat stress
Mitosis
Pachytene
spermatocyte
Meiosis I
Secondary
spermatocytes
Meiosis II
Round spermatids
Elongated
spermatids
Testicular
spermatozoa
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
Figure 11. Spermatocytes exhibit stage-specific
susceptibility to heat stress. Testicular germ cells exhibit
stage-specific susceptibility to heat stress. Pre-meiotic germ cells
express cell survival factors that protect them against heat stress.
By contrast, meiotic germ cells (pachytene spermatocytes and
round spermatids) are most susceptible to heat stress; they also
have limited capacity for DNA repair.
stress, apoptosis and reduction in DNA repair gene expression
(F igure 10). Increases in testicular cell metabolism during heat
stress may be so high that testicular blood flow cannot provide
sufficient tissue oxygenation, thereby creating oxidative stress
to the tissue [155] . During hypoxia, hypoxia-inducible factor
(Hif )-1a translocates from the cytoplasm to the nucleus to
form a heterodimer with Hif-1b (also known as aryl hydrocar-
bon receptor nuclear translocator), now known as HIF1. The
formation of the Hif-1a–Hif-1b heterodimer provides genomic
protection from oxidative stress [172] . Following mild hyperther-
mia, the mouse testis undergoes hypoxia and oxidative stress
and responds with increased expression of Hif-1a mRNA/pro-
tein in the interstitial compartment and increased expression
of Hif-1a protein in the nuclei of germ cells [155] . Antioxidants,
expressed during hypoxia, are downregulated in mouse germ
cells following hyperthermia [163] , but not in testicular somatic
cells, as whole mouse testis exhibit increased expression of tes-
ticular anti­oxidants (HMOX1, GPX1 and GSTA) following
heat stress [155] . Thus, germ cells are particularly vulnerable to
hypoxia and hyperthermia, which, in turn, induce apoptosis
pathways and ultimately loss of male germ cells.
241
 Review Phillips & Tanphaichitr

apoptosis of actively dividing germ cells

would reduce sperm counts, thus con-
tributing to male infertility in morbidly
Adult-onset diseases
obese men. Animal studies also point to
Obesity diminished embryo survival following
Diabetes paternal heat stress [157,158,163,174] , provid-
Cardiovascular disease ing another mechanism by which testicu-
Reproductive cancers
Infertility
lar heat stress contributes to reproductive
loss. There remain significant technical
limitations in measuring scrotal tempera-
tures in humans in a relatively noninva-
0 10 20 30 40
sive manner. These limitations must be
Weeks overcome to further investigate the rela-
tionship between testicular hyperthermia,
obesity and male infertility.
Expert Rev. Endocrinol. Metab. © Future Science Group (2010)

Figure 12. Fetal origins of adult-onset diseases. Endocrine disruption

The testis exhibits germ cell stage-specific susceptibility to heat
stress (Figure 11) . As described previously, premeiotic germ cells
express cell survival factors, including HSF1 and Hsp70, that protect
against heat stress [161,164] . In response to heat stress, as spermatocytes
undergo meiosis, they begin to exhibit significant DNA damage that
subsequently initiates apoptosis pathways [154] . HSF1 seems to be
associated with cell survival only in premeiotic and somatic cells,
such that meiotic (pachytene spermatocytes and early spermatids)
and postmeiotic stages are most susceptible to heat stress [153,154,173] .
Taken together, it can be speculated that a combination of fac-
tors, including sedentary lifestyle and suprapubic and inner thigh
adipose tissue deposits, increase testicular temperatures, thereby
triggering apoptosis pathways. As discussed, heat-stress-induced
It has been well established that envi-
ronmental chemicals (endocrine disrupters) are reproductive
toxicants and can be associated with impaired semen quality
and reproductive potential in animals and humans [175–178] . An
endocrine disruptor is defined as [176] :
“as an exogenous agent that interferes with the synthesis, secretion,
transport, binding, action or elimination of natural hormones in
the body that is responsible for the maintenance of homeostasis,
reproduction, development and/or behavior.”
Baillie-Hamilton proposed that the obesity epidemic over
the past 40 years may also be related to the increased use of
industrial chemicals with demonstrated endocrine-modulating

A B Fatty acids, ‘obesogens’

Estrogens Retinoid acid
Estrogen-dependent Adipocyte differentiation/
gene expression proliferation
ER-α
RXR PPAR-γ
ERE PPRE

C D Fatty acids, ‘obesogens’

Diethylstilbestrol Retinoid acid
Adipogenic effects? Unknown effects?
ER-α
RXR PPAR-γ
PPRE ERE

Expert Rev. Endocrinol. Metab. © Future Science Group (2010)

Figure 13. ER-α- and PPAR-γ-dependent gene expression. (A) ER-α. Following ligand (estrogens) binding, ER-α forms a homodimer
that together with transcription factors, assemble as a pre-initiation complex at the ERE present in the promoter region of estrogen-
responsive genes. (B) PPAR-γ. Once activated by ligand (fatty acids, putative obesogens), PPAR-γ forms a heterodimer with RXR and
binds as a complex to PPRE in target gene promoter regions. (C) DES-mediated ER-α and PPAR-γ signal crosstalk. ER-α may also bind the
PPRE consensus sequence. DES-binding to ER-α induces adipogenic effects in the rodent penis, possibly through PPAR-γ signal crosstalk.
(D) PPAR-γ and ER-α signal crosstalk. Similarly, PPAR-γ may bind the ERE consensus sequence. Although the consequences on male
reproduction are unknown, such signal crosstalk may represent yet another mechanism by which putative obesogens including
phthalates, organotins and phytoestrogens may disrupt endocrine function.
DES: Diethylstilbestrol; ER: Estrogen receptor; ERE: Estrogen response element; PPRE: PPAR response elements; RXR: Retinoid X receptor.

242 Expert Rev. Endocrinol. Metab. 5(2), (2010)

 Obesity & semen quality Review

activity [179–181] . Male infertility and obes-

ity may therefore share an environmental A GnRH B
GnRH
etiology caused by perturbations in normal
Insulin Leptin
endocrine pathways. FSH, LH
resistance resistance
The Barker hypothesis relates poor fetal FSH, LH
nutrition to adult-onset diseases including T Insulin
coronary heart disease, Type 2 diabetes Leptin
and metabolic dysfunction [182] , and has 1 2
formed the basis for the developmental ori-
1
gins of health and disease paradigm, which
Leptin
similarly posits a correlation between peri- T E2
T 1
natal health and the eventual develop-
T
ment of chronic diseases (Figure 12) [183,184] .
Toxicologists have also identified neona- 3 t°C
2
tal development as a ‘critical window of Chemical
exposure’, such that chemical exposures obesogens
(e.g., endocrine disrupters) have been
linked to adult-onset reproductive cancers
[177,185,186] . Taken together, these models
support the extreme sensitivity of the neo-
natal period to environmental influences, Expert Rev. Endocrinol. Metab. © Future Science Group (2010)
and as proposed by Baillie-Hamilton [179]
Figure 14. Mechanisms of obesity-induced male infertility. (A) Normal-weight
and Newbold and colleagues [187] , the males. In normal-weight individuals, male reproduction is stimulated by the
models provide an explanation for fetal hypothalamus–pituitary–testis (HPT) axis, with negative feedback provided by
origins of adult obesity risk. testosterone. Increasing evidence points to the stimulatory roles of leptin and insulin in
The intersection between estrogenic the HPT axis including testis functions. (B) Obese males. Male obesity is characterized by
and adipogenic pathways has been best high serum estrogen, leptin and insulin levels. Testicular testosterone production is
reduced, but may still provide negative feedback to the HPT axis (not shown), although
examined in a series of studies defining to a lesser extent than in the normal-weight males. Three main biological mechanisms
adipogenesis in penile corpus cavernosum link obesity to impaired male reproductive function: (1) hypogonadism:
induced by activation of ER-α by potent hypogonadotropic hypogonadism caused by negative feedback by estrogens or
estrogen disrupter, diethylstilbestrol insulin/leptin resistance, and hypergonadotropic hypogonadism caused by direct actions
(DES) (Figure 13A) [188–190] . Neonatal expo- of leptin on the testis, (2) testicular heat-stress-/hypoxia-induced apoptosis, and (3)
endocrine disruption by ‘obesogens’: environmental chemicals that may be stored in
sure to DES (3–4 mg/kg) generates adult adipose tissue and have the potential to modulate both estrogenic and adipogenic
rats that are infertile with gross penile pathways. Dotted lines indicate proposed mechanisms and solid lines indicate
abnormalities, including the appearance established mechanisms.
of adipocytes in the cavernous spaces of E2: Estradiol; FSH: Follicle-stimulating hormone; GnRH: Gonadotropin-releasing
the corpora cavernosa penis. Similarly, his- hormone; LH: Luteinizing hormone; T: Testosterone; t: Temperature.
tological changes to the penis along with
male infertility were observed following postnatal exposures to genes involved in fatty acid storage and the repression of genes
DES (1 mg/kg) [188,189] . Goyal and colleagues have hypothesized necessary for adipocyte lipolysis. Once activated by ligand (fatty
that estrogen-dependent differentiation and proliferation of stro- acids, putative obesogens), PPAR-γ forms a heterodimer with
mal cells occur following estrogen exposure during a critical retinoid X receptor and binds as a complex to PPAR response
development period (1–12 postnatal days) [190] . This transforma- elements in target gene promoter regions (Figure 13B) [193] . ER-α
tion replaces endothelial and smooth muscle cells in the corpora and PPAR-γ pathways exhibit several instances of ‘signal cross-
cavernosa with adipocytes, resulting in grossly abnormal mor- talk’, including shared coactivators involved in adipocyte dif-
phology of the penis and infertility. Transgenic mice lacking ferentiation such as the recently identified constitutive coactiva-
ER-α (α-ERKO) are ‘resistant’ to neonatal DES exposure and tor of PPAR-γ [193] . ER-α and PPAR-γ may each bind directly
do not exhibit penile deformities. These studies thereby confirm to either PPAR response elements [194] or estrogen response
a role for ER-α in DES-mediated abnormalities of the corpora elements (Figure 13C & D) [195–197] . It is the latter mechanism that
cavernosa in both rats and mice [191] . Furthermore, this develop- is proposed to trigger DES-induced differentiation of stromal
mental disruption has been recently elucidated as a ‘biological cells and subsequent penile abnormalities in rodents [192] .
overlap’ between PPAR-γ and ER-α (Figure 13B & C) [192] . Modulation of adipocyte function and differentiation is
The PPAR family includes three isotypes PPAR-α, -b and -γ. now recognized as a subset of endocrine disruption. Such envi-
PPAR-γ, a nonsteroidal nuclear receptor, regulates proliferation ronmental chemicals have been termed ‘metabolic disrupt-
and differentiation of adipocytes through the promotion of ers’ [198] or ‘obesogens’ [199] . Obesogenic pathways proposed

www.expert-reviews.com 243
 Review Phillips & Tanphaichitr
include nuclear receptors involved in lipid metabolism, such as
PPAR-γ, liver X receptor and farnesoid X receptor [200] . Several
xeno-PPAR-γ ligands have been identified, including phthalate
monoesters [201] , such as di(2-ethylhexyl) phthalate [202] and its
metabolite mono(2-ethylhexyl)phthalate [198] , organotin com-
pounds triphenyltin and tributyltin [200,203–206] , dioxins [207] and
phytoestrogen genistein [208] , many of which have established
toxicity to the reproductive system [178,209] . Studies performed in
laboratory and wildlife animals provide additional evidence for
crosstalks between endocrine and adipogenic pathways, further
implicating that environmental contaminants, which can be
endocrine disrupters, probably also modulate adipocyte differen-
tiation and contribute to reproductive pathologies (Figure 13C & D) .
Conclusion
Three main biological mechanisms can be used to explain the
relationship between obesity and male infertility: hypogonad-
ism; testicular heat-stress-/hypoxia-induced apoptosis and
endocrine disruption by obesogens (Figure 14) . Obesity-induced
hypogonadism appears to be present in most morbidly obese
men, driven by peripheral conversion of androgens to estrogens
and leptin/insulin resistance. Obese men diagnosed with hypo-
gonadism may have several treatment options, including weight
loss and short-term aromatase inhibitor treatment. Similarly,
testicular heat stress, although difficult to ascertain medically,
could be anticipated following gradation of the pannus (supra-
pubic/abdominal fat overhang). Testicular heat stress may be
alleviated through increased activity, weight loss and use of
air-cooling devices during sleep. Future areas for investigation
include the roles of adipocytokines and endocrine disrupters
in male fertility and obesity. Prenatal exposures to endocrine
disrupters may reprogram not only reproductive and endocrine
pathways but also molecular modulation of adipocytes. Obesity
is, therefore, a causal factor in male infertility, and for some
individuals, prenatal exposures may confer additional risk via
intersecting endocrine and adipogenic signaling pathways.
Expert commentary
Clinical knowledge in the identification and treatment of obe-
sity‑induced male infertility is still lacking. The assessment of
male infertility relies on numbers of sperm and morphological
abnormalities, with little functional analysis beyond estimates
of motility. Subfertility is undoubtedly underestimated, simply
because clinics lack tools to provide functional semen analysis,
including sperm–egg binding and acrosome/capacitation assays.
Screening for insulin resistance and hypogonadism should be
considered as part of infertility diagnostics for overweight and
obese male patients. As the age of onset for Type 2 diabetes is
declining, men under the age of 40 years should be included in
this screening. BMI and waist:hip ratio data should be collected
for male infertility patients along with standard endocrine pro-
files to identify who would benefit from weight loss or treatment
with hormone therapies. Medications used to treat Type 2 dia-
betes (sulfonylureas, biguanides, e.g., metformin and thiazoli-
dinediones) have not been well examined for their impacts on
244
male fertility. Information on exposure to endocrine disrupters
and other environmental contaminants should be gathered by
occupation and lifestyle questionnaires and it may help explain
idiopathic forms of male infertility. In general, it is anticipated
that the obese man is likely to exhibit hypogonadism and is
hyperestrogenic, conditions that would cause the greatest risk
to male infertility.
Five-year view
The issue of infertility in the obese male is critical in the context
of the obesity epidemic in the Western world. Within the next
5 years, the obesity epidemic will begin to evolve into the Type 2
diabetes epidemic, with an explosion of men and women devel-
oping insulin resistance. As we learn more about the molecular
biology underlying insulin resistance, the intriguing findings of
concomitant suppression of Leydig cell testosterone production
may be further elucidated. Certainly, there is a need for more
robust studies examining semen quality in insulin-resistant
men. Adipocytokines are hormones released from adipocytes,
including leptin (reviewed here), resistin and adiponectin.
Investigation of the physiological roles of these adipocytokines
is in its infancy, although links between adipocytokines and
insulin resistance have already been postulated. Kisspeptins
and their modulation of the hypothalamic–pituitary–gonadal
axis in both men and women is a field that is developing at a
rapid pace. Understanding the neuroendocrine modulation of
the reproductive system and its potential sensitivity to endocrine
disrupters and nutritional stressors will contribute significantly
to this field. The contribution of environmental stressors (nutri-
tion, endocrine disrupters and infectious agents) to fetal devel-
opment, and ultimately adult-onset diseases, including obesity
and infertility, will be investigated using molecular approaches.
Although this review has focused on male infertility, the poten-
tial for environmental stressors to create epigenetic changes
to the germ line will have important implications for future
generations. Endocrine disrupters, particularly environmental
estrogens, are well-established reproductive toxicants and target
steroid hormone signaling pathways associated with nuclear
receptor superfamily members. The recent characterization
of nongenomic steroid hormone receptors has the potential to
revolutionize the field of endocrinology. Chemicals with the
capacity to perturb adipose physiology have only recently been
identified and termed obesogens or metabolic disrupters. The
importance of these chemicals to obesity, diabetes and male
infertility remains to be elucidated.
Financial & competing interests disclosure
Nongnuj Tanphaichitr is supported by grants from the Canadian
Institutes of Health Research (CIHR) and the Natural Sciences and
Engineering Research Council of Canada (NSERC). The authors have
no other relevant affiliations or financial involvement with any organiza-
tion or entity with a financial interest in or financial conflict with the
subject matter or materials discussed in the manuscript apart from
those disclosed.
No writing assistance was utilized in the production of this manuscript.
Expert Rev. Endocrinol. Metab. 5(2), (2010)
 Obesity & semen quality Review

Key issues
• BMI is negatively correlated with subfertility.
• Metabolic syndrome, including obesity and diabetes, intersects with male infertility due to hypogonadism.
• Adipose tissue secretes leptin and estrogen, both of which modulate male reproduction.
• Leptin has central effects at the hypothalamus, which indirectly stimulates release of gonadotropins.
• Leptin has local testicular effects, negatively regulating spermatogenesis and steroidogenesis.
• Testicular temperature elevations in obese, sedentary men may be sufficient to impair spermatogenesis.
• Fetal period represents a critical window of development, wherein environmental stressors (nutrition, chemical exposures) may
contribute to adult onset diabetes, obesity or infertility.
• Obesogens, or metabolic disrupters, are chemicals in the environment that modulate adipogenic pathways and may also
impair reproduction.

References
1 Adamson GD, Baker VL. Subfertility:
causes, treatment and outcome. Best Pract.
Res. Clin. Obstet Gynaecol. 17, 169–185
(2003).
2 Kasturi SS, Tannir J, Brannigan RE. The
metabolic syndrome and male infertility.
J. Androl. 29, 251–259 (2008).
3 Mokdad AH, Serdula MK, Dietz WH,
Bowman BA, Marks JS, Koplan JP. The
spread of the obesity epidemic in the
United States, 1991–1998. JAMA 282,
1519–1522 (1999).
4 Mokdad AH, Ford ES, Bowman BA et al.
Prevalence of obesity, diabetes, and
obesity-related health risk factors, 2001.
JAMA 289, 76–79 (2003).
5 Collins S. Overview of clinical
perspectives and mechanisms of obesity.
Birth Defects Res. 73, 470–471 (2005).
6 Naz RK, Rajesh PB. Role of tyrosine
phosphorylation in sperm capacitation/
acrosome reaction. Reprod. Biol.
Endocrinol. 9(2), 75 (2004).
7 Visconte PE. Understanding the
molecular basis of sperm capacitation
through kinase design. PNAS 106(3),
667–668 (2009).
8 World Health Organization. WHO
Laboratory Manual for the Examination of
Human Semen and Sperm – Cervical
Mucus Interaction (4th Edition).
Cambridge University Press, Cambridge,
UK (1999).
9 Carruthers M, Trinick TR, Jankowska E,
Traish AM. Are the adverse effects of
glitazones linked to induced testosterone
deficiency? Cardiovasc. Diabetol. 7, 30
(2008).
10 Price TM, O’Brien SN, Welter BH,
George R, Anandjiwala JK. Oestrogen
regulation of adipose tissue lipoprotein
lipase-possible mechanisms of body fat
distribution. Am. J. Obstet. Gynecol. 178,
101–107 (1998).
11 Singh R, Artaza JN, Taylor WE,
Gonzalez-Cadavid NF, Bhasin S.
Androgens stimulate myogenic
differentiation and inhibit adipogenesis in
C3H 10T1/2 pluripotent cells through an
androgen receptor-mediated pathway.
Endocrinology 144(11), 5081–5088
(2003).
12 Singh R, Artaza JN, Taylor WE et al.
Testosterone inhibits adipogenic
differentiation in 3T3- L1 cells: nuclear
translocation of androgen receptor complex
with β-catenin and T-cell factor 4 may
bypass canonical Wnt signaling to
down-regulate adipogenic transcription
factors. Endocrinology 147(1), 141–154
(2006).
13 McTernan PG, Anderson LA, Anwar AJ.
Glucocorticoid regulation of P450
aromatase activity in human adipose tissue:
gender and site differences. J. Clin.
Endocrin. Metab. 87(3), 1327–1336
(2002).
14 Oken E. Gillman MW. Fetal origins of
obesity. Obes. Res. 11, 496–506 (2003).
15 Pauli EM, Legro RS, Demers LM,
Kunselman AR, Dodson WC, Lee PA.
Diminished paternity and gonadal function
with increasing obesity in men. Fertil.
Steril. 90, 346–351 (2008).
16 Romero-Corral A, Lopez-Jimenez F,
Sierra-Johnson J, Somers VK.
Differentiating between body fat and lean
mass-how should we measure obesity? Nat.
Clin. Pract. Endocrinol. Metab. 4, 322–323
(2008).
17 Jensen TK, Andersson AM, Jorgensen N
et al. Body mass index in relation to semen
quality and reproductive hormones among
1,558 Danish men. Fertil. Steril. 82,
863–870 (2004).
18 Hammoud AO, Wilde N, Gibson M, Parks
A, Carrell DT, Meikle AW. Male obesity
and alteration in sperm parameters. Fertil.
Steril. 90(6), 2222–2225 (2008).
19 Kort HI, Massey JB, Elsner CW et al.
Impact of body mass index values on sperm
quantity and quality. J. Androl. 27,
450–452 (2006).
20 Koloszár S, Fejes I, Závaczki Z, Daru J,
Szöllosi J, Pál A. Effect of body weight
on sperm concentration in
normozoospermic males. Arch. Androl.
51, 299–304 (2005).
21 Hofny ER, Ali ME, Abdel-Hafez HZ et al.
Semen parameters and hormonal profile in
obese fertile and infertile males. Fertil.
Steril. DOI: 10.1016/j.fertstert.2009.03.085
(2009) (Epub ahead of print).
22 Aggerholm AS, Thulstrup AM, Toft G,
Ramlau-Hansen CH, Bonde JP.
Is overweight a risk factor for reduced
semen quality and altered serum sex
hormone profile? Fertil. Steril. 90,
619–626 (2008).
23 Duits FH, van Wely M, van der Veen F,
Gianotten J. Healthy overweight male
partners of subfertile couples should not
worry about their semen quality. Fertil.
Steril. DOI: 10.1016/j.fertnstert.
2009.05.075 (2009) (Epub ahead of print).
24 Nicopoulou SC, Alexiou M, Michalakis K
et al. Body mass index vis-à-vis total sperm
count in attendees of a single andrology
clinic. Fertil. Steril. 92(3), 1016–1017
(2009).
25 Ramlau-Hansen CH, Thulstrup AM, Nohr
EA, Bonde JP, Sørensen TI, Olsen J.
Subfecundity in overweight and obese
couples. Hum. Reprod. 22(6), 1634–1637
(2007).
26 Sallmén M, Sandler DP, Hoppin JA, Blair
A, Baird DD. Reduced fertility among
overweight and obese men. Epidemiol.
17(5), 520–523 (2006).
27 Nguyen RH, Wilcox AJ, Skjaerven R,
Baird DD. Men’s body mass index and
infertility. Human Reprod. 22(9),
2488–2493 (2007).

www.expert-reviews.com 245
 Review Phillips & Tanphaichitr
28 Fejes I, Koloszar S, Zavackcski Z, Daru J,
Szollosi J, Pal A. Effect of body weight on
testosterone/estradiol ratio in
olgozoospermic patients. Arch. Androl. 52,
97–102 (2006).
29 Zorn B, Osredkar J, Meden-Vrtovec H,
Majdic G. Leptin levels in infertile male
patients are correlated with inhibin B,
testosterone and SHBG but not with sperm
characteristics. Int. J. Androl. 30, 439–444
(2007).
30 Kley HK, Solbach HG, McKinnan JC,
Krüskemper HL. Testosterone decrease and
estrogen increase in male patients with
obesity. Acta Endocrinol. 91, 553–563,
(1979).
31 Zumoff B, Strain GW, Miller LK et al.
Plasma free and non-SHBG-bound
testosterone are decreased in obese men in
proportion to their degree of obesity.
J. Clin. Endocrinol. Metab. 71, 929–931
(1990).
32 Strain GW, Zumoff B, Miller LK et al.
Effect of massive weight loss on
hypothalamic–pituitary–gonadal function
in obese men. J. Clin. Endocrinol. Metab.
66, 1019–1023 (1988).
33 Zumoff B, Strain GW. A perspective on
the hormonal abnormalities of obesity: are
they cause or effect? Obes. Res. 2, 56–67,
(1994).
34 Schneider G, Kirschner MA, Berkowitz R,
Ertel NH. Increased estrogen production in
obese men. J. Clin. Endocrinol. Metab. 48,
633–638 (1979).
35 Zumoff B, Strain GW, Kream J, O’Connor
J, Levin J, Fukushima DK. Obese young
men have elevated plasma estrogen levels,
but obese premenopausal women do not.
Metabolism 30, 1011– 1014 (1981).
36 Strain GW, Zumoff B, Kream J et al. Mild
hypogonadotropic hypogonadism in obese
men. Metabolism 31, 871–875 (1982).
37 Jung A, Schuppe HC. Influence of genital
heat stress on semen quality in humans.
Andrologia 39(6), 203–215 (2007).
38 Gat Y, Zukerman Z, Chakraborty J,
Gornish M. Varicocele, hypoxia and male
infertility. Fluid mechanics analysis of the
impaired testicular venous drainage
system. Hum. Reprod. 20(9), 2614–2619
(2005).
39 Petak SM, Nankin HR, Spark RF et al.
American association of clinical
endocrinologists medical guidelines for
clinical practice for the evaluation and
treatment of hypogonadism in adult male
patients – 2002 update. Endocr. Pract. 8,
439–456 (2002).
246
40 Couse JF, Lindzey J, Grandien K,
Gustafsson JA, Korach KS. Tissue
distribution and quantitative analysis of
estrogen receptor-a (ERa) and estrogen
receptor-b (ERb) messenger ribonucleic acid
in the wild-type and ERa-knockout mouse.
Endocrinology 138, 4613–4621 (1997).
41 Laflamme N, Nappi RE, Drolet G, Labrie
C, Rivest S. Expression and
neuropeptidergic characterization of
estrogen receptors (ERa and ERb)
throughout the rat brain: anatomical
evidence of distinct roles of each subtype.
J. Neurobiol. 36, 357–378 (1998).
42 Shughrue PJ, Lane MV, Merchenthaler I.
Comparative distribution of estrogen
receptor-a and -b mRNA in the rat central
nervous system. J. Comp. Neurol. 388,
507–525 (1997).
43 Strain GW, Zumoff B. The effect of
bariatric surgery on the abnormalities of
the pituitary–gonadal axis in obese men.
Surg. Obes. Relat. Dis. 2(2), 75–77
(2006).
44 Cohen PG. The hypogonadal–obesity
cycle: role of aromatase in modulating the
testosterone–estradiol shunt – a major
factor in the genesis of morbid obesity.
Med. Hypotheses 52(1), 49–51 (1999).
45 Marin P, Oden B, Bjorntorp P.
Assimilation and mobilization of
triglycerides in subcutaneous abdominal
and femoral adipose tissue in vivo in men:
effects of androgens. J. Clin. Endocrinol.
Metab. 80, 239–243 (1995).
46 Kapoor D, Channer KS, Jones TH.
Rosiglitazone increases bioactive
testosterone and reduces waist
circumference in hypogonadal men with
Type 2 diabetes. Diabetes Vasc. Dis. Res.
5(2), 135–137 (2008).
47 Cohen PG. Aromatase, adiposity, aging
and disease. The hypogonadal–metabolic–
atherogenic-disease and aging connection.
Med. Hypotheses 56(6), 702–708 (2001).
48 Hammoud AO, Gibson, M, Hunt SC,
Carrell D, Adamas TD, Meikle W. Effect
of weight loss after Roux-en-Y gastric
bypass surgery on the male reproductive
hormonal profile. Fertil. Steril. 88, S1–S2
(2007)
49 Roth MY, Amory JK, Page ST. Treatment
of male infertility secondary to morbid
obesity. Nat. Clin. Pract. Endocrinol.
Metab. 4, 415–419 (2008).
50 de Boer H, Verschoor L, Ruinemans-
Koerts J, Jansen M. Letrozole normalizes
serum testosterone in severely obese men
with hypogonadotropic hypogonadism.
Diabetes Obes. Metab. 7, 211–215 (2005).
51 Bierman EL, Bagdade JD, Porte D Jr.
Obesity and diabetes: the odd couple.
Am. J. Clin. Nutr. 21(12), 1434–1437
(1968).
52 Pasquali R, Casimirri F, De Iasio R et al.
Insulin regulates testosterone and sex
hormone-binding globulin concentrations
in adult normal weight and obese men.
J. Clin. Endocrinol. Metab. 80(2),
654–658 (1995)
53 Haffner SM, Shaten J, Stern MP, Smith
GD, Kuller L. Low levels of sex hormone-
binding globulin and testosterone predict
the development of non-insulin-dependent
diabetes mellitus in men. MRFIT Research
Group. Multiple Risk Factor Intervention
Trial. Am. J. Epidemiol. 143, 889–897
(1996).
54 Stellato RK, Feldman HA, Hamdy O,
Horton ES, McKinlay JB. Testosterone, sex
hormone-binding globulin, and the
development of Type 2 diabetes in
middle-aged men: prospective results from
the Massachusetts male aging study.
Diabetes Care 23, 490–494 (2000).
55 Oh JY, Barrett-Connor E, Wedick NM,
Wingard DL; Rancho Bernardo Study.
Endogenous sex hormones and the
development of Type 2 diabetes in older
men and women: the Rancho Bernardo
study. Diabetes Care 25, 55–60 (2002).
56 Laaksonen DE, Niskanen L, Punnonen K
et al. Testosterone and sex hormone-
binding globulin predict the metabolic
syndrome and diabetes in middle-aged
men. Diabetes Care 27(5), 1036–1041
(2004).
57 Niskanen L, Laaksonen DE, Punnonen K,
Mustajoki P, Kaukua J, Rissanen A.
Changes in sex hormone-binding globulin
and testosterone during weight loss and
weight maintenance in abdominally obese
men with the metabolic syndrome. Diabetes
Obes. Metab. 6(3), 208–215 (2004).
58 Laaksonen DE, Niskanen L, Punnonen K
et al. Sex hormones, inflammation and the
metabolic syndrome: a population-based
study. Eur. J. Endocrinol. 149(6), 601–608
(2003).
59 Barrett-Connor E, Khaw KT, Yen SS.
Endogenous sex hormone levels in older
men with diabetes mellitus. Am. J. Epidem.
132, 895–901 (1990).
60 Andersson B, Marin P, Lissner L, Vermeulen
A, Bjorntorp P. Testosterone concentrations
in women and men with NIDDM. Diabetes
Care 17, 405–411 (1994).
61 Dhindsa S, Prabhakar S, Sethi M,
Bandyopadhyay A, Chaudhuri A,
Dandona P. Frequent occurrence of
Expert Rev. Endocrinol. Metab. 5(2), (2010)

hypogonadotropic hypogonadism in Type 2
diabetes. J. Clin. Endocrin. Met. 89,
5462–5468 (2004).
62 Tsai EC, Matsumoto AM, Fujimoto WY,
Boyko EJ. Association of bioavailable, free,
and total testosterone with insulin
resistance: influence of sex hormone-
binding globulin and body fat. Diabetes
Care 27, 861–868 (2004).
63 Osuna JA, Gomez-Perez R, Arata-
Bellabarba G, Villaroel V. Relationship
between BMI, total testosterone, sex
hormone binding-globulin, leptin, insulin
and insulin resistance in obese men. Arch.
Androl. 52, 355–361 (2006).
64 Yeap BB, Chubb SA, Hyde Z et al. Lower
serum testosterone is independently
associated with insulin resistance in
non-diabetic older men: the Health In Men
Study. Eur. J. Endocrinol. 161, 591–598
(2009).
65 Pitteloud N, Mootha VK, Dwyer AA et al.
Relationship between testosterone levels,
insulin sensitivity, and mitochondrial
function in men. Diabetes Care 28,
1636–1642 (2005).
66 Pitteloud N, Hardin M, Dwyer AA et al.
Increasing insulin resistance is associated
with a decrease in Leydig cell testosterone
secretion in men. J. Clin. Endocrinol.
Metab. 90, 2636–2641 (2005).
67 Lin T, Vinson N, Terracio L.
Characterization of insulin and
insulin‑like growth factor receptors in
purified Leydig cells and their role in
steroidogenesis in primary culture:
a comparative study. Endocrinology 119,
1641–1647 (1986).
68 Bebakar WM, Honour JW, Foster D, Liu
YL, Jacobs HS. Regulation of testicular
function by insulin and transforming
growth factor-b. Steroids 55, 266–269
(1990).
69 Burcelin R, Thorens B, Glauser M,
Gaillard RC, Pralong FP. Gonadotropin-
releasing hormone secretion from
hypothalamic neurons stimulation by
insulin and potentiation by leptin.
Endocrinology 144, 4484–4491 (2003).
70 Echavarría Sánchez MG, Franco Laguna E,
Juárez Bengoa A, Villanueva Díaz CA.
Seminal quality and hormones in patients
with diabetes mellitus Type 2. Ginecol.
Obstet. Mex. 75, 241–246 (2007).
71 Ali ST, Shaikh RN, Siddiqi NA, Siddiqi
PQ. Semen analysis in insulin-dependent/
non-insulin-dependent diabetic men with/
without neuropathy. Arch. Androl. 30,
47–54 (1993).
www.expert-reviews.com
Obesity & semen quality
72 Vignon F, Le Faou A, Montagnon D et al.
Comparative study of semen in diabetic
and healthy men. Diabetes Metab. 17,
350–354 (1991).
73 Zhang Y, Proenca R, Maffei M, Barone M,
Leopold L, Friedman JM. Positional
cloning of the mouse obese gene and its
human homologue. Nature 372, 425–432
(1994).
74 Lee GH, Proenca R, Montez JM et al.
Abnormal splicing of the leptin receptor in
diabetic mice. Nature 379, 632–635
(1996).
75 Wang MY, Zhou YT, Newgard CB, Unger,
RH. A novel leptin receptor isoform in rat.
FEBS Lett. 392, 87–90 (1998).
76 Frühbeck G. Intracellular signalling
pathways activated by leptin. Biochem. J.
393(Pt 1), 7–20 (2006).
77 Tartaglia LA. The leptin receptor. J. Biol.
Chem. 272(10), 6093–6096 (1997).
78 Lammert A, Kiess W, Bottner A, Glasow
A, Kratzsch J. Soluble leptin receptor
represents the main leptin binding activity
in human blood. Biochem. Biophys. Res.
Commun. 283(4), 982–988 (2001).
79 Halaas JL, Gajiwala KS, Maffei M et al.
Weight-reducing effects of the plasma
protein encoded by the obese gene. Science
269(5223), 543–546 (1995).
80 Tena-Sempere M, Barreiro ML. Leptin in
male reproduction: the testis paradigm.
Mol. Cell. Endocrinol. 188(1–2), 9–13
(2002).
81 Cohen P, Zhao C, Cai X et al. Selective
deletion of leptin receptor in neurons leads
to obesity. J. Clin. Invest. 108, 1113–1121
(2001).
82 Chua SC, Chung WK, Wu-Peng XS et al.
Phenotypes of mouse diabetes and rat fatty
due to mutations in the OB (leptin)
receptor. Science 271, 994–996 (1996).
83 Gibson WT, Farooqi IS, Moreau M et al.
Congenital leptin deficiency due to
homozygosity for the d133G mutation:
report of another case and evaluation of
response to four years of leptin therapy.
J. Clin. Endocrinol. Metab. 89(10),
4821–4826 (2004).
84 Strobel A, Issad T, Camoin L, Ozata M,
Strosberg AD. A leptin missense mutation
associated with hypogonadism and morbid
obesity. Nat. Genet. 18, 213–215 (1998).
85 Ozata M, Ozdemir IC, Licinio J. Human
leptin deficiency caused by a missense
mutation: multiple endocrine defects,
decreased sympathetic tone, and immune
system dysfunction indicate new targets for
leptin action, greater central than
Review
peripheral resistance to the effects of leptin,
and spontaneous correction of leptin-
mediated defects. J. Clin. Endocrinol.
Metab. 84(10), 3686–3695 (1999).
86 Mazen I, El-Gammal M, Abdel-Hamid M,
Amr K. A novel homozygous missense
mutation of the leptin gene (N103K ) in an
obese Egyptian patient. Mol. Genet. Metab.
97(4), 305–308 (2009).
87 Farooqi IS, Wangensteen T, Collins S et al.
Clinical and molecular genetic spectrum of
congenital deficiency of the leptin receptor.
N. Engl. J. Med. 356(3), 237–247 (2007).
88 Farooqi IS, Jebb SA, Langmack G et al.
Effects of recombinant leptin therapy in a
child with congenital leptin deficiency.
N. Engl. J. Med. 341, 879–884 (1999).
89 Farooqi IS, Matarese G, Lord GM et al.
Beneficial effects of leptin on obesity, T cell
hyporesponsiveness, and neuroendocrine/
metabolic dysfunction of human congenital
leptin deficiency. J. Clin. Invest. 110,
1093–1103 (2002).
90 Margetic S, Gazzola C, Pegg GG, Hill RA.
Leptin: a review of its peripheral actions
and interactions. Int. J. Obes. Relat. Metab.
Disord. 26, 1407–1433 (2002).
91 Isidori A, Fabbri A. Leptin and androgens
in male obesity: evidence for leptin
contribution to reduced androgen levels.
J. Clin. Endocrinol. Metab. 84, 3673–3680
(1999).
92 Vettor R, De Pergola G, Pagano C et al.
Gender differences in serum leptin in obese
people: relationships with testosterone,
body fat distribution and insulin sensitivity.
Eur. J. Clin. Invest. 27, 1016–1024 (1997).
93 Zorn B, Osredkar J, Meden-Vrtovec H,
Majdic G. Leptin levels in infertile male
patients are correlated with inhibin B,
testosterone and SHBG but not with sperm
characteristics. Int. J. Androl. 30(5),
439–444 (2007).
94 Hanafy S, Halawa FA, Mostafa T, Mikhael
NW, Khalil KT. Serum leptin correlates in
infertile oligozoospermic males. Andrologia
39(5), 177–180 (2007).
95 Caro JF, Kolaczynski JW, Nyce MR et al.
Decreased cerebrospinal-fluid/serum leptin
ratio in obesity: a possible mechanism for
leptin resistance. Lancet 348(9021),
159–161 (1996).
96 Jéquier E. Leptin signaling, adiposity, and
energy balance. Ann. NY Acad. Sci. 967,
379–388 (2002).
97 Couce ME, Green D, Brunetto A, Achim
C, Lloyd RV, Burguera B. Limited brain
access for leptin in obesity. Pituitary
4(1–2), 101–110 (2001).
247
 Review Phillips & Tanphaichitr
98 Banks WA, Kastin AJ, Huang W, Jaspan
JB, Maness LM. Leptin enters the brain by
a saturable system independent of insulin.
Peptides 17(2), 305–311 (1996).
99 Banks WA. The blood–brain barrier as a
cause of obesity. Curr. Pharm. Des. 14(16),
1606–1614 (2008).
100 Wong ML, Licinio J, Yildiz BO et al.
Simultaneous and continuous 24-hour
plasma and cerebrospinal fluid leptin
measurements: dissociation of
concentrations in central and peripheral
compartments. J. Clin. Endocrinol. Metab.
89(1), 258–265 (2004).
101 Kalra SP. Central leptin insufficiency
syndrome: an interactive etiology for
obesity, metabolic and neural diseases and
for designing new therapeutic
interventions. Peptides 29(1), 127–138
(2008).
102 Cunningham MJ, Clifton DK, Steiner RA.
Leptin’s actions on the reproductive axis:
perspectives and mechanisms. Biol. Reprod.
60(2), 216–222 (1999).
103 Sweeney, G. Leptin signalling. Cell. Signall.
14, 655–663 (2002).
104 Mounzih K, Lu R, Chehab FF. Leptin
treatment rescues the sterility of genetically
obese ob/ob males. Endocrinology 138(3),
1190–1193 (1997).
105 Cleary MP, Bergstrom HM, Dodge TL,
Getzin SC, Jacobson MK, Phillips FC.
Restoration of fertility in young obese
(Lep(ob) Lep(ob)) male mice with low dose
recombinant mouse leptin treatment. Int. J.
Obes. Relat. Metab. Disord. 25(1), 95–97
(2001).
106 Gottsch ML, Cunningham MJ, Smith JT
et al. A role for kisspeptins in the regulation
of gonadotropin secretion in the mouse.
Endocrinology 145(9), 4073–4077 (2004).
107 Kotani M, Detheux M, Vandenbogaerde A
et al. The metastasis suppressor gene
KiSS-1 encodes kisspeptins, the natural
ligands of the orphan G protein-coupled
receptor GPR54. J. Biol. Chem. 276(37),
34631–34636 (2001).
108 Tena-Sempere M. GPR54 and kisspeptin
in reproduction. Hum. Reprod. Update
12(5), 631–639 (2006).
109 Smith JT, Acohido BV, Clifton DK,
Steiner RA. KiSS-1 neurones are direct
targets for leptin in the ob/ob mouse.
J. Neuroendocrinol. 18(4), 298–303
(2006).
110 Quennell JH, Mulligan AC, Tups A et al.
Leptin indirectly regulates gonadotropin-
releasing hormone neuronal function.
Endocrinology 150(6), 2805–2812 (2009).
248
111 Tapanainen JS, Tilly JL, Vihko KK, Hsueh
AJW. Hormonal control of apoptotic cell
death in the testis: gonadotropins and
androgens as testicular cell survival factors.
Mol. Endocrinol. 7, 643–650 (1993).
112 Sinha Hikim AP, Swerdloff RS. Hormonal
and genetic control of germ cell apoptosis in
the testis. Rev. Reprod. 4(1), 38–47 (1999).
113 Yan W, Samson M, Jégou B, Toppari
J. Bcl-w forms complexes with Bax and
Bak, and elevated ratios of Bax/Bcl-w and
Bak/Bcl-w correspond to spermatogonial
and spermatocyte apoptosis in the testis.
Mol. Endocrinol. 14(5), 682–699 (2000).
114 Sofikitis N, Giotitsas N, Tsounapi P,
Baltogiannis D, Giannakis D, Pardalidis
N. Hormonal regulation of
spermatogenesis and spermiogenesis.
J. Steroid Biochem. Mol. Biol. 109(3–5),
323–330 (2008).
115 Bhat GK, Sea TL, Olatinwo MO et al.
Influence of a leptin deficiency on
testicular morphology, germ cell apoptosis,
and expression levels of apoptosis-related
genes in the mouse. J. Androl. 27(2),
302–310 (2006).
116 Lee J, Richburg JH, Younkin SC,
Boekelheide K. The Fas system is a key
regulator of germ cell apoptosis in the
testis. Endocrinology 138, 2081–2088
(1997).
117 Ishikawa T, Fujioka H, Ishimura T,
Takenaka A, Fujisawa M. Expression of
leptin and leptin receptor in the testis of
fertile and infertile patients. Andrologia 39,
22–27 (2007).
118 Herrid M, O’Shea T, McFarlane JR.
Ontogeny of leptin and its receptor
expression in mouse testis during the
postnatal period. Mol. Reprod. Dev. 75(5),
874–880 (2008).
119 Banks WA, McLay RN, Kastin AJ,
Sarmiento U, Scully S. Passage of leptin
across the blood–testis barrier. Am. J.
Physiol. 276, E1099–E1104 (1999).
120 El-Hefnawy T, Ioffe S, Dym M.
Expression of the leptin receptor during
germ cell development in the mouse testis.
Endocrinology 141, 2624–2630 (2000).
121 Caprio M, Fabbrini E, Ricci G et al.
Ontogenesis of leptin receptor in rat
Leydig cells. Biol. Reprod. 68(4),
1199–1207 (2003).
122 Tena-Sempere M, Pinilla L, Zhang FP
et al. Developmental and hormonal
regulation of leptin receptor (Ob-R)
messenger ribonucleic acid expression in
rat testis. Biol. Reprod. 64, 634–643
(2001).
123 Glander HJ, Lammert A, Paasch U,
Glasow A, Kratzsch J. Leptin exists in
tubuli seminiferi and in seminal plasma.
Andrologia 34, 227–233 (2002).
124 Cioffi JA, Shafer AW, Zupancic TJ et al.
Novel B219/OB receptor isoforms:
possible role of leptin in hematopoiesis and
reproduction. Nat. Med. 2, 585–589
(1996).
125 O’Donnell L, Robertson KM, Jones ME,
Simpson ER. Estrogen and spermatogenesis.
Endocr. Rev. 22, 289–318 (2001).
126 Caprio M, Isidori AM, Carta AR, Moretti
C, Dufau ML, Fabbri A. Expression of
functional leptin receptors in rodent Leydig
cells. Endocrinology 140, 4939–4947 (1999).
127 Herrid M, Xia Y, O’Shea T, McFarlane JR.
Leptin inhibits basal but not
gonadotrophin-stimulated testosterone
production in the immature mouse and
sheep testis. Reprod. Fertil. Dev. 20(4),
519–528 (2008).
128 Tena-Sempere M, Pinilla L, Gonzalez LC,
Dieguez C, Casanueva FF, Aguilar E.
Leptin inhibits testosterone secretion from
adult rat testis in vitro. J. Endocrinol. 161,
211–218 (1999).
129 Tena-Sempere M, Pinilla L, González LC
et al. In vitro pituitary and testicular effects
of the leptin-related synthetic peptide
leptin(116–130) amide involve actions both
similar to and distinct from those of the
native leptin molecule in the adult rat. Eur.
J. Endocrinol. 142(4), 406–410 (2000).
130 Ahima RS, Osei SY. Leptin signaling.
Physiol. Behav. 81, 223–241(2004).
131 Bjørbæck C, Uotani S, da Silva B, Flier JS.
Divergent signaling capacities of the long
and short isoforms of the leptin receptor.
J. Biol. Chem. 272, 32686–32695 (1997).
132 Bjørbæck C, Kahn BB. Leptin signaling in
the central nervous system and the
periphery. Rec. Prog. Horm. Res. 59,
305–331 (2004).
133 Ghilardi N, Skoda RC. The leptin receptor
activates janus kinase 2 and signals for
proliferation in a factor-dependent cell line.
Mol. Endocrinol. 11, 393–399 (1997).
134 Aquila S, Rago V, Guido C, Casaburi I,
Zupo S, Carpino A. Leptin and leptin
receptor in pig spermatozoa: evidence of
their involvement in sperm capacitation and
survival. Reproduction 136(1), 23–32
(2008).
135 Ruiz-Cortés ZT, Martel-Kennes Y, Gévry
NY, Downey BR, Palin MF, Murphy BD.
Biphasic effects of leptin in porcine
granulosa cells. Biol. Reprod. 68(3),
789–796 (2003).
Expert Rev. Endocrinol. Metab. 5(2), (2010)

136 Stocco DM, Wang X, Jo Y, Manna PR.
Multiple signaling pathways regulating
steroidogenesis and steroidogenic acute
regulatory protein expression: more
complicated than we thought. Mol.
Endocrinol. 19(11), 2647–2659 (2005).
137 Matsuda T, Nakamura T, Nakao K et al.
STAT3 activation is sufficient to maintain
an undifferentiated state of mouse
embryonic stem cells. EMBO J. 18(15),
4261–4269 (1999).
138 Tena-Sempere M, Pinilla L, Zhang FP
et al. Developmental and hormonal
regulation of leptin receptor (Ob-R)
messenger ribonucleic acid expression in
rat testis. Biol. Reprod. 64(2), 634–643
(2001).
139 von Sobbe HU, Koebnick C, Jenne L,
Kiesewetter F. Leptin concentrations in
semen are correlated with serum leptin and
elevated in hypergonadotrophic
hypogonadism. Andrologia 35(4), 233–237
(2003).
140 Ando S, Aquila S. Arguments raised by the
recent discovery that insulin and leptin are
expressed in and secreted by human
ejaculated spermatozoa. Mol. Cell.
Endocrinol. 245, 1–6 (2005).
141 Aquila S, Gentile M, Middea E et al.
Leptin secretion by human spermatozoa.
J. Clin. Endocrinol. Metab. 90, 4753–4761
(2005).
142 Chen B, Guo JH, Lu YN et al. Leptin and
varicocele-related spermatogenesis
dysfunction: animal experiment and
clinical study. Int. J. Androl 32(5),
532–541 (2008).
143 Visconti PE, Bailey JL, Moore GD,
Pan D, Olds-Clarke P, Kopf GS.
Capacitation of mouse spermatozoa. I.
Correlation between the capacitation
state and protein tyrosine
phosphorylation. Development 121,
1129–1137 (1995).
144 De Ambrogi M, Spinaci M, Galeati G,
Tamanini C. Leptin receptor in boar
spermatozoa. Int. J. Androl. 30, 458–461
(2007).
145 Li HW, Chiu PC, Cheung MP, Yeung
WS, O WS. Effect of leptin on motility,
capacitation and acrosome reaction of
human spermatozoa. Int. J. Androl. 32(6),
687–694 (2008).
146 Jope T, Lammert A, Kratzsch J, Paasch U,
Glander HJ. Leptin and leptin receptor in
human seminal plasma and in human
spermatozoa. Int. J. Androl. 26, 335–341
(2003).
www.expert-reviews.com
Obesity & semen quality
147 Hjollund NH, Storgaard L, Ernst E,
Bonde JP, Olsen J. Impact of diurnal
scrotal temperature on semen quality.
Reprod. Toxicol. 16(3), 215–221 (2002).
148 Jung A, Schill WB, Schuppe HC. Genital
heat stress in men of barren couples:
a prospective evaluation by means of a
questionnaire. Andrologia 34(6), 349–355
(2002).
149 Carlsen E, Andersson AM, Petersen JH,
Skakkebaek NE. History of febrile illness
and variation in semen quality. Hum.
Reprod. 18(10), 2089–2092 (2003).
150 Hjollund NH, Bonde JP, Jensen TK,
Olsen J. Diurnal scrotal skin temperature
and semen quality. The Danish First
Pregnancy Planner Study Team. Int.
J. Androl. 23(5), 309–318 (2000).
151 Hjollund NH, Storgaard L, Ernst E,
Bonde JP, Olsen J. The relation between
daily activities and scrotal temperature.
Reprod. Toxicol. 16(3), 209–214 (2002).
152 Magnusdottir EV, Thorsteinsson T,
Thorsteinsdottir S, Heimisdottir M,
Olafsdottir K. Persistent organochlorines,
sedentary occupation, obesity and human
male subfertility. Hum. Reprod. 20(1),
208–215 (2005).
153 Lue YH, Hikim AP, Swerdloff RS et al.
Single exposure to heat induces stage-
specific germ cell apoptosis in rats: role of
intratesticular testosterone on stage
specificity. Endocrinology 140, 1709–1717
(1999).
154 Paul C, Melton DW, Saunders PT. Do
heat stress and deficits in DNA repair
pathways have a negative impact on male
fertility? Mol. Hum. Reprod. 14(1), 1–8
(2008).
155 Paul C, Teng S, Saunders PT. A single,
mild, transient scrotal heat stress causes
hypoxia and oxidative stress in mouse
testes, which induces germ cell death.
Biol. Reprod 80(5), 913–919 (2009).
156 Yin Y, Hawkins KL, DeWolf WC,
Morgentaler A. Heat stress causes
testicular germ cell apoptosis in adult
mice. J. Androl. 18(2), 159–165 (1997).
157 Zhu BK, Setchell BP. Effects of paternal
heat stress on the in vivo development of
preimplantation embryos in the mouse.
Reprod. Nut. Dev. 44, 617–629 (2004).
158 Cammack KM, Mesa H, Lamberson WR.
Genetic variation in fertility of heat-
stressed male mice. Theriogenology 66,
2195–2201 (2006).
159 Eddy EM. Role of heat shock protein
HSP70-2 in spermatogenesis. Rev. Reprod.
4(1), 23–30 (1999).
Review
160 Georgopoulos C, Welch WJ. Role of the
major heat shock proteins as molecular
chaperones. Annu. Rev. Cell. Biol. 9,
601–634 (1993).
161 Vydra N, Malusecka E, Jarzab M et al.
Spermatocyte-specific expression of
constitutively active heat shock factor 1
induces HSP70i-resistant apoptosis in
male germ cells. Cell Death Differ. 13(2),
212–222 (2006).
162 Mosser DD, Caron AW, Bourget L,
Denis-Larose C, Massie B. Role of the
human heat shock protein hsp70 in
protection against stress-induced
apoptosis. Mol. Cell. Biol. 17(9),
5317–5327 (1997).
163 Rockett JC, Mapp FL, Garges JB, Luft
JC, Mori C, Dix DJ. Effects of
hyperthermia on spermatogenesis,
apoptosis, gene expression, and fertility in
adult male mice. Biol. Reprod. 65,
229–239 (2001).
164 Izu H, Inouye S, Fujimoto M, Shiraishi K,
Naito K, Nakai A. Heat shock
transcription factor 1 is involved in
quality-control mechanisms in male germ
cells. Biol. Reprod. 70, 18–24 (2004).
165 Fernandes M, Xiao H, Lis JT. Fine
structure analyses of the Drosophila and
Saccharomyces heat shock factor – heat
shock element interactions. Nucleic Acids
Res. 22(2), 167–173 (1994).
166 Salmand PA, Jungas T, Fernandez M,
Conter A, Christians ES. 2008 Mouse
heat-shock factor 1 (HSF1) is involved in
testicular response to genotoxic stress
induced by doxorubicin. Biol. Reprod.
79(6), 1092–1101.
167 Widlak W, Winiarski B, Krawczyk A,
Vydra N, Malusecka E, Krawczyk Z.
Inducible 70 kDa heat shock protein does
not protect spermatogenic cells from
damage induced by cryptorchidism. Int.
J. Androl. 30(2), 80–87 (2007).
168 Tramontano F, Malanga M, Farina B,
Jones R, Quesada P. Heat stress reduces
poly(ADPR)polymerase expression in rat
testis. Mol. Hum. Reprod. 6(7), 575–581
(2000).
169 Jia Y, Castellanos J, Wang C et al.
Mitogen-activated protein kinase
signaling in male germ cell apoptosis in
the rat. Biol. Reprod. 80(4), 771–780
(2009).
170 Johnson C, Jia Y, Wang C et al. Role of
caspase 2 in apoptotic signaling in primate
and murine germ cells. Biol. Reprod. 79(5),
806–814 (2008).
249
 Review Phillips & Tanphaichitr
171 Krumschnabel G, Sohm B, Bock F, Manzl
C, Villunger A. The enigma of caspase-2:
the laymen’s view. Cell. Death Differ. 16(2),
195–207 (2009).
172 Weidemann A, Johnson RS. Biology of
HIF-1a. Cell. Death Differ. 15, 621–627
(2008).
173 Setchell BP. The Parkes Lecture. Heat and
the testis. J. Reprod. Fert. 114, 179–194
(1998).
174 Paul C, Murray AA, Spears N, Saunders
PT. A single, mild, transient scrotal heat
stress causes DNA damage, subfertility
and impairs formation of blastocysts in
mice. Reproduction 136(1), 73–84 (2008).
175 Carlsen E, Giwereman A, Keiding N,
Skakkebaek NE. Evidence for decreasing
sperm quality of semen during the past 50
years. Br. Med. J. 304, 609–613 (1992).
176 US Environmental Protection Agency.
Special Report on Environmental Endocrine
Disruption: an Effects Assessment and
Analysis. Office of Research and
Development. Washington, DC, USA,
EPA/630/R-96/012 (1997).
177 WHO. Global assessment of the state-of-
the-sience of endocrine disruptors.
International Programme on Chemical
Safety. Damstra T, Barlow S, Bergman A,
Kavlock R, Van Der Kraak G (Eds).
WHO, Geneva, Switzerland (2002).
178 Phillips KP, Tanphaichitr N. Human
exposure to endocrine disrupters and
semen quality. J. Toxicol. Environ. Health
B Crit. Rev. 11(3–4), 188–220 (2008).
179 Baillie-Hamilton PF. Chemical toxins: a
hypothesis to explain the global obesity
epidemic. J. Altern. Comp. Med. 8, 185–192
(2002).
180 Newbold R, Padilla-Banks E, Snyder RJ,
Phillips TM, Jefferson WN.
Developmental exposure to endocrine
disruptors and the obesity epidemic.
Reprod. Toxicol. 23, 290–296 (2007).
181 Newbold R, Padilla-Banks E, Snyder RJ,
Jefferson WN. Perinatal exposure to
environmental estrogens and the
development of obesity. Mol. Nut. Food Res.
51, 912–917 (2007).
182 Barker DJ, Eriksson JG, Forsen T,
Osmond C. Fetal origins of adult
disease: strength of effects and biological
basis. Int. J.Epidemiol. 31, 1235–1239
(2002).
183 Gluckman PD, Hanson MA.
Developmental origins of disease
paradigm: a mechanistic and evolutionary
perspective. Ped. Res. 56, 311–317 (2004).
250
184 Hanson M, Gluckman P, Bier D et al.
Report on the 2nd World Congress on
Fetal Origins of Adult Disease, Brighton,
UK, June 7–10, 2003. Ped. Res. 55,
894–897 (2004).
185 Pryor JL, Hughes C, Foster W, Hales BF,
Robaire B. Critical windows of exposure
for children’s health: the reproductive
system in animals and humans. Environ.
Health Perspect. 108, 491–503 (2000).
186 Skakkebaek NE, Rajpert-De Meyts E,
Main KM. Testicular dysgenesis syndrome:
An increasingly common developmental
disorder with environmental aspects. Hum.
Reprod. 16, 972–978 (2001).
187 Newbold RR, Padilla-Banks E, Jefferson
WN, Heindel JJ. Effects of endocrine
disruptors on obesity. Int. J. Androl. 31(2),
201–208 (2008).
188 Goyal HO, Braden TD, Williams CS
et al. Abnormal morphology of the penis
in male rats exposed neonatally to
diethylstilbestrol is associated with altered
profile of estrogen receptor-a protein, but
not of androgen receptor protein:
a developmental and
immunocytochemical study. Biol. Reprod.
70, 1504–1517 (2004).
189 Goyal HO, Braden TD, Williams CS,
Dalvi P, Mansour MM, Williams JW.
Permanent induction of morphological
abnormalities in the penis and penile
skeletal muscles in adult rats treated
neonatally with diethylstilbestrol or
estradiol valerate: a dose–response study.
J. Androl. 26, 32–43 (2005).
190 Goyal HO, Braden TD, Williams CS,
Dalvi P, Mansour M, Williams JW.
Estrogen-induced abnormal accumulation
of fat cells in the rat penis and associated
loss of fertility depends upon estrogen
exposure during critical period of penile
development. Toxicol. Sci. 87(1), 242–254
(2005).
191 Goyal HO, Braden TD, Cooke PS et al.
Estrogen receptor a mediates estrogen-
inducible abnormalities in the developing
penis. Reprod. 133(5), 1057–1067 (2007).
192 Mansour MM, Goyal HO, Braden TD
et al. Activation of penile proadipogenic
peroxisome proliferator-activated receptor g
with an estrogen: interaction with estrogen
receptor a during postnatal development.
PPAR Res. 2008, 651419 (2008).
193 Li D, Kang Q, Wang DM. Constitutive
coactivator of peroxisome proliferator-
activated receptor (PPARg), a novel
coactivator of PPARg that promotes
adipogenesis. Mol. Endocrinol. 21(10),
2320–2333 (2007).
194 Keller H, Givel F, Perroud M, Wahli W.
Signaling cross-talk between peroxisome
proliferator-activated receptor/retinoid X
receptor and estrogen receptor through
estrogen response elements. Mol.
Endocrinol. 9(7), 794–804 (1995).
195 Kuiper GG, Enmark E, Pelto-Huikko M,
Nilsson S, Gustafsson JA. Cloning of a
novel receptor expressed in rat prostate and
ovary. Proc. Natl Acad. Sci. USA 93(12),
5925–5930 (1996).
196 Kuiper GG, Carlsson B, Grandien K et al.
Comparison of the ligand binding
specificity and transcript tissue distribution
of estrogen receptors a and b.
Endocrinology 138(3), 863–870 (1997).
197 Kraus WL, Weis KE, Katzenellenbogen
BS. Inhibitory cross-talk between steroid
hormone receptors: differential targeting of
estrogen receptor in the repression of its
transcriptional activity by agonist- and
antagonist-occupied progestin receptors.
Mol. Cell. Biol. 15(4), 1847–1857 (1995).
198 Feige JN, Gelman L, Rossi D et al. The
endocrine disruptor monoethyl-hexyl-
phthalate is a selective peroxisome
proliferator-activated receptor g modulator
that promotes adipogenesis. J. Biol. Chem.
282(26), 19152–19166 (2007).
199 Grün F, Blumberg B. Perturbed nuclear
receptor signaling by environmental
obesogens as emerging factors in the
obesity crisis. Rev. Endocr. Metab. Disord.
8(2), 161–171 (2007).
200 Grün F, Blumberg B. Environmental
obesogens: organotins and endocrine
disruption via nuclear receptor signaling.
Endocrinology 147, S50–S55 (2006).
201 Müllerová D, Kopecký J. White adipose
tissue: storage and effector site for
environmental pollutants. Physiol. Res.
56(4), 375–381 (2007).
202 Ryu JY, Whang J, Park H et al. Di(2-
ethylhexyl) phthalate induces apoptosis
through peroxisome proliferators-activated
receptor-g and ERK 1/2 activation in testis
of Sprague-Dawley rats. J. Toxicol. Environ.
Health A. 70(15–16), 1296–1303 (2007).
203 Matthiessen P, Gibbs P. Critical appraisal
of the evidence for tributyltinmediated
endocrine disruption in mollusks. Environ.
Toxicol. Chem. 17, 37–43 (1998).
204 Grün F, Watanabe H, Zamanian Z et al.
Endocrine disrupting organotin
compounds are potent inducers of
adipogenesis in vertebrates. Mol.
Endocrinol. 20, 2141–2155 (2006).
205 Tabb MM, Blumberg B. New modes of
action for endocrine-disrupting chemicals.
Mol. Endocrinol. 20(3), 475–482 (2006).
Expert Rev. Endocrinol. Metab. 5(2), (2010)

206 Nakanishi T. Endocrine disruption
induced by organotin compounds:
organotin’s function as a powerful agonist
for nuclear receptors rather than an
aromatase inhibitor. J. Toxicol. Sci. 33(3),
269–276 (2008).
207 Remillard RB, Bunce NJ. Linking dioxins
to diabetes: epidemiology and biologic
plausibility. Environ. Health Perspect.
110(9), 853–858 (2002).
208 Dang ZC, Audinot V, Papapoulos SE,
Boutin JA, Lowik CW. Peroxisome
proliferator-activated receptor g (PPAR g)
as a molecular target for the soy
phytoestrogen genistein. J. Biol. Chem.
278, 962–967 (2003).
www.expert-reviews.com
View publication stats
Obesity & semen quality
209 Phillips KP, Foster WG. Key developments
in endocrine disrupter research and human
health. J. Toxicol. Environ. Health B Crit.
Rev. 11(3–4), 322–344 (2008).
Affiliations
• Karen Phillips, PhD
Assistant Professor, Interdisciplinary School
of Health Sciences, Faculty of Health
Sciences, Principal Scientist, Institute of
Population Health, University of Ottawa,
43 Templeton Street, Room 215, Ottawa,
ON K1N 6N5, Canada
Tel.: +1 613 562 5800 ext. 8678
karen.phillips@uottawa.ca
Review
• Nongnuj Tanphaichitr, PhD
Senior Scientist, Ottawa Hospital Research
Institute, and Professor in Obstetrics and
Gynecology, and Biochemistry/
Microbiology/Immunology,
University of Ottawa, 725 Parkdale
Avenue, Ottawa, ON K1Y 4E9, Canada
Tel.: +1 613 798 5555 ext. 13715
Fax: +1 613 761 5365
ntanphaichitr@ohri.ca
251