Pyospermia: background and controversies

Abstract

Pyospermia (or leukocytospermia) is suspected based on the presence of >1 × 106 round cells/mL of ejaculate and diagnosed using peroxidase stain revealing >1 × 106 white blood cells/mL. The presence of white blood cells is a concern for overt infections or excessive inflammation, both of which have been postulated to negatively impact bulk semen parameters and fertilization capability. The threshold for pyospermia has been debated upon in the literature, as has the optimal treatment method. In the absence of clinical infectious symptoms, it appears that antibiotics, anti-inflammatory agents, and/or frequent ejaculation may improve bulk semen parameters in men with pyospermia. Further research is needed to adequately assess the effect of these methods on pregnancy and live birth outcomes, especially among couples attempting natural conception compared to those attempting intrauterine insemination or in vitro fertilization. Pyospermia (or leukocytospermia) is suspected based on the presence of >1 × 106 round cells/mL of ejaculate and diagnosed using peroxidase stain revealing >1 × 106 white blood cells/mL. The presence of white blood cells is a concern for overt infections or excessive inflammation, both of which have been postulated to negatively impact bulk semen parameters and fertilization capability. The threshold for pyospermia has been debated upon in the literature, as has the optimal treatment method. In the absence of clinical infectious symptoms, it appears that antibiotics, anti-inflammatory agents, and/or frequent ejaculation may improve bulk semen parameters in men with pyospermia. Further research is needed to adequately assess the effect of these methods on pregnancy and live birth outcomes, especially among couples attempting natural conception compared to those attempting intrauterine insemination or in vitro fertilization. Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/posts/xfre-d-20-00208Pyospermia (or leukocytospermia) is a confusing topic with regard to male infertility, fraught with contradictory data of variable quality. Therefore, what is a new practitioner to do when faced with a patient with 5 × 106 or 0.5 × 106 white blood cells (WBCs)/mL ejaculate? This minireview article was written as a primer for the diagnosis, etiology, and treatment of pyospermia specifically for trainees and providers who may not routinely see patients with infertility.MethodsA brief review of the literature was performed by searching PubMed using the search terms “pyospermia,” “leukocytospermia,” “male infertility,” and “treatment.” In particular, review articles and prospective trials comparing treatment modalities were included. Guidelines from major international societies were reviewed for consensus statements on pyospermia diagnosis and management.DiagnosisApproximately 15% of all couples trying to conceive are affected by infertility, and nearly half of these cases are attributable to the male factor. In a standard evaluation by the American Urological Association (AUA), men provided 2 semen samples for analyses, in which several variables are reported: semen volume, pH, sperm concentration, motility, morphology, total motile count, and the concentration of round cells. Pyospermia is suspected if there are over 1 × 106 round cells/mL under a light microscope, but this must diagnosed using to from other cells The round cells and white blood cells in the PubMed cells are as or cells and cells may or as or of in semen a PubMed are to in and the of of of and fertilization of on semen parameters and of sperm PubMed are for PubMed and methods may for semen to the and for in peroxidase has been by the for the and of it is to have compared with or methods by the diagnosis of and as cells in PubMed in of the pyospermia as the presence of over 1 × 106 of semen optimal evaluation of the and The round cells and white blood cells in the PubMed the of from the round In of were to have >1 × 106 round but for were to have international in to pyospermia diagnosis and that patients with >1 × 106 semen for or optimal evaluation of the there are on patients based on symptoms, semen or on the or of The Urological Association not pyospermia in of but it in the in which semen is not PubMed the Association of that it is what impact and have on sperm and in the semen may a of a of or as may in the diagnosis of treatment for is the to symptoms, it is not this improve the of treatment may anti-inflammatory agents, to and In a of of round the Association of has peroxidase to from round cells may sperm Association of on male the PubMed the threshold for pyospermia has been debated upon in the of in the ejaculate have been to with of and and in a sperm and PubMed was to in samples with over × 106 that the threshold of 1 × 106 is of by and on sperm in PubMed The of from the PubMed compared semen from patients with with those from patients for evaluation and those from men a and the of sperm at this was the threshold for has that a of >1 × 106 has a of for and that a optimal threshold may × 106 The of from the PubMed with a threshold for pyospermia is the of the presence of in the semen is of a or may the The and effect of and on semen PubMed or sperm as Pyospermia in with and a of PubMed methods are to which may other not using standard and is that there are in the semen that sperm and the presence of and in the semen is In a review of semen from men to The and effect of and on semen PubMed a of 15% and a pyospermia of The that the presence of impact on sperm concentration, morphology, or there was and which the as this pyospermia the a in sperm concentration, morphology, and were by those of of and on semen parameters in PubMed who in the bulk semen parameters men with or which as of of patients the for of not have in the semen the concentration of may not a of the presence of in the ejaculate a new for using a to that are not in semen from men of of to semen PubMed the by and semen in that it is not the presence of but the of as that the semen or research is needed to the and This has the to new treatment for male for pyospermia are for men with as as pyospermia. The are or anti-inflammatory and are on the that presence is to or excessive or of for the evaluation and treatment of in male PubMed a literature review of pyospermia and In of pyospermia was in patients with compared with that in and in was patients to pyospermia treatment for the for the frequent ejaculation and frequent The that the of and frequent ejaculation was the with the at of treatment and of in men with PubMed were all in couples male pyospermia ejaculation was to which may and and ejaculation improve of in men with a using 2 for a with and frequent of men in the of pyospermia compared with of the men in the and of the men in the In treatment of with in male PubMed in the semen parameters in men with with for This to of which was × 106 the pregnancy was in patients treatment compared with that in the in the literature are as for for with or frequent ejaculation pyospermia is to to to anti-inflammatory have been and sperm and sperm in male patients with and PubMed the effect of for that cells in men with pyospermia and The was by the of a but the if not in pyospermia at the of the and were the bulk semen parameters to improve from a of and to and at pregnancy of are a of anti-inflammatory that and pregnancy of with PubMed of for to men with pyospermia. from to from to and pyospermia were were and intrauterine insemination the of with clinical and the effect of treatment on semen PubMed to patients with pyospermia. semen pyospermia the sperm concentration from × to × and the and from to and from to the were by the of and the anti-inflammatory in the literature are as for anti-inflammatory for 1 or for 2 have been by the do patients treatment the or is it that patients may of bulk semen parameters to improve with what is the effect on pregnancy and live birth this by on has to based on the by of on in vitro fertilization and sperm PubMed that there was in the fertilization or in couples with and pyospermia who in vitro fertilization with or sperm the pyospermia from × 106 to 2 × 106 the for pyospermia treatment if the is for by of on semen parameters and of sperm PubMed that couples with >1 × 106 who fertilization and compared with couples with × 106 in this the pregnancy were the in a of over couples who with or and pregnancy were in couples with of are for PubMed The effect in the pyospermia was of pregnancy and diagnosis and treatment at the of at are in pyospermia for men with >1 × 106 round cells/mL in semen is for men with infectious and/or >1 × 106 in the pyospermia with infectious are 2 for which a semen with the pyospermia stain is with >1 × 106 in the pyospermia but with of may on anti-inflammatory as for 2 and frequent ejaculation semen with pyospermia is and if there are over 1 a of 2 for is a of the all men a for is to assess for that may to excessive or the of are to or at the of these when is who are for pyospermia are that the do not to affected by the presence of in the pyospermia is by the presence of >1 × 106 round cells/mL. is diagnosed using peroxidase stain and is by the presence of >1 × 106 with is in patients with infectious in the absence of symptoms, it is pyospermia is of or or is a treatment have been antibiotics, anti-inflammatory agents, and frequent with on bulk semen Further research is needed to adequately assess the effect of these methods on pregnancy outcomes, especially among couples attempting natural conception compared to those attempting intrauterine insemination or Discuss: You can discuss this article with its authors and other readers at Discuss: You can discuss this article with its authors and other readers at Discuss: You can discuss this article with its authors and other readers at Pyospermia (or leukocytospermia) is a confusing topic with regard to male infertility, fraught with contradictory data of variable quality. Therefore, what is a new practitioner to do when faced with a patient with 5 × 106 or 0.5 × 106 white blood cells (WBCs)/mL ejaculate? This minireview article was written as a primer for the diagnosis, etiology, and treatment of pyospermia specifically for trainees and providers who may not routinely see patients with brief review of the literature was performed by searching PubMed using the search terms “pyospermia,” “leukocytospermia,” “male infertility,” and “treatment.” In particular, review articles and prospective trials comparing treatment modalities were included. Guidelines from major international societies were reviewed for consensus statements on pyospermia diagnosis and brief review of the literature was performed by searching PubMed using the search terms “pyospermia,” “leukocytospermia,” “male infertility,” and “treatment.” In particular, review articles and prospective trials comparing treatment modalities were included. Guidelines from major international societies were reviewed for consensus statements on pyospermia diagnosis and 15% of all couples trying to conceive are affected by infertility, and nearly half of these cases are attributable to the male factor. In a standard evaluation by the American Urological Association (AUA), men provided 2 semen samples for analyses, in which several variables are reported: semen volume, pH, sperm concentration, motility, morphology, total motile count, and the concentration of round cells. Pyospermia is suspected if there are over 1 × 106 round cells/mL under a light microscope, but this must diagnosed using to from other cells The round cells and white blood cells in the PubMed cells are as or cells and cells may or as or of in semen a PubMed are to in and the of of of and fertilization of on semen parameters and of sperm PubMed are for PubMed and methods may for semen to the and for in peroxidase has been by the for the and of it is to have compared with or methods by the diagnosis of and as cells in PubMed in of the pyospermia as the presence of over 1 × 106 of semen optimal evaluation of the and The round cells and white blood cells in the PubMed the of from the round In of were to have >1 × 106 round but for were to have international in to pyospermia diagnosis and that patients with >1 × 106 semen for or optimal evaluation of the there are on patients based on symptoms, semen or on the or of The Urological Association not pyospermia in of but it in the in which semen is not PubMed the Association of that it is what impact and have on sperm and in the semen may a of a of or as may in the diagnosis of treatment for is the to symptoms, it is not this improve the of treatment may anti-inflammatory agents, to and In a of of round the Association of has peroxidase to from round cells may sperm Association of on male the PubMed the threshold for pyospermia has been debated upon in the of in the ejaculate have been to with of and and in a sperm and PubMed was to in samples with over × 106 that the threshold of 1 × 106 is of by and on sperm in PubMed The of from the PubMed compared semen from patients with with those from patients for evaluation and those from men a and the of sperm at this was the threshold for has that a of >1 × 106 has a of for and that a optimal threshold may × 106 The of from the PubMed 15% of all couples trying to conceive are affected by infertility, and nearly half of these cases are attributable to the male factor. In a standard evaluation by the American Urological Association (AUA), men provided 2 semen samples for analyses, in which several variables are reported: semen volume, pH, sperm concentration, motility, morphology, total motile count, and the concentration of round cells. Pyospermia is suspected if there are over 1 × 106 round cells/mL under a light microscope, but this must diagnosed using to from other cells The round cells and white blood cells in the PubMed cells are as or cells and cells may or as or of in semen a PubMed are to in and the of of of and fertilization of on semen parameters and of sperm PubMed are for PubMed and methods may for semen to the and for in The peroxidase has been by the for the and of it is to have compared with or methods by the diagnosis of and as cells in PubMed in of the pyospermia as the presence of over 1 × 106 of semen optimal evaluation of the and The round cells and white blood cells in the PubMed the of from the round In of were to have >1 × 106 round but for were to have pyospermia. international in to pyospermia diagnosis and that patients with >1 × 106 semen for or optimal evaluation of the there are on patients based on symptoms, semen or on the or of The Urological Association not pyospermia in of but it in the in which semen is not PubMed In the Association of that it is what impact and have on sperm and in the semen may a of a of or as may in the diagnosis of treatment for is the to symptoms, it is not this improve the of treatment may anti-inflammatory agents, to and In a of of round the Association of has peroxidase to from round cells may sperm Association of on male the PubMed the threshold for pyospermia has been debated upon in the of in the ejaculate have been to with of and and in a sperm and PubMed was to in samples with over × 106 that the threshold of 1 × 106 is of by and on sperm in PubMed The of from the PubMed compared semen from patients with with those from patients for evaluation and those from men a and the of sperm at this was the threshold for has that a of >1 × 106 has a of for and that a optimal threshold may × 106 The of from the PubMed with a threshold for pyospermia is the of the presence of in the semen is of a or may the The and effect of and on semen PubMed or sperm as Pyospermia in with and a of PubMed methods are to which may other not using standard and is that there are in the semen that sperm and the presence of and in the semen is In a review of semen from men to The and effect of and on semen PubMed a of 15% and a pyospermia of The that the presence of impact on sperm concentration, morphology, or there was and which the as this pyospermia the a in sperm concentration, morphology, and were by those of of and on semen parameters in PubMed who in the bulk semen parameters men with or which as of of patients the for of not have in the semen the concentration of may not a of the presence of in the ejaculate a new for using a to that are not in semen from men of of to semen PubMed the by and semen in that it is not the presence of but the of as that the semen or research is needed to the and This has the to new treatment for male for pyospermia are with a threshold for pyospermia is the of the presence of in the semen is of a or may the The and effect of and on semen PubMed or sperm as Pyospermia in with and a of PubMed methods are to which may other not using standard and is that there are in the semen that sperm and The the presence of and in the semen is In a review of semen from men to The and effect of and on semen PubMed a of 15% and a pyospermia of The that the presence of impact on sperm concentration, morphology, or there was and which the as this pyospermia the a in sperm concentration, morphology, and were by those of of and on semen parameters in PubMed who in the bulk semen parameters men with or which as of of patients the for of not have in the semen the concentration of may not a of the presence of in the ejaculate a new for using a to that are not in semen from men of of to semen PubMed the by and semen in that it is not the presence of but the of as that the semen or research is needed to the and This has the to new treatment for male for pyospermia are for men with as as pyospermia. The are or anti-inflammatory and are on the that presence is to or excessive or of for the evaluation and treatment of in male PubMed a literature review of pyospermia and In of pyospermia was in patients with compared with that in and in was patients to pyospermia treatment for the for the frequent ejaculation and frequent The that the of and frequent ejaculation was the with the at of treatment and of in men with PubMed were all in couples male pyospermia ejaculation was to which may and and ejaculation improve of in men with a using 2 for a with and frequent of men in the of pyospermia compared with of the men in the and of the men in the In treatment of with in male PubMed in the semen parameters in men with with for This to of which was × 106 the pregnancy was in patients treatment compared with that in the in the literature are as for for with or frequent ejaculation pyospermia is to to to anti-inflammatory have been and sperm and sperm in male patients with and PubMed the effect of for that cells in men with pyospermia and The was by the of a but the if not in pyospermia at the of the and were the bulk semen parameters to improve from a of and to and at pregnancy of are a of anti-inflammatory that and pregnancy of with PubMed of for to men with pyospermia. from to from to and pyospermia were were and intrauterine insemination the of with clinical and the effect of treatment on semen PubMed to patients with pyospermia. semen pyospermia the sperm concentration from × to × and the and from to and from to the were by the of and the anti-inflammatory in the literature are as for anti-inflammatory for 1 or for 2 have been by the do patients treatment the or is it that patients may of bulk semen parameters to improve with what is the effect on pregnancy and live birth this by for men with as as pyospermia. The are or anti-inflammatory and are on the that presence is to or excessive or of for the evaluation and treatment of in male PubMed a literature review of pyospermia and In of pyospermia was in patients with compared with that in and in was patients to pyospermia treatment for the for the frequent ejaculation and frequent The that the of and frequent ejaculation was the with the at of treatment and of in men with PubMed were all in couples male pyospermia ejaculation was to which may and and ejaculation improve of in men with a using 2 for a with and frequent of men in the of pyospermia compared with of the men in the and of the men in the In treatment of with in male PubMed in the semen parameters in men with with for This to of which was × 106 the pregnancy was in patients treatment compared with that in the in the literature are as for for with or frequent ejaculation of for the evaluation and treatment of in male PubMed a literature review of pyospermia and In of pyospermia was 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of are a of anti-inflammatory that and pregnancy of with PubMed of for to men with pyospermia. from to from to and pyospermia were were and intrauterine insemination the of with clinical and the effect of treatment on semen PubMed to patients with pyospermia. semen pyospermia the sperm concentration from × to × and the and from to and from to the were by the of and the anti-inflammatory in the literature are as for anti-inflammatory for 1 or for 2 have been by the do patients treatment the or is it that patients may of bulk semen parameters to improve with what is the effect on pregnancy and live birth this by pyospermia is to to to anti-inflammatory have been and sperm and sperm in male patients with and PubMed the effect of for that cells in men with pyospermia and The was by the of a but the if not in pyospermia at the of the and were the bulk semen parameters to improve from a of and to and at pregnancy of are a of anti-inflammatory that and pregnancy of with PubMed of for to men with pyospermia. from to from to and pyospermia were were and intrauterine insemination the of with clinical and the effect of treatment on semen PubMed to patients with pyospermia. semen pyospermia the sperm concentration from × to × and the and from to and from to the were by the of and In the anti-inflammatory in the literature are as for anti-inflammatory for 1 or for 2 have been by the do patients treatment the or is it that patients may of bulk semen parameters to improve with what is the effect on pregnancy and live birth this by on has to based on the by of on in vitro fertilization and sperm PubMed that there was in the fertilization or in couples with and pyospermia who in vitro fertilization with or sperm the pyospermia from × 106 to 2 × 106 the for pyospermia treatment if the is for by of on semen parameters and of sperm PubMed that couples with >1 × 106 who fertilization and compared with couples with × 106 in this the pregnancy were the in a of over couples who with or and pregnancy were in couples with of are for PubMed The effect in the pyospermia was of pregnancy and This has to based on the by of on in vitro fertilization and sperm PubMed that there was in the fertilization or in couples with and pyospermia who in vitro fertilization with or sperm the pyospermia from × 106 to 2 × 106 the for pyospermia treatment if the is for by of on semen parameters and of sperm PubMed that couples with >1 × 106 who fertilization and compared with couples with × 106 in this the pregnancy were the in a of over couples who with or and pregnancy were in couples with of are for PubMed The effect in the pyospermia was of pregnancy and diagnosis and treatment at the of at are in pyospermia for men with >1 × 106 round cells/mL in semen is for men with infectious and/or >1 × 106 in the pyospermia with infectious are 2 for which a semen with the pyospermia stain is with >1 × 106 in the pyospermia but with of may on anti-inflammatory as for 2 and frequent ejaculation semen with pyospermia is and if there are over 1 a of 2 for is a of the all men a for is to assess for that may to excessive or the of are to or at the of these when is who are for pyospermia are that the do not to affected by the presence of in the pyospermia is by the presence of >1 × 106 round cells/mL. is diagnosed using peroxidase stain and is by the presence of >1 × 106 with is in patients with infectious in the absence of symptoms, it is pyospermia is of or or is a treatment have been antibiotics, anti-inflammatory agents, and frequent with on bulk semen Further research is needed to adequately assess the effect of these methods on pregnancy outcomes, especially among couples attempting natural conception compared to those attempting intrauterine insemination or diagnosis and treatment at the of at are in pyospermia for men with >1 × 106 round cells/mL in semen is for men with infectious and/or >1 × 106 in the pyospermia with infectious are 2 for which a semen with the pyospermia stain is with >1 × 106 in the pyospermia but with of may on anti-inflammatory as for 2 and frequent ejaculation semen with pyospermia is and if there are over 1 a of 2 for is a of the all men a for is to assess for that may to excessive or the of are to or at the of these when is who are for pyospermia are that the do not to affected by the presence of in the In pyospermia is by the presence of >1 × 106 round cells/mL. is diagnosed using peroxidase stain and is by the presence of >1 × 106 with is in patients with infectious in the absence of symptoms, it is pyospermia is of or or is a treatment have been antibiotics, anti-inflammatory agents, and frequent with on bulk semen Further research is needed to adequately assess the effect of these methods on pregnancy outcomes, especially among couples attempting natural conception compared to those attempting intrauterine insemination or

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