The Male The Male Biological ClockBiological Clock

John L. Frattarelli, M.D., FACOGJohn L. Frattarelli, M.D., FACOGReproductive Medicine Associates of New Reproductive Medicine Associates of New

JerseyJersey

Male Menopause/Adrenopause?

– Decreased • Testosterone levels

• Libido

• Hair

• Muscle mass

• Strength

– Increased• Weight

• Erectile dysfunction

• Infertility

• Depression

• Cholesterol

As men age:As men age:

Male InfertilityMale Infertility

• 30-40 % infertile couples30-40 % infertile couples

• Etiologies:Etiologies:– stress, fever, infections, drugs, work/environment stress, fever, infections, drugs, work/environment

hazards, agehazards, age

• Semen analysisSemen analysis– spermatogenesis 74 daysspermatogenesis 74 days– 14 days to pass through testis14 days to pass through testis

Male Infertility

31.716.6

98.9

8.55.8

54.2

2.31.5

6.5

0 5 10 15 20 25 30 35

Idiopathic

Varicocele

Infection

Hypogonadism

Cryptorchidism

Malformation

Systemic

Immunologic

Tumor

Obstruction

Other

Hum Reprod Update 1999; 5(2): 120

Percent (%)

AGE?AGE?

Semen AnalysisSemen Analysis• VolumeVolume >2.0 cc>2.0 cc• pHpH 7.2 - 7.87.2 - 7.8• ConcentrationConcentration 20 mil/mL20 mil/mL• TotalTotal >40 mil>40 mil• MotilityMotility >50% forward/25% rapid>50% forward/25% rapid• MorphologyMorphology >30%*>30%*

>14%**>14%**• WBCWBC <1 mil/mL<1 mil/mL

*WHO, 1992*WHO, 1992**Kruger Strict Criteria, 1999**Kruger Strict Criteria, 1999

Sperm Density

0

5

10

15

20

25

Per

cent

(%

)

0-20

21-4

041

-60

61-8

0

81-1

00

101-

120

121-

140

141-

160

>160

Million/mL

Fertile Infertile

J Urol 1951; 66(3): 436

Sperm Morphology features as a Prognostic Factor in IVF

0

25

50

75

100

Per

cent

(%

)

0-14% 15-30% 31-45% 46-60%

Morphology (%)

Fert/egg0 FertPR/retPR/ET

Kruger TF et al. Fertil Steril 1986; 46: 1118

Effect of male age on sperm quality and fertilityKidd et al. Fertil Steril 2001

• Review of the published literature from 1980-1999• Volume

– Decrease 3-30% from age 30 to 50• Seminal vesicle and prostate changes

• Concentration– No change

• No control for abstinence• Motility

– Decrease 3-37% from age 30 to 50• Prostate and epididymal changes

• Morphology– Decrease 4-22% from age 30 to 50

• Germinal epithelium and epididymal changes• Pregnancy rates

– Confounded by age but a trend for a 38% decrease from age 30 to 50

Male Factor Treatment Pregnancy rate results from RCT

• Bromocriptine– 4 trials– OR 0.7, 95% CI 0.15-3.24

• Androgen therapy– 11 trials, n=930– OR 1.1, 95% CI 0.75-1.61

• Clomiphene citrate– 10 trials, n=738– OR 1.56, 95% CI 0.99-2.19

Cochrane Reviews 2003

IUIIUI• Need 1 million motile Need 1 million motile

spermsperm

• Prefer > 5 million Prefer > 5 million motilemotile

• Little benefit >10 Little benefit >10 million motilemillion motile

• IUI vs Timed CoitusIUI vs Timed Coitus

– Meta-analysisMeta-analysis

– 17 RCT, n=3662 cycles17 RCT, n=3662 cycles• Natural cycleNatural cycle

– OR 2.43 (1.5-3.8)OR 2.43 (1.5-3.8)• COHCOH

– OR 2.14 (1.3-3.5)OR 2.14 (1.3-3.5)

– Common OR for fecundity Common OR for fecundity = 2.37 = 2.37

• 95% CI 1.43-3.9095% CI 1.43-3.90

Cochrane Reviews 2003

Evidence for declining fertility in older men

• 8515 planned pregnancies• Large population study questionnaire• Gestations >24 weeks

Ford et al. Hum Reprod, 2000Ford et al. Hum Reprod, 2000

0

20

40

60

80

100

Preg

nanc

y ra

te

<25 25-29 30-34 35-39 40>

6-months6-months

Male ageMale ageFemale ageFemale age

0

20

40

60

80

100

Preg

nanc

y ra

te

<25 25-29 30-34 35-39 40>

12-months12-months

Evidence for declining fertility in older menFord et al. Hum Reprod, 2000Ford et al. Hum Reprod, 2000

00.20.40.60.8

11.2

Odds

ratio

<25 25-29 30-34 35-39 40>

Male ageMale ageFemale ageFemale age

12-months12-months• Adjusted odds

ratios– Adjusted for

partner age, BMI, smoking, passive smoke, education, duration of cohabitation, duration of OC use, alcohol consumption

Outcome rates and male age in 1023 donor oocyte cycles.

Frattarelli in press, Frattarelli in press, 20072007

0

20

40

60

80

100

Rat

e (%

)

Implantation Pregnancy Loss Live Birth

overall< 36 years36-40 years41-45 years46-50 years51-55 years> 55 years

Outcome rates and male age in 1023 donor oocyte cycles.

Frattarelli in press, Frattarelli in press, 20072007

0

20

40

60

80

100

Rat

e (%

)

Implantation Pregnancy Loss Live Birth Blast

< 50 years> 50 years

P<0.05P<0.05

P<0.05P<0.05

P<0.05P<0.05

Couple age and Miscarriage rate

• N=3174

• Data from European Multicenter Study on Infertilty and Subfertility 1991-1993

• Combined male and female ages to make a single categorical variable for multiple logistic regression

0

2

4

6

8

10

Adju

sted

OR

20-29 30-34 35-39 40-64

20-29

30-34

35-44

Paternal age Mat

erna

l age

Mat

erna

l age

de La Rochebrochard and Thonneau, Hum Reprod 2002de La Rochebrochard and Thonneau, Hum Reprod 2002

Outcome rates and male age in 1023 donor oocyte cycles.

Frattarelli in press, Frattarelli in press, 20072007

0

5

10

15

20

25

30

Los

s ra

te (

%)

<36 36-40 41-45 46-50 51-55 >55

Male age

P<0.05P<0.05

24.4

41.5

0

5

10

15

20

25

30

35

40

45

Per

cen

t (%

)

Loss rate

<50 years>50 years

P<0.05P<0.05

The impact of paternal age on aneuploidy rates in first trimester losses

26.1 25

34.6

0

10

20

30

40

Rat

e (%

)

Controls Paternal age <40 Paternal age >40

• Controls = IVF patients using autologous oocytes (n=23)– Mean female age = 28.7 ± 1.1– Mean male age = 33.7 ± 7.6

• Donor oocyte group (n=50)– Mean donor age = 27.8 ± 3.9– Mean female age = 39.6 ± 5.0– Mean male age = 41.5 ± 6.8

Frattarelli in press, Frattarelli in press, 20072007

Early hints at the link between paternal age and

birth defects

• 1912-Dr. Weinberg– Achondroplasia more often in younger siblings

• Dr. Penrose– Paternal age associated with de novo AD mutations

• Now >20 disorders associated with paternal age– Alpert, Crouzon, Pfeiffer, Marfan, Achrondoplasia,

neurofibromatosis, osteogenesis imperfecta

Meiosis vs Mitosis

• Women have ~24 divisions in the cells that give rise to their eggs

• Men have >30 rounds of mitosis prior to puberty– About 23 replications

per year

Spermatogenesis

• ~23 replications per year

• Age 30– 380 mitotic divisions

• Age 40– 610 mitotic divisions

• Age 50– 840 mitotic divisions

Primary Spermatocyte

Secondary Spermatocyte

Spermatids

Normal Sperm

n

2n

n

nn nn

nn n

n

Meiosis I

Meiosis II

Male Infertility

• Infertile males with oligospermia or azoospermia (n = 9766)

– 5.8% incidence of chromosomal abnormalities• 4.2% sex chromosome• 1.5% autosome

– Baseline fertile males: 0.5%

Johnson, Fertil Steril 1998Johnson, Fertil Steril 1998

Karyotypic Abnormalities

• Frequency is inversely proportional to sperm concentration

• Most common anomaly is Klinefelter syndrome– atrophic hyalinized testes

depleted of germ cells

0

5

10

15

Kar

ytyp

e ab

nrom

ality

(%)

Sharlip et al. Fertil Steril 2002

Male Infertility• Cytogenetic surveys of

oligospermic and azoospermic males

– oligo-: 4.6 % with cytogenetic abnormalities

• 1.6 % sex chromosomal• 3.0 % autosomal

– azoo-: 13.7 % with cytogenetic abnormalities

• 12.6 % sex chromosomal• 1.1 % autosomal

0

2

4

6

8

10

12

14

% c

ytog

enet

ic

abno

rmal

itie

sOligo- Azoo-

DNA damage in sperm

• N=66

• Ages 20-57

• Gradual increased in DNA damage – Most pronounced after age 35

• ?Apoptosis decreases with age?

Singh et al. Fertil Steril 2003Singh et al. Fertil Steril 2003

Influence of Paternal Age on Down Syndrome

• Incidence from 1983-1997

• N =3419 cases• NY state DOH

congenital malformations registry

• No paternal influence until >35 years

• Paternal age contributes 50% risk

0

200

400

600

800

<24 25-29 30-34 35-39 40>

Rat

e pe

r 10

0,00

0 B

irth

s

Maternal Age uncorrected for Paternal AgeMaternal Age CORRECTED for Paternal Age

Fisch et al. J Urol 2003Fisch et al. J Urol 2003

SchizophreniaPaternal Age Group

RR (95% CI)

<24 1

25-29 1.14 (0.8-1.5)

30-34 1.42 (1.0-2.0)

35-39 1.64 (1.1-2.4)

40-44 1.73 (1.1-2.7)

45-49 2.02 (1.2-3.5)

>50 2.96 (1.6-5.5)

Maternal Age Group

RR (95% CI)

<24 1

25-29 1.01 (0.8-1.3)

30-34 1.10 (0.8-1.4)

35-39 1.2 (0.8-1.7)

>40 1.2 (0.8-1.7)

-Israeli psychiatric registry-Israeli psychiatric registry-Controlled for age of other parent-Controlled for age of other parent-Also for sex, ethnicity, and education-Also for sex, ethnicity, and education

Malaspina et al. Arch Gen Psychiatry 2001Malaspina et al. Arch Gen Psychiatry 2001

Risk at paternal age of 40 Risk at paternal age of 40 ~ 1/110~ 1/110Similar to the female risk Similar to the female risk of Downs at the same ageof Downs at the same age

2% incidence of schizophrenia for 2% incidence of schizophrenia for males >50 yearsmales >50 years

Yp

Yq

SRYRPS4YZFY

YRRM1

YRRM1, YRRM2DAZ AZF region

Yq12

Yq11Yq11

PAR1

MicrodeletionsMicrodeletions

• Yq11 microdeletionsYq11 microdeletions

– 10-15% azo- / severely 10-15% azo- / severely oligozoospermic menoligozoospermic men

– AZF =azoospermia factor

– AZFa to AZFc in the Yq11.21-23 region

– To small to be detected by To small to be detected by karyotypingkaryotyping

– Can be detected by PCRCan be detected by PCR

Brandell et al. Hum Repro 1998

Yp

Yq

SRYRPS4YZFY

YRRM1

YRRM1, YRRM2DAZ AZF region

Yq12

Yq11Yq11

PAR1

Microdeletions

• N=5000 infertile males screened for Y-chromosome mutations in the AZF region

– 8.2% infertile males– 0.4% fertile males

Foresta et al. Endo Rev 2001

8.2

0.4

0

5

10

% A

ZF

del

etio

n

Infertile Fertile

Intracytoplasmic Sperm Injection (ICSI)

ICSI-Derived Offspring

• Of concern because of increased sperm aneuploidy in OAT males

• 1% incidence of sex chromosome aneuploidy in ICSI conceptions– 0.14 % - 0.19 % baseline

(non-ICSI)

– ? Unidentified Klinefelter’s mosaics

• Consider karyotyping all infertile males?

• Consider prenatal diagnosis for all ICSI-derived pregnancies?

5 year follow up of ICSI Children• Examination at 5 years of age• Matched to spontaneous conception controls

– Maternal age– Gender– Child age– Same centers

• Assessment– Growth– General health– Chronic illnesses– Surgical intervention– Neurological development

• Results– ICSI children had more surgical interventions (13% vs 10.5%)– Otherwise equivalent outcomes

Bonduelle et al Reprod Biomed Online 2004: 91-101

Summary

• Male aging– Decreased spermatogenesis– Decreased fertility– Increased miscarriage risk– Increased aneuploidy rates

Recommendations

• Karyotyping should be strongly considered– translocations, sex chromosome aneuploidy,

gonadal mosaicism

• Screening for AZF microdeletions• Preimplantation genetic screening• Amniocentesis/CVS• Genetic Counseling• Donor sperm