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Immunosuppressive Medications

One of the hallmarks and major advances in transplantation medicine has been the advent of effective immunosuppressive therapy. Although these agents are essential for the maintenance of allograft viability, many of them potentially contribute to male infertility. Below is a brief summary of the more commonly used agents and their known effects on fertility.5

• Azathioprine-No adverse effect on male infertility demonstrated, although occasional hematopoetic suppression was noted in offspring.

• Prednisone-Studies using a short course of high-dose exogenous steroids (prednisone 30 mg/day for 30 days) revealed the development of spermatogenic arrest, decreased sperm density, and impaired motility in men with normal baseline semen parameters. Baseline oligospermic men did not demonstrate a similar deterioration in their semen parameters. Fortunately, patients on a short course of low-dose exogenous steroids (prednisone 10 mg/day for 30 days) did not have changes in their semen analysis. Furthermore, testicular biopsy performed on these patients revealed normal spermatogenesis with preservation of Sertoli and Leydig cell microscopic architecture. Most organ transplant recipients receive maintenance doses of prednisone which are closer to the low-dose therapy regimen.

• Cyclosporine A (CsAj-This has perhaps been the most rigorously studied immunosuppressive agent in terms of its impact on male fertility. CsA at therapeutic levels often causes a decrease in serum testosterone, a decrease in intratesticular testosterone, and an increase in serum gonadotropin levels (LH and FSH). These changes are frequently associated with coinciding impairments in sperm density and motility. It is unclear whether the detrimental effects of CsA are mediated at the level of the HPG axis or else at the level of the testicle itself. One hypothesis, which is supported by some animal studies, suggests that CsA interferes with LH signal transduction at the Leydig cell level, with secondarily impaired testosterone production. Supplementation of these animals with exogenous HCG (an LH agonist) improved testosterone production, spermato-genesis, and sperm densities.

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100 Pregnancy Tips

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