Male immune infertility: criteria for differential diagnosis

Introduction. Autoimmune reactions against spermatozoa represent a recognized cause of male infertility. The presence of antisperm antibodies (ASAs) can lead to reduced sperm motility, impaired capacitation and acrosome reaction, as well as increased sperm DNA fragmentation. However, current WHO guidelines do not establish definitive diagnostic criteria for «male immune infertility.» Instead, they recommend developing regional reference ranges based on the 5th to 95th percentile values derived from fertile men populations.

Objective. To establish reference ranges for the percentage of ASAs-IgG-positive spermatozoa in fertile Russian men in order to enhance the clinical and economic effectiveness of infertility management in couples.

Materials & Methods. The study is an observational, multicenter, cross-sectional, retrospective analysis. Antisperm antibodies (ASAT) on spermatozoa were assessed using the mixed antiglobulin reaction (“MAR-IgG”) method recommended by the WHO (“FertiPro”, Beernem, Belgium). A cohort of fertile men (n = 358) was selected based on the following criteria: 1) their partners achieved pregnancy (hCG > 100 mIU/ml and/or ultrasound confirmation of a gestational sac) occurring naturally within 12 months after discontinuation of contraception, with the semen analysis performed within 3 months of conception at a specialized andrology laboratory; 2) absence of any specific treatment for at least 3 months prior to the date of conception. Two subgroups were identified: subgroup 1 (n = 255), in which semen volume, concentration, motility, and morphology met the WHO 2021 reference ranges; and subgroup 2 (n = 337), in which these parameters corresponded to Russian regional reference criteria (Bozhedomov et al., 2023).

Results. In the cohort of fertile men (n = 358), MAR-IgG test results ranged from 0 to 100%, with a median of 0% and the 5th to 95th percentiles spanning 0% to 40%. MAR-IgG levels exceeding 40% were observed in 4.5% of cases (16 out of 358). Within subgroup 1, all instances of MAR-IgG > 10% were identified as statistical outliers based on the standard English “non-outlier range,” with the 95th percentile at 36%. According to the Russian reference criteria, MAR-IgG values above 12% and the 95th percentile of 40% were considered outliers. No statistically significant differences were found between subgroups 1 and 2 regarding distribution patterns and frequency of cases exceeding these thresholds (p > 0.05).

Conclusion. In Russian men, the proportion of IgG-positive progressively motile spermatozoa should not exceed 12%. When this proportion ranges from 13% to 40%, an immune-mediated contribution to infertility is considered probable. Pregnancy is statistically unlikely when more than 40% of progressively motile spermatozoa are IgG-positive, even in the presence of normozoospermia, indicating a threshold for clinically significant immune infertility.

1. Wilson L. Sperm agglutinins in human semen and blood. Proc Soc Exp Biol Med. 1954;85(4):652-655. DOI: 10.3181/00379727-85-20982

2. Vazquez-Levin MH, Marín-Briggiler CI, Veaute C. Antisperm antibodies: invaluable tools toward the identification of sperm proteins involved in fertilization. Am J Reprod Immunol. 2014;72(2):206-218. DOI: 10.1111/aji.12272

3. Mazumdar S, Levine AS. Antisperm antibodies: etiology, pathogenesis, diagnosis, and treatment. Fertil Steril. 1998;70(5):799-810. DOI: 10.1016/s0015-0282(98)00302-1

4. Restrepo B, Cardona-Maya W. Antisperm antibodies and fertility association. Actas Urol Esp. 2013;37(9):571-578. DOI: 10.1016/j.acuro.2012.11.003

5. Francavilla F, Santucci R, Barbonetti A, Francavilla S. Naturally-occurring antisperm antibodies in men: interference with fertility and clinical implications. An update. Front Biosci. 2007;12:2890-2911. DOI: 10.2741/2280

6. Bozhedomov VA, Nikolaeva MA, Ushakova IV, Lipatova NA, Bozhedomova GE, Sukhikh GT. Functional deficit of sperm and fertility impairment in men with antisperm antibodies. J Reprod Immunol. 2015;112:95-101. DOI: 10.1016/j.jri.2015.08.002

7. Galimov Sh.N., Bozhedomov V.A., Galimova E.F., Pavlov V.N., Sukhikh G.T. Male infertility: molecular and immunological aspects. Moscow: GEOTAR-Media; 2020. (In Russian).

8. Gupta S, Sharma R, Agarwal A, Boitrelle F, Finelli R, Farkouh A, Saleh R, Abdel-Meguid TA, Gül M, Zilaitiene B, Ko E, Rambhatla A, Zini A, Leisegang K, Kuroda S, Henkel R, Cannarella R, Palani A, Cho CL, Ho CCK, Zylbersztejn DS, Pescatori E, Chung E, Dimitriadis F, Pinggera GM, Busetto GM, Balercia G, Salvio G, Colpi GM, Çeker G, Taniguchi H, Kandil H, Park HJ, Maldonado Rosas I, de la Rosette J, Cardoso JPG, Ramsay J, Alvarez J, Molina JMC, Khalafalla K, Bowa K, Tremellen K, Evgeni E, Rocco L, Rodriguez Peña MG, Sabbaghian M, Martinez M, Arafa M, Al-Marhoon MS, Tadros N, Garrido N, Rajmil O, Sengupta P, Vogiatzi P, Kavoussi P, Birowo P, Kosgi R, Bani-Hani S, Micic S, Parekattil S, Jindal S, Le TV, Mostafa T, Toprak T, Morimoto Y, Malhotra V, Aghamajidi A, Durairajanayagam D, Shah R. Antisperm Antibody Testing: A Comprehensive Review of Its Role in the Management of Immunological Male Infertility and Results of a Global Survey of Clinical Practices. World J Mens Health. 2022;40(3):380-398. DOI: 10.5534/wjmh.210164

9. Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, Lamb DJ, Mulhall JP, Niederberger C, Sandlow JI, Sokol RZ, Spandorfer SD, Tanrikut C, Treadwell JR, Oristaglio JT, Zini A. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. J Urol. 2021;205(1):36-43. DOI: 10.1097/JU.0000000000001521

10. Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, Lamb DJ, Mulhall JP, Niederberger C, Sandlow JI, Sokol RZ, Spandorfer SD, Tanrikut C, Treadwell JR, Oristaglio JT, Zini A. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part II. Fertil Steril. 2021;115(1):62-69. DOI: 10.1016/j.fertnstert.2020.11.016

11. Bozhedomov V.A., Korneev I.A., Lipatova N.A., Bozhedomova G.E., Kamarina R.A., Nikolaeva M.A., Galimova E.F., Galimov Sh.N., Epanchintseva E.A., Pavlov V.N., Kamalov A.A. Reference parameters of baseline ejaculate analysis of fertile men: Russian regional features (multicenter cross-sectional retrospective study). Urologiia. 2023;(5):48-56. (In Russian). DOI: 10.18565/urology.2023.5.48-56

12. Mukherjee AG, Gopalakrishnan AV. Anti-sperm Antibodies as an Increasing Threat to Male Fertility: Immunological Insights, Diagnostic and Therapeutic Strategies. Reprod Sci. 2024;31(11):3303-3322. Erratum in: Reprod Sci. 2024;31(8):2537. DOI: 10.1007/s43032-024-01610-y

13. Leathersich S, Hart RJ. Immune infertility in men. Fertil Steril. 2022;117(6):1121-1131. DOI: 10.1016/j.fertnstert.2022.02.010

14. Sinisi AA, Di Finizio B, Pasquali D, Scurini C, D’Apuzzo A, Bellastella A. Prevalence of antisperm antibodies by SpermMARtest in subjects undergoing a routine sperm analysis for infertility. Int J Androl. 1993;16(5):311-314. DOI: 10.1111/j.1365-2605.1993.tb01197.x

15. Tüttelmann F, Nieschlag E. Classification of andrological disorders. In: Nieschlag E, Behre HM, Nieschlag S, eds. Andrology: male reproductive health and dysfunction. Berlin: Springer; 2010.

16. Yasin AL, Yasin AL, Basha WS. The Epidemiology of Anti-Sperm Antibodies Among Couples with Unexplained Infertility in North West Bank, Palestine. J Clin Diagn Res. 2016;10(3):QC01-3. DOI: 10.7860/JCDR/2016/15788.7380

17. Heidenreich A, Bonfig R, Wilbert DM, Strohmaier WL, Engelmann UH. Risk factors for antisperm antibodies in infertile men. Am J Reprod Immunol. 1994;31(2-3):69-76. DOI: 10.1111/j.1600-0897.1994.tb00849.x

18. Barbonetti A, Castellini C, D’Andrea S, Cordeschi G, Santucci R, Francavilla S, Francavilla F. Prevalence of anti-sperm antibodies and relationship of degree of sperm auto-immunization to semen parameters and post-coital test outcome: a retrospective analysis of over 10 000 men. Hum Reprod. 2019;34(5):834-841. DOI: 10.1093/humrep/dez030

19. Bellis MA, Hughes K, Hughes S, Ashton JR. Measuring paternal discrepancy and its public health consequences. J Epidemiol Community Health. 2005;59(9):749-754. DOI: 10.1136/jech.2005.036517

20. Muncey W, Scott M, Lathi RB, Eisenberg ML. The paternal role in pregnancy loss. Andrology. 2025;13(1):146-150. DOI: 10.1111/andr.13603

21. Silva AF, Ramalho-Santos J, Amaral S. The impact of antisperm antibodies on human male reproductive function: an update. Reproduction. 2021;162(4):R55-R71. DOI: 10.1530/REP-21-0123

22. Bozhedomov V.A., Sukhikh G.T. Immune male infertility. Study guide. Moscow: E-noto, 2018. (In Russian).