How to Correctly Diagnose MAGI

Conventional WHO criteria for MAGI (Fig. 25.1) should be integrated with the ultrasound exploration of the male accessory glands and an accurate leukocyte assessment (by immunocytochemistry). Therefore, we propose an algorithm for the assessment of MAGI based on sequential levels (Fig. 25.2). Each level includes relative "processes" broken down into specific "actions" and "outcomes."

Table 25.4 Conventional sperm parameters, seminal leukocyte concentration, and basal and fMLP-stimulated radical oxygen species production from three categories of patients with ultrasound-positive MAGI according to the presence of Gram-negative or Gram-positive microorganisms (>105 CFU/mL)

Prostatovesiculitis (« = 78)

Prostatovesiculoepididymitis (« = 72) Gram negative Gram positive (« = 39) " (« = 33)

Spemt parameters and seminal leukocytes Sperm concentration (mil/mL) 32 (10-102.6) Total sperm number

(mil/ejaculate) Progressive motility (%) Normal forms (%) Seminal leukocytes (mil/mL)

(23.5—473.2) 18.0 (13-28) 22.5 (15-23) 1.9(1.1-4.7)

101.4

Radical oxygen species production (45% Percoll fraction) Baseline (xlO3 cpm) 92.2 75.3 (48-143.5)

fMLP-stimulated (xlO3 cpm) 225.7 182.4(120-879)

(15.2-315.3) 16.0 (10-23) 18.0 (10-22) 3.5+(1.4-7.0)

Values are expressed as median and the 10th-90th percentiles in parentheses. "p<0.01 vs. both prostatitis alone or prostatovesiculitis; +p<0.01 vs. prostatitis

Table 25.5 Conventional sperm parameters, seminal leukocyte concentration, and basal and fMLP-stimulated radical oxygen specie production from three categories of patients with ultrasound-positive MAGI according to the presence of C. trachomatis or U. urealyticum

Prostatovesiculitis (« = 27)

Prostatovesiculoepididymitis (« = 51)

Parameters

Spetm parameters and seminal leukocytes Sperm concentration 23.0 (8.0-52.6)

Total sperm number 87.4 (14.5-178.3)

(mil/ejaculate) Progressive motility (%) 13.0 (6.0-18.0) Normal forms (%) 20.0 (15.0-26.0)

Seminal leukocytes 3.2 (2.6-6.2)

Radical oxygen species production (45% Percoll fraction) Baseline (xlO3 cpm) 273.6 197.3

(165.0-487.4) (136.8-989.3) fMLP-stimulated 525.7 397.2

101.6

(18.2-373.2) 14.0 (8.0-20.0) 22.4 (18.0-28.0) 3.0(1.8-5.2)

59.0

(12.0-146.7) 10.4 (2.4-15.0) 14.0(10.0-22.0) 4.6+ (3.0-7.4)

Values are expressed as median and the 10th-90th percentiles in parentheses. "p<0.01 vs. both prostatitis alone or prostatovesiculitis; +p<0.01 vs. prostatitis

STEP

ACTION

Medical history Physical examination Sperm analysis (including routine leukocyte assessment) Additional testing (biochemical markets) if necessary

Quantitative sperm culture Urethral swabs after prostate massage for Chlamydia and Ureaplasma urealyticum detection Optional tests Stamey test Leukocyte assessment after prostate massage

OUTCOME

Diagnosis of non-specific MAGI

Diagnosis of MAGI due to pathogen microbes, Chlamydia, Ureaplasma

Scrotal and transrectal prostate-vesicular ultrasound

Scrotal and transrectal prostate-vesicular ultrasound

Chronic inflammatory response

Assessment of the various leukocyte subpopulations (by immunocytochemical staining) ROS production

Optional testing

Assessment of cytokines and total antioxidant capacity

Diagnosis of prostatitis, prostate-vesiculitis, or prostate-vesicular-epididymitis

Identification of patients who require anti-inflammatory and antioxidant administration after antimicrobical treatment

Fig. 25.2 Algorithm for the diagnosis of MAGI based on sequential levels scans

(a) To suspect/identify the presence of MAGI, only "first-line testing" is required. This includes collection of the clinical history, urogenital physical examination, and sperm analysis including seminal leukocyte measurement. The presence of OAT in combination with other factors allows to suspect/identify the presence of MAGI

(b) When a diagnosis of MAGI is suspected, "second-line testing" which included microbiological investigation (sperm culture and urethral swabs) allows identifying the etiological nature of MAGI

(c) "Second-line testing" includes also the attempt to localize the site(s) of the inflammatory process by ultrasound scans (didymoepididymal and transrectal prostatovesicular ultrasonography). The localization of the inflammatory process is based on the presence of a significant number of ultrasound abnormalities, for each gland (Table 25.1). These abnormalities have been found strongly associated with elevated bacteriospermia (>10. CFU/mL) and ROS overproduction in studies on selected infertile infected patients [16, 19]

(d) In patients with complicated (microbial or amicrobial) MAGI (PV or PVE), "third-line testing" is needed to evaluate the host inflammatory response and to prescribe a rationale therapeutic strategy. This third-line testing includes the accurate assessment of leukocytospermia and the production of spermiotoxic leukocyte-related products (ROS and cytokines) [16, 18-20] which may impair sperm function by inducing DNA damage and/or apoptosis [20, 24, 48]

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