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Year : 2016  |  Volume : 7  |  Issue : 3  |  Page : 90-94

Study of seminal fluid parameters and fertility of male sickle-cell disease patients and potential impact of hydroxyurea treatment

Sickle Cell Clinic and Molecular Biology Lab, Veer Surendra Sai Medical College and Hospital, Burla, Sambalpur, Odisha, India

Date of Web Publication26-Oct-2016

Correspondence Address:
Lulup K Sahoo
Senior Resident, Department of Neurology, S.C.B. Medical College, Room No. 59, P.G. Hostel, Cuttack, Odisha - 753 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5127.192984

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Context: Male sickle-cell disease (SCD) patients often have moderate to severe hypogonadism resulting in abnormal seminal fluid parameters. Hydroxyurea (HU) used in SCD patients has been found to further aggravate the testicular dysfunction.
Aims: To study the seminal fluid parameters and fertility of male SCD patients and to evaluate the potential impact of HU treatment on the above factors.
Settings and Design: This was a prospective study of 100 male SCD patients of age group 18 to 45 years.
Materials and Methods: Seminal fluid analysis was done before starting low dose of HU (10 mg/kg/day) and every 3 months after initiation of HU. Patients with abnormal seminal parameters before HU therapy were not given HU therapy. In SCD patients with HU therapy, who developed abnormal seminal fluid parameters, HU was stopped for 3 months and seminal fluid parameters were re-evaluated.
Results: Among SCD patients without HU therapy, nine (18%) patients developed oligospermia and two (4%) developed azoospermia. Among SCD patients with HU therapy, 10 (20%) patients developed oligospermia and five (10%) developed azoospermia. Seminal fluid parameters reverted to normal after stoppage of HU for 3 months in 73% of patients.
Conclusions: Alteration of sperm parameters is seen in a significant number of SCD patients. Also, alterations of seminal fluid parameters are exacerbated by HU treatment even with low dose.

Keywords: Azoospermia, hydroxyurea, oligospermia, sickle-cell disease

How to cite this article:
Sahoo LK, Kullu BK, Patel S, Rout P, Patel NK, Purohit P, Meher S. Study of seminal fluid parameters and fertility of male sickle-cell disease patients and potential impact of hydroxyurea treatment. J Appl Hematol 2016;7:90-4

How to cite this URL:
Sahoo LK, Kullu BK, Patel S, Rout P, Patel NK, Purohit P, Meher S. Study of seminal fluid parameters and fertility of male sickle-cell disease patients and potential impact of hydroxyurea treatment. J Appl Hematol [serial online] 2016 [cited 2023 May 29];7:90-4. Available from: https://www.jahjournal.org/text.asp?2016/7/3/90/192984

  Introduction Top

Sickle-cell disease (SCD) is one of the most common human autosomal recessive disorders caused by a mutational substitution of thymine for adenine in the sixth codon (GAG to GTG) of the globin gene on chromosome 11p.[1] SCD patients often have moderate to severe hypogonadism of unknown origin, although several mechanisms have been suggested such as primary hypogonadism,[2],[3],[4],[5] hypogonadism induced by repeated testicular infarction,[6] zinc deficiency,[7],[8] and puberty delay due to span height retardation.[9],[10],[11]

Hydroxyurea (HU) remains the only approved disease modifying therapy for SCD.[1] HU increases the fetal hemoglobin which has higher oxygen carrying capacity and does not undergo sickling under low oxygen tension. Low dose HU therapy (10 mg/kg/day) is found to be effective in improving clinical and hematological parameters in SCD with improved quality of life. HU, being an antimitotic agent, has been reported to impair human spermatogenesis. HU is also associated with testicular atrophy,[12],[13],14] a reversible decrease in sperm count[12],[13],[14] and abnormal sperm morphology[13],[14] and motility.[12] So, HU treatment can aggravate the testicular dysfunction in SCD patients.

SCD is a major public health problem in the state of Odisha, India. The sickle-gene frequency is 10–30% in general population in Odisha.[15] The use of HU is increasing in SCD patients due to its beneficial effect in reducing painful crises and blood transfusion requirement but there are limitations to HU because of its toxicities. SCD itself causes abnormalities in seminal fluid parameters, which also may be aggravated by HU therapy. On the basis of the above observations, we conducted this study to evaluate seminal fluid parameters and fertility of men suffering from SCD and to analyze the potential impact of HU.

Subject and Methods

This was a hospital-based prospective study undertaken on SCD patients in age range of 18 to 45 years enrolled in Sickle Cell Clinic and Molecular Biology Lab of Veer Surendra Sai Medical College and Hospital, Burla, Odisha, India during the period from September 2011 and October 2013. Ethical approval was obtained from the institutional ethics committee and patients were recruited in the study after their written consent.

Screening, diagnosis and clinical evaluation

Screening of SCD was initially done by sickling slide test. Those patients who were found positive were subjected to agarose gel Hb electrophoresis in an alkaline medium (pH 8.6). Quantification of various hemoglobin including HbF and HbS was done by High Performance Liquid Chromatography (HPLC) using VARIANT. Hemoglobin tasting system (Bio-Rad Lab, Hercules, CA, USA) on the principle of cation exchange HPLC according to manufacturer’s guidelines. Confirmation of SCD (codon 6 = GAG to GTG mutation) was done by amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) using established protocols.[16]

We randomly selected 50 SCD patients (Group I) who did not require HU therapy. Again another 50 patients, who needed HU therapy and had normal sperm parameters prior to HU therapy, were randomly selected and assigned to Group II. Group II patients were given low dose HU therapy 10 mg/kg/day. SCD patients with one or more of the following complications were included in Group II and were given low dose HU therapy: (a) painful crises ≥3 episodes in previous 1 year and (b) ≥2 blood transfusions in last 1 year. Painful crisis was defined as an acute painful event that required oral/injectable analgesics and that lasted for at least 4 h when no other cause could explain the symptom.

A detailed history was taken in all cases with reference to age, marital status, fertility in the form of number of issues, family history, history of painful crisis, and blood transfusion. Married male SCD patients with regular sexual activity in the form of regular unprotected sexual intercourse for 12 months or more were asked whether he had caused a pregnancy or not. Routine hematological evaluation such as complete blood count, liver function tests, and serum creatinine were done in all patients and repeated every 3 months following HU therapy.

Group I patients were evaluated for seminal fluid analysis and those who had azoospermia were subjected for Fine Needle Aspiration Cytology of Testis (FNAC) of testis. In Group II, seminal fluid analysis and routine hematological evaluation were done prior to HU therapy and during HU therapy every 3 months. HU was temporarily stopped in those who developed oligo or azoospermia during HU treatment and again tested for seminal quality after 3 months. Those who developed azoospermia were subjected to FNAC of testis. HU was restarted after normalization of sperm parameters.

Exclusion criteria

Patients with following criteria were excluded from the study: (a) patients with other sickle-cell syndrome such as HbS/β-thal, HbS/HbE, HbS/HbC, HbS/HbD Punjab, and others; (b) male patients <18 years and >45 years; (c) patients who refused to give consent; and (d) patients who had taken HU for less than 80% of days.

Evaluation of seminal fluid parameters

Seminal fluid sample was collected in a sterile container by masturbation after minimum 3 days of sexual abstinence and analyzed after liquefaction according to World Health Organization (WHO) criteria.[17] The parameters assessed included volume of ejaculate, sperm concentration, motility, sperm morphology, and viability. The normal semen volume is 2–6 ml, normal sperm concentration ≥15 million/ml, normal motility ≥40% motile [progressive (PR) + nonprogressive (NP)] or ≥32 % with progressive motility, normal morphology in ≥4% of sperms, and normal viability is ≥58% viable sperm.[17]

Evaluation of fertility

Evaluation of fertility is done by taking history of patient’s marital status and whether the patient had caused at least one pregnancy.


FNAC was done in patients who showed azoospermia. FNAC of testis was done with 22G needle by aseptic method after giving local xylocaine injection into spermatic cord bilaterally. Smears were stained with hematoxylin and eosin (H and E) stain and examined under microscope (1250 magnification) for spermatogenic cells and sertoli cells.

  Results Top

The mean age of SCD patients in Group I (non-HU) was 26.02 ± 6.86 years (age range 18–45 years) and in Group II (with HU) mean age was 25.86 ± 6.5 years (age range 19–45 years). In our study, clinical indication of HU therapy was painful crisis alone in 31 cases (62%), repeated blood transfusion alone in four (8%) of cases, and combined painful crisis and repeated blood transfusion in 15 (30%) cases.

The level of HbS in Group I (non-HU) was 71.064 ± 10.534 and HbF was 17.958 ± 6.859. The level of HbS in Group II prior to HU therapy was 70.850 ± 15.719 and HbF was 19.892 ± 4.265. The level of HbS in Group II after HU therapy was 68.766 ± 15.371 and HbF was 23.138 ± 5.403.

Evaluation of fertility

In our study, out of 50 non-HU (Group I) patients, 36 patients (72%) were unmarried and 14 patients (28%) were married. 13 out 14 married men (93%) had caused at least one pregnancy. In 50 patients with HU therapy (Group II), 43 patients (86%) patients were unmarried and seven patients (14%) were married. Six out of seven married men (86%) had caused at least one pregnancy.

Seminal fluid parameters in SCD patients without HU therapy (Group I)

In 50 patients without HU therapy, the mean sperm concentration was 48.60 ± 27.73 million/ml with oligospermia seen in nine patients (18%) and azoospermia in two patients (4%). The mean normal morphology was 77.3 ± 20.66% [Table 1] and [Table 2].
Table 1: Seminal fluid analysis in sickle-cell disease patients

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Table 2: Seminal fluid analysis in sickle-cell disease patients (N= 50)

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Impact of HU on sperm parameters in Group II

(A) Seminal fluid parameters prior to HU therapy:

The mean sperm concentration was 54.28 ± 16.2 million/ml and mean normal morphology was 85.3 ± 10.27% [Table 3].
Table 3: Impact of hydroxyurea on seminal fluid analysis in sickle-cell disease patients

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(B) Seminal fluid parameters during HU therapy:

The mean sperm concentration during HU therapy was 39.26 ± 29.32 million/ml with normal morphology 73.3 ± 30.96% with oligospermia seen in 10 patients (20%), and azoospermia in five patients (10%). Comparison of sperm parameters before and during HU therapy showed significant reduction in sperm concentration (P value <0.0001) with reduction in both normal morphology and motility [Table 3] and [Table 4].
Table 4: Impact of hydroxyurea on seminal fluid analysis in sickle-cell disease patients (N= 50)

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(C) Seminal fluid parameters after stoppage of HU therapy:

Among the total 15 (30%) of hypogonadism patients (oligospermia + azoospermia), 11 patients (73%) reverted back to normal following stoppage of HU therapy for 3 months but four patients (27%) did not revert [Table 4].

FNAC of testis

FNAC of testis was done in two non-HU patients with azoospermia and in four HU receiving patients with azoospermia. In non-HU (Group I), one patient showed absent spermatogenesis with other being normal. In HU receiving group (Group II), three out of four patients showed absent spermatogenesis [Table 5].
Table 5: FNAC of testis

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  Discussion Top

Because of the longer life expectancy of SCD patients due to advent of HU therapy, the evaluation of possible side effects of HU on male fertility has therefore become a question of public health. Any deleterious impact of HU on spermatogenesis and sperm parameters would represent a major concern necessitating advice on sperm cryopreservation as a preventive measure to preserve future male fertility.

In our study, we analyzed the seminal fluid parameters of 50 SCD patients without HU therapy and 50 SCD patients with HU therapy. In the SCD patients without HU therapy, the mean sperm concentration was 48.60 ± 27.73 million/ml with oligospermia seen in nine (18%) patients, and azoospermia in two (4%) patients. Overall we detected 22% of oligo-azoospermia in patients without HU therapy. In the study by Berthaut,[18] 40% of individual values of concentration of spermatozoa were below normal and at least one sperm parameter was abnormal in 91% of patients before HU treatment. The possible mechanism may be owing to primary hypogonadism or hypogonadism induced by repeated testicular infarction.

A decrease in semen volume in patients with SCD was previously described,[19] suggesting associated abnormalities like disease of seminal vesicle, prostate. In our study, the volume of ejaculate was in normal range, in agreement with Osegbe and Akinyanju[5] study, which did not find any significant difference in ejaculate volume between SCD patients and fertile male controls.In the present series of 50 patients who received low dose HU therapy, there is significant reduction in mean sperm concentration when comparing semen before and during treatment (54.28 ± 16.2 vs 39.26 ± 29.32 million/ml). During HU treatment, 10 (20%) patients developed oligospermia and five (10%) developed azoospermia. In the study by Berthaut,[18] where high dose HU (20–30 mg/kg/day) was used, showed affection of all sperm parameters in semen samples. The possible mechanism may be owing to antimitotic activity of HU.

After stopping HU treatment for 3 months in patients who developed oligo or azoospermia, 73% of patients reverted to normal, indicating reversibility of HU induced gonadal dysfunction in most cases.

In our study, FNAC of testis of two azoospermic patients without HU therapy showed absent spermatogenesis in one patient. FNAC of testis in four azoospermic patients on HU therapy showed absent spermatogenesis in three patients. Jones et al.[20] had found that, testes from HU treated rats showed significant atrophic degeneration in seminiferous tubules compared to control.

  Conclusion Top

The study has several limitations including a small sample size, lack of testing for gonadal hormones such as follicle stimulating hormone (FSH), luteinising hormone (LH) and testosterone for confirming central or peripheral cause of hypogonadism and lack of testicular biopsy. Despite these limitations, the study indicates that alteration of sperm parameters is seen in a significant number of SCD patients. Also, alterations of sperm parameters are exacerbated by HU treatment even with low dose. Therefore, treatment with HU in adolescent and adult male SCD patients should be preceded by routine assessment seminal fluid parameters and followed up regularly every 3 months for any change in sperm parameters for evidence of HU toxicity. HU treatment should be stopped temporarily in patients who develop alteration of sperm parameters and again restarted after normalization of sperm parameters.


I am (Lulup Kumar Sahoo) grateful to my teacher late Dr. D.K. Patel for his constant guidance and blessings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Dada OA, Nduka EU. Endocrine function and haemoglobinopathies: Relation between the sickle cell gene and circulating plasma levels of testosterone, luteinising hormone (LH) and follicle stimulating hormone (FSH) in adult males. Clin Chim Acta 1980;105:269-73.  Back to cited text no. 3
el-Hazmi MA, Bahakim HM, al-Fawaz I. Endocrine functions in sickle cell anaemia patients. J Trop Pediatr 1992;38:307-13.  Back to cited text no. 4
Osegbe DN, Akinyanju OO. Testicular dysfunction in men with sickle cell disease. Postgrad Med J 1987;63:95-8.  Back to cited text no. 5
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Prasad AS, Schoomaker EB, Ortega J, Brewer GJ, Oberleas D, Oelshlegel FJ Jr. Zinc deficiency in sickle cell disease. Clin Chem 1975;21:582-7.  Back to cited text no. 7
Prasad AS, Cossack ZT. Zinc supplementation and growth in sickle cell disease. Ann Intern Med 1984;100:367-71.  Back to cited text no. 8
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Zago MA, Kerbauy J, Souza HM, Figueiredo MS, Costa FF, Cruz SM et al. Growth and sexual maturation of Brazilian patients with sickle cell diseases. Trop Geogr Med 1992;44:317-21.  Back to cited text no. 11
Fiscor G, Ginsberg LC. The effect of hydroxyurea and mitomycin C on sperm motility in mice. Mutat Res 1980;70:383-7.  Back to cited text no. 12
Evenson DP, Jost LK. Hydroxyurea exposure alters mouse testicular kinetics and sperm chromatin structure. Cell Prolif 1993;26:147-59.  Back to cited text no. 13
Wiger R, Hongslo JK, Evenson DP, De Angelis P, Schwarze PE, Holme JA. Effects of acetaminophen and hydroxyurea on spermatogenesis and sperm chromatin structure in laboratory mice. Reprod Toxicol 1995;9:21-33.  Back to cited text no. 14
Patel DK. Epidemiology and clinical aspects of sickle cell disease in India. Lecture at 5th Brazilian symposium sickle cell disease and other hemoglobinopathies held in Belo Horizonte, Brazil. 3rd to 7th October 2009.  Back to cited text no. 15
Wu DY, Ugozzoli L, Pal BK, Wallace RB. Allele-specific enzymatic amplification of β-globin genomic DNA for diagnosis of sickle cell anemia. Proc Natl Acad Sci U S A 1989;86:2757-60.  Back to cited text no. 16
World Health Organization. WHO laboratory manual for the examination and processing of hydroxyureaman semen. 5th ed. Switzerland: WHO Press; 2010.  Back to cited text no. 17
Berthaut I. Influence of sickle cell disease and treatment with hydroxyurea on sperm parameters and fertility of human males. Haematologica 2008;93:988-93.  Back to cited text no. 18
Agbaraji VO, Scott RB, Leto S, Kingslow LW. Fertility studies in sickle cell disease: Semen analysis in adult male patients. Int J Fertil 1988;33:347-52.  Back to cited text no. 19
Jones KM, Niaz MS, Brooks CM, Roberson SI, Aguinaga MP, Hills ER et al. Adverse effects of a clinically relevant dose of hydroxyurea used for the treatment of sickle cell disease on male fertility end points. Int J Environ Res Public Health 2009;6:1124-44.  Back to cited text no. 20


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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