Prostatitis Impacts Sperm Beyond Standard Semen Analysis

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Prostatitis impacts Sperm Beyond Standard Semen Analysis

Chronic Prostatitis/Chronic Pelvic Pain Syndrome Leads to Impaired Semen Parameters, Increased Sperm DNA Fragmentation and Unfavorable Changes of Sperm Protamine mRNA Ratio


Prostatitis is a common disease that affects men of all ages, although studies report that it is more prevalent in men aged 35-50 years old.

The National Institutes of Health (NIH) classifies prostatitis into 4 categories:

  • Type I – Acute bacterial prostatitis
  • Type II – Chronic bacterial prostatitis
  • Type III – Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
    • Type III A – Presence of leukocytes in the expressed prostatic secretions (EPS)
    • Type III B – Absence of inflammation in the EPS
  • Type IV –  Asymptomatic prostatitis

In previous studies, patients with CP/CPPS were found to have impaired semen parameters according to WHO standard semen analysis. However, fertility experts have recently begun to analyse other semen parameters such as DNA fragmentation, high DNA stainability (HDS) and sperm proteins such as protamine, when assessing male fertility.

One particular study reported that even males with normal sperm parameters but elevated DFI (DNA fragmentation Index), above 20% had decreased odds of conceiving.

Similarly, HDS which marks less condensed chromatin, more easily stained by acridine orange, has been linked to reduced fertility rates in IUI and IVF cycles.

This compaction of DNA in sperm is regulated by the protein protamine, specifically Protamine 1 and Protamine 2. Their ratio remains constant (0.8-1.2), according to several studies, with any variation outside this range linked to decreased pregnancy rates and impaired embryo quality.

However, DNA fragmentation, HDS and protamine 1/2 mRNA ratios have not been comprehensively studied in CP/CPPS patients to date.


To characterise the fertility of males with CP/CPPS by evaluating sperm DNA fragmentation, HDS and protamine mRNA ratios, and potential associations with conventional semen parameters.


The study comprised of 2 groups, a patient group of 41 males suffering from CP/CPPS, and a control group of 22 healthy males.

Patients suffering from both subtypes of Type III CP/CPPS were included in this study. Patients suffering from lower urinary lower urinary tract symptoms (LUTS) with benign prostate syndrome (BPS), prostate cancer, chronic epididymitis/orchitis or bacterial infections were excluded from the study.

Men in the patient group had a median age of 40 years, ranging from 22-62, while men in the control group had a median age of 29.5 years, ranging from 20-41.

Blood, urine (pre and post-prostatic massage) and ejaculate samples was collected from participants.

Semen samples was collected according to WHO 2010 guidelines from participants following 2-7 days of sexual abstinence and analysed within 1 hour of collection.

Sperm DNA fragmentation was evaluated using the most commonly used assay method, sperm chromatin structure assay (SCSA). SCSA also allowed the measurement of high DNA stainability (HDS) and a cut-off value was defined to identify abnormal stainability.

Finally protamine 1/2 mRNA ratios was calculated following measurement of RNA concentrations using the NanoDrop 1000 Spectrophotometer.


Initial analysis of semen parameters showed that CP/CPPS patients, when compared to healthy men, had significantly:

  • lower semen volumes (2.3 vs. 3.5 mL)
  • lower pH (7.8 vs. 8.3)
  • lower total motility (62.0 vs. 75.5 %)
  • lower progressive motility (53.0 vs. 64.5 %)
  • lower normal morphology (8.0 vs. 14.0 %)
  • lower vitality (61.0 vs. 86.5 %)

The amount of peroxidase-positive cells (0.1 vs. 0.0 × 106/mL) and immature germ cells (0.56 vs. 0.0 × 106/mL) was also higher in CP/CPPS patients.

Interestingly, despite the reduced semen volume, there was no statistically significant difference in the total sperm count or sperm cell concentration per ejaculate between the 2 groups.

Analysis of biochemical and inflammatory parameters showed no significant difference in seminal components fructose, alpha-glucosidase and elastase between both groups. However, inflammatory marker IL-8 was significantly higher in the patient group compared to controls (3503 vs. 1680 pg/mL). There was also a moderate decrease in zinc levels (6.6 vs 10.3 µmol) among CP/CPPS patients, although this was not statistically significant (P= 0.066).

Sperm DNA fragmentation analysis revealed CP/CPPS patients had significantly higher DFI levels, with 36.6% of patients exhibiting a DFI greater than 25% and 29.3% of patients exhibiting a DFI greater than 30%, while none of the control group males had a DFI higher than 25%.

Correlation analysis of DFI to conventional semen parameters in the patient group, revealed statistically significant negative correlations, meaning as DFI increased, total number of sperm cells, sperm cell concentration, total and progressive motility, normal morphology and protamine mRNA ratio decreased. At the same time, positive correlations was observed, meaning as DFI increased, sperm head defects and tail defects also increased.

High DNA Stainability analysis of semen samples revealed no significant difference between CP/CPPS patients and healthy males.

However when compared to conventional semen parameters, statistically significant negative correlations were noted, meaning as DFI increased, total sperm cell number, sperm cell concentration and normal morphology decreased. At the same time, statistically significant positive correlations were observed, meaning as DFI increased, head defects and peroxidase-positive cells also increased.

Advanced statistical analysis revealed no significant relationship between HDS and DFI meaning neither test is viable substitute for the other.

Initial analysis of sperm Protamine mRNA ratios found no significant difference in the median protamine mRNA ratio of CP/CPPS patients and healthy males (1.08 vs. 0.95).

However when categorising participants according to ‘in range’ and ‘out of range’ values a significant difference in the ‘in range’ and ‘out of range’ population was seen among the 2 groups.

 CP/CPPS group (%)Healthy male group (%)
In range (0.8 – 1.2)21.963.6
Out of range (<0.8 or > 1.2)78.136.4
Out of range (<0.8)36.613.6
Out of range (>1.2)41.522.7

Overall the majority of CP/CPPS patients had protamine 1/2 mRNA ratios which would be considered out of range of regular fertility.

Correlation analysis of Protamine mRNA ratios to conventional semen parameters in the patient group, revealed statistically significant negative correlations, meaning as Protamine mRNA ratios increased, DFI and tail defects decreased.

Finally, potential associations between inflammatory parameters and DFI, HDS or protamine mRNA ratio was evaluated. To do this CP/CPPS patients were categorised into 3 groups:

  • None (Patients who had no elevated inflammatory marker)
  • One (Patients who had one elevated inflammatory marker)
  • More than One (Patients who had more than one elevated inflammatory marker)

The results of this analysis found no significant associations between inflammation and DFI, HDS or protamine mRNA ratio. However patients with more than one elevated inflammatory marker, exhibited a median protamine mRNA ratio that was out of the range of regular fertility (<0.8 or >1.2).


Males diagnosed with prostatitis had significantly impaired sperm quality, with significantly decreased total and progressive motility, normal morphology (8.0 vs. 14.0 %) and vitality (61.0 vs. 86.5 %), along with increased prevalence of abnormal sperm DNA fragmentation levels and protamine mRNA ratios.


  1. Small study size
  2. No reference value for HDS to compare


The study was funded by the German Research Foundation.



A laboratory test.

No symptoms.


DNA fragmentation
The separation or breaking of DNA strands into pieces.

DNA fragmentation index (DFI)
A measurement that reflects the integrity of and the damage to DNA.

Inflammation of the epididymis, a highly convoluted duct behind the testis, along which sperm passes to the vas deferens.

Germ cells
Precursor cells which differentiate into an egg or sperm.

A proinflammatory cytokine produced by macrophages and other cell types such as epithelial cells.

White blood cells.

The middle number of a sorted data set.

Inflammation of one or both testicles.

Peroxidase-positive cells
Peroxidase test of leucocytes (white blood cells).

Also known as semen, organic fluid containing sperm.

An instrument which measures the concentration of a known substance in a solution.

Similar studies

Condorelli R A, et al. (2017). Chronic prostatitis and its detrimental impact on sperm parameters: a systematic review and meta-analysis.

Schagdarsurengin U, et al. (2017). Chronic Prostatitis Affects Male Reproductive Health and Is Associated with Systemic and Local Epigenetic Inactivation of C-X-C Motif Chemokine 12 Receptor C-X-C Chemokine Receptor Type 4.


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