Introduction

About 15% of all couples trying to conceive are afflicted with cases of infertility, mainly on the side of the XY chromosome holders. There are multiple ways that a person identifying as male at birth can be susceptible to infertility, one of them being infection in their genitalia. Infections tend to lead to the overpopulation of leukocytes or white blood cells in the afflicted region to combat the infection. The presence of excess leukocytes tends to lower available sperm count which makes it harder for the egg from the female to be fertilised and form a zygote. Pyospermia, also known as leukocytospermia is when there are too many leukocytes - over a million in a millilitre - present in ejaculated semen.¹

Leukocytes or white blood cells are cells made by the immune system and blood, their rudimentary function is to help the body fight off infection and reduce the chances of spreading the infection. It is quite normal to find some leukocytes in semen. When an ejaculation is analysed, an increased amount of semen can point toward an increase in oxidative stress within a person’s body which in turn leads to a decrease in sperm count.² This condition is temporary and can be reverted once detected, to resolve infertility and enable the couple to get pregnant. This article aims to clarify the topics of pyospermia and its effect on sperm production and quality, trying to find the underlying causes, methods of sperm analysis that could help differentially diagnose this condition, and potential treatment options. 

What role does sperm actually play?

Sperm are cells produced by the secondary sexual organs in people assigned male at birth. It plays numerous roles in the body, some key functions being:

• Formation of Male Reproductive fluids: Semen, in the male body, consists of sperm cells. Semen is the fluid that transports and nourishes sperm cells during ejaculation. It also acts as a shield, protecting them from the acidic environment in the female reproductive system, ensuring that they don’t get replenished. 
• Hormone production: Produced within the testes of the male reproductive system, sperm helps produce certain hormones, such as testosterone. Testosterone is a prevalent hormone present in males, participating in the regulation of various aspects. This includes sperm production, proper functioning of the male reproductive function, and development of sexual characteristics. 
• Sperm motility: Sperm have a tail-like end termed flagellum, which helps them move easily in search of the egg within the female reproductive tract. The motility of the sperm is an important factor through which it navigates and penetrates the egg to initiate pregnancy.
• Acrosome Release: Once past the barriers and into the female reproductive tract, the sperm is required to release all the necessary stored enzymes, these enzymes help get rid of the protective layers around the egg, leading to fertilisation.³

In summary, sperm helps aid the process of the fertilisation of the egg in the ovum encapsulated within the female reproductive tract, by delivering genetic material across. 

How does sperm become pyospermic?

Oxidative stress arises when there is a disruption in production amongst the balance of free radicals - reactive oxygen species - and antioxidant defences in the body’s tissues, weakening the ability of the body to detoxify these reactive products.⁴ This thereby leads to a build-up of toxins in the body leading to inflammation in the affected regions. In most cases, oxidative stress can arise due to genitourinary infections that lead to an inflammation in the reproductive tract or other infections that lead to systemic infections. 

Non-infectious conditions, such as:⁵

• Poor sperm viability
• Autoimmune disorders, 
• Congenital genitourinary malformation
• Varicocele
• Narcotics
• Chronic prostatitis.

Pyospermia can also be initiated due to pathogenic attacks upon the body.⁶ 

• Bacteria: Chlamydia trachomatis or Escherichia coli; 
• Viruses: Human papillomavirus, cytomegalovirus or Human simplex virus.

These are some examples of diseases and pathogens that could cause the onset of inflammation and pyospermia-like conditions. 

Identification of pyospermia

The threshold of diagnosis of pyospermia is riddled with uncertainty, for the query that if the presence of excess leukocytes within sperm is truly indicative of a true pyospermia infection or it could, at times, simply be an inflammatory process being carried out by the body to rid itself of foreign infectious toxins and pathogens. 

To verify whether the person afflicted with this condition is indeed suffering from pyospermia, a follow-up culture test is carried out. Certain cultures are needed to identify potential genitourinary pathogens that go undetected during regular anaerobic or aerobic cultures. 

Further studies suggested that it is not solely the increase in leukocyte count and presence of infectious bacterial pathogens, but also the proportion at which the healthy bacteria are present in the genital tract compared to the infectious ones. 

Although this field is still an ever-growing one and still needs to be thoroughly researched to establish a strong relationship between fertility, microorganisms, and seminal plasma composition. 

What to do when you suspect pyospermia?

Symptoms of pyospermia:

Not always presenting itself with obviously noticeable symptoms, pyospermia can exist as a comorbidity with other conditions,⁸ like:

• Sexual dysfunction: Ejaculatory dysfunction - painful or difficult ejaculations - or erectile dysfunctions - painful or difficult erections - are experiences that negatively impact one's sexual life and could be sexual dysfunctions that could hint towards pyospermia. 
• Infertility: The elevated levels of leukocytes in sperm composition tend to reduce the motility of the sperm, making it unable to reach the egg in the female reproductive tract. 
• Change in semen appearance: Semen that has been afflicted with pyospermia may have a foul, unpleasant odour and be more viscous than it regularly is. It appears to have a thicker composition and may have a slightly green or yellow tint to it as opposed to its usual creamy white colour. 
• Pain or discomfort whilst urinating: As a characteristic of most, if not all, genitourinary tract infections, individuals can also undergo mild to severe discomfort while urinating that could be persistent or intermittent. An overall uncomfortable sensation in parts of the male genital area, such as the penis, testicles, or perineum (region present in between the anus and genitals).
• Urinary issues: The increase in urination frequency, with a feeling of urgency to urinate. During urination, a burning sensation is felt followed by pain in some instances. 

However, it is important to note that not all individuals afflicted with pyospermia will feel all or even any of the symptoms depending on the underlying cause of this condition. If facing any sort of issues or concerns on one's reproductive health, it is advised to consult with your local healthcare provider to have a professional opinion and not self-diagnose. 

Treatment

When undergoing irritation whilst urinating or developing concerns about reproductive or sexual health, a healthcare professional must be contacted. A rudimentary semen analysis will be conducted that will be analysed by scientists to detect any abnormalities.  If required, they will perform further testing using a Papanicolaou (pap) stain - also known as pyospermia staining - for a sperm count greater than 1 million round cells/millilitre in the initial semen analysis. 

Increased leukocytes that present with infectious symptoms are usually prescribed 100mg of doxycycline, to be taken twice a day for 4 weeks. Non-infectious symptoms when presented with increased leukocyte count, are treated with 200mg of celecoxib, to be taken once a day for two weeks. After the course of medication is completed, another semen analysis is conducted to examine sperm count.⁹ 

As part of the routine treatment, other lifestyle factors such as smoking habits, diet, exercise, excessive alcohol intake, illicit drug use, and use of saunas or hot tubs, etc. that could affect pyospermia are also examined. 

Outlook of pyospermia

Pyospermia is largely a temporary issue that can easily be reverted and leukocyte count can be brought down in semen with accurate administration and treatment. Patients also are suggested to undergo IVF treatment in a few cases.¹⁰

Summary

The increase of leukocytes in semen is a common condition with implications for fertility in people assigned as male at birth and their quality of sperm. The leukocytes lead to increased inflammation in the genitourinary tract, causing semen motility to decrease and the prevalence of infection and reduction of fertility in males. The presence of over a million leukocytes per millilitre of semen does not immediately point towards the presence of pyospermia but does point towards higher chances of it. It is easily treatable, and advice from one’s healthcare provider can help the identification and regression of this condition, leading to a reduction in leukocyte count and thereby an increase in sperm quality and motility.