Introduction 

Pyospermia is also referred to as leukocytospermia. It appears as an unusual increase in the amount of white blood cells called the leukocytes in the people assigned male at birth (AMAB)sperm. The World Health Organization (WHO) contributed to the knowledge on pyospermia by defining the condition as the appearance of more than 1 million leukocytes in one milliliter of semen. Although in a normal state, semen contains a minimal concentration below 1 million leukocytes per milliliter or no white blood cells. This condition can negatively affect the ability of AMAB people to impregnate people assigned female at birth (AFAB)by increasing oxidative stress, damaging sperm DNA, and impairing sperm function.¹

Importance of understanding its causes

Understanding the causes of pyospermia is essential for effective diagnosis and treatment. Below are highlighted reasons.

1. Impact on AMABfertility: Pyospermia can reduce sperm quality and volume, which may leading to inability to impregnate their AFABcounterpart in other words it result to infertility. It is often connected to oxidative stress, which cause damages to sperm DNA and impairs motility²
2. Indication for other health issues: Pyospermia may indicate infections, inflammation, or other systemic disorders such as autoimmune disorders or varicocele. Identifying these causes allows for designing medical care that are aimed at restoring reproductive health³
3. Treatment plan development: The knowledge of the specific causes of pyospermia, whether bacterial infections, chronic inflammation, or obstructive conditions, guides caregivers to make appropriate treatments plans for treatment such as antibiotics, anti-inflammatory medications, or lifestyle changes³ 

Symptoms of pyospermia

Most times people experiencing pyospermia show no symptoms but sometimes they may present with:^3,4 

• Discoloured semen which may be yellowish or greenish tint
• Pain or discomfort during ejaculation
• If caused by infection, there may be signs of infection such as fever or genital discomfort.

Implications on AMAB fertility

1. Oxidative stress: Excess white blood cells release reactive oxygen species (ROS), causing damage to sperm DNA and membranes
2. Reduced Sperm Quality: Pyospermia can impair sperm movement, structure, and life, significantly reducing reproductiveness
3. Chronic Inflammation: Persistent pyospermia may result in long-term damage to the reproductive organs, further jeopardising the ability of AMABto impregnate their partners

Link between pyospermia and sexually transmitted infections (STIs)

In the introductory section of the article, we noted that infection such as sexually transmitted infections (STIs) is one of the causes of pyospemia. STIs such as chlamydia and gonorrhea are common causes of genital tract infections that lead to an increased number of leukocyte in semen. These infections trigger inflammation in the reproductive organs, contributing to pyospermia.

How STIs contributor to pyospermia

Sexually transmitted infections (STIs) introduce pathogens into the AMABreproductive tract, when this happens, the immune system releases leukocytes to fight the infection. The leukocyte released produce reactive oxygen species that destroy the pathogen causing infection, but these leukocytes excessively accumulate in the seminal fluid they cause damage to sperm cells and weaken their function.¹ 

STIs additionally cause inflammation in the prostate, epididymis, and seminal vesicles, which may affect the extent the blood vessels is permeable in these organs, causing more leukocyte to enter the semen.⁴

Gonorrhoea

Gonorrhea is a disease that can be transmitted during sexual intercourse. It is caused by the bacteria organism called Neisseria gonorrhoeae. When this organism gets into the urethra it causes it to be inflamed resulting in symptoms like pains while urinating and discharge from the penis. If unattended to, gonorrhea can also ascend to the epididymis (the tube that stores sperm behind the testicles) causing inflammation in the area. Infection of the epididymis can lead to severe pain, swelling, and potential infertility.^1,4

Chlamydia

Chlamydia, another STI caused by the Chlamydia trachomatis. The symptoms are not mostly seen and can cause damage to the reproductive system once neglected. Similar to gonorrhoea, chlamydia can cause contamination of the urethra and epididymis by the disease-causing organism, although the symptoms may be milder or absent. Chlamydia can compromise sperm health by inducing inflammation and oxidative stress in the reproductive tract which can be destructive to the sperm DNA, reduces sperm movement and lifespan.^1,5

Diagnosis of pyospermia

Semen analysis for detecting white blood cells

Using the World Health Organization (WHO) definition as a reference point, one can be diagnosed of pyospermia if the leukocytes present in one millilitre of semen is greater than 1 × 10⁶. Semen analysis is a vital tool in diagnosing pyospermia. Key steps include:

Detection methods

• Peroxidase Test: Identifies granulocytes by staining peroxidase-positive cells, though it does not detect other leukocyte types like lymphocytes⁷
• Immunohistochemical Staining: Uses monoclonal antibodies (e.g., CD45) to confirm WBC presence, considered the gold standard despite being time-consuming and costly⁶
• Microscopic Examination: Differentiates white blood cells (WBCs) from immature germ cells via round cell identification, often combined with confirmatory tests⁶

Culture tests and PCR for STIs

Infections, particularly sexually transmitted infections (STIs), are common causes of pyospermia. Diagnostic approaches include:

Semen Culture: Identifies bacterial pathogens like Staphylococcus aureus (49.3% of cases), Escherichia coli, and Streptococcus species.² Reflexive semen cultures are recommended for samples with elevated WBC counts.⁷

PCR Testing:

• Multiplex PCR (M-PCR): Simultaneously detects pathogens like Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes simplex virus (HSV) in semen with 100% sensitivity and 99.7% specificity⁷
• Single PCR (sPCR): Used for human papillomavirus (HPV) genotyping, revealing associations between infections and impaired sperm parameters⁷

Additional tests

1. Urinalysis: Screens for urinary tract infections (UTIs) or STIs, often combined with post-prostatic massage urethral cultures for higher accuracy⁶
2. Physical Examination: Assesses for signs of inflammation (e.g., epididymitis, prostatitis) or anatomical abnormalities like urethral strictures⁶
3. Imaging: Ultrasound or MRI may evaluate obstructions (e.g., varicocele, ejaculatory duct blockages) contributing to leukocytospermia^2,6

Importance of early diagnosis and treatment

1. Preventing Chronic Complications: STIs if left untreated can cause scarring, blockages such as urethral strictures, and permanent damage to sperm quality, leading to irreversible infertility⁸
2. Reducing Oxidative Stress (ROS): Early detection of STIs facilitates the use of antibiotics such as doxycycline, tetracycline and, macrolides which eliminates pathogens, thereby curbing inflammation and ROS production, thus preserving sperm integrity⁹
3. Halting Disease Progression: STIs like chlamydia often do not show visible symptoms but still cause pyospermia. Regular screenings enable healthcare providers to render timely intervention before it leads to significant reproductive damage⁸

Preventive measures to reduce risk and protect fertility

By addressing STIs early and adopting preventive strategies, individuals can reduce their chances of getting pyospermia-related fertility challenges and maintaining quality reproductive health. The following practices are to be followed to mitigate pyospermia related to sexually transmitted infections. 

1. Safe Sex Practices: these involve using condoms during sex to minimize STI transmission risk, limiting the number of sexual partners and ensuring there is mutual STI testing while being sexually active⁸
2. Regular STI Screenings: there is a need for annual testing for sexually active individuals, especially after unprotected exposure. This will help reduce the spread of STIs and prevent associated pyospermia⁸
3. Lifestyle Modifications: Certain lifestyles such as smoking, excessive alcohol, and illicit drugs have to be stopped to prevent pyospermia as they exacerbate oxidative stress. Also adopting and maintaining genital hygiene helps prevent infections that may cause pyospermia⁸
4. Prompt Medical Attention: The need to seek proper medical service is often overlooked to prevent pyospermia. It is important to report symptoms and seek evaluation for symptoms like discolored semen or pelvic pain. Following is adherence to prescribed antibiotic regimens to eradicate all forms of infections that are sexually transmitted^8,10

Summary 

Pyospermia (leukocytospermia) is strongly associated with sexually transmitted infections (STIs) such as chlamydia (Chlamydia trachomatis) and gonorrhoea (Neisseria gonorrhoeae). These infections trigger inflammation in the AMABreproductive tract leading to health issues like, urethritis, prostatitis, or epididymitis, therefore causing an influx of white blood cells that is the leukocyte into the seminal fluid. An increased leukocytes of above 1 million/mL releases reactive oxygen species (ROS), which damage sperm DNA, impair sperm movements, and reduce fertility rate in AMAB.

Understanding the link between pyospermia and STIs highlights the importance of early detection and treatment to preserve people’sability to impregnate their partners and prevent further complications. Addressing STIs such as gonorrhoea and chlamydia highlight the importance of early detection and treatment through antibiotics or antivirals is critical to prevent long-term reproductive health issues by reducing inflammation in AMABreproductive organs, restoring sperm quality, and preserving male fertility.