Effect of treatment of chronic hepatitis c virus patients with direct-acting anti-retroviral drugs on semen and hormonal parameters

Abstract

Objective

Hepatitis C virus (HCV) infection is known to influence the seminal and hormonal parameters of infected men. This study was performed to assess the effects of HCV clearance using direct-acting antiviral (DAA) agents on semen and hormonal parameters.

Methods

A total of 50 patients with chronic HCV were enrolled, and conventional semen analysis was performed according to World Health Organization guidelines. Basal levels of total testosterone, free testosterone (FT), follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), prolactin, and sex hormone-binding globulin (SHBG) were assessed before and 3 months after treatment with DAAs.

Results

Following DAA treatment, statistically significant increases were observed in sperm motility and the proportion of grade A sperm. Additionally, the percentage of abnormal forms was significantly decreased after treatment (p=0.000). However, no significant differences were observed in semen volume, concentration, or total sperm count. Sex hormone analysis of patients after DAA treatment revealed significant increases in FT, LH, and FSH levels, along with significant decreases in SHBG, prolactin, and E2 levels.

Conclusion

Following HCV clearance, we noted an improvement in sperm motility and an increase in the percentage of sperm with normal morphology. Treatment with DAAs was also associated with increased levels of FT and LH, along with decreased levels of SHBG, prolactin, and E2.

Introduction

Available data regarding the impact of hepatitis C virus (HCV) on semen quality are conflicting [1]. Consequently, the effects of HCV on semen quality and sex hormone levels, along with the role of direct-acting antiviral (DAA) drug treatment, have attracted substantial interest. In this study, we comprehensively summarized the changes observed in the semen characteristics and hormonal profiles of male patients with chronic HCV before and after treatment with DAAs.

Infection with HCV is a global health problem that impacts millions of individuals around the world [2]. Despite the fact that HCV is preventable and curable, approximately 185 million people had been infected as of 2005, with an additional 3 to 4 million individuals newly infected each year [3]. HCV infection is more prevalent among male members of a given population, and men consistently exhibit lower rates of viral clearance compared to women [4]. In addition to representing a leading cause of liver-related mortality, HCV infection is also linked to a range of extrahepatic manifestations, such as cardiovascular morbidity, diabetes mellitus, fatigue, and depression [5].

Another suggested extrahepatic manifestation of chronic HCV infection is the alteration of seminal parameters, potentially negatively affecting spermatogenesis [6]. However, a separate study found that HCV infection does not affect semen quality, indicating that HCV may not have a detrimental impact on sperm [7]. Previous research has also demonstrated that low total testosterone (TT), low free testosterone (FT), and elevated sex hormone-binding globulin (SHBG) levels are extrahepatic manifestations of chronic HCV infection relative to healthy controls [8,9].

The treatment of chronic HCV infection continues to advance rapidly. In 2011, the first protease inhibitors—telaprevir and boceprevir—were approved for use in combination with pegylated interferon and ribavirin to treat chronic HCV genotype 1 [10-14]. Over recent years, several oral antiviral agents that target various HCV proteins have been rapidly developed. These new therapies include additional protease inhibitors, nucleotide and non-nucleotide polymerase inhibitors, nonstructural protein 5A (NS5A) inhibitors, and cyclophilin inhibitors [15-18]. Sofosbuvir, the first polymerase inhibitor to be approved for chronic HCV treatment, is a nucleotide analog that inhibits nonstructural protein 5B (NS5B) polymerase. This antiviral agent is effective across all HCV genotypes and is well-tolerated with minimal side effects [19]. Sofosbuvir-based combination therapies have achieved very high cure rates, exceeding 90% in certain patient groups [20].

A recent study by El Kassas et al. [21] demonstrated a significant improvement in HCV-associated sexual dysfunction in both sexes following HCV clearance with DAA treatment. To our knowledge, no prior studies have assessed the impact of these new drugs on semen parameters and sex hormone levels. Consequently, the present study was conducted to evaluate semen and hormonal parameters in male patients with chronic HCV infection before and 3 months after initiating treatment with these new oral antiviral medications.

Methods

1. Study population

The study included 50 male patients ranging in age from 21 to 58 years, all of whom had chronic HCV infection. These individuals were randomly selected from the patients admitted to the National Hepatology and Tropical Medicine Research Institute (NHTMRI). Each patient had tested positive for anti-HCV antibodies and had displayed detectable serum HCV RNA, as confirmed by polymerase chain reaction, for a minimum of 6 months. All participants were deemed eligible to receive a DAA regimen. The study design received approval from the NHTMRI Ethical Committee (approval no. ITH00106), and informed consent was obtained from each participant.

2. Laboratory assessments

Two semen samples were collected 3 to 5 days after the patient’s last ejaculation and were analyzed at an andrology laboratory. The initial semen sample was obtained prior to the commencement of treatment, while the subsequent sample was collected 3 months after treatment initiation, marking the end of the treatment period. Semen analysis was performed according to guidelines established by the World Health Organization. Blood samples were collected from each patient to assess the levels of several hormones: SHBG, follicle-stimulating hormone (FSH), luteinizing hormone (LH), TT, FT, estradiol (E2), and prolactin. These measurements were taken prior to treatment and again after 3 months of the new antiviral therapy. The following criteria excluded individuals from participating in the study: (1) evidence of cirrhosis, whether determined clinically or by liver biopsy, FibroScan, or fibrosis-4 score; (2) portal hypertension; (3) prior use of interferon; (4) varicocele; (5) cryptorchidism; (6) testicular atrophy; (7) use of medications that influence sex hormone and/or vitamin metabolism; (8) drug abuse; and (9) current excessive alcohol consumption.

3. Statistical analysis

Data were collected, revised, coded, and entered into SPSS ver. 23 (IBM Corp.). Quantitative data were presented as means, standard deviations, and ranges for parametric distributions. Qualitative variables were expressed as numbers and percentages. Comparisons between groups with qualitative data were performed using the chi-square test. For two paired groups with quantitative data and parametric distributions, the paired t-test was utilized. The confidence interval was established at 95%, and an acceptable margin of error was set at 5%. Consequently, a p-value of less than 0.05 was considered to indicate statistical significance.

Results

In the present study, we investigated semen parameters and sex hormone levels in male patients with chronic HCV infection who were candidates for DAA treatment. Our aim was to determine the impact of the virus and its subsequent clearance on semen quality and hormonal concentrations. A total of 50 patients were enrolled in the study. Their ages ranged from 21 to 58 years, with a mean±standard deviation age of 40.98±11.40 years. Among these participants, 40 patients (80%) were married and had children, while six (12%) reported sexual dysfunction.

The mean total sperm motility and grade A progressive motility (before treatment: 44.8%±15.75% and 21.9%±13.13%, respectively) exhibited highly significant improvement (p<0.001) following treatment with DAAs (after treatment: total motility, 52.56%±13.92%; grade A progressive motility, 29.2%±12.75%). Additionally, sperm morphology demonstrated a highly significant improvement after viral clearance (41.52%±15.88% abnormal compared to 51.84%±21.86% before treatment). No significant changes were observed in semen volume or sperm concentration between pre- and post-treatment values (Table 1, Figure 1).

Table 1.

Comparison of semen parameters before and after direct-acting antiviral treatment

Test	Mean±SD	Mean difference	95% CI	p-value
Volume (mL)		−0.06	−0.21 to 0.09	0.430
Before	2.05±0.51
After	2.11±0.44
Concentration (million/mL)		0.26	−0.91 to 1.43	0.660
Before	22.5±9.42
After	22.24±8.33
Total count (million/ejaculate)		−0.71	−5.55 to 4.13	0.770
Before	46.75±26.1
After	47.46±20.6
Motility (%)		−7.76	−10.61 to −4.91	0.000a)
Before	44.8±15.75
After	52.56±13.92
Grade A (%)		−7.30	−9.14 to −5.46	0.000a)
Before	21.9±13.13
After	29.2±12.75
Grade B (%)		−0.56	−3.31 to 2.19	0.680
Before	22.9±8.87
After	23.46±10.33
Abnormal forms (%)		10.32	7.13 to 13.51	0.000a)
Before	51.84±21.86
After	41.52±15.88

SD, standard deviation; CI, confidence interval.

^a)Indicates highly significant test.

Figure 1.

Comparison of semen analysis before and after direct-acting antiviral treatment. Conc., concentration; ejac, ejaculate; Ab., abnormal.

Treatment with DAAs was associated with highly significant increases in the levels of LH and FT (p=0.000), as well as highly significant decreases in the levels of SHBG and prolactin (p=0.000), compared with pre-treatment hormone levels. E2 levels exhibited a mild but significant decrease (p<0.003) after treatment, while FSH and TT showed no significant changes (Table 2, Figure 2).

Table 2.

Comparison of sex hormone levels before and after direct-acting antiviral treatment

Test	Mean±SD	Mean difference	95% CI	p-value
SHBG (nmol/L)		12.86	10.78 to 14.94	0.001a)
Before	60.94±11.81
After	48.08±11.59
FT (ng/mL)		−3.16	–3.81 to −2.51	0.001a)
Before	6.13±4.24
After	9.29±4.7
LH (mIU/mL)		−0.71	−0.98 to −0.43	0.001a)
Before	3.29±0.77
After	4±0.88
FSH (mIU/mL)		−0.65	−1.34 to 0.04	0.063
Before	4.06±1.72
After	4.71±1.71
PRL (ng/mL)		2.81	2.33 to 3.29	0.001a)
Before	11.01±3.69
After	8.2±2.71
TT (ng/mL)		−0.23	−0.59 to 0.12	0.196
Before	3.15±1.09
After	3.38±0.85
E2 (pg/mL)		6.77	0.79 to 12.75	0.003b)
Before	39.29±13.43
After	32.52±14.2

SD, standard deviation; CI, confidence interval; SHBG, sex hormone-binding globulin; FT, free testosterone; LH, luteinizing hormone; FSH, follicle-stimulating hormone; PRL, prolactin; T test, total testosterone; E2, estradiol.

^a)Indicates highly significant test; ^b)Indicates significant test.

Figure 2.

Comparison of sex hormone levels before and after direct-acting antiviral treatment. SHBG, sex hormone-binding globulin; LH, luteinizing hormone; FSH, follicle-stimulating hormone; PRL, prolactin; TT, total testosterone; E2, estradiol.

Discussion

The relationship between androgen levels, liver function impairment, and chronic viral infection is complex. Active HCV infection can cause or exacerbate liver dysfunction, which is acknowledged as a risk factor for both hypogonadism and altered semen production [22]. The pathophysiological process underlying sexual dysfunction in male patients with HCV is multifactorial. Several mechanisms have been proposed to explain this condition, including hormonal changes, psychological impact, and iatrogenic causes [23].

In the present study, serum SHBG levels were elevated, yet still within the normal range, in patients with HCV. SHBG exhibits a greater affinity for testosterone compared to estrogens, potentially affecting the delivery of testosterone to target tissues [24]. SHBG can bind approximately 80% of circulating testosterone, and its serum concentration is inversely related to the level of FT [25]. Nguyen et al. [10] reported that more severe liver disease was associated with lower FT and higher SHBG levels.

We noted that a sustained virologic response was associated with the restoration of liver function, accompanied by a decrease in SHBG and an increase in FT. These results are consistent with the findings of Chaudhury et al. [22], who investigated testosterone and SHBG levels and found that HCV clearance was associated with reduced SHBG concentrations.

Following DAA therapy, we also observed increases in LH and FSH levels, along with decreases in prolactin and E2 levels. Durazzo et al. [6] reported lower serum FT levels in patients with HCV compared to healthy controls, but they found no significant differences in FSH, LH, or prolactin levels. In comparison, Safarinejad et al. [26] observed lower levels of LH and FSH in patients with the infection. Hofny et al. [9] reported elevated prolactin levels in patients with hepatitis C, linking these findings to a reduction in sperm count and other semen abnormalities.

In the present study, we observed a significant decrease in the proportion of abnormal sperm forms following treatment. This aligns with the findings of Durazzo et al. [6], who similarly reported an improvement in sperm morphology after treatment. Furthermore, we observed significant increases in sperm motility and the proportion of grade A sperm following treatment with DAA. However, semen volume, concentration, and total sperm count were not significantly impacted.

Ghanem et al. [27] investigated 30 male patients with chronic HCV who were treated with pegylated interferon in combination with ribavirin. They reported a decrease in sperm concentration and significant impairment in motility among patients with HCV receiving combined antiviral therapy [27]. In a separate study, Hofer et al. [28] examined 15 male patients with chronic HCV treated with pegylated interferon alpha-2a and ribavirin, finding that sperm motility was impaired during antiviral treatment. The evident discrepancy in results may stem from differences in treatment regimens. Our patients completed a course of DAA treatment, whereas patients in the previous studies received combination therapy with pegylated interferon and ribavirin.

In conclusion, treatment of HCV with DAAs leads to a significant increase in sperm motility and a decrease in abnormal sperm morphology. Additionally, this treatment elevates the levels of FT, LH, and FSH while decreasing the concentrations of SHBG, prolactin, and E2.