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3-5 There have been relatively few studies of newer AEDs (oxcarbazepine [OXC], levetiracetam [LEV], or lamotrigine [LTG]), and some of them are controversial. 6, 7 In this study, newly diagnosed male adult patients with epilepsy were randomized to receive OXC, LEV, or LTG monotherapy to observe the quality of semen, sexual function, and sex hormones before and after treatment, and to explore the effects of these AEDs on the reproductive and sexual functions of male adult patients with epilepsy.

Thirty?eight newly diagnosed male adult patients with epilepsy were enrolled at the Epilepsy Center Sichuan Provincial People's Hospital from April 2015 to November 2016. The diagnosis was in line with the classification of epilepsy defined by the International League Against Epilepsy (1981). Only patients with generalized or focal epilepsy, with generalized or secondary generalized tonic–clonic seizures, were recruited into the present study.

Patients with genital organic or functional lesions were excluded; patients were also required to be free of serious psychosis, diabetes, malignant neoplasm, and other progressive neurological diseases.

Patients signed informed consent and agreed to enter the study before recruitment. Twenty?six volunteers in the same period were recruited as the healthy control group. The institutional ethics committee of Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital provided ethical approval for this study. The AED group was randomly divided into 3 subgroups and given OXC (300?900 mg/d), LEV (1000?1500 mg/d), or LTG (100?150 mg/d). Each subgroup was administered monotherapy for ?6 months.

The semen samples were collected from the healthy control group and from the AED group.

In the AED group, semen samples were collected both before and 6 months after medication. All semen samples were obtained by masturbation 3?7 days after abstinence and quantified by a pipette. The semen was kept at a constant temperature of 37°C for 30 minutes (or until liquefaction). The total number, the pH value, the fast forward movement rate (FFMR), and the survival rate of the sperm from all participants were evaluated by the same researchers, who were unaware of the group allocations. All operations were conducted in accordance with World Health Organization standards. The sexual function of the patients was evaluated using the International Index of Erectile Function Scale?5 and the Premature Ejaculation Diagnostic Tool Self?Assessment Scale.

8, 9 The 2 questionnaires were completed by those who had had a sexual experience.

Six patients did not complete the questionnaire because they had no sexual experience.

Five?milliliter samples of blood after early morning fasting was collected from study patients diagnosed with epilepsy before or after medication treatment.

The levels of sex hormones, estradiol, testosterone, luteinizing hormone (LH), follicle?stimulating hormone (FSH), and prolactin, were determined by chemiluminescence analysis. The chemiluminescence analyzer (serial number iSR05848) and detection kit were purchased from Abbott Laboratories (Abbott Park, IL, USA).

The

analyses

Demographic data, marriage status, and fertility rate of male patients with epilepsy and the healthy control group.

Age, y Disease course, y Marriage rate, % Birth rate, % Education levels, n Elementary or under Middle school College or above Pre?AEDs 38 28.09 ± 3.08 4.61 ± 5.48 26.32a a Pearson chi?square test for comparison of male epilepsy patients and control participants regarding marriage rate and fertility rate, P 15.79a a Pearson chi?square test for comparison of male epilepsy patients and control participants regarding marriage rate and fertility rate, P 0 20 18 Control 26 28.00 ± 4.68 – 57.69 46.15 0 8 18 P .99 .012 .008 – – .14 OXC 16 28.30 ± 4.65 7.69 ± 7.18 37.50 18.75 0 9 7 LEV 11 29.00 ± 6.12 3.42 ± 5.53 18.18 18.18 0 5 6 LTG 11 27.00 ± 3.21 5.57 ± 2.37 18.18 9.10 0 6 5 P .85 .08 .46 .87 – – .92. AED, antiepileptic drug; LEV, levetiracetam; LTG, lamotrigine; OXC, oxcarbazepine.

a Pearson chi?square test for comparison of male epilepsy patients and control participants regarding marriage rate and fertility rate, P.

The total number of sperm, FFMR, survival rate, and normal sperm rate in male adult patients with epilepsy before treatment were lower than those in healthy controls ( P .05; Table 2).

AED, antiepileptic drug; CON, control; FFMR, fast forward movement rate; LEV, levetiracetam; LTG, lamotrigine; OXC, oxcarbazepine.

a Mann?Whitney test showed that the total sperm count, FFMR, survival rate, and normal sperm count of male patients with epilepsy before treatment were significantly lower than after treatment ( P b Before and after treatment with OXC, P. 3.3 Comparison of sexual function among the groups. The erectile function scale scores and premature ejaculation index scores of male adult patients with epilepsy before treatment were lower than those of the healthy control group, but there was no statistically significant difference.

The erectile function before and after AED treatment had a trend toward improvement, whereas premature ejaculation did not improve, although both were not significantly different ( P > .05; Table 3). Erectile function score Premature ejaculation index score Pre?AEDs 38 19.36 ± 1.57 4.14 ± 2.19 CON 26 21.50 ± 3.73 4.26 ± 3.01 P .09 .90 Pre?OXC 16 19.31 ± 1.08 4.10 ± 1.89 OXC 16 20.09 ± 1.87 6.30 ± 3.65 P , before/after .30 .53 Pre?LEV 11 19.36 ± 2.03 4.20 ± 3.08 LEV 11 20.27 ± 2.61 7.00 ± 3.90 P , before/after .17 .40 Pre?LTG 11 19.43 ± 1.97 4.18 ± 1.50 LTG 11 20.82 ± 2.18 8.00 ± 5.73 P , sildenafil teva online before/after .22 .17. AED, antiepileptic drug; CON, control; LEV, levetiracetam; LTG, lamotrigine; OXC, oxcarbazepine.

Compared with the healthy control group, the male adult patients with epilepsy before treatment, and the patients with epilepsy in the 3 different drug treatment subgroups before and after treatment, sex hormone levels were not significantly different ( P > .05; Table 4).

E2, pmol/L T, nmol/L LH, mIU/mL FSH, mIU/mL PRL, mIU/L Pre?AEDs 38 110.84 ± 42.63 19.41 ± 4.41 3.36 ± 1.72 3.68 ± 2.40 265.14 ± 97.38 CON 26 106.58 ± 31.52 17.18 ± 6.26 2.61 ± 1.17 2.93 ± 1.50 224.01 ± 59.73 P .99 .86 .22 .51 .40 Pre?OXC 16 108.12 ± 35.23 19.45 ± 3.41 3.40 ± 2.07 3.67 ± 1.96 266.35 ± 95.34 OXC 16 119.33 ± 25.90 17.02 ± 6.69 3.66 ± 1.41 3.98 ± 2.46 209.06 ± 86.35 P , before/after .93 .74 .91 .98 .27 Pre?LEV 11 112.81 ± 43.18 19.38 ± 5.87 3.31 ± 1.46 3.64 ± 2.01 263.57 ± 117.87 LEV 11 133.91 ± 48.20 18.46 ± 6.05 2.44 ± 1.06 3.37 ± 1.17 208.29 ± 61.61 P , before/after .32 .99 .20 .97 .27 Pre?LTG 11 111.56 ± 42.75 19.50 ± 4.67 3.42 ± 1.34 3.70 ± sildenafil 25 mg tablet price 3.21 266.36 ± 67.27 LTG 11 120.10 ± 16.73 22.39 ± 6.43 3.67 ± 2.49 4.70 ± 1.60 285.22 ± 109.54 P , before/after .92 .61 .91 .42 .94.

AED, antiepileptic drug; CON, control; E2, estradiol; FSH, follicle?stimulating hormone; LEV, levetiracetam; LH, luteinizing hormone; LTG, lamotrigine; OXC, oxcarbazepine; PRL, prolactin; T, testosterone.

It has been reported that the incidence of sexual dysfunction in male patients with epilepsy is 5 times higher than that in healthy people, and the incidence of sexual hyperactivity is about 2.9%. 10 A number of studies have shown that epilepsy and AEDs (especially older AEDs) have a complex effect on male sex hormones, reproductive organs, and sexual function, leading to a decrease in fertility in male patients with epilepsy.

4, 5 In this study, the marriage rate and birth rate of the male adult patients with epilepsy were significantly lower than those of the healthy group, which may be related to the patients’ anxiety caused by seizures and different degrees of social discrimination.

That the fertility rate of the adult male epilepsy patients was lower than that of the healthy controls may be related to the low occurrence of marriage and the impact of seizures on reproductive function. In this study, we only recruited those patients with generalized and secondary generalized tonic–clonic seizures; patients with focal seizures (except for secondary generalized tonic–clonic seizures) were excluded, because they rarely seek medical care and show poor medical compliance. It has been reported in both animal and clinical studies that an epileptic seizure itself can affect the secretion of sex hormones.

In animal experiments, a partial or generalized seizure can lead to abnormal sex hormone levels; repeated seizure attacks can cause gonadal size changes and decreased sexual function. 10 Clinical studies have also observed that abnormal brain epileptiform discharges may directly interfere with the function of the hypothalamic?pituitary?gonadal axis, especially in temporal lobe epilepsy, which may cause abnormalities in the secretion of sex hormones and lead to reproductive endocrine disorders. 10 It is known that AEDs can cause endocrine disorders in male patients with epilepsy, which is particularly common in older AEDs such as the enzyme inducer classes (CBZ, PHT, PB, etc) and liver enzyme inhibitors (VPA). This class of drugs induces hepatic cytochrome P450 to increase the synthesis of sex hormone–binding globulin, decreases the level of free androgens, or promotes the conversion of testosterone to estradiol by aromatase. This affects the function of the hypothalamic?pituitary?gonadal axis and causes sex hormone disorders. 11 Enzyme inhibitory AEDs can affect the output of gonadotrophin?releasing hormone neurons by affecting serotonin and ??aminobutyric acid (GABA) neurons, thereby increasing the concentration of dehydroepiandrosterone sulfate, causing negative feedback regulation and a reduction of LH and FSH. The study on the impact of AEDs on the level of sex hormones in male patients with epilepsy has yielded differing results. Malatkova et al 13 reported that sex hormone disorders in 12 patients returned to normal after CBZ was replaced by OXC.

Verrotti et al 14 showed that OXC can have a dose?dependent effect on reproductive endocrine function, and serum testosterone, sex hormone–binding protein, and gonadotropin levels all increased when OXC doses were >900 mg/d.

Harden et al 15 reported that a marked increase in testosterone levels was observed after 1 month of LEV treatment in 8 male adult patients with epilepsy.

However, Spencer showed that in 26 adult male patients with epilepsy, no statistically significant changes were found in sex hormone levels measured before taking LEV and after taking it for 13.7 weeks. 16 Herzog et al 17, 18 and Gil?Nagel et al 18 observed no change in sex hormone levels in men with epilepsy after LTG administration. In our study, monotherapy of OXC, LEV, or LTG alone did not cause obvious changes of sex hormones in male adult patients with epilepsy.

We speculated that conventional doses of OXC, LEV, or LTG alone or their metabolites do not mainly affect the cytochrome P450 enzyme system.

Semen quality decline is also one of the important factors that causes impaired fertility disorders of male patients with epilepsy.

In the maturation of sperm, sex hormone regulation plays a very important role; LH stimulates testicular stromal cells to synthesize testosterone, and FSH acts on supporting cells in the seminiferous tubules, leading to synthesis of androgen?binding globulin (ABP).

Then, ABP and testosterone are combined and carried in spermatogonia and spermatocytes, so that germ cells obtain stable, high concentrations of androgen, and effectively differentiate into mature sperm. Many studies have shown that epilepsy and a variety of AEDs can adversely affect the quality of sildenafil price 50 mg semen, particularly older AEDs, most of which can affect the sex hormones and in turn have an impact on the occurrence and maturation of sperm.

19, 20 The epileptic abnormal discharge of brain neurons can also affect the function of the hypothalamic?pituitary?gonadal axis, indirectly affecting the quality of sperm.

The effect of the AEDs on semen quality has only been reported by a few authors. Calabro et al 21 reported the case of a male patient with epilepsy who was diagnosed as infertile and had a marked reduction in semen quality. After 3 months of LTG treatment, the sperm count increased 2.7?fold and sperm motility increased 68%, and a pregnancy resulted after 5 months.

Cansu et al 22 found in an animal study that OXC can reduce the number of spermatocytes at all developmental stages, although the difference was not statistically significant. Kose?Ozlece et al 23 observed a significant decrease in sperm count and viability as the dose of VPA was increased, but the semen quality was restored after the VPA dose was tempered by combination with LTG. Baysal et al 24 found that when male rats received oral LEV for 70 days, histological examination of the rat's genital histopathology and sildenafil kroger semen analysis showed that at 300 mg/kg/d LEV, the male rats had obvious testicular damage, and the effect of LEV on rat semen quality was shown to be dose?dependent.

In our study, the semen quality of the patients with epilepsy was significantly decreased compared with the healthy control group, suggesting that the reduction of semen quality may be mainly because of the seizures themselves.

There was a trend toward improvement in all sperm parameters before and after treatment with the 3 different novel AEDs compared with those before treatment, but there was only a statistically significant difference in the OXC treatment group. In the LEV and LTG treatment groups, although comparison between before and after treatment showed a substantial improvement, no significant difference was observed. We believe that these 3 AEDs have no significant negative effects on male semen quality at therapeutic doses and may improve the semen quality to some extent; treatment with OXC can improve the survival rate and FFMR of the sperm. It has been reported that men with epilepsy experience sexual dysfunction, including loss of libido, erectile dysfunction, and orgasm disorders.

25 In addition, some studies have reported that in male patients with epilepsy, the degree of sexual dysfunction is negatively correlated with anxiety and depression, not correlated with the frequency of seizures, but closely correlated with the location of epileptic seizures.

This includes temporal lobe epilepsy, in which sexual dysfunction occurs more often than in other types of epilepsy.

26 The possible mechanism is the temporal lobe area, especially the amygdala, which has a direct anatomical relationship with the hypothalamus and can act through repeated epileptiform discharges, leading to sexual dysfunction. 26 There have also been studies reporting that when measuring the genital blood flow in patients with epilepsy, patients with temporal lobe epilepsy had less blood flow to the genitals; this may, to some extent, explain the sexual dysfunction. 27 Newer AEDs (OXC, LEV, or LTG) might affect sexual function less than older AEDs.

4, 5, 28 They can cause sexual dysfunction by affecting the secretion of sex hormones 11 or by increasing the inhibition of GABA, inhibiting nerve conduction and reducing the transmission of sexual stimuli.

29 The effect of these AEDs on sexual function has been less reported, with contrasting results.

Different studies have pointed out that OXC can both improve sexual function in patients with epilepsy and can also cause sexual dysfunction.

Luef et al 6 reported that among 228 adult male epilepsy patients with partial seizures and sexual dysfunction, 181 (79.4%) of them improved their sexual function after being treated with OXC monotherapy or by replacing other AEDs with OXC monotherapy for 12 weeks of treatment; moreover, 23 (10.1%) patients did not get worse, and the improvement in sexual function was more obvious in patients who had previously used enzyme?inducing AEDs.