313
poisoning by inorganic mercury, including depression, irritability, failure of memory and concentration, and hand tremor, are found also in victims of methyl mercury poisoning. Methyl mercury is fat-soluble and has a particular affinity for brain tissue.
JOAN D. CROSS IAN M. DALE Department of Clinical Physics and Bio-Engineering LORETTA GOOLVARD West of Scotland Health Boards, Glasgow G4 9LF J. M. A. LENIHAN Department of Forensic Medicine, University of Glasgow
HAMILTON SMITH
SPERM-ANTIBODY TESTING IN INFERTILITY
SiR,—The article on hostility testing by Morgan et al. is interesting since the test provides a useful screen for immunological causes of infertility. Indeed we agree with Stone and Shulmanthat sperm-antibody tests should be included more frequently in the panel of diagnostic tests on an infertile couple. In our laboratory, when testing for sperm isoantibodies in infertile women, we usually use semen from normal donors as antigen, as do most laboratories. However, when we test with sperm from the partner and from
donors,
we
sometimes get
discordant results. RESULTS
and donors’ sperm, while in fifteen cases (50%) the tests were negative with both. In ten cases (33%)-and this is the most important result-the patient’s samples agglutinated her partner’s spermatozoa but not the pool of donors’ spermatozoa. In only one case (but with very low titre) did we observe positivity in the serum exclusively with donor sperm. In all thirty cases the pattern was the same,with the gel agglutination and capillary methods. The high number of positive cases is surprising. However, an isoimmune antisperm reaction was suspected, in theory at least, in these patients-indeed this was why we selected them in the way we did. The percent positivity in the search for antispermatozoa isoantibodies of the sperm-agglutinating type in unselected infertile women in our records is 10.5%. Furthermore if the tests had been performed with donor spermatozoa only, the percent positivity in our selected group would have been 17%. Use of spermatoza from the partner revealed positivity that would otherwise have been undected. The titres are given in the table. These data, if confirmed, emphasise the importance of doing spermagglutinin tests in infertile women (seminal and immunological patterns permitting) not only with sperm from donors but also with sperm from the partner if false negativity is to be avoided. We would offer two hypotheses to explain this discordance. First, besides common species-specific antigens, on sperm membrane individual antigens could be expressed; a particular immunisation mechanism and/or immune response could induce synthesis of antibodies against the latter antigens. Secondly, the surface sperm antigens present in all the members of the same species could be present with a variable quantitative degree in the individuals ; the immune response in the female would then be directed against the prevailing surface antigens on the spermatozoa of the partner. F. DONDERO Medical Pathology II, and Obstetrics and Gynæcology I and II,
M. CERASARO M. NICOTRA I. M. COGHI
University of Rome, Rome, Italy
H-Y ANTIGEN IN A MALE WITH A
45, X KARYOTYPE
SIR,-It is of great interest that H-Y antigen is detectable in XX males and XX true hermaphrodites, both of whom have testicular tissue but lack a recognisable Y chromosome.These observations suggest that testis-determining genes and the H-Y
To explore this discordance we tested the blood serum and cervical mucus of thirty infertile women with, as antigen, sperm from the partner and a donor pool. Patients were selected on the following criteria: (1) they had had so-called idiopathic infertility for at least 2 years; the husband had normal semen and no antisperm autoantibody (agglutinating, immobilising, cytotoxic) in blood serum or seminal plasma; and (2) consistently poor postcoital test, repeated at least three times. Donors also had normal semen and were negative in antisperm autoantibody tests. Furthermore, to avoid false positivity or negativity, all samples were tested with normal control serum and serum previously demonstrated to be positive. The gelatin agglutination method and capillary method 3 were used, with the precautions emphasised by Shulman. In four cases (13%) tests were positive with both partner’s
1. Morgan, H., Stedronska, J., Hendry, 2. 3.
W.
F., Chamberlain, G. V. P.,
Dewhurst, C. J. Lancet, 1977, i, 1228. Stone, M. L., Shulman, S. ibid. 1977, ii, 663. Shulman, S. Reproduction and Antibody Response. C.R.C. Press, 1975.
Cytotoxicity
of anti-mouse-H-Y antiserum after
absorption
8- - -8, unabsorbed; --8 absorbed with female XX cells; 0- - -0 absorbed with male XO cells; 0———0 absorbed with male XY cells. Points
are
s.n.±109%.
means
of 3 double-blind assays
by
two
observers.
314 locus are extremely closely linked or, more probably, one and the same. This hypothesis is confirmed by our studies of H-Y antigen in a previously described2 45, X male with no evidence of mosaicism in blood and skin cultures. At birth this patient was of normal height and weight, had some Turner-like features (i.e., nuchal cutis laxa, short neck, shielded chest, Turnerlike dermatoglyphics) but normal male sexual development in spite of mild hypogenitalism. Serological cross-reactivity between the H-Y antigen of mouse and man allows the detection of H-Y antigen on human cells by absorption of anti-mouse H-Y antiserum.3 This test showed (fig. 1) that cells from the 45, X male carried as much H-Y antigen as those from 46, XY normal males. The XO male is very rare: only one has been previously described.4 Like XX males and XX true hermaphrodites, XO males havea "sex reversed syndrome". Testicular tissue in these three conditions develops in the absence of the Y chromosome but our results suggest that H-Y antigen and the development. of testes are always associated, strengthening the likelihood that they have a common, or closely linked, structural genetic basis. Cattedra di Istologia ed Embriologia e Clinica Pediatrica II, Università di Modena, Italy Laboratoire du Centre Hospitalier,
Chambéry, France
generale,
A. FORABOSCO E. CHELI B. NOEL
J. TOUS
RENAL GRAFT ACCEPTANCE WITHOUT AZATHIOPRINE
SIR,-In provocative articleSheriff and co-workers asked whether azathioprine is necessary in renal transplantation. They conclude that, when azathioprine is stopped there seems to be no good indication for restarting it. We have some experience with azathioprine withdrawal in renal-transplant patients. In seven patients with cadaveric renal grafts azathioprine was stopped for medical reasons (table). Mean observation period without azathioprine was 7.7 (maximum 18.7) months in four patients with good primary transplant function. Acute rejections in two of these patients were reversed by high-dose methylprednisolone. At the end of the period of observation time serum-creatinine values were no higher than those found before azathioprine was stopped. In three further patients with chronic renal rejection azathioprine withdrawal did not seem to accelerate the course of progressive transplant failure. a
1. 2.
Lancet, 1976, ii, 1008. Forabosco, A., and others. Clin. Genet. 1977, 12, 97. 3. Tous, J., Pochat, D., Noel, B. Rev. Franç. Endocr. Clin. 1978, 19, 49. 4. Lo Curto, F., and others, Am. J. Dis. Child. 1974, 128. 90. 5. Cattanach, B. M. in Birth Defects (edited by H. G. Motulsky and W. Lenz); p. 129. Amsterdam, 1974. 6. Sheriff, M. H. R., Yayha, T., Lee, H. A. Lancet, 1978, i, 118.
Basic
prednisolone therapy was slightly increased in two pa-
tients, diminished in four patients, and unchanged in
one
pa-
tient. We agree with Sheriff et al. that, when azathioprine is stopped for medical reasons, renal grafts can be well tolerated for long periods without any alternative immunosuppression. P. SCHMIDT H. KOPSA
J. ZAZGORNIK
1st Medical Department, University of Vienna,
P. PILS P. BALCKE
A 1090 Vienna, Austria
TEMPERATURE AND PLATELET AGGREGATION DURING STORAGE OF WHOLE BLOOD
SjR,—Cold storage of platelet-rich plasma, platelet
concen-
platelet aggregation and reduced platelet viability.1-6 Nevertheless, although many centres now advise short-term storage of platelet concentrates and platelet-rich plasma at room temperature, whole blood is still stored refrigerated, partly because of the unknown effects of long term (up to 35 days) storage at room temperature and also to inhibit bacterial multiplication. At least one blood-pack manufacturer (Fenwall) advises storage of whole blood at 1-6°C. However, in our experience whole blood storage at 1°C is considerably worse, in respect of cellular aggregation, than trates, and whole blood
can
result in
storage at 4°C, and at room temperature little or no aggregation is observed even after 21 days storage. Cellular aggregation was measured using the screen filtration pressure (S.F.P.) method7 on samples from standard units of blood. The units were collected from fourteen healthy male volunteers aged 19-55 into polyvinyl-chloride blood packs (McGraw Laboratories) containing 63 ml citrate-phosphate-dextrose as anticoagulant. Storage temperatures of 1 ± 0.50 and 4 + 0.5OC were carefully maintained in cooled incubators. Ambient room temperatures varied between 14 and 21°C. All packs were gently mixed by hand during collection and immediately before sampling at 1, 2, 3, 4, 8, 14, and 21
days. Platelet aggregation occurred rapidly at 1°C (reaching the maximum measurable, 600 mm Hg, within 24 h) whereas at room temperature s.F.P. did not change. At 40C the results were variable but showed a general increased aggregation,
1. 2. 3. 4. 5. 6. 7.
Benner, K. U., Brunner, R. Thromb. Res. 1973, 2, 331. Murphy, S., Gardner, F. H. New Engl. J. Med. 1969, 280, 1094. Kattlove, H. E., Alexander, B. Blood, 1971,38, 39. Shively, J. A., Gott, C. L., De Jongh, D. S. Vox Sang. 1970, 18, 204. Baldini, M. G., Steiner, M., Kim, B. K. Transfusion 1976, 16, 17. Baldini, M. G., Costea, N., Dameshek, W. Blood, 1960, 16, 1669. Swank, R. L. New Engl. J. Med. 1961, 265, 728.
AZATHIOPRINE WITHDRAWAL AFTER RENAL TRANSPLANTATION
*Acute rejection 5 days after azathioprine stopped (max. serum-creatinine 0.20 mmol/1). tAcute rejection 15.7months after azathioprine stopped (max. creatinine 0.16 mmol/1). #Returned to regular dialysis.
§Died.
Second transplant.
c.M.v.D.=Cytomegalovirus.
poisoning by inorganic mercury, including depression, irritability, failure of memory and concentration, and hand tremor, are found also in victims of methyl mercury poisoning. Methyl mercury is fat-soluble and has a particular affinity for brain tissue.
JOAN D. CROSS IAN M. DALE Department of Clinical Physics and Bio-Engineering LORETTA GOOLVARD West of Scotland Health Boards, Glasgow G4 9LF J. M. A. LENIHAN Department of Forensic Medicine, University of Glasgow
HAMILTON SMITH
SPERM-ANTIBODY TESTING IN INFERTILITY
SiR,—The article on hostility testing by Morgan et al. is interesting since the test provides a useful screen for immunological causes of infertility. Indeed we agree with Stone and Shulmanthat sperm-antibody tests should be included more frequently in the panel of diagnostic tests on an infertile couple. In our laboratory, when testing for sperm isoantibodies in infertile women, we usually use semen from normal donors as antigen, as do most laboratories. However, when we test with sperm from the partner and from
donors,
we
sometimes get
discordant results. RESULTS
and donors’ sperm, while in fifteen cases (50%) the tests were negative with both. In ten cases (33%)-and this is the most important result-the patient’s samples agglutinated her partner’s spermatozoa but not the pool of donors’ spermatozoa. In only one case (but with very low titre) did we observe positivity in the serum exclusively with donor sperm. In all thirty cases the pattern was the same,with the gel agglutination and capillary methods. The high number of positive cases is surprising. However, an isoimmune antisperm reaction was suspected, in theory at least, in these patients-indeed this was why we selected them in the way we did. The percent positivity in the search for antispermatozoa isoantibodies of the sperm-agglutinating type in unselected infertile women in our records is 10.5%. Furthermore if the tests had been performed with donor spermatozoa only, the percent positivity in our selected group would have been 17%. Use of spermatoza from the partner revealed positivity that would otherwise have been undected. The titres are given in the table. These data, if confirmed, emphasise the importance of doing spermagglutinin tests in infertile women (seminal and immunological patterns permitting) not only with sperm from donors but also with sperm from the partner if false negativity is to be avoided. We would offer two hypotheses to explain this discordance. First, besides common species-specific antigens, on sperm membrane individual antigens could be expressed; a particular immunisation mechanism and/or immune response could induce synthesis of antibodies against the latter antigens. Secondly, the surface sperm antigens present in all the members of the same species could be present with a variable quantitative degree in the individuals ; the immune response in the female would then be directed against the prevailing surface antigens on the spermatozoa of the partner. F. DONDERO Medical Pathology II, and Obstetrics and Gynæcology I and II,
M. CERASARO M. NICOTRA I. M. COGHI
University of Rome, Rome, Italy
H-Y ANTIGEN IN A MALE WITH A
45, X KARYOTYPE
SIR,-It is of great interest that H-Y antigen is detectable in XX males and XX true hermaphrodites, both of whom have testicular tissue but lack a recognisable Y chromosome.These observations suggest that testis-determining genes and the H-Y
To explore this discordance we tested the blood serum and cervical mucus of thirty infertile women with, as antigen, sperm from the partner and a donor pool. Patients were selected on the following criteria: (1) they had had so-called idiopathic infertility for at least 2 years; the husband had normal semen and no antisperm autoantibody (agglutinating, immobilising, cytotoxic) in blood serum or seminal plasma; and (2) consistently poor postcoital test, repeated at least three times. Donors also had normal semen and were negative in antisperm autoantibody tests. Furthermore, to avoid false positivity or negativity, all samples were tested with normal control serum and serum previously demonstrated to be positive. The gelatin agglutination method and capillary method 3 were used, with the precautions emphasised by Shulman. In four cases (13%) tests were positive with both partner’s
1. Morgan, H., Stedronska, J., Hendry, 2. 3.
W.
F., Chamberlain, G. V. P.,
Dewhurst, C. J. Lancet, 1977, i, 1228. Stone, M. L., Shulman, S. ibid. 1977, ii, 663. Shulman, S. Reproduction and Antibody Response. C.R.C. Press, 1975.
Cytotoxicity
of anti-mouse-H-Y antiserum after
absorption
8- - -8, unabsorbed; --8 absorbed with female XX cells; 0- - -0 absorbed with male XO cells; 0———0 absorbed with male XY cells. Points
are
s.n.±109%.
means
of 3 double-blind assays
by
two
observers.
314 locus are extremely closely linked or, more probably, one and the same. This hypothesis is confirmed by our studies of H-Y antigen in a previously described2 45, X male with no evidence of mosaicism in blood and skin cultures. At birth this patient was of normal height and weight, had some Turner-like features (i.e., nuchal cutis laxa, short neck, shielded chest, Turnerlike dermatoglyphics) but normal male sexual development in spite of mild hypogenitalism. Serological cross-reactivity between the H-Y antigen of mouse and man allows the detection of H-Y antigen on human cells by absorption of anti-mouse H-Y antiserum.3 This test showed (fig. 1) that cells from the 45, X male carried as much H-Y antigen as those from 46, XY normal males. The XO male is very rare: only one has been previously described.4 Like XX males and XX true hermaphrodites, XO males havea "sex reversed syndrome". Testicular tissue in these three conditions develops in the absence of the Y chromosome but our results suggest that H-Y antigen and the development. of testes are always associated, strengthening the likelihood that they have a common, or closely linked, structural genetic basis. Cattedra di Istologia ed Embriologia e Clinica Pediatrica II, Università di Modena, Italy Laboratoire du Centre Hospitalier,
Chambéry, France
generale,
A. FORABOSCO E. CHELI B. NOEL
J. TOUS
RENAL GRAFT ACCEPTANCE WITHOUT AZATHIOPRINE
SIR,-In provocative articleSheriff and co-workers asked whether azathioprine is necessary in renal transplantation. They conclude that, when azathioprine is stopped there seems to be no good indication for restarting it. We have some experience with azathioprine withdrawal in renal-transplant patients. In seven patients with cadaveric renal grafts azathioprine was stopped for medical reasons (table). Mean observation period without azathioprine was 7.7 (maximum 18.7) months in four patients with good primary transplant function. Acute rejections in two of these patients were reversed by high-dose methylprednisolone. At the end of the period of observation time serum-creatinine values were no higher than those found before azathioprine was stopped. In three further patients with chronic renal rejection azathioprine withdrawal did not seem to accelerate the course of progressive transplant failure. a
1. 2.
Lancet, 1976, ii, 1008. Forabosco, A., and others. Clin. Genet. 1977, 12, 97. 3. Tous, J., Pochat, D., Noel, B. Rev. Franç. Endocr. Clin. 1978, 19, 49. 4. Lo Curto, F., and others, Am. J. Dis. Child. 1974, 128. 90. 5. Cattanach, B. M. in Birth Defects (edited by H. G. Motulsky and W. Lenz); p. 129. Amsterdam, 1974. 6. Sheriff, M. H. R., Yayha, T., Lee, H. A. Lancet, 1978, i, 118.
Basic
prednisolone therapy was slightly increased in two pa-
tients, diminished in four patients, and unchanged in
one
pa-
tient. We agree with Sheriff et al. that, when azathioprine is stopped for medical reasons, renal grafts can be well tolerated for long periods without any alternative immunosuppression. P. SCHMIDT H. KOPSA
J. ZAZGORNIK
1st Medical Department, University of Vienna,
P. PILS P. BALCKE
A 1090 Vienna, Austria
TEMPERATURE AND PLATELET AGGREGATION DURING STORAGE OF WHOLE BLOOD
SjR,—Cold storage of platelet-rich plasma, platelet
concen-
platelet aggregation and reduced platelet viability.1-6 Nevertheless, although many centres now advise short-term storage of platelet concentrates and platelet-rich plasma at room temperature, whole blood is still stored refrigerated, partly because of the unknown effects of long term (up to 35 days) storage at room temperature and also to inhibit bacterial multiplication. At least one blood-pack manufacturer (Fenwall) advises storage of whole blood at 1-6°C. However, in our experience whole blood storage at 1°C is considerably worse, in respect of cellular aggregation, than trates, and whole blood
can
result in
storage at 4°C, and at room temperature little or no aggregation is observed even after 21 days storage. Cellular aggregation was measured using the screen filtration pressure (S.F.P.) method7 on samples from standard units of blood. The units were collected from fourteen healthy male volunteers aged 19-55 into polyvinyl-chloride blood packs (McGraw Laboratories) containing 63 ml citrate-phosphate-dextrose as anticoagulant. Storage temperatures of 1 ± 0.50 and 4 + 0.5OC were carefully maintained in cooled incubators. Ambient room temperatures varied between 14 and 21°C. All packs were gently mixed by hand during collection and immediately before sampling at 1, 2, 3, 4, 8, 14, and 21
days. Platelet aggregation occurred rapidly at 1°C (reaching the maximum measurable, 600 mm Hg, within 24 h) whereas at room temperature s.F.P. did not change. At 40C the results were variable but showed a general increased aggregation,
1. 2. 3. 4. 5. 6. 7.
Benner, K. U., Brunner, R. Thromb. Res. 1973, 2, 331. Murphy, S., Gardner, F. H. New Engl. J. Med. 1969, 280, 1094. Kattlove, H. E., Alexander, B. Blood, 1971,38, 39. Shively, J. A., Gott, C. L., De Jongh, D. S. Vox Sang. 1970, 18, 204. Baldini, M. G., Steiner, M., Kim, B. K. Transfusion 1976, 16, 17. Baldini, M. G., Costea, N., Dameshek, W. Blood, 1960, 16, 1669. Swank, R. L. New Engl. J. Med. 1961, 265, 728.
AZATHIOPRINE WITHDRAWAL AFTER RENAL TRANSPLANTATION
*Acute rejection 5 days after azathioprine stopped (max. serum-creatinine 0.20 mmol/1). tAcute rejection 15.7months after azathioprine stopped (max. creatinine 0.16 mmol/1). #Returned to regular dialysis.
§Died.
Second transplant.
c.M.v.D.=Cytomegalovirus.
