The Effect and Safety of Lisinopril in Non-hypertensive Men With Infertility From Low Sperm Count

September 21, 2013 updated by: Dr. Mbah Anthony Uche, University Of Nigeria Teaching Hospital

A 5-year Prospective, Placebo-controlled, Crossover Evaluation of the Efficacy and Tolerability of Low-dose Lisinopril in Normotensives With Idiopathic Oligospermic Infertility

This study was conceived in order to explain what the investigators previously observed suggesting that lisinopril, a drug normally used to treat patients with high blood pressure and heart failure, may be effective in treating infertile men with low sperm count. The investigators hypothesized, therefore, that the drug will not only improve sperm quantity and quality but also increase the fertility in such patients. The investigators first of all reviewed the results of previously published investigations and found out that there was only a few previous studies done in humans.with this class of drugs. Besides, the methods used in conducting most of those studies have been so faulted that the results cannot be trusted to be showing the true picture. The investigators looked at the various faults pointed out with respect to the their design and conduct and took care of them while designing the investigators own study. This was an attempt to provide more credible answers to the question of whether lisinopril, and possibly other drugs of similar mode of action, can be useful in rectifying the problem of infertility caused by low sperm count and , if so, whether it will be safe to use it in people who do not have high blood pressure or heart failure. In order to achieve this the investigators studied 33 patients with sperm of low cell concentration, low percentage of motile cells and high percentage of abnormal cells from no known cause. The patients were randomly allocated to receive either lisinopril 2.5mg daily (17 patients) or daily placebo (16 patients)and their sperm characteristics were examined at intervals, starting from the beginning of the study until when it ended 282 weeks later. The patients were also monitored for adverse events throughout the period. The data form all the patients that took part in the random allocation of treatments at the beginning of the study were included in the analysis that followed, irrespective of whether they completed the study or not.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Introduction. Infertility constitutes the cause for about 16.6% of patients seeking consultations at the primary healthcare level. Male factor infertility accounts for about 50% of all infertility problems. Of this percentage seminal fluid abnormality of unknown cause is common, occurring in up to 60% of males with unexplained, this type of infertility. Although some subjects with seminal fluid defects have fathered children those with infertility have long posed a major therapeutic challenge. The rationale for using the various hormonal and non-hormonal drugs currently available is, at best, empirical as most of the efficacy trials conducted yielded conflicting results. Although assisted fertilization techniques have now increased the number of therapeutic options available to couples with infertility problems there is still a very serious limitation in the access to the new technology, especially in low-income countries. Besides, there are additional concerns regarding the possible untoward effects. These lingering problems underscore the need for continuing to search for other effective treatment options that will not only be cheaper and more accessible but also less complicated and non-invasive.

The current study was occasioned by our previous, independent observations (albeit fortuitous) of normalization of seminal fluid parameters as well as spouse pregnancies in two men with long-standing, idiopathic azoospermia. The common factor between the two men was treatment with low-dose (2.5mg per day) Lisinopril, an angiotensin converting enzyme inhibitor or ACEI prescribed for the concomitant hypertension. A review of the available literature on the efficacy studies of various types of angiotensin converting enzyme inhibitors on sperm count and quality revealed a near-consistent finding of improvement in animal studies. However, methodological flaws have rendered the results in the very scanty human studies extremely difficult to interpret. The current study design was intentionally rigorous; efforts having been consciously made to control for most known confounding factors as far as was possible.

Methods. The study was conducted at the University of Nigeria Teaching Hospital, Enugu. A prior approval of the detailed study protocol was obtained from the Ethics Committee of the same hospital. Each of the patients gave informed consent before enrollment into the study. The investigation was a longitudinal, randomized, double-blind and placebo-controlled clinical trial with a crossover design. The subjects for this investigation were selected from a volunteer pool of male patients attending the fertility clinic of University of Nigeria Teaching Hospital, Enugu. At the time of enrollment each subject was given explicit information about the study with respect to the intention, the expectations from him, the procedure, the planned duration of the investigation, and the potential adverse reactions that could occur from the intended medication. The recruitment of patients took place from March 1998 to September 2001 while the actual study lasted for five years, from January 2002 to December 2006. In strict compliance with the protocol requirement all the participants entered the study within 7 days of starting the onset and they were being followed up concurrently. Throughout the period of the clinical trial the patients mandated to continue their different "background" fertility medications in the same doses as they were being prescribed by their attending fertility physicians. The rationale for this was to avoid the unethical situation whereby a group taking placebo would be denied medication. Conceited efforts were made to exclude subjects with any background medication that had a documented interaction with lisinopril. The apparent superfluity of combining a crossover design (which provides for a within-subjects control) with a separate (between-subjects) control was deliberate. That was done in an effort to control, in one swoop, for two potentially confounding factors; viz., the possible effect on the study out-come of the concurrent background medications, and the possible event of a random, seasonal variation in human seminal fluid characteristics. Throughout the whole period of the study the investigators kept in close touch with the patients by phone calls in order to continually motivate them, remind them of scheduled appointment dates, monitor compliance and detect any possible incidence of adverse drug effect.

Assessment of compliance to the medications: Compliance to the medications was monitored by a combination of oral interviews and physical inspection of medication containers for pill counting. These were done at every scheduled visit, through sporadic phone calls and by unscheduled home visits. The level of compliance of each patient was expressed in percent (%) and calculated as the actual number of doses taken/the expected number of doses multiplied by 100 for the period under consideration.

Adverse events monitoring:

The patients were encouraged to report every event promptly by phone to one of the authors (NOG), no matter however minor and not minding whether related to lisinopril or not. Entries were promptly made and then one of the physicians in the team was detailed to make proper assessment of every reported case and make recommendations with respect to further management and/or the need or otherwise for withdrawal of the patient from the trial. Medical interventions, where needed, were given without any cost to the patients. In addition, the serum potassium concentrations and blood pressures (supine and erect) were measured in every patient at each of the scheduled visits in furtherance of the adverse events monitoring.

Clinical measurements:

Blood pressure measurements were done with mercury sphygmomanometers fitted with adult-size cuffs (Accoson, England) while korotcoffs I and V were used for systolic and diastolic blood pressures respectively. This was because these had given more concordant results among the team members than the traditional I and IV Korotcoffs. The mean arterial blood pressure (MAP) of each patient was calculated using the conventional formula; MAP = [(2 x diastolic) + systolic] divided by 3.

Laboratory measurements:

Seminal fluid for analysis was each time collected by self-masturbation in a room close to the laboratory and submitted promptly to the analysts. The collected semen specimens were incubated at 37 degrees Centigrade and allowed to stand for 1 hour in order to thaw. The pipette method was used for the ejaculate volume while microscopic methods were used for the total sperm cell count, the percentage of sperm cell motility and the percentage of abnormal sperm cell morphology in accordance with the World Health Organization (WHO) guidelines. Serum potassium levels were estimated using the flame photo-metric method as described by Davidson and Henry. The latter was a safeguard against hyperkalemia, a well documented, severe side effect of ACEI therapy.

Statistical analysis:

The statistical analysis was done with the Statistical Package for the Social Sciences version 16 (SPSS - 16) software. All the data analyses were performed on the basis of the intention-to-treat in which last observations after the baseline were carried forward to end point. Prior to the analysis all the parameter data were examined for distributional patterns using the Shapiro-Wilk Normality test. All the seminal fluid data as well as the serum potassium values were found to be skewed and so were normalized with logarithmic transformations. Two-group comparisons were performed using the unpaired Student's t-tests while proportions were compared using the Fisher's Exact tests. The data from longitudinally measured out-come parameters were analyzed using two-way repeated measures (mixed model) analysis of variance (mixed model ANOVA). Bonferroni's post-hoc multiple comparison tests were run wherever a statistically significant difference was found (at p < 0.05) in either the within-subjects means, the between-subjects means or the interaction. The post-hoc tests were done in order to explore further the patterns of within-subjects parameter changes with the duration of treatment in both groups. The unwanted events reported during treatment with lisinopril and during placebo treatment were compared for statistical significance with the Koch's adaptation of Wilcoxon-Mann-Whitney- rank-sum test.

Study Type

Interventional

Enrollment (Actual)

33

Phase

  • Phase 2

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Nigeria
      • Enugu, Nigeria, 01129
        • University of Nigeria Teaching Hospital, Ituku-Ozalla,

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

24 years to 34 years (Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

Male

Description

The subjects for this investigation were selected from a volunteer pool of male patients attending the fertility clinic of University of Nigeria Teaching Hospital, Enugu. The criteria for their selection were:

Inclusion criteria:

  • regular attendance and on treatment for low sperm count or oligospermia in the fertility clinic for at least 2 years
  • total sperm count at selection from 5 million/ml to 10 million/ml,
  • white blood cell (WBC) count less than 1 million per ml of the ejaculate
  • evidence of undergone comprehensive investigations to exclude secondary causes of low sperm count, (e) evidence of comprehensive investigations to exclude female factor infertility in the spouse
  • an assurance of a personal commitment to continue participating in the study until the end-point was reached and (g) normal blood pressure.

Exclusion criteria:

  • Patients who did not give their consent to participate
  • did not meet the diagnostic criteria for oligospermia at the time of recruitment
  • failed to fulfill any of the above inclusion criteria, even if the diagnostic criteria are fulfilled.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Crossover Assignment
  • Masking: Quadruple

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Placebo Comparator: Sugar pill
Started with Placebo until the crossover.
Experimental: Lisinopril
Started with Lisinopril until the crossover
Drug: Lisinopril
The two groups of patients, A and B, were randomly allocated treatments in a double-blind fashion. Group A was started on the coded drug "DY1" while group B was started on the coded drug "DZ2". Both "DY1" and "DZ2" were very identical in appearance. At week 96 the drugs were swopped between the groups such that group A changed to drug "DZ2" while group B changed to drug "DY1". There was no intervening washout period. The codes were concealed until after the data analysis.
Other Names:
  • (Zestril®, AstraZeneca Pharmaceuticals,Washington NC, USA)

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Changes From Baseline in the Seminal Fluid Characteristics Throughout the Study
Time Frame: Week 96.
The seminal fluid characteristics were assessed twice before the entry of each patient and both at least two-weeks apart. The two values were averaged and recorded as baseline for week 0 while subsequent changes from the baseline were monitored during each of the scheduled visits at weeks 6, 12, 24, 48, 96, 102, 114, 138, 186 and 282. The two groups swopped treatments at the 96th week. The number of pregnancies achieved was also documented throughout the study period.
Week 96.
Total Sperm Cell Count Per Milliliter of Seminal Fluid.
Time Frame: Week 96
the number of sperm cells counted per milliliter volume of seminal fluid
Week 96
Proportion of Sperm Cells With Normal Motility (%)
Time Frame: Week 96
This was determined as the proportion (percent) of the total sperm cells exhibiting both rhythmic and propulsive movements considered to be of normal intensity.
Week 96
Proportion of Sperm Cells With Abnormal Morphology (%)
Time Frame: Week 96
Proportion (per cent) of sperm cells with abnormal appearance
Week 96
Ejaculate Volume
Time Frame: Week 282
The volume in milliliters of seminal fluid produced per ejaculation.
Week 282
Total Sperm Cell Count
Time Frame: Week 282
The total number of sperm cells found in each milliliter of seminal fluid.
Week 282
Proportion of Sperm Cells With Normal Motility (%)
Time Frame: Week 282
The proportion (per cent) of the sperm cells exhibiting both rhythmic and propulsive movements considered to be of normal intensity.
Week 282
Proportion of Sperm Cells With Abnormal Morphology (%)
Time Frame: Week 282
The proportion (per cent) of the total number of sperm cell with abnormal appearance.
Week 282

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Adverse Events Monitoring
Time Frame: At weeks 6, 12, 24, 48, 96, 102, 114,138, 186 and 282
The patients were encouraged to report every event promptly by phone to one of the authors (NOG), no matter however minor.Blood pressure measurements were done with mercury sphygmomanometers fitted with adult-size cuffs (Accoson, England). Serum potassium levels were estimated using the flame photometric method as described by Davidson and Henry
At weeks 6, 12, 24, 48, 96, 102, 114,138, 186 and 282

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

University Of Nigeria Teaching Hospital

Investigators

  • Principal Investigator: Anthony U Mbah, MD, FMCP, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

March 1, 1998

Primary Completion (Actual)

December 1, 2006

Study Completion (Actual)

December 1, 2006

Study Registration Dates

First Submitted

August 2, 2011

First Submitted That Met QC Criteria

August 3, 2011

First Posted (Estimate)

August 4, 2011

Study Record Updates

Last Update Posted (Estimate)

November 25, 2013

Last Update Submitted That Met QC Criteria

September 21, 2013

Last Verified

September 1, 2013

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • GHF/GrS/99/S.3

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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