Reply: A study of finger lengths, semen quality and sex hormones in 360 young men from the general Danish population

Sir, We thank Drs Voracek and Dressler for their interest in ourpublication ‘A study of finger lengths, semen qualityand sex hormones in 360 young men from the general Danish population’(Bang et al., 2005). We agree that our findings are interesting.It is somewhat peculiar that the average second to fourth digitratio (2D:4D) found in the Danish men is higher than that     

East-West gradient in semen quality in the Nordic-Baltic area: a study of men from the general population in Denmark,Norway, Estonia and Finland

BACKGROUND: Denmark and Norway have a three-fold higher incidence of testicular cancer than Estonia and Finland. Groups of young men from Denmark, Norway, Finland and Estonia were investigated to elucidate whether semen parameters and other related parameters follow a gradient between these countries, as does the gradient in incidence of testicular cancer. METHODS: In total, 968 young men from the general population in these four countries were investigated according to the same protocol. Possible confounders were evaluated, and included in the statistical analysis when appropriate. Inter-laboratory differences in assessment of sperm concentrations were controlled by an external quality control programme and morphology assessment was centralized to one person. RESULTS: The Finnish and Estonian men had an adjusted median sperm concentration of 54 and 57 x 10(6)/ml, respectively and the Norwegian and Danish men 41 x 10(6)/ml. The corresponding total sperm counts were 185, 174, 133 and 144 x 10(6). The frequency of normal sperm in men from Finland was 8.9%, Estonia 9.2%, Norway 6.9% and Denmark 6.4%. Within all four groups of men, a relationship between increasing levels of inhibin-B and increasing sperm counts was observed. However, inhibin-B levels were not predictive of sperm count differences between countries. CONCLUSIONS: It is believed that the men examined were representative of the normal population of young men in all four countries as they were recruited from groups attending a compulsory medical examination, and not selected for known fertility or semen quality. Moreover, the majority of participants had no prior knowledge of their fertility potential. It appears that an east-west gradient exists in the Nordic-Baltic area with regard to semen parameters, this being in parallel with the incidences of testicular cancer. Further investigations are required to determine whether these findings are due to genetic differences, to different environments, or perhaps to a combination of both factors.     

High frequency of sub-optimal semen quality in an unselected population of young men

Male reproductive function seems to have deteriorated considerably during the past 4-5 decades. However, studies of the reproductive function in unselected populations have not previously been reported. As the large majority of young men in Denmark are subjected to a compulsory medical examination for military service, this provided a unique opportunity to study the reproductive function in an unbiased population. Altogether 891 young men delivered a blood sample in which reproductive hormones were measured. From 708 of these men data were also obtained on semen quality and testis size. The median sperm concentration was 41 x 10(6)/ml (mean 57.4 x 10(6)/ml). Men with ejaculation abstinence above 48 h had slightly higher sperm concentrations (median 45 x10(6)/ml, mean 63.2 x 10(6)/ml), but even in this subgroup, 21 and 43% respectively had sperm counts below 20 x 10(6)/ml and 40 x 10(6)/ml. Among men with no history of reproductive diseases and a period of abstinence above 48 h, as many as 18 and 40% respectively had concentrations below 20 and 40 x 10(6)/ml. Sperm counts were positively correlated with testis size, percentage normal spermatozoa and inhibin B, and negatively correlated with percentage immotile spermatozoa and follicle stimulating hormone. Possible causes for this high frequency of young men with suboptimal semen quality are obscure and need to be explored. Whether these findings apply for young male populations of comparable countries remains to be seen.     

Computer-assisted semen analysis parameters as predictors for fertility of men from the general population. The Danish First Pregnancy Planner Study Team

The predictive value of sperm motility parameters obtained by computer-assisted semen analysis (CASA) was evaluated for the fertility of men from general population. In a prospective study with couples stopping use of contraception in order to try to conceive, CASA was performed on semen samples from 358 men. A recently developed CASA system, Copenhagen Rigshospitalet Image house sperm Motility Analysis System (CRISMAS) was used for assessment of motility parameters. This system has an editing function which allows correction of tracks made by the computer. Probably due to this function, the concentration assessment made by CRISMAS was very close to that made by the technician (median difference <5%) in all concentration ranges. Correlation between CASA parameters and fertility of normal couples (measured as probability of achieving pregnancy) was examined by the Cox regression model. In univariate models ln(sperm concentration) [beta = 0.331, risk ratio (RR) = 1.392, P = 0.0001], ln(total sperm count) (beta = 0.252, RR = 1.286, P = 0.0007) and percentage motile spermatozoa (beta = 0.014, RR = 1.014, P = 0.0004) were most significant predictors for fertility. In a multivariate analysis ln(sperm concentration) (beta = 0.268, RR = 1.307, P = 0.0016) and percentage motile spermatozoa (beta = 0.010, RR = 1.010, P = 0.011) but even more significantly the combined parameter, ln(concentration of motile spermatozoa) (beta = 0.329, RR = 1.389, P = 0.0001), were the only parameters of predictive value for fertility of men in the general population. In conclusion, these parameters obtained by CASA measurements can be used for prediction of fertility potential in normal men. This appears to be the first study showing the value of CASA in prediction of fertility in the general male population.     

Fertility and offspring sex ratio of men who develop testicular cancer: a record linkage study

Analysis of associations between testicular cancer, subfertility and offspring sex ratio (proportion of males born among newborns) was performed on 3530 Danish men, born 1945-1980, who developed testicular cancer in the period 1960-1993. As the basis of comparison we used the total population of Danish men born in the period 1945-1980 (n = 1 488 957) and their biological children (n = 1 250 989). Men who developed testicular cancer had, prior to the cancer diagnosis, a reduced fertility (standardized fertility rate ratio: 0.93, 95% confidence interval: 0.89-0.97) and a significantly lower proportion of boys (48.9%, P: = 0.02) compared with the general population (51.3%). The reduction in fertility was more pronounced in men with non-seminoma but the reduction in offspring sex ratio was independent of histological type. This confirms earlier results from less conclusive studies and indicates that testicular cancer, male subfertility and a female-biased sex ratio among new-born infants are characteristics of male reproduction that are linked by biological mechanisms.     

Evolution of semen quality in North-eastern Spain: a study in 22,759 infertile men over a 36 year period

A retrospective study was conducted in a large population to determine whether sperm quality has changed in Northeastern Spain between 1960 and 1996. From a total initial population of 22,759 men, two separate groups were studied: men with spermatozoa (n = 20,411) and those with azoospermia (n = 1364). After adjustment for age and sexual abstinence, multiple linear regression analyses were used to assess changes in semen parameters over time. A 0.2% decline was observed in semen volume in the spermatozoa group (P < 0.001). No significant increase (0.04%) in sperm count (x 10(6)/ml) was observed in the spermatozoa group. There was a 0.4% increase in motile spermatozoa in the spermatozoa group (P < 0.001). There was a statistically significant decline in normal spermatozoa (3.6%) in the spermatozoa group (P < 0.001). Of the total population, 1364 men had azoospermia (6.0%). The changes observed in the semen parameters analysed in this large population showed no evidence of a deteriorating sperm quality, although a statistically significant decline was observed in the percentage of normal spermatozoa.     

A population-based study of polymorphisms in genes related to sex hormones and abdominal aortic aneurysm

Male gender and family history are risk factors for abdominal aortic aneurysm (AAA). We hypothesized that genes involved in sex hormones might be important in AAA. We investigated the association of aortic diameter with single-nucleotide polymorphisms (SNPs) in genes determining circulating sex hormones and their action. We genotyped 74 tagging SNPs across four genes (steroid 5α reductase, subfamily A, polypeptide 1 (SRD5A1), cytochrome P450, family 19, subfamily A, polypeptide 1 (CYP19A1), androgen receptor (AR) and estrogen receptor 2 (ESR2)) related to sex hormone production and action in 1711 men, 640 of whom had an AAA. One genotype was also assessed in an independent cohort of 782 men, of whom 513 had large AAAs. Associations were assessed adjusting for other risk factors for AAA. One SNP in CYP19A1 was strongly associated with aortic diameter. Subjects who had the rare homozygote genotype (TT) for CYP19A1g.49412370C>T (SNP ID rs1961177), had an increased aortic diameter (coefficient 5.058, SE 1.394, P=0.0003, under a recessive model). This SNP was not associated with aortic diameter in an independent cohort, which included patients with larger AAAs. Our findings do not support an important role of genetic polymorphisms in genes determining sex hormones in aortic dilatation in men. The association of one SNP in CYPA9A1 with small but not large AAA may suggest differences between AAA formation and progression. This SNP warrants further investigation in another large population, including patients with small AAAs.     

Impact of therapy and androgen receptor polymorphism on sperm concentration in men treated for testicular germ cell cancer: a longitudinal study

BACKGROUND: Testicular cancer (TC) patients have a high survival rate, and the question of post-therapy recovery of sperm production and its dependence on genetic predisposition is of major interest. METHODS: Ejaculates were obtained from 112 TC patients at one or more of the following time points: post-orchidectomy, or 6, 12, 24, 36 and 60 months post-therapy. The lengths of the androgen receptor (AR) function modulating CAG and GGN repeats in leukocyte DNA were also analysed. RESULTS: No significant decrease in sperm concentration was seen in men who received 1-2 cycles of adjuvant chemotherapy (ACT). Radiotherapy (RT) or more than two cycles of chemotherapy (HCT) caused an initial decline in sperm concentration, which returned to pre-treatment levels 2-5 years after therapy. In the HCT group, sperm concentration 12-24 months post-treatment (T(12-24)) was inversely correlated with CAG length (rho = -0.72, P = 0.03). The type of treatment, but not the concentration at T(0), was an independent predictor of sperm concentration at T(6) (P < 0.0005) and T(12-24) (P = 0.004). CONCLUSION: ACT did not induce a significant decline in sperm concentration. After HCT and RT, a significant reduction of sperm concentration was observed, recovering to pre-treatment levels 2-5 years post-treatment. In HCT-treated patients, the AR CAG length influenced the recovery of spermatogenesis.     

Semen quality in a residential, geographic and age representative sample of healthy Chinese men

BACKGROUND: Population-based study of semen quality is rare in literature. METHODS: Healthy men aged 20-60 years from six Chinese provinces were invited to participate in the study between December 2000 and November 2002. Posters were distributed in the participating counties to enroll 200 subjects from each province. Medians, percentiles, and proportions below lower threshold of the WHO criteria for semen parameters were calculated. Generalized linear models were used to examine the determinants of semen quality. RESULTS: Semen samples from 1191 healthy Chinese men were collected and analysed. The medians (5th and 95th percentiles) were 2.3 ml (1.0-4.5) for semen volume, 65 x 10(6)/ml (20-150) for semen concentration, 154 x 10(6)/ejection (29-421) for sperm count, 19% (5-32) for rapid progressive motility, 46% (29-66) for progressive motility, 67% (47-81) for total motile spermatozoa, 70% (48-88) for sperm viability and 39% (23-76) for normal morphology. Many healthy Chinese men had semen parameter values below the lower threshold of the WHO criteria. Region, age, abstinence duration and season were important determinants of semen quality. CONCLUSIONS: Chinese men have lower values of semen parameters according to WHO standard, and a lower threshold for normal semen parameters for Chinese men should be considered.     

A mixed methods study of physical activity and quality of life in adolescents with Turner syndrome

Women with Turner syndrome (TS) have a high morbidity from both medical and psychological conditions with a negative impact on quality of life (QoL). Physical activity is a modifiable behavior shown to reduce risk for these chronic medical and mental health conditions and enhance QoL in other populations. Limited research suggests that adolescents and women with TS are less likely to engage in or enjoy physical activity than peers. This mixed methods study aimed to document physical activity levels in a sample of youth with TS and explore how factors unique to TS contribute to and are affected by physical activity. A cross‐sectional sample of 21 girls (12–21 years) with TS and their parents (n = 21) completed standardized questionnaires to quantify habitual physical activity (3‐day physical activity recall) and QoL (PROMIS) and participated in individual interviews focused on their experience with physical activity. Quantitative and qualitative results were synthesized using a phenomenological mixed methods approach. Results indicate that our sample engaged in less physical activity than peers and only 19% met recommendations for 1 hr per day of moderate‐to‐vigorous physical activity. Parents reported significant problems with peer relationships and psychological stress, and peer relationships scores correlated with physical activity. Reported barriers to physical activity included physical and psychosocial complications related to TS as well as unique developmental considerations specific to adolescence. Quantitative and qualitative results supported that structured fitness options embedded into routines enhanced activity levels. Results were compiled into specific recommendations for clinical care and areas of future research.     

Comparison of semen quality obtained by electroejaculation and spontaneous ejaculation in men suffering from ejaculation disorder

BACKGROUND: Electroejaculation has become an accepted form of semen procurement in men suffering from anejaculation. However, sperm in these ejaculates often exhibit low motility. The aetiology of asthenozoospermia remains uncertain. It may be related to primary low-grade motility of sperm from anejaculatory men or to detrimental effects of the electroejaculation process itself. The aim of this study was to determine whether the procedure of electroejaculation alters the quality of the semen by comparing the characteristics of the electroejaculates with those of the normal ejaculates of the same patients. METHODS: Nine men suffering from ejaculation disorders underwent 14 procedures of electroejaculation. The sperm concentration and motility of the 14 samples from electroejaculation were compared with 20 collected at a later date after successful ejaculation by the same patients. RESULTS: The mean +/- SD concentration of the electroejaculates was (52.3 +/- 42.1)x10(6)/ml and of the natural samples (67.4 +/- 38.1)x10(6)/ml. No statistical difference was found between the two groups. The mean percentage of sperm showing progressive motility following electroejaculation was 23.1 +/- 18.8% and 36.3 +/- 16.7% after spontaneous ejaculation. No statistical difference was found between the groups (P = 0.082). Likewise, the quality of sperm motility was similar after both methods of procurement. CONCLUSIONS: In our small-sized study group (nine men with ejaculation disorders), the concentration and the motility of sperm obtained by electroejaculation were not significantly different from sperm obtained naturally.     

Clinical adaptation of the sperm ubuquitin tag immunoassay (SUTI): relationship of sperm ubiquitylation with sperm quality in gradient-purified semen samples from 93 men from a general infertility clinic population

BACKGROUND: The proteolytic chaperone peptide ubiquitin accumulates in defective human spermatozoa. Immunodetection of ubiquitin in human sperm samples correlates with semen quality and male fertility. METHODS: Semen samples from 93 men from couples seeking infertility treatment were separated on a PureSperm density gradient and screened by immunofluorescence microscopy with anti-ubiquitin antibodies. The percentage of spermatozoa with head ubiquitylation was recorded and compared with clinical semen evaluation and embryo development data after IVF or ICSI. Subjects were divided into the following four groups based on the initial clinical diagnosis of the couples; group 1, male factor; group 2, idiopathic infertility; group 3, female infertility with neither partner having children previously; and group 4, female infertility with male partners having children from previous relationships. RESULTS: The percentage of sperm with ubiquitylated heads remaining after PureSperm separation in the respective groups was 4.0% (male factor), 2.5% (idiopathic infertility), 0.7% (female infertility and presumed fertile male) and 0.9% (female infertility with established fertile male). Negative correlations between sperm ubiquitin and several parameters reflective of embryo development after assisted fertilization were found within the male factor group. CONCLUSIONS: Use of this simplified ubiquitin-based sperm quality assay is feasible in a clinical environment. Since the gradient separation does not completely deplete the defective spermatozoa, the modified light microscopic sperm ubiquitin tag immunoassay could add a new level of stringency to the selection of human spermatozoa for ICSI.     

Meiotic behaviour of the sex chromosomes in three patients with sex chromosome anomalies (47,XXY, mosaic 46,XY/47,XXY and 47,XYY) assessed by fluorescence in-situ hybridization

Meiotic studies using multicolour fluorescent in-situ hybridization (FISH) and chromosome painting were carried out in three patients with sex chromosome anomalies (47,XXY; 46,XY/47,XXY and 47,XYY). In the two patients with Klinefelter syndrome, although variable percentages of XXY cells (88.5 and 28.3%) could be found in the pre-meiotic stages, none of the abnormal cells entered meiosis, and all pachytenes were XY. However, the abnormal testicular environment of these patients probably resulted in meiotic I non-disjunction, and a certain proportion of post-reductional cells were XY (18.3 and 1.7%). The fact that none of the spermatozoa were XY also suggests the existence of an arrest at the secondary spermatocyte or the spermatid level. In the XYY patient, most (95.9%) premeiotic cells were XYY. The percentage of XYY pachytenes was 57.9%. The sex chromosomes were either in close proximity (XYY) or the X chromosome was separated from the two Ys (X + YY). A high proportion (42.1%) of post-reductional germ cells were XY. However, only 0.11% of spermatozoa were disomic for the sex chromosomes. In this case, the data suggest the existence of an arrest of the abnormal cells at the primary and the secondary spermatocyte or the spermatid level, giving rise to the continuous elimination of abnormal cells in the germ-cell line along spermatogenesis. The fact that the proportion of diploid spermatozoa was only increased in one of the three cases (XXY) is also suggestive of an arrest of the abnormal cell lines in these patients. The two apparently non-mosaic patients were, in fact, germ-cell mosaics. This suggests that the cytogenetic criteria used to define non-mosaic patients may be inadequate; thus, the risk of intracytoplasmic sperm injection in apparently non-mosaics may be lower than expected.     

Relationship between semen quality and the seminal plasma components carnitine, alpha-glucosidase, fructose, citrate and granulocyte elastase in infertile men compared with a normal population

The seminal plasma components neutral alpha-glucosidase, carnitine, fructose, citrate, and polymorphonuclear granulocyte (PMN) elastase in 253 men were determined. The seminal plasma of 221 infertile men, a control group with proved fertility and 13 patients after vasectomy were investigated. The concentrations of free carnitine (212 versus 521 micromol/l, n = 219, P < 0.001), total carnitine (437 versus 743 micromol/l, n = 219, P < 0.001), and the activity of neutral alpha-glucosidase (15.1 versus 23.4 IU/l, n = 236, P < 0.05) were significantly reduced in the infertile patient group as compared to the fertile control group, the concentration of PMN elastase (102 versus 48 microg/l, n = 234, P < 0.05) being significantly increased in the infertile patients. In the patients after vasectomy the activity of neutral alpha-glucosidase was the only epididymal marker that was significantly reduced (4.3 versus 9. 8 IU/l, n = 35, P = 0.002) in comparison with the patients with testicular azoospermia. At a limit of 6 IU/l the sensitivity of the method was 92% and the specificity was 72%. Altogether, the epididymal markers were reduced in subfertile patients compared with the control group. For the differential diagnosis of azoospermia only the determination of the neutral alpha-glucosidase activity is useful.     

人精液质量、解脲脲原体感染与精浆和血清中自介素6含量的关系研究

目的　研究人精液质量、解脲脲原体感染与精浆和血清中IL 6含量的关系。方法　精液质量检查 ,精液UU培养 ,酶标双抗体夹心法测定精浆和血清中的IL 6含量。结果　感染组与非感染组之间精浆中的IL 6含量无统计差异 ,而感染组血清中的IL 6含量显著高于非感染组血清中的IL 6含量 (P <0 .0 5)。精液质量正常组与异常组之间的精浆和血清中IL 6含量都无统计差异。结论　UU感染引起血清IL 6升高 ,但并不能引起精浆IL 6升高。IL 6在生精管道和精液中发挥作用受IL 6的量和IL 6受体的量影响     

Search for ethnic,geographic, and other factors in the epidemiology of Down syndrome in South America: Analysis of data from the ECLAMC project, 1967–1997

We have analyzed data on 3,157 cases of Down syndrome (DS) from nine South American countries in consecutive series of hospital live births over a 30‐year period, with particular emphasis on possible ethnic or geographic variations in maternal age‐adjusted incidence. The data constitute the largest series of DS cases assembled to date from an area lacking advanced health care systems. Absolute incidence rates were estimated from total hospital live births; relative rates were estimated from matched case‐control data using conditional logistic regression. Maternal age‐adjusted rates were closely similar to those reported elsewhere, and showed little or no dependency on other factors investigated, including paternal age, birth order, ancestral origin, country of birth, maternal educational level, maternal ABO and Rhesus blood groups, interval to and outcome of mother's previous pregnancy, and parental consanguinity. The absence of an effect of high birth order was particularly notable because of the relatively large number of grand multipara resulting from high fertility in this population. The study adds to a body of evidence suggesting that maternal age‐adjusted DS rates vary little across human populations, and are therefore unlikely to be greatly influenced by genetic or environmental factors that differ between them. An unusual finding was of a markedly lower sex ratio (98 males per 100 females) than has been reported in other DS samples. © 2001 Wiley‐Liss, Inc.     

舟山海岛地区不育症患者的精液质量与年龄等因素的关系

目的探讨海岛不育男性精液质量与年龄、文化程度和不育时间的关系。方法采用统一调查表,对2004年3月~2005年9月在舟山市生殖研究中心门诊的228例不育症男性患者进行流行病学问卷调查及精液常规分析（SFA）。资料应用SPSS13.0统计软件进行处理。结果（1）研究对象的平均年龄为31.00岁,不育时间是3.00年;文化程度以初中为主,占24.12%,其次是高中,占20.18%;（2）b级、d级、正常形态和体部、尾部畸形精子比例在不同文化程度和年龄组之间的差异有统计学意义（P〈0.05）;（3）在不同的不育时间组之间极慢或不动（d级）精子比例有统计学意义（P〈0.05）。结论（1）生殖损害在年龄分布中有提前的趋势。（2）研究对象的年龄、文化程度和不育时间等因素可能与精液质量有关。     

The peritubular myofibroblasts in the testes from normal men and men with Klinefelter's syndrome. A quantitative, ultrastructural, and immunohistochemical study.

The ultrastructure and immunostaining with antibodies against actin, desmin, and vimentin were studied in the peritubular myofibroblasts of testes from normal men and men with Klinefelter' syndrome (KS). The seminiferous tubules were classified into five types (a-e), related to the progressive degree of sclerosis measured as thickening of the lamina propria. In control testes, only types a and b tubules were present, whereas the testes from men with KS showed types b, c, d, and e tubules. The ultrastructural study revealed abundant microfilament bundles with electron-dense bodies in the cell periphery of the myofibroblasts in a and b tubules. In c tubules, the microfilament bundles of the myofibroblasts were lacking in electron-dense bodies. Myofibroblasts in tubules d and e showed scanty microfilament bundles. Immunostaining of peritubular myofibroblasts with anti-actin antibodies was intense in tubule types a-c and scanty in types d and e. Immunostaining of myofibroblasts with anti-desmin antibodies was intense in tubule types a and b, and negative in types c-e. Immunostaining with anti-vimentin antibodies was weak in tubule types a-c and intense in types d and e. Quantitative study revealed that with the progression of sclerosis, the number and volume per cross-sectioned tubule of actin-containing cells and, mainly, desmin-containing cells decrease while the number and volume of vimentin-containing cells increase.     

The Apolipoprotein B/Apolipoprotein A 1 ratio in relation to metabolic syndrome and its components in a sample of the Tunisian population

Objective

This study was undertaken to investigate the relationship between the Apolipoprotein B/Apolipoprotein A 1 (ApoB/ApoA 1) ratio and various characteristics of the metabolic syndrome (MetS) in a sample of the Tunisian population.

Methods

The study included 330 adults aged 35–74 (172 patients with MetS and 158 controls). Waist circumference (WC), blood pressure (BP), HDL-cholesterol (HDL-C), triglycerides (TG), glucose, insulin, and apolipoprotein concentrations were measured. Homeostasis model assessment (HOMA) was used to assess insulin resistance (IR). MetS was defined by NCEP-ATPIII report.

Results

The ApoB/ApoA 1 ratio was significantly higher in patients with MetS versus normal control subjects (p < 0.001). Mean values of ApoB/ApoA 1 ratio increased significantly as the numbers of MetS components increased in men (p < 0.001) and women (p < 0.001). ApoB/ApoA 1 ratio showed statistically significant associations with WC, HDL-C, TG, systolic and diastolic BP, and HOMA-IR. After adjusting for age and gender, the high ApoB/ApoA 1 ratio was significantly associated with the presence of MetS (odds ratio [OR] = 6.10), IR (OR = 1.88), and with each of the MetS components, including: high WC (OR = 2.43), High TG (OR = 6.14), and low HDL-C (OR = 6.92).

Conclusions

Our findings suggest that the ApoB/ApoA 1 ratio is strongly associated with MetS and its components, as well as with IR.     

A population study of the association between sexual function, sexual satisfaction and depressive symptoms in men

BACKGROUND: Depression and erectile dysfunction (ED) have a complex and bi-directional relationship. We examined the relationships between erectile dysfunction and depressive symptoms or diagnosed depression, sexual activity and sexual satisfaction. METHODS: A population survey of men aged 40-70 years was carried out in Brazil, Italy, Japan and Malaysia in 1997-1998. A questionnaire was used to collect life style, sexual behaviors and medical data. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. ED was classified as moderate or complete if the men reported they were "sometimes" or "never" able to achieve and maintain an erection satisfactory for sexual intercourse. Only men with a sexual partner and not taking psychoactive drugs were considered. RESULTS: Diagnosed depression was reported by 2.0% of the men, depressive symptoms by 21.0%. The prevalence of moderate or complete ED was 17.8%. Sexual satisfaction related to the frequency of sexual intercourse and inversely related to depressive symptoms. Depressive symptoms were positively associated with being single (odds ratio [OR] 1.7), widowed, separated or divorced (OR 2.2), moderate or complete ED (1.8), heart disease (1.6) and smoking (1.6), and negatively associated with age, physical activity and frequency of sexual intercourse. LIMITATIONS: Cross-sectional studies cannot establish a temporal cause-effect relationship. However, the confirmation of known associations reassures about the validity of the original findings. CONCLUSIONS: The findings suggest that depressive symptoms are linked to ED by the mediation of decreased sexual activity and the dissatisfaction generated by the inability to have a healthy sexual life.