Author: V. Dimov, M.D., Assistant Professor, Allergist/Immunologist, University of Chicago; A. Bewtra, M.D., M.B.B.S., Professor, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Allergist/Immunologist, Fort Lauderdale, Florida
A 26-year-old Caucasian female is referred to the allergy clinic for skin prick testing for suspected semen allergy. For the last 5 years, she reports symptoms when she has unprotected intercourse with her husband. She has no symptoms when she has a protected intercourse. The typical symptoms are burning, swelling, and redness outside the vaginal area that start 10 to 15 minutes after intercourse and last from hours to days. The patient reports that on the first day of intercourse, she will have symptoms for a few hours, but if she has intercourse the very next day, then the symptoms are worse and last for days rather than hours. She and her husband expressed an interest in conceiving and had already seen an OB/GYN physician who prescribed Clomid (Clomiphene). Since then the patient had a menstrual period and she is here for skin prick testing to semen allergy. Her husband brought a container with previously collected semen fluid to the clinic.
Past medical history (PMH)
Mild asthma, allergic rhinitis.
Medications
Veramyst (fluticasone) nasal spray, albuterol prn (uses very rarely), Clomid, loratidine (stopped six days ago for the skin prick testing).
Physical examination
Stable vital signs (VSS), normal physical examination.
What would you do next?
Skin prick testing with positive control with histamine, negative control with normal saline and semen fluid.
Test results: The patient’s skin prick testing showed a positive skin control with histamine, a wheal of 5 x 5 mm, a flare of 15 x 15 mm, a negative control with saline 0 x 0 mm for both wheal and flare, and and a positive reaction to the semen fluid with 4 x 3 mm for the wheal and 10 x 7 mm for the flare. We read the test after 15 minutes.
What would you recommend for this patient?
The patient has a diagnosis of semen allergy confirmed by medical history, symptoms timeline and positive skin prick testing.
In order to avoid symptoms, we advised the patient and her husband to have protected sexual intercourse with condoms in the future.
In terms of conceiving a baby, we recommend that she should work closely with her OB/GYN and once she begins to have ovulatory cycles, as determined by a pelvic ultrasound, the plan is for her to be placed on prednisone for 7 to 10 days around the expected time of ovulation. A possible consideration, if this does not work, would be intrauterine insemination with washed semen.
After she finalizes her plan about conception, we will change her intranasal steroid to budesonide, which is a category B medication in pregnancy. She is to follow up prn with us regarding further follow-up with her OB/GYN and the allergy clinic here.
Final diagnosis
Semen allergy.
What did we learn from this case?
Women with seminal plasma protein allergy (SPPA) have an immunologic response to human semen. The immunological mechanism of semen allergy is a type I hypersensitivity reactions.
Symptoms vary from local inflammation and pruritus to systemic anaphylaxis after exposure. The first case was documented in Germany in 1958.
Patients with SPPA often have recurrent vaginitis associated with intercourse and are unresponsive to traditional therapies. Semen allergy should be on the list of differential diagnoses for recurrent vaginitis in sexually active women. SPPA may also present as ‘vulvar vestibulitis syndrome’ or ‘burning semen syndrome’.
The gold standard of diagnosis is absence of symptoms with condom use.
Treatment may involve artificial insemination for those seeking pregnancy, oral corticosteroids, immunotherapy, or antihistamines, rather than use of a condom or abstinence.
Systemic and localized reactions can be prevented by use of condoms. However, partners should always be instructed on the use of an automatic epinephrine injector (EpiPen) and it should be available.
Conception
In patients who wish to conceive, and/or condoms are unacceptable, immunotherapy with seminal fluid can be performed. Alternatively, patients can conceive by artificial insemination with washed spermatozoa.
Here are the suggested diagnostic steps from AAAAI Ask the Expert and Dr. Bernstein (http://buff.ly/16yXcPD):
1) Test by PST to whole seminal fluid. This requires letting the ejaculate liquefy for 30 min and centrifuge for 10 minutes to separate seminal fluid from spermatozoa. Also test sexual partner as a negative control. You do not have to sterilize the seminal fluid for prick testing. Intracutaneous testing to whole seminal fluid should not be performed as it will cause an irritant response.
2) Both the patient and her sexual partner should be screened for STD's.
3) Some women have trouble with all men whereas other have symptoms with only one.
4) For localized seminal plasma hypersensitivity, skin testing is not always concordant with serologic testing. Patients can send their serum and their sexual partner's serum and a 5 day pooled ejaculate to Dr. Bernstein's laboratory to test for sIgE to whole seminal plasma.
5) There is cross reactivity between dog allergens and seminal plasma.
6) Patients with localized seminal plasma hypersensitivity should first undergo intravaginal graded challenge; dilute whole seminal fluid with sterile water to 1:100,000 dilution and instill 10 cc of volume intravaginally every 10-15 minutes up to a `1:1 dilution to see if this alleviates symptoms. There are reported cases that this may be effective. If not then the patient may be a candidate for subcutaneous desensitization to relevant fractionated seminal plasma proteins.
References
Allergy to coitus. Jones WR. Aust N Z J Obstet Gynaecol. 1991 May;31(2):137-41.
Human Seminal Plasma Protein Allergy: A Diagnosis Rarely Considered. Barbara GlaserLudman. Journal of Obstetric, Gynecologic, & Neonatal Nursing, Volume 28 Issue 4, Pages 359 - 363, 2006.
Seminal Fluid. AAAAI Ask the Expert, 2003.
Immunologic disorders of the female and male reproductive tract. Annals of Allergy, Asthma & Immunology, Volume 108, Issue 6 , Pages 390-395, June 2012.
IgE-Mediated Allergy against Human Seminal Plasma. Weidinger S, Ring J, Köhn J. Immunology of Gametes and Embryo Implantation. Chem Immunol Allergy. Basel, Karger, 2005, vol 88, pp 128-138.
Allergy to human seminal plasma: a presentation of six cases. Kroon S. Acta Derm Venereol. 1980;60(5):436-9.
Diagnosis and treatment of human seminal plasma hypersensitivity. Lee-Wong M, Collins JS, Nozad C, Resnick DJ. Obstet Gynecol. 2008 Feb;111(2 Pt 2):538-9.
Anaphylaxis to husband's seminal plasma and treatment by local desensitization. Lee J, Kim S, Kim M, Chung YB, Huh JS, Park CM, Lee KH, Kim JH. Clin Mol Allergy. 2008 Dec 5;6:13.
Management of seminal fluid hypersensitivity reactions. AAAAI Ask the Expert, 2011.
The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update. J Allergy Clin Immunol 2010; 126(3):477-522. The segment dealing with seminal fluid allergy begins on page 480.e17, under the heading "Seminal Fluid Anaphylaxis."
Related reading
Frequent Sex Cures Women's Semen Allergy. Fox News, 11/2008.
Woman discovers she's allergic to her husband. Daily Mail, 2009.
A 5-Year Followup of Human Seminal Plasma Allergy http://bit.ly/M3mDMX
Involvement of the dog allergen Can f 5 in a Case of Human Seminal Plasma Allergy http://goo.gl/cQSvj
Successful intravaginal graded challenge after a systemic reaction with skin prick testing to seminal fluid http://buff.ly/XKq4Ak
Vaginal pain with intercourse: is it seminal fluid allergy? AAAAI Ask the Expert answers: http://buff.ly/16yXcPD
Skin test may not be reliable for diagnosis of sensitization to seminal fluid proteins. Caused by PGs rather than IgE http://buff.ly/1wES08b
Published: 12/23/2008
Updated: 05/07/2013
17 comments:
Oh my. I've been a practicing OB-GYN for 17 years and have never seen a case. If I saw one, I actually would not really know what to do. Now I at least have an idea. Thanks Dr. Dimov.
I'm 27. I just got married and since then I have had the worst itching. It's been 6 months of hell. I never had sex before then so this has been my only experience and it has not been so good because of it. I went to several gynos. All told me I had bacteria and yeast infection. So I've had 6 months straight of antibiotics and yeast infection meds. I've even been admitted to the hospital because of the pain. They gave me percaset and prednisone for the pain and inflamation. No one could stop the itching permanantly. The last gyno told me I may have herpes. I was extremely depressed when the results came back positive for herpes even though my husband is negative for any and all stds. I wondered how I could have herpes if no one has ever been down there except for my husband and he's clean. I saw something on Oprah about semen allergy but when I mentioned it to my gyno he dismissed it and said not to believe everything i saw on tv. Well it turns out I do not have herpes, bacteria or a yeast infection. It is in fact semen allergy. Now that I know this we only have protected sex and feel 100% better. I can't believe more drs don't know about this. Please doctors I know you think you know it all but please do more research. New things come out all the time. and if at least 1 out of the 5 gynos I saw within 6 months could have known about this I would have saved a lot of money on copays, hospital bills, and meds. Not to mention how much time I would have saved. Instead of enjoying my first experience with my new husband we have had to abstain from sex during the painful outbreaks.
This case describes local human seminal protein hypersensitivity. HSPS can present with post-coital anaphylaxis, which is frightening. Testing to whole semen is less sensitive than to fractionated semen, which I think only the Cincy group does, but fraction 1 and 4 are the most allergenic. Treatment involves rapid intravaginal desensitization by small aliquots, followed by frequent intercourse. Using this, most couples can conceive without using IVF methods. The actual allergen is unknown but thought to come from the prostate.
How safe is it to skin test with semen fluid? what if you inoculate a disease?
Thank you for your comments.
Re: "Testing to whole semen is less sensitive than to fractionated semen, which I think only the Cincy group does, but fraction 1 and 4 are the most allergenic. The actual allergen is unknown but thought to come from the prostate."
Testing with fractionated semen is not widely available but it can be used as part of research protocols. There are different allergens suspected to play a role in the sensitization.
Re: "How safe is it to skin test with semen fluid? what if you inoculate a disease?"
The testing is done with the partner's seminal fluid to which the patient has already been exposed during unprotected intercourse - the reason why they present to the clinic. Of course, just like with every procedure, the patient has to be informed of the risks, including STDs, and an informed consent is obtained prior to the testing.
I thought I was crazy. For seven years I have been telling my doctors that I have pain, burning, swelling and unbelievable itching after intercourse with my partner of 16 yrs. They could find nothing. They told me to stop scratching! It is miserable. Finally a doctor gave me cortisone cream and I have gotten some relief. Everything I tried, scrubbing, using hot water, changing soaps and detergents, nothing helped. The gyn told me to use warm not hot water, dont scrub, dont towel dry but use a hair dryer, and take anti- histamines at bed time. No one ever mentioned an allergy to sperm. I wish doctors would start listening to women and stop thinking we are all crazy.
I am a 60 yr old married woman.I have been married to my husband 30+yrs and we have three grown children.I had problems look like yeast infection and I treated for that several times.There was no reason for me to have yeast infection.I am a very clean person.Lately I started feeling sever burning and pain after intercourse.My husbands comment was"if I cannot have sex with you I don't know what I will do to you."Sadley he started preparing for a divorce.He went to the court with a petition stating I am domestic abuser.so he wants to have restrain order.We all surprised he got it but with a hand written letter to the judge he trow out the petition..Now I realized this 70 yr old man wants to go and have other woman.I am glad I found this article.
The problem is women don't know they have the allergy. They think exactly what the doctor tells them, an infection. I have taken sooooo many antibiodics, I felt I was going to get immune to them. I have also been given a MRI to make sure I did not have any sists or stones that could be causing the infections. The doctor told me there have been studys done on women how get reacurring UTIs and they put them in two groups. One group has stones or sists and the other group is perfectly healthy. I was in the second group and he perscribed me a mild antibiodic to take after intercourse. I always thought that an allergy was the problem but never diaognosed. I have also realized once I started taking allergy shots because of allergic reactions to proteins in eggs, meat, milk and so on, my allergic reactions to unprotected sex also dimenished. Could proteins in semen be the same protein in foods? I did not finish my allergy shot treatment and I feel the symptoms are slowly comming back. Do you see a pattern?
Is it possible to have with one man and not another? I had it with my ex, but have never had this reaction again. Hmmmmmmmmmm something else to think about.
I'm 27 yrs old been married for 2 years been trying to have kids for 6 i have had a stillbirth at 32 weeks and 11 miscarriages since 2004 untill september 2010
i just got back from the hospital today they have done a Skin prik test and i was allergic to my husband semen
could this be the actual cause of the miscarriages ?
please email me back on j.t.pc.helpers@gmail.com
the doctors are going to try desanitising for 3 years
2-3 months weekly visits to the hospital and after that once a month for the following 2.5 yrs
Please help me ?
i have been having very bad burning and pain after unprotected sex with my boyfriend and my doctor thought it might be and std or sti but we have only been with each other and then my tests came out negative i felt really frustrated and then i researched a semen allergy and i am happy that i have finally found somthing that makes sense and now reading these i feel im not alone i just wish more doctors knew about this so they wont look at anyone else crazy
Hi, I am married since 8 months and suffering from severe burning after unprotected intercourse since then. My gyn kept on giving me antibiotics but there was no difference and now I feel that she doesn't have the solution even. I just want to ask what should I do if I plan to conceive and is there medication for this problem other than having a protected intetcourse please help doctor! Please
For about four years I have been suffering with a sinus/nasal allergic reaction to my own semen. Exposure to it invariably results in a pronounced and prolonged episode of sneezing and blowing my nose, etc.
I have mentioned this to several GPs with no helpful response. It really isn't funny. It's embarrassing to say the least, and generally interrupts and interferes with any post-coital chat.
Very glad I found this article. I suffer from recurrent BV infections, (SO FRUSTRATING) and have narrowed it down to my husbands sperm as the cause. Doctors just tell us that we have to live with it, it is an acidic thing... however just last night I noticed hives that appeard on my skin about 15 minutes after I washed semen off of the same spot. Started searching the web for causes, and it seems every symptom associated with semen allergy has been nothed in myself and overlooked by doctors. My husband is a sailor, and doctors cannot get past that.... I cant even begin to count how many STD tests we have had to endure (all negative) because the doctors have no clue! Thanks for sharing everyone. You've given me hope in finding the answer I've been long seeking!
I am sure I have the allergy. 2 days after unprotected sex I get a yeast infection. When my husband and I use condoms I don't get yeast infections. We have been trying to conceive for 15 months now with no luck. I can't get my primary care physician or my ob/gyn to believe that this is what is going on. I am extremely frustrated. I am going to print this article with some others and take it to my next ob/gyn appointment.
My husband and I have being separated for years, we have going back and forward with each other. I never could understand why I always got itchy reaction on my vagina. So the last time I even got swollen sinus, so I started to look online and found this article. How come is it that I react to his semen and not to other men's semen?
I am a 54 yr old woman, married to the same man for 25+ years. I have been having systemic allergy symptoms for 4-5 months. Occasionally, I would wake up in the night wheezing. It progressed over the last few months sometimes almost to the point of not being able to breath at all. I take Benadryl at night and keep an inhaler by my bed. I finally put 2 and 2 together and realized it only happened on the nights we had intercourse. I went this morning for a "prick" test at the Asthma and Allergy Office and guess what? Allergic to my husband's semen!!! My doctor said it is so rare that she hasn't seen anyone like me in 3-4 years. She is researching the desensitizing protocol and will get back with me.
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