1
|
Corona G, Minhas S, Giwercman A, Bettocchi C, Dinkelman-Smit M, Dohle G, Fusco F, Kadioglou A, Kliesch S, Kopa Z, Krausz C, Pelliccione F, Pizzocaro A, Rassweiler J, Verze P, Vignozzi L, Weidner W, Maggi M, Sofikitis N. Sperm recovery and ICSI outcomes in men with non-obstructive azoospermia: a systematic review and meta-analysis. Hum Reprod Update 2020; 25:733-757. [PMID: 31665451 DOI: 10.1093/humupd/dmz028] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 07/18/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Factor affecting sperm retrieval rate (SRR) or pregnancy rates (PR) after testicular sperm extraction (TESE) in patients with non-obstructive azoospermia (NOA) have not been systematically evaluated. In addition, although micro-TESE (mTESE) has been advocated as the gold standard for sperm retrieval in men with NOA, its superiority over conventional TESE (cTESE) remains conflicting. OBJECTIVE AND RATIONALE The objective was to perform a meta-analysis of the currently available studies comparing the techniques of sperm retrieval and to identify clinical and biochemical factors predicting SRR in men with NOA. In addition, PRs and live birth rates (LBRs), as derived from subjects with NOA post-ICSI, were also analysed as secondary outcomes. SEARCH METHODS An extensive Medline, Embase and Cochrane search was performed. All trials reporting SRR derived from cTESE or mTESE in patients with NOA and their specific determinants were included. Data derived from genetic causes of NOA or testicular sperm aspiration were excluded. OUTCOMES Out of 1236 studies, 117 studies met the inclusion criteria for this study, enrolling 21 404 patients with a mean age (± SD) of 35.0 ± 2.7 years. cTESE and mTESE were used in 56 and 43 studies, respectively. In addition, 10 studies used a mixed approach and 8 studies compared cTESE with mTESE approach. Overall, a SRR per TESE procedure of 47[45;49]% (mean percentage [95% CI]) was found. No differences were observed when mTESE was compared to cTESE (46[43;49]% for cTESE versus 46[42;49]% for mTESE). Meta-regression analysis demonstrated that SRR per cycle was independent of age and hormonal parameters at enrolment. However, the SRR increased as a function of testis volume. In particular, by applying ROC curve analysis, a mean testis volume higher than 12.5 ml predicted SRR >60% with an accuracy of 86.2% ± 0.01. In addition, SRR decreased as a function of the number of Klinefelter's syndrome cases included (S = -0.02[-0.04;-0.01]; P < 0.01. I = 0.12[-0.05;0.29]; P = 0.16). Information on fertility outcomes after ICSI was available in 42 studies. Overall, a total of 1096 biochemical pregnancies were reported (cumulative PR = 29[25;32]% per ICSI cycle). A similar rate was observed when LBR was analysed (569 live births with a cumulative LBR = 24[20;28]% per ICSI cycle). No influence of male and female age, mean testis volume or hormonal parameters on both PR and LBR per ICSI cycle was observed. Finally, a higher PR per ICSI cycle was observed when the use of fresh sperm was compared to cryopreserved sperm (PR = 35[30;40]%, versus 20[13;29]% respectively): however, this result was not confirmed when cumulative LBR per ICSI cycle was analysed (LBR = 30[20;41]% for fresh versus 20[12;31]% for cryopreserved sperm). WIDER IMPLICATIONS This analysis shows that cTESE/mTESE in subjects with NOA results in SRRs of up to 50%, with no differences when cTESE was compared to mTESE. Retrieved sperms resulted in a LBR of up to 28% ICSI cycle. Although no difference between techniques was found, to conclusively clarify if one technique is superior to the other, there is a need for a sufficiently powered and well-designed randomized controlled trial to compare mTESE to cTESE in men with NOA.
Collapse
Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Medical Department, Endocrinology Unit, Azienda Usl Bologna Maggiore-Bellaria Hospital, Bologna, Italy
| | - Suks Minhas
- Department of Urology, Imperial College NHS Healthcare, London, UK
| | - Aleksander Giwercman
- Molecular Reproductive Medicine, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Carlo Bettocchi
- Department of Urology, Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Gert Dohle
- Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Ferdinando Fusco
- Department of Neurosciences, Human Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Ates Kadioglou
- Department of Urology, Istanbul Faculty of Medicine, University of Istanbul, Istanbul, Turkey
| | - Sabine Kliesch
- Department of Clinical and Surgical Andrology, Centre of Reproductive Medicine and Andrology (CeRA), Münster University Hospital (UKM), Münster, Germany
| | - Zsolt Kopa
- Andrology Centre, Department of Urology Semmelweis University, Budapest, Hungary
| | - Csilla Krausz
- Andrology, Women's Endocrinology and Gender Inconguence Unit, Department of Experimental and Clinical Biomedical Sciences, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Fiore Pelliccione
- Diabetes and Metabolism Unit, Department of Internal Medicine, Azienda ASL 02 Chieti-Lanciano-Vasto, F. Renzetti Hospital, Lanciano, Italy
| | - Alessandro Pizzocaro
- Endocrinology Unit, Department of Biomedical Sciences, Humanitas University and Humanitas Research Center IRCCS, Rozzano, Milan, Italy
| | - Jens Rassweiler
- Department of Urology, SLK-Kliniken Heilbronn, University of Heidelberg, Heilbronn, Germany
| | - Paolo Verze
- Department of Neurosciences, Human Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Linda Vignozzi
- Andrology, Women's Endocrinology and Gender Inconguence Unit, Department of Experimental and Clinical Biomedical Sciences, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Wolfgang Weidner
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Giessen, Germany
| | - Mario Maggi
- Diabetes and Metabolism Unit, Department of Internal Medicine, Azienda ASL 02 Chieti-Lanciano-Vasto, F. Renzetti Hospital, Lanciano, Italy
| | - Nikolaos Sofikitis
- Department of Urology, Ioannina University School of Medicine, Ioannina, Greece
| |
Collapse
|
3
|
Assessment of the use of contrast enhanced ultrasound in guiding microdissection testicular sperm extraction in nonobstructive azoospermia. BMC Urol 2018; 18:48. [PMID: 29792185 PMCID: PMC5966902 DOI: 10.1186/s12894-018-0367-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study is to assess the value of contrast-enhanced ultrasound (CEUS) as a new non-invasive approach to locate the testicular area in which spermatogenesis is most likely to be found in non-obstructive azoospermic testes and to evaluate the accuracy of CEUS as a predictor of successful sperm retrieval. METHODS CEUS was performed in 120 nonobstructive azoospermia (NOA) patients. Microdissection testicular sperm extraction (M-TESE) was performed on the best and poorest perfusion areas selected by CEUS and on conventional areas. RESULTS In the 187 testicles that underwent M-TESE, the sperm retrieval rates (SRRs) in the best perfusion area and poorest perfusion area over the maximal longitudinal section and conventional area were 63.1, 34.7 and 47.1%. According to receiver operating characteristic (ROC) analysis, the arrival times (AT) ≤27 s, time-to-peak intensity (TTP) ≤45 s, and peak intensity (PI) ≥11 dB were the best predictors of positive sperm retrieval. The location of the best perfusion area was able to guide M-TESE to improve the success rates. CONCLUSIONS Testicle CEUS is suggested to be performed in all patients with NOA. If AT≤27 s, TTP ≤ 45 s or PI≥11 dB are found in the best perfusion area, M-TESE is strongly recommended.
Collapse
|
4
|
Altinkilic B, Pilatz A, Diemer T, Wolf J, Bergmann M, Schönbrunn S, Ligges U, Schuppe HC, Weidner W. Prospective evaluation of scrotal ultrasound and intratesticular perfusion by color-coded duplex sonography (CCDS) in TESE patients with azoospermia. World J Urol 2017; 36:125-133. [PMID: 28429094 DOI: 10.1007/s00345-017-2039-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/13/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The objective of this study was to assess whether CCDS might improve the outcome of testicular sperm retrieval in patients with azoospermia. Furthermore, we evaluated potential sonographic alterations of the testis before and after trifocal and Micro-TESE. METHODS 78 patients were enrolled prospectively: 24 with obstructive azoospermia (OA) and 54 with non-obstructive azoospermia (NOA). 31 of 54 patients in the NOA group had negative surgical sperm retrieval. Testicular volume, hormonal parameters and sonographical findings were compared before and after TESE. The spermatogenetic score was determined for all retrieval sites. CCDS was performed at the upper, middle and lower segment of the testis. Ultrasound parameters and peak systolic velocity (PSV) were measured pre- and post-operatively. RESULTS Testicular volume and epididymal head size were significantly increased in OA patients compared to NOA patients. Ultrasound parameters were comparable between NOA patients with and without successful sperm retrieval. A higher intratesticular PSV was significantly correlated with a better spermatogenic score in the corresponding sonographic position. However, after adjustment for other clinical confounders, PSV does not show a significant influence on the spermatogenic score. Testicular volume decreased significantly in all patients post-operatively after 6 weeks (p < 0.001). Finally, the PSV significantly increased in all patients 24 h after surgery and nearly returned to baseline levels after 6 weeks (p < 0.001). CONCLUSIONS A higher intratesticular PSV may be helpful as a pre-operative diagnostic parameter in mapping for better sperm retrieval, but CCDS does not help to predict successful testicular sperm retrieval after adjustment for other clinical confounders.
Collapse
Affiliation(s)
- Bora Altinkilic
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany.
| | - Adrian Pilatz
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| | - Thorsten Diemer
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| | - Julia Wolf
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| | - Martin Bergmann
- Institute of Veterinary Anatomy, Histology and Embryology, Justus-Liebig University Giessen, Frankfurter Str. 98, 35392, Giessen, Germany
| | - Sarah Schönbrunn
- Department of Statistics, TU Dortmund University, Dortmund, Germany
| | - Uwe Ligges
- Department of Statistics, TU Dortmund University, Dortmund, Germany
| | - Hans-Christian Schuppe
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| | - Wolfgang Weidner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University Giessen, Rudolf-Buchheim-Str. 7, 35392, Giessen, Germany
| |
Collapse
|
8
|
Souza CAB, Cunha-Filho JSL, Fagundes P, Freitas FM, Passos EP. Sperm Recovery Prediction in Azoospermic Patients Using Doppler Ultrasonography. Int Urol Nephrol 2005; 37:535-40. [PMID: 16307338 DOI: 10.1007/s11255-005-0918-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate power Doppler ultrasonography to predict sperm recovery in azoospermic patients. METHODS Color Doppler and power Doppler ultrasonography of testis were performed in 38 patients before testicular sperm extraction. Analysis of blood flow included the pulsatility and resistance index of intratesticular vessels and testicular artery, and power Doppler of testis. The results of power Doppler of testis were classified into three categories: 0, no vessels found; 1, one to three vessels; 2, more than three vessels found. RESULTS Power Doppler of both testis showed a significant difference between obstructive azoospermia and non-obstructive azoospermia (Fisher's exact test - P = 0.02), and between the groups with and without sperm recovery (Fisher's exact test - P = 0.001). Doppler indices of intratesticular vessels and testicular artery were similar between the groups. CONCLUSIONS Testicular Power Doppler assessment showed that patients with obstructive azoospermia have better blood flow than patients with non-obstructive azoospermia, and power Doppler is able to predict sperm recovery in azoospermic patients.
Collapse
Affiliation(s)
- C A B Souza
- Human Reproduction Center, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | | | | | | | | |
Collapse
|
10
|
Har-Toov J, Eytan O, Hauser R, Yavetz H, Elad D, Jaffa AJ. A new power Doppler ultrasound guiding technique for improved testicular sperm extraction. Fertil Steril 2004; 81:430-4. [PMID: 14967385 DOI: 10.1016/j.fertnstert.2003.07.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2003] [Revised: 07/03/2003] [Accepted: 07/03/2003] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a noninvasive procedure that employs image processing of power Doppler ultrasound (PDUS) images of several orthogonal cross-sections of the testis to construct a three-dimensional (3D) mapping of preferential testicular regions in which spermatozoa are most likely to be found in nonobstructive azoospermic testes. DESIGN Clinical study. SETTING Ultrasound and andrology units in a large university-affiliated municipal hospital. PATIENT(S) Twenty-four nonobstructive azoospermic men. INTERVENTION(S) Before testicular sperm extraction was performed, PDUS images were acquired at seven cross-sections to reconstruct a 3D testicular vascularity index (TVI) matrix for spatial mapping of testicular regions in which spermatozoa are most likely to be found. The predictions based on TVI values of 107 regions were compared with the biopsy results. MAIN OUTCOME MEASURE(S) Prediction of presence or absence of spermatozoa by TVI values. RESULT(S) The prediction rate of the TVI matrix for the presence or absence of spermatozoa was 74.8%. The positive predicted value was 72%, negative predicted value was 75.6%, and specificity was 89.8%, but sensitivity was 47.3%. CONCLUSION(S) Our technique may obviate the need for arbitrary multiple biopsies that inflict some degree of damage upon testicular tissue and may increase the success rate of identifying viable spermatozoa in testicular tissue.
Collapse
Affiliation(s)
- Joseph Har-Toov
- Ultrasound Unit, Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | | | | | | |
Collapse
|