PROBABILITY OF SPERM RECOVERY IN NON-OBSTRUCTIVE AZOOSPERMIC PATIENTS PRESENTING WITH TESTES VOLUME LESS THAN 10 ml/FSH LEVEL EXCEEDING 20 mIU/ml

Repeated microdissection testicular sperm extraction in patients with non-obstructive azoospermia: Outcome and predictive factors

Objective

To assess the feasibility of repeated sperm recovery in patients with non-obstructive azoospermia (NOA), as little is known about the extraction rate in repeated microdissection testicular sperm extraction (microTESE) in these patients.

Patients and Methods

A total of 134 men with NOA had their first sperm recovery between January 2013 and February 2020. Repeated microTESE had been done mostly for patients with a successful initial retrieval.

Results

In the 323 procedures performed on the 134 men with NOA, sperm could be retrieved in 236 procedures (73.1%). A total of 88, 61 and 40 men underwent two, three and four sperm retrievals, respectively. In these cycles, sperm could be extracted in 65 (73.9%), 53 (86.9%) and 37 (92.5%) men, respectively. During the first microTESE procedure, sperm could be extracted in 81 (60.4%) men with NOA. In all, the success rate was significantly different between subgroups, showing highest rate in hypospermatogenesis cases (95.6%), followed by maturation arrest (58.5%), and Sertoli cell-only syndrome (56.0%). However, this difference was not significant at the third and fourth repeated microTESE. The FSH levels and testicular volume were among the noticeable factors affecting success of sperm retrieval. The duration between the first and second biopsies significantly increased the success rate by a factor of 1.3-fold/month; however, afterwards, the duration did not play any role in the success of microTESE. The success of previous trial significantly increased the probability of success by 10.1-fold in the second trial, 5.6-fold in the third trial, and 16.5 folds in the fourth.

Conclusion

Repeated MD -TESE ensures a high sperm recovery rate in patients with NOA. These data also show that when no spermatozoa can be obtained after thawing cryopreserved testicular sperm for ICSI in NOA patients, a repeat microTESE procedure can be planned.

Abbreviations

ICSI: intracytoplasmic sperm injection; IVF: in vitro fertilisation; MA: maturation arrest; (N)OA: (non-)obstructive azoospermia; OR: odds ratio; SCOS, Sertoli cell-only syndrome; SRR: spermatozoa retrieval rate; (micro)TESE: (microdissection) testicular sperm extraction

Spermatozoa retrieval in azoospermia and expression profile of JMJD1A, TNP2, and PRM2 in a subset of the Karachi population

BACKGROUND

The difficulties encountered in surgical spermatozoa retrieval for intracytoplasmic sperm injection procedure in azoospermic men have stressed the dire need for a robust biomarker for the prediction of spermatozoa retrieval. Data have highlighted the role of JMJD1A (Jumonji domain-containing 1A), a histone H3K9 demethylase, and other nuclear proteins, protamines (PRM) and transition nuclear proteins (TNP), as biomarkers in male infertility.

OBJECTIVE

To access successful spermatozoa retrieval at the time of intracytoplasmic sperm injection by evaluating the mRNA expression profile of JMJD1A, TNP, and PRM in testicular tissue.

MATERIALS/METHODS

About 100 azoospermic patients, who visited the Australian Concept Infertility Medical Center, Karachi for spermatozoa retrieval by testicular sperm extraction or microsurgical testicular sperm extraction participated in the study. mRNA expression of the JMJD1A, TNP1, TNP2, PRM1, and PRM2 genes was determined. Patients were categorized into successful spermatozoa retrieval (n = 42) group and unsuccessful spermatozoa retrieval (n = 58) group.

RESULTS

Azoospermic men in successful spermatozoa retrieval had significantly increased expression of JMJD1A, TNP2, and PRM2. The hormonal parameters - follicle-stimulating hormone, luteinizing hormone, and thyroid-stimulating hormone were significantly higher in unsuccessful spermatozoa retrieval. Multivariate analysis showed a significant association between JMJD1A, TNP2, PRM2, and successful spermatozoa retrieval. The area under the receiver operating characteristics curve showed a significant discriminatory ability to predict the spermatozoa retrieval outcome in azoospermic patients for mRNA expression of JMJD1A, TNP2, and PRM2 was 71, 72, and 73%, respectively. The area under the curve for follicle-stimulating hormone, luteinizing hormone, and thyroid-stimulating hormone was 0.67, 0.81, and 0.65, respectively.

DISCUSSION

Our study demonstrates that the mRNA expression profile of JMJD1A, TNP2, and PRM2 along with hormonal parameters, is a useful marker to assess the probability of spermatozoa retrieval before intracytoplasmic sperm injection intervention.

CONCLUSION

The probability of spermatozoa retrieval in azoospermic patients is increased when the mRNA expression profile of JMJD1A, TNP2, and PRM2 in testicular tissue is increased.

Evaluating the quality of reported outcomes for microsurgical TESE in men with non-obstructive azoospermia: A methodological analysis

BACKGROUND

Publications of microsurgical testicular sperm extraction (mTESE) techniques and outcomes are heterogeneous, which may limit creation of best surgical practices.

OBJECTIVE

To study the quality and heterogeneity of published mTESE outcomes via a methodological analysis.

MATERIALS/METHODS

A systematic methodological analysis of all published literature on the use of mTESE in men with non-obstructive azoospermia from 1999 to the July 2020 was performed. PubMed and MEDLINE searches were performed using the search terms "microdissection TESE OR microsurgical TESE." Publications were evaluated on their reporting of pre-operative factors, intraoperative techniques, surgical and clinical outcomes, and adverse events.

RESULTS

Fifty-five studies met inclusion criteria. Surgical technique and sperm retrieval rates were the most reported criteria. Reporting on the presence of an embryologist intraoperatively was observed in approximately 30% of articles, while other procedural details including method of sperm quantification, quantity retrieved, and number of cryopreserved vials were observed in fewer than 10% of articles. Clinical outcomes, including pregnancy rates and live birth rates, were reported in fewer than 40% of the articles. Fetal outcomes including fetal and neonatal anomalies were rarely reported. Fetal growth restriction, preterm delivery, small or large for gestational age, and NICU admissions were never reported.

CONCLUSION

There are inconsistencies in reporting quality of mTESE outcomes, specifically a lack of information on the quantity and quality of sperm retrieved, the role of embryology intraoperatively, and clinical outcomes, such as live birth rate and fetal anomalies. These gaps may guide development of standardized reporting guidelines to better assess and compare clinical outcomes across institutions and maintain focus on couples-centric fertility outcomes in future mTESE studies.

The Role of Hormone Stimulation in Men With Nonobstructive Azoospermia Undergoing Surgical Sperm Retrieval

Nonobstructive azoospermia, (NOA) is the most common cause of azoospermia. NOA is characterized by hypergonadotropic hypogonadism, testicular failure, and impaired spermatogenesis. The recent development of surgical sperm retrieval techniques such as microsurgical testicular sperm extraction (mTESE) has, for the first time, allowed some men with NOA to father biological children. It is common practice for endocrine stimulation therapies such as gonadotropins, selective estrogen receptor modulators (SERMs), and aromatase inhibitors to be used prior to mTESE to increase intratesticular testosterone synthesis with the aim of improving sperm retrieval rates; however, there is currently a paucity of data underpinning their safety and efficacy. We present 2 cases of men with NOA undergoing endocrine stimulation therapy and mTESE. We also discuss the current evidence and controversies associated with the use of hormonal stimulation therapy in couples affected by this severe form of male infertility.

Follicle-stimulating hormone may predict sperm retrieval rate and guide surgical approach in patients with non-obstructive azoospermia

Testicular sperm aspiration- (TESA) or micro-dissection testicular sperm extraction- (MD-TESE) combined intracytoplasmic sperm injection (ICSI) was the only option for non-obstructive azoospermia (NOA) patients to have a biological offspring and they had different success rates in sperm retrieval. Our study aimed to find predictor(s) for predicting the sperm retrieval rate (SRR) in NOAs and guide clinicians in choosing different surgical approaches, TESA or MD-TESE for NOAs. 294 NOAs who had undergone TESA or MD-TESE were divided into TESA group and MD-TESE group. Depending on sperm retrieval, each group was divided into two subgroups: successful subgroups and failure subgroups. They respectively were 24 cases and 131 cases, 53 cases and 86 cases. Clinical data, including body mass index (BMI), testicular volume, and serum hormone levels, were analyzed in a retrospective manner. The results showed that follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and SRR were lower in TESA group as compared to these in MD-TESE group, while testicular volume was higher (P < 0.05). The surgical approach of sperm retrieval significantly affected the SRR (P < 0.05). In TESA subgroups, testicular volume, FSH and LH differed significantly (P < 0.05). In MD-TESE subgroups, the level of FSH and LH differed significantly between both groups (P < 0.05). Using logistics regression, we found a negative correlation (β=-0.083) between FSH and the SRR in TESA group but a positive correlation (β = 0.064) in MD-TESE group (P < 0.05). In conclusion, serum FSH level can predict the SRR of NOAs and guide the clinicians while selecting the suitable surgery approach for NOAs.

Predictive model to estimate the chances of successful sperm retrieval by testicular sperm aspiration in patients with nonobstructive azoospermia

OBJECTIVE

To explore predictors of successful sperm retrieval (SR) and to identify potentially suitable candidates for testicular sperm aspiration (TESA), a more straightforward, less traumatic, and less costly procedure than open surgical SR methods.

DESIGN

Retrospective chart review.

SETTING

Academic tertiary medical center.

PATIENTS

A total of 297 patients with nonobstructive azoospermia.

INTERVENTIONS

All patients underwent full clinical evaluation before undergoing a staged SR procedure, starting with TESA and proceeding to microsurgical testicular sperm extraction (microTESE). Predictors of positive SR with TESA were selected using the least absolute shrinkage and selection operator (LASSO) regression analysis using k-fold cross-validation. The obtained regression coefficients were used to create a predictive model, and a receiver operating characteristic (ROC) curve was obtained to express its predictive ability. Cut-off values for each significant predictor were also identified using ROC analysis.

MAIN OUTCOME MEASURE(S)

Development of a prediction model for positive SR with TESA.

RESULTS

Overall, a positive SR was observed in 23.6% of patients undergoing TESA. Average testis size (P = .017) and serum follicle-stimulating hormone (FSH) level (P < .001) were the significant predictors of positive SR identified by LASSO regression analysis. The predictive model had an AUC of 0.742 with a sensitivity of 73.9% and specificity of 69.9%. Patients presenting with an average testis size >7.75 mL and serum FSH level <8.5 IU/L had a TESA-positive SR of 43%.

CONCLUSIONS

TESA may be a suitable alternative to microTESE in selected nonobstructive azoospermia patients presenting with an average testis size >7.75 mL and serum FSH level <8.5 IU/L.

Determining an optimal cut-off value for follicle-stimulating hormone to predict microsurgical testicular sperm extraction outcome in patients with non-obstructive azoospermia

Objective To determine the optimal cut-off value for follicle stimulating hormone (FSH) to predict the outcome of microsurgical testicular sperm extraction (micro-TESE) in patients with nonobstructive azoospermia (NOA). Subjects and methods We included a total number of 180 patients with NOA. The serum level of FSH was determined and all the subjects underwent micro-TESE. We determined the optimal cut-off value for FSH and assessed whether the test could be effectively used as a successful predictor of sperm retrieval by calculating the Receiver Operating Characteristic (ROC) area under the curve. Results Overall we included a total number of 171 patients with mean age of 34.3 ± 8.6 years. The micro-TESE was considered to be successful in 79 (43.8%) while it failed in 92 (56.2%) patients. We found that the mean level of serum FSH was significantly higher in group those with failed micro-TEST compared to successful group (p < 0.001). The cut-off value for FSH was calculated to be 14.6 mIU/mL to predictive the outcome of micro-TESE with a sensitivity of 83.5% [73.5%-90.9%] and a specificity of 80.3% [69.5%-88.5%]. At this value, the other parameters were calculated to be PPV, 81.5%; NPV, 82.4; LR+, 4.23; and LR-, 0.21. Conclusions The results of the current study indicate that FSH plasma levels above 14.6 mIU/mL can be considered to be the failure predictor of the micro-TESE in NOA patients.

Association of genetic variants in SOHLH1 and SOHLH2 with non-obstructive azoospermia risk in the Chinese population

OBJECTIVE

Spermatogenesis and oogenesis specific basic helix-loop-helix 1 (SOHLH1) and spermatogenesis and oogenesis specific basic helix-loop-helix 2 (SOHLH2) play essential roles for both spermatogenesis and oogenesis. The aim of this study was to evaluate the association of SOHLH1 and SOHLH2 single nucleotide polymorphisms (SNPs) with non-obstructive azoospermia (NOA) in the Chinese population.

STUDY DESIGN

In this study, we assessed 7 single nucleotide polymorphisms (SNPs) of SOHLH1 and SOHLH2 with Sequenom iplex technology in 361 NOA cases and 368 fertile controls.

RESULTS

We found that the SNPs rs1328626 and rs6563386 of SOHLH2 were significantly associated with NOA risk, of which, a protective effect of minor allele T of rs1328626 on NOA (P = 0.038, odds ratio [OR] = 0.799, 95% confidence interval [CI] = 0.645-0.988) and a significantly increased risk of the SNP rs6563386 with the minor allele G to NOA (P = 0.029, OR = 1.402, 95% CI = 1.034-1.9) were observed, respectively. Our data indicated that the haplotype GC of the variants rs1328626 and rs6563386 conferred a significantly increased risk of NOA (P = 0.031, OR = 1.397, 95% CI = 1.031-1.895). Moreover, we found the genotype distribution of rs1328641 was significantly associated with testes volume in the NOA patients (P = 0.022).

CONCLUSIONS

The polymorphisms rs1328626 and rs6563386 of the SOHLH2 gene would be the genetic risk factors for NOA in the Chinese population. The SNP rs1328641 might influence testes development in the NOA patients.

Association of single nucleotide polymorphisms in the USF1, GTF2A1L and OR2W3 genes with non-obstructive azoospermia in the Chinese population

PURPOSE

To research the association between the single nucleotide polymorphisms (SNPs) of three spermatogenesis-related genes (USF1, GTF2A1L and OR2W3) and non-obstruction azoospermia (NOA).

METHODS

We investigated 361 NOA cases and 368 controls from the Chinese Han population, and we used Sequenom iplex technology to analyze the candidate 9 SNPs from the USF1, GTF2A1L and OR2W3 genes.

RESULTS

In this study, we found that the variant rs2516838 of USF1 was associated with NOA susceptibility (P = 0.020, OR = 1.436), and the haplotype TCG of the variants rs1556259, rs2516838, and rs2774276 of USF1 conferred an increased risk of NOA (P = 0.019, OR = 1.436). Furthermore, we found that the rs11204546 genotype of OR2W3 and the rs11677854 genotype of GTF2A1L were correlated with the FSH level in the patients (P = 0.004 and P = 0.018, respectively).

CONCLUSIONS

Our results provided a new insight into susceptibility of USF1 variant with male infertility. Clinically, the SNPs (rs11204546 of OR2W3 and rs11677854 of GTF2A1L ) might be additional valuable molecular predictive markers for assessing the treatment of NOA patients.

Genetic study of Hormad1 and Hormad2 with non-obstructive azoospermia patients in the male Chinese population

PURPOSE

To evaluate the association of the Hormad1 and Hormad2 single nucleotide polymorphisms (SNPs) variants with non-obstructive azoospermia (NOA) in the Chinese population.

METHODS

In the present study, we assessed 10 single nucleotide polymorphisms (SNPs) of Hormad1 and Hormad2 using Sequenom iplex technology in 361 NOA cases and 368 normal controls from Chinese population.

RESULTS

We observed no statistical differences in the distribution of allele frequencies. Further genetic model analysis and haplotype analysis also showed no significant difference between the two groups. However, we found that genotype distribution of rs718772 of Hormad2 was significantly different between the larger testis group (average testis volume ≥10 ml) and the small testis group (average testis volume <10 ml) in the NOA patients (P = 0.035).

CONCLUSIONS

In conclusion, Hormad1 and Hormad2 might not be the susceptible genes for the non-obstructive azoospermia in our study population. However, rs718772 of Hormad2 variant might be associated with testis development in NOA patients.

Sperm retrieval and live birth rates in presumed Sertoli-cell-only syndrome in testis biopsy: a single centre experience

We aimed to investigate sperm retrieval rates (SRR) by testicular sperm extraction (TESE), factors affecting SRR, and fertilization rate (FR), implantation rate (IR), clinical pregnancy rate (CPR) and live birth rate (LBR) in patients with presumed Sertoli-cell-only syndrome in testis biopsy (SCOS). We retrospectively evaluated files of 134 patients with SCOS who underwent TESE. Group I were patients in whom spermatozoa were retrieved and Group II were patients in whom no spermatozoa could be retrieved. SRR, Follicle stimulating hormone (FSH), Luteinizing hormone (LH), and testosterone levels, and the volume of testicles were compared between groups. In addition, FR, IR, CPR and LBR were determined. Sperm retrieval was achieved in 37 (27.6%) patients (Group I), and the remaining 97 (72.4%) patients made Group II. There were no significant differences in age, infertility time, testicular volume, serum FSH, LH and testosterone levels between Groups I and II (p > 0.05). Intracytoplasmic sperm injection (ICSI) was performed in 36 patients. FR, IR, and CPR were 60.86 ± 23.03, 36.53 ± 41.78 and 51.3% respectively. Cycle and patient based LBRs were 37.8 and 45.1% respectively. SRR in SCOS is lower than patients with non-obstructive azoospermia (NOA) in general. No parameters to predict spermatozoa retrieval were determined. In patients with SCOS, ICSI achieves similar live birth rate to other patients with NOA.

Clinical comparison of conventional testicular sperm extraction and microdissection techniques for non-obstructive azoospermia

Background

We compared the efficacy of microdissection testicular sperm extraction (microdissection TESE) and conventional TESE in patients with non-obstructive azoospermia (NOA) and related the positive sperm recovery to certain variables: follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, testicular volume and histology.

Methods

Sperm retrieval rates (SRR) in patients with NOA who underwent microdissection TESE (n = 65) or conventional TESE (n = 68) were compared and related to the different variables.

Results

SRR by microdissection TESE (56.9%) was significantly higher than conventional TESE (38.2%). There was a positive relation between the SRR and increased testicular volume or decreased FSH levels. No effect of Testosterone or Prolactin levels on SRR by using either technique was observed. Sperm were recovered from those with hypospermatogenesis in 84% and 92.9% by conventional and microdissection TESE, respectively (P = 0.3). In cases of maturation arrest the SRR was 27.3% and 36.4%, respectively (P = 0.6). In cases of Sertoli-cell-only syndrome (SCOS) the SRR was 6.2% and 26.9%, respectively (P = 0.03). No major operative complications occurred in any patient in either group, and no patient required post-operative hormone replacement to treat hypogonadism.

Conclusions

Microdissection TESE significantly had twice better probability of success of SRR when compared to conventional TESE. No secure pre-operative prognostic elements of sperm recovery exist for NOA patients. Microdissection TESE appears to be recommendable in cases of atrophied testicles, high FSH concentration, or when SCOS with high FSH concentration can be predicted.

Keywords

Microdissection TESE; Sperm retrieval; Non-obstructive azoospermia; Histopathology; FSH concentration; Orchidometry

In the era of micro-dissection sperm retrieval (m-TESE) is an isolated testicular biopsy necessary in the management of men with non-obstructive azoospermia?

OBJECTIVES

To assess the outcome of sperm retrieval using micro-dissection-TESE (m-TESE) and simultaneous diagnostic biopsy in NOA to determine if the final definitive histology correlated with the outcome of sperm retrieval by m-TESE in men with NOA. To determine if there was a correlation between FSH levels and positive sperm retrieval rates and assessed the success rate of m-TESE as either a primary or a salvage procedure after previous negative sperm retrieval. The EAU guidelines (2010) recommend that in men with non obstructive azoospermia 'a testicular biopsy is the best procedure to define the histological diagnosis and the possibility of finding sperm'. However, these guidelines do not identify which patients should have a diagnostic biopsy and if this biopsy should be performed as an isolated procedure or synchronously with sperm retrieval. It is also suggested that there is a correlation between the histological diagnosis and possibility of finding sperm on testis biopsy.

PATIENTS AND METHODS

100 men with NOA underwent a m-TESE sperm retrieval between 2005 and 2010 at a single centre. All patients underwent hormonal analysis (serum FSH, Testosterone and LH levels) and genetic analyses after full counselling including; Y-deletion, CF-gene analysis and karyotype. Thirty five men had previously undergone unsuccessful TESA/TESE or diagnostic biopsy at other centres. All patients underwent synchronous sperm retrieval and biopsy of the testis, which was sent for histopathological examination on the day of an ICSI cycle or as an isolated procedure.

RESULTS

Mean age of patients was 37.25 (range 29-56 years). The mean serum FSH levels in the Sertoli cell only, maturation arrest and hypospermatogenesis groups were 21.3 IU/L (2.8-75), 16.18 (1.6-67) and 14.17 IU/L (0.8-42.3) respectively. SR rates in the respective groups were 42.85%, 26.6% and 75.86% (P= 0.023). There were no post-operative complications. In the 35 men who had previously undergone unsuccessful procedures elsewhere, the SR rates were 57.1%. The overall sperm retrieval rate was 50%. There was no correlation between SR and FSH levels (P= 0.28).

CONCLUSION

M-TESE should be considered the gold standard for retrieval of testicular sperm in NOA, even in cases where there has been previously unsuccessful attempts. FSH levels and histology cannot be used to predict the success of sperm retrieval. An isolated diagnostic testicular biopsy is not recommended in men with NOA, as a significant proportion of men undergoing m-TESE will have successful a sperm retrieval irrespective of previous histology or previous unsuccessful surgery.

Conventional testicular sperm extraction combined with the microdissection technique in nonobstructive azoospermic patients: a prospective comparative study

OBJECTIVE

To perform conventional and microdissection testicular sperm extraction (TESE) at the same session and compare their effectiveness.

DESIGN

Prospective comparative study.

SETTING

University hospital setting.

PATIENT(S)

The study included 335 patients with nonobstructive azoospermia.

INTERVENTION(S)

Microdissection TESE was performed to 77 patient with atrophic testes. An additional 258 patients underwent conventional TESE using three incisions on three quadrants of the testis (upper, middle, and lower). Microdissection TESE was performed by enlarging the middle incision vertically when no spermatozoa could be detected using the conventional technique.

MAIN OUTCOME MEASURE(S)

Sperm retrieval, fertilization, clinical pregnancy rate (PR), and live birth rate were evaluated. The relation between sperm retrieval rate and FSH level and testis volume was also investigated.

RESULT(S)

Spermatozoa was detected in 33.7% of patients using conventional TESE. The spermatozoa detected increased to 50.8% using microdissection TESE. The increase was statistically significant. In the primary microdissection TESE group, the surgical retrieval rate was 20.8%. The overall sperm retrieval rate was 43.9%. There was a significant relation between the sperm retrieval rate and testis volume, whereas there was no relation between sperm retrieval rate and FSH levels. The overall fertilization rate, clinical PR, and live birth rate were 57.1%, 50.4%, 36.4%, respectively.

CONCLUSION(S)

Conventional TESE combined with microdissection TESE can be used in selected patients. Sperm retrieval rate of TESE can be low in patients with atrophic testes.

Sperm acquisition in nonobstructive azoospermia: what are the options?

Approximately 10% of male-factor infertility is caused by azoospermia, and nearly two thirds of these patients have nonobstructive azoospermia (NOA). As experience has been gained, increasing numbers of men who have NOA are having sperm retrieved from their testes and used for intracytoplasmic sperm injection with vitro fertilization. This article reviews the various sperm retrieval techniques, discussing the advantages and disadvantages and the outcomes of each. Predictive factors for sperm retrieval are presented, as are some of the controversies that exist regarding sperm acquisition in NOA.

Azoospermia: is sample centrifugation indicated? A national survey of practice and the Oxford experience

OBJECTIVE

Some men with azoospermia on general laboratory testing have low quantities of sperm in the ejaculate that can only be identified through sample centrifugation and careful examination of the pellet droplets (extended sperm preparation [ESP]). Such sperm can be used for IVF-ICSI as an alternative to either surgical sperm retrieval (SSR) or donor sperm. The aims of the present study were to: 1) assess UK IVF clinic practice with regard to ESP in men with azoospermia; and 2) to analyze the outcome of ESP and SSR in azoospermic men attending the Oxford Fertility Unit.

DESIGN

National survey of all 70 IVF units plus chart review.

SETTING

Assisted conception unit.

PATIENT(S)

One hundred twenty-two azoospermic men referred to the Oxford Fertility Unit.

MAIN OUTCOME MEASURE(S)

Proportions of UK IVF clinics performing ESP for azoospermia. Proportions of azoospermic men in Oxford with sperm identified at ESP and, if necessary, SSR. Relationship between serum FSH and outcome.

RESULT(S)

In part 1 of the study, 55 (79%) of the 70 UK IVF clinics returned completed questionnaires. Fifty clinics (91%) routinely performed ESP for men with azoospermia on general laboratory testing, four clinics (7%) proceeded straight to SSR without prior ESP, and one clinic varied in their approach. When clinics were asked whether they used serum FSH levels when considering whether to proceed to SSR 28 (51%) did, 9 (16%) did not, and 18 (33%) varied in their approach. The value placed on testicular volume similarly varied. Part 2 of the study included 122 men referred to the Oxford Fertility Unit with azoospermia on general laboratory testing. Eighty-seven men underwent ESP. Motile sperm was found, cryopreserved, and later used during IVF-ICSI treatment in 19 men (22%). Eighty-one men underwent SSR (after either a negative ESP or declining ESP). Viable sperm was found in 66 men undergoing SSR (81%). There was a statistically significant relationship between serum FSH and the chance of retrieving sperm with SSR (P=0.002) but not with ESP.

CONCLUSION(S)

The majority (91%) of IVF clinics in the UK routinely perform ESP in men with azoospermia on general testing. Only half routinely used serum FSH levels as predictors of SSR outcome. The value of ESP is confirmed by our findings in Oxford. Twenty-two percent of men with azoospermia on general laboratory testing had sufficient sperm found at ESP to proceed to IVF-ICSI without resorting to the use of either SSR or donor sperm. Serum FSH levels were not related to the chance of finding sperm during ESP but were related to the outcome of SSR. Our results suggest that ESP should be considered for all men with azoospermia and no apparent obstruction.

Testicular sperm extraction and ICSI in patients with post-chemotherapy non-obstructive azoospermia

146 MD-TESE procedures were performed in 74 patients presenting with non-obstructive azoospermia (NOA). Five of the 74 patients displayed a history of chemotherapy. Etiology of chemotherapies included testicular cancer, osteosarcoma, Ewing sarcoma, and malignant lymphoma of the stomach. Post-chemotherapy duration was 2.5-18 years. All patients underwent MD-TESE using local anesthesia with spermatic block and sedation. Extracted sperm was cryopreserved for ICSI. Histopathologic examination revealed Sertoli cell-only syndrome in all five patients; however, sperm were retrieved in 3 subjects. Post-chemotherapy MD-TESE and ICSI can be applied successfully in some patients with NOA. However, freezing semen prior to chemotherapy is recommended.

Elevated follicle-stimulating hormone levels and the chances for azoospermic men to become fathers after retrieval of elongated spermatids from cryopreserved testicular tissue

OBJECTIVE

To assess individual chances for a live-born child in azoospermic men by performance of testicular sperm extraction (TESE) followed by intracytoplasmatic sperm injection (ICSI).

DESIGN

A retrospective cohort study.

SETTING

An academic fertility care center and research unit.

PATIENT(S)

Two hundred three couples who wished to have a child; all men had azoospermia.

INTERVENTION(S)

All men were operated for TESE; 112 men were found to have elongated spermatids (ES), and 209 ICSI cycles were performed in these men using cryopreserved tissue.

MAIN OUTCOME MEASURE(S)

Predictors for the chances to obtain live sperm and for probabilities of fertilization, clinical pregnancies, and live births.

RESULT(S)

Testicular volume, FSH, and inhibin B levels were predictors for the presence of ES. Intracytoplasmic sperm injection resulted in 23 pregnancies, leading to 20 live births. Despite the presence of ES and performance of ICSI in cases of FSH levels >or=20 IU/L, no pregnancy resulted in these men (n = 21). Receiver operating characteristics revealed FSH levels of >or=20 IU/L as cutoff for treatment success. The number of testicular tubuli containing ES served as a predictor for clinical pregnancy as well as for live birth. Cigarette smoking by the male partner exerted a significant negative influence on treatment success.

CONCLUSION(S)

The degree of completely maintained spermatogenesis within the biopsy appears to reflect intrinsic abilities of spermatozoa to induce normal embryo development. Charts based on regression models are presented for counseling patients before TESE; these explain chances of finding ES and probability of successful ICSI. Obtaining offspring is unlikely in cases of azoospermia and of FSH levels of >or=20 IU/L.