Fertilization and pregnancy using intentionally cryopreserved testicular tissue as the sperm source for intracytoplasmic sperm injection in 10 men with non-obstructive azoospermia

Clinical Outcomes and Live Birth Rate Resulted From Microdissection Testicular Sperm Extraction With ICSI-IVF in Non-Obstructive Azoospermia: A Single-Center Cohort Study

BACKGROUND

Most of data available in the literature reported the sperm retrieval rate and limited intracytoplasmic sperm injection (ICSI) results of microdissection testicular sperm extraction (micro-TESE) in non-obstructive azoospermia (NOA) patients with different etiologies. Unfortunately, there is currently a lack of comprehensive data to guide clinicians in conducting comprehensive consultations with NOA patients.

OBJECTIVES

To obtain more comprehensive evidence-based data and clinical outcomes for better consultation of NOA patients who opted to undergo micro-TESE combined with ICSI-IVF.

METHODS

It was a retrospective study involved 968 NOA patients underwent micro-TESE during January 2015 to December 2019. Embryological, clinical, and live birth outcomes were demonstrated comprehensively and three kinds of stratification analyses were performed based on ICSI-IVF cycles using frozen and fresh sperm, different etiologies of NOA and various amounts of sperm retrieved.

RESULTS

The sperm retrieval rate was 44.6%, and ICSI was performed in 299 couples leading to 150 clinical pregnancies and 140 live-birth deliveries. The clinical pregnancy rate (CPR) was 50.17%, and the cumulative live birth rate (LBR) was 46.82%, and the low birth defects rate was 1.43%. No significant difference was observed about cumulative LBR in frozen sperm group and fresh sperm group (47.5% vs 42.9%, P>0.05). NOA patients with AZFc microdeletions had the lowest rate of a high-score embryo on day 3 (4.4%, P<0.05) and the lowest cumulative LBR (19.4%, P<0.05). NOA patients with lower sperm count (having fewer than 20 sperms retrieved) had significantly lower cumulative LBR than those with higher sperm count (having more than 20 sperms retrieved) (28.1% vs 51.9%, P<0.05).

CONCLUSIONS

For those NOA patients who stepped in ICSI-IVF cycles, the cumulative LBR was 46.82%. No significant difference was indicated in the LBR between ICSI-IVF cycles using frozen or fresh testicular sperm. Compared to other etiologies, NOA caused by AZFc microdeletions have the poorest embryological and clinical outcomes. Patients with less testicular sperm retrieved have poorer embryological and clinical outcomes.

Clinical outcomes of microdissection testicular sperm extraction-intracytoplasmic sperm injection with fresh or cryopreserved sperm in patients with nonobstructive azoospermia

We performed this study to evaluate the clinical outcomes of microdissection testicular sperm extraction-intracytoplasmic sperm injection (micro-TESE-ICSI) treatment that used fresh or cryopreserved sperm in patients with nonobstructive azoospermia (NOA). A total of 338 NOA patients with 344 consecutive cycles received treatment in the reproductive medicine center of Peking University Third Hospital in Beijing, China, from January 2014 to December 2017. Fresh oocytes and fresh sperm were used in 222 patients with 234 cycles (Group A). Fresh oocytes and cryopreserved sperm were used in 116 patients with 110 cycles (Group B). We compared patient characteristics, embryonic development, and pregnancy outcomes between Groups A and B. There was no statistical difference in the patient characteristics, and no differences were observed with fertilization or quality embryo rates between Groups A and B. The rates of clinical pregnancy and live birth were both higher for Group A than those for Group B (both P < 0.05). In conclusion, fresh testicular sperm appears to produce better ICSI outcomes than cryopreserved testicular sperm in patients with NOA.

Comparison of intracytoplasmic sperm injection outcome with fresh versus frozen-thawed testicular sperm in men with nonobstructive azoospermia: a systematic review and meta-analysis

PURPOSE

The purpose of the study is to explore testicular sperm cryopreservation in patients with nonobstructive azoospermia (NOA) whether affect the outcome of subsequent intracytoplasmic sperm injection (ICSI).

METHODS

A systematic review and meta-analysis was conducted by searching the MEDLINE and EMBASE databases for relevant published studies in English language (1997-2017). Studies were eligible if they included the comparison of using fresh and frozen-thawed testicular sperm followed by ICSI. Two reviewers independently performed data extraction, quality assessment and assessed the risk of bias. The overall summary risk estimated the number of events. A meta-analysis was conducted using a random effects or fixed effects model analysis according to the test of heterogeneity.

RESULTS

A total of 17 studies with 1,261 ICSI cycles were identified. Analysis of the present data showed no difference in the fertilization outcome when comparing fresh versus frozen-thawed spermatozoa (RR = 1.02, 95% CI 0.86-1.09). Similarly, no difference in CR (RR = 1.01, 95% CI 0.96-1.05), good embryo rate (RR = 1.01, 95% CI 0.95-1.09), and IR (RR = 0.93, 95% CI 0.66-1.30) was observed if the spermatozoa was fresh or frozen-thawed. Finally, no difference in CPR or LBR was noted when using fresh or frozen-thawed cycles were analyzed separately (RR = 1.03, 95% CI 0.86-1.24; RR 1.11, 95% CI 0.88-1.41, respectively).

CONCLUSIONS

In men with NOA, the ICSI outcome is not affected by whether the retrieved testicular sperm is fresh or frozen. Sperm cryopreservation ought to be considered in every surgical sperm retrieval case, which remain feasible even in patients with few testicular sperm retrieved.

Adolescent Klinefelter syndrome: is there an advantage to testis tissue harvesting or not?

It is currently unclear whether an adolescent with 47,XXY Klinefelter syndrome will be better off having testicular sperm extraction (TESE) performed in an effort to ‘preserve fertility’ for the future or, alternatively, should be advised to simply wait until adulthood when he and his partner are ready to begin a family. This report will provide data suggesting that there is no obvious ‘preservation’ benefit and that recommending TESE to the 47,XXY boy and his parents may not be as helpful as it might appear and may be overly aggressive.

Microfluidics: The future of microdissection TESE?

Non-obstructive azoospermia (NOA) is a severe form of infertility accounting for 10% of infertile men. Microdissection testicular sperm extraction (microTESE) includes a set of clinical protocols from which viable sperm are collected from patients (suffering from NOA), for intracytoplasmic sperm injection (ICSI). Clinical protocols associated with the processing of a microTESE sample are inefficient and significantly reduce the success of obtaining a viable sperm population. In this review we highlight the sources of these inefficiencies and how these sources can possibly be removed by microfluidic technology and single-cell Raman spectroscopy.

Efficacy of cryopreservation of embryos generated by intracytoplasmic sperm injection with spermatozoa from frozen testicular tissue

PURPOSE

To evaluate the viability of frozen embryos generated by intracytoplasmic sperm injection (ICSI) with frozen testicular spermatozoa.

METHODS

A total of 68 fresh embryo transfer (ET) cycles and 85 subsequent frozen-thawed ET (FET) cycles were grouped according to the source of spermatozoa: fresh testicular spermatozoa (TESE) or frozen-thawed testicular spermatozoa (t-TESE).

RESULTS

There were no significant differences in the age of female patients, number of oocytes, or fertilization rates in fresh ET cycles with TESE (TESE-fresh ET) versus t-TESE (t-TESE-fresh ET). The rate of embryo survival after thawing (95.7 % vs. 94.0 %) was similar in frozen ET cycles (FET) with TESE (TESE-FET) and with t-TESE (t-TESE-FET). While there were significant differences in the proportion of good quality embryos, no statistical differences were found in the pregnancy or clinical abortion rates between the two groups. Moreover, delivery rates were not significantly different.

CONCLUSIONS

Although the proportion of good quality embryos was affected by cryopreservation of testicular tissue, embryo survival rate was not. As well, subsequent pregnancy could be achieved successfully via t-TESE-FET cycles. Therefore, FET is not affected by the cryopreservation of testicular tissue, and avoids further oocyte retrieval and TESE procedures.

Sperm recovery and IVF after testicular sperm extraction (TESE): effect of male diagnosis and use of off-site surgical centers on sperm recovery and IVF

Objective

Determine whether testicular sperm extractions and pregnancy outcomes are influenced by male and female infertility diagnoses, location of surgical center and time to cryopreservation.

Patients

One hundred and thirty men undergoing testicular sperm extraction and 76 couples undergoing 123 in vitro fertilization cycles with testicular sperm.

Outcome Measures

Successful sperm recovery defined as 1–2 sperm/0.5 mL by diagnosis including obstructive azoospermia (n = 60), non-obstructive azoospermia (n = 39), cancer (n = 14), paralysis (n = 7) and other (n = 10). Obstructive azoospermia was analyzed as congenital absence of the vas deferens (n = 22), vasectomy or failed vasectomy reversal (n = 37) and “other”(n = 1). Sperm recovery was also evaluated by surgical site including infertility clinic (n = 54), hospital operating room (n = 67) and physician’s office (n = 11). Treatment cycles were evaluated for number of oocytes, fertilization, embryo quality, implantation rate and clinical/ongoing pregnancies as related to male diagnosis, female diagnosis, and use of fresh or cryopreserved testicular sperm.

Results

Testicular sperm recovery from azoospermic males with all diagnoses was high (70 to 100%) except non-obstructive azoospermia (31%) and was not influenced by distance from surgical center to laboratory. Following in vitro fertilization, rate of fertilization was significantly lower with non-obstructive azoospermia (43%, p = <0.0001) compared to other male diagnoses (66%, p = <0.0001, 59% p = 0.015). No differences were noted in clinical pregnancy rate by male diagnosis; however, the delivery rate per cycle was significantly higher with obstructive azoospermia (38% p = 0.0371) compared to diagnoses of cancer, paralysis or other (16.7%). Women diagnosed with diminished ovarian reserve had a reduced clinical pregnancy rate (7.4% p = 0.007) compared to those with other diagnoses (44%).

Conclusion

Testicular sperm extraction is a safe and effective option regardless of the etiology of the azoospermia. The type of surgical center and/or its distance from the laboratory was not related to success. Men with non-obstructive azoospermia have a lower chance of successful sperm retrieval and fertilization.

Effect of different cryoprotectant agents on spermatogenesis efficiency in cryopreserved and grafted neonatal mouse testicular tissue

Restoration of male fertility associated with use of the cryopreserved testicular tissue would be a significant advance in human and animal assisted reproductive technology. The purpose of this study was to test the effects of four different cryoprotectant agents (CPA) on spermatogenesis and steroidogenesis in cryopreserved and allotransplanted neonatal mouse testicular tissue. Hank's balanced salt solution (HBSS) with 5% fetal bovine serum including either 0.7 M dimethyl sulfoxide (DMSO), 0.7 M propylene glycol (PrOH), 0.7 M ethylene glycol (EG), or glycerol was used as the cryoprotectant solution. Donor testes were collected and dissected from neonatal pups of CD-1 mice (one day old). Freezing and seeding of the testicular whole tissues was performed using an automated controlled-rate freezer. Four fresh (non-frozen) or frozen-thawed pieces of testes were subcutaneously grafted onto the hind flank of each castrated male NCr nude recipient mouse and harvested after 3 months. Fresh neonatal testes grafts recovered from transplant sites had the most advanced rate of spermatogenesis with elongated spermatid and spermatozoa in 46.6% of seminiferous tubules and had higher levels of serum testosterone compared to all other frozen-thawed-graft groups (p<0.05). Fresh grafts and frozen-thawed grafts in the DMSO group had the highest rate of tissue survival compared to PrOH, EG, and glycerol after harvesting (p>0.05). The most effective CPA for the freezing and thawing of neonatal mouse testes was DMSO in comparison with EG (p<0.05) in both pre-grafted and post-grafted tissues based on histopathological evaluation. Likewise, the highest level of serum testosterone was obtained from the DMSO CPA group compared to all other cryoprotectants evaluated (p<0.05). The typical damage observed in the frozen-thawed grafts included disruption of the interstitial stroma, intercellular connection ruptures, and detachment of spermatogonia from the basement membrane. These findings indicate that neonatal mouse testes were most effectively preserved when frozen with HBSS medium with DMSO and that the type of CPA is a significant factor to obtain the most advanced stages of spermatogenesis and steroidogenesis after cryopreservation, thawing, and transplantation of neonatal mouse testes.

Evaluation of the azoospermic male

When presented with an azoospermic patient, a thorough history and careful, considered physical examination often leads to a definite or presumptive diagnosis. An algorithmic, logical thought process is important to have in mind when embarking on the evaluation. Adjunctive laboratory tests, such as hormonal assays or genetic studies, are often complementary and/or additive and allow a very precise determination to be made as to the etiologies, either genetic or acquired. It is only with this information that a therapeutic plan can be made for the patient. As will be discussed, a targeted approach to testing is far more satisfying and cost-effective than a blind, shotgun approach.

Gene therapy and intracytoplasmatic sperm injection (ICSI) - a review

Human gene therapy (HGT), the treatment or prevention of disease by gene transfer is, regarded by many, as a potential revolution in medicine, because gene therapies target the causes of disease, whereas most current drugs treat the symptoms. Micro-assisted fertilization in the form of intracytoplasmatic sperm injection (ICSI) has truly revolutionized the treatment options for couples with impaired semen quality, and those with both obstructive and non-obstructive azoospermia. ICSI involves the injection of a single sperm directly into the cytoplasm of a mature egg (oocyte) using a glass needle (pipette). Fertilization with this technique occurs in 50%-80% of injected oocytes, but may damage a small percentage of them. With gene therapy, there are new and varied strategies for gene transfer and genome sequence manipulation with improved methodologies that use the technique of microinjection such as the intracytoplasmatic sperm injection-mediated transgenesis (ICSI-Tr), active transgenesis or the pronuclear microinjection technique. This review will look at these methods as well as their potential applications and limitations.

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.

Histological evaluation of the human testis--approaches to optimizing the clinical value of the assessment: mini review

Testicular biopsy is a crucial assessment in reproductive practice with diagnostic and prognostic importance for assisted reproductive technologies (ARTs) and risk of testicular neoplasia. Endocrine and genetic tests cannot reliably distinguish obstructive azoospermia (OA) from non-obstructive azoospermia (NOA) or predict recovery of mature spermatids by testicular sperm extraction (TESE). Currently, divergent histological reporting systems and the use of imprecise terminology seriously degrade the value of the literature on TESE recovery rates and hamper evaluation of treatments and research on genotype-phenotype relationships. The rising incidence of testis cancer and carcinoma in situ (CIS), especially in infertile populations, requires that every effort be made for its early detection. We provide a systematic approach to the histological classification of spermatogenic disorders and detection of CIS in adult patients. We evaluate a large consecutive series of bilateral biopsies from infertile men and report (i) the frequency of bilateral or discordant patterns that supports the use of bilateral biopsy for comprehensive evaluation and (ii) a high prevalence of mixed patterns, particularly within the hypospermatogenesis classification, that helps account for reported success of TESE. We propose a new diagnosis code for testicular biopsies that addresses the needs of ART clinicians and allows data storage and retrieval of value in clinical practice and research.

Sperm harvesting and cryopreservation during vasectomy reversal is not cost effective

OBJECTIVE

To determine whether sperm harvesting and cryopreservation at the time of vasectomy reversal is cost-effective.

DESIGN

Model of actual costs and results at five institutions.

SETTING

Multicenter study comprising five centers, including university hospitals and private practices.

PATIENT(S)

Men undergoing vasectomy reversal.

INTERVENTION(S)

We established two models for vasectomy reversal. The first model was sperm harvesting and cryopreservation at the time of vasectomy reversal. The second model was sperm harvesting at the time of IVF only if the patient remained azoospermic after vasectomy reversal. Vasectomy reversal procedures modeled included bilateral vasovasostomy and bilateral epididymovasostomy. The costs for each procedure at the five institutions were collated and median costs determined.

MAIN OUTCOME MEASURE(S)

Median cost of procedure and calculated financial comparisons.

RESULT(S)

The median cost of testicular sperm extraction/cryopreservation performed at the time of bilateral vasovasostomy was $1,765 (range, $1,025-$2,800). The median cost of microsurgical epididymal sperm aspiration or testicular sperm extraction with cryopreservation performed at the time of epididymovasostomy was $1,209 (range, $905-$2,488). The average of the median costs for percutaneous sperm aspiration or testicular sperm aspiration for those patients with a failed vasectomy reversal was $725 (range, $400-$1,455).

CONCLUSION(S)

Sperm retrieval with cryopreservation at the time of vasectomy reversal is not a cost-effective management strategy.

The utility of optical loupe magnification for testis sperm extraction in men with nonobstructive azoospermia

The testis of patients with nonobstructive azoospermia (NOA) harbors sperm in approximately 30% to 60% of cases. Use of an operating microscope has been shown to result in better sperm retrieval rates. This investigation was undertaken to evaluate the ability of a modified microsurgical approach using magnifying loupes (3.5x) to improve the rates of sperm retrieval during testis sperm extraction (TESE). The study group consisted of patients with NOA who underwent TESE. Before December 1998, TESE was conducted in a standard fashion, and from 1999 on, loupe magnification was used. Comparison was made between the 2 groups with regard to sperm retrieval rates, need for bilateral TESE, and number of tunical incisions. Overall sperm retrieval rates did not differ between the 2 groups (45% vs 50%). However, in patients with testicular volumes of 10 mL or less, patients who underwent standard TESE had a retrieval rate of 27% compared with 42% when using the optical loupe magnification (P = .025). The use of loupe magnification may permit surgeons without access to or experience using an operating microscope to obtain better rates of sperm retrieval in men with NOA who have testicular volumes of 10 mL or less.

Cumulative pregnancy rate after ICSI with cryopreserved testicular tissue in non-obstructive azoospermia

The aim of the present study was to describe a simplified and inexpensive method of testicular tissue freezing, to assess the cumulative clinical pregnancy rate (CPR) by this technique, and to provide useful information for counselling couples with non-obstructive azoospermia. One hundred and sixty-five couples with non-obstructive azoospermic males pursuing assisted conception, from December 1995 to December 2002, were included. In all cases, the testicular tissue retrieved by open multiple-biopsy (both sides, by testicular sperm extraction) was frozen using a simple liquid nitrogen vapour freezing technique and was stored in liquid nitrogen thereafter. Only mature spermatozoa were used for intracytoplasmic sperm injection (ICSI) after thawing. Expected CPR were calculated using the Kaplan-Meier survival analysis. A total of 281 cycles were performed resulting in 53 clinical pregnancies. Crude and expected CPR (95% confidence intervals) after three cycles were 32.1 (25.7-40.1) and 55.7% (37.0-74.4) respectively. In conclusion, this simplified method for freezing testicular tissue resulted in a satisfactory outcome after ICSI in cases of non-obstructive azoospermia.

Optimizing cryopreservation of human testicular tissue: comparison of protocols with glycerol, propanediol and dimethylsulphoxide as cryoprotectants

BACKGROUND

Cryopreservation of testicular tissue is an option in fertility preservation for pre-pubertal boys who will lose spermatogenic cells as a result of chemotherapy. We compared three different protocols and cryoprotectants in cryopreservation of testicular tissue.

METHODS

Testicular tissue obtained from 16 infertile men was evaluated by light microscopy(LM), immunostaining against MAGE-A4, transmission electron microscopy (TEM) and organ culture. Seminiferous tubules (1312) from non-frozen (n = 16) and frozen-thawed samples (n = 34) were studied following cryopreservation using protocols with either 1,2-propanediol (PrOH), glycerol or dimethylsulphoxide (DMSO) as cryoprotectants.

RESULTS

Normal structure was seen in 86 +/- 6% (mean +/- SD) of the fresh tissue. After freezing with DMSO, 70 +/- 6% and after PrOH, 37+/-3% of the tubules were judged to be good. When glycerol was used, the structure of the basal compartment of the tubules was severely damaged. The ultrastructure of the cryopreserved samples as revealed by TEM and MAGE-positive spermatogonia confirmed the findings. Cryopreserved Leydig cells maintained their morphology and ability to release testosterone in culture.

CONCLUSION

DMSO as a cryoprotectant (at a 0.7 mol/l concentration) proved to maintain the structure of testicular tissue, especially spermatogonia, after cryopreservation better than PrOH or glycerol.

Live birth following intracytoplasmic sperm injection after a 15-hour weather-related delay in cryopreservation of testicular sperm

OBJECTIVE

To report a live birth after transfer of cryopreserved blastocysts derived from testicular sperm that were cryopreserved 15 hours after biopsy due to inclement weather.

DESIGN

Case report.

SETTING

University-affiliated private clinic.

PATIENT(S)

Couple undergoing IVF with intracytoplasmic sperm injection (ICSI) using testicular extracted sperm for male factor infertility due to unexplained obstructive azoospermia.

INTERVENTION(S)

An IVF case involving testicular biopsy, cryopreservation, and thawing of testicular tissue, ICSI, embryo freezing, and transfer of cyropreserved blastocysts.

MAIN OUTCOME MEASURE(S)

The ability to use cryopreserved testicular tissue in which optimal time from biopsy to freezing had been delayed because the weather was inclement.

RESULT(S)

In spite of a 15-hour delay in processing and cryopreservation of the testicular biopsy, subsequent thawing yielded viable sperm that resulted in viable embryos after ICSI. Transfer of fresh embryos was unsuccessful. However, subsequent use of supernumerary viable blastocysts that were frozen resulted in the live birth of a baby.

CONCLUSION(S)

A 15-hour delay in processing and cryopreservation of a testicular biopsy did not affect the viability of the extracted sperm after thawing. Although it is desirable to freeze the testicular specimen as soon as possible, the delay in processing in this case due to inclement weather did not affect the potential for fertilization and implantation of a viable cryopreserved blastocyst.

Factors affecting outcome after ICSI with spermatozoa retrieved from cryopreserved testicular tissue in non-obstructive azoospermia

There is a lack of data regarding variables affecting the treatment outcome for non-obstructive azoospermia when spermatozoa from cryopreserved testicular specimens are utilized for ICSI. The objective of the present retrospective analysis was to investigate the effect of various parameters on treatment outcome in such cases. One hundred and sixty-five couples with non-obstructive azoospermic males undergoing a total of 297 cycles were included. In all cases the testicular tissue retrieved by multiple open-biopsy testicular sperm extraction was stored in liquid nitrogen and, after thawing, only mature spermatozoa were used for ICSI. When no motile spermatozoa were recovered, immotile spermatozoa were used. In 159 cycles, motile spermatozoa were utilized for ICSI, while in 138 cycles immotile spermatozoa were utilized. Higher normal fertilization rate (60.4 +/- 3.1 versus 51.3 +/- 1.6%, P < 0.05), number of embryos transferred (2.8 +/- 0.06 versus 2.6 +/- 0.04, P < 0.05), modified cumulative embryo score (31.2 +/- 1.6 versus 23.9 +/- 0.8, P < 0.001), and proportion of motile spermatozoa injected (67.8 versus 49.8%, P < 0.05) were observed in cycles that resulted in clinical pregnancies. Binary logistic regression analysis showed that sperm motility (odds ratio 2.06, 95% CI 1.1-3.9, P < 0.05), but not woman's age, number of treatment cycle, type of GnRH-analogue used for pituitary suppression, number of oocytes retrieved or number of embryos transferred was a significant determinant of the likelihood of clinical pregnancy. In conclusion, sperm motility after freeze/thawing of testicular tissue is the major determinant of the success of ICSI in non-obstructive azoospermia.

Crude cumulative delivery rate following ICSI using intentionally frozen–thawed testicular spermatozoa in 51 men with non-obstructive azoospermia

This prospective study evaluated the crude cumulative delivery rate following delayed intracytoplasmic sperm injection (ICSI) using spermatozoa recovered by testicular extraction (TESE) and intentionally frozen in men with non-obstructive azoospermia (NOA). This procedure can be termed 'cryoTESE-ICSI'. This study involved a series of 118 patients who underwent testicular biopsy for diagnosis of NOA in the period from January 1998 to December 2002. Testicular histology confirmed the diagnosis of NOA. Testicular parenchyma was obtained surgically from both testicles under general anaesthesia. Cryopreservation of spermatozoa was performed in 51 of 118 patients (43%). Ninety-nine delayed ICSI procedures were performed. Frozen-thawed suspensions were used in all cycles. Application of pentoxifylline was required to stimulate spermatozoa in 52% of cases. Fertilization, embryo transfer, and ongoing pregnancy rates were 60, 98 and 29% respectively. The crude cumulative delivery rate was 49% after two cycles and 57% after four cycles. A total of 39 healthy children were born in 29 deliveries. Thus, cryoTESE-ICSI is an effective procedure for routine use in patients with NOA. The main advantages of cryoTESE-ICSI are to (i) avoid repeated surgical biopsy, (ii) ensure the availability of spermatozoa when the ovarian stimulation cycle is begun, and (iii) allow programmed biopsy and therefore dissociate it from ICSI.

Should diagnostic testicular sperm retrieval followed by cryopreservation for later ICSI be the procedure of choice for all patients with non-obstructive azoospermia?

BACKGROUND

This was a retrospective study to determine if diagnostic testicular biopsy followed by cryopreservation should be the procedure of choice for all patients with testicular failure.

METHODS

The first part of the study analysed 97 ICSI cycles scheduled with frozen-thawed testicular sperm for 69 non-obstructive azoospermia (NOA) patients. The second part focused on a subgroup of 32 patients who underwent 42 ICSI cycles with frozen and 44 cycles with fresh testicular sperm. Sperm characteristics, fertilization, embryo quality, pregnancy and implantation rates were evaluated.

RESULTS

Part I: The average time needed to find sperm was 113 min per cycle and 17 min per individual sperm. Fertilization rate, embryo transfer rate, ongoing pregnancy and implantation rates were 58.4%, 83%, 20.8% and 11.3%, respectively. Part II: The search time per sperm was higher (P=0.016) in frozen (18 min) than in fresh suspensions (13 min). A higher embryo transfer rate was observed in fresh cycles than in frozen cycles (93.2% vs 76.2%, P=0.028). Fertilization, ongoing pregnancy and implantation rates were comparable for the two groups.

CONCLUSIONS

Even in a programme with low-restrictive criteria for patient allocation and for sperm cryopreservation, diagnostic testicular biopsy followed by cryopreservation can be the procedure of choice for patients with testicular failure.

Role of testicular tissue telomerase assay for the prediction of the presence of testicular spermatozoa in azoospermic men with varicoceles, pre- and post-varicocelectomy

We evaluated the reproductive potential of frozen/thawed testicular spermatozoa of azoospermic men with left varicocele. The role of testicular tissue telomerase assay (TTA) in the prediction of the presence of testicular spermatozoa pre- and post-varicocelectomy was investigated, as well. Therapeutic testicular biopsy and TTA were performed in 82 nonobstructed azoospermic (NOA) men with varicoceles. Testicular spermatozoa were found in 33 men and processed for cryopreservation. Oocytes were later recovered from the spouses of the latter azoospermic men with varicoceles and injected with frozen/thawed testicular spermatozoa. Among the 49 men who were negative for testicular spermatozoa, 22 men underwent subsequently subinguinal microsurgical varicocelectomy. A total of 198 mature oocytes were successfully injected and 101 were normally fertilized and subsequently cleaved. Transfer of these 101 embryos in 26 women resulted in nine full-term pregnancies. Thirteen healthy babies were delivered. A cut-off value of TTA of 39 TPG U microg(-1) protein had an overall diagnostic accuracy equal to 90.2% to predict the presence of testicular spermatozoa pre-varicocelectomy. Within the group of men who were negative for testicular spermatozoa a cut-off value of TTA equal to 28 TPG U microg(-1) protein (pre-varicocelectomy) had a 84.2 % diagnostic accuracy to recognize the men who would become positive for either ejaculated or testicular spermatozoa post-varicocelectomy. Testicular spermatozoa can be found in 40% of NOA men with left varicocele. Ooplasmic injections with frozen/thawed testicular spermatozoa have a role in the therapeutic management of non-obstructive azoospermia associated with varicocele. Pre-varicocelectomy, a TTA cut-off value equal to 39 TPG U microg(-1) protein has a 90.2% diagnostic accuracy to indicate the men positive/negative for testicular spermatozoa. In addition, pre-varicocelectomy, a cut-off value equal to 28 TPG U microg(-1) protein has a 84.2% diagnostic accuracy to identify those men with varicoceles without testicular spermatozoa, who will become positive/negative for spermatozoa (either ejaculated or testicular) post-varicocelectomy.

Influence of motility on the outcome of in vitro fertilization/intracytoplasmic sperm injection with fresh vs. frozen testicular sperm from men with obstructive azoospermia

OBJECTIVE

To assess the efficacy of fresh vs. frozen testicular sperm on fertilization and pregnancy using intracytoplasmic sperm injection.

DESIGN

Retrospective study.

SETTING

Hospital-based infertility research laboratory.

PATIENT(S)

One hundred sixty patients with obstructive azoospermia undergoing testicular sperm extraction (TESE).

INTERVENTION(S)

Sections of seminiferous tubule were cryopreserved after TESE. Sperm motility and fertilizing ability were determined after thawing seminiferous tubule sections.

MAIN OUTCOME MEASURES

Sperm motility and optimal fertilization and pregnancy rate.

RESULT(S)

Intracytoplasmic sperm injection was performed using fresh testicular sperm (fresh-sperm group; 84 cases) and thawed seminiferous tubules (thawed-sperm group; 177 cases). The overall fertilization rate was 65.4%, and the pregnancy rate was 34.0%. In the fresh-sperm group, the fertilization rate was 70.9%, and the pregnancy rate was 38.8%. In the thawed-sperm group, the fertilization rate was 62.7%, and the pregnancy rate was 21.7%. Fertilization rates were higher using fresh motile sperm vs. nonmotile sperm (77.0% vs. 29.3%). Pregnancy rates were higher using fresh motile sperm vs. nonmotile sperm (44.3% vs. 20.0%). The fertilization and pregnancy rates of motile vs. nonmotile sperm extracted from the thawed seminiferous tubule were 70.0% vs. 50.9% and 33.9% vs. 27.3%, respectively. Motile spermatozoa could be obtained several hours after thawing in most of the cases.

CONCLUSION(S)

Optimal fertilization and pregnancy rates were achieved using fresh vs. frozen sperm obtained using TESE when motile sperm were identified. Motile spermatozoa provided superior results to nonmotile sperm and are necessary for optimal fertilization and pregnancy outcomes.

Cryobiology of ovarian and testicular tissue

Cryopreservation of ovarian and testicular tissue can be used in young individuals who are likely to lose their gonadal function prematurely because of chemotherapy, radiotherapy or a known genetic condition causing gonadal failure. Tissue cryopreservation is relatively well established, but freezing techniques have still to be optimized. Slow programmed freezing using propanediol or dimethylsulphoxide as a cryoprotectant is the most established method. Tissue cryopreservation is highly experimental. No human pregnancies have been achieved as yet, although re-implantation experiments have been started. Maturation of gametes in vitro from cryopreserved tissue is far from being clinically applicable. Cryopreservation of spermatozoa and embryos is an established method, whenever applicable. Cryopreservation of oocytes is still experimental, but successful pregnancies have been achieved by several clinics. Cryopreservation of testicular spermatozoa for intracytoplasmic sperm injection (ICSI) is an established method and should be performed whenever a testicular biopsy is being carried out.

Posthumous reproduction: current and future status

Posthumous reproduction became possible with the technologies of sperm cryopreservation and ART. The legal and social status of children born as a result of these technologies continue to evolve. The proper disposition of unwanted stored gametes and embryos remains unknown. Physicians are increasingly asked to make quick judgments on posthumous gamete retrieval. The procedures for gamete harvest are technically simple; however, one must carefully select cases with definitive prior intent to have children. There is a need for standardized legal protocols to protect the physician and the patient. The physician must use sound judgment and comply with accepted standards, when present, before performing any service for posthumous sperm retrieval and reproduction.

Late reproductive sequelae following treatment of childhood cancer and options for fertility preservation

The successful treatment of childhood cancer can be associated with impaired gonadal function in adulthood. Chemotherapy and radiotherapy may damage germ-cell spermatogonia, resulting in impaired spermatogenesis or sterility in the male, or may hasten oocyte depletion with truncated fecundity and premature menopause in the female. The only established option in current clinical practice for preserving male fertility is cryopreservation of spermatozoa. The only strategy currently available for preserving female fertility is cryopreservation of embryos. Harvesting and storage of ovarian cortical tissue from girls and young women before potentially gonadotoxic chemotherapy has been available in a number of centres but there have been no live births and the procedure remains experimental. Standards for best practice in the cryopreservation of gonadal tissue, including the criteria for providing a service, patient identification and selection, standard operating procedures and requirements for safe storage, remain to be defined. Recent advances in assisted reproduction may circumvent natural conception barriers and the implications of impaired DNA integrity may be manifest as an increased risk of congenital abnormalities and chromosomal disorders in the offspring. In this chapter we consider the late reproductive sequelae following treatment for childhood cancer and options for fertility preservation.

Postchemotherapy ejaculatory azoospermia: fatherhood with sperm from testis tissue with intracytoplasmic sperm injection

PURPOSE

To define the success of testis sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) in azoospermic men with a history of chemotherapy.

PATIENTS AND METHODS

In a retrospective study, 23 men with ejaculatory azoospermia and a history of chemotherapy underwent TESE in a search for usable spermatozoa. In six patients cryopreserved tissue and in nine patients fresh tissue provided sperm for an ICSI cycle. Histologic analysis of the testis was performed in all patients. The presence or absence of sperm, fertilization rates with ICSI, and final outcomes of pregnancy were recorded.

RESULTS

Spermatozoa were found on TESE in 15 (65.2%) of 23 men. On histopathology, the predominant pattern observed was Sertoli cell only (47.8%), followed by hypospermatogenesis (30.4%), mixed (17.4%), and late maturation arrest (4.3%). The fertilization rate was 65.2%, and ongoing/delivered pregnancies occurred in 30.8% of cycles. Six healthy boys and four healthy girls have been born to date.

CONCLUSION

Men who are azoospermic and have had prior cytotoxic therapy make up a small subgroup of males with nonobstructive azoospermia. It is important to define and characterize this subgroup and better define their true fertility potential. Approximately two thirds of these men have retrievable testis sperm, which may be used with ICSI to have healthy offspring. This exciting avenue for paternity has heretofore not been available to such patients.

Intracytoplasmic sperm injection with testicular spermatozoa in men with azoospermia

PURPOSE

The aim of the study was to gain an insight into the optimal management of the infertile couple with the husband suffering from azoospermia.

METHODS

One hundred and forty-two intracytoplasmic sperm injection (ICSI) cycles performed with testicular extracted spermatozoa were retrospectively analysed. The following factors were investigated for their possible influence on fertilization, cleavage, damage, pregnancy, and ongoing pregnancy rates: the use of fresh, cryopreserved, and preincubated (24 h) spermatozoa and the etiology of the husbands' azoospermia (obstructive and nonobstructive). All microinjections were performed with apparently normal spermatozoa--a head with a tail of normal length. In 116 cycles at least two embryos were available for transfer.

RESULTS

The overall fertilization, clinical pregnancy, and ongoing pregnancy rates obtained for the 116 cycles were 65.0, 30.2, and 22.4% respectively. Similar outcomes were obtained for cycles using fresh testicular and cryopreserved testicular spermatozoa. Similarly, no significant differences were obtained between the cycles using spermatozoa from obstructive or nonobstructive azoospermic patients. An increase in motility after a 24-h preincubation was observed, and although this group was relatively small (n = 17), a significant improvement in fertilization (73.7%) and pregnancy (53.9%) rate was obtained when the testicular sample was preincubated for 24 h. This improvement prevailed in the obstructive azoospermic group, but was less pronounced in nonobstructive patients.

CONCLUSIONS

This study shows that the outcome of fresh and frozen-thawed testicular spermatozoa in ICSI is comparable, obstructive and nonobstructive etiologies perform the same, and that preincubation of testicular spermatozoa results in increased fertilization and pregnancy rates. All testicular biopsies are therefore performed the day before oocyte retrieval, superfluous spermatozoa cryopreserved, and the remaining testicular homogenate preincubated for the 24 h prior to oocyte retrieval. With this regime, most azoospermic patients are treated successfully, irrespective of the use of fresh or frozen-thawed spermatozoa from obstructive or nonobstructive cases.

Efficiency of using frozen-thawed testicular sperm for multiple intracytoplasmic sperm injections

PURPOSE

To compare fertilization and pregnancy rates of fresh and frozen-thawed testicular sperm injections (TESE-ICSI).

METHODS

Sperm collected from the testes of 28 azoospermic patients by an open testicular biopsy technique was used for initial ICSI or cryopreserved.

RESULTS

Fresh-sperm ICSI treatment (28 cycles) resulted in a 58.1% fertilization rate and a 32.1% clinical pregnancy rate per embryo transfer, while frozen-thawed sperm (24 subsequent cycles) had rates of 54.5 and 29.2%, respectively. The PR was lower using frozen-thawed sperm from nonobstructive azoospermia patients (9.1%) than from obstructive azoospermia patients (46.2%). PR declined to 0% upon the fourth ICSI attempt.

CONCLUSIONS

Fertilization, embryo cleavage, and pregnancy rates were unaffected by fresh or frozen-thawed sperm use. A 57.1% cumulative clinical PR was achieved using the latter. The PR was significantly lower using frozen-thawed sperm from nonobstructive azoospermia patients than from obstructive azoospermia patients.

Effects of various cryopreservation media and freezing-thawing on the morphology of rat testicular biopsies

Currently, testicular sperm extraction is successfully combined with intracytoplasmic sperm injection into the oocyte (ICSI). Several pieces of a testicular biopsy can be frozen and thawed until the ICSI attempt. In this study, the effects of freezing-thawing on the morphology of rat testicular biopsies stored in different cryopreservation media were analysed. Each cryopreservation medium contained glycerol and/or dimethyl sulfoxide (DMSO) as cryoprotectants. In general, both glycerol and DMSO, when applied at moderate concentrations (6-25%), preserved the structure of the seminiferous epithelium. The freezing-thawing procedure had no significant effect on tubular diameter; however, it caused a 'folding' of the lamina propria and notable damage to Sertoli cells, spermatogonia and spermatocytes. Round and elongated spermatids and spermatozoa displayed occasional nuclear damage, vacuolization, and shrinkage/swelling of the cytoplasm. However, the vast majority of these cells maintained their normal structure in nearly all the applied cryomedia. It is concluded that freezing-thawing of testicular biopsies, and the cryopreservation medium, have a significant impact on the structure of the seminiferous epithelium, particularly on its basal compartment.

Intracytoplasmic sperm injection with cryopreserved testicular spermatozoa

To assess if testicular sperm cryopreservation is a valid alternative to repetition of testicular sperm retrieval techniques, results of a cryopreservation technique in pills have been retrospectively analyzed. Enough motile spermatozoa for ICSI were obtained in 172 from 190 (90.5%) frozen-thawed testicular sperm samples. Overall, 249 couples underwent 390 ICSI cycles, 156 using fresh and 234 using cryopreserved testicular sperm. Mean two-pronuclear fertilization rates per cycle were not significantly different after ICSI with fresh (62.0%) or with cryopreserved (63.2%) spermatozoa. Mean embryo cleavage rate per cycle was higher in the fresh (90.6%) than in the cryopreserved (84.6%) group (P = 0.016). However, clinical pregnancy rates per cycle (28.2% with fresh vs 27.8% with cryopreserved), implantation rates (12.2% vs 13.1%) and ongoing pregnancy rates per cycle (22.4% vs 21.8%) were not significantly different. Cryopreservation of testicular spermatozoa is an effective technique that can be used both in obstructive and in non-obstructive azoospermia.

Cryopreservation of testicular tissue

Cryopreservation of testicular tissue might benefit prepubertal boys who have to undergo chemotherapy or radiotherapy. Cryopreservation of testicular tissue is feasible. Live offspring have been born to mice, but not other species after transplantation of testicular cells. Spermatogenesis in vitro would be an excellent option for boys with leukaemia, but the method is not feasible for the time being. Cryopreservation of biopsied testicular tissue for intracytoplasmic sperm injection (ICSI) is a feasible option for infertility treatment of azoospermic men. Testicular sperm can be frozen as cell suspension, or within a piece of testicular tissue. Both methods result in pregnancies. Testicular needle biopsy is a simple method to obtain tissue for histological diagnosis, for ICSI and for cryopreservation for use in the future. Testicular sperm should be cryopreserved whenever a testicular biopsy is carried out.

Outcome of ICSI cycles using frozen-thawed surgically obtained spermatozoa in poor responders to ovarian stimulation: cancellation or proceeding to ICSI?

OBJECTIVE

To investigate the ICSI outcome of the patients who produced four follicles or less after ovarian stimulation using frozen-thawed surgically obtained spermatozoa.

STUDY DESIGN

The patient cohort of this study was composed of a carefully selected group of 20 men suffering from obstructive and non-obstructive azoospermia and in whom spermatozoa had been seen in their harvested epididymal aspirates and testicular tissues and the cryopreserved specimens had been used for subsequent ICSI cycles. This group of men represent those in whom the female partners produced only four follicles or less after ovarian stimulation.

RESULTS

For the cases of obstructive azoospermia with MESA (n=6) a total of nine cycles was carried out. Four couples went through one cycle, one couple underwent two cycles, one couple accomplished three cycles. Out of the nine cycles, seven went to embryo transfer. No pregnancy occurred in the MESA-ICSI group of patients. The mean+/-S.D. number of oocytes per cycle was 2.556+/-1.236, the mean+/-S.D. number of embryos per transfer was 1.444+/-1.014. Two couples did not have an embryo replacement because of absence of fertilisation. The mean+/-S. D. number of gonadotropin ampoules was 53.88+/-37.30 and the mean+/-S.D. duration of ovarian stimulation was 13.38+/-4.534 days. For the cases of non-obstructive azoospermia with TESE (n=14) a total of 16 cycles was carried out. Thirteen couples went through one cycle, one couple accomplished three cycles. Out of the 16 cycles, 11 cycles went to embryo transfer. One pregnancy occurred in the TESE-ICSI group of patients, which produced live offspring. The mean+/-S.D. number of oocytes per cycle was 3.00+/-1.211, the mean+/-S.D. number of embryos per transfer was 1.313+/-1.195. Five couples did not have an embryo replacement, four of them because of absence of fertilisation and one because of abnormal fertilisation (3 PN). The mean+/-S.D. number of gonadotropin ampoules was 81. 77+/-53.40 and the mean+/-S.D. duration of ovarian stimulation was 16.71+/-3.667 days.

CONCLUSION

In our opinion, these data show that it is possible to achieve satisfactory fertilisation rates using frozen-thawed epididymal and testicular spermatozoa obtained from men with obstructive or non-obstructive azoospermia, but the limiting factor in reaching the stage of embryo transfer is the poor ovarian response to stimulation induction. It therefore seems preferable to cancel these cycles, in the hope that a better response might be obtained in a subsequent cycle, avoiding in this way financial and emotional implications.

Testicular tissue cryopreservation in boys. Ethical and legal issues: case report

Sperm preservation prior to chemotherapy and radiotherapy is common practice in adult males. Spermatozoa are usually retrieved from an ejaculated sample although there are occasions when testicular tissue is used as the source. These techniques of sperm preservation present minimal ethical objections as the patients give their informed consent. Sperm preservation in children presents practical and ethical dilemmas in that the children cannot always give their informed consent, there are no regulatory guidelines and there is no guarantee that spermatogenesis is occurring. With the rapid advances in reproductive technology and the possible future use of immature germ cells by in-vitro maturation or transplantation, the demand for immature testicular tissue preservation is likely to increase. More information for the parents and oncologists with regard to this subject is needed to allow informed decisions to be made on behalf of the children. These issues are discussed using two cases of children having testicular tissue preservation.

In vitro fertilization outcomes after intracytoplasmic sperm injection with fresh or frozen-thawed testicular spermatozoa

OBJECTIVE

To compare the outcomes of intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF) with fresh and cryopreserved testicular spermatozoa in patients with obstructive and nonobstructive azoospermia.

DESIGN

Retrospective analysis of consecutive ICSI cycles.

SETTING

Large urban reproductive medicine program.

PATIENT(S)

Twenty-nine patients with obstructive and nonobstructive azoospermia undergoing testicular sperm extraction for a total of 46 IVF-ICSI cycles (12 fresh, 34 frozen).

INTERVENTION(S)

Testicular sperm extraction, cryopreservation, and IVF-ICSI with fresh or frozen-thawed spermatozoa.

MAIN OUTCOME MEASURE(S)

Fertilization rates, embryo cleavage rates, embryo implantation rates, clinical pregnancy rates per cycle and per embryo transfer, and delivery and spontaneous abortion rates.

RESULT(S)

No statistically significant differences were noted in any of the parameters examined between IVF-ICSI cycles from fresh or frozen-thawed testicular spermatozoa. Fertilization rates were 56% with fresh vs. 61% with frozen-thawed testicular sperm, cleavage rates 92% vs. 95%, implantation rates 26% vs. 17%, clinical pregnancy rates per cycle 33% vs. 41%, and pregnancy rates per embryo transfer 33% vs. 45%, respectively. Delivery rates were 75% with fresh vs. 69.2% with frozen-thawed testicular sperm, and spontaneous abortion rates 25% and 30.8%, respectively.

CONCLUSION(S)

No differences were found in IVF-ICSI outcomes between cryopreserved and fresh testicular sperm. In addition, cryopreservation provides several advantages for the patients and reproductive team.

The relative viability of human spermatozoa from the vas deferens, epididymis and testis before and after cryopreservation

Testicular and epididymal spermatozoa are routinely used with in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) to achieve pregnancies. In addition, excess cryopreserved spermatozoa can be thawed and used for ICSI. However, information on the recovery of epididymal and testicular spermatozoa after freeze-thaw is lacking. This is important to determine the feasibility of using previously cryopreserved aspirated spermatozoa for ICSI. We prospectively compared the viability of fresh and frozen-thawed spermatozoa from the vas deferens, epididymis and testicle by several measures. Testis spermatozoa were obtained from men with non-obstructive azoospermia (n = 5), epididymal spermatozoa from men with obstructive azoospermia (n = 8), and vasal spermatozoa from fertile men by vasal irrigation at vasectomy (n = 5). The viability of fresh spermatozoa was assessed by motility, two vital stains (carboxyfluorescein, 0.08 mg/ml and propidium iodide, 20 mg/ml) and the hypo-osmotic swelling assay (HOS; 100 mmol/l citrate and fructose). After cryopreservation, spermatozoa were thawed and all viability measures repeated. Although fresh vasal spermatozoa were the most motile, testicular spermatozoa exhibited similar, high viability (91 and 86% respectively) by vital stain. Spermatozoa from testis, epididymis and vas deferens survived cryopreservation equally well by vital stain, but not by motility. As a selection measure, the HOS assay identified significantly more viable epididymal and testicular spermatozoa than did motility in both fresh and frozen-thawed populations. It appears feasible to use frozen-thawed extracted spermatozoa for ICSI when motility and a selection measure such as the HOS assay are used. With fresh testis spermatozoa, selection methods may not be necessary prior to ICSI, as cell viability is high.

Extraction of testicular sperm from previously cryopreserved tissue in couples with or without transport of oocytes and testicular tissue

OBJECTIVE

To evaluate results of IVF and intracytoplasmic sperm injection (ICSI) with extraction of sperm from frozen-thawed testicular tissue.

DESIGN

Retrospective follow-up study.

SETTING

Fertility center.

PATIENT(S)

Thirty-five couples with transport of testicular tissue from a transport clinic and 125 local couples.

INTERVENTION(S)

Extraction of testicular sperm by maceration and enzymatic digestion from frozen-thawed testicular tissue before ICSI.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate (PR) and implantation rate in couples with obstructive or nonobstructive azoospermia, motile or immotile sperm, and differing male serum FSH values.

RESULT(S)

The clinical PR per ET and implantation rate per embryo in couples with transport of testicular tissue were 40% and 18%, respectively, in cases of obstructive azoospermia and 37% and 26%, respectively, in cases of nonobstructive azoospermia. In the local couples, these rates were 42% and 19%, respectively, in cases of obstructive azoospermia and 18% and 10%, respectively, in cases of nonobstructive azoospermia. The implantation rates for ICSI were 26% with motile sperm and 11% with immotile sperm in the transport group and 16% and 8%, respectively, in the local group. Male serum FSH level did not clearly correlate with implantation rate.

CONCLUSION(S)

Clinical PR and implantation rate are not affected by transport of testicular tissue but are significantly affected by nonobstructive azoospermia and the use of immotile sperm. No major increase in chromosomal aberration or congenital malformation was noted in the offspring of this limited group.