Sperm retrieval and fertilization in repeated percutaneous epididymal sperm aspiration

Current progress on the curative effects of vasoepididymostomy for patients with obstructive azoospermia: An updated systematic review and meta-analysis of human studies

BACKGROUND

Obstructive azoospermia (OA) is an important cause of male infertility, and epididymal OA (EOA) is a common disease. Microsurgical reconstruction is a common technique used in the treatment of EOA. In the present study, we analyzed the effectiveness of microsurgical vasoepididymostomy (MVE) at different levels and compared the differences among several MVE techniques.

MATERIALS AND METHODS

A literature search was conducted in the PubMed, Web of Science, and Embase databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The included studies were published in English until May 14, 2021. The R 4.1.2 software was utilized to evaluate the event rate, risk ratio (RR), and 95% confidence interval (CI).

RESULTS

A total of 51 studies involving 2853 patients with OA were included in our meta-analysis. The overall mean patency rate of patients who underwent MVE was 67.20% (95% [CI]:63.30%-71.10%), and the overall mean natural pregnancy rate of their partners was 40.05% (95% [CI]: 35.30%-45.60%). The pooled results showed that the patency rate of bilateral MVE was higher than that of unilateral MVE (RR = 1.42; 95% [CI]:1.25-1.61; p < 0.00). A comparison of the anastomotic site of MVE showed that the caudal/corpus area was favorable for the patency rate (RR = 1.17; 95% [CI]:1.04 - 1.32; p < 0.00). The caudal area was also advantageous for the patency rate (RR = 1.20; 95% CI:1.03 - 1.41; p < 0.04). Compared with typical MVE (65.20%, 95% [CI]:61.40%-69.10%), deferential vessel-sparing MVE with a higher overall mean patency rate (83.60%, 95% [CI]:75.40%-91.70%).

CONCLUSIONS

The meta-analyses indicated that MVE is a high- and cost-effective therapeutic method for patients with EOA, and deferential vessel-sparing MVE could be mainstream in the near future.

Sperm recovery and ICSI outcomes in men with non-obstructive azoospermia: a systematic review and meta-analysis

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.

Current practices in fertility preservation in male cancer patients

The incidence of a cancer diagnosis in children and young adolescents is increasing. With better treatments, the number of young cancer survivors living through reproductive age is increasing. Fertility preservation of these men and women has become essential and needs to be discussed prior to the start of cancer treatment. Here we review the current guidelines for male oncofertility patients and highlight some of the important gonadotoxic effects of chemotherapy, radiotherapy and surgery. Options for fertility preservation are also discussed along with resources that should be made available to all patients.

Sperm retrieval and quality evaluation

Technical refinements in sperm retrieval methods and the application of advanced reproductive technologies (ART) using surgically retrieved sperm have enabled biological paternity in azoospermic men who were considered untreatable 20 years ago. Achievement of optimal reproductive outcomes in these patients benefits greatly from a multistep, interdisciplinary process of sperm acquisition that involves reproductive endocrinologists, urologists, or other specialists in male subfertility, and laboratory personnel with expertise in characterizing and isolating sperm from surgically retrieved specimens. The critical steps in this process are discussed in this chapter.

An update on sperm retrieval techniques for azoospermic males

The use of non-ejaculated sperm coupled with intracytoplasmic sperm injection has become a globally established procedure for couples with azoospermic male partners who wish to have biological offspring. Surgical methods have been developed to retrieve spermatozoa from the epididymides and the testes of such patients. This article reviews the methods currently available for sperm acquisition in azoospermia, with a particular focus on the perioperative, anesthetic and technical aspects of these procedures. A critical analysis of the advantages and disadvantages of these sperm retrieval methods is provided, including the authors' methods of choice and anesthesia preferences.

Predictive factors for sperm retrieval and sperm injection outcomes in obstructive azoospermia: do etiology, retrieval techniques and gamete source play a role?

Obstructive azoospermia is a relatively common male infertility condition. The main etiologies of obstructive azoospermia include congenital, surgical-derived, traumatic and post-infectious cases. Although seminal tract reconstruction is a cost-effective treatment in most cases, this approach may not be feasible or desired in some cases. In such cases, assisted reproduction techniques offer a method for achieving pregnancy, notably via sperm retrieval and intracytoplasmic sperm injection. This process requires several considerations and decisions to be made, including the cause and duration of obstruction, which sperm retrieval technique to use, and whether to use fresh or frozen-thawed sperm. We present a review of obstructive azoospermia and assisted reproduction techniques, highlighting the most relevant aspects of the decision-making process for use in clinical practice.

Reproductive potential of men with obstructive azoospermia undergoing percutaneous sperm retrieval and intracytoplasmic sperm injection according to the cause of obstruction

PURPOSE

We evaluated the retrieval rates and reproductive outcomes of percutaneous sperm retrieval according to the cause of obstructive azoospermia.

MATERIALS AND METHODS

We retrospectively studied the records of 146 men with obstructive azoospermia who underwent sperm retrieval for intracytoplasmic sperm injection. Patients were grouped by the cause of obstruction, including 32 with congenital bilateral absence of the vas deferens, 59 with vasectomy and 55 with obstruction due to post-infection disease. Sperm were retrieved percutaneously from the epididymis or testis. We compared retrieval rates and intracytoplasmic sperm injection outcomes, including neonatal results, in the groups of men with obstructive azoospermia.

RESULTS

The success of sperm retrieval was similar among the etiology groups, including 100% for congenital bilateral absence of the vas deferens, 96.6% for vasectomy and 96.3% for previous infection. Significantly fewer men in the congenital bilateral absence of the vas deferens group needed testicular aspiration compared to those in the post-infection and vasectomy groups (3.1% vs 23.6% and 30.5%, respectively, p <0.001). Sperm cryopreservation was possible in 26.7% of the cases and did not significantly differ among the groups. Live birth rates after sperm injection were similar in the congenital (34.4%), vasectomy (32.2%) and previous infection (36.4%) groups. Birth parameters, prematurity and low birth weight rates were comparable among the groups.

CONCLUSIONS

Percutaneous sperm retrieval is an effective method to retrieve sperm in men with obstructive azoospermia irrespective of the cause of obstruction. The chance of achieving a live birth and the profile of neonates born after sperm injection do not seem to be related to the cause of obstruction.

The outcome of ART in males with impaired spermatogenesis

AIMS:

This study was conducted to evaluate the outcomes of assisted reproductive technology (ART) procedures, viz., intrauterine insemination (IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in males with impaired spermatogenesis.

SETTINGS AND DESIGN:

The subjects of the study were infertile couples who were undergoing ART treatment due to male factor indications. The project was designed to correlate the outcome of the ART treatment and its efficacy in different study groups.

METHODS:

Males were grouped as: 1. oligozoospermia (n = 153), 2. asthenoteratozoospermia (n = 158), 3. obstructive azoospermia (n = 110) and 4. nonobstructive azoospermia (n = 58). Patients from groups 1 and 2 were considered for IUI, IVF and ICSI. Those from group 3 were considered for IVF and ICSI and the 4th group underwent only ICSI treatment.

RESULTS:

Oligozoospermia showed lower pregnancy rates with IUI than with both IVF and ICSI. An average minimum native and postharvest count was obtained to get an acceptable IUI outcome. Asthenoteratozoospermia had the lowest pregnancy rate with IUI as compared to IVF, whereas ICSI showed significantly higher pregnancy rates in this group. Obstructive azoospermia showed significant improvement with ICSI over IVF. In nonobstructive azoospermia, ICSI resulted in a 27.58% pregnancy rate.

CONCLUSION:

The IUI outcome was impressive though less effective whereas there was no difference between the IVF and ICSI outcomes in oligozoospermia. In asthenoteratozoospermia, ICSI showed a significant advantage over IUI and IVF, with IUI resulting in poor outcome in this group. In obstructive azoospermia, ICSI had a distinct advantage over IVF whereas in nonobstructive azoospermia, ICSI, the only option, was found to be effective and helpful in achieving an acceptable pregnancy rate.

Predictive factors of repeat sperm aspiration success

OBJECTIVES

To evaluate the outcomes of repeated testicular sperm aspirations (TESAs) and to investigate whether the interval between TESA procedures, success in the first attempt, and patient age might influence the results.

METHODS

The patient population in the present study consisted of couples undergoing TESA for intracytoplasmic sperm injection. Of these, 189, 46, 42, and 19 male patients underwent 1, 2, 3, and 4 sperm retrievals, respectively. The effects of the interval between TESA procedures, success of the previous attempts, and patient age on sperm recuperation in a repeated procedure were evaluated.

RESULTS

Of the patients with nonobstructive azoospermia from whom sperm was not retrieved in the first procedure, 16.6% had successful sperm retrieval at the second procedure. In 57.1% of the patients who did not achieve sperm recuperation for the second attempt, sperm could be retrieved in the third procedure. Finally, of the patients without success in the third attempt, 40.0% had successful sperm retrieval at the fourth attempt. Success in the preceding TESA procedure positively influenced the success of sperm retrieval in a repeated attempt, and a trend for a negative effect of paternal age in the success of a repeated TESA attempt was noted. However, the interval between procedures had no influence on TESA success.

CONCLUSIONS

The results of our study have shown that patient age and the success of the first TESA may predict the results of additional attempts. However, TESA may result in sperm recovery even when the first recovery procedure was not successful. Moreover, sperm recovery did not seem to be affected by the interval between procedures.

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.

Percutaneous epididymal sperm aspiration (PESA) in men with obstructive azoospermia

OBJECTIVES

Assessing the efficiency of repeated percutaneous epididymal sperm aspiration (PESA) in men with obstructive azoospermia, and also the possibility of cryopreservation of remaining material for future use in intracytoplasmic sperm injection (ICSI).

METHOD

Retrospective study, in which 79 procedures of PESA were assessed in 58 patients (mean age = 45 years), whose partners had mean age of 34 years. Vasectomy was the most frequent cause of obstructive azoospermia (n = 46).

RESULTS

Motile spermatozoa were obtained in 65 procedures (82%). PESA was twice repeated for 15 patients, 3 times for 5 patients, and 4 times for 1 patient. Spermatozoa were found in 13 (87%) patients in the second attempt, in 4 (80%) patients in the third attempt, and in the only patient that had accomplished 4 procedures. In 30 procedures (37%), we have obtained enough material for cryopreservation. In 12 among the 13 samples thawed (n = 13 patients), motile spermatozoa were found, and ICSI was accomplished. Four patients that did not use their samples requested the elimination of the material. Total rate of pregnancy per transference was 21/55 (38%). In 14 PESA procedures, it was not possible to find spermatozoa; in these cases, the patients opted for accomplishing the procedure of testicular sperm aspiration (TESA).

CONCLUSION

PESA is an efficient and simple method of retrieving spermatozoa, allowing repeated procedures. Additionally, spermatozoa collected through PESA can be cryopreserved.

The efficacy of repeat percutaneous epididymal sperm aspiration procedures

PURPOSE

The development of intracytoplasmic sperm injection spawned new methods of sperm retrieval for men with obstructive azoospermia who did not want to undergo reconstruction of the seminal tract. There is a wide array of different procedures that may be performed in these cases, for instance percutaneous epididymal sperm aspiration (PESA) and microepididymal sperm aspiration. However, concerns regarding the presence of sperm in a second PESA attempt due to possible fibrosis have been suggested by many authors. We evaluate if it is worthwhile to repeat percutaneous epididymal sperm aspiration.

MATERIALS AND METHODS

The records of 20 patients (23 attempts) who underwent repeat PESA from January 1996 to September 2000 for assisted reproductive technique purposes were reviewed. In all patients the repeat procedure was performed on the same side as the previous PESA. Data were collected on patient age, presence of motile sperm during PESA, epididymal side, pregnancies and abortion rates.

RESULTS

Mean patient age +/- SD was 32.4 +/- 5.6 years. One patient was excluded from our analysis due to lack of information on the chart regarding the side of the procedure. Repeat PESA was performed in the right epididymis in 12 attempts and in the left in 10. Of the remaining 19 patients 14 (73.68%) did not and 5 (26.3%) have sperm in the epididymal fluid. In these 5 patients 8 repeat PESA procedures were performed (3 procedures in 1 and motile sperm was always found (8 of 22 attempts, 36.4%). Three patients achieved pregnancy with the motile sperm retrieved from the repeat PESA (3 of 8 repeat attempts, 37.5%). No abortions were detected.

CONCLUSIONS

More than a third of repeat PESA attempts resulted in the presence of motile sperm. Before performing testicular sperm aspiration or extraction in patients who have undergone previous PESA without achieving pregnancy, repeat PESA may be done. Further attempts should be added in the future to confirm these results.

Serial ultrasonography, hormonal profile and antisperm antibody response after testicular sperm aspiration

BACKGROUND

In many fertility centres, intracytoplasmic sperm injection (ICSI) with epididymal or testicular spermatozoa is a routine treatment for men with azoospermia. In this prospective study, the physiological consequences after testicular sperm aspiration (TESA), using suction and a 19 gauge needle, were evaluated.

METHODS AND RESULTS

Thirty-five consecutive men with azoospermia underwent TESA. Testicular ultrasonography with Doppler flow imaging was performed and testicular volumes were evaluated pre-operatively and 3 months after aspiration. If focal testicular lesions were found, further examinations were performed 6 and 9 months after TESA. Serum FSH, testosterone and antisperm antibodies (ASA) were analysed. Focal testicular lesions were seen in four out of 61 testes (6.6%) at the 3 month investigation point. Three lesions were resolved after 6 months and all after 9 months. Testicular echogenicity remained unchanged in 50 cases (82%) 3 months after TESA. Four men (11.4%) reported severe subjective discomfort post-operatively, but only one had a medical consultation where an intratesticular haematoma was diagnosed. There were no significant changes in FSH and testosterone after surgery and testicular volumes were similar after 3 months. There were three borderline cases of ASA in serum, but none was classified as ASA-positive.

CONCLUSIONS

The puncture method of testicular sperm aspiration seems to be a safe method for sperm retrieval, with minimal physiological consequences.

Sperm retrieval, fertilization, and pregnancy outcome in repeated testicular sperm aspiration

PURPOSE

To report the outcome of sperm retrieval and results after ICSI in up to six repeated testicular sperm aspiration procedures.

METHODS

Twenty-two men with obstructive and thirty-four men with nonobstructive azoospermia underwent 50 and 91 needle aspirations, respectively. Sufficiency of spermatozoa for ICSI and cryopreservation, fertilization rate, and pregnancy outcome was analyzed retrospectively.

RESULTS

No major differences were found in sperm recovery or pregnancy outcome in the repeated cycles. Testicular aspirate containing motile spermatozoa with maintained fertilizing capacity was obtained in up to six repeated procedures in the nonobstructive group. No postoperative complications were reported for any of the participants.

CONCLUSIONS

Testicular sperm aspiration is a simple and effective method of sperm retrieval, which can be performed from the same testis up to several times with good recovery of motile spermatozoa for ICSI and maintaining high fertilization and pregnancy rates, in men with both obstructive and nonobstructive azoospermia.

Use of electively cryopreserved microsurgically aspirated epididymal sperm with IVF and intracytoplasmic sperm injection for obstructive azoospermia

OBJECTIVE

To investigate the efficacy of using intentionally cryopreserved epididymal sperm in selected cases of obstructive azoospermia.

DESIGN

A retrospective, nonrandomized study.

SETTING

Academic research environment.

PATIENTS

One hundred forty-one couples undergoing first-time IVF/ICSI using either fresh or cryopreserved epididymal sperm.

INTERVENTIONS

The epididymides were microsurgically aspirated.

MAIN OUTCOME MEASURES

Clinical pregnancy rates.

RESULTS

Motile sperm were obtained from all men. For the fresh group, the mean total sperm aspirated was 99 x 10(6) with 5.5 vials frozen per patient after ICSI and 82 x 10(6) with 4.7 vials frozen per patient in the cryopreserved group. No statistically significant difference in oocyte fertilization rate or number of embryos transferred was noted between groups. Of 108 patients using freshly aspirated sperm, 72 (66.7%) achieved clinical pregnancy. Of 33 patients in the group using cryopreserved sperm, 20 (60.6%) achieved clinical pregnancy (P=0.47).

CONCLUSIONS

In selected ideal cases of unreconstructable azoospermia, elective open microsurgical epididymal sperm aspiration with cryopreservation yields pregnancy rates similar to that employing fresh sperm. The advantages of this method are: (1) Use of cryopreserved sperm obviates the logistics problems associated with the use of fresh sperm. (2) Abundant high-quality sperm can be cryopreserved in a single procedure for all future attempts at IVF/ICSI. Rarely, viable sperm will not be present after thawing, and fresh retrieval will be necessary.