In-vitro fertilization treatment for severe male factor: the fertilization potential of immotile spermatozoa obtained by testicular extraction

Reliability of hypo-osmotic swelling test on fresh and frozen-thawed ejaculated or testicular immotile sperm: A sibling oocyte study

The viability of sperm is a crucial factor for achieving a successful pregnancy in intracytoplasmic sperm injection (ICSI) cycles. The aim of this study was to evaluate the accuracy of the hypo-osmotic swelling test (HOST) in fresh and frozen-thawed sperm samples of different origins (ejaculated/testicular). A retrospective analysis was conducted on the outcomes of 2167 oocytes subjected to ICSI using motile and immotile-HOST-positive sperm from 2011 to 2023. We evaluated embryonic development, as well as clinical, obstetric, and neonatal outcomes in four groups based on different sperm origins (ejaculated/testicular) and processing (fresh/frozen). When comparing the results of ICSI between motile and immotile-HOST-positive sperm within each group, it was observed that there were no significant differences in the outcomes for fresh samples. However, for frozen-thawed samples, fertilization rates and blastocyst development rates were significantly lower when ICSI was performed with immotile-HOST-positive sperm compared to motile sperm. Of note, clinical, obstetric, and neonatal outcomes were statistically similar across all groups. Our findings indicate that HOST is more reliable in fresh samples than in those subjected to the freeze-thaw process. Nonetheless, HOST is considered a safe method for selecting viable sperm in all subgroups.

Immunobiology of pregnancy: from basic science to translational medicine

Embryo implantation failure and spontaneous abortions represent the main causes of infertility in developed countries. Unfortunately, incomplete knowledge of the multiple factors involved in implantation and fetal development keeps the success rate of medically assisted procreation techniques relatively low. According to recent literature, cellular and molecular mechanisms of 'immunogenic tolerance' towards the embryo are crucial to establish an 'anti-inflammatory' state permissive of a healthy pregnancy. In this review we dissect the role played by the immune system in the endometrial-embryo crosstalk, with a particular emphasis towards the fork-head-box-p3 (Foxp3+) CD4+CD25+ regulatory T (Treg) cells and discuss the most recent therapeutic advances in the context of early immune-mediated pregnancy loss.

Are Clinical Outcomes of Micro-TESE in Non-obstructive Azoospermic Men Affected by the Use of Fresh or Frozen Gametes?

Background: The combination of microsurgical testicular sperm extraction (mTESE) and intracytoplasmic sperm injection (ICSI) has become a common management option, with sperm motility being positively associated with successful outcomes. However, few studies have investigated whether the use of fresh or thawed gamete combinations affect clinical outcomes.

Objectives: To determine whether the clinical outcomes of ICSI cycles using mTESE recovered testicular sperm of non-obstructive azoospermia (NOA) patients are affected by using fresh or thawed gametes.

Material and Methods: A retrospective study was conducted of NOA patients who underwent mTESE between 2017 and 2020 at Monash IVF assisted reproductive clinics in Melbourne, Australia. The impact of gamete fresh/frozen status and sperm motility was investigated on clinical outcomes such as fertilization, blastocyst formation, clinical pregnancy, and live birth rates (LBRs).

Results:A total of 103 NOA patients underwent mTESE, with a 65.1% successful surgical-sperm-retrieval. In total 56 patients contributed to 68 ICSI cycles, with a 35.1% fertilization rate and 25% LBR per embryo transfer. Compared with fresh testicular sperm, thawed testicular sperm did not affect clinical outcomes, including LBRs [16.7% vs 12.0%; odds ratio (OR) 0.68 (0.18–2.70)]. However, the use of thawed oocytes had a negative effect on fertilization rates [fresh-oocytes, 37.8%; vitrified-oocytes, 34.5%; OR 0.86 (0.02–0.48)]. Cycles using only motile sperm had a greater fertilization rate than those using a combination of motile and non-motile sperm (49.6% vs 37.2%, p ¡ 0.05). Importantly, when exclusively non-motile sperm were available (n = 26 cycles) their injection resulted in a very low fertilization rate (2.7%) and no live births were recorded.

Conclusion: Micro-TESE is an effective treatment for NOA patients, with no clear advantage of using fresh over thawed sperm, however, the use of vitrified compared with fresh oocytes requires further investigation. Importantly, patients should be informed of the poor outcomes with the use of non-motile sperm in mTESE ICSI cycles.

ICSI outcomes for infertile men with severe or complete asthenozoospermia

BACKGROUND

Severe or complete asthenozoospermia is a rare entity that can lead to male infertility. In this study, we explored whether different extents of severe or complete asthenozoospermia could affect intracytoplasmic sperm injection (ICSI) outcomes and compared the ICSI outcomes using testicular spermatozoa with those using ejaculated spermatozoa in couples with complete asthenozoospermia.

RESULTS

Ninety-seven couples with severe or complete asthenozoospermia who underwent ICSI between January 2014 and December 2018 were included. According to the sperm category used in ICSI, patients were categorized into four groups: ejaculated progressive motile sperm group (Ep-group), ejaculated non-progressive motile sperm group (En-group), ejaculated immotile sperm group (Ei-group), and testicular sperm group (TESE-group). We compared the baseline characteristics, hormone profile, semen parameters, normal fertilization, good-quality embryos on day 3, transferred embryos, and ICSI outcomes in the four groups. The clinical pregnancy rate was significantly increased in the Ep-group (65.4%, P = 0.019) and TESE-group (63.6%, P = 0.035) compared with that in the Ei-group (23.1%). The ongoing pregnancy rate in the Ei-group was significantly lower than that in the Ep-group (23.1% vs. 61.5%, P = 0.041). Moreover, the biochemical pregnancy rate, ongoing pregnancy rate, and live birth rate were much lower in the Ei-group than in the TESE-group (30.8% vs. 63.6%, 23.1% vs. 40.4% and 23.1% vs. 40.4%, respectively).

CONCLUSIONS

In couples with complete asthenozoospermia, testicular spermatozoa should be preferred to ejaculated spermatozoa for obtaining a better ICSI outcome. With the appropriate selection of testicular spermatozoa, the extent of severe or complete asthenozoospermia may not affect the ICSI outcomes. Future studies with a larger sample size are warranted to validate these findings.

Cumulative IVF outcomes after retrieval of testicular spermatozoa: should we use immotile spermatozoa for ICSI?

RESEARCH QUESTION

What are the cumulative clinical pregnancy rates (CPR) and live births rates (LBR) in intracytoplasmic sperm injection (ICSI) cycles using testicular motile compared with immotile spermatozoa, obtained from testicular sperm aspiration (TESA) or extraction (TESE)?

DESIGN

A retrospective analysis of ICSI cycles using TESA or TESE over a period of 7 years. Cycles were divided into two groups according to the motility of the retrieved spermatozoa: Group A consisted of couples with motile spermatozoa; Group B of couples with immotile spermatozoa. Group B was subdivided into two groups: B1 consisted of couples with motile spermatozoa and B2 with immotile spermatozoa after the addition of pentoxifylline.

RESULTS

No differences in CPR and LBR per transfer was found between the study groups after fresh embryo transfer. No pregnancies were achieved by vitrified-warmed embryo transfer in group B2. Fertilization rates decreased when using immotile spermatozoa (64.4%, 56%, 37.9%, for groups A, B1 and B2, respectively, P < 0.001). Top-quality embryo rates were higher in groups A and B1 compared with B2 (40.7% and 40.1% versus 19.1%, respectively, P = 0.015). Cumulative CPR (53%, 41.7%, 13.6% for groups A, B1 and B2, respectively, P = 0.005) and LBR (42.4%, 30%, 13.6% for groups A, B1 and B2, respectively P = 0.03) per oocyte retrieval was significantly higher when using motile spermatozoa compared with motile or immotile spermatozoa after adding pentoxifylline.

CONCLUSIONS

Although fertilization, top-quality embryo rates, cumulative CPR and LBR decreased when using immotile spermatozoa, ICSI is still valid; therefore, it should be considered and offered to couples before embarking on a donor sperm insemination cycle, or cryopreserving oocytes for future additional testicular sperm retrieval.

Potential of testicular sperm to support embryonic development to the blastocyst stage is comparable to that of ejaculated sperm

PURPOSE

Recent studies have shown that improved clinical outcomes can be achieved by transferring blastocysts rather than cleavage-stage embryos. However, blastocyst transfer is not performed in all patients. The aim of this study was to compare clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles using testicular sperm (TE) with those of ICSI cycles using ejaculated sperm (EJ).

METHODS

ICSI was performed using EJ in 141 cycles and TE in 37 cycles. Embryos were cultured for 5 days. The quality of embryos was assessed on days 3 and 5 before embryo transfer.

RESULTS

Fertilization rate was 77.3% in the EJ group and 69.6% in the TE group (p < 0.05). The good-quality embryos on day 3 and 5 were not different between the EJ and TE groups. Embryos did not develop to blastocyst stage in 7 cycles of the EJ group (5.0%) and 2 cycles of the TE group (5.4%). There were no significant differences in blastocyst formation and blastocyst quality (46.1% vs. 47.5% and 5.7% vs 5.8%, respectively) on day 5 between both groups. Embryos were transferred in all cycles. Implantation (22.8 vs. 24.7%), clinical pregnancy (44.7 vs. 43.2%), miscarriage (21.7 vs. 33.3%), and delivery (76.5 vs. 66.7%) did not differ between EJ group and TE group. Clinical outcomes of ICSI were not different between the EJ and TE groups.

CONCLUSIONS

In conclusion, the potential of testicular sperm supporting embryonic development to blastocysts is comparable to that of ejaculated sperm. Therefore, this study suggests that blastocyst transfer can be a very useful assisted reproductive technique in the ICSI cycles that require the use of testicular sperm, and the clinical outcomes of the cycles are comparable to those of ICSI cycles using ejaculated sperm.

Successful intracytoplasmic sperm injection with testicular spermatozoa from a man with multiple morphological abnormalities of the sperm flagella: a case report

PURPOSE

The purpose of this study is to analyze the sperm morphology of a Chinese man affected with multiple morphological abnormalities of the sperm flagella (MMAF) and observe the intracytoplasmic sperm injection (ICSI) outcome.

METHODS

A Chinese man was diagnosed with multiple morphological abnormalities of the sperm flagella by semen analysis and electron microscopy. Testicular spermatozoa were injected intracytoplasmically, and the following ICSI results were observed.

RESULTS

All the spermatozoa from his ejaculate were immotile and morphologically abnormal in the flagellum. In transmission electron microscopy assays, most spermatozoa showed disorganized fibrous sheath, accompanied by distortion of various cytoskeletal components, and missing of the central pair microtubules. Testicular sperm was injected to the oocytes in two ICSI cycles, with fertilization rates of 45.5 and 40.0%. Finally, a healthy female infant was delivered at the second ICSI cycle.

CONCLUSIONS

Fertilization and pregnancy could be achieved by intracytoplasmic sperm injection, regardless of severe flagellar defects. ICSI is effective for MMAF-affected man, and testicular sperm is an alternative when no motile sperm is available.

Testicular sperm aspiration (TESA) for infertile couples with severe or complete asthenozoospermia

The aim of the study was to evaluate reproductive outcomes in a cohort of infertile couples with severe and complete asthenozoospermia undergoing TESA (testicular sperm aspiration) with ICSI. We conducted a retrospective study of 28 couples with complete or severe asthenozoospermia who underwent TESA between January 2010 and December 2015. We compared TESA-ICSI outcomes of these couples to ejaculate ICSI outcomes of 40 couples with severe asthenozoospermia treated during the same time period at our institution. Couples with female factor infertility and/or female aged ≥39 were excluded. Sperm retrieval rates and ICSI outcomes [(MII oocytes, fertilization rate, good embryo rate (transferred and frozen), couples with embryo transfer (per cycle started), clinical pregnancy (per embryo transfer)] were recorded. Patients were grouped based on whether they had ejaculated (Ej-group) or testicular (TESA-group) spermatozoa used. Testicular sperm patients were further classified based on whether they had complete asthenozoospermia (0% total motility) (Tc-group) or severe asthenozoospermia (≤1% progressive motility) (Ts-group). Mean (±SD) male and female ages were 36 ± 6 and 32 ± 4, respectively. Sperm recovery by testicular sperm aspiration (TESA) was successful in 100% (28/28) of the men. The overall clinical pregnancy rate (CPR) per cycle started was 34% (23/68) with a mean of 1.1 ± 0.4 embryos transferred per transfer. Fertilization rates were significantly lower in TESA-group compared to Ej-group (52% vs. 67%, respectively; p = 0.001), while male age was significantly higher in TESA-group compared to Ej-group (34 ± 6 vs. 37 ± 6, respectively; p = 0.03). Moreover, female age was significantly higher in Tc-group compared to Ts-group (30 ± 4 vs. 33 ± 3, respectively; p = 0.0285). However, there were no significant difference in clinical pregnancy rate per embryo transfer in the Tc-group, Ts-group, and Ej-group (50% vs. 45% vs. 57%, respectively; p = 0.8219). The data suggest that testicular sperm-ICSI is no better than ejaculated sperm-ICSI in couples with severe or complete asthenozoospermia. Randomized, controlled trials comparing ejaculated vs. testicular spermatozoa are needed to assess the true benefit of TESA-ICSI in these couples.

Treatment strategies for severe oligoasthenoteratozoospermia (OAT) (<0.1 million/mL) patients

Intracytoplasmic sperm injection (ICSI) using spermatozoa from patients with severe oligoasthenoteratozoospermia is still a challenge. Although spermatozoa are available, lower fertilisation rates as well as compromised pregnancy rates are observed after ICSI. We aimed at identifying respective parameters in the pre-values of ejaculate samples used for couple counselling. The clinical pre-values of 121 patients and their corresponding 228 ICSI cycles performed between 2002 and 2010 were retrospectively analysed. Patients were divided into three groups: (i) group 1 (G1, n = 51) where all patients showed at least once <0.1 million/mL and ICSI was performed using ejaculate alone; (ii) group 2 (G2, n = 14) patients had once <0.1 Mill/mL or azoospermia and a testicular biopsy before start of ICSI; (iii) group 3 (G3, n = 56) patients were azoospermic and directed immediately to testicular sperm extraction (TESE). The pre-values of G2 differed significantly from G1 in terms of volume and motility. Lutenizing hormone (LH) and follicle-stimulating hormone (FSH) values were equal in G1 and G2, but showed significant differences in comparison to G3. Testis volume was significantly higher in G3. In the corresponding ICSI cycles, the percentage of cancelled embryo transfers was highest in G3. We did not find any correlations of hormonal markers or sperm pre-values with the success rates of ICSI. In our patient cohort, spermatozoa retrieved either from ejaculate or testicular biopsies have nearly identical chances in achieving pregnancies. Patients in need of TESE before ICSI have significantly lower sperm counts. However, it is not possible to calculate threshold values as indicator for TESE.

Myoinositol improves sperm parameters and serum reproductive hormones in patients with idiopathic infertility: a prospective double-blind randomized placebo-controlled study

Male infertility is a multifactorial disorder that affects a significant percentage of couples. Its etiology and pathogenesis remain elusive in about one-third of the cases; this is referred to as idiopathic infertility. Inositols mediate the sperm processes involved into oocyte fertilization, such as penetration of the ovum cumulus oophorus, binding with the zona pellucida and the acrosome reaction. The aim of this double-blind, randomized, placebo-controlled trial was to evaluate the efficacy and safety of myoinositol (the most abundant form of inositols present in nature) treatment in men with idiopathic infertility. To accomplish this, we evaluated the effects of myoinositol on sperm parameters and reproductive hormones at baseline and after 3 months of treatment in men with idiopathic infertility. No adverse reaction was observed. Myoinositol significantly increased the percentage of acrosome-reacted spermatozoa, sperm concentration, and total count and progressive motility compared to placebo. In addition, myoinositol rebalanced serum luteinizing hormone, follicle-stimulating hormone, and inhibin B concentrations. The clinical improvement of idiopathic infertile patients should encourage myoinositol use for the treatment of this disorder, even though its detailed mechanisms at the testicular level remain still unclear.

Pregnancy outcome after ICSI with thawed testicular sperm from men with non-obstructive azoospermia compared to ICSI with ejaculated sperm from men with severe oligoasthenoteratozoospermia and IVF with normal ejaculated sperm

The aim of the study was to evaluate the clinical pregnancy outcomes, fetal complications and malformation rate of intracytoplasmic injection of thawed cryopreseverd sperm extracted by testicular aspiration from men with non-obstructive azoospermia (NOA) compared with intracytoplasmic injection of fresh ejaculated sperm from men with severe oligoteratoasthenozoospermia (OTA) and standard in vitro fertilization using ejaculated sperm from normospermic men. The mean oocyte fertilization rate was significantly lowest for ICSI with testicular aspirated sperm (NOA group). However, there was no significant difference among the three groups in pregnancy outcomes, namely rates of spontaneous abortion, biochemical pregnancy, extrauterine pregnancy, singleton multifetal pregnancy, preterm delivery before 36 weeks' gestation, maternal complications, transfer to the neonatal intensive care unit, intrauterine growth restriction or fetal malformations. These results suggest that despite some earlier findings that intracytoplasmic injection of aspirated sperm from men with NOA is associated with lower fertilization rates and embryo quality, the pregnancy and immediate neonatal outcomes may be unaffected.

Absolute asthenozoospermia and ICSI: what are the options?

BACKGROUND

Complete asthenozoospermia, i.e. 100% immotile spermatozoa in the ejaculate, is reported at a frequency of 1 of 5000 men. Its diagnosis implies a poor fertility prognosis even with ICSI. It is extremely important to distinguish between two different groups of patients with complete asthenozoospermia, i.e. virtual or absolute asthenozoospermia. With the former group having some motile spermatozoa after extensive processing of the semen, absolute asthenozoospermia can be associated with metabolic deficiencies, ultrastructural abnormalities of the sperm flagellum, necrozoospermia otherwise it can be idiopathic. In the management of persistent absolute asthenozoospermia, it is very important to elucidate its nature and whenever possible to correct the potential causes.

METHODS

We reported data published in the literature on the aetiology of absolute asthenozoospermia and the different techniques to improve ICSI outcome. We propose an algorithm for diagnosis and treatment of this condition. RESULTS Different results regarding fertilization, cleavage and pregnancy rate have been published in patients with absolute asthenozoospermia undergoing ICSI. However, the results vary widely depending on the sperm origin and the technique applied for immotile sperm selection. The percentage of viable spermatozoa varies between 0 and 100%.

CONCLUSIONS

Absolute immotile spermatozoa is one of the most important causes of reduced fertilization and pregnancy rates after ICSI and different techniques are used to improve ICSI outcomes. However, it still remains unclear which is the best technique to improve the pregnancy outcomes in these couples.

The number of spermatozoa collected with testicular sperm extraction is a novel predictor of intracytoplasmic sperm injection outcome in non-obstructive azoospermic patients

The purpose of this study was to determine the relationships between monitors of spermatogenesis and predictors of the intracytoplasmic sperm injection (ICSI) outcome in patients with non-obstructive azoospermia (NOA) undergoing testicular sperm extraction (TESE). Seventy-nine patients with NOA (mean age: 43.6±5.2 years), each of whom yielded (97 000±3040) spermatozoa with conventional TESE, were considered in our analysis. Their partners (mean age: 35.8±5.1 years) underwent a total of 184 ICSI cycles; 632 oocytes were collected, 221 oocytes were injected, 141 oocytes were fertilized, 121 embryos were obtained, 110 embryos were transferred, 14 clinical pregnancies were achieved and only one miscarriage occurred. Multivariate regression analysis indicated relationships between the percentage of fertilized oocytes, transferred embryos and clinical pregnancies with the following variable values: female partner's age, number of spermatozoa collected, testicular volume, male partner's levels of follicle stimulating hormone (FSH), number of oocytes collected, number of oocytes injected and number of ICSI cycles. A significant inverse relationship was found between female partner's age or male partner's FSH levels and biochemical pregnancies. A significant direct relationship emerged between the number of ICSI cycles and the percentage of oocytes fertilized, embryos transferred and biochemical pregnancies, and between the number of spermatozoa collected per testicular biopsy and biochemical pregnancies. The number of spermatozoa was positively linked to the number of clinical pregnancies, independent of the number of ICSI cycles and the number of oocytes collected/injected. The number of spermatozoa collected, FSH level and testicular volume are monitors of spermatogenesis linked to ICSI success.

Assisted reproductive technology outcomes in azoospermic men: 10 years of experience with surgical sperm retrieval

An azoospermic man suffers from an absence of sperm in the ejaculate and this condition is present in about 10% of infertile men. Obstructive azoospermia (OA) is characterized by an occlusion or partial absence of the reproductive tract with the presence of normal spermatogenesis. On the other hand, non-obstructive azoospermia (NOA) is characterized by impaired spermatogenesis. In these cases, spermatozoa can be obtained by percutaneous epididymal or testicular sperm aspiration (PESA and TESA, respectively) and used for intracytoplasmic injection (ICSI). To compare ICSI outcomes using spermatozoa that were surgically retrieved by PESA and TESA, azoospermic patients were divided into the following categories: (i) TESA-NOA (n = 102), (ii) TESA-OA (n = 103), and (iii) PESA-OA (n = 171). Fertilization, pregnancy, and implantation rates were compared between the groups. We noted a lower normal fertilization rate (p = 0.0017) and a higher abortion rate (p = 0.0387) among men in the TESA group who had OA when compared with men in the PESA group who had OA. On the other hand, a lower normal fertilization rate (p = 0.05) and a lower rate of non-cleaved embryos (p = 0.034) was found in the TESA group of NOA patients as compared to the TESA group of OA patients. No statistically significant differences were detected between the TESA and PESA groups and the OA and NOA groups, respectively. The clinical outcomes of embryos arising from ICSI cycles using spermatozoa harvested via PESA and TESA were similar, regardless of whether the patient had obstructive or non-obstructive azoospermia.

The effect of condition/state of testicular spermatozoa injected to the outcome of TESE-ICSI-ET cycles

OBJECTIVE

The effect of state/condition of spermatozoa (fresh/motile, fresh/immotile, frozen/motile and frozen/immotile) to fertilization, embryo formation/development, implantation and pregnancy/delivery and abortion rates were studied.

STUDY DESIGN

The data of a total of 167 TESE-ICSI-ET cycles with fresh and cryopreserved, motile and immotile testicular spermatozoa collected with testicular biopsy from patients suffering from non-obstructive azoospermia were analyzed retrospectively. Analysis of variance (ANOVA) was used to distinguish the group effects in fertilization, embryo formation, and implantation ratio. The group effect was evaluated by using non-parametric statistics and the independent grouping variable was also the "semen state/condition". "Semen state/condition" groups were created according to fresh or frozen, and motile or non-motile (immotile) characteristics. For comparing the four groups, Kruskal-Wallis ANOVA and Median-test was applied. The analysis was carried out using Statistica for Windows (StatSoft, Inc., Chicago, USA).

RESULTS

Independently of state/condition of testicular spermatozoa injected into oocytes, no differences were found in fertilization and implantation/pregnancy rates. No difference was obtained in embryo development of oocytes injected with fresh/immotile or frozen/motile spermatozoa. However, difference was found in embryo development of oocytes injected with fresh/motile or frozen/immotile testicular spermatozoa (87% vs. 73%; P<0.04). Comparing embryo development of oocytes injected with fresh vs. frozen spermatozoa difference was also found (83% vs. 74%; P<0.01). No difference was found in the abortion rates between the groups. Differences were observed in the implantation rates, however, these differences could not be verified statistically.

CONCLUSION

The presented data show that condition of injected testicular spermatozoa has influence to embryo development and even frozen/immotile testicular spermatozoa is able to induce/support fertilization and early embryo development.

Intracytoplasmic sperm injection in livestock species: an update

Intracytoplasmic sperm injection (ICSI) is a powerful technique in the field of assisted reproduction (ART) and provides exciting opportunities for studying the basic mechanisms of fertilization and early embryo development. Nevertheless, its application in agriculture and conservation biology has been greatly hampered by the low success rate reported for this method in respect of economically important species. Specifically, the rates of blastocyst formation and live newborn are greatly reduced when zygotes are generated by ICSI. Except for humans, ICSI remains a low efficiency technology in comparison with alternatives such as in vitro fertilization (IVF) and its application is less widespread. In this paper, we discuss the present status, applications and factors affecting ICSI in pigs and other species.

Severe oligoasthenoteratozoospermias, secretory and obstructive azoospermias: motility as a criterion of sperm viability

PURPOSE

Comparison of pregnancy rates in cases of Secretory Azoospermias (SA), Obstructive Azoospermias (OA) and severe Oligoasthenoteratozoospermias (OATZ). Evaluation of sperm motility as a quality criterion.

METHODS

In SA cases (n = 35), 9 samples were cryopreserved. In OA cases (epididymal aspiration: n = 91; testicular biopsy: n = 206), all samples were cryopreserved. 596 OATZ ejaculates were included.

RESULTS

In SA cases, 2 pregnancies were achieved from 9 ICSI cycles. In OA, motile sperm rates were higher in testicular biopsies. After thawing sperm motility was not different between testicular and epididymal origin. 2 pregnancies were achieved with immotile testicular sperm after thawing, but none with immotile epididymal sperm. In OATZ cases, one pregnancy was obtained from the 9 cryopreserved ejaculates and 35.3% with fresh motile sperm.

CONCLUSIONS

In SA cases, the use of donor sperm is recommended due to the lower pregnancy rate achieved. Motility, before and after cryopreservation, as a criterion of sperm viability is discussed and its use should be reconsidered in some cases.

The use of the modified hypo-osmotic swelling test for the selection of immotile testicular spermatozoa in patients treated with ICSI: a randomized controlled study

BACKGROUND

Various methods for the selection of viable sperm from among immotile testicular spermatozoa for use in ICSI have been described in non-randomized studies. We have conducted a randomized controlled study to compare the use of the modified hypo-osmotic swelling (HOS) test (50% culture medium + 50% Milli-Q grade water) with that of sperm selection on the basis of their morphology alone.

METHODS

A total of 79 couples with immotile testicular spermatozoa treated with ICSI were randomly assigned into two groups. In the first group, spermatozoa used for injection were selected using the modified HOS test, while in the second group spermatozoa were selected on the basis of their morphology.

RESULTS

The fertilization rate was significantly higher in the HOS test group (43.6%) compared with the no-HOS test group (28.2%) [odds ratio (OR) 2.494; 95% confidence interval (CI) 1.606-3.872]. The pregnancy and ongoing pregnancy rates were also higher in the HOS test group (27.3% versus 20.5%) compared with the no-HOS test group (5.7% versus 2.9%) (OR 6.188, 95% CI 1.282-29.860; and OR 8.743, 95% CI 1.050-72.783, respectively).

CONCLUSIONS

The use of the modified HOS test for the selection of viable sperm from among immotile testicular spermatozoa for ICSI results in higher fertilization, pregnancy and ongoing pregnancy rates compared with morphological selection.

Feasibility of refreezing human spermatozoa through the technique of liquid nitrogen vapor

OBJECTIVE

To assess the feasibility of refreezing human semen using the technique of liquid nitrogen vapor with static phases.

MATERIALS AND METHODS

Twenty samples from 16 subjects who required disposal of their cryopreserved semen were thawed, corresponding to 6 cancer patients and 10 participants in the assisted reproduction (AR) program. Samples were refrozen using the technique of liquid nitrogen vapor with static phases, identical to the one used for the initial freezing, and thawed again after 72 hours. We assessed the concentration of motile spermatozoa, total and progressive percent motility and spermatic vitality, according to criteria of the World Health Organization (WHO), as well as spermatic morphology according to the strict Kruger criterion, after the first and after the second thawing.

RESULTS

We observed a significant decrease in all the parameters evaluated between the first and the second thawing. Median values for the concentration of motile spermatozoa decreased from 2.0x10(6)/mL to 0.1x10(6)/mL (p < 0.01); total percent motility from 42% to 22.5% (p < 0.01); progressive percent motility from 34% to 9.5% (p < 0.01); vitality from 45% to 20% (p < 0.01); and morphology from 5% to 5% (p = 0.03). There was no significant difference in the spermatic parameters between the cancer and assisted reproduction groups, both after the first and after the second thawing. We observed that in 100% of cases there was retrieval of motile spermatozoa after the second thawing.

CONCLUSION

Refreezing of human semen by the technique of liquid nitrogen vapor allows the retrieval of viable spermatozoa after thawing.

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.

Pregnancy after ICSI with ejaculated immotile spermatozoa from a patient with immotile cilia syndrome: a case report and review of the literature

This study presents a case of intracytoplasmic sperm injection (ICSI) with ejaculated immotile spermatozoa from a patient with immotile cilia syndrome. Semen analysis of the patient suffering from immotile cilia syndrome revealed an extreme oligoasthenoteratozoospermia (OAT: count <1.4 x 10(6)/ml, 0% motility and 3% normal morphology). Electron microscopy of sperm flagella showed the absence of inner and outer dynein arms. During the ICSI cycle, the hypo-osmotic swelling test (HOS) was used for the identification of viable spermatozoa in the pool of immotile spermatozoa for ICSI. A normal fertilization rate was found in eight out of the 12 oocytes. A first fresh double embryo transfer resulted in a late miscarriage at 21 weeks. A second healthy singleton pregnancy occurred after transfer of two frozen-thawed embryos from the same ICSI procedure. Although only one successful ICSI case of the immotile cilia syndrome combined with HOS is described here, HOS might be a simple but valuable tool to obtain normal fertilization and pregnancy for patients suffering from immotile spermatozoa.

Predictive factors for motile sperm recovery using testicular biopsy in nonobstructive azoospermic patients

OBJECTIVE

The objective of the present study was to assess the predictive value of hormone values, histological analysis for the finding of motile spermatozoa on testicular biopsy in nonobstructive azoospermia.

METHODS

This cross-sectional study assessed serum follicle-stimulating hormone (FSH), luteinizing hormone, prolactin and total testosterone values in 50 patients undergoing testicular biopsy prior to ICSI. P < 0.05 was considered significant.

RESULTS

Recovery was successful in 28 cases, and motile spermatozoa were retrieved in 7. Significant differences were detected between presence of motile spermatozoa and absence of spermatozoa in terms of FSH values (P = 0.003, one-way ANOVA). The other variables did not present statistical differences. A receiver operating characteristic curve showed that FSH levels below 17.00 IU/L were predictive of motile spermatozoa recovery.

CONCLUSIONS

FSH values can serve as a predictive factor for the recovery of motile spermatozoa using biopsy in azoospermic patients. On the other hand, histological analysis and other hormone values were not helpful in the prediction of motile sperm.

Successful pregnancies after using immotile spermatozoa from ejaculate, epididymis and testis

OBJECTIVE

To assess the efficacy of intracytoplasmic sperm injection (ICSI) in term of pregnancy rate with immotile spermatozoa from ejaculate, epididymis and testis.

STUDY DESIGN

A retrospective study was conducted between January 1998 and March 2001. We performed intracytoplasmic sperm injection with immotile spermatozoa, in 160 couples during 172 cycles.

RESULTS

The birth rate per cycle was 38.4% in immotile spermatozoa from ejaculate, 35.4% from testis and 38.7% from epididymis.

CONCLUSION

This retrospective analysis shows that immotile spermatozoa retrieved from epididymis or testicle gives similar fertilization and pregnancies rates as immotile spermatozoa from ejaculate.

The effect of pure FSH administration in non-obstructive azoospermic men on testicular sperm retrieval

BACKGROUND

In cases of azoospermia due to impaired spermatogenesis, spermatozoa can be retrieved by sperm extraction (TESE) from testicular biopsy.

OBJECTIVE

To evaluate the efficacy of pure follicle-stimulating hormone (pFSH) on sperm recovery, and measure the predictive value of testicular histology.

STUDY DESIGN

In all, 108 patients were studied. These included those with Sertoli cell-only (n=16), focal spermatogenesis (n=36), maturation arrest (n=19) and hypospermatogenesis (n=37) in previous explorative biopsies. All had normal serum FSH, LH and testosterone levels. In 63 cases, 75IU pFSH were administered, either i.m. or s.c., three times a week, for 3 months and the control group (n=45) no treatment was given.

RESULTS

The sperm retrieval rate was 64% (40/63 pts.) in pFSH treated men versus 33% (15/45 pts.) in controls (P<0.01). In Sertoli cell-only patients, the rate was 2/7 (28%) versus 4/9 (44%) in controls and treated men, respectively (P>0.05); and 3/8 (37%) versus 5/11 (45%) in maturation arrest (P>0.05); 6/14 (42%) versus 18/23 (78%) in hypospermatogenesis (P<0.05); and 4/16 (25%) versus 13/20 (65%) in focal spermatogenesis (P<0.01). Treatment with pFSH also improved the quantity of retrieved spermatozoa compared to control values (P<0.05).

CONCLUSION

pFSH treatment improves the success of TESE for non-obstructive azoospermic men with normal FSH levels.

Testicular sperm results in elevated miscarriage rates compared to epididymal sperm in azoospermic patients

CONTEXT

Several sperm retrieval techniques are available for use on azoospeermic men. Comparisons between spermatozoa retrieved from the testicles and epididymis in relation to pregnancy and miscarriage rates are not well established.

OBJECTIVE

To compare pregnancy and miscarriage rates using sperm retrieved from the testes and epididymis using intracytoplasmic sperm injection. Furthermore, we evaluated the fertilization and pregnancy rates according to the status of the spermatozoa retrieved (motile or immotile).

DESIGN

Retrospective study.

SETTING

A private center for assisted fertilization.

PARTICIPANTS

One hundred and eight consecutive patients who presented with azoospermia were included in our study, on whom a total of 144 retrieval procedures were performed.

PROCEDURES

Of the 144 retrieval procedures, 104 were testicular sperm aspirations (TESA) and 40 were epididymal sperm aspirations (PESA). PESA was the first approach in obstructive patients (n = 68), whereas TESA was used when the former failed. For non-obstructive patients (n = 40), TESA was the method of retrieval.

MAIN MEASUREMENTS

Pregnancy and miscarriage rates according to spermatozoa characteristics (motile or immotile).

RESULTS

The number of cycles performed using spermatozoa retrieved from the testicles and epididymis was 81 and 30, respectively. Motile spermatozoa had higher fertilization (2PN) and pregnancy rates compared to immotile spermatozoa (p < 0.05). Also, motile spermatozoa had lower miscarriage rates compared to immotile spermatozoa (p < 0.0001). No differences were seen in pregnancy rates with testicular spermatozoa (n = 28) compared to epididymal spermatozoa (n = 13) (p = 0.1). However, the miscarriages rates were higher in spermatozoa retrieved from the testicles (n = 12) compared to epididymis retrievals (n = 1) (p = 0.01).

CONCLUSIONS

Although pregnancy rates were similar when the intracytoplasmic sperm injection was performed with spermatozoa retrieved from the testicles and epididymis, the use of testicular spermatozoa yields a significantly higher miscarriage rate. It is possible that the higher miscarriage rate seen in patients using spermatozoa retrieved from the testicles is linked to high genetic sperm abnormalities.

Effects of the hypo-osmotic swelling test on the outcome of intracytoplasmic sperm injection for patients with only nonmotile spermatozoa available for injection: a prospective randomized trial

OBJECTIVE

Hypo-osmotic swelling test (HOST) has been shown to be an effective method for the selection of live sperm. On-going pregnancies were obtained by using HOST-selected sperm. The aim of this study was to evaluate the effect of using HOST-selected "live" sperm versus nonselected sperm on the outcome of intracytoplasmic sperm injection cycles when only nonmotile sperm were available for injection.

DESIGN

Prospective randomized study.

SETTING

Governmental tertiary care hospital.

PATIENT(S)

Thirty ICSI cycles with no motile sperm were included in this study.

INTERVENTION(S)

For the HOST group, potentially live spermatozoa detected by hypo-osmotic reaction of the tail were injected into oocytes. For the No-HOST group, the sperm were randomly injected into the oocytes without checking the viability.

MAIN OUTCOME MEASURE(S)

The fertilization, cleavage, embryo quality, pregnancy, and implantation rates were assessed for the two groups.

RESULT(S)

Among 30 cycles, 15 fall into each group. Fertilization, cleavage rates, and the number of good quality embryos were similar between two groups.

CONCLUSION(S)

HOST-selected live spermatozoa can be safely used for intracytoplasmic sperm injection to establish pregnancies. There is a tendency for higher pregnancy and implantation rates to result, but it does not reach statistical significance.

Diagnostic and therapeutic testis biopsy

Testicular biopsy has been traditionally used as a diagnostic tool in the management of infertility. With the advent of assisted reproductive technology, testicular biopsy is now used therapeutically to retrieve sperm for intracytoplasmic sperm injection (ICSI). The feasibility of testicular sperm extraction for ICSI is reviewed in this article. Although less invasive techniques such as testicular fine needle aspiration and percutaneous needle biopsy are efficacious, particularly in cases of obstructive azoospermia, studies in the current literature support that open testicular biopsy is a more reliable method to obtain testicular specimen. Different measures to reduce the complication rate of open testicular biopsy, including the application of microsurgical techniques, are addressed here. Other areas of recent development related to testicular biopsy that are reviewed include processing of testicular tissue, cryopreservation of retrieved spermatozoa, in vitro maturation of spermatozoa, and microinjection of immature spermatogenic precursor cells.

Nonobstructive azoospermia

Nonobstructive azoospermia (NOA) remains a challenging condition in reproductive medicine to manage. The genetic basis of NOA related to partial deletions of the Y-chromosome has been intensely investigated. Such information is of prognostic value and allows more insightful genetic counseling of couples who opt for assisted reproductive technology. Testicular sperm extraction (TESE) combined with intracytoplasmic sperm injection has allowed many men with NOA to father their own biologic children. Although studies in the current literature support open testicular biopsy as the most reliable method to obtain testicular sperm, less invasive techniques such as testicular fine-needle aspiration and percutaneous needle biopsy are feasible alternatives in selected groups of patients. Measures to improve the efficacy of TESE, including the application of microsurgical techniques, are addressed. Other recent developments related to the management of NOA reviewed include processing of testicular tissue, cryopreservation of retrieved spermatozoa, in-vitro maturation of germ cells and microinjection of immature spermatogenic precursor cells.