Prediction of successful outcome of microdissection testicular sperm extraction in men with idiopathic nonobstructive azoospermia

Clinical predictors of successful outcomes for couples with nonobstructive azoospermic male partners undergoing micro-TESE

ABSTRACT

Nonobstructive azoospermia (NOA) is the most challenging and complex clinical scenario for infertile men. Besides circumstances such as hypogonadotropic hypogonadism, surgical sperm retrieval is typically necessary, and microdissection testicular sperm extraction (micro-TESE) is the procedure of choice for men with NOA desiring to father children with their own gametes. Micro-TESE results in the highest numbers of sperm cells retrieved for use with in vitro fertilization/intracytoplasmic sperm injection (ICSI) in comparison to all other techniques for surgical sperm retrieval in men with NOA. Several factors may affect sperm retrieval rate and ICSI outcomes, including the patient's age, testicular volume, histopathological and genetic profile, and serum hormone levels. This article aims to review the medical literature describing predictors of successful micro-TESE and the outcomes of ICSI in men with NOA.

Association of higher serum follicle-stimulating hormone levels with successful microdissection testicular sperm extraction outcomes in nonobstructive azoospermic men with reduced testicular volumes

ABSTRACT

To investigate the impact of preoperative serum follicle-stimulating hormone (FSH) levels on the probability of testicular sperm retrieval, we conducted a study of nonobstructive azoospermic (NOA) men with different testicular volumes (TVs) who underwent microdissection testicular sperm extraction (micro-TESE). A total of 177 NOA patients undergoing micro-TESE for the first time from April 2019 to November 2022 in Shenzhen Zhongshan Obstetrics and Gynecology Hospital (formerly Shenzhen Zhongshan Urology Hospital, Shenzhen, China) were retrospectively reviewed. The subjects were divided into four groups based on average TV quartiles. Serum hormone levels in each TV group were compared between positive and negative sperm retrieval subgroups. Overall sperm retrieval rate was 57.6%. FSH levels (median [interquartile range]) were higher in the positive sperm retrieval subgroup compared with the negative outcome subgroup when average TV was <5 ml (first quartile [Q1: TV <3 ml]: 43.32 [17.92] IU l -1 vs 32.95 [18.56] IU l -1 , P = 0.048; second quartile [Q2: 3 ml ≤ TV <5 ml]: 31.31 [15.37] IU l -1 vs 25.59 [18.40] IU l -1 , P = 0.042). Elevated serum FSH levels were associated with successful micro-TESE sperm retrieval in NOA men whose average TVs were <5 ml (adjusted odds ratio [OR]: 1.06 per unit increase; 95% confidence interval [CI]: 1.01-1.11; P = 0.011). In men with TVs ≥5 ml, larger TVs were associated with lower odds of sperm retrieval (adjusted OR: 0.84 per 1 ml increase; 95% CI: 0.71-0.98; P = 0.029). In conclusion, elevated serum FSH levels were associated with positive sperm retrieval in micro-TESE in NOA men with TVs <5 ml. In men with TV ≥5 ml, increases in average TVs were associated with lower odds of sperm retrieval.

Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations

PURPOSE

Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA.

MATERIALS AND METHODS

A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process.

RESULTS

Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit.

CONCLUSIONS

This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines.

Erectile Function and Sexual Activity Are Declining in the Younger Generation: Results from a National Survey in Japan

PURPOSE

Twenty five years have passed since the first national survey on erectile dysfunction (ED) in Japan. The Japanese Society for Sexual Medicine conducted a nationwide survey on the actual status of sexual function targeting men over 20 years old in Japan using validated questionnaires commonly used in clinical practice.

MATERIALS AND METHODS

Japanese men aged 20 to 79 years participated in our online epidemiological study on sexual dysfunction. Erectile status was assessed by direct questioning and specific questionnaires. Risk factors and frequencies of sexual intercourse, masturbation, nocturnal erections, and feeling sexual desire were assessed. The prevalence of these risk factors was compared between men with and without ED. Prevalence and frequencies were calculated for each 5-year age group. Main outcomes were the prevalence and number of patients with ED and simultaneous evaluation of age-related variations.

RESULTS

Direct questioning of the men revealed that 13.0% felt troubled by ED. Although 81.0% of them had at least some ED symptoms based on a Sexual Health Inventory For Men score of ≤21, the prevalence of men with ED by Erection Hardness Score (EHS), the most appropriate questionnaire for Japanese with low sexual activity, was 30.9%, indicating that 14,012,596 men have ED. Most risk factors were related with ED, whereas frequencies of sexual intercourse, masturbation, nocturnal erections, and feeling sexual desire were affected by aging. However, the low frequency of these factors in the young generation was surprising.

CONCLUSIONS

The EHS-based assessment revealed a prevalence of ED of 30.9%, which affected approximately 14 million men, and that the sexual desire, erection stiffness, orgasms, and satisfaction were lower than expected in young Japanese men, especially those aged 20 to 24 years, although those factors tended to worsen with aging. We believe that these findings actually reveal the current sexual status of men in Japan.

Parameters affecting the success rate of microscopic testicular sperm extraction in male patients with a solitary testis and non-obstructive azoospermia

PURPOSE

We aimed to compare the success rate of spermatozoa retrieval through microscopic testicular sperm extraction (mTESE) in non-obstructive azoospermic (NOA) men with a solitary testis with that of mTESE in NOA men with bilateral testes and the parameters affecting these rates.

METHODS

A retrospective cross-sectional study of factors contributing to infertility in NOA patients with a solitary testis and men with bilateral testes was carried out. In this multicenter study, 74 patients with NOA with a solitary testis were matched with 74 patients with bilateral testes in terms of age, duration of infertility, and volume of the solitary testis from 2770 patients with NOA with bilateral testes. Hormonal parameters, presence of varicocele, history of varicocelectomy, history of undescended testis and karyotype analysis results were compared.

RESULTS

Spermatozoa were obtained from 40 (54.1%) patients with a solitary testis and 42 (56.76%) patients with bilateral testes. No differences were found regarding age, duration of infertility, or mean testicular volume between patients with a solitary testis and patients with bilateral testes. When serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were compared regardless of sperm retrieval status, it was observed that both levels were greater in the group of patients with a solitary testis (p < 0.01). Patients with solitary and bilateral testes from whom spermatozoa were obtained had larger testes than those from whom spermatozoa could not be obtained (p < 0.05). Similarly, the serum levels of FSH and LH were significantly greater in patients with a solitary testis than in those with bilateral testes (p < 0.05).

CONCLUSIONS

To the best of our knowledge, this is the first study in the literature to evaluate the parameters that influence mTESE outcome in NOA patients with a solitary testis and NOA patients with bilateral testes. Greater testicular volume was found to positively affect spermatozoa retrieval for patients with a solitary testis. The higher levels of FSH and LH in patients with a solitary testis than in patients with bilateral testes of similar testicular volume may be due to a compensatory mechanism developed by the hypothalamic-pituitary-gonadal axis. The fact that these hormones are higher in patients with a solitary testis does not mean that the number of spermatozoa obtained through mTESE will be decreased.

Non-Obstructive Azoospermia and Intracytoplasmic Sperm Injection: Unveiling the Chances of Success and Possible Consequences for Offspring

Non-obstructive azoospermia (NOA) is found in up to 15% of infertile men. While several causes for NOA have been identified, the exact etiology remains unknown in many patients. Advances in assisted reproductive technology, including intracytoplasmic sperm injection (ICSI) and testicular sperm retrieval, have provided hope for these patients. This review summarizes the chances of success with ICSI for NOA patients and examines preoperative factors and laboratory techniques associated with positive outcomes. Furthermore, we reviewed possible consequences for offspring by the use of ICSI with testicular sperm retrieved from NOA patients and the interventions that could potentially mitigate risks. Testicular sperm retrieved from NOA patients may exhibit increased chromosomal abnormalities, and although lower fertilization and pregnancy rates are reported in NOA patients compared to other forms of infertility, the available evidence does not suggest a significant increase in miscarriage rate, congenital malformation, or developmental delay in their offspring compared to the offspring of patients with less severe forms of infertility or the offspring of fertile men. However, due to limited data, NOA patients should receive specialized reproductive care and personalized management. Counseling of NOA patients is essential before initiating any fertility enhancement treatment not only to mitigate health risks associated with NOA but also to enhance the chances of successful outcomes and minimize possible risks to the offspring.

Role of Follicle-stimulating Hormone, Inhibin B, and Anti-Müllerian Hormone in Predicting Sperm Retrieval from Men with Nonobstructive Azoospermia Undergoing Microdissection Testicular Sperm Extraction: A Systematic Review and Meta-analysis

Background and objective

No clear-cut markers for predicting positive sperm retrieval (+SR) at microdissection testicular sperm extraction (mTESE) have been identified thus far. Our aim was to conduct a systematic review and meta-analysis to evaluate the ability of follicle-stimulating hormone (FSH), inhibin B (InhB), and anti-Müllerian hormone (AMH) to predict +SR in men with nonobstructive azoospermia (NOA) undergoing mTESE.

Methods

We performed a search in the PubMed, EMBASE, Web of Science, and Scopus databases according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Thirty-four publications were selected for inclusion in the analysis.

Key findings and limitations

Overall, the mean +SR rate was 45%. Pooled standardized mean difference (SMD) values revealed significant hormonal differences between the +SR and -SR groups, with lower FSH (SMD -0.30), higher InhB (SMD 0.54), and lower AMH (SMD -0.56) levels in the +SR group. Pooled odds ratios (Ors) revealed no significant prediction of +SR by either FSH (OR 1.03, 95% confidence interval [CI] 1.00-1.06) or InhB (OR 1.01, 95% CI 1.00-1.02), despite variations in baseline levels and study heterogeneity. Conversely, AMH had significant predictive value (OR 0.82, 95% CI 0.73-0.92), with lower baseline levels in the +SR group. InhB and FSH levels were higher in the +SR group, while InhB exhibited the opposite trend.

Conclusions and clinical implications

Despite study heterogeneity, our meta-analysis findings support the ability of AMH to predict +SR for men with NOA undergoing mTESE.

Patient summary

We conducted a review and analysis of results from previous studies. Our findings show that for men with an infertility condition called nonobstructive azoospermia, blood levels of anti-Müllerian hormone can predict successful extraction of sperm using a microsurgical technique. Levels of two other hormones did not predict successful sperm extraction.

The Role of Circular RNAs in Male Infertility and Reproductive Cancers: A Narrative Review

Infertility is a global health problem affecting about 15% of all couples, of which 50% are due to male infertility. Although the etiology of infertility is known in most infertile men, idiopathic male infertility remains a challenge. Therefore, there is a need for novel diagnostic methods to detect the underlying mechanisms and develop appropriate therapies. Recent studies have focused on the role of non-coding RNAs (ncRNAs) in male infertility. Circular RNAs (CircRNAs), a type of ncRNAs, are found to play a key role in the development of some pathological conditions, including cardiovascular diseases, diabetes, cancers, autoimmune diseases, etc. Several studies have reported the presence of CircRNAs and their target genes in the human reproductive system. In addition, their expression in testicular tissues, sperm cells, and seminal fluid has been identified. Abnormal expression of CircRNAs has been associated with azoospermia and asthenozoospermia in infertile men. The present narrative review provides a brief description of the role of CircRNAs in spermatogenic cells, male infertility, and reproductive cancers. In addition, some CircRNAs have been identified as potential biomarkers for disease detection and treatment.

Predictive factors for successful testicular biopsy

INTRODUCTION

Infertility, the inability to conceive, constitutes a major problem in modern societies. It affects 10 to 15 percent of couples in the United States. Evaluation of infertile men is usually complex and often demands a testicular biopsy.

MATERIALS AND METHODS

We reviewed all azoospermic men submitted to testicular biopsy, in our center, during infertility investigation between January 2015 and December 2021.

RESULTS

A total of 117 patients with a mean age of 36.5 was considered. Biopsy was positive, as defined by the presence of viable spermatozoids by microscopy, in 48.7% of patients (n = 57). Patients were divided in two separate groups based on positive (PB) or negative biopsy (NB) and compared. PB-group had normal serum total testosterone levels and higher than NB-group (3.7 ng/mL vs. 2.85 ng/mL, p = 0.021), and normal serum FSH levels and lower than NB-group (6.0 mIU/mL vs. 16.0 mIU/mL, p < 0.001). The groups were similar concerning serum LH levels (3.9 mIU/mL vs. 6.3 mIU/mL, p = 0.343.

CONCLUSIONS

Predicting outcomes of testicular biopsy is a difficult task. Our study found that men with normal testicular volume, normal levels of testosterone and FSH and those with type 1 diabetes mellitus had a higher probability of positive testicular biopsy.

Testosterone to Luteinizing Hormone Ratio as a Potential Predictor of Sperm Retrieval in Non-Obstructive Azoospermia Patients

PURPOSE

This study assessed the outcomes of microsurgical testicular sperm extraction (mTESE) and potential preoperative predictors of sperm retrieval (SR) in patients with non-obstructive azoospermia (NOA).

MATERIALS AND METHODS

Clinical data of 111 NOA patients who underwent mTESE was reviewed retrospectively. Baseline patient characteristics, including age, body mass index (BMI), testicular volumes, and preoperative endocrine levels, such as testosterone (T), follicle-stimulating hormone (FSH), serum-luteinizing hormone (LH), prolactin, sex hormone-binding globulin (SHBG), FSH/LH ratio along with T/LH ratio, were analyzed. After categorizing the patients into two groups based on SR success or failure, logistic regression analysis was performed to identify the preoperative predictors of successful SR.

RESULTS

Sixty-eight patients had successful SR (61.3%), whereas 43 patients (38.7%) showed negative results. Failed SR group had elevated serum FSH and LH levels, whereas successful SR patients had a significantly larger testicular volume (p<0.001). Moreover, the successful group had a higher T/LH ratio (p<0.001). Multivariate logistic analysis showed that the T/LH ratio, serum FSH levels, and bilateral testicular volumes were significantly associated with successful sperm extraction.

CONCLUSION

In addition to traditional predictors, such as testicular volume and preoperative FSH levels, the T/LH ratio is a potential independent predictor of successful SR in infertile patients with NOA.

A Machine Learning Approach for the Prediction of Testicular Sperm Extraction in Nonobstructive Azoospermia: Algorithm Development and Validation Study

BACKGROUND

Testicular sperm extraction (TESE) is an essential therapeutic tool for the management of male infertility. However, it is an invasive procedure with a success rate up to 50%. To date, no model based on clinical and laboratory parameters is sufficiently powerful to accurately predict the success of sperm retrieval in TESE.

OBJECTIVE

The aim of this study is to compare a wide range of predictive models under similar conditions for TESE outcomes in patients with nonobstructive azoospermia (NOA) to identify the correct mathematical approach to apply, most appropriate study size, and relevance of the input biomarkers.

METHODS

We analyzed 201 patients who underwent TESE at Tenon Hospital (Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris), distributed in a retrospective training cohort of 175 patients (January 2012 to April 2021) and a prospective testing cohort (May 2021 to December 2021) of 26 patients. Preoperative data (according to the French standard exploration of male infertility, 16 variables) including urogenital history, hormonal data, genetic data, and TESE outcomes (representing the target variable) were collected. A TESE was considered positive if we obtained sufficient spermatozoa for intracytoplasmic sperm injection. After preprocessing the raw data, 8 machine learning (ML) models were trained and optimized on the retrospective training cohort data set: The hyperparameter tuning was performed by random search. Finally, the prospective testing cohort data set was used for the model evaluation. The metrics used to evaluate and compare the models were the following: sensitivity, specificity, area under the receiver operating characteristic curve (AUC-ROC), and accuracy. The importance of each variable in the model was assessed using the permutation feature importance technique, and the optimal number of patients to include in the study was assessed using the learning curve.

RESULTS

The ensemble models, based on decision trees, showed the best performance, especially the random forest model, which yielded the following results: AUC=0.90, sensitivity=100%, and specificity=69.2%. Furthermore, a study size of 120 patients seemed sufficient to properly exploit the preoperative data in the modeling process, since increasing the number of patients beyond 120 during model training did not bring any performance improvement. Furthermore, inhibin B and a history of varicoceles exhibited the highest predictive capacity.

CONCLUSIONS

An ML algorithm based on an appropriate approach can predict successful sperm retrieval in men with NOA undergoing TESE, with promising performance. However, although this study is consistent with the first step of this process, a subsequent formal prospective multicentric validation study should be undertaken before any clinical applications. As future work, we consider the use of recent and clinically relevant data sets (including seminal plasma biomarkers, especially noncoding RNAs, as markers of residual spermatogenesis in NOA patients) to improve our results even more.

Germ cell-specific proteins AKAP4 and ASPX facilitate identification of rare spermatozoa in non-obstructive azoospermia

Non-obstructive azoospermia (NOA), the most severe form of male infertility, could be treated with intra-cytoplasmic sperm injection, providing spermatozoa were retrieved with the microdissection testicular sperm extraction (mTESE). We hypothesized that testis- and germ cell-specific proteins would facilitate flow cytometry-assisted identification of rare spermatozoa in semen cell pellets of NOA patients, thus enabling non-invasive diagnostics prior to mTESE. Data mining, targeted proteomics, and immunofluorescent microscopy identified and verified a panel of highly testis-specific proteins expressed at the continuum of germ cell differentiation. Late germ cell-specific proteins AKAP4_HUMAN and ASPX_HUMAN (ACRV1 gene) revealed exclusive localization in spermatozoa tails and acrosomes, respectively. A multiplex imaging flow cytometry assay facilitated fast and unambiguous identification of rare but morphologically intact AKAP4⁺/ASPX⁺/Hoechst⁺ spermatozoa within debris-laden semen pellets of NOA patients. While the previously suggested markers for spermatozoa retrieval suffered from low diagnostic specificity, the multi-step gating strategy and visualization of AKAP4⁺/ASPX⁺/Hoechst⁺ cells with elongated tails and acrosome-capped nuclei facilitated fast and unambiguous identification of the mature intact spermatozoa. AKAP4⁺/ASPX⁺/Hoechst⁺ assay may emerge as a non-invasive test to predict retrieval of morphologically intact spermatozoa by mTESE, thus improving diagnostics and treatment of severe forms of male infertility.

Testicular Core Extraction: Important Technique for Determining Sperm Retrieval Method in Non-obstructive Azoospermia

OBJECTIVE

To assess the value of preliminary testicular core extraction (TCE) as a tool for determining whether to pursue clinic testicular extraction (cTESE) versus microscopic testicular sperm extraction (mTESE) to minimize both financial burden and procedural complexity.

METHODS

All men with non-obstructive azoospermia (NOA) from 2018 to 2022 who underwent clinic TCE were analyzed. Patients who were found to have sperm on initial TCE were recommended cTESE. Patients who did not have sperm on initial TCE were recommended for mTESE. Sensitivity, specificity, positive predictive value, and negative predictive value of TCE were calculated. Cost reductions were determined based on this institution's fees. A nonparametric Wilcoxon test was performed to determine statistical significance between the results of the TCE sperm present and sperm absent groups.

RESULTS

Of the 82 NOA patients undergoing TCE, 51 (62.2%) core biopsies were positive for sperm and 31 (37.8%) were negative for sperm. The SRR for 35 men who then underwent cTESE following sperm seen on TCE was 97.1%. The SRR for 8 men who underwent mTESE after no sperm was found on TCE was 75%. The positive predictive value of TCE for successful TESE result is 94.4% for men with NOA. Treatment success rate of TCE and cTESE was 79.1% with a cost reduction of 59.4%.

CONCLUSION

TCE is a prognostic tool to guide decision making between cTESE and mTESE and maximize sperm retrieval rate while mitigating financial burden and operative complexity. TCE is important to identify ideal candidates for both procedures to maximize efficacy and safety amongst men with NOA.

Histological and immunohistochemical outcomes after microdissection TESE in contrast with hormonal profile, testis volume and genetics in patients with azoospermia

A limited number of individuals with non-obstructive azoospermia (NOA) may recover spermatozoa through traditional testicular sperm extraction (TESE) techniques. There is an ongoing debate over the effectiveness of microdissection TESE compared to standard TESE methods. Microdissection TESE (micro-TESE) techniques enable the identification of spermatogenesis foci in non-obstructive forms of azoospermia. Only histological examination can provide an objective and definitive assessment of the testicular phenotype. This study aimed to evaluate the correlation between histopathological findings after microdissection TESE (micro-TESE) and the predictive role of various factors in determining the success of sperm retrieval. We evaluated 24 patients with azoospermia who underwent micro-TESE and considered the patient's hormonal profile, testis ultrasound, genetic evaluation, histology, and immunohistology (PLAP antibody) of collected testis biopsies. The preoperative blood FSH level, in conjunction with other parameters, may aid in the prediction of micro-TESE success. Sensitivity increases, and specificity decreases with higher FSH levels. Furthermore, testicular volume and FSH levels are typically normal in patients with maturation arrest. In conclusion, hormones, ultrasound evaluation of the testicles, testis volume, and available genetic tests have a predictive value in differentiating obstructive azoospermia (OA) from NOA with various sensitivity and specificity rates. Histological and immunohistochemical evaluation establishes the testicular phenotype accurately and guides patient management.

Can PCNA and LIM15 gene expression levels predict sperm retrieval success in men with non-obstructive azoospermia?

INTRODUCTION AND OBJECTIVES

It is necessary to be able to predict sperm retrieval before microdissection testicular sperm extraction (mTESE) in azoospermic men. This study established the importance of proliferating cell nuclear antigen (PCNA) and LIM15 gene expression levels in predicting the success of sperm retrieval by mTESE.

MATERIALS AND METHODS

One hundred and forty-three men who were diagnosed with non-obstructive azoospermia (NOA) were included in the study. Patients' age, total testosterone and follicle stimulating hormone values, testicular volume and testicular histology were recorded by prospectively. PCNA and LIM15 gene expression levels were determined by real-time PCR in the materials from both ejaculate and testicular specimens.

RESULTS

Testis volume and histology were the most important factors in predicting the sperm retrieval rate (SRR). The PCNA and LIM15 gene expression levels measured in testicular tissues and the LIM15 gene expression levels measured in ejaculate significantly correlated with the SRR in mTESE (p=0.038, p=0.022, and p=0.004, respectively). Although the PCNA gene expression level measured in ejaculate was higher in men with successful sperm retrieval, the difference was not statistically significant (p=0.061). According to the multivariate logistic regression analysis, testicular volume and LIM15 gene expression level in ejaculate were independent predictive parameters for sperm retrieval.

CONCLUSION

The data showed that LIM15 gene expression level in ejaculate is a useful molecular marker to predict the SRR before mTESE.

Development and validation predictive models of sperm retrieval for azoospermic men undergoing testicular sperm aspiration: a multicentre, retrospective, cohort study

PURPOSE

Testicular sperm aspiration (TESA) is widely used to retrieve sperm from testis. Diagnostic testicular biopsy should not be routinely performed for azoospermia. Therefore, a good predictive model is needed before TESA.

METHODS

A total of 1972 azoospermia patients constituted the modelling set, and 260 azoospermia patients from two other centres constituted the validation set. An integrated predictive model was built using logistic regression. Receiver operating characteristic (ROC), calibration and decision curve analyses were performed to evaluate the performance of follicle-stimulating hormone (FSH), semen volume, testicular volume and the integrated model.

RESULTS

The FSH level was the best univariate predictor for successful sperm retrieval (SSR) and was better than semen volume and testicular volume alone (p<0.001, threshold 6.17 IU/L, modelling set area under receiver operating characteristic curve (AUC) 0.80, accuracy 0.79; validation set AUC 0.87, accuracy 0.78). The integrated predictive model had excellent accuracy for predicting SSR (modelling set: AUC 0.93, accuracy 0.89; validation set: AUC 0.96, accuracy: 0.89). Calibration curve analysis indicated that the integrated model calibration was good and better than that of FSH, semen volume and testicular volume alone. Decision curve analysis indicated with a threshold probability between 0.05 and 0.98, the integrated model added more benefit than treating either all or no patients.

CONCLUSIONS

The integrated model has excellent discrimination and good calibration. It can help azoospermic men make better decisions before TESA. It should be noted that TESA is not the first-line treatment for non-obstructive azoospermia because of a low sperm retrieval rate.

Combined Trifocal and Microsurgical Testicular Sperm Extraction Enhances Sperm Retrieval Rate in Low-Chance Retrieval Non-Obstructive Azoospermia

Background: Low-chance retrieval non-obstructive azoospermic (NOA) patients are a subpopulation of NOA patients. The objective of this study is to compare the surgical outcome of microsurgical-assisted testicular sperm extraction (M-TeSE) and combined trifocal/M-TeSE in low-chance retrieval NOA patients. Material and Methods: A single-center retrospective analysis of NOA patients who underwent testicular sperm extraction was performed. Low-chance retrieval NOA (testicular volume < 10 cc and FSH > 12.4 UI/L) was set as the inclusion criteria. Re-do TeSE procedures were excluded from the current analysis. Data were extrapolated from clinical records and operative notes. We compared data from patients who underwent classic M-TeSE (group A) with that from patients submitted to combined trifocal/M-TeSE (group B). Sperm retrieval rate (SRr) was the primary outcome of the study. Surgical outcomes and postoperative complications were evaluated. A multivariate analysis was conducted to investigate predictive factors for positive SR. Results: Overall, 80 patients (60 patients in Group A and 20 patients in Group B) fulfilled the inclusion criteria. The average (SD) age was 35 (8.2) years. The average preoperative FSH was 27.5 (13) UI/L. The average testicular volume was 6.3 (3) cc on the left side and 6.8 (2.5) cc on the right. Groups were similar in terms of preoperative parameters. The overall SRr was 28%. Patients in group B had higher SRr than those in group A (29.4% vs. 26.9%, p < 0.03). We identified a significant association between testicular histopathology and positive SR (hypospermatogenesis 100%, spermatogenic arrest 32%, and Sertoli cell-only syndrome 22%). The histopathology report was the only significant predicting factor for SR in the multivariate analysis. Conclusion: The combined trifocal and M-TeSE approach is safe and may represent a valuable approach to enhance the SRr in low-chance retrieval NOA. The histopathology report is confirmed to be the only valuable predicting factor for a positive SR.

Factors predicting successful sperm retrieval in men with nonobstructive Azoospermia: A single center perspective

Predicting successful sperm retrieval is essential in counseling infertile men with Azoospermia.

Objectives

To assess the predictors of successful sperm extraction in men with nonobstructive Azoospermia.

Patients and Methods

A retrospective study included all patients with nonobstructive Azoospermia from January 2018 to May 2019. Subdivided into two groups, group I (negative sperm retrieval) and group II (positive sperm retrieval).

Results

A total of 108 patients with a mean age of 36.8 ± 10 years were included. The rate of successful sperm retrieval was 47.2%. Group I included 57 patients (52.8%) with a mean age of 33.98 ± 6.18, and group II included 51 patients (47.2%) with a mean age of 40.04 ± 12.22 (p = 0.008). Follicular stimulating hormone (FSH) levels were significantly higher in group I (18.55 ± 13 vs. 7.97 ± 7.11; p < 0.004). Similarly, in group I, luteinizing hormone was significantly higher (11.4 ± 7.45 vs. 5.9 ± 4.4; p < 0.001). Age and FSH were the independent predictors of successful micro-TESE. Additionally, successful pregnancies were 13.7% of patients, 28.6% of which gave rise to living birth.

Conclusion

Patients' age and serum FSH are independent predictors of successful sperm retrieval for infertile men with nonobstructive Azoospermia; young patients with high FSH levels could have little chance of sperm retrieval.

Micro-testicular sperm extraction outcomes for non-obstructive azoospermia in a single large clinic in Victoria

AIMS

To evaluate the results of microdissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI) for treatment of non-obstructive azoospermia (NOA).

MATERIALS AND METHODS

We retrospectively analysed data of 88 consecutive patients with clinical NOA who were treated with micro-TESE by a single surgeon, between August 2014 and September 2020, in Melbourne, Victoria. Upon a successful sperm retrieval, sperm was either used fresh for ICSI, frozen for future use or both. The outcome measures were sperm retrieval rate (SRR), and in vitro fertilisation (IVF)/ICSI results. Furthermore, SRR was calculated for the predominant causes and histopathological patterns.

RESULTS

The overall SRR was 61.2%. It was significantly higher in patients with a history of cryptorchidism and other childhood diseases (100%) than in the other NOA groups (P < 0.05). Patients with Klinefelter syndrome had a 75% SRR. Among the different types of testicular histology, the highest SRR were noted in patients with complete hyalinisation (100%) and hypospermatogenesis (92.9%), and low with Sertoli cell-only syndrome (46.3%). The SRR has significantly increased from 33.3% in 2015-2016 to 73.6% in 2019-2020 (P = 0.009). Of the 52 patients with SSR, 47 underwent IVF/ICSI. Fertilisation rate was 42.4%. Twenty-nine couples achieved at least one good-quality embryo and had embryo transfer. Nineteen achieved pregnancy (40.4%), and in three patients a miscarriage resulted.

CONCLUSIONS

This is the first report from Australia showing that micro-TESE is an effective treatment for NOA with high SRR. The increasing success rates over several years indicate the importance of surgical skill and laboratory staff experience.

Outcomes and affecting factors for ICSI and microTESE treatments in nonobstructive azoospermia patients with different etiologies: A retrospective analysis

INTRODUCTION

Nonobstructive azoospermia (NOA) is a common and severe form of male infertility. Microdissection testicular sperm extraction (microTESE) combined with intracytoplasmic sperm injection (ICSI) is an optimal treatment for men with NOA. However, the outcomes and affecting factors of ICSI for NOA patients with different etiologies receiving microTESE treatment are still unclear.

METHODS

A total of 335 NOA patients undergoing microTESE from January 2017 to December 2021 were included in this retrospective analysis. The patients were divided into five groups (idiopathic, Klinefelter syndrome (KS), Y chromosome microdeletions (YCMDs), cryptorchidism and mumps orchitis) according to the etiologies. The clinical characteristics and outcomes of microTESE and ICSI were collected and comparisons were performed between clinical characteristics of patients who had successful sperm retrieval (SSR) and sperm retrieval failure (SRF). In addition, relationships between clinical characteristics and rates of SSR were explored by Kendall correlation analysis.

RESULTS

The overall SSR rate was 40.90%. SSR rate of the idiopathic group (31.22%) was the lowest and was much lower than that of other groups (KS: 48.65%, 28/58; YCMDs: 60.87%; cryptorchidism: 80.95%; mumps orchitis: 75.00%). The overall fertilization rate was 72.26%. No group differences were found among five groups (idiopathic: 73.91%; KS: 71.43%; YCMDs: 64.29%; cryptorchidism: 70.59%; mumps orchitis: 77.78%). The overall clinical pregnancy rate was 66.67%. No group differences were found among five groups (idiopathic: 68.63%; KS: 65.00%; YCMDs: 44.44%; cryptorchidism: 66.67%; mumps orchitis: 85.71%). The overall live birth rate was 66.67%. No group differences were found among five groups (idiopathic: 71.43%; KS: 53.85%; YCMDs: 50.00%; cryptorchidism: 75.00%; mumps orchitis: 66.67%). For SSR patients, the average age was significantly lower in the idiopathic group, while the average testicular volume was significantly greater in the cryptorchidism and mumps orchitis groups. However, no significant differences were found in the level of follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (T) between patients who had SSR and SRF. In addition, negative relationships were found between age and rates of SSR in idiopathic NOA patients while positive relationships were found between testis volume and rates of SSR in patients with cryptorchidism and mumps orchitis.

CONCLUSION

Patients with idiopathic NOA had lowest SSR. In addition, the age in idiopathic NOA patients was a predictor for SSR while testicular volume in NOA patients with cryptorchidism and mumps orchitis was a predictor for SSR. However, the relationships between clinical characteristics and clinical outcomes in NOA patients were preliminary, and further validation needed to be carried out in a larger sample to increase statistical capacity before a definitive conclusion could be drawn.

FSH levels and testicular volumes are associated with the severity of testicular histopathology in men with non-obstructive azoospermia

Purpose

The purpose of this study is to assess a potential association between FSH levels and testicular volumes with the severity of testicular histopathology on testicular biopsy in men with non-obstructive azoospermia (NOA) undergoing microdissection testicular sperm extraction (microTESE).

Methods

A retrospective chart review was performed from the electronic health records of men who underwent microTESE with NOA.

Results

Eighty-six men with NOA underwent microTESE with concomitant testicular biopsy for permanent section to assess the testicular cellular architecture. The histopathological patterns were categorized by severity indicating the odds of sperm retrieval into 2 categories. The unfavorable category included Sertoli cell only pattern and early maturation arrest (n = 50) and the favorable category included late maturation arrest and hypospermatogenesis patterns (n = 36). In the men with unfavorable histopathologic patterns, the mean FSH level was 22.9 ± 16.6 IU/L, and the mean testicular volume was 10.4 ± 6.0 cc. This was in comparison to men with favorable histopathologic patterns revealing a mean FSH level of FSH 13.3 ± 12.0 with a mean testicular volume of 13.3 ± 5.9 cc. There was a statistically significant higher FSH level in men with unfavorable histopathology than favorable (p = 0.004) as well as a significant smaller mean testicular volume in men with unfavorable histopathology (p = 0.029).

Conclusions

Higher serum FSH levels and smaller testicular volumes are associated with more severe testicular histopathological patterns in men with NOA.

Clinical benefit for cryopreservation of single human spermatozoa for ICSI: A systematic review and meta-analysis

BACKGROUND

Systematic reviews have focused on sperm recovery and post-thaw parameters after cryopreservation, but there no information on the associated clinical outcomes. In recent years, an increasing number of studies have reported cryopreservation of a single sperm due to the importance of fertility preservation.

OBJECTIVES

To assess whether the cryopreservation of single human spermatozoa improves clinical outcomes in patients with azoospermia or severe oligospermia.

MATERIALS AND METHODS

We conducted an extensive literature search using the following databases, CENTRAL, CNKI, Cochrane Systematic Reviews, EMBASE, MEDLINE, PUBMED, and Web of Science for relevant studies published through December 31, 2019. We calculated the pooled proportions of cryopreservation of single human spermatozoon to assess the recovery, survival, fertilization, pregnancy, miscarriage, and delivery rates. Subgroup analyses were performed for the following covariates, a) different carriers, b) year of publication, and c) source of sperm.

RESULTS

We included 25 studies, which included 13 carriers. The pooled proportion of recovery rate of spermatozoa cryopreserved was 92% (95% CI, 87%-96%), and the survival, fertilization, pregnancy, miscarriage, and delivery rate were 76% (95% CI, 69%-83%), 63% (95% CI, 58%-67%), 57% (95% CI, 39%-74%), 12% (95% CI, 0%-33%), and 40% (95% CI, 12%-71%), respectively. Based on the subgroup analysis, the recovery and survival rates of frozen spermatozoa in subgroup of different carriers were statistically significant. In the past decaade, frozen single human spermatozoon technology has improved the recovery rates of frozen-thawed spermatozoa. However, the differences in clinical outcomes of frozen spermatozoa in subgroup of different sources of sperm were not statistically significant.

DISCUSSION AND CONCLUSION

The techniques for single human spermatozoa are feasible and efficient and may benefit patients with severe oligospermia or azoospermia. This article is protected by copyright. All rights reserved.

Hormonal markers as noninvasive predictors of sperm retrieval in non-obstructive azoospermia

Non-obstructive azoospermia (NOA) is one of the leading causes of male factor infertility, which results from impaired spermatogenesis. Currently, the sole feasible therapeutic option for men with NOA to father their biologic children is sperm retrieval by testicular sperm extraction (TESE) approaches followed by an intracytoplasmic sperm injection program. Nevertheless, the rate of sperm retrieval from NOA men following TESE has remained as low as 50%, leading to a significant number of unsuccessful TESE operations. Given that TESE is associated with multiple side effects, the prediction of TESE outcome preoperatively can abolish unnecessary operations and thereby prevent NOA patients from sustaining adverse side effects. As the process of spermatogenesis is under the regulation of hormones, the hormonal profile of serum and/or seminal plasma may contain useful information about spermatogenesis status and can potentially predict the chance of sperm retrieval from NOA patients. A large body of literature is available on the predictive capability of different serum and seminal plasma hormones such as FSH, LH, testosterone, inhibin B, AMH, estradiol, prolactin, and leptin in a stand-alone basis or combinational fashion with respect to the TESE outcome. The present review aimed to evaluate the potential of these hormonal markers as noninvasive predictors of sperm retrieval in men with NOA.

Predictors of testicular sperm retrieval in patients with non-obstructive azoospermia: a review

Azoospermia is divided into two categories of obstructive azoospermia and non-obstructive azoospermia. Before 1995, couples with a male partner diagnosed with non-obstructive azoospermia had to choose sperm donation or adoption to have a child. Currently, testicular sperm aspiration or micro-dissection testicular sperm extraction combined with intracytoplasmic sperm injection allows patients with non-obstructive azoospermia to have biological offspring. The sperm retrieval rate is significantly higher in micro-dissection testicular sperm extraction compared with testicular sperm aspiration. Additionally, micro-dissection testicular sperm extraction has the advantages of minimal invasion, safety, limited disruption of testicular function, a low risk of postoperative intratesticular bleeding, and low serum testosterone concentrations. Failed micro-dissection testicular sperm extraction has significant emotional and financial implications on the involved couples. Testicular sperm aspiration and micro-dissection testicular sperm extraction have the possibility of failure. Therefore, predicting the sperm retrieval rate before surgery is important. This narrative review summarizes the existing data on testicular sperm aspiration and micro-dissection testicular sperm extraction to identify the possible factor(s) that can predict the presence of sperm to guide clinical practice. The predictors of surgical sperm retrieval in patients with non-obstructive azoospermia have been widely studied, but there is no consensus.

A panel of extracellular vesicle long noncoding RNAs in seminal plasma for predicting testicular spermatozoa in nonobstructive azoospermia patients

STUDY QUESTION

Whether the testis-specific extracellular vesicle (EV) long noncoding RNAs (lncRNAs) in seminal plasma could be utilized to predict the presence of testicular spermatozoa in nonobstructive azoospermia (NOA) patients?

SUMMARY ANSWER

Our findings indicate that the panel based on seminal plasma EV lncRNAs was a sensitive and specific method in predicting the presence of testicular spermatozoa and may improve clinical decision-making of NOA.

WHAT IS KNOWN ALREADY

The adoption of sperm retrieval techniques, especially microdissection testicular sperm extraction (mTESE), in combination with ICSI has revolutionized treatment for NOA. However, there are no precise and noninvasive methods for predicting whether there are testicular spermatozoa in NOA patients before mTESE.

STUDY DESIGN, SIZE, DURATION

RNA sequencing was performed on seminal plasma EVs from 6 normozoospermic men who underwent IVF due to female factor and 5 idiopathic NOA patients who failed to obtain testicular spermatozoa by mTESE and were diagnosed as having Sertoli cell-only syndrome by postoperative pathology. A biomarker panel of lncRNAs was constructed and verified in 96 NOA patients who underwent mTESE. Decision-making process was established based on the panel in seminal plasma EVs from 45 normozoospermia samples, 43 oligozoospermia samples, 62 cryptozoospermia samples, 96 NOA samples.

PARTICIPANTS/MATERIALS, SETTING, METHODS

RNA sequencing was done to examine altered profiles of EV lncRNAs in seminal plasma. Furthermore, a panel consisting of EV lncRNAs was established and evaluated in training set and validation sets.

MAIN RESULTS AND THE ROLE OF CHANCE

A panel consisting of nine differentially expressed testis-specific lncRNAs, including LOC100505685, SPATA42, CCDC37-DT, GABRG3-AS1, LOC440934, LOC101929088 (XR_927561.2), LOC101929088 (XR_001745218.1), LINC00343 and LINC00301, was established in the training set and the AUC was 0.986. Furthermore, the AUC in the validation set was 0.960. Importantly, the panel had a unique advantage when compared with models based on serum hormones from the same group of NOA cases (AUC, 0.970 vs 0.723; 0.959 vs 0.687, respectively). According to the panel of lncRNAs, a decision-making process was established, that is when the score of an NOA case exceeds 0.532, sperm retrieval surgery may be recommended.

LIMITATIONS, REASONS FOR CAUTION

In the future, the sample size needs to be further expanded. Meanwhile, the regulatory functions and mechanism of lncRNAs in spermatogenesis also need to be elucidated.

WIDER IMPLICATIONS OF THE FINDINGS

When the score of our panel is below 0.532, subjecting the NOA patients to ineffective surgical interventions may not be recommended due to poor sperm retrieval rate.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (81871110, 81971314 and 81971759); the Guangdong Special Support Plan-Science and Technology Innovation Youth Top Talents Project (2016TQ03R444); the Science and Technology Planning Project of Guangdong Province (2016B030230001 and 201707010394); the Key Scientific and Technological Program of Guangzhou City (201604020189); the Pearl River S&T Nova Program of Guangzhou (201806010089); the Transformation of Scientific and Technological Achievements Project of Sun Yat-sen University (80000-18843235) and the Youth Teacher Training Project of Sun Yat-sen University (17ykpy68 and 18ykpy09). There are no competing interests related to this study.

TRIAL REGISTRATION NUMBER

N/A.

Evaluation of Microdissection Testicular Sperm Extraction (mTESE), Outcomes and Predictive Factors in Ireland: The Gold Standard for Men with Non-Obstructive Azoospermia

Background

Microdissection testicular sperm extraction (mTESE) is the gold standard approach in sperm retrieval in men with non-obstructive azoospermia (NOA). The purpose of the study was to assess the outcomes for Irish men who have undergone mTESE with a single surgeon.

Methods

This is a retrospective, single cohort study. Thirty-four patients underwent mTESE between September 2015 and June 2019. A p<0.05 was considered statistically significant.

Results

In this study, sperm retrieval rate (SRR) was 47.06%. (16/34). The mean age in those who had retrieved sperm at mTESE was 37.9±2.6 years. Johnson Score (JS) and FSH were statistically different between successful and unsuccessful mTESE groups (p=0.017*10^-5 and p=0.004, respectively). Optimal cutoff values for FSH, T and JS were 15 IU/L, 13 nmol/L and 5, respectively. The pregnancy rate was 63.64% (7/11) among men who went on to use mTESE sperm in an ICSI cycle.

Conclusion

The combination of mTESE/Intracytoplasmic sperm injection (ICSI) is the best option available for men with NOA who prefer to achieve paternity using their own DNA. Given the overall SRRs in mTESE, it is imperative to continue research for a predictive model to better counsel azoospermic men regarding the use of mTESE. For this purpose, large, multicenter, randomized controlled trials are needed.

Relationship between serum zinc concentration and semen quality in newly-wed men

OBJECTIVES

To clarify factors associated with semen quality and confirm whether there is an association between semen quality and serum zinc concentration.

METHODS

A semen test was performed on 217 men just after or just before marriage. Variables assessed in the study were: age; symptomatic scores, including sexual function evaluated using several specific questionnaires; endocrinological profiles, especially follicle-stimulating hormone; and serum zinc concentrations. Based on World Health Organization criteria for assessing sperm quality, semen volume ≥1.5 mL, sperm concentration ≥15 million/mL, or sperm motility rate ≥40%, the men were grouped according to whether they had values below or above these criteria. The two groups were compared with regard to the study variables, and correlation between serum zinc concentration and semen quality was evaluated. Independent predictors for inclusion in the group with values below the criteria were investigated further.

RESULTS

Of the 217 men included in the study, 45 (20.7%) were categorized as having values below the World Health Organization criteria. The men in this group were significantly older and had significantly worse sexual function, significantly higher follicle-stimulating hormone levels, and significantly lower serum zinc concentrations, than those in the group with values above the criteria. There was no significant correlation between serum zinc concentration and semen quality. However, the independent predictors for having values below the criteria in binomial logistic regression analysis were follicle-stimulating hormone and serum zinc concentration.

CONCLUSION

We suggest that semen analysis may be considered in men with a low level of serum zinc and high level of follicle-stimulating hormone when developing a life plan for fertilization.

Can preoperative parameters predict successful sperm retrieval and live birth in couples undergoing testicular sperm extraction and intracytoplasmic sperm injection for azoospermia?

Background

We aimed to determine if the success of TESE and live-birth following TESE-ICSI can be predicted from readily available preoperative parameters for couples with azoospermia. Our methodology was as follows, this was a cohort study of couples who attended the fertility service (from 2009-2019) at an NHS hospital in whom the male partner was diagnosed with azoospermia and required conventional TESE with multiple biopsies to obtain sperm. Of 414 men included, 223 had successful TESE and of those 178 have used sperm in ICSI cycle(s). Predictive models were developed using logistic regression. We assessed model performance by internally validated concordance statistics and calibration plots. Successful sperm retrieval was defined as the presence of motile sperm which survived the freeze-thaw process and live-birth defined as delivery after 34 weeks of gestation.

Results

Successful TESE was associated with higher male age and lower FSH. The TESE model discriminated well with a c statistic of 0.81 (0.77-0.85). Live-birth was associated with lower maternal age, earlier ICSI cycle, and lower testicular volume. The live-birth model also discriminated well with a c statistic of 0.70 (0.64-0.76).

Conclusions

These results support the pragmatic counselling of couples diagnosed with azoospermia about the chances of success of the TESE procedure and of biological parenthood prior to surgical intervention. The models help to discriminate between men who have a high or low chance of successful TESE and couples who have a higher chance of achieving a live-birth after successful TESE. This will allow couples to make a better assessment of the balance of risk versus benefit prior to commitment to surgical interventions.

Hormonal Treatment of Men with Nonobstructive Azoospermia: What Does the Evidence Suggest?

Hormonal stimulation of spermatogenesis prior to surgery has been tested by some authors to maximize the sperm retrieval yield in patients with nonobstructive azoospermia. Although the rationale of such an approach is theoretically sound, studies have provided conflicting results, and there are unmet questions that need to be addressed. In the present narrative review, we reviewed the current knowledge about the hormonal control of spermatogenesis, the relationship between presurgical serum hormones levels and sperm retrieval rates, and the results of studies investigating the effect of hormonal treatments prior to microdissection testicular sperm extraction. We pooled the available data about sperm retrieval rate in patients with low vs. normal testosterone levels, and found that patients with normal testosterone levels had a significantly higher chance of successful sperm retrieval compared to those with subnormal T levels (OR 1.63, 95% CI 1.08–2.45, p = 0.02). These data suggest that hormonal treatment may be justified in patients with hypogonadism; on the other hand, the available evidence is insufficient to recommend hormonal therapy as standard clinical practice to improve the sperm retrieval rate in patients with nonobstructive azoospermia.

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

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

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

OBJECTIVE

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

DESIGN

Retrospective chart review.

SETTING

Academic tertiary medical center.

PATIENTS

A total of 297 patients with nonobstructive azoospermia.

INTERVENTIONS

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

MAIN OUTCOME MEASURE(S)

Development of a prediction model for positive SR with TESA.

RESULTS

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

CONCLUSIONS

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

A comprehensive assessment of predictors of fertility outcomes in men with non-obstructive azoospermia undergoing microdissection testicular sperm extraction

BACKGROUND

Microdissection testicular sperm extraction (microTESE) in men with non-obstructive azoospermia (NOA) is the procedure that results in the highest number of sperm cells retrieved for in vitro fertilization (IVF). This study presents a novel assessment of predictors of sperm retrieval as well as downstream embryology and pregnancy outcomes in cases of men with NOA undergoing microTESE.

METHODS

A retrospective chart review of 72 men who underwent microTESE for predictors of fertility outcomes including sperm retrieved at microTESE, embryology progression to embryo transfer (ET), clinical pregnancy, live birth, and surplus sperm retrieved for additional IVF/intracytoplasmic injection cycles beyond one initial cycle. Statistical models for each of these outcomes were fitted, with a p-value of < 0.05 considered significant for the parameters estimated in each model.

RESULTS

Seventy-two men underwent microTESE, and 51/72 (70.8%) had sperm retrieved. Of those, 29/43 (67.4%) reached ET. Of the couples who underwent ET, 21/29 (72.4%) achieved pregnancy and 18/29 (62.1%) resulted in live birth. Of the men with sperm retrieved, 38/51 (74.5%) had surplus sperm cryopreserved beyond the initial IVF cycle. Age, testicular volume, FSH, and testicular histopathology were assessed as predictors for sperm retrieved at microTESE, progression to ET, pregnancy, live birth, and surplus sperm. There were no preoperative predictors of sperm retrieval, clinical pregnancy, or live birth. Age predicted reaching ET, with older men having increased odds. FSH level had a negative relationship with surplus sperm retrieved. Men with hypospermatogenesis histology had higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm.

CONCLUSIONS

Men who underwent microTESE with a hypospermatogenesis histopathology had better outcomes, including higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm retrieved. Increasing male partner age increased the odds of reaching ET. No other clinical factors were predictive for the outcomes considered.

A risk prediction model of sperm retrieval failure with fine needle aspiration in males with non-obstructive azoospermia

STUDY QUESTION

Can we predict the risk of sperm retrieval failure among men with non-obstructive azoospermia (NOA) before they undergo fine needle aspiration (FNA)?

SUMMARY ANSWER

Our model, which includes FSH level, age and testicular volume as variables, can predict the risk of sperm retrieval failure with FNA.

WHAT IS KNOWN ALREADY

Combined with ICSI, testicular sperm aspiration (TESA) can enable patients with NOA to have their own genetic offspring. Nearly all reproductive medicine centres in China have applied FNA, but approximately half of patients with NOA experience testicular sperm retrieval failure. Nevertheless, the models developed to predict the likelihood of obtaining spermatozoa with testicular sperm extraction (TESE) cannot accurately predict sperm retrieval, and few of these models have been sufficiently validated.

STUDY DESIGN, SIZE, DURATION

This study involved three cohorts including 597 men with NOA. From 1 January 2015 to 31 July 2017, a retrospective cohort of 317 males with NOA who underwent FNA procedures at a university affiliated hospital were included to build a risk prediction model of sperm retrieval failure with FNA. Then, from 25 October 2017 to 31 March 2018, two prospective cohorts of 61 and 219 males with NOA from the same hospital and one other reproductive specialist hospital respectively, were recruited to validate the risk prediction model.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All men with NOA undergoing their first TESE procedure as part of a fertility treatment were included. The primary end-point was the presence of one or more spermatozoa (regardless of their motility) obtained with FNA. A binary multivariable logistic model was built to predict the risk of sperm retrieval failure after TESA using the dataset from the retrospective cohort. A cut-off value for risk was calculated with receiver operating characteristic (ROC) curve analysis. Two validation sets from the prospective cohort were used to validate the risk prediction model by measures including prediction accuracy and the true positive rate.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 327 (54.8%) males with NOA experienced sperm retrieval failure with FNA. FSH level, age and testicular volume were included in the prediction model for sperm retrieval failure risk. The model had an AUC of 82.3% (95% CI: 77.6–87.1%) and a cut-off value of 64.61% with a sensitivity of 0.677 and specificity of 0.863 for predicted risk. The predictive accuracies were 85.25 and 83.56% in the external validation sets from two centres. Specifically, 85.71 and 85.15% of NOA patients from two centres that experienced sperm retrieval failure were correctly identified using our model.

LIMITATIONS, REASONS FOR CAUTION

A small proportion of males with NOA in whom sperm were successfully retrieved with FNA were misclassified; therefore, TESA techniques with higher sperm retrieval rates may be attempted in patients with high predicted risks of sperm retrieval failure rather than terminating the efforts to produce a genetic offspring. In addition, the ability to achieve a live birth using sperm retrieved with FNA was not tested in this study.

WIDER IMPLICATIONS OF THE FINDINGS

We would recommend the use of micro-TESE for men with NOA and a high predicted risk of FNA failure.

STUDY FUNDING/COMPETING INTEREST(S)

This study was partly supported by National Key R&D Program of China (No. 2017YFC0907305), the National Natural Science Foundation of China (No.81803332), Sichuan Science & Technology Program (No. 2018SZ0144, 2016SZ0066, 2018SZ0284 and 2018FZ0043), Chengdu Science & Technology Bureau (No. 2018-YF05-01265-SN), Postdoctoral Research foundation of Sichuan University (No. 2018SCU12012) and West China Second University Hospital of Sichuan University (No. kx027). There are no competing interests related to this study.

TRIAL REGISTRATION NUMBER

Not applicable.

Prediction of sperm extraction in non-obstructive azoospermia patients: a machine-learning perspective

STUDY QUESTION

Can a machine-learning-based model trained in clinical and biological variables support the prediction of the presence or absence of sperm in testicular biopsy in non-obstructive azoospermia (NOA) patients?

SUMMARY ANSWER

Our machine-learning model was able to accurately predict (AUC of 0.8) the presence or absence of spermatozoa in patients with NOA.

WHAT IS KNOWN ALREADY

Patients with NOA can conceive with their own biological gametes using ICSI in combination with successful testicular sperm extraction (TESE). Testicular sperm retrieval is successful in up to 50% of men with NOA. However, to the best of our knowledge, there is no existing model that can accurately predict the success of sperm retrieval in TESE. Moreover, machine-learning has never been used for this purpose.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of 119 patients who underwent TESE in a single IVF unit between 1995 and 2017 was conducted. All patients with NOA who underwent TESE during their fertility treatments were included. The development of gradient-boosted trees (GBTs) aimed to predict the presence or absence of spermatozoa in patients with NOA. The accuracy of these GBTs was then compared to a similar multivariate logistic regression model (MvLRM).

PARTICIPANTS/MATERIALS, SETTING, METHODS

We employed univariate and multivariate binary logistic regression models to predict the probability of successful TESE using a dataset from a retrospective cohort. In addition, we examined various ensemble machine-learning models (GBT and random forest) and evaluated their predictive performance using the leave-one-out cross-validation procedure. A cutoff value for successful/unsuccessful TESE was calculated with receiver operating characteristic (ROC) curve analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

ROC analysis resulted in an AUC of 0.807 ± 0.032 (95% CI 0.743–0.871) for the proposed GBTs and 0.75 ± 0.052 (95% CI 0.65–0.85) for the MvLRM for the prediction of presence or absence of spermatozoa in patients with NOA. The GBT approach and the MvLRM yielded a sensitivity of 91% vs. 97%, respectively, but the GBT approach has a specificity of 51% compared with 25% for the MvLRM. A total of 78 (65.3%) men with NOA experienced successful TESE. FSH, LH, testosterone, semen volume, age, BMI, ethnicity and testicular size on clinical evaluation were included in these models.

LIMITATIONS, REASONS FOR CAUTION

This study is a retrospective cohort study, with all the associated inherent biases of such studies. This model was used only for TESE, since micro-TESE is not performed at our center.

WIDER IMPLICATIONS OF THE FINDINGS

Machine-learning models may lay the foundation for a decision support system for clinicians together with their NOA patients concerning TESE. The findings of this study should be confirmed with further larger and prospective studies.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Division of Obstetrics and Gynecology, Soroka University Medical Center, there are no potential conflicts of interest for all authors.

Predictors of surgical sperm retrieval in non-obstructive azoospermia: summary of current literature

Intracytoplasmic sperm injection (ICSI), combined with surgical sperm retrieval (SR) techniques, is the sole option for patients with non-obstructive azoospermia to achieve fertility; however, with suboptimal results. Given the variability in clinical presentation, the potential role of factors that can predict the likelihood of successful testicular SR needs to be clarified. This article summarizes the current evidence concerning the variables predicting SR success in non-obstructive azoospermic patients with spermatogenic failure. For this, we used 60 articles, including 46 original papers and six meta-analyses. Clinical and laboratory factors, as well as adjuvant therapies and surgical retrieval methods, were the factors most commonly investigated. We found that Klinefelter syndrome, Y chromosome microdeletions in regions AZFa/b, and Sertoli cell-only histopathology were associated with reduced SR success. By contrast, testis volume > 12.5 ml, history of cryptorchidism, use of micro-TESE as the sperm retrieval method, and adjuvant therapy were associated with improved SR success. None of the predictors, alone or combined, provide definitive information about the chances of harvesting sperm in men with non-obstructive azoospermia, except for Y chromosome microdeletions in regions AZFa/b. In the latter, SR success is virtually nil. We conclude that SR outcomes in men with non-obstructive azoospermia are difficult to predict based on the existing variables. Although several predictors can be used for patient counseling, their clinical value is limited to either ensure SR success or discourage reproductive urologists from recommending SR to men with non-obstructive azoospermia seeking fertility. A notable exception includes the deletions involving the regions AZFa and/or AZFb of the Y chromosome; the affected patients should be counseled against undergoing SR.

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.

Deficient Expression of DGCR8 in Human Testis is Related to Spermatogenesis Dysfunction, Especially in Meiosis I

Introduction

DiGeorge syndrome critical region gene 8 (DGCR8) contributes to miRNA biogenesis, and defects in its expression could lead to defects in spermatogenesis.

Methods

Here, we assess gene and protein expression levels of DGCR8 in the testicular biopsy specimens obtained from men with obstructive azoospermia (OA, n = 19) and various types of non-obstructive azoospermia (NOA) including maturation arrest (MA, n = 17), Sertoli cell-only syndrome (SCOS, n = 20) and hypospermatogenesis (HYPO, 18). Also, samples of men with NOA were divided into two groups based on successful and unsuccessful sperm recovery, NOA+ in 21 patients and NOA− in 34 patients.

Results

Examinations disclosed a severe decrease in DGCR8 in samples with MA and SCOS in comparison to OA samples (P < 0.001). Also, the results showed DGCR8 has significantly lower expression in testis tissues of NOA− group in comparison to NOA+ group (p<0.05). Western blot analysis confirmed that the DGCR8 protein was not expressed in SCOS samples and had a very low expression in MA and HYPO samples.

Discussion

The results of this survey showed that DGCR8 is an important gene for the entire spermatogenesis pathway. Moreover, DGCR8 gene plays an important role in the diagnosis of NOA subgroups, and also the expression changes in it might contribute to SCOS or MA phenotypes. This gene with considering other related genes can also be a predictor of sperm retrieval.

Prediction of microdissection testicular sperm extraction outcome in men with idiopathic nonobstruction azoospermia

The aim of the present study is to assess whether the preoperative clinical indicators have an impact on sperm retrieval rate (SRR) in men with idiopathic nonobstructive azoospermia (NOA).We retrospectively studied 241 consecutive men with NOA who underwent microdissection testicular sperm extraction from 2016 to 2019 in the Reproductive Medicine Center, including 154 patients diagnosed with idiopathic NOA. They were grouped according to preoperative indicators, including average testicular volume, follicle-stimulating hormone (FSH), luteinizing hormone, Testosterone (T), and pathology, respectively.The overall SRR was 20.0% (31/155). Men with testicular volume of ≤5 mL had significant higher SRR than men with testes 5 to 10 and ≥10 mL (35.6% vs 12.3%, P = .002; 35.6% vs 16.2, P = .049, respectively). The SRR in men with FSH ≥ 24.8 mIU/mL was significant higher, compared with FSH level of 12.4 to 24.8 mIU/mL (32.6% vs 15.8%, P = .033). Men with Sertoli cell-only had significantly lower SRR than other pathological type (8.1%). Men with an FSH ≥ 24.8 mIU/mL in testicular volume ≤5 mL group had a significantly higher SRR than FSH level of 12.4 to 24.8 mIU/mL in testicular volume of ≤5 to 10 mL group (44.0% vs 11.4%, P = .002). Men with a luteinizing hormone level of 8.6 to 17.2 mIU/mL in testicular volume of 5 to 10 mL group had a poor prognosis, with an SRR of only 6.5%.Severely reduced testicular volume (≤5 mL) and severely increased FSH level (≥24.8 mIU/mL) had the better sperm retrieval outcome, which can be used as independent predictors in men with idiopathic NOA. And a combination of testicular volume and the hormone seemed to be useful in further increase predictive value.

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

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

Upregulation of the RNF8 gene can predict the presence of sperm in azoospermic individuals

Objective

In this study, specimens from testicular biopsies of men with nonobstructive azoospermia (NOA) were used to investigate whether RNF8 gene could serve as a biomarker to predict the presence of sperm in these patients.

Methods

Testicular biopsy specimens from 47 patients were classified according to the presence of sperm (positive vs. negative groups) and investigated for the expression of RNF8. The level of RNF8 gene expression in the testes was compared between these groups using reverse-transcription polymerase chain reaction.

Results

The expression level of RNF8 was significantly higher in testicular samples from the positive group than in those from the negative group. Moreover, the area under the curve of RNF8 expression for the entire study population was 0.84, showing the discriminatory power of RNF8 expression in differentiating between the positive and negative groups of men with NOA. A receiver operating characteristic curve analysis showed that RNF8 expression had a sensitivity of 81% and a specificity of 84%, with a cutoff level of 1.76.

Conclusion

This study points out a significant association between the expression of RNF8 and the presence of sperm in NOA patients, which suggests that quantified RNF8 expression in testicular biopsy samples may be a valuable biomarker for predicting the presence of spermatozoa in biopsy samples.

Sperm retrieval success and testicular histopathology in idiopathic nonobstructive azoospermia

Prior studies have investigated sperm retrieval rates in men with nonobstructive azoospermia (NOA) secondary to specific etiologies, yet most cases of NOA are idiopathic. We compared sperm retrieval rates and testicular histopathology in idiopathic NOA (iNOA) and nonidiopathic NOA (niNOA). We performed a retrospective review of men with NOA who underwent microdissection testicular sperm extraction (microTESE) between 2000 and 2016. Men with no history of malignancy or cryptorchidism and negative genetic evaluation were considered idiopathic. Multivariable regression determined the association between idiopathic etiology and primary outcomes of sperm retrieval and active spermatogenesis on histopathology. Among 224 men, 86 (38.4%) were idiopathic, 75 (33.5%) were nonidiopathic, and 63 (28.1%) did not undergo genetic testing. Median age and serum testosterone were higher among iNOA or no testing versus niNOA. Median follicle-stimulating hormone (FSH) was lower among iNOA or no testing versus niNOA. A higher proportion of iNOA or no testing versus niNOA had a clinical varicocele. Sperm retrieval rates were similar between iNOA, niNOA, and no testing (41.8% vs 48.0% vs 55.6%, respectively; P = 0.255). Active spermatogenesis was seen in a higher proportion of iNOA or no testing versus niNOA (31.4% and 27.0% vs 16.0%, P = 0.073). On multivariable analysis, iNOA was not associated with sperm retrieval or spermatogenesis (P = 0.430 and P = 0.078, respectively). Rates of sperm retrieval and spermatogenesis on testis pathology were similar in men with iNOA and niNOA. These data will be useful to clinicians in preoperative counseling for men with NOA and negative genetic evaluation.

Redox status assessment in infertile patients with non-obstructive azoospermia undergoing testicular sperm extraction: A prospective study

BACKGROUND

Oxidative stress (OS) is one of the most prevalent causes of sperm damage, through the toxic effects of endogenously generated hydrogen peroxide, superoxide anion, and hydroxyl radicals. Peripheral leukocytes represent a feasible model for studying the pathophysiology of OS-mediated homeostasis, which can be responsible for cell dysfunction and cell injury.

OBJECTIVE

To evaluate the redox status in patients with non-obstructive azoospermia (NOA), establishing the potential role exerted by reactive oxygen species (ROS) in the genesis of testicular secretory injury.

MATERIAL AND METHODS

From May 2018 to March 2019, 39 patients were enrolled in this prospective single-center cohort study and divided into two groups. Group 1 included 19 patients with NOA, and Group 2 included 20 normozoospermic men, partners of women with infertility tubal factor. All patients underwent serum blood tests. NOA underwent testicular sperm extraction (TeSE). ROS production (in lymphocytes, monocytes, and granulocytes) was assessed by fluorescence-activated cell sorting (FACS) analysis. Plasma oxidative stress was evaluated by lipid peroxidation markers (MDA) and total antioxidant capacity (TAC) both assessed by fluorometric techniques.

RESULTS

Mean lymphocyte ROS production resulted 967.0 ± 224.5 vs 728.0 ± 98.0 (NOA vs Controls, P < .001), monocyte ROS resulted 2102.5 ± 517.5 vs 1253 ± 171 (P < .001), and granulocyte ROS were 2366.5 ± 595.4 vs 1751.0 ± 213.0 (P < .001). Significant increases plasma lipid peroxidation markers were found in NOA patients compared with controls (2.7 ± 0.8 vs 0.37 ± 0.2 nmol/mL, P < .001). Significant decreased TAC was evident in NOA compared with controls (13.4 ± 3.9 vs 3.0 ± 0.2 µmol/mL Trolox equivalents, P < .001). No significant differences were found in blood leukocyte subpopulations ROS production, plasma lipid peroxidation, and TAC comparing groups (positive vs negative sperm retrieval, P > .05).

CONCLUSION

ROS production can be directly related to disorders of spermatogenesis, leading to severe conditions of male infertility, including azoospermia.

Infertility case presentation in Zinner syndrome: Can a long-lasting seminal tract obstruction cause secretory testicular injury?

Zinner syndrome (ZS) could represent an uncommon cause of male infertility, as result of the ejaculatory duct block, which typically leads to low seminal volume and azoospermia. A 27-year-old Caucasian man reported persistent events of scrotal-perineal pain and dysuria during the past 6 months. The andrological examination showed testicular volume of 10 ml bilaterally. Follicle-stimulating hormone was 32.0 IU/L, luteinising hormone was 16.3 IU/L, total testosterone was 9.0 nmol/L, and 17-beta-oestradiol was 0.12 nmol/L. The semen analysis revealed absolute azoospermia, semen volume of 0.6 ml and semen pH of 7.6. The abdominal contrast-enhanced computed tomography showed (a) left kidney agenesis; (b) an ovaliform hypodense mass of 65 × 46 millimetres with fluid content, which was shaping the bladder and the left paramedian prostatic region, compatible with a left seminal vesicle pseudocyst; and (c) an enlargement of the right seminal vesicle. The patient was diagnosed with ZS, and he was scheduled for robot-assisted laparoscopic left vesiculectomy. Subsequently, testis biopsy was characterised by complete germ cell aplasia. The onset symptomatology is often blurred and difficult to detect. It is important to diagnose and manage early this condition, because a long-lasting seminal tract obstruction could determine an irreversible secretory testicular injury.

Parameters predicting sperm retrieval rates during microscopic testicular sperm extraction in nonobstructive azoospermia

The aim of this study was to investigate the predictive value of the parameters that might have an effect on the success of microscopic testicular sperm extraction (micro-TESE) in infertile patients with nonobstructive azoospermia (NOA). Between 2003 and 2014, 860 patients with NOA were retrospectively analysed. The effect of age, infertility duration, history of varicocelectomy, herniorrhaphy or orchiopexy, presence of solitary testis, tobacco use, previous testicular biopsy results, history of orchitis, usage of human chorionic gonadotropin in the past three months, presence of undescended or retractile testis, presence of varicocele, testicular volume, levels of serum follicle-stimulating hormone, luteinising hormone, and testosterone, presence of Klinefelter syndrome and micro-deletion of Y chromosome on sperm retrieval rates were evaluated. In 45.8% (n = 394) of the patients who underwent micro-TESE, spermatozoon was adequately obtained. Multiple logistic regression analysis demonstrated that previous successful testicular biopsy (OR = 15.346; GA = 5.45-43.16; p < .001) and higher testicular volumes significantly increase sperm retrieval rate in micro-TESE. The testicular volume cut-off as 11 ml was found to be the most significant factor. Although currently testicular biopsy result is not being used as a diagnostic method, it is significantly associated with micro-TESE result.

Step-by-step loupes-mTESE in non-obstructive azoospermic men, a retrospective study

Background

Men with non-obstructive azoospermia (NOA) may have sperm in their testes and a procedure of sperm retrieval and assisted reproduction is required in them to allow fertility. Standard procedures such as fine needle aspiration (FNA) and conventional testicular sperm extraction (cTESE) harvest random samples with a sperm retrieval rate (SRR) of 45%. Microdissection testicular sperm extraction (mTESE) is nowadays considered to be the most accurate technique to retrieve sperm in men with NOA. This procedure can identify dilated tubules that are more likely to contain viable sperm with a SRR of 60%.

Results

In our center, testicular biopsy was conducted in a standard fashion in 321 patients with NOA until March 2003. From then to December 2017, due to the lack of an operating microscope, we used 6 fold magnifying loupes to perform a step-by-step macro- mTESE in 1050 patients. Sperm was found in the first testis in 61% of the cases, leading to stop the procedure with less testicular damage. We increased our SRR from 43 to 51.8% in an acceptable operating time of 75mn for both sides.

Conclusions

In institutions where surgeons cannot afford an operating microscope, this modified mTESE technique using × 6 magnifying loupes is reliable, especially in patients with low testicular volumes and high FSH, in whom dilated tubules can be easily identified from the surrounding tissue.

Predictive value of FSH, testicular volume, and histopathological findings for the sperm retrieval rate of microdissection TESE in nonobstructive azoospermia: a meta-analysis

We performed this meta-analysis to evaluate the predictive value of different parameters in the sperm retrieval rate (SRR) of microdissection testicular sperm extraction (TESE) in patients with nonobstructive azoospermia (NOA). All relevant studies were searched in PubMed, Web of Science, EMBASE, Cochrane Library, and EBSCO. We chose three parameters to perform the meta-analysis: follicle-stimulating hormone (FSH), testicular volume, and testicular histopathological findings which included three patterns: hypospermatogenesis (HS), maturation arrest (MA), and Sertoli-cell-only syndrome (SCOS). If there was a threshold effect, only the area under the summary receiver operating characteristic curve (AUSROC) was calculated. Otherwise, the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and the diagnostic odds ratio (DOR) were also calculated. Twenty-one articles were included in our study finally. There was a threshold effect among studies investigating FSH and SCOS. The AUSROCs of FSH, testicular volume, HS, MA, and SCOS were 0.6119, 0.6389, 0.6758, 0.5535, and 0.2763, respectively. The DORs of testicular volume, HS, and MA were 1.98, 16.49, and 1.26, respectively. The sensitivities of them were 0.80, 0.30, and 0.27, while the specificities of them were 0.35, 0.98, and 0.76, respectively. The PLRs of them were 1.49, 10.63, and 1.15, respectively. And NLRs were 0.73, 0.72, and 0.95, respectively. All the investigated factors in our study had limited predictive value. However, the histopathological findings were helpful to some extent. Most patients with HS could get sperm by microdissection TESE.

FSHB -211 G>T Polymorphism as Predictor for TESE Success in Patients With Unexplained Azoospermia

CONTEXT

Testicular sperm extraction (TESE) followed by assisted reproductive techniques often remains the only therapeutic option for men with azoospermia due to spermatogenic failure. Reproductive parameters, such as gonadotropin levels and testicular volume or histopathology, contribute to the prediction of sperm retrieval rate (SRR) in TESE. However, there is an eminent lack of noninvasive predictive factors for TESE outcome.

OBJECTIVE

To clarify the impact of three common genetic variants affecting FSH and its cognate receptor on testicular histopathology patterns and SRR in TESE.

DESIGN

We evaluated the association of the single-nucleotide polymorphisms (SNP) FSHB -211G>T (rs10835638), FSHR -29G>A (rs1394205), and FSHR c.2039A>G (rs6166) with testicular histopathology and SRR in patients with azoospermia.

SETTING

Tertiary referral center for andrology.

PATIENTS OR OTHER PARTICIPANTS

Men (n = 1075) with azoospermia who underwent TESE (grouped by clinical pathologies).

INTERVENTION(S)

All participants underwent TESE.

MAIN OUTCOME MEASURE(S)

Testicular histopathology, SRR, and reproductive hormone levels.

RESULTS

FSHB -211G>T was significantly associated with reduced chances of sperm retrieval in patients with unexplained azoospermia. Indicating an additional mechanism, the association of the SNP with SSR could not be solely attributed to decreased FSH levels.

CONCLUSION

A common genetic factor was significantly associated with SRR in TESE. In perspective, a calculator or score including the noninvasive parameters FSH level, testicular volume, and FSHB haplotype should be considered to estimate the chances for sperm retrieval in men with azoospermia.

Analysis of factors affecting repeat microdissection testicular sperm extraction outcomes in infertile men

OBJECTIVE

There is no clear consensus on which patients and how many of microscopic testicular sperm extraction (mTESE) procedures will be successful. In this study, we aimed to evaluate the sperm retrieval rates and factors affecting these rates in men who underwent repeat mTESEs.

MATERIAL AND METHODS

A total of 346 patients who underwent mTESE for sperm retrieval were included in the study. Patients were divided into groups according to the number of mTESE operations. Patients' karyotype, follicle-stimulating hormone (FSH) and testosterone levels, varicocele presence, and testis volumes were recorded from patient files. The sperm retrieval rates were compared between groups, and predicting factors for successful sperm retrieval were evaluated.

RESULTS

Microscopic TESE was applied for the first time in 244 patients, 1-2 times in 73 patients, and 3-4 times in 29 patients. There was a significant difference between groups in preoperative FSH values and postoperative testicular histopathology (p=0.004 and p<0.001). The sperm retrieval rate in the group of patients who had not undergone previous TESE was higher than the group of patients that had undergone TESE for 1-2 times and 3-4 times (p=0.028). In addition, testicular volume, histology, karyotype, and Y-chromosome microdeletion were predicting factors for successful sperm retrieval (p=0.011, p=0.039, p=0.002, and p<0.001, respectively).

CONCLUSION

Our results confirm the necessity for repeat mTESE operations to be performed by experienced surgeons in reference centers to optimize the chance of reduced sperm retrieval rates with recurrent biopsies.