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

Diffusion tensor imaging and fiber tractography of the epididymis in men with non-obstructive azoospermia

BACKGROUND

Scrotal magnetic resonance imaging, including diffusion tensor imaging and fiber tractography has emerged as a valuable, non-invasive method in the evaluation of non-obstructive azoospermia. The epididymis has a crucial role in male infertility.

OBJECTIVES

To evaluate the role of diffusion tensor imaging and fiber tractography of the epididymis in the work-up of non-obstructive azoospermia.

MATERIALS AND METHODS

This prospective study included 22 men with non-obstructive azoospermia and 15 controls. Scrotal magnetic resonance imaging, including diffusion tensor imaging, was performed. The epididymal apparent diffusion coefficient and fractional anisotropy were measured. Fiber tractography reconstructions were created. Non-parametric statistics compared apparent diffusion coefficient and fractional anisotropy of the epididymis between: (1) non-obstructive azoospermia and normal men; (2) histologic phenotypes of non-obstructive azoospermia; (3) non-obstructive azoospermia men, with positive and negative sperm retrieval; and (4) non-obstructive azoospermia men, with idiopathic and non-genetic etiology. Visual assessment of the epididymal fiber tracts was performed.

RESULTS

Lower epididymal fractional anisotropy (p = 0.027) was observed in men with non-obstructive azoospermia in comparison to normal population. Fractional anisotropy decreased (p = 0.033) in cases with idiopathic non-obstructive azoospermia in comparison to men with non-genetic etiology. Fiber tractography showed abnormalities in epididymal fiber tracts in men with non-obstructive azoospermia, including decrease in number and/or thickness and disorganization. However, diffusion tensor imaging parameters were unable to differentiate the histologic types of non-obstructive azoospermia and to predict the results of sperm retrieval (p > 0.05).

DISCUSSION AND CONCLUSION

Our preliminary observations showed that diffusion tensor imaging and fiber tractography of the epididymis provide valuable, non-invasive biomarkers in the work-up of non-obstructive azoospermia, although the clinical significance of these findings is yet to be determined. However, diffusion tensor imaging data were not predictive for the presence of spermatozoa before microdissection testicular sperm extraction.

Ex vivo microscopic testicular sperm extraction at the time of radical orchiectomy in men with nonobstructive azoospermia (NOA): a scoping review

ABSTRACT

Testicular tumor is the most common solid malignancy in males under 40 years of age. This malignancy is known to have a negative impact on male fertility. Therefore, several techniques for sperm retrieval have been proposed, including microdissection testicular sperm extraction (mTESE). The objective of this study was to review the literature on the outcomes of oncological (Onco)-mTESE at the time of radical orchiectomy. We conducted a comprehensive literature search through PubMed, Scopus, and Cochrane Central Controlled Register of Trials. Only studies reporting ex vivo mTESE in patients with testicular tumor were considered. Twelve papers met the inclusion criteria and were included in this review. Tumor size was identified as the sole preoperative factor influencing spermatogenesis. The considered studies demonstrated a satisfactory success rate for Onco-mTESE, associated with a similarly valid percentage of live healthy births through assisted reproductive technology. Currently, no comparison has been made between Onco-mTESE and conventional Onco-TESE, hence further assessment is required. In cases where the tumor completely replaces the cancer-bearing testicle, a contralateral micro-TESE may be a viable alternative. However, the surgeon should evaluate associated risks and benefits preoperatively. In conclusion, Onco-mTESE at the time of radical orchiectomy appears to be a promising therapeutic option for young patients with testicular tumors. Nevertheless, additional studies are necessary to achieve a definitive conclusion.

Embryologist staffing in assisted reproductive technology laboratories: An international comparative review

Background

Embryologists are crucial in assisted reproductive technology (ART), yet their duties, education, and licensing requirements vary significantly across countries, complicating the determination of optimal staffing levels in ART laboratories. With anticipated advancements such as automation in ART laboratories, this review comprehensively analyzes factors necessary for appropriate future staffing.

Main Findings

A comprehensive literature search was conducted using PubMed to identify relevant articles up to July 2024, employing keywords such as "embryologist," "staffing," and "certification." Articles were evaluated for content related to laboratory operations, and guidelines from five organizations regarding licensing and education were compared.

Results

The review revealed significant international differences in embryologist certification, duties, and staffing recommendations. These disparities, along with the integration of advanced ART technologies and regulatory requirements, significantly impact future staffing needs in ART laboratories.

Conclusion

The definitions of an ART cycle and required staffing levels vary across organizations, influenced by the certification and duties of embryologists in different countries. Adequate embryologist staffing is essential for ensuring laboratory quality control and impacting patient ART outcomes. As new technologies and automation reshape laboratory workflows, collaborative efforts among organizations, countries, and embryologist associations are essential for developing comprehensive educational curricula and determining appropriate staffing levels.

A step closer to parenthood with non-obstructive azoospermia: Unveiling the impact of microdissection testicular sperm extraction in Australia's largest single-centre study

BACKGROUND

Non-obstructive azoospermia (NOA) diagnosis poses challenges for couples seeking parenthood. Microdissection testicular sperm extraction (MD-TESE) excels in retrieving testicular sperm cells for NOA cases. However, limited live birth data in Australian NOA patients hinders accurate counselling.

AIMS

This study aimed to determine the likelihood of infertile couples with a male partner diagnosed with NOA conceiving biological children using MD-TESE / intracytoplasmic sperm injection (ICSI).

MATERIALS AND METHODS

A retrospective cohort study included 108 NOA men treated at a public fertility unit and a private fertility centre (May 2009-May 2022).

PRIMARY OUTCOME

live birth rate (LBR); secondary outcomes: sperm retrieval rate, pregnancy rate, and neonatal outcomes.

RESULTS

Among 108 patients undergoing MD-TESE, the positive sperm retrieval rate (PSRR) was 64.8% (70/108). Histology best predicted sperm retrieval success, with hypo-spermatogenesis yielding a 94.1% PSRR. Age, testicular volume, and hormonal parameters had no significant impact. Mean male age: 35.4 years; mean partner age: 32.7 years. Fertilisation rate: 50.7%. LBR per initiated cycle: 58.7% (37/63); per embryo transfer: 63.8% (37/58); per initially diagnosed NOA man: 34.3% (37/108). Cumulative LBR: 74.1% (43/58); twin rate: 10.8% (4/37). No neonatal deaths or defects were observed among 47 live offspring.

CONCLUSION

This study provides valuable data for counselling NOA couples on the probability of conceiving biological offspring. MD-TESE and ICSI yielded favourable PSRR (64.8%) and LBR (63.8%). However, couples should be aware that once NOA is confirmed, the chance of taking home a baby is 34%.

Training and competency assessment of Clinical Embryologists and licensing of the profession in European countries

STUDY QUESTION

How is the acquisition and testing of theoretical and practical knowledge in Clinical Embryology and the licensing of ART laboratory personnel carried out in European countries?

SUMMARY ANSWER

Twelve out of 31 European countries have established some kind of verification of laboratory competency and skills in ART: in 7 countries, this was related to licensing, but where organized education for Clinical Embryologists existed, there were vast differences in the way these processes were undertaken.

WHAT IS KNOWN ALREADY

In 2015, a report by the ESHRE Embryology Certification Committee concluded that regardless of the large number of people working in IVF laboratories, Clinical Embryology was only recognized as an official profession in 3 out of 27 European national health systems. In most countries, Clinical Embryologists needed to be officially registered under an alternative profession and there were limited opportunities for organized education in this specialist field. Five years after this report, the ESHRE Working Group on Embryologist Training Analysis conducted a survey to collect detailed information about how Clinical Embryologists from different European countries are acquiring their theoretical knowledge and practical skills in ART, and how their level of education and competence in Clinical Embryology is verified.

STUDY DESIGN SIZE DURATION

Two questionnaires about the possibilities for acquiring the education and training needed to work in ART and verification of this knowledge were prepared by the ESHRE Working Group on Embryologist Training Analysis. The first was sent in 2020 to a panel of invited lead European Embryologists who attended an Expert Meeting held in Rome, Italy. In order to have a more comprehensive and updated picture, in 2021 the same survey was also sent to the ESHRE Committee of National Representatives (CNRs). At the end of 2021, the second survey with specific questions, more focused on Clinical Embryologists' training and licencing, was sent to the CNRs who reported on verification of education in Clinical Embryology.

PARTICIPANTS/MATERIALS SETTING METHODS

The first survey consisted of 17 questions. It was initially submitted to 14 lead Embryologists and then resubmitted to the 34 ESHRE CNRs. Representatives from 31 countries responded. A second survey with 23 questions was sent to the 12 ESHRE CNRs who reported an established national system of verification of education in Clinical Embryology, with specific questions focused on the training of Clinical Embryologists. All 12 CNRs responded.

MAIN RESULTS AND THE ROLE OF CHANCE

Analysis showed that European national education programmes in Clinical Embryology could be split into 4 categories: non-existent (13 countries), recommended (5 countries), simple compulsory (9 countries), and complex compulsory (4 countries). A national document stating the minimum education requirements for staff to work in an IVF laboratory was reported by 19 respondents. The requirement to follow a prescribed theoretical and laboratory training programme in ART was compulsory in 9 and 10 countries, respectively. Some form of verification of laboratory skills, theoretical knowledge in ART, and continuing professional development was required in 12, 10, and 9 countries, respectively. A national trainee's logbook format was reported by seven respondents and a national tutorial system was available in six countries. Only seven countries had official licensing of ART laboratory staff. The title of Clinical Embryologist was not recognized in 13 countries and in 6 countries, it was used only by professional bodies, while in 12 countries the profession was at least cited in governmental regulations. The ESHRE Clinical Embryologist Certificate was officially recognized in eight countries.

LIMITATIONS REASONS FOR CAUTION

The survey took place in two steps and the results were then combined to provide a representative picture for most of the European countries sampled. The vast majority, but not all, of the CNRs answered the request to participate in the survey.

WIDER IMPLICATIONS OF THE FINDINGS

The professional recognition of Clinical Embryology within Europe is steadily evolving. However, it remains a concern that many countries continue to not recognize Clinical Embryology as a profession, with a vast difference in the reported organization of educational and training programmes and verification of skills. It is recommended that a training programme for Clinical Embryology and ART in Europe should be standardized and relevant issues should be addressed by competent authorities and European Union institutions. ESHRE is best placed to take a leading role in this educational process.

STUDY FUNDING/COMPETING INTERESTS

The Working Group members who are the authors of this article did not receive payments for the completion of this study. The authors have no conflicts of interest to declare.

Outcomes and predictive factors of successful salvage microdissection testicular sperm extraction (mTESE) after failed classic TESE: results from a multicenter cross-sectional study

Microdissection testicular sperm extraction (mTESE) has been proposed as a salvage treatment option for men with a previously failed classic TESE (cTESE), but data are scarce. We aimed to assess the outcome of and potential predictors of successful salvage mTESE in a cohort of men previously submitted to unfruitful cTESE. Data from 61 men who underwent mTESE after a failed cTESE between 01/2014 and 10/2020, at 6 tertiary-referral centres in Italy were analysed. All men were investigated with semen analyses, testicular ultrasound, hormonal and genetic blood testing. Pathological diagnosis from TESE was collected in every man. Descriptive statistics and logistic regression models were used to investigate potential predictors of positive sperm retrieval (SR+) after salvage mTESE. Baseline serum Follicle-Stimulating hormone (FSH) and total testosterone levels were 17.2 (8.6-30.1) mUI/mL and 4.7 (3.5-6.4) ng/mL, respectively. Sertoli-cell-only syndrome (SCOS), maturation arrest (MA) and hypospermatogenesis were found in 24 (39.3%), 21 (34.4%) and 16 (26.2%) men after cTESE, respectively. At mTESE, SR+ was found in 30 (49.2%) men. Patients with a diagnosis of hypospermatogenesis had a higher rate of SR+ (12/16 (75%)) compared to MA (12/21 (57.1%)) and SCOS (6/24 (25%)) patients at mTESE (p < 0.01). No clinical and laboratory differences were observed between SR+ and SR- patients at mTESE. There were no significant complications after mTESE. At multivariable logistic regression analysis, only hypospermatogenesis (OR 9.5; p < 0.01) was independently associated with SR+ at mTESE, after accounting for age and FSH.In conclusion, salvage mTESE in NOA men with previous negative cTESE was safe and promoted SR+ in almost 50%. A baseline pathology of hypospermatogenesis at cTESE emerged as the only independent predictor of positive outcomes at salvage mTESE.

Sperm Selection Procedures for Optimizing the Outcome of ICSI in Patients with NOA

Retrieving spermatozoa from the testicles has been a great hope for patients with non-obstructive azoospermia (NOA), but relevant methods have not yet been developed to the level necessary to provide resolutions for all cases of NOA. Although performing testicular sperm extraction under microscopic magnification has increased sperm retrieval rates, in vitro selection and processing of quality sperm plays an essential role in the success of in vitro fertilization. Moreover, sperm cryopreservation is widely used in assisted reproductive technologies, whether for therapeutic purposes or for future fertility preservation. In recent years, there have been new developments using advanced technologies to freeze and preserve even very small numbers of sperm for which conventional techniques are inadequate. The present review provides an up-to-date summary of current strategies for maximizing sperm recovery from surgically obtained testicular samples and, as an extension, optimization of in vitro sperm processing techniques in the management of NOA.