In the era of micro-dissection sperm retrieval (m-TESE) is an isolated testicular biopsy necessary in the management of men with non-obstructive azoospermia?

A review of testicular histopathology in nonobstructive azoospermia

ABSTRACT

One major challenge in male factor infertility is nonobstructive azoospermia (NOA), which is characterized by spermatozoa-deficient semen without physical duct blockage. This review offers a thorough overview of the histopathology of the testes in NOA cases, clarifying its complex etiology and emphasizing the possible value of histopathology inspection for both diagnosis and treatment. Variable histopathological findings have been linked to NOA, such as tubular hyalinization, Sertoli cell-only syndrome, hypospermatogenesis, and germ cell arrest. Understanding the pathophysiology and forecasting the effectiveness of treatment are further enhanced by both morphometric and ultrastructural analyses. The potential significance of testicular biopsy in forecasting reproductive outcomes is assessed, especially concerning assisted reproductive technologies like intracytoplasmic sperm injection (ICSI). Besides, testicular microlithiasis, serum hormone profiles, and testicular size are investigated concerning NOA histopathology. It is concluded that understanding the histopathological patterns in NOA is crucial for its accurate diagnosis and appropriate management. Further research is still warranted to improve understanding of the complex pathophysiology underlying NOA.

Microdissection testicular sperm extraction in male partner with non-obstructive azoospermia: Fresh or frozen-thawed sperm for intracytoplasmic sperm injection?

AIM

To compare the outcomes of intracytoplasmic sperm injection (ICSI) of fresh and cryopreserved sperm obtained via microdissection testicular sperm extraction (micro-TESE) in cases of non-obstructive azoospermia (NOA).

METHODS

A total of 147 patients with NOA who underwent micro-TESE and obtained viable sperm via micro-TESE at Istanbul Medipol In Vitro Fertilization unit were recruited retrospectively. The cases were divided into two groups depending on the sperm used (fresh or frozen-thawed) for ICSI: The micro-TESE group (n = 93) underwent ICSI cycles with fresh spermatozoa and the micro-TESE-Thaw group (n = 54) underwent ICSI cycles with cryopreserved spermatozoa. Patient demographics, embryo development, and pregnancy outcomes were compared between the two groups.

RESULTS

No statistical difference was observed between the two groups in terms of demographic features (age, body mass index, etc.) and cycle characteristics (induction protocol, gonadotropin dose, etc.). Fertilization rates and embryo quality were also similar between the groups. Higher clinical pregnancy and live birth rates were observed in the micro-TESE group than in the micro-TESE-Thaw group (p <0.04 and p <0.003, respectively). The miscarriage rate was higher in the micro-TESE-Thaw group, although the difference did not reach statistical significance.

CONCLUSION(S)

In cases where frozen sperm obtained by micro-TESE are used, even if viable and motile sperm are found after thawing, there may be a negative impact on the ICSI result. Fresh testicular spermatozoa appear to result in better clinical pregnancy and live birth rates than cryopreserved testicular spermatozoa in males with NOA.

Differentiation between nonobstructive azoospermia and obstructive azoospermia: then and now

ABSTRACT

Male infertility has seen an increase in prevalence with cases of azoospermia estimated to affect 10%-15% of infertile men. Confirmation of azoospermia subsequently necessitates an early causal differentiation between obstructive azoospermia (OA) and nonobstructive azoospermia (NOA). Although less common when compared to NOA, OA can represent upward 20%-40% of cases of azoospermia. While there are a multitude of etiologies responsible for causing NOA and OA, correctly distinguishing between the two types of azoospermia has profound implications in managing the infertile male. This review represents an amalgamation of the current guidelines and literature which will supply the reproductive physician with a diagnostic armamentarium to properly distinguish between NOA and OA, therefore providing the best possible care to the infertile couple.

Developing a nomogram model for predicting non-obstructive azoospermia using machine learning techniques

Azoospermia, defined by the absence of sperm in the ejaculate, manifests as obstructive azoospermia (OA) or non-obstructive azoospermia (NOA). Reliable predictive models utilizing biomarkers could aid in clinical decision-making. This study included 352 azoospermia patients, with 152 diagnosed with OA and 200 with NOA. The data were randomly divided into a training set (244 cases) and a validation set (108 cases) for machine learning analysis. The training set was utilized for univariate and multivariate logistic regression to identify key predictors of NOA. Following this, nine machine learning. This study included 352 azoospermia patients, with 152 diagnosed with OA and 200 with NOA. The data were randomly divided into a training set (244 cases) and a validation set (108 cases) for machine learning analysis. The training set was utilized for univariate and multivariate logistic regression to identify key predictors of NOA. Following this, nine machine learning methods were employed to refine the prediction model. A novel nomogram model was developed, and its predictive performance was evaluated using receiver operating characteristic curves, calibration plots, and decision curve analysis. Univariate and multivariate logistic regression analyses identified semen pH and follicle-stimulating hormone (FSH) as positive predictors of NOA, while mean testicular volume (MTV) and inhibin B (INHB) were negatively correlated with NOA. Among nine machine learning methods evaluated, the Gradient Boosting Decision Trees achieved the highest performance with an area under the curve (AUC) of 0.974, whereas Random Forest showed the lowest AUC at 0.953. The nomogram model, incorporating these four factors, demonstrated robust predictive performance with AUCs of 0.984 in the training set and 0.976 in the validation set. Calibration and decision curve analysis confirmed the model's accuracy and clinical utility. Optimal cut-off points for biomarkers were identified: FSH at 7.50 IU/L (AUC = 0.96), INHB at 43.45 pg/ml (AUC = 0.95), MTV at 9.92 ml (AUC = 0.91), and semen pH at 6.95 (AUC = 0.71). The novel nomogram model incorporating FSH, INHB, MTV, and pH effectively predicts NOA in patients. This model offers a valuable tool for personalized diagnosis and management of azoospermia.

Comparison of obstetrical and neonatal outcomes between fresh versus frozen-thawed testicular sperm derived from microTESE

PURPOSE

To compare obstetrical and neonatal outcomes of embryo transfer cycles using fresh vs. frozen-thawed testicular sperm derived from microTESE in non-obstructive azoospermia (NOA) patients.

DESIGN

The retrospective cohort study included a total of 48 couples diagnosed with NOA who underwent 93 ET cycles, both fresh and frozen-thawed embryos, and resulted in pregnancy. ET cycles were divided into two groups according to sperm type, fresh (46 cycles, 49.5%) or frozen (47 cycles, 50.5%) testicular sperm. The primary outcome was the birth weight of newborns correlated with gestational week (birth weight percentile).

RESULTS

A comparison of patients' basic characteristics and ET cycle parameters showed no significant clinical differences between the groups. A total of 172 embryos were transferred, 86 (50%) in each group. A higher rate of good-quality blastocysts was found in the fresh testicular group (83.3% vs. 50%, p = 0.046). A comparison of pregnancy outcomes showed no significant differences in clinical pregnancy, implantation, or live birth rates. A total of 53 cycles resulted in live birth, 26 (49%) and 27 (51%) in the fresh and frozen groups, respectively. No difference was found in pregnancy length, delivery mode, or obstetrical complications. A total of 61 newborns were included, 31 (51%) and 30 (49%) in fresh and frozen testicular groups, respectively. No significant differences were found in mean birth weight or birth weight percentile between the groups.

CONCLUSION

No significant differences were found in obstetrical outcomes when comparing ET cycles using fresh or frozen-thawed testicular sperm retrieved from microTESE. Moreover, there is no association between the sperm source and the birth weight of newborns.

From Diagnosis to Treatment: Comprehensive Care by Reproductive Urologists in Assisted Reproductive Technology

Infertility is a global health concern, with male factors playing an especially large role. Unfortunately, however, the contributions made by reproductive urologists in managing male infertility under assisted reproductive technology (ART) often go undervalued. This narrative review highlights the important role played by reproductive urologists in diagnosing and treating male infertility as well as any barriers they face when providing services. This manuscript presents a comprehensive review of reproductive urologists' role in managing male infertility, outlining their expertise in diagnosing and managing male infertility as well as reversible causes and performing surgical techniques such as sperm retrieval. This manuscript investigates the barriers limiting urologist involvement such as limited availability, awareness among healthcare professionals, and financial constraints. This study highlights a decrease in male fertility due to lifestyle factors like sedentary behavior, obesity, and substance abuse. It stresses the significance of conducting an evaluation process involving both male and female partners to identify any underlying factors contributing to infertility and to identify patients who do not require any interventions beyond ART. We conclude that engaging urologists more effectively in infertility management is key to optimizing fertility outcomes among couples undergoing assisted reproductive technology treatments and requires greater education among healthcare providers regarding the role urologists and lifestyle factors that could have an effect on male fertility.

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.

[Analysis of clinical outcome of synchronous micro-dissection testicular sperm extraction and intracytoplasmic sperm injection in male infertility with Y chromosome azoospermia factor c region deletion]

OBJECTIVE

To analyze the clinical treatment results of male infertility caused by Y chromosome azoospermia factor c region(AZFc) deletion after synchronous micro-dissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI) and to guide the treatment of infer- tile patients caused by AZFc deletion.

METHODS

The clinical data of infertile patients with AZFc deletion who underwent synchronous micro-TESE in Peking University Third Hospitalfrom January 2015 to December 2019 were retrospectively analyzed. The clinical outcomes of ICSI in the patients who successfully obtained sperm were followed up and we compared the outcomes between the first and second synchronous procedures, including fertilization rate, high-quality embryo rate, clinical pregnancy rate, abortion rate and live birth rate.

RESULTS

A total of 195 male infertile patients with AZFc deletion underwent micro-TESE. Fourteen patients were cryptozoospermia and their sperms were successfully obtained in all of them during the operation, and the sperm retrieval rate (SRR) was 100%(14/14). The remaining 181 cases were non obstructive azoospermia, and 122 cases were successfully found the sperm, the SRR was 67.4%(122/181). The remaining 59 patients with NOA could not found mature sperm during micro-TESE, accounting for 32.6% (59/181). We followed up the clinical treatment outcomes of the patients with successful sperm retrieved by synchronous micro-TESE and 99 patients were enrolled in the study. A total of 118 micro-TESE procedures and 120 ICSI cycles were carried out. Finally 38 couples successfully gave birth to 22 male and 22 female healthy infants, with a cumulative live birth rate of 38.4% (38/99). In the fresh-sperm ICSI cycle of the first and second synchronous operation procedures, the high-quality embryo rate, clinical pregnancy rate of the fresh embryo transfer cycle and live birth rate of the oocyte retrieve cycle were 47.7% vs. 50.4%, 40.5% vs. 50.0%, and 28.3% vs. 41.2%, respectively. The second operation group was slightly higher than that of the first synchronous operation group, but there was no significant difference between the groups.

CONCLUSION

Male infertility patients caused by AZFc deletion have a high probability of successfully obtaining sperm in testis through micro-TESE for ICSI and give birth to their own offspring with their own biological characteristics. For patients who failed in the first synchronous procedure, they still have the opportunity to successfully conceive offspring through reoperation and ICSI.

Microdissection oncoTESE (micro-oncoTESE) in azoospermic men with suspected testicular cancer: Analysis of outcomes from a specialist centre

Objective:

The main aim of this study was to report the outcomes of azoospermic men with suspicious testicular lesions, undergoing microsurgical sperm retrieval (micro-oncoTESE) at the time of radical/partial orchidectomy.

Patients and methods:

Testicular lesions suspicious for cancer were confirmed on ultrasound scanning. In patients undergoing radical inguinal orchidectomy, ex vivo microdissection of the unaffected testicular parenchyma was performed. Microdissection was performed in vivo for partial orchidectomy. The primary outcome measure was surgical sperm retrieval (SSR) rate.

Results:

A total of 33 patients (median age 33 years, interquartile range (IQR) 22) with suspected testicular cancer (TCa) underwent micro-oncoTESE. Histological analysis confirmed TCa in 26 patients and benign pathology in 7 patients. The overall SSR rate was 39%. Sub-analysis of patients with TCa and benign histology found that the SSR was 46% and 14%, respectively. There was no significant difference in maximum tumour length between successful and unsuccessful SSR groups 33.9 mm ± 23 (SD) versus 29.8 mm ± 17.5 (SD) ( p = 0.62).

Conclusion:

Based on our cohort, micro-oncoTESE provides an option for sperm retrieval in azoospermic men with testicular lesions.

European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility

CONTEXT

The European Association of Urology (EAU) has updated its guidelines on sexual and reproductive health for 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health, including advances and areas of controversy in male infertility.

EVIDENCE ACQUISITION

The panel performed a comprehensive literature review of novel data up to January 2021. The guidelines were updated and a strength rating for each recommendation was included that was based either on a systematic review of the literature or consensus opinion from the expert panel, where applicable.

EVIDENCE SYNTHESIS

The male partner in infertile couples should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors causing fertility impairment. Infertile men are at a higher risk of harbouring and developing other diseases including malignancy and cardiovascular disease and should be screened for potential modifiable risk factors, such as hypogonadism. Sperm DNA fragmentation testing has emerged as a novel biomarker that can identify infertile men and provide information on the outcomes from assisted reproductive techniques. The role of hormone stimulation therapy in hypergonadotropic hypogonadal or eugonadal patients is controversial and is not recommended outside of clinical trials. Furthermore, there is insufficient evidence to support the widespread use of other empirical treatments and surgical interventions in clinical practice (such as antioxidants and surgical sperm retrieval in men without azoospermia). There is low-quality evidence to support the routine use of testicular fine-needle mapping as an alternative diagnostic and predictive tool before testicular sperm extraction (TESE) in men with nonobstructive azoospermia (NOA), and either conventional or microdissection TESE remains the surgical modality of choice for men with NOA.

CONCLUSIONS

All infertile men should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors. Increasing data indicate that infertile men are at higher risk of cardiovascular mortality and of developing cancers and should be screened and counselled accordingly. There is low-quality evidence supporting the use of empirical treatments and interventions currently used in clinical practice; the efficacy of these therapies needs to be validated in large-scale randomised controlled trials.

PATIENT SUMMARY

Approximately 50% of infertility will be due to problems with the male partner. Therefore, all infertile men should be assessed by a specialist with the expertise to not only help optimise their fertility but also because they are at higher risk of developing cardiovascular disease and cancer long term and therefore require appropriate counselling and management. There are many treatments and interventions for male infertility that have not been validated in high-quality studies and caution should be applied to their use in routine clinical practice.

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.

Non-obstructive azoospermia: current and future perspectives

Infertility affects 1 in 6 couples, and male factor infertility has been implicated as a cause in 50% of cases. Azoospermia is defined as the absence of spermatozoa in the ejaculate and is considered the most extreme form of male factor infertility. Historically, these men were considered sterile but, with the advent of testicular sperm extraction and assisted reproductive technologies, men with azoospermia are able to biologically father their own children. Non-obstructive azoospermia (NOA) occurs when there is an impairment to spermatogenesis. This review describes the contemporary management of NOA and discusses the role of hormone stimulation therapy, surgical and embryological factors, and novel technologies such as proteomics, genomics, and artificial intelligence systems in the diagnosis and treatment of men with NOA. Moreover, we highlight that men with NOA represent a vulnerable population with an increased risk of developing cancer and cardiovascular comorbodities.

Histology and sperm retrieval among men with Y chromosome microdeletions

In this review of Y chromosome microdeletions, azoospermia factor (AZF) deletion subtypes, histological features and microTESE sperm retrieval rates are summarized after a systematic literature review. PubMed was searched and papers were identified using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Approximately half of infertile couples have a male factor contributing to their infertility. One of the most common genetic etiologies are Y chromosome microdeletions. Men with Y chromosome microdeletions may have rare sperm available in the ejaculate or undergo surgical sperm retrieval and subsequent intracytoplasmic sperm injection to produce offspring. Azoospermia or severe oligozoospermia are the most common semen analysis findings found in men with Y chromosome microdeletions, associated with impaired spermatogenesis. Men with complete deletions of azoospermia factor a, b, or a combination of any loci have severely impaired spermatogenesis and are nearly always azoospermic with no sperm retrievable from the testis. Deletions of the azoospermia factor c or d often have sperm production and the highest likelihood of a successful sperm retrieval. In men with AZFc deletions, histologically, 46% of men demonstrate Sertoli cell only syndrome on biopsy, whereas 38.2% have maturation arrest and 15.7% have hypospermatogenesis. The microTESE sperm retrieval rates in AZFc-deleted men range from 13-100% based on the 32 studies analyzed, with a mean sperm retrieval rate of 47%.

Sperm retrieval rates and clinical outcomes for patients with different causes of azoospermia who undergo microdissection testicular sperm extraction-intracytoplasmic sperm injection

The aim of our study was to compare the sperm retrieval rates (SRRs) and clinical outcomes of patients with different causes of azoospermia who underwent microdissection testicular sperm extraction-intracytoplasmic sperm injection (micro-TESE-ICSI). We conducted a retrospective study at the Reproductive Medicine Center of Peking University Third Hospital in Beijing, China, from January 2014 to December 2017. This study examined 769 patients with nonobstructive azoospermia who underwent 347 cycles of micro-TESE-ICSI. Patients with azoospermia were classified into Group A (Klinefelter syndrome, n = 284, 125 cycles), Group B (azoospermia Y chromosome factor c [AZFc] microdeletion, n = 91, 64 cycles), Group C (cryptorchidism, n = 52, 39 cycles), Group D (previous mumps and bilateral orchitis, n = 23, 23 cycles), and Group E (idiopathic azoospermia, n = 319, 96 cycles). Clinical characteristics, SRR, embryonic development, and pregnancy outcomes of the patients were compared between all groups. Patients in Group D had the highest and most successful SRR. The average SRR for all patients was 46.0%. The rates of clinical pregnancy, implantation, and live birth in Group D were 78.3%, 65.0%, and 74.0%, respectively, which were higher than those in all other groups (P < 0.05). Group B patients had the lowest clinical pregnancy, implantation, and live birth rates of all groups (P < 0.05). No differences were found in the miscarriage rate or birth defects among the groups (P > 0.05). Patients with orchitis had the highest SRR and best clinical outcomes. Although AZFc microdeletion patients had a higher SRR, their clinical outcomes were worse.

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

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

The Role of Hormone Stimulation in Men With Nonobstructive Azoospermia Undergoing Surgical Sperm Retrieval

Nonobstructive azoospermia, (NOA) is the most common cause of azoospermia. NOA is characterized by hypergonadotropic hypogonadism, testicular failure, and impaired spermatogenesis. The recent development of surgical sperm retrieval techniques such as microsurgical testicular sperm extraction (mTESE) has, for the first time, allowed some men with NOA to father biological children. It is common practice for endocrine stimulation therapies such as gonadotropins, selective estrogen receptor modulators (SERMs), and aromatase inhibitors to be used prior to mTESE to increase intratesticular testosterone synthesis with the aim of improving sperm retrieval rates; however, there is currently a paucity of data underpinning their safety and efficacy. We present 2 cases of men with NOA undergoing endocrine stimulation therapy and mTESE. We also discuss the current evidence and controversies associated with the use of hormonal stimulation therapy in couples affected by this severe form of male infertility.

Kallman syndrome and central non-obstructive azoospermia

The understanding of male factors of infertility has grown exponentially in the past ten years. While clear guidelines for obstructive azoospermia have been developed, management of non-obstructive azoospermia has lagged. Specifically, management of Kallmann Syndrome and central non-obstructive azoospermia has been limited by a lack of understanding of the molecular pathogenesis and investigational trials exploring the best option for management and fertility in these patients. This review aims to summarize our current understanding of the causes of central hypogonadotropic hypogonadism with a focus on genetic etiologies while also discussing options that endocrinologists and urologists can utilize to successfully treat this group of infertile men.

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.

Some of the Factors Involved in Male Infertility: A Prospective Review

Infertility is defined as the inability of couples to have a baby after one year of regular unprotected intercourse, affecting 10 to 15% of couples. According to the latest WHO statistics, approximately 50-80 million people worldwide sufer from infertility, and male factors are responsible for approximately 20-30% of all infertility cases. The diagnosis of infertility in men is mainly based on semen analysis. The main parameters of semen include: concentration, appearance and motility of sperm. Causes of infertility in men include a variety of things including hormonal disorders, physical problems, lifestyle problems, psychological issues, sex problems, chromosomal abnormalities and single-gene defects. Despite numerous efforts by researchers to identify the underlying causes of male infertility, about 70% of cases remain unknown. These statistics show a lack of understanding of the mechanisms involved in male infertility. This article focuses on the histology of testicular tissue samples, the male reproductive structure, factors affecting male infertility, strategies available to find genes involved in infertility, existing therapeutic methods for male infertility, and sperm recovery in infertile men.

Failed sperm retrieval from severely oligospermic or non-obstructive azoospermic patients on oocyte retrieval day: Emergent oocyte cryopreservation is a feasible strategy

Purpose

Unexpected sperm retrieval failure on the day of oocyte retrieval is not common but frequently happened in patients with severe oligospermia or non-obstructive azoospermia(NOA). Oocyte cryopreservation is a common strategy after failed collection of sperm when concurrent ovarian stimulation is underwent. However, the use of oocyte vitrification in such male-infertility cases remains unclear.

Objective

To investigate the outcomes of emergent oocyte cryopreservation after failed sperm retrieval from severe oligospermic or non-obstructive azoospermic (NOA) patients on oocyte retrieval day.

Methods

Design: Retrospective cohort study

Setting: Academic fertility center at Lee Women's Hospital, Taiwan, between March 2015 and August 2017.

Patients: For 203 couples with NOA(n = 200) or severe oligospermia(n = 3), testicular spermatozoa (n = 67 cycles) or frozen donor sperm (n = 209 cycles) were injected into fresh or frozen-thawed oocytes via 276 intracytoplasmic sperm injection (ICSI) cycles.

Main Outcome Measures: Clinical pregnancy and live-birth rates (LBRs).

Results

In the 67 cycles involving the use of fresh testicular spermatozoa, no significant differences were observed between fresh and warmed oocytes with respect to the fertilization rates (69.2% vs. 74.1%; p = 0.27), number of Day-3 embryos (8.6±4.4 vs. 6.4±3.4; p = 0.08), number of good-quality Day-3 embryos (4.5±3.9vs. 4.7±3.0; p = 0.45), implantation rates (29.1% vs. 17.8%; p = 0.21), clinical pregnancy rates (36.4% vs. 26.8.0%; p = 0.81), live birth rates (36.4% vs. 14.3%; p = 0.46), or perinatal outcomes. In the 209 cycles involving the use of frozen donor sperm, no significant differences were seen between the two groups, except that the mean birth weights were significantly lower with fresh oocyte pregnancies than with warmed oocytes (2952±196 gm vs 2643±700 gm; p = 0.006).

Conclusions

Emergent oocyte cryopreservation is a feasible strategy to manage unexpected sperm retrieval failure from severe oligospermic or NOA patients on the oocyte retrieval day. There is no detrimental effect on the live birth rate when testicular spermatozoa or frozen donor sperm are injected into the thawed oocytes compared with fresh oocytes.

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.

Testicular sperm extraction in men with sertoli cell-only testicular histology - 1680 cases

Objective:

To study the outcomes of testicular sperm extraction (TESE) among men with pure Sertoli cell-only histology identified during diagnostic testicular biopsy.

Methods:

This retrospective cohort study involved 1680 cases of patients with nonobstructive azoospermia (NOA) diagnosed with pure Sertoli cell-only histology who underwent testicular biopsy with TESE in a reference center in Brazil by a single surgeon. Sperm retrieval rates (SSR) were the main outcome measure.

Results:

Overall, 14.83% of patients with Sertoli cell-only had sperm retrieved with TESE in quantity that allowed the performance of ICSI. No differences were observed in SSR based on testis volume (<15 mL vs. <15 mL) or serum FSH level.

Conclusions:

Patients with Sertoli cell-only histology can be counseled that they have some likelihood of sperm retrieval with TESE. Based on the findings, patients to be submitted to testicular biopsy for histologic analysis may be concomitantly prepared for ICSI with TESE in case sperm is available.

Novel method of histopathological analysis after testicular sperm extraction in patients with nonobstructive and obstructive azoospermia

Objective

To assess whether the “testicular pool” could be used for histological analysis and whether it gave more accurate information than the standard testicular biopsy.

Methods

Between January 2017 and March 2018, this single-center prospective study included 60 azoospermic men undergoing conventional bilateral testicular sperm extraction. Six samples were excised from each testicle and transferred to an embryologist. One additional biopsy was randomly taken from each testis for a histological analysis. After processing, the testicular pool was also sent for a histological analysis, which showed normal spermatogenesis (NS), hypospermatogenesis (HYPO), maturation arrest (MA), Sertoli cell-only syndrome (SCOS), and tubular atrophy (TA).

Results

Twenty of the 60 patients (33.3%) had obstructive azoospermia (OA), while the remaining 40 (66.6%) had nonobstructive azoospermia. Their mean age was 40.5 years. All patients with OA had previously undergone unsuccessful testicular fine-needle aspiration. Successful sperm retrieval (SSR) occurred in 93.3% of patients. Histological analysis of the testicular biopsy revealed NS in 12 patients (20%), HYPO and TA in 28 patients (46.6%), MA in eight patients (13.3%), and SCOS in 12 patients (20%). The testicular pool analysis showed NS in 12 patients (20%), HYPO and TA in 44 patients (73.3%), MA in four patients (6.6%), and SCOS in no patients. In four patients with MA (6.6% of the total sample) and 12 patients with SCOS (20% of the total sample) according to the standard testicular biopsy, the embryologist found SSR with cryopreservation. Overall, in 44 patients (73.3%), the testicular pool analysis confirmed the histological findings of the standard testicular biopsy. In the 16 cases (26.6%) with a discrepancy between the single-biopsy histological findings and SSR, the testicular pool analysis confirmed the embryological data on SSR.

Conclusion

The testicular pool proved to be easily analyzable, practical, manageable, and more accurate for predicting sperm retrieval than standard testicular biopsy.

A clinical trial on the consistency of bilateral testicular tissue histopathology and Johnsen score: single side or bilateral side biopsy?

To evaluate and compare left and right testicular tissue histopathology and Johnsen score, and to investigate the necessity for bilateral testicular biopsy. We recruited180 patients with non-obstructiveazoospermia (NOA) on testicular biopsy who had undergonetesticular sperm aspiration (TESA). Pathological sections of testicular tissue were diagnosed by specially-assigned doctors, who evaluated pathological findings, determined the Johnsen score and confirmed for the presence or absence of sperm. Sperm positive rates for left and right testicular histopathology were 55.0% and 51.7% respectively, and the proportion of Johnsen scores≥8 for left and right testes were 53.3% and 50.0%, respectively. Cohen kappa values revealed that the identification of sperm in bilateral testicular samples was not consistent and was related to random effects; Optimized cut-off value for bilateral testicular volume was 11ml (Johnsen score ≥8), and optimized cut-off values of E₂ on left and right testes were 144.5pmol/L and 133.5 pmol/L (Johnsen score≤7). However, age, serum prolactin (PRL), follicle stimulating hormone (FSH), luteinizing hormone (LH) and total testosterone (TT) levels were not accurate predictors for the existence of testicular sperm. There was nostatistical significance between left and right testicular histopathology in terms of sperm positive rates or Johnsen score; the Johnsen score were caused entirely by random effects and a score from one side could not represent the other side. Therefore, we recommend that both testes need to undergo surgery when NOA patients undergo testicular biopsy or sperm retrieval.

Outcome of Oocyte Vitrification Combined with Microdissection Testicular Sperm Extraction and Aspiration for Assisted Reproduction in Men

Background

As a safety and efficacy protocol, oocyte vitrification has been widely used in IVF treatment. The aim of this study was to evaluate the outcome of ICSI-ET utilizing vitrified oocytes with sperm obtained from non-obstructive azoospermia (NOA) patients via micro-TESE.

Material/Methods

A total of 150 NOA patients underwent micro-TESE. Ten patients were unable to ejaculate and refused to accept TESA at the time of oocyte retrieval; later, these patients underwent TESA. A total of 174 obstructive azoospermia (OA) patients underwent TESA. Vitrified oocytes were used with micro-TESE in 35 cycles (group 1), and TESA in 10 cycles (group 2). Fresh oocytes were used with micro-TESE in 38 cycles (group 3) and TESA in 174 cycles (group 4).

Results

The overall sperm retrieval rate of the 150 NOA patients was 48.7% (73/150). A total of 257 cycles of ICSI-ET were conducted with testicular spermatozoa; 212 cycles utilized fresh oocytes and 45 cycles utilized vitrified oocytes. No differences were observed with fertilization (73.8%, 77.2%,72.8%, 73.6%), implantation (33.3%, 34.7%, 33.8%, 37.5%), or clinical pregnancy rates (51.4%, 60%, 52.6%, 51.7%) for groups 1 through 4, respectively (P>0.05). Developmental competence was greatest among couples using sperm obtained via TESA rather than micro-TESE, not dependent on whether vitrified or fresh oocytes were utilized. Fertilization, implantation, and clinical pregnancy rates did not differ between using fresh vs. vitrified oocytes, nor did they differ between using testicular sperm derived from men with NOA vs. men with OA.

Conclusions

Vitrified oocytes combined with micro-TESE showed similar clinical efficacy when compared with fresh oocytes.

Pregnancy and live birth after follicle-stimulating hormone treatment for an infertile couple including a male affected by Sertoli cell-only syndrome

In males with nonobstructive azoospermia, one of the main histopathologic patterns of the testis is Sertoli cell-only syndrome (SCOS), in which no germ cells are present and only Sertoli cells are contained in the seminiferous tubules. There is not any formal treatment for this pathological condition. However, several studies reported the possibility to perform testicular sperm extraction in patients with SCOS, although, according to some authors, sperm retrieval is possible only in the presence of focal spermatogenesis. We report the case of an infertile couple in whom the 30-year-old male was azoospermic. After the diagnosis, the patient underwent multiple bilateral testicular biopsies, which showed a histological pattern corresponding to SCOS. We administered a cycle of hormone stimulation followed by medically assisted procreation procedures to the male patient. Therefore, the male patient was treated with follicle-stimulating hormone gonadotropin for a total of 7 months (150 IU recombinant human follicle stimulating hormone three times per week). After carrying out a new multiple testicular sperm extraction, several spermatozoa were microscopically observed, and it was then possible to perform an intracytoplasmic sperm injection with subsequent embryo transfer of the blastocyst into the wife’s uterus, and so pregnancy was established and developed. Subsequently, the pregnancy resulted in the live birth of a girl.

Outcome of ICSI with motile testicular spermatozoa obtained through microscopically assisted testicular sperm extraction in relation to the ovarian response

INTRODUCTION

To determine the relationship between AFC, basal FSH level, woman's age, the number of oocytes retrieved and the outcome of ICSI with testicular spermatozoa obtained with microscopically assisted testicular sperm extraction.

MATERIAL AND METHODS

In this retrospective cohort study, a total of 340 couples who underwent ICSI treatment with testicular sperm were enrolled. Women aged?40years and the first cycles of couples were included. ICSI was performed with motile testicular spermatozoa obtained from 89 men with obstructive azoospermia and 251 men with nonobstructive azoospermia. GnRH-antagonist protocol was used for ovulation induction. Simple linear regression was carried out to analyze relationship between the AFC, basal FSH, woman's age, the number of oocytes, and the live birth rate (LBR). Receiver operator characteristic curves (ROC) were formed to detect cut-off values below which LBR was significantly decreased. ROC curve analysis demonstrated that the cut-off level of the number of oocytes retrieved to predict the LBR was 7. According to this cut-off level, all patients were divided into two groups. Women with retrieved<7 oocytes were included in Group 1 and women with retrieved?7 oocytes were included in Group 2.

RESULTS

The mean age of men was 35.1±4.9years. The mean age, mean FSH level and mean AFC of women were 32.1±4.9years, 6.9±2.7 IU/L, 7.6±3.4, respectively. Significant correlations were found between AFC, the number of oocytes retrieved, and the LBR per ICSI cycle with testicular spermatozoa. The LBR was significantly lower in women with AFC<8 than those with AFC?8. Independently, the LBR was significantly lower in cycles with<7 oocytes retrieved compared to those with ?7. Embryo transfer was not achieved in 37 cycles with<7 oocytes (37/167, 22.1%) and 18 cycles with?7 (18/173, 10.4%) because of the absence of transfer-quality embryos (P=0.005). The LBRs were the lowest in cycles with one or two oocytes available (8.3 and 8.3%, respectively), but these rates were not statistically different than those in cycles with 3, 4, 5 and 6 oocytes (14.2, 17.2, 18.5, 17.6%, respectively, P=0.810).

CONCLUSIONS

AFC and the number of oocytes retrieved are important prognostic factors in an ICSI cycle with testicular sperm in women ?40years, yielding significantly diminished LBRs with<8 antral follicles and/or<7 oocytes retrieved.

Salvage micro-dissection testicular sperm extraction; outcome in men with non-obstructive azoospermia with previous failed sperm retrievals

OBJECTIVE

To assess the outcome of micro-dissection testicular exploration sperm extraction (m-TESE) as a salvage treatment in men with non-obstructive azoospermia (NOA) in whom no sperm was previously found on single/multiple TESE or testicular sperm aspiration (TESA).

PATIENTS AND METHODS

In all, 58 men with NOA underwent m-TESE. All the patients had previously undergone either single/multiple TESE or TESA with no sperm found. All the patients underwent an m-TESE using a standard technique. Serum follicle-stimulating hormone (FSH), testosterone and histopathological diagnosis were examined as predictive factors for sperm recovery. All patients underwent preoperative genetic screening. One patient was found to have an azoospermic factor c (AZFc) micro-deletion and five were diagnosed with Kleinfelter's syndrome.

RESULTS

The mean (range) patient age was 39.0 (26-57) years. Spermatozoa were successfully retrieved in 27 men by m-TESE (46.5%). The mean (range) FSH level was 19.4 (1.6-58.5) IU/L. There was no correlation in age (mean age retrieved 38.1 years, not retrieved 39.7 years, P = 0.38), FSH levels (mean FSH retrieved 21.4 IU/L, not retrieved 17.7 IU/L, P = 0.3) and the ability to find sperm by m-TESE. However, there was a significant difference in testosterone levels and sperm retrieval (mean testosterone retrieved 14.99 nmol/L, not retrieved 11.39 nmol/L, P < 0.05). Patients with a diagnosis of Sertoli-cell-only (SCO) syndrome [14/35 (40%)] and maturation arrest [four of 11 (36%)] had lower sperm retrieval rates than those in the hypospermatogenesis group [nine of 12 (75.0%)] (P < 0.05). There were no significant complications after m-TESE.

CONCLUSIONS

In men with NOA who have undergone previous attempts at sperm retrieval with negative results, a salvage m-TESE offers a significant chance of finding sperm even in SCO syndrome. There does seem to be a correlation between preoperative testosterone levels and the ability to successfully find sperm.

Microdissection testicular sperm extraction in men with Sertoli cell-only testicular histology

OBJECTIVE

To study the outcomes of microdissection testicular sperm extraction (microTESE) among men with pure Sertoli cell-only histology on diagnostic testicular biopsy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENT(S)

Six hundred forty patients with pure Sertoli cell-only histology on testicular biopsy who underwent microTESE by a single surgeon.

INTERVENTION(S)

MicroTESE.

MAIN OUTCOME MEASURE(S)

Sperm retrieval rates.

RESULT(S)

Overall, 44.5% of patients with Sertoli cell only had sperm retrieved with microTESE. No difference was noted in sperm retrieval rates based on testis volume (≥15 mL vs. <15 mL, 35.3% vs. 46.1%, respectively). Patients with ≥15 mL testicular volume and FSH 10-15 mU/mL had the worst prognosis, with a sperm retrieval rate of 6.7%.

CONCLUSION(S)

Patients with previous testicular biopsy demonstrating Sertoli cell-only histology can be counseled that they have a reasonable likelihood of sperm retrieval with the contemporary delivery of microTESE. Given this finding, the utility of testicular biopsy before microTESE is further questioned.

Progressing management of non-obstructive azoospermia in the era of microdissection testicular sperm extraction

Previously, it was absolutely impossible for azoospermic men to reproduce except in some obstructive azoospermic cases for whom reconstruction of the seminal pathway was successful. However, nowadays, intracytoplasmic sperm injection and microdissection testicular sperm extraction have brought about chances of biological paternity in some non-obstructive azoospermic men. It is almost 15 years since the first trials of testicular sperm retrieval using surgical microscopy for non-obstructive azoospermia were reported. In this manuscript, the progress and outcomes of these novel techniques since then are reviewed, the controversial points are discussed and the latest research to achieve pregnancies in tough non-obstructive azoospermic couples are introduced. Not only the bright side of the renovations, but the underlying concerns are also discussed.

Azoospermia due to spermatogenic failure

This article summarizes the current literature regarding azoospermia caused by spermatogenic failure. The causes and genetic contributions to spermatogenic failure are reviewed. Medical therapies including use of hormonal manipulation, whether guided by a specific abnormality or empiric, to induce spermatogenesis are discussed. The role of surgical therapy, including a discussion of varicocelectomy in men with spermatogenic failure, as well as an in-depth review of surgical sperm retrieval with testicular sperm extraction and microdissection testicular sperm extraction, is provided. Finally, future directions of treatment for men with spermatogenic failure are discussed, namely, stem cell and gene therapy.

Clinical characteristics and treatment of azoospermia and severe oligospermia patients with Y-chromosome microdeletions

Clinical characteristics, testicular pathology, serum levels of reproductive hormones, and genetic analysis were compared among 100 azoospermic, 20 oligozoospermic cases with azoospermia factor (AZF) microdeletion, and 50 fertile males to evaluate the relationship between the AZF microdeletion regions and the azoospermia phenotype. AZF microdeletion region, testicular volume, and serum reproductive hormone levels of patients were compared against histological examination of testicular biopsies. The number of cases of AZFa, AZFb, AZFc, AZFb + c, and AZFa + b + c microdeletion was respectively 2 (1.7%), 15 (12.5%), 77 (64.2%), 24 (20.0%), and 2 (1.7%). The testicular volume of patient with AZF microdeletion was smaller (P < 0.01), while luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels were significantly higher than that of fertile individuals (P < 0.01 and P < 0.05, respectively). Among the patients, testicular volume with AZFb-microdeletion cases was larger compared to patients with AZFc or AZFb + c microdeletions (P < 0.05 and P < 0.01, respectively), whereas FSH levels were significantly lower than that of AZFc or AZFb + c microdeletions (P < 0.05). The Johnsen score of patients with an AZFb + c microdeletion was lower than that of patients with AZFb and AZFc microdeletions, but no significant difference was observed. Pathological findings of testicular biopsies poorly correlated with the pattern of AZF deletion, with the AZFc microdeletion exhibiting the most varied phenotypes. In subsequent assisted reproductive treatments, sperm from patients with an AZFc microdeletion that was obtained by testicular sperm aspiration (TESA) or microdissection testicular sperm extraction (m-TESE) were more likely to result in pregnancy. Combined with testis pathology pattern, the specific region of AZF microdeletion and hormonal assessments provide reliable prognostic information on the chance of successful sperm retrieval for assisted reproductive technologies.

Clinical characteristics and reproductive outcomes in infertile men with testicular early and late maturation arrest

OBJECTIVE

To compare the clinical characteristics and reproductive outcomes of nonobstructive azoospermic men with uniform early and late maturation arrest.

METHODS

Patients with biopsy-documented uniform maturation arrest undergoing testicular sperm retrieval and complete medical records were enrolled in the present study. Their medical history, physical examination findings, testicular volume, serum hormone parameters, genetic anomalies, sperm retrieval, and reproductive outcomes were retrospectively analyzed.

RESULTS

In a cohort of 223 nonobstructive azoospermic men, 34 men with uniform maturation arrest (21 early maturation arrest and 13 late maturation arrest) were identified. No significant differences were seen in the age distribution, testicular volume, or hormone parameters between patients with early and late maturation arrest. Only 13 patients (38.2%) had a normal serum follicle-stimulating hormone level and normal testicular volume. Patients with early maturation arrest had a greater frequency of overall genetic anomalies, and patients with late maturation arrest had a greater frequency of previous testicular insults. The sperm retrieval and impregnation rate were nonsignificantly greater in patients with late maturation arrest.

CONCLUSION

Maturation arrest has a variety of causes and presents with diverse phenotypes. Not all patients with uniform maturation arrest have a normal follicle-stimulating hormone level or testicular volume. Patients with early maturation arrest have a greater incidence of genetic anomalies and are more likely to have worse reproductive outcomes than are patients with late maturation arrest.