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Pozzi E, Venigalla G, Raymo A, Ila V, Achermann APP, Esteves SC, Salonia A, Ramasamy R. Eligibility for the medical therapy among men with non-obstructive azoospermia-Findings from a multi-centric cross-sectional study. Andrology 2024. [PMID: 38804793 DOI: 10.1111/andr.13670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 04/08/2024] [Accepted: 05/14/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Existing literature does not provide accurate epidemiological data regarding the true prevalence of men with non-obstructive azoospermia (NOA) who would be eligible for hormonal optimization therapy, according to specific pre-treatment criteria. OBJECTIVES To investigate the characteristics of those men with NOA who would qualify for the medical therapy prior to any SR procedure in a large multi-centric cross-sectional study. MATERIALS AND METHODS Complete data from 1644 NOA patients seeking medical help for primary infertility at three tertiary referral centers from USA, Brazil, and Italy were analyzed. Baseline serum hormone levels were collected for all patients. NOA was confirmed after two consecutive semen analyses. Genetic tests, including karyotype analysis and Y microdeletions, were performed on all patients. Patients with secondary hypogonadism (total testosterone (T) levels less than 300 ng/dL and luteinizing hormone (LH) levels less than 8 mIU/mL) were earmarked as potential candidates for receiving clomiphene citrate (CC) and/or human chorionic gonadotropin (hCG). Patients with a T to 17β-estradiol (E2) ratio < 10 were classified as eligible for aromatase inhibitors (AIs) therapy (e.g., anastrazole). A third sub-cohort was created by combining the criteria of the first two sub-cohorts. Descriptive statistics was used to detail overall characteristics and differences between the different sub-cohorts. RESULTS Among the 1,644 men, 28% (n = 460) had T < 300 ng/dL and LH < 8 mIU/mL, thereby being potentially suitable for CC and/or hCG, while 37% (n = 607) had a T to E2 ratio < 10 thus potentially suitable for AIs. Lastly, 17.7% (n = 280) met the criteria for potential eligibility for both CC and/or hCG and AIs. CONCLUSIONS Findings from this multicentric cross-sectional study reveal that about 30% of men with NOA were eligible for hormonal treatment with CC and/or hCG while 37% were found to be potential candidates for AIs, and 17% for both therapies. Therefore, these findings show that a only a small subset of NOA patients can benefit from medical therapy prior to considering any SR procedures.
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Affiliation(s)
- Edoardo Pozzi
- Desai Sethi Urology Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
- Vita-Salute San Raffaele University, Milan, Italy
- Division of Experimental Oncology, Unit of Urology, (URI), IRCCS Ospedale San Raffaele, Milan, Italy
| | - Greeshma Venigalla
- Desai Sethi Urology Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Adele Raymo
- Desai Sethi Urology Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Vishal Ila
- Desai Sethi Urology Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Arnold P P Achermann
- Department of Surgery, Division of Urology, University of Campinas, Campinas, Sao Paulo, Brazil
- Faculty of Health, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sandro C Esteves
- Department of Surgery, Division of Urology, University of Campinas, Campinas, Sao Paulo, Brazil
- Faculty of Health, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andrea Salonia
- Vita-Salute San Raffaele University, Milan, Italy
- Division of Experimental Oncology, Unit of Urology, (URI), IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ranjith Ramasamy
- Desai Sethi Urology Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
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Khanmohammadi N, Malek F, Takzaree N, Malekzadeh M, Khanehzad M, Akanji OD, Rastegar T. Sertoli Cell-Conditioned Medium Induces Differentiation of Bone Marrow-Derived Mesenchymal Stem Cells to Male Germ-Like Cells in Busulfan-Induced Azoospermic Mouse Model. Reprod Sci 2024; 31:375-392. [PMID: 37737972 DOI: 10.1007/s43032-023-01332-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/15/2023] [Indexed: 09/23/2023]
Abstract
Non-obstructive azoospermia is a severe form of male infertility, with limited effective treatments. Bone marrow mesenchymal stem cells (BMSCs) can differentiate to different cell lines; therefore, transplantation of these cells is used for treatment of several diseases. Since these cells require induction factors to differentiate into germ cells, we co-transplanted bone marrow stem cells (BMSCs) with Sertoli cell-conditioned medium (SCCM) into the testis of azoospermic mice. This study was carried out in two sections, in vitro and in vivo. For in vitro study, differentiating factors (c-kit and ID4) were examined after 15 days of co-culture of bone marrow cells with Sertoli cell-conditioned medium, while for in vivo study, the azoospermia model was first created by intraperitoneal administration of a single-dose busulfan (40 mg/kg) followed by single-dose CdCl2 (2 mg/kg) after 4 weeks. Mice were divided into 4 groups including control (azoospermia), BMSC, SCCM, and BMSC + SCCM. Eight weeks after transplantation, samples were assessed for proliferation and differentiation via the expression level of MVH, ID4, SCP3, Tp1, Tp2, and Prm1 differentiation markers. The results showed that BMSC co-cultured with SCCM in vitro differentiated BMSC to germ-like cells. Similarly, in vivo studies revealed a higher level of BMSC differentiation into germ-like cells with significant higher expression of differentiation markers in transplanted groups compared to the control. This study confirmed the role of SCCM as an inductive factor for BMSC differentiation to germ cells both in vivo and in vitro conditions.
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Affiliation(s)
- Nasrin Khanmohammadi
- Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Malek
- Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrin Takzaree
- Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrnoush Malekzadeh
- Department of Anatomy, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Khanehzad
- Department of Anatomy, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Tayebeh Rastegar
- Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Methorst C, Faix A, Huyghe E. [Medical treatments for male infertility]. Prog Urol 2023; 33:653-680. [PMID: 38012910 DOI: 10.1016/j.purol.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Treatments to stimulate spermatogenesis and antioxidant food supplements are often offered to infertile patients either before sperm extraction surgery to improve results, or as part of medically assisted reproduction or spontaneous fertility to increase the likelihood of a live birth. METHODS A bibliographic search limited to English-language literature on men published before 5/2023 was carried out, including clinical trials, literature reviews and meta-analyses on spermatogenesis-stimulating molecules and antioxidant treatments. RESULTS Several medical treatments seem capable of improving male fertility: they act mainly by stimulating spermatogenesis through hormones, or by reducing the effects of oxidative stress. With regard to oligoasthenozoospermia, the literature shows that certain hormonal treatments stimulating spermatogenesis are useful. In the case of non-obstructive azoospermia, the value of treatment depends on the patient's FSH and testosterone levels. AOX supplementation appears to improve certain spermogram parameters and have an impact on pregnancy and live birth rates. CONCLUSION This review should help urologists gain a better understanding of the various medical treatments and enable them to define an appropriate therapeutic strategy, tailored to the patient and the couple, in order to obtain the best results.
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Affiliation(s)
- C Methorst
- Service de médecine de la reproduction, hôpital des 4-villes, Saint-Cloud, France
| | - A Faix
- Clinique Saint-Roch, 560 avenue du Colonel-Pavelet-dit-Villars 34000 Montpellier, France
| | - E Huyghe
- Département d'urologie, hôpital de Rangueil, CHU de Toulouse, Toulouse, France; Service de médecine de la reproduction, hôpital Paule-de-Viguier, CHU de Toulouse, Toulouse, France; UMR DEFE, Inserm 1203, université de Toulouse, université de Montpellier, Montpellier, France.
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Male infertility and gonadotropin treatment: What can we learn from real-world data? Best Pract Res Clin Obstet Gynaecol 2023; 86:102310. [PMID: 36682942 DOI: 10.1016/j.bpobgyn.2022.102310] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022]
Abstract
Gonadotropin therapy to treat specific male infertility disorders associated with hypogonadotropic hypogonadism is evidence-based and effective in restoring spermatogenesis and fertility. In contrast, its use to improve fertility in men with idiopathic oligozoospermia or nonobstructive azoospermia remains controversial, despite being widely practiced. The existence of two major inter-related pathways for spermatogenesis, including FSH and intratesticular testosterone, provides a rationale for empiric hormone stimulation therapy in both eugonadal and hypogonadal males with idiopathic oligozoospermia or nonobstructive azoospermia. Real-world data (RWD) on gonadotropin stimulating for these patient subsets, mainly using human chorionic gonadotropin and follicle-stimulating hormone, accumulated gradually, showing a positive therapeutic effect in some patients, translated by increased sperm production, sperm quality, and sperm retrieval rates. Although more evidence is needed, current insights from RWD research indicate that selected male infertility patients might be managed more effectively using gonadotropin therapy, with potential gains for all parties involved.
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Rahbar M, Asadpour R, Azami M, Mazaheri Z, Hamali H. Improving the process of spermatogenesis in azoospermic mice using spermatogonial stem cells co-cultured with epididymosomes in three-dimensional culture system. Life Sci 2022; 310:121057. [DOI: 10.1016/j.lfs.2022.121057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/28/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022]
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6
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Laursen RJ, Alsbjerg B, Elbaek HO, Povlsen BB, Jensen KBS, Lykkegaard J, Esteves SC, Humaidan P. Recombinant gonadotropin therapy to improve spermatogenesis in nonobstructive azoospermic patients – A proof of concept study. Int Braz J Urol 2022. [PMID: 35168313 PMCID: PMC9060167 DOI: 10.1590/s1677-5538.ibju.2022.99.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Purpose: Nonobstructive azoospermia (NOA) associated with primary spermatogenic failure is a common cause of male infertility usually considered untreatable; however, some reports have suggested that hormonal stimulation to boost the intra-testicular testosterone level and spermatogenesis might increase the chance of achieving pregnancy using homologous sperm. Materials and Methods: We report a series of eight NOA males who received long-term treatment with recombinant human chorionic gonadotropin twice a week for spermatogenesis stimulation. Six males received additional recombinant follicle-stimulating hormone (FSH) supplementation 150-225 IU twice weekly. Results: After recombinant gonadotropin therapy, viable spermatozoa were retrieved from the ejaculate in two patients and by testicular sperm aspiration (TESA) in another two subjects. Singleton spermatozoon retrieved from testes were frozen by vitrification on Cell-Sleeper devices. Two live births were obtained after intracytoplasmic sperm injection with ejaculated spermatozoa and one live birth and an ongoing pregnancy using thawed spermatozoa from TESA. Conclusion: Our proof-of-concept study indicates that hormonal therapy with recombinant gonadotropins could be considered in infertile men with NOA as an alternative to sperm donation. Large-scale studies are needed to substantiate hormone stimulation therapy with recombinant gonadotropins in routine clinical practice for this severe form of male infertility.
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Affiliation(s)
| | - Birgit Alsbjerg
- Skive Regional Hospital, Denmark; Universidade Estadual de Campinas, Brasil
| | | | | | | | | | - Sandro C. Esteves
- Universidade Estadual de Campinas, Brasil; Clínica de Andrologia e Reprodução Humana, Brasil; Aarhus University, Denmark
| | - Peter Humaidan
- Skive Regional Hospital, Denmark; Universidade Estadual de Campinas, Brasil
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7
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Laursen RJ, Alsbjerg B, Elbaek HO, Povlsen BB, Jensen KBS, Lykkegaard J, Esteves SC, Humaidan P. Recombinant gonadotropin therapy to improve spermatogenesis in nonobstructive azoospermic patients - A proof of concept study. Int Braz J Urol 2022; 48:471-481. [PMID: 35168313 DOI: 10.1590/s1677-5538.ibju.2022.9913] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Nonobstructive azoospermia (NOA) associated with primary spermatogenic failure is a common cause of male infertility usually considered untreatable; however, some reports have suggested that hormonal stimulation to boost the intra-testicular testosterone level and spermatogenesis might increase the chance of achieving pregnancy using homologous sperm. MATERIALS AND METHODS We report a series of eight NOA males who received long-term treatment with recombinant human chorionic gonadotropin twice a week for spermatogenesis stimulation. Six males received additional recombinant follicle-stimulating hormone (FSH) supplementation 150-225 IU twice weekly. RESULTS After recombinant gonadotropin therapy, viable spermatozoa were retrieved from the ejaculate in two patients and by testicular sperm aspiration (TESA) in another two subjects. Singleton spermatozoon retrieved from testes were frozen by vitrification on Cell-Sleeper devices. Two live births were obtained after intracytoplasmic sperm injection with ejaculated spermatozoa and one live birth and an ongoing pregnancy using thawed spermatozoa from TESA. CONCLUSION Our proof-of-concept study indicates that hormonal therapy with recombinant gonadotropins could be considered in infertile men with NOA as an alternative to sperm donation. Large-scale studies are needed to substantiate hormone stimulation therapy with recombinant gonadotropins in routine clinical practice for this severe form of male infertility.
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Affiliation(s)
| | - Birgit Alsbjerg
- The Fertility Clinic Skive, Skive Regional Hospital, Denmark.,Departamento de Cirurgia, Divisão de Urologia, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brasil
| | | | | | | | | | - Sandro C Esteves
- Departamento de Cirurgia, Divisão de Urologia, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brasil.,ANDROFERT, Clínica de Andrologia e Reprodução Humana, Campinas, SP, Brasil.,Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Peter Humaidan
- The Fertility Clinic Skive, Skive Regional Hospital, Denmark.,Departamento de Cirurgia, Divisão de Urologia, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brasil
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8
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Peng T, Liao C, Ye X, Chen Z, Lan Y, Fu X, An G. Gonadotropins treatment prior to microdissection testicular sperm extraction in non-obstructive azoospermia: a single-center cohort study. Reprod Biol Endocrinol 2022; 20:61. [PMID: 35365173 PMCID: PMC8973804 DOI: 10.1186/s12958-022-00934-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Microdissection testicular sperm extraction (micro-TESE) in combination with ICSI can make paternity possible for non-obstructive azoospermia (NOA) patients. Testicular sperm can be successfully retrieved in nearly half of NOA patients. Nevertheless, not many convincing protocols are established to improve sperm retrieval rate (SRR). The goal of this study was to evaluate whether gonadotropins therapy before micro-TESE could improve sperm retrieval rate and affect the ICSI outcomes in non-obstructive azoospermia patients with hypergonadotropic hypogonadism. METHODS This retrospective cohort study included a total of 569 non-obstructive azoospermia men who underwent micro-TESE with or without 3-month of preoperative hCG / hCG plus highly purified urinary FSH (uFSH) between January 2016 and December 2019. The primary outcome was the sperm retrieval rate of micro-TESE. RESULTS Sperm was found in 27 patients among 395 NOA men who accepted preoperative gonadotropins treatment (6.8%, 27/395) in post-treatment semen analysis for ICSI. One hundred forty nine out of 542 patients could successfully obtain enough sperm for ICSI through the micro-TESE (overall SRR = 27.5%). There was a statistically significant difference in the SRR between the preoperative gonadotropins treatment and non-gonadotropins treatment groups (31.2%, 115/368 vs. 19.5%, 34/174, P = 0.006). In the multivariable analysis with IPTW according to the propensity score, there was a significant association between preoperative gonadotropins treatment and the SRR (OR, 1.59; 95% CI: 1.02-2.52; P = 0.042). No differences in the clinical pregnancy rate, live birth delivery rate, or miscarriage rate were observed between the two groups. CONCLUSION Preoperative gonadotropins therapy seems to have a role in improving SRR in NOA patients with hypergonadotropic hypogonadism. We found that gonadotropins therapy had no effect on ICSI clinical outcomes and live birth.
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Affiliation(s)
- Tianwen Peng
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, China
| | - Chen Liao
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, China
| | - Xin Ye
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, China
| | - Zhicong Chen
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, China
| | - Yu Lan
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, China
| | - Xin Fu
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, China
| | - Geng An
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, China.
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9
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Abstract
Hypogonadism can be present in up to 40% in men who present with couple infertility. Testosterone is the major androgen regulating-spermatogenesis in men; as a result, men with either primary or secondary hypogonadism may be subfertile because of impaired spermatogenesis. The clinical impact of hypogonadism on fertility potential depends on the timing of its onset (fetal, prepubertal, or postpubertal) and effect on semen parameters. Treatment pathways and success rates differ according to the cause of hypogonadism and the time of its onset. When medical therapy fails to induce sufficient sperm, assisted reproductive technologies are considered.
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Affiliation(s)
- Nikoleta Papanikolaou
- Section of Investigative Medicine Imperial College London, Hammersmith Hospital, 6th Floor, Commonwealth Building, 150 Du Cane Road, London W12 0NN, UK
| | - Rong Luo
- Section of Investigative Medicine Imperial College London, Hammersmith Hospital, 6th Floor, Commonwealth Building, 150 Du Cane Road, London W12 0NN, UK
| | - Channa N Jayasena
- Section of Investigative Medicine Imperial College London, Hammersmith Hospital, 6th Floor, Commonwealth Building, 150 Du Cane Road, London W12 0NN, UK.
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10
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Holtermann Entwistle O, Sharma A, Jayasena CN. What must be considered when prescribing hormonal pharmacotherapy for male infertility? Expert Opin Pharmacother 2022; 23:1003-1008. [DOI: 10.1080/14656566.2022.2043272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Aditi Sharma
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Channa N. Jayasena
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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11
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Tharakan T, Corona G, Foran D, Salonia A, Sofikitis N, Giwercman A, Krausz C, Yap T, Jayasena CN, Minhas S. OUP accepted manuscript. Hum Reprod Update 2022; 28:609-628. [PMID: 35526153 PMCID: PMC9434299 DOI: 10.1093/humupd/dmac016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 02/24/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The beneficial effects of hormonal therapy in stimulating spermatogenesis in patients with non-obstructive azoospermia (NOA) and either normal gonadotrophins or hypergonadotropic hypogonadism prior to surgical sperm retrieval (SSR) is controversial. Although the European Association of Urology guidelines state that hormone stimulation is not recommended in routine clinical practice, a significant number of patients undergo empiric therapy prior to SSR. The success rate for SSR from microdissection testicular sperm extraction is only 40–60%, thus hormonal therapy could prove to be an effective adjunctive therapy to increase SSR rates. OBJECTIVE AND RATIONALE The primary aim of this systematic review and meta-analysis was to compare the SSR rates in men with NOA (excluding those with hypogonadotropic hypogonadism) receiving hormone therapy compared to placebo or no treatment. The secondary objective was to compare the effects of hormonal therapy in normogonadotropic and hypergonadotropic NOA men. SEARCH METHODS A literature search was performed using the Medline, Embase, Web of Science and Clinicaltrials.gov databases from 01 January 1946 to 17 September 2020. We included all studies where hormone status was confirmed. We excluded non-English language and animal studies. Heterogeneity was calculated using I2 statistics and risk of bias was assessed using Cochrane tools. We performed a meta-analysis on all the eligible controlled trials to determine whether hormone stimulation (irrespective of class) improved SSR rates and also whether this was affected by baseline hormone status (hypergonadotropic versus normogonadotropic NOA men). Sensitivity analyses were performed when indicated. OUTCOMES A total of 3846 studies were screened and 22 studies were included with 1706 participants. A higher SSR rate in subjects pre-treated with hormonal therapy was observed (odds ratio (OR) 1.96, 95% CI: 1.08–3.56, P = 0.03) and this trend persisted when excluding a study containing only men with Klinefelter syndrome (OR 1.90, 95% CI: 1.03–3.51, P = 0.04). However, the subgroup analysis of baseline hormone status demonstrated a significant improvement only in normogonadotropic men (OR 2.13, 95% CI: 1.10–4.14, P = 0.02) and not in hypergonadotropic patients (OR 1.73, 95% CI: 0.44–6.77, P = 0.43). The literature was at moderate or severe risk of bias. WIDER IMPLICATIONS This meta-analysis demonstrates that hormone therapy is not associated with improved SSR rates in hypergonadotropic hypogonadism. While hormone therapy improved SSR rates in eugonadal men with NOA, the quality of evidence was low with a moderate to high risk of bias. Therefore, hormone therapy should not be routinely used in men with NOA prior to SSR and large scale, prospective randomized controlled trials are needed to validate the meta-analysis findings.
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Affiliation(s)
- Tharu Tharakan
- Correspondence address. Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK. Tel: +44-020-3311-1234; E-mail:
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Bologna, Italy
| | - Daniel Foran
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Andrea Salonia
- Department of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Department of Urology, University Vita-Salute San Raffaele, Milan, Italy
| | - Nikolaos Sofikitis
- Department of Urology, Ioannina University School of Medicine, Ioannina, Greece
| | | | - Csilla Krausz
- Department of Experimental and Clinical Biomedical Sciences, University Hospital of Careggi (AOUC), University of Florence, Florence, Italy
| | - Tet Yap
- Department of Urology, Guy’s and St Thomas’ Hospital, London, UK
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12
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Minhas S, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, Cocci A, Corona G, Dimitropoulos K, Gül M, Hatzichristodoulou G, Jones TH, Kadioglu A, Martínez Salamanca JI, Milenkovic U, Modgil V, Russo GI, Serefoglu EC, Tharakan T, Verze P, Salonia A. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility. Eur Urol 2021; 80:603-620. [PMID: 34511305 DOI: 10.1016/j.eururo.2021.08.014] [Citation(s) in RCA: 219] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/20/2021] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Suks Minhas
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK.
| | | | - Luca Boeri
- Department of Urology, Foundation IRCCS Ca' Granda - Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Paolo Capogrosso
- Department of Urology and Andrology, Ospedale di Circolo and Macchi Foundation, Varese, Italy
| | - Joana Carvalho
- CPUP: Center for Psychology of Porto University, Faculty of Psychology and Educational Sciences, Porto University, Porto, Portugal
| | - Nusret Can Cilesiz
- Department of Urology, Taksim Training & Research Hospital, Istanbul, Turkey
| | - Andrea Cocci
- Department of Minimally Invasive and Robotic Urologic Surgery and Kidney Transplantation, University of Florence, Florence, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Konstantinos Dimitropoulos
- Academic Urology Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Murat Gül
- School of Medicine, Department of Urology, Selcuk University, Konya, Turkey
| | | | - Thomas Hugh Jones
- Centre for Diabetes and Endocrinology, Barnsley Hospital NHS Trust, Barnsley, UK
| | - Ates Kadioglu
- Department of Urology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | | | - Uros Milenkovic
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Vaibhav Modgil
- Manchester Andrology Centre, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, UK
| | - Giorgio Ivan Russo
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Ege Can Serefoglu
- Department of Urology, Biruni University School of Medicine, Istanbul, Turkey
| | - Tharu Tharakan
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Paolo Verze
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Fisciano, Italy
| | - Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
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Kailash Y, Raheem AA, Homa ST. How Successful Is Surgical Sperm Retrieval in Klinefelter Syndrome? FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:636629. [DOI: 10.3389/frph.2021.636629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Klinefelter Syndrome (KS) is characterized by the presence of an extra X chromosome. It was first diagnosed in 1942 in a group of azoospermic men. KS is the most common chromosomal abnormality encountered in infertile men and accounts for more than 10% of the causes of azoospermia. Men who are azoospermic may still father children via testicular sperm extraction followed by intracytoplasmic sperm injection (ICSI). This review article summarizes the success rates of the available techniques for surgical sperm retrieval (SSR) in KS including conventional testicular sperm extraction (cTESE) and micro testicular sperm extraction (mTESE), as well as the risks of these procedures for future fertility. The evidence indicates that the SSR rate is as successful in non-mosaic men with KS as those with normal karyotypes, with retrieval rates of up to 55% reported. The influence of different factors that affect the chances of a successful outcome are discussed. In particular, the impact of aneuploidy rate, physical characteristics, co-morbidities, reproductive endocrine balance and the use of different hormone management therapies are highlighted. Evidence is presented to suggest that the single most significant determinant for successful SSR is the age of the patient. The success of SSR is also influenced by surgical technique and operative time, as well as the skills of the surgeon and embryology team. Rescue mTESE may be used successfully following failed TESE in KS patients in combination with hormone stimulation.
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