Sperm retrieval rate and patient factors in azoospermia factor c microdeletion azoospermia: a systematic review

OBJECTIVE

To reveal the overall sperm retrieval rate (SRR) and range in patients with azoospermia factor c (AZFc) microdeletion azoospermia by microdissection testicular sperm extraction (mTESE) and discuss the differences of preoperative patient factors among studies with various SRRs.

PATIENTS AND METHODS

We searched PubMed, Web of Science and Embase until February 2023. All studies reporting SRRs by mTESE and required parameters of patients with AZFc microdeletions were included. The primary outcome was the SRR and, if available, the pregnancy rate (PR) and live-birth rate (LBR) after intracytoplasmic sperm injection were also investigated as secondary outcomes.

RESULTS

Eventually 11 cohort studies were included in this review. A total number of 441 patients underwent mTESE and in 275 of them sperm was obtained, reaching an overall SRR of 62.4%. The SRRs among studies had a wide range from 25.0% to 85.7%. The studies reporting higher SRRs generally had older mean ages, and higher follicle-stimulating hormone and testosterone levels. Only four studies provided practical data on pregnancies and live-born children of patients with AZFc microdeletions, so the overall PR and LBR were unavailable.

CONCLUSIONS

The overall SRR of patients with AZFc microdeletion azoospermia was 62.4%. The effect of patient factors in SR needs further evidence in future work.

Noninvasive Prediction of Sperm Retrieval Using Diffusion Tensor Imaging in Patients with Nonobstructive Azoospermia

Microdissection testicular sperm extraction (mTESE) is the first-line treatment plan for nonobstructive azoospermia (NOA). However, studies reported that the overall sperm retrieval rate (SRR) was 43% to 63% among men with NOA, implying that nearly half of the patients fail sperm retrieval. This study aimed to evaluate the diagnostic performance of parameters derived from diffusion tensor imaging (DTI) in predicting SRR in patients with NOA. Seventy patients diagnosed with NOA were enrolled and classified into two groups based on the outcome of sperm retrieval during mTESE: success (29 patients) and failure (41 patients). Scrotal magnetic resonance imaging was performed, and the DTI parameters, including mean diffusivity and fractional anisotropy, were analyzed between groups. The results showed that there was a significant difference in mean diffusivity values between the two groups, and the area under the curve for mean diffusivity was calculated as 0.865, with a sensitivity of 72.2% and a specificity of 97.5%. No statistically significant difference was observed in fractional anisotropy values and sex hormone levels between the two groups. This study demonstrated that the mean diffusivity value might serve as a useful noninvasive imaging marker for predicting the SRR of NOA patients undergoing mTESE.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of varicocele repair on sperm retrieval rate and testicular histopathological patterns in men with nonobstructive azoospermia

Varicocele adversely affects semen parameters. However, the effect of varicocele repair on the sperm retrieval rate and testicular histopathological patterns in men with nonobstructive azoospermia has not been widely reported. We retrospectively assessed the sperm retrieval rates and testicular histopathological patterns in men with nonobstructive azoospermia who were referred to the Urology Clinic in Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) and Bunda General Hospital (Jakarta, Indonesia) between January 2009 and December 2019. We compared patients who had undergone a surgical sperm retrieval procedure for assisted reproductive technology no earlier than three months after varicocele repair and those who had not undergone varicocele repair. The study included 104 patients (age range: 26-54 years), 42 of whom had undergone varicocele repair before the sperm retrieval procedure and 62 who had not. Motile spermatozoa were found in 29 (69.1%) and 17 (27.4%) patients who had undergone varicocele repair before the sperm retrieval procedure and those who had not undergone the repair, respectively (relative risk: 2.51; 95% confidence interval: 1.60-3.96; P < 0.001). A predicted probabilities graph showed consistently higher sperm retrieval rates for patients with varicocele repair, regardless of their follicle-stimulating hormone levels. Patients who underwent varicocele repair showed higher testicular histopathological patterns (P = 0.001). In conclusion, men with nonobstructive azoospermia and clinical varicocele who underwent varicocele repair before the sperm retrieval procedure had higher sperm retrieval rates compared to those who did not undergo varicocele repair.

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.

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

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

Sperm retrieval success and testicular histopathology in idiopathic nonobstructive azoospermia

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

Fertility management of Klinefelter syndrome

Introduction: Klinefelter syndrome (KS) represents the most common chromosomal abnormality in the general population, and one of the most common genetic etiologies of nonobstructive azoospermia (NOA) and in severe oligospermia. Once considered untreatable, men with KS and NOA now have a variety of treatment options to obtain paternity.Areas covered: The cornerstone of treatment for both KS and NOA patients remains the surgical retrieval of viable sperm, which can be used for intracytoplasmic sperm injection to obtain pregnancy. Although the field has advanced significantly since the early 1990s, approximately half of men with KS will ultimately fail fertility treatments. Presented is a critical review of the available evidence that has attempted to identify predictive factors for successful sperm recovery. To optimize surgical success, a variety of treatment modalities have also been suggested and evaluated, including hormonal manipulation and timing of retrieval.Expert opinion: Individuals with KS have a relatively good prognosis for sperm recovery compared to other men with idiopathic NOA. Surgical success is heavily dependent upon surgical technique and the experience of the andrology/embryology team tasked with the identification and use of testicular sperm.

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.

Microdissection testicular sperm extraction: Overall results and impact of preoperative testosterone level on sperm retrieval rate in patients with nonobstructive azoospermia

Objective:

The main objective is to review the overall result and impact of preoperative testosterone level on sperm retrieval rate (SRR) by microdissection testicular sperm extraction (micro-TESE) in patients with nonobstructive azoospermia (NOA).

Materials and Methods:

We retrospectively reviewed the files of patients who underwent micro-TESE for NOA from August 2013 to December 2014. All patients were evaluated with history, physical examination, and hormonal assessment. Patients who had previous micro-TESE, obstructive azoospermia, or who took hormone therapy were excluded from the study. Patients were classified into two groups. Group A included patients who had low testosterone (<10 nmol/L), and Group B included patients with normal testosterone (>10 nmol/L). The primary endpoint was to review the overall results of the procedure and the impact of preoperative testosterone level on sperm retrieval.

Results:

A total of 264 patients with NOA underwent micro-TESE. Group A included 133 patients with low testosterone (<10 nmol/l) with a median age of 36 ± 6.59 years, and Group B included 131 patients with normal testosterone (>10 nmol/L) with a median age of 33 ± 7.88 years (P = 0.1350). There was no significant difference in follicle-stimulating hormone (P = 0.2467), luteinizing hormone (P = 0.1078), prolactin (P = 0.5619), and testicular volume (P = 0.4052), whereas a significant difference was found in testosterone level (P = 0.0001) in both groups. Overall, sperm were successfully retrieved in 48.8% of men. SRR in Group B was significantly higher (57.25%) than that in Group A (40.60%) (P = 0.0068). SRR in patients with Sertoli-cell-only pathology was 30.35%, hypospermatogenesis was 89.74%, and maturation arrest was 32.43%.

Conclusion:

Micro-TESE is a successful and safe procedure in NOA patients with a poor prognosis. Preoperative testosterone level has a significant impact in the SRR by micro-TESE.

Effect of seasonal variation on the success of micro-dissection testicular sperm extraction: A pilot study

The aim of this study is to investigate the relationship between seasonal variation and the success of micro-dissection testicular sperm extraction (mTESE). A total of 395 patients who were diagnosed with non-obstructive azoospermia, who had undergone mTESE operation for the first time, and who did not have an obstructive pathology, were included in the study. The patients were divided into 12 groups according to the month of the operation and four groups according to the season. The groups were compared with regard to age, duration of infertility, BMI, hormone profile and sperm retrieval rate of mTESE. The maximum sperm retrieval rate was obtained in January (69.7%) and the minimum sperm retrieval rate was obtained in November (50.0%). No statistically significant difference was detected when the mTESE results were compared with regard to months (p = 0.638). The maximum sperm retrieval rate was obtained in the summer (62.8%) and the minimum was obtained in spring (57.0%). No statistically significant difference was determined between groups created according to seasons (p = 0.865). We did not observe a statistically significant relationship between the sperm retrieval rate and the seasons. Studies conducted in regions with different climate features could better reveal the relationship between seasonal variation and the success of mTESE.

Reporting on longitudinal live birth rates and cumulative delivery rates are more realistic outcome measures than sperm retrieval rates in couples undergoing mTESE-ICSI

The live birth rates (LBRs) in men with non-obstructive azoospermia (NOA) undergoing microdissection TESE (mTESE) are under reported, with surgical sperm retrieval rate often used as the primary outcome measure. We analysed longitudinal and cumulative delivery rates following mTESE- intracytoplasmic sperm injection (ICSI) in NOA. Sperm was retrieved in 45% of patients undergoing mTESE. Median male and female age were 42 years (IQR 37-47) and 35 years (IQR 31-38) respectively. A total of 141 ICSI cycles and 23 frozen embryo transfers resulted in 62 pregnancies and 37 LBRs. The longitudinal LBR, crude and expected cumulative delivery rates after five cycles were 15.5%, 48.7% and 71.1%, respectively. Reassuringly, there was no significant difference in pregnancy rate (PR) (p = 0.37) or LBR (p = 0.68) using fresh or frozen sperm or embryo (p = 0.74). Sperm retrieval was significantly correlated with Johnsen score (JS) (p = 0.006) and hypospermatogenesis (HS) (p = 0.04), whilst LBR only significantly correlated with female age (p = 0.04). The longitudinal LBR for a couple embarking on mTESE for azoospermia is only 15.5%, although the cumulative delivery rates are promising. Reassuringly, the outcomes using fresh versus frozen embryos or sperm are comparable. Reporting on delivery rates from a single mTESE procedure are more objective and realistic measures of treatment success in men with NOA.

[Application of microdissection testicular sperm extraction in non-obstructive azoospermia]

The development of testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) has made it possible for patients with non-obstructive azoospermia to have their own children. However, sperm retrieval by conventional TESE succeeds but in a subset of patients and, therefore, how to improve the success rate of sperm retrieval is becoming a focus of research. Recent studies suggest that microdissection TESE, although with its limitations, has obvious advantages over traditional sperm retrieval methods. This article presents an overview on the characteristics, predictive factors, sperm retrieval rate, post-operative complications, and improvement of microdissection TESE.

Predicting sperm retrieval rates in testicular sperm extraction for azoospermia according to endocrine profiles

Background and Aims:  The present study was carried out to examine the predictive value of endocrine profiles as indicators of the sperm retrieval rate on testicular sperm extraction (TESE) in azoospermic men. Methods:  Prior to TESE, the serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, testosterone, dihydrotestosterone (DHT), estradiol and 17 α-hydroxyprogesterone were measured and the sagittal cross-sections of the testis were acquired using ultrasonography. Results:  The sperm retrieval rates according to the cause of azoospermia were 40% for idiopathic azoospermia, and 100% for obstructive azoospermia, cryptorchidsm and ejaculatory disorder. Based on the endocrinological profiles, the sperm retrieval rates showed significant differences at 100% for FSH  15 mIU/mL or LH  2 mIU/mL, 0% for FSH > 60 mIU/mL or LH > 12 mIU/mL, and 33% for the intermediate groups (P < 0.01). Comparison of the retrieval of spermatozoa and serum DHT level for the intermediate group also showed a significant difference, with retrieval rates of 58% for DHT  0.5 ng/mL and 0% for DHT > 0.5 ng/mL (P < 0.01). Conclusions:  The etiology, serum FSH, LH and DHT levels are useful in predicting the sperm retrieval rates on TESE in azoospermic patients. (Reprod Med Biol 2005; 4: 239-245).