P-011 Deep testicular tissue dissection is most often required to retrieve testicular sperm in patients with non-obstructive azoospermia undergoing microdissection testicular sperm extraction

Study question

How successful is sperm retrieval from the testicular surface of patients with non-obstructive azoospermia (NOA) undergoing microdissection testicular sperm extraction (mTESE)?

Summary answer

Enough good quality sperm for ICSI could be retrieved from the testicular surface in only 33 out of 224 patients (14.7%)

What is known already

Due to the anatomic singularity of NOA, characterized by the heterogeneous distribution of histologically and functionally distinct seminiferous tubules, retrieving enough good quality sperm for ICSI may require a complete testicular dissection. While conventional TESE (cTESE) may reach only the seminiferous tubules located in the testis surface, mTESE allows the nearly complete exploration of the whole testicular parenchyma. This is the reason why mTESE provides better sperm retrieval rates compared to cTESE, according to two systematic reviews and one meta-analysis: the superiority of mTESE compared to cTESE, however, has been challenged by a recent meta-analysis.

Study design, size, duration

Retrospective cohort study on 224 patients, aged 37 (20-54) years, who underwent unilateral (71, 31.7%) or bilateral (153, 68.3%) mTESE from January 2018 through May 2021. 175 patients were naïve for mTESE, while 49 underwent a salvage mTESE following one or more previously failed conventional TESE.

Participants/materials, setting, methods

The testis was opened like a book following a transversal incision of the testis covering two-thirds to three-quarters of its circumference: the entire surface of the testicular parenchyma was explored first in search for dilated seminiferous tubules. If no/ not enough sperm were retrieved, the testis was opened till to be fully bivalve, and the deeper portion of the testicular parenchyma was explored both into hilum direction and orthogonally to the para-equatorial section plan.

Main results and the role of chance

Sperm was retrieved in 114 patients (50.8%), 67 (94.3%) undergoing unilateral and 47 (30.7%) undergoing bilateral mTESE: only 15/153 (9.8%) had their testicular sperm retrieved in the second testis following the unsuccessful sperm retrieval in the first testis, while in the remaining cases sperm had to be retrieved from both testes to obtain enough good quality sperm for ICSI. Histopathology demonstrated Sertoli-cell only syndrome in 65.6% of operated testes, while maturation arrest was found in 19.8%, hypospermatogenesis in 12.6% and hyalinosis in 1.5%. Sperm were obtained from the testis surface in 33 out of 114 patients (28.9%); in the remaining patients a deeper dissection was needed. No difference was seen among patients with sperm found in the surface or requiring deeper dissection in terms of age, testis volume, serum testosterone level, and histopathological subcategories; although serum FSH and LH level were significantly lower in patients with sperm retrieved from the testicular surface, on multivariate logistic regression they were not found to predict the chance of retrieving sperm from the surface (OR 0.96, 95% CI 0.92-1.007, p = 0.104 and OR 0.95, 95% CI 0.85-1.06, p = 0.405, respectively).

Limitations, reasons for caution

the amount of testicular tissue dissected was strictly dependent upon the chance of finding enough sperm for ICSI in the specimens handled by the biologist in the operating room: we cannot exclude that in some patients enough sperm could be obtained from the testis surface following further extensive search

Wider implications of the findings

mTESE is to be preferred to cTESE, since in most patients with NOA seminiferous tubules containing sperm may be found in the deeper portion of the testicular parenchyma. This may be particularly true for patients with unfavorable histopathological patterns, such as Sertoli cell only syndrome or maturation arrest.

Trial registration number

Not applicable

A medico-legal definition of femicide

Femicide refers to the extreme form of violence against someone belonging to the female gender, i.e. the killing of a woman. Research shows that, to date, gender-based violence remains largely a hidden phenomenon with prevalence often being underestimated by official statistics and data missing in numerous countries. It can be argued that the under-reporting may be suggestive of a legislative gap that needs addressing. This work aims to reach a shared medico-legal definition of femicide stemming from a comprehensive review of the current legislation of countries around the world. In addition, it appraises forensic pathology studies focusing on the murder of women as well as the most relevant documents published by prominent international organizations fighting violence against women. Review of the literature shows a scarcity of national legislations concerning specifically femicide, despite the attention given to this phenomenon by international organizations fighting violence against women. Additionally, a non-homogeneous framing of the term femicide arises from the forensic pathology literature and national laws. Starting from one of the funding principle of medical ethics - autonomy - authors propose to define femicide as a murder perpetrated because of a failure to recognize the victim's right to self-determination. This definition would give the forensic pathologist a central role in identifying femicide cases among the murders of women. A shared forensic approach is needed, ideally employing standardized methodology to compare international data and to standardize scientific research in the field.

P–008 The diameter of standard seminiferous tubules varies with the different histological patterns in patients with non-obstructive azoosperm

Study question

Does the standard, not-dilated seminiferous tubules (STs) diameter vary according with different testis histology patterns in patients with non-obstructive azoospermia (NOA)?

Summary answer

The standard STs diameter differed significantly among cases with different testis histology: hypospermatogenesis (HYPO) had the highest STs diameter compared to the other histological subgroups.

What is known already

During microdissection testicular sperm extraction (mTESE), the identification of dilated STs, as subjectively evaluated at high magnification by comparing their apparent caliber with that of the surroundings, is crucial to identify residual foci of intact spermatogenesis and to retrieve sperm. Previous studies have demonstrated that dilated STs contain sperm in most cases, but it is not clear why in some cases an apparent normal tubular caliber does not correspond to spermatogenesis integrity. Aim of the present study was to assess whether different histology patterns could affect the STs diameter.

Study design, size, duration

We retrospectively evaluated 168 patients with NOA undergoing unilateral (N = 91) or bilateral (N = 77) mTESE from 2018 through 2019. One or more biopsy samples representative of the overall appearance of the testicular parenchyma were taken from one (for unilateral mTESE) or both testes (for bilateral mTESE), was fixed in Bouin’s solution and sent to the pathologist. Histological analysis was conducted by the same experienced pathologist, who examined at least 100 different tubule sections per biopsy sample.

Participants/materials, setting, methods

Each tubule section (N = 100 per sample) was evaluated at 10X magnification with a micrometer to measure the tubule diameter, then the mean ST diameter was computed. The basal membrane (BM) thickening was evaluated in every section, and a score was assigned by multiplying the degree of BM fibrosis (mild=1, moderate=2, severe=3) for the number of sections (e.g. BM score for moderate fibrosis in 50 sections=2x50=100). Leydig cells hyperplasia (LCH), if present, was also annotated.

Main results and the role of chance

The median + interquartile range STs diameter was 140; 110–185 mm, while the median BM score was 100; 10–150. Sertoli cell only syndrome (SCO) was found in 51.1% of cases, focal SCO (FSCO) in 4,7%, early (EMA) and late (LMA) maturation arrest in 10.2 and 2.73% respectively, HYPO in 26.17% and hyalinosis (HL) in 5% of cases. LCH was found in 46.88% of samples. STs diameter, BM score and LCH differed significantly among the different histological patterns: STs diameter was 125; 100–148 in SCO, 162; 102–187 in FSCO, 130; 100–175 in EMA, 145; 130–195 in LMA, 205; 170–240 in HYPO and 57.5; 42.5–100 in HL. HYPO samples also had the lowest BM score (20;1–100; p < 0.0001) and LCH prevalence (23.8%, p < 0.0001) compared to the other histological subgroups (HS). A multinomial logistic regression for prediction of different histological subgroups was run with STs diameter, BM score and LCH as candidate predictors: the model explained the 29% of variability of the outcome and correctly classified 69% of cases. STs diameter significantly predicted FSCO (RR 1.02, 95% CI 1.0–1.04), LMA (RR 1.02, 95% CI1–1.04) and HYPO (1.03, 95%CI 1.02–1.04), while BM score significantly predicted HL (RR 1.07, 95%CI 1.02–1.13).

Limitations, reasons for caution

The STs were carefully cut before extraction in order to preserve their structural integrity, however the accuracy of such a method of estimating the STs diameter needs to be assessed by further studies.

Wider implications of the findings: The identification of dilated STs remains the best strategy to retrieve sperm by mTESE, since larger STs diameters are mostly associated with the more favorable histological patterns. However, dilated STs may be also found in cases with LMA, which explains why in some cases dilated STs do not contain sper.

Trial registration number

Not applicable

Identification of extracellular vesicles and characterization of miRNA expression profiles in human blastocoel fluid

In this study, for the first time, we demonstrated the presence of microRNAs and extracellular vesicles in human blastocoel fluid. The bioinformatic and comparative analyses identified the biological function of blastocoel fluid microRNAs and suggested a potential role inside the human blastocyst. We found 89 microRNAs, expressed at different levels, able to regulate critical signaling pathways controlling embryo development, such as pluripotency, cell reprogramming, epigenetic modifications, intercellular communication, cell adhesion and cell fate. Blastocoel fluid microRNAs reflect the miRNome of embryonic cells and their presence, associated with the discovery of extracellular vesicles, inside blastocoel fluid, strongly suggests their important role in mediating cell communication among blastocyst cells. Their characterization is important to better understand the earliest stages of embryogenesis and the complex circuits regulating pluripotency. Moreover, blastocoel fluid microRNA profiles could be influenced by blastocyst quality, therefore, microRNAs might be used to assess embryo potential in IVF cycles.

[Laser assisted intracytoplasmic sperm injection: a more effective and faster technique of immobilization of spermatozoa than traditional one]

AIM

Intracytoplasmic sperm injection (ICSI) is employed routinely in the assisted reproductive technique, in particular in case of male factor infertility. Recently, some options have been introduced in the micromanipulation system employed in ICSI, improving the performance of this technique. One of these is a no-contact laser, mostly used for the assisted hatching and the blastomere biopsy in preimplantation genetic diagnosis. One of the most important step of the ICSI technique is the sperm immobilization. Normally, this is performed by the operator and needs some time.

METHODS

A one-year perspective-comparative study has been carried out and the results obtained with the traditional technique of immobilization of spermatozoa have been compared with those obtained with the laser technique (spermatozoa previously immobilized by no-contact laser). We have evaluated 3 parameters: 1) fertilization rate; 2) cleavage rate and 3) time needed to immobilize sperm.

RESULTS

Some interesting findings have been observed: the embryo quality, fertilization rate and cleavage rate seem the same in both groups. The most interesting finding is the drastic reduction of the time needed for microinjection when the laser technique is used.

CONCLUSIONS

This technique will reduce the total time needed to perform the ICSI, decreasing the time of exposure of the gametes outside the incubator and reducing the possibility of irreversible damage.

Human chorionic gonadotropin free beta-subunit in the human seminal plasma: a new marker for spermatogenesis?

In the past 20 years, several factors were detected in the human seminal plasma and proposed as markers for spermatogenesis. Human chorionic gonadotropin (hCG) and its beta-subunit were therefore investigated, and their seminal levels were found to be higher than those detected in the serum and to correlate with sperm parameters.

OBJECTIVE

We designed a retrospective study to determine the suitability of hCG free beta-subunit concentration in the seminal plasma of fertile and infertile male patients as marker of spermatogenesis.

STUDY DESIGN

A total of 79 infertile male patients were divided into four groups by their semen analysis results (group 1 [n=8]: azoospermia; group 2 [n=21]: severe oligozoospermia; group 3 [n=40]: oligoasthenospermia (OAS); group 4 [n=10]: asthenospermia) and 10 healthy volunteers of proven fertility were evaluated.

RESULTS

The hCG free beta-subunit levels in the seminal plasma were found to be significantly higher (P<0.0001) in the control group in respect to those assayed in the infertile patients and showed a correlation with sperm count (r=0.5) and total motile sperm density (r=0.5). Twenty-five patients were on treatment with oral Mesterolone (100mg daily) plus Tamoxifen (20mg daily) for 3-6 months. Apart from a significant improvement (P<0.05) in sperm morphology, no significant changes in sperm count and motility were observed after the treatment in all the patients. In the seminal plasma of 10 patients who showed a significant increase in sperm count, hCG free beta-subunit levels were found to be significantly higher compared to those detected in the remaining patients (P<0.01). In all patients, these levels remained unchanged after the treatment.

CONCLUSIONS

The evidence regarding the positive correlation between hCG free beta-subunit levels in the seminal plasma and sperm concentration is consistent with the previous results regarding hCG levels. A previous study demonstrated that testosterone levels in seminal plasma correlated with sperm concentrations; from the same evidence regarding hCG we hypothesize that seminal plasma testosterone and hCG levels are correlated. Thus, hCG may play a paracrine role in the intratesticular regulation of testosterone secretion.

Molecular and cytogenetic characterization of an azoospermic male with a de-novo Y;14 translocation and alternate centromere inactivation

BACKGROUND

Y-autosome (Y/A) translocations have been reported in association with male infertility. Different hypotheses have been made as to correlations between Y/A translocations and spermatogenetic disturbances. We describe an azoospermic patient with a de-novo Y;14 translocation: 45,X,dic(Y;14)(q12;p11).

METHODS AND RESULTS

Cytogenetic, fluorescent in-situ hybridization (FISH) and molecular studies have been performed. A 14/22 (D14Z1/D22Z1) centromere and a Y centromere (DYZ1) probe both showed a signal on the translocation chromosome, confirming its dicentricity. Each copy of the translocation chromosome had only one primary constriction, with inactivation of the Y centromere in most (90%) of the cells. The 14 centromere was inactive in the remaining cells (10%). FISH and molecular deletion mapping analysis allowed acute assignment of the Yq breakpoint to the junction of euchromatin and heterochromatin (Yq12), distal to the AZF gene location (Yq11).

CONCLUSIONS

This study supports the hypothesis that in Y/A translocations infertility might be related to meiotic disturbances with spermatogenetic arrest. In addition, sex chromosome molecular investigations, performed on single spermatids, suggest a highly increased risk of producing chromosomally abnormal embryos.