The relationship of testicular stiffness with Johnsen score and sperm retrieval outcome in men with non-obstructive azoospermia

Background

The pathological Johnsen score (JS) is a quantitative histological scoring system used to assess spermatogenesis in men with nonobstructive azoospermia (NOA), while elastic modulus derived from shear wave elastography (SWE) is a diagnostic tool for evaluating spermatogenic dysfunction. In this prospective observational study, we aimed to investigate whether testicular stiffness measured by SWE could serve as a substitute for JS in predicting sperm retrieval outcomes in men with NOA.

Methods

This prospective cohort study analyzed 140 testes from 115 consecutive outpatient participants with NOA who had sought treatment at the reproductive medical center of a tertiary care hospital between January 2018 and October 2021. Testicular volume, elastic modulus, JS, and sperm retrieval outcomes were calculated. Statistical differences in parameters between the positive and negative sperm retrieval groups were determined using the Mann-Whitney test. Spearman rank correlation analysis was performed to determine the correlations between JS and either testicular volumes or elastic modulus. Receiver operating characteristic (ROC) curves were drawn to evaluate the diagnostic performance of the testicular elastic modulus and testicular volume.

Results

The JS correlated positively with testicular volume and negatively with the maximum elastic modulus (Emax) and mean elastic modulus (Emean), with correlation coefficients of 0.804, -0.686, and -0.456, respectively (P<0.01). There were significant differences in JS, testicular volume, and Emax between participants with positive and negative sperm retrieval of microdissection testicular sperm extraction (micro-TESE) (P<0.01). ROC curves were plotted for JS, testicular volume, and Emax to distinguish between participants with positive and negative sperm retrieval. The areas under the ROC curves (AUCs) were 0.783 [95% confidence interval (CI): 0.707-0.859; P<0.01], 0.737 (95% CI: 0.651-0.823; P<0.01), and 0.729 (95% CI: 0.643-0.814; P<0.01), respectively. When the cutoff value of JS was 4.5, its sensitivity and specificity were 60.3% and 89.6%, respectively. When the cutoff value of Emax was 3.75 kPa, its sensitivity and specificity were 79.1% and 64.4%, respectively. The sensitivity and specificity were 68.5% and 83.6%, respectively when the cutoff value of testicular volume was 8.17 mL. Emax combined with testicular volume improved this diagnostic value, with an AUC of 0.742 (95% CI: 0.657-0.828; P<0.01), and sensitivity and specificity were 83.6% and 68.5%, respectively.

Conclusions

Our study suggests that the combination of testicular stiffness and volume measurements may serve as a viable alternative to pathological JS in predicting the likelihood of successful sperm retrieval prior to micro-TESE procedures.

Testicular sperm retrieval for intracytoplasmic sperm injection: when to consider it after unsuccessful intracytoplasmic sperm injection with ejaculated sperm?

BACKGROUND

The question of whether patients are more likely to succeed with testicular sperm intracytoplasmic sperm injection (T-ICSI) after unsuccessful ICSI with ejaculated sperm (Ej-ICSI) remains unknown.

OBJECTIVE

The study aimed to identify potential predictors of successful T-ICSI in men with idiopathic infertility and oligozoospermia (sperm concentration < 15 × 106/mL, non-azoospermic) who had previously experienced unsuccessful Ej-ICSI.

MATERIALS AND METHODS

In total, 154 couples with male partners who had oligozoospermic conditions after two unsuccessful cycles of Ej-ICSI switched to T-ICSI. Before initiating T-ICSI, the sperm DNA fragmentation index (DFI) was assessed in ejaculated specimens. Participants were divided into two groups: group A (live birth (+), n = 60) and group B (live birth (-), n = 94).

RESULTS

Fertilization, clinical pregnancy, live births, and miscarriages had rates of 72.7%, 44.2%, 39%, and 5.2%, respectively. The total motile sperm (TMS) count in group A was significantly higher (3.8 ± 1.5 million) than in group B (3 ± 1.6 million; p = 0.002). DFI was significantly higher in group A (24.2 ± 12.3) than in group B (18.1 ± 11; p = 0.001). Hormone levels and oocyte counts showed no statistically significant differences between groups. Multivariate regression analysis revealed that TMS (odds ratio [OR]: 1.46; 95% CI, 1.14-1.87, p = 0.003) and DFI (OR: 1.04; 95% CI, 1.01-1.08, p = 0.009) were found to be significant predictors of live birth outcomes. At a cutoff point of 2.55 (area under the curve [AUC] = 0.65), the optimal sensitivity and specificity values for TMS were 78% and 48%, respectively. At a cutoff point of 25.8 (AUC = 0.65), DFI had a maximum sensitivity of 51.7% and a specificity of 78.7%.

CONCLUSIONS

TMS and DFI were found to be significant predictors of live birth outcomes in couples with oligozoospermic male partners undergoing T-ICSI. These findings may help clinicians tailor treatment strategies for this specific patient population.

Association of the minimal cyclophosphamide equivalent dose and outcome of microdissection testicular sperm extraction in patients with persistent azoospermia after chemotherapy

Objective

To investigate whether the minimal cyclophosphamide equivalent dose (mCED), a novel approach for estimating alkylating agent exposure, is associated with the sperm retrieval rates by microdissection testicular sperm extraction (mTESE) in azoospermic postchemotherapy cancer survivors.

Design

A retrospective cohort study conducted between 2002 and 2017.

Setting

An academic medical center.

Patients

A total of 28 azoospermic postchemotherapy cancer survivors who underwent mTESE.

Interventions

Chemotherapy exposure and mCED calculation.

Main Outcome Measures

The primary outcome was the association between the mCED and sperm retrieval rate using mTESE. The mCED value for each patient's regimen received was estimated using the lowest recommended dosing regimen from the range of recommended doses at the time of administration.

Results

Spermatozoa were successfully retrieved in 11 (39.3%) of the patients. Age at the time of receiving chemotherapy and mCED were significant factors associated with sperm retrieval. An mCED of <4,000 mg/m2 had a higher sperm retrieval rate (10/14, 71.4%) than an mCED of >4,000 mg/m2 (0/8, 0). The hormone levels were not significantly different when comparing patients with and without successful sperm retrieval. Seminoma, nonseminomatous germ cell tumor, and acute lymphoblastic leukemia had favorable sperm retrieval rates-100% (2/2), 66.7% (2/3), and 66.7% (2/3), respectively-although the numbers of patients in each group were small.

Conclusion

Among this cohort of patients with cancer who required chemotherapy regimens, successful sperm retrieval by mTESE was only noted among cancer survivors receiving an mCED of <4,000 mg/m2.

Ex-vivo microscopic oncotesticular sperm extraction: step-by-step surgical technique at time of radical orchiectomy

OBJECTIVE

To demonstrate the intraoperative surgical techniques required for simultaneous radical orchiectomy and microscopic oncotesticular sperm extraction (m-OncoTESE) in a step-by-step fashion.

DESIGN

Video presentation.

SETTING

University Hospital (University of Chicago).

PATIENTS

A 37-year-old man (status after right orchiectomy at another institution for stage II-C testicular seminoma with positive preoperative tumor markers) was referred for contralateral orchiectomy of multifocal left testis mass and fertility preservation. Semen analysis before, microscopic testicular sperm extraction during, and semen or testicular specimen analysis after the first orchiectomy were unable to identify any sperm. A postoperative analysis of the m-OncoTESE performed on the left testis resulted in the cryopreservation of 200,000 motile sperm for future assisted reproductive technology (i.e., in vitro fertilization or in vitro fertilization-intracytoplasmic sperm injection).

INTERVENTIONS

Left radical orchiectomy and left m-OncoTESE.

MAIN OUTCOME MEASURES

A comprehensive visual documentation of m-OncoTESE surgical techniques with concurrent commentary detailing the reasons behind each surgical step. A brief discussion on the background of m-OncoTESE and alternative fertility preservation methods accompanies the procedure.

RESULTS

This video provides a step-by-step guide to performing an m-OncoTESE (proceeding a radical orchiectomy in a patient with testicular cancer) as a means of fertility preservation in an azoospermic patient. Successful extraction and cryopreservation of testicular spermatozoa were achieved after targeted ex-vivo testicular microdissection.

CONCLUSIONS

Sperm extraction via m-OncoTESE is a viable option for azoospermic patients with testicular cancer undergoing radical orchiectomies. The use of preoperative imaging and microsurgical techniques facilitates and optimizes surgical dissection and sperm recovery.

Microdissection testicular sperm extraction outcomes in azoospermic patients with bilateral orchidopexy

BACKGROUND

Cryptorchidism is considered to be one of the most common causes of non-obstructive azoospermia. There are several surgical techniques to retrieve sperm in these patients. Microdissection testicular sperm extraction (m-TESE) is a recent sperm retrieval technique which is considered to be a safe, non-blind, and feasible method.

OBJECTIVES

This study aimed to investigate sperm retrieval rate (SRR) by the mTESE method in patients who have undergone orchidopexy due to bilateral cryptorchidism.

MATERIALS AND METHODS

In this retrospective study, 56 ex-cryptorchid patients, who underwent mTESE due to post orchidopexy azoospermia, were included. Patients with hypogonadotropic hypogonadism, Klinefelter syndrome, azoospermia factors (AZF) microdeletion, or chromosomal translocation were excluded from the study. Data were obtained from medical files.

RESULTS

SRR in this study was 46%. Patients were divided into two groups of negative (n = 30) and positive (n = 26) based on the sperm extraction outcomes. There was no statistically significant difference between two groups regarding the mean age at mTESE, mean age at orchidopexy, testicular size, and serum testosterone concentration. However, testicular location, histological patterns, FSH, and LH level showed to have statistically significant relation with sperm retrieval results. But, according to our logistic regression, none of the included variable in the model including FSH, LH, histopathology, and testis location have a significant effect on the presence of the sperm.

DISCUSSION

In the present study, SRR was significantly higher in patients with scrotal testis and low level of FSH and LH.

CONCLUSIONS

Performing mTESE could be recommended in ex-cryptorchid patients with post orchidopexy NOA. Preoperative testicular biopsy seems to be unnecessary while clinical criteria can perfectly define NOA.

Comparison of sperm retrieval rate between superficial and deep dissection during microscopic testicular sperm extraction

Objective

The purpose of the study was to compare the outcome of microscopic testicular sperm extraction (micro-TESE) between superficial and deep dissection on the same testicle in terms of sperm retrieval rate (SRR).

Patients and Methods

In a retrospective study from June 2019 to October 2021, 44 patients with nonobstructive azoospermia who underwent micro-TESE with positive results (mature sperm identified) were included. Eight patients were excluded from the study due to deficient documentation on superficial and deep dissection. A total of 36 patients were included; 60 testicles were examined for superficial and deep biopsies. Testicular histopathology was performed in all patients, and a hormonal evaluation was obtained before the micro-TESE attempt.

Results

Thirty-six patients and 60 testicles were included in the study. Of them, 47 (78.3%) testicles had positive results. Superficial TESE was positive in 38 (63.3%) testicles, and deep TESE was successful in 45 (75.0%) testicles. An improvement of 13.9% in the SRR was observed, following deep dissection. However, there was no statistically significant difference (P = 0.166). Rates of positive sperm retrieval (from any side) did not differ significantly based on patients' age, microdissection testicular sperm extraction sides, and hormonal concentrations; these differences were not apparent after superficial or deep TESE.

Conclusion

The presented findings suggest that although successful SRRs of deep TESE were higher than that of its superficial counterpart, there was no significant statistical difference. A larger body of evidence is needed to provide a higher grade of recommendation.

Azoospermia factor c microdeletions and outcomes of assisted reproductive technology: a systematic review and meta-analysis

OBJECTIVE

To investigate whether Azoospermia Factor c (AZFc) microdeletions affect Assisted Reproductive Technology (ART) outcomes.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENTS

Infertile men with and without AZFc microdeletions.

INTERVENTION(S)

Electronic databases were searched for case-control studies reporting sperm retrieval rates and outcomes of ART in infertile men with and without AZFc microdeletions from inception to April 2023. Study quality was assessed using the Newcastle-Ottawa Scale. Summary effect sizes (odds ratio [OR] with 95% confidence interval [CI]) were calculated for both categories of infertile men.

MAIN OUTCOME MEASURES

The primary outcome was successful sperm retrieval and the secondary outcomes were outcomes of ART.

RESULTS

Case-control studies reporting sperm retrieval rates and ART outcomes in men with AZFa and AZFb deletions were unavailable. On the basis of the data from 3,807 men, sperm retrieval rates were found to be higher in men with AZFc microdeletions compared to their non-deleted counterparts [OR = 1.82, 95% CI 0.97, 3.41], but the difference was not statistically significant. A significantly lower fertilization rate (OR = 0.61, 95% CI [0.50, 0.74]), clinical pregnancy rate (OR = 0.61, 95% CI [0.42, 0.89]), and live birth rate (OR = 0.54, 95% CI [0.40, 0.72]) were observed in men with AZFc deletions compared with men without deletions. There was no statistically significant difference in rates of embryo cleavage, blastocyst formation, good-quality embryos, implantation, and miscarriage between the two groups. On correcting for female factors, the fertilization rate (OR = 0.76, 95% CI [0.71, 0.82]), cleavage rate (OR = 0.54, 95% CI [0.41, 0.72]), clinical pregnancy rate (OR = 0.39, 95% CI [0.30, 0.52]), and live birth rate (OR = 0.48, 95% CI [0.35, 0.65]) were significantly lower in men with AZFc deletions compared with controls.

CONCLUSIONS

Presence of AZFc microdeletions adversely affects outcomes of ART in infertile men. Further in-depth studies delineating the role of the AZF genes in embryonic development are necessary to understand the full-impact of this finding.

CLINICAL TRIAL REGISTRATION NUMBER

CRD42022311738.

Surgically retrieved spermatozoa for ICSI cycles in non-azoospermic males with high sperm DNA fragmentation in semen

Intracytoplasmic sperm injection (ICSI) using surgically retrieved spermatozoa outside the classic context of azoospermia has been increasingly used to overcome infertility. The primary indications include high levels of sperm DNA damage in ejaculated spermatozoa and severe oligozoospermia or cryptozoospermia, particularly in couples with ICSI failure for no apparent reason. Current evidence suggests that surgically retrieved spermatozoa for ICSI in the above context improves  outcomes, mainly concerning pregnancy and miscarriage rates. The reasons are not fully understood but may be related to the lower levels of DNA damage in spermatozoa retrieved from the testis compared with ejaculated counterparts. These findings are consistent with the notion that excessive sperm DNA damage  can be a limiting factor responsible for the failure to conceive. Using testicular in preference of low-quality ejaculated spermatozoa bypasses post-testicular sperm DNA damage caused primarily by oxidative stress, thus increasing the likelihood of oocyte fertilization by genomically intact spermatozoa. Despite the overall favorable results, data remain limited, and mainly concern males with confirmed sperm DNA damage in the ejaculate. Additionally, information regarding the health of ICSI offspring resulting from the use of surgically retrieved spermatoa of non-azoospermic males is still lacking. Efforts should be made to improve the male partner's reproductive health for safer ICSI utilization. A comprehensive andrological evaluation aiming to identify and treat the underlying male infertility factor contributing to sperm DNA damage is essential for achieving this goal.

Enzymatic tissue processing after testicular biopsy in non-obstructive azoospermia enhances sperm retrieval

STUDY QUESTION

What is the added value of enzymatic processing of testicular biopsies on testicular sperm retrieval (SR) rates for patients with non-obstructive azoospermia (NOA)?

SUMMARY ANSWER

In addition to mechanical mincing, enzymatic digestion increased SR rates in testicular biopsies of NOA patients.

WHAT IS KNOWN ALREADY

Many studies focus on the surgical approach to optimize recovery of testicular sperm in NOA, and in spite of that, controversy still exists about whether the type of surgery makes any difference as long as multiple biopsies are taken. Few studies, however, focus on the role of the IVF laboratory and the benefit of additional lab procedures, e.g. enzymatic digestion, in order to optimize SR rates.

STUDY DESIGN SIZE DURATION

This retrospective single-center cohort study included all patients who underwent their first testicular sperm extraction (TESE) by open multiple-biopsy method between January 2004 and July 2022. Only patients with a normal karyotype, absence of Y-q deletions and a diagnosis of NOA based on histology were included. The primary outcome was SR rate after mincing and/or enzymes. The secondary outcome was cumulative live birth (CLB) after ICSI with fresh TESE and subsequent ICSI cycles with frozen TESE.

PARTICIPANTS/MATERIALS SETTING METHODS

Multiple biopsies were obtained from the testis, unilaterally or bilaterally, on the day of oocyte retrieval. Upon mechanical mincing, biopsies were investigated for 30 min; when no or insufficient numbers of spermatozoa were observed, enzymatic treatment was performed using Collagenase type IV. Multivariable regression analysis was performed to predict CLB per TESE by adjusting for the following confounding factors: male FSH level, female age, and requirement of enzymatic digestion to find sperm.

MAIN RESULTS AND THE ROLE OF CHANCE

We included 118 patients, of whom 72 (61.0%) had successful SR eventually. Spermatozoa were retrieved after mechanical mincing for 28 patients (23.7%; 28/118) or after additional enzymatic digestion for another 44 patients (37.2%; 44/118). Thus, of the 90 patients requiring enzymatic digestion, sperm were retrieved for 44 (48.9%). Male characteristics were not different between patients with SR after mincing or enzymatic digestion, in regard to mean age (34.5 vs 34.5 years), testis volume (10.2 vs 10.6 ml), FSH (17.8 vs 16.9 IU/l), cryptorchidism (21.4 vs 34.1%), varicocele (3.6 vs 4.6%), or histological diagnosis (Sertoli-cell only 53.6 vs 47.7%, maturation arrest 21.4 vs 38.6%, sclerosis/atrophy 25.0 vs 13.6%).Of the 72 patients with sperm available for ICSI, 23/72 (31.9%) achieved a live birth (LB) after the injection with fresh testicular sperm (and fresh or frozen embryo transfers). Of the remaining 49 patients without LB, 34 (69.4%) had supernumerary testicular sperm frozen. Of these 34 patients, 19 (55.9%) continued ICSI with frozen testicular sperm, and 9/19 (47.4%) had achieved an LB after ICSI with frozen testicular sperm. Thus, the total CLB was 32/118 (27.1%) per TESE or 32/72 (44.4%) per TESE with sperm retrieved.Of the female characteristics (couples with sperm available), only female age (30.3 vs 32.7 years; P = 0.042) was significantly lower in the group with a LB, compared to those without.The CLB with testicular sperm obtained after enzymatic digestion was 31.8% (14/44), while the CLB with sperm obtained after mincing alone was 64.3% (18/28). Multivariable logistic regression analysis showed that when enzymatic digestion was required, it was associated with a significant decrease in CLB per TESE (OR: 0.23 (0.08-0.7); P = 0.01).

LIMITATIONS REASONS FOR CAUTION

Limitations of the study are related to the retrospective design. However, the selection of only patients with NOA, and specific characteristics (normal karyotype and absence Y-q deletion) and having their first TESE, strengthens our findings.

WIDER IMPLICATIONS OF THE FINDINGS

Enzymatic processing increases the SR rate from testicular biopsies of NOA patients compared to mechanical mincing only, demonstrating the importance of an appropriate laboratory protocol. However, NOA patients should be counseled that when sperm have been found after enzymatic digestion, their chances to father a genetically own child may be lower compared to those not requiring enzymatic digestion.

STUDY FUNDING/COMPETING INTERESTS

None reported.

TRIAL REGISTRATION NUMBER

N/A.

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.

Evaluating the Predictive Value of Diagnostic Testicular Biopsy for Sperm Retrieval Outcomes in Men with Non-Obstructive Azoospermia

BACKGROUND

Non-obstructive azoospermia (NOA) presents a challenge in male infertility management. This study aimed to assess the efficacy of diagnostic testicular biopsy (DTB) in predicting sperm retrieval success via therapeutic testicular biopsy (TTB) and to understand the role of systemic inflammation in microdissection testicular sperm extraction (mTESE) outcomes.

METHODS

A retrospective analysis was conducted on 50 NOA males who underwent mTESE at the University of Ioannina's Department of Urology from January 2017 to December 2019. All participants underwent thorough medical evaluations, including semen analyses and endocrinological assessments.

RESULTS

DTB did not detect spermatozoa in half of the patients who later showed positive sperm findings in TTB. Preoperative variables, such as age, plasma levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TT), prolactin (PRL), estradiol (E2), and inflammation biomarkers (neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-eosinophil ratio (MER)), were not consistently predictive of sperm retrieval success. Notably, TTB-negative patients had elevated NLR and PLR values, suggesting a possible link between systemic inflammation and reduced sperm retrieval during mTESE.

CONCLUSIONS

The findings question the necessity of an initial DTB, which might provide misleading results. A negative DTB should not deter further TTB or intracytoplasmic sperm injection (ICSI) attempts. The study emphasizes the need for further research to refine diagnostic approaches and deepen the understanding of factors influencing sperm retrieval in NOA patients, ultimately enhancing their prospects of biological parenthood.

Diffusion-weighted magnetic resonance imaging and magnetic resonance spectroscopy for non-invasive characterization of azoospermia: A prospective comparative single-center study

BACKGROUND

Azoospermia affects about 15% of childless males. The differential diagnosis between subtypes of azoospermia is the initial step in its management.

OBJECTIVES

To investigate the role of diffusion-weighted magnetic resonance imaging and proton magnetic resonance spectroscopy in distinguishing obstructive azoospermia from non-obstructive azoospermia and predicting sperm retrieval together with histological alterations in men with non-obstructive azoospermia.

MATERIALS AND METHODS

This prospective comparative study involved 60 men with obstructive azoospermia (group A) and 60 men with non-obstructive azoospermia (group B). Scrotal proton magnetic resonance spectroscopy and diffusion-weighted magnetic resonance imaging were conducted for all participants to respectively evaluate testicular metabolites and normalized apparent diffusion coefficient 1 week before sperm retrieval.

RESULTS

Apparent diffusion coefficient was significantly higher in group B as compared to group A (0.47 ± 0.11 vs. 0.29 ± 0.05; and 0.46 ± 0.14 vs. 0.28 ± 0.02) for the right and left testis, respectively. Conversely, testicular choline and lipids were significantly higher in group A as compared to group B. Normalized apparent diffusion coefficient, choline, and lipids at cut-off levels of 0.353, 0.31, and 0.725 could differentiate between obstructive azoospermia and non-obstructive azoospermia (area under the curve = 0.963; confidence interval = 0.939-0.986, area under the curve = 0.985; confidence interval = 0.974-0.997, and area under the curve = 0.970; confidence interval = 0.940-0.999, respectively). Regarding the prediction of sperm retrieval in the non-obstructive azoospermia group, choline levels had the highest area under the curve (0.923), and its cut-off level was 0.195. The normalized apparent diffusion coefficient was significantly lower in men with positive sperm retrieval as compared to men with unsuccessful retrieval. Finally, it was revealed that all magnetic resonance imaging parameters except creatine could independently predict testicular histology in men with non-obstructive azoospermia. The highest prediction was 95% in normal spermatogenesis, and the least prediction was 40% in spermatid arrest. Regression analysis was used to detect final predictors and extrapolate an equation that could be used to predict testicular pathology CONCLUSIONS: Normalized apparent diffusion coefficient and proton magnetic resonance spectroscopy are helpful in differentiating obstructive azoospermia from non-obstructive azoospermia and predicting sperm retrieval and related histological alterations in men with non-obstructive azoospermia.

Anti-Müllerian hormone predicts positive sperm retrieval in men with idiopathic non-obstructive azoospermia-findings from a multi-centric cross-sectional study

STUDY QUESTION

Is it possible to identify a reliable marker of successful sperm retrieval (+SR) in men with idiopathic non-obstructive azoospermia (iNOA) undergoing microdissection testicular sperm extraction (mTESE)?

SUMMARY ANSWER

A higher likelihood of +SR during mTESE is observed in men with iNOA and lower preoperative serum anti-Müllerian hormone (AMH) levels, with good predictive accuracy achieved using an AMH threshold of <4 ng/ml.

WHAT IS KNOWN ALREADY

AMH has been previously linked to +SR in men with iNOA undergoing mTESE prior to ART.

STUDY DESIGN, SIZE, DURATION

A multi-centre cross-sectional study was carried out with a cohort of 117 men with iNOA undergoing mTESE at three tertiary-referral centres.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data from 117 consecutive white-European men with iNOA presenting for primary couple's infertility associated with a pure male factor at three centres were analysed. Descriptive statistics was applied to compare patients with negative (-SR) versus +SR at mTESE. Multivariate logistic regression models were fitted to predict +SR at mTESE, after adjusting for possible confounders. Diagnostic accuracy of the factors associated with +SR was assessed. Decision curve analyses were used to display the clinical benefit.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 60 (51.3%) men had an -SR and 57 (48.7%) had a +SR at mTESE. Patients with +SR had lower levels of baseline AMH (P = 0.005) and higher levels of estradiol (E2) (P = 0.01). At multivariate logistic regression analysis, lower levels of AMH (odds ratio: 0.79; 95% CI: 0.64-0.93, P = 0.03) were associated with +SR at mTESE, after adjusting for possible confounders (e.g. age, mean testicular volume, FSH, and E2). A threshold of AMH <4 ng/ml achieved the highest accuracy for +SR at mTESE, with an AUC of 70.3% (95% CI: 59.8-80.7). Decision curve analysis displayed the net clinical benefit of using an AMH <4 ng/ml threshold.

LIMITATIONS, REASONS FOR CAUTION

There is a need for external validation in even larger cohorts, across different centres and ethnicities. Systematic reviews and meta-analysis to provide high level of evidence are lacking in the context of AMH and SR rates in men with iNOA.

WIDER IMPLICATIONS OF THE FINDINGS

Current findings suggest that slightly more than one in two men with iNOA had -SR at mTESE. Overall, men with iNOA with lower levels of AMH had a significantly higher percentage of successful SR at surgery. A threshold of <4 ng/ml for circulating AMH ensured satisfactory sensitivity, specificity, and positive predictive values in the context of +SR at mTESE.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by voluntary donations from the Urological Research Institute (URI). All authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Testosterone to Luteinizing Hormone Ratio as a Potential Predictor of Sperm Retrieval in Non-Obstructive Azoospermia Patients

PURPOSE

This study assessed the outcomes of microsurgical testicular sperm extraction (mTESE) and potential preoperative predictors of sperm retrieval (SR) in patients with non-obstructive azoospermia (NOA).

MATERIALS AND METHODS

Clinical data of 111 NOA patients who underwent mTESE was reviewed retrospectively. Baseline patient characteristics, including age, body mass index (BMI), testicular volumes, and preoperative endocrine levels, such as testosterone (T), follicle-stimulating hormone (FSH), serum-luteinizing hormone (LH), prolactin, sex hormone-binding globulin (SHBG), FSH/LH ratio along with T/LH ratio, were analyzed. After categorizing the patients into two groups based on SR success or failure, logistic regression analysis was performed to identify the preoperative predictors of successful SR.

RESULTS

Sixty-eight patients had successful SR (61.3%), whereas 43 patients (38.7%) showed negative results. Failed SR group had elevated serum FSH and LH levels, whereas successful SR patients had a significantly larger testicular volume (p<0.001). Moreover, the successful group had a higher T/LH ratio (p<0.001). Multivariate logistic analysis showed that the T/LH ratio, serum FSH levels, and bilateral testicular volumes were significantly associated with successful sperm extraction.

CONCLUSION

In addition to traditional predictors, such as testicular volume and preoperative FSH levels, the T/LH ratio is a potential independent predictor of successful SR in infertile patients with NOA.

Successful Bilateral Sperm Retrieval in a Hypogonadal Patient with Non-Obstructive Azoospermia Showing Normal Serum 17-Hydroxyprogesterone Levels Suggestive of Normal Intratesticular Testosterone Production: A Case Report

The impact of hypogonadism on the probability of retrieving testicular sperm from patients with non-obstructive azoospermia (NOA) is still a matter of debate. Conflicting evidence in this field may be justified by the striking differences between serum and intratesticular testosterone (ITT) levels found in men with severe spermatogenic dysfunction, so that normal ITT levels may coexist with low serum testosterone levels. Here we report the case of a patient with NOA with a steadily reduced serum testosterone level irresponsive to hormonal stimulation with human chorionic gonadotropin. Supported by his normal serum 17-hydroxyprogesterone (17 OHP) levels, previously suggested to be marker of ITT levels, microdissection testicular sperm extraction was performed for both testes on two separate occasions, resulting in the retrieval of enough sperm for ICSI. Three ICSI cycles were then performed, one blastocyst was transferred, and five were cryopreserved. This case report suggests that normal serum 17 OHP levels, being suggestive of normal ITT levels, may support the decision to proceed with surgical sperm retrieval in hypogonadal patients with NOA, even for those irresponsive to hormonal treatment.

Development of a predictive model for increasing sperm retrieval success by microdissection testicular sperm extraction in patients with nonobstructive azoospermia

Microdissection testicular sperm extraction (micro-TESE) is widely used to treat nonobstructive azoospermia. However, a good prediction model is required to anticipate a successful sperm retrieval rate before performing micro-TESE. This retrospective study analyzed the clinical records of 200 nonobstructive azoospermia patients between January 2021 and December 2021. The backward method was used to perform binary logistic regression analysis and identify factors that predicted a successful micro-TESE sperm retrieval. The prediction model was constructed using acquired regression coefficients, and its predictive performance was assessed using the receiver operating characteristic curve. In all, 67 patients (sperm retrieval rate: 33.5%) underwent successful micro-TESE. Follicle-stimulating hormone, anti-Müllerian hormone, and inhibin B levels varied significantly between patients who underwent successful and unsuccessful micro-TESE. Binary logistic regression analysis yielded the following six predictors: anti-Müllerian hormone (odds ratio [OR] = 0.902, 95% confidence interval [CI]: 0.821-0.990), inhibin B (OR = 1.012, 95% CI: 1.001-1.024), Klinefelter's syndrome (OR = 0.022, 95% CI: 0.002-0.243), Y chromosome microdeletion (OR = 0.050, 95% CI: 0.005-0.504), cryptorchidism with orchiopexy (OR = 0.085, 95% CI: 0.008-0.929), and idiopathic nonobstructive azoospermia (OR = 0.031, 95% CI: 0.003-0.277). The prediction model had an area under the curve of 0.720 (95% CI: 0.645-0.794), sensitivity of 65.7%, specificity of 72.2%, Youden index of 0.379, and cut-off value of 0.305 overall, indicating good predictive value and accuracy. This model can assist clinicians and nonobstructive azoospermia patients in decision-making and avoiding negative micro-TESE results.

Inhibin B-to-Anti-Mullerian Hormone Ratio as Noninvasive Predictors of Positive Sperm Retrieval in Idiopathic Non-Obstructive Azoospermia

Background: The lack of clinically useful biomarkers for predicting micro-TESE outcomes in males with idiopathic NOA. To find clinically reliable serum reproductive hormone markers to predict the outcome of sperm retrieval in men with idiopathic NOA undergoing micro-TESE. Methods: We analyzed the clinical data of 168 men with idiopathic NOA treated with micro-TESE. The clinical predictors of a successful sperm retrieval were put to the test using logistic regression analysis. The clinical net benefit was calculated using a decision-curve analysis, and the predictive power of each variable was assessed using the ROC-derived area under the curve. Result: Between positive group and negative group for sperm retrieval, there was a statistically significant difference in INHB, AMH, and INHB/AMH. AMH, INHB, and INHB/AMH were each independent predictors of successful sperm retrieval, with INHB (OR1.02, p = 0.03), AMH (OR0.85, p = 0.01), INHB/AMH (OR1.08, p < 0.01). The ROC curve determined the optimal cut-off values for serum INHB and INHB/AMH in positive sperm retrieval patients undergoing micro-TESE. 21.51 pg/mL was the cut-off value for INHB. The cut-off value for INHB/AMH was 3.19, which had a 86.3% sensitivity and a 53.8% specificity. Using INHB and INHB/AMH prior to micro-TESE sperm retrieval in idiopathic NOA patients improved the net benefit of positive sperm retrieval, and the net benefit score of INHB/AMH was better than that of INHB, according to decision analysis curves. Conclusion: Serum INHB have predictive value for sperm retrieval outcomes in idiopathic NOA patients undergoing micro-TESE. Combining INHB and AMH, INHB/AMH seems to be a better predictor.

Delaying testicular sperm extraction in 47,XXY Klinefelter patients does not impair the sperm retrieval rate, and AMH levels are higher when TESE is positive

STUDY QUESTION

Should testicular sperm extraction (TESE) in non-mosaic 47,XXY Klinefelter syndrome (KS) patients be performed soon after puberty or could it be delayed until adulthood?

SUMMARY ANSWER

The difference in sperm retrieval rate (SRR) in TESE was not significant between the 'Young' (15-22 years old) cohort and the 'Adult' (23-43 years old) cohort of non-mosaic KS patients recruited prospectively in parallel.

WHAT IS KNOWN ALREADY

Several studies have tried to define predictive factors for TESE outcome in non-mosaic KS patients, with very heterogeneous results. Some authors have found that age was a pejorative factor and recommended performing TESE soon after puberty. To date, no predictive factors have been unanimously recognized to guide clinicians in deciding to perform TESE in azoospermic KS patients.

STUDY DESIGN, SIZE, DURATION

Two cohorts (Young: 15-22 years old; Adult: 23-43 years old) were included prospectively in parallel. A total of 157 non-mosaic 47,XXY KS patients were included between 2010 and 2020 in the reproductive medicine department of the University Hospital of Lyon, France. However 31 patients gave up before TESE, four had cryptozoospermia and three did not have a valid hormone assessment; these were excluded from this study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data for 119 patients (61 Young and 58 Adult) were analyzed. All of these patients had clinical, hormonal and seminal evaluation before conventional TESE (c-TESE).

MAIN RESULTS AND THE ROLE OF CHANCE

The global SRR was 45.4%. SRRs were not significantly different between the two age groups: Young SRR=49.2%, Adult SRR = 41.4%; P = 0.393. Anti-Müllerian hormone (AMH) and inhibin B were significantly higher in the Young group (AMH: P = 0.001, Inhibin B: P < 0.001), and also higher in patients with a positive TESE than in those with a negative TESE (AMH: P = 0.001, Inhibin B: P = 0.036). The other factors did not differ between age groups or according to TESE outcome. AMH had a better predictive value than inhibin B. SRRs were significantly higher in the upper quartile of AMH plasma levels than in the lower quartile (or in cases with AMH plasma level below the quantification limit): 67.7% versus 28.9% in the whole population (P = 0.001), 60% versus 20% in the Young group (P = 0.025) and 71.4% versus 33.3% in the Adult group (P = 0.018).

LIMITATIONS, REASONS FOR CAUTION

c-TESE was performed in the whole study; we cannot rule out the possibility of different results if microsurgical TESE had been performed. Because of the limited sensitivity of inhibin B and AMH assays, a large number of patients had values lower than the quantification limits, preventing the definition a threshold below which negative TESE can be predicted.

WIDER IMPLICATIONS OF THE FINDINGS

In contrast to some studies, age did not appear as a pejorative factor when comparing patients 15-22 and 23-44 years of age. Improved accuracy of inhibin B and AMH assays in the future might still allow discrimination of patients with persistent foci of spermatogenesis and guide clinician decision-making and patient information.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by a grant from the French Ministry of Health D50621 (Programme Hospitalier de Recherche Clinical Régional 2008). The authors have no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

NCT01918280.

The predictive factors of successful sperm retrieval for men with Y chromosome AZFc microdeletion

PURPOSE

To identify key predictors for successful sperm retrieval in men with AZFc microdeletion.

METHODS

Totally, 71 infertile men with confirmed AZFc microdeletion were studied. For each patient, the endocrine profile including serum follicle stimulating hormone (FSH), luteinizing hormone, total testosterone, prolactin, and estradiol was recorded, along with intratesticular testosterone levels (ITT), age, and testicular size. The factors were further analyzed to determine the key predictors for successful sperm retrieval.

RESULTS

Of the 71 men with AZFc microdeletion, 52 (73.2%) were classified as having non-obstructive azoospermia (NOA), 7 (9.9%) as having cryptozoospermia, and 12 (15.8%) as having severe oligoasthenoteratozoospermia. Of the 52 men with azoospermia, 47 received microdissection testicular sperm retrieval, and sperm retrieval was successful in 35 of those cases (74.5%). A significantly lower serum FSH (p = 0.03) was found in those patients from whom sperm could be successfully retrieved. The area under the receiving operating characteristic curve for FSH was determined to be 0.721. Using an FSH cutoff point of 12.95 mIU/mL, the model for predicting successful sperm retrieval was found to have 51.4% sensitivity, 83.3% specificity, 90.0% positive predictive value, and 37.0% negative predictive value. ITT levels were obtained from 7 NOA patients, the mean ITT and the mean ITT/serum testosterone ratio was 1932.8 ng/ml and 567.2 in 6 men with successful sperm retrieval, whereas, in a patient with fail sperm retrieval, the levels were 2370 ng/ml and 393.0.

CONCLUSION

Men exhibiting AZFc microdeletion with discernible spermatogenesis from whom sperm was successfully retrieved by mTESE generally presented with relatively lower FSH levels.

Development and validation predictive models of sperm retrieval for azoospermic men undergoing testicular sperm aspiration: a multicentre, retrospective, cohort study

PURPOSE

Testicular sperm aspiration (TESA) is widely used to retrieve sperm from testis. Diagnostic testicular biopsy should not be routinely performed for azoospermia. Therefore, a good predictive model is needed before TESA.

METHODS

A total of 1972 azoospermia patients constituted the modelling set, and 260 azoospermia patients from two other centres constituted the validation set. An integrated predictive model was built using logistic regression. Receiver operating characteristic (ROC), calibration and decision curve analyses were performed to evaluate the performance of follicle-stimulating hormone (FSH), semen volume, testicular volume and the integrated model.

RESULTS

The FSH level was the best univariate predictor for successful sperm retrieval (SSR) and was better than semen volume and testicular volume alone (p<0.001, threshold 6.17 IU/L, modelling set area under receiver operating characteristic curve (AUC) 0.80, accuracy 0.79; validation set AUC 0.87, accuracy 0.78). The integrated predictive model had excellent accuracy for predicting SSR (modelling set: AUC 0.93, accuracy 0.89; validation set: AUC 0.96, accuracy: 0.89). Calibration curve analysis indicated that the integrated model calibration was good and better than that of FSH, semen volume and testicular volume alone. Decision curve analysis indicated with a threshold probability between 0.05 and 0.98, the integrated model added more benefit than treating either all or no patients.

CONCLUSIONS

The integrated model has excellent discrimination and good calibration. It can help azoospermic men make better decisions before TESA. It should be noted that TESA is not the first-line treatment for non-obstructive azoospermia because of a low sperm retrieval rate.

Combined Trifocal and Microsurgical Testicular Sperm Extraction Enhances Sperm Retrieval Rate in Low-Chance Retrieval Non-Obstructive Azoospermia

Background: Low-chance retrieval non-obstructive azoospermic (NOA) patients are a subpopulation of NOA patients. The objective of this study is to compare the surgical outcome of microsurgical-assisted testicular sperm extraction (M-TeSE) and combined trifocal/M-TeSE in low-chance retrieval NOA patients. Material and Methods: A single-center retrospective analysis of NOA patients who underwent testicular sperm extraction was performed. Low-chance retrieval NOA (testicular volume < 10 cc and FSH > 12.4 UI/L) was set as the inclusion criteria. Re-do TeSE procedures were excluded from the current analysis. Data were extrapolated from clinical records and operative notes. We compared data from patients who underwent classic M-TeSE (group A) with that from patients submitted to combined trifocal/M-TeSE (group B). Sperm retrieval rate (SRr) was the primary outcome of the study. Surgical outcomes and postoperative complications were evaluated. A multivariate analysis was conducted to investigate predictive factors for positive SR. Results: Overall, 80 patients (60 patients in Group A and 20 patients in Group B) fulfilled the inclusion criteria. The average (SD) age was 35 (8.2) years. The average preoperative FSH was 27.5 (13) UI/L. The average testicular volume was 6.3 (3) cc on the left side and 6.8 (2.5) cc on the right. Groups were similar in terms of preoperative parameters. The overall SRr was 28%. Patients in group B had higher SRr than those in group A (29.4% vs. 26.9%, p < 0.03). We identified a significant association between testicular histopathology and positive SR (hypospermatogenesis 100%, spermatogenic arrest 32%, and Sertoli cell-only syndrome 22%). The histopathology report was the only significant predicting factor for SR in the multivariate analysis. Conclusion: The combined trifocal and M-TeSE approach is safe and may represent a valuable approach to enhance the SRr in low-chance retrieval NOA. The histopathology report is confirmed to be the only valuable predicting factor for a positive SR.

Referral Patterns for Infertile Men: Predictors of Continued Treatment by Reproductive Endocrinologist versus Referral to a Nearby Urologist

INTRODUCTION

We evaluated fertility clinic management of male factor infertility, including patient education and referral for urological evaluation and care.

METHODS

Using 2015-2018 Centers for Disease Control and Prevention Fertility Clinic Success Rates Reports, 480 operative fertility clinics in the United States were identified. Clinic websites were systematically reviewed for content regarding male infertility. Structured telephone interviews of clinic representatives were performed to determine clinic-specific practices for management of male factor infertility. Multivariable logistic regression models were used to predict how clinic characteristics (geographic region, practice size, practice setting, in-state andrology fellowship, state-mandated fertility coverage, annual in vitro fertilization cycles and percentage of in vitro fertilization cycles for male factor infertility) were associated with reproductive endocrinologist physician management of male infertility and/or referral to a urologist.

RESULTS

We interviewed 477 fertility clinics and analyzed available websites (474). The majority of websites (77%) discussed male infertility evaluation, while 46% discussed treatment. Clinics that were academically affiliated, had an accredited embryo laboratory and referred patients to a urologist were less likely to have the reproductive endocrinologist manage male infertility (all p <0.05). Practice affiliation, practice size and website discussion of surgical sperm retrieval were the strongest predictors of nearby urological referral (all p <0.05).

CONCLUSIONS

Variability in patient-facing education, and fertility clinic setting and size influence fertility clinics' management of male factor infertility.

Multi-stage screening cell-free seminal mRNAs to diagnose completion of meiosis and predict testicular sperm retrieval in men with non-obstructive azoospermia

BACKGROUND

Differential diagnosis of men with subtypes of non-obstructive azoospermia (NOA) is important for their treatment. Many genes are transcripted during meiosis. We hypothesized that some of these genes can be detected in cell-free seminal mRNAs (cfs-mRNA) and be developed as non-invasive biomarkers for diagnosing NOA subtypes.

OBJECTIVE

To screen cfs-mRNA to diagnose the completion of meiosis and predict successful sperm retrieval (SR) in men with NOA.

MATERIALS AND METHODS

NOA patients who visited our institutes from September 2018 to December 2020 for testicular histopathological diagnosis (n = 109) or testicular SR (n = 92) were screened for participation in the study. Microarray and real-time quantitative PCR were used in five stages to obtain candidate cfs-mRNAs for comparisons between patients with early maturation arrest (eMA, meiosis not completed) and late MA or hypospermatogenesis (meiosis completed), and between NOA patients with successful SR and SR failure.

RESULTS

Twelve cfs-mRNAs were selected based on this comparison between men with eMA and hypospermatogenesis and their gene expression and function information. Of these, AKAP1, BOLL, TCP11, and SETX predominantly derived from testes and germ cells were proposed as candidate cfs-mRNAs. Further quantification in men with NOA demonstrated significantly higher levels of BOLL cfs-mRNA (P < 0.0001) in men with late MA or hypospermatogenesis (n = 23), compared with men with eMA (n = 51); and significantly higher levels (P < 0.0001) in patients with successful SR (n = 44) when compared with patients with SR failure (n = 37). Interestingly, with a similar cutoff value, BOLL cfs-mRNA showed high sensitivity and specificity in diagnosing late MA and hypospermatogenesis (>404 copies/mL) and predicting successful SR (>415 copies/mL). Correlation of BOLL mRNA levels was observed in paired semen and testicular tissues.

DISCUSSION AND CONCLUSIONS

We propose that BOLL cfs-mRNA is a promising non-invasive marker for diagnosing the completion of meiosis and predicting successful testicular SR in men with NOA. This article is protected by copyright. All rights reserved.

Does testicular sperm retrieval adversely impact spermatogenesis over the long-term?

Testicular sperm retrieval (TSR) techniques are valuable in the context of severe idiopathic male factor infertility; however, there are few studies in the literature examining the long-term impact of TSR on testicular function. The objective was to determine whether testicular sperm aspiration (TESA) or microdissection testicular sperm extraction (micro-TESE) worsens the pre-existing spermatogenesis deficiency in men with either cryptozoospermia or severe oligozoospermia. The study population consisted of 145 men with either cryptozoospermia or severe oligozoospermia that underwent TESA or micro-TESE and had long-term post-operative semen analyses (SA). Patients with SA prior to and following TSR were included (n = 24). Amongst them, 16 men underwent TESA and 8 underwent micro-TESE. The follow-up SA was obtained at a mean of 3.0 ± 2.0 years following TSR (range: 0.3-8.3 years) amongst all participants. The post-operative semen parameters in the TESA group were similar to the pre-intervention parameters (p > 0.1). Similarly, the micro-TESE cohort did not demonstrate significant alterations in semen parameters post-intervention (p > 0.05). None of the men in the study became azoospermic following the TSR. Our study indicates TESA or micro-TESE do not appear to worsen the pre-existing spermatogenesis deficiencies in cryptozoospermic and oligozoospermic men over a long-term period. Larger studies are required to corroborate these findings.

Micro-testicular sperm extraction outcomes for non-obstructive azoospermia in a single large clinic in Victoria

AIMS

To evaluate the results of microdissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI) for treatment of non-obstructive azoospermia (NOA).

MATERIALS AND METHODS

We retrospectively analysed data of 88 consecutive patients with clinical NOA who were treated with micro-TESE by a single surgeon, between August 2014 and September 2020, in Melbourne, Victoria. Upon a successful sperm retrieval, sperm was either used fresh for ICSI, frozen for future use or both. The outcome measures were sperm retrieval rate (SRR), and in vitro fertilisation (IVF)/ICSI results. Furthermore, SRR was calculated for the predominant causes and histopathological patterns.

RESULTS

The overall SRR was 61.2%. It was significantly higher in patients with a history of cryptorchidism and other childhood diseases (100%) than in the other NOA groups (P < 0.05). Patients with Klinefelter syndrome had a 75% SRR. Among the different types of testicular histology, the highest SRR were noted in patients with complete hyalinisation (100%) and hypospermatogenesis (92.9%), and low with Sertoli cell-only syndrome (46.3%). The SRR has significantly increased from 33.3% in 2015-2016 to 73.6% in 2019-2020 (P = 0.009). Of the 52 patients with SSR, 47 underwent IVF/ICSI. Fertilisation rate was 42.4%. Twenty-nine couples achieved at least one good-quality embryo and had embryo transfer. Nineteen achieved pregnancy (40.4%), and in three patients a miscarriage resulted.

CONCLUSIONS

This is the first report from Australia showing that micro-TESE is an effective treatment for NOA with high SRR. The increasing success rates over several years indicate the importance of surgical skill and laboratory staff experience.

Nomogram based on a circular RNA biomarker for predicting the likelihood of successful sperm retrieval via microdissection testicular sperm extraction in patients with idiopathic non-obstructive azoospermia

BACKGROUND

Many circular RNAs (circRNAs) are specifically expressed in the testes and seminal plasma of patients with non-obstructive azoospermia (NOA), highlighting them as potential predictors of microdissection testicular sperm extraction (micro-TESE) outcomes. Although research has indicated that circular RNA monoglyceride lipase (circ_MGLL) is highly expressed in the testicular tissues of patients with NOA, the association between circ_MGLL expression and sperm retrieval outcomes (SROs) in patients with idiopathic non-obstructive azoospermia (iNOA) receiving micro-TESE remains unclear.

METHODS

This single-center, retrospective cohort study enrolled 114 patients with iNOA who underwent micro-TESE at Northwest Women's and Children's Hospital from January 2017 to November 2021. A logistic regression model was used to examine associations between SRO and circ_MGLL expression in testicular tissues, the results of which were used in conjunction with previous findings to establish a nomogram. The predictive performance of the circ_MGLL-based nomogram was evaluated via calibration curves, receiver operating characteristic curves, and decision curve analysis (DCA) using an internal validation method.

RESULTS

The generalized additive model indicated that the probability of successful SRO for micro-TESE decreased as circ_MGLL expression increased in testicular tissues. Across the entire cohort, univariate logistic regression analysis revealed that circ_MGLL expression was inversely associated with SRO in patients with NOA. This trend did not change after stratification according to age, body mass index, testicular volume, follicle-stimulating hormone (FSH) level, luteinizing hormone (LH) level, testosterone (T) level, or pathological type (or after adjusting for these confounders) (odds ratio <1, P < 0.001). A nomogram was then generated by integrating circ_MGLL, pathological types, and FSH, LH, and T levels. The circ_MGLL-based predictive model achieved satisfactory discrimination, with an area under the curve of 0.857, and the calibration curves demonstrated impressive agreement. The DCA indicated that the net clinical benefit of the circ_MGLL-based predictive model was greater than that of circ_MGLL alone.

CONCLUSION

circ_MGLL is significantly associated with the SRO of micro-TESE in patients with iNOA. The circ_MGLL-based nomogram developed in the current study can predict successful SRO with high accuracy.

Prediction Models for Successful Sperm Retrieval in Patients with Non-Obstructive Azoospermia Undergoing Microdissection Testicular Sperm Extraction: Is There Any Room for Further Studies?

Several prediction models for successful sperm retrieval (SSR) in patients with azoospermia due to spermatogenic dysfunction (also termed non-obstructive azoospermia—NOA) have been developed and published in the past years, however their resulting prediction accuracy has never been strong enough to translate their results in the clinical practice. This notwithstanding, the number of prediction models being proposed in this field is growing. We have reviewed the available evidence and found that, although patients with complete AZFc deletion or a history of cryptorchidism may have better probability of SSR compared to those with idiopathic NOA, no clinical or laboratory marker is able to determine whether a patient with NOA should or should not undergo microdissection testicular sperm extraction (mTESE) to have his testicular sperm retrieved. Further research is warranted to confirm the utility of evaluating the expression of noncoding RNAs in the seminal plasma, to individuate patients with NOA with higher probability of SSR.

A systemic review and meta-analysis exploring the predictors of sperm retrieval in patients with non-obstructive azoospermia and chromosomal abnormalities

To identify the most prevalent chromosomal abnormalities in patients with non-obstructive azoospermia (NOA), consolidate their surgical sperm retrieval (SSR) rates and determine the significant predictors of positive SSR in this patient population. A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Fifty-three studies including 2965 patients were identified through searching the PubMed database. Klinefelter Syndrome (KS) was the most prevalent chromosomal abnormality reported in 2239 cases (75.5%). Azoospermia factor c (AZFc) microdeletions were the second most common (18.6%), but men with these deletions had higher SSR rates than patients with KS (41.95% with AZFc vs. 38.63% with KS). When examining predictors of SSR in KS patients, younger age was a significant predictor of positive SSR in patients undergoing microsurgical testicular sperm extraction (micro-TESE). Higher testosterone was a favourable predictor in those undergoing micro-TESE and conventional TESE. Lower luteinizing hormone (LH) and follicular stimulating hormone (FSH) values were significantly associated with positive SSR with testicular sperm aspiration (TESA). No parameter predicted SSR rates in patients with AZFc microdeletions. Overall, genetic abnormalities have significant implications on SSR success in patients with NOA.

Tissue and sperm handling before assisted reproductive technology (ART): A systematic review

Objective

: To explore the medical literature on techniques of tissue and sperm handling after surgical retrieval for intracytoplasmic sperm injection (ICSI).

Methods

: A search was performed in PubMed and Google Scholar databases, according to a modified Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guideline, considering the studies investigating tissue handling and sperm selection techniques for ICSI.

Results

: Overall, 42 articles were included in this study, investigating sample handling, methods for sperm selection, and the use of chemical compounds to improve sperm motility and fertilisation rates.

Conclusion

: The ideal sperm handling method should provide a high sperm count, high vitality and appropriate sperm function, without side-effects. In this review the most common and useful techniques are described and the best combination strategies discussed in clinical scenarios.

Performing Microdissection Testicular Sperm Extraction: Surgical Pearls from a High-Volume Infertility Center

Microdissection testicular sperm extraction (mTESE) has been demonstrated to be the gold-standard surgical technique for retrieving testicular sperm in patients with non-obstructive azoospermia (NOA) as it enables the exploration of the whole testicular parenchyma at a high magnification, allowing the identification of the rare dilated seminipherous tubules that may contain sperm, usually surrounded by thinner or atrophic tubules. MTESE requires a skilled and experienced surgeon whose learning curve may greatly affect the sperm retrieval rate, as demonstrated in previous reports. The present review is intended to offer a precise and detailed description of the mTESE surgical procedure, accompanied by an extensive iconography, to provide urologists with valuable information to be translated into clinical practice. Advice about the pre-surgical and post-surgical management of patients is also offered.

sperm retrieval with in vitro fertilization: a contemporary, comparative analysis

OBJECTIVE

To explore the primary options available to men who desire fertility after a vasectomy.

DESIGN

Literature review.

SETTING

University of Miami Miller School of Medicine.

PATIENT(S)

Men with a previous vasectomy now seeking fertility.

INTERVENTION(S)

The two main options to achieve paternity for men following vasectomy include vasectomy reversal (VR) and surgical sperm retrieval with subsequent in vitro fertilization (IVF).

MAIN OUTCOME MEASURE(S)

We reviewed and compared the important considerations for men deciding between these 2 options, including: obstructive interval, female partner age, antisperm antibodies, male partner age, female infertility factors, and cost.

RESULT(S)

Both VR and IVF represent reasonable options for the couple seeking fertility after vasectomy. Specific circumstances may favor one modality over another, depending on obstructive interval, possible female fertility factors, female partner age, male partner age, and cost. In the absence of insurance coverage, VR is often more cost-effective than IVF. Alternatively, when a female factor may contribute to infertility in addition to vasectomy, IVF is often the better choice. Antisperm antibodies are unlikely to contribute to infertility following a successful VR.

CONCLUSION(S)

VR or surgical sperm retrieval with IVF are reasonable options for couples seeking children after vasectomy. Pregnancy rates for both options are overall similar, so prior to pursuing either option, a thorough discussion with a reproductive urologist who possesses microsurgical skills in VR and a reproductive endocrinologist with expertise in IVF is imperative. Making a final choice through shared decision-making while considering these points is ideal.

"Second-look" Micro Testicular Sperm Extraction (MicroTESE) in Patients with Non-obstructive Azoospermia Following Histopathological Analysis

Introduction:

Microdissection testicular sperm extraction (microTESE) is considered the gold standard method for surgical sperm retrieval among patients with non-obstructive azoospermia (NOA).

Aim:

This study aimed to evaluate the correlation between histopathological findings after failed microTESE procedure and outcomes of the „second-look“ procedure and to provide insight into the most common histopathological patterns after testicular biopsy within our population.

Methods:

The retrospective study included 33 selected patients with NOA, who had undergone unsuccessful sperm retrieval. The diagnosis of NOA was made after the assessment of the patient’s history data, a physical examination, semen analysis, the hormonal profile, and genetic studies. After negative sperm retrieval, histopathological report has been analyzed for „second-look“ microTESE attempt.

Results:

Five testicular histopathological patterns were found: hypospermatogenesis (9,1%), Sertoli cell-only syndrome (43%), germ cell maturation arrest (15%), seminiferous tubule hyalinization (15%), mixed pattern (21%). Y-microdeletions were detected in 5 patients, of which 3 patients showed AZFc region deletions. Only 3 patients (9,1%) underwent a „second-look“ procedure after the evaluation of histopathological reports. After the stimulation therapy and „second-look“ procedure, we had a positive outcome in a single patient (33,3%). Mean FSH value in patients with confirmed spermatogenesis was 17.26±3.11IU/l, while mean FSH value in patients without presence or germ cell statistically significantly exceeded and was 24.28±4.71IU/L (p=0.038).

Conclusion:

Histopathological reports following the microTESE procedure are obligatory for the proper selection of patients who are candidates for the „second-look“ microTESE attempt. Patients with Sertoli cell-only syndrome and hypospermatogenesis particularly can benefit from the “second-look” procedure.

Intrasurgical parameters associated with successful sperm retrieval in patients with non-obstructive azoospermia undergoing salvage microdissection testicular sperm extraction

BACKGROUND

Patients with non-obstructive azoospermia with a previously failed conventional testicular sperm extraction may undergo a salvage microdissection testicular sperm extraction with the probability of successful sperm retrieval being almost dependent upon the number of previous surgical attempts and to different histopathologic categories.

OBJECTIVES

To determine whether the seminiferous tubules pattern and the histological categories could affect the sperm retrieval rate in patients with non-obstructive azoospermia undergoing salvage microdissection testicular sperm extraction after failed conventional testicular sperm extraction.

MATERIALS AND METHODS

Seventy-nine patients undergoing unilateral or bilateral salvage microdissection testicular sperm extraction were evaluated. During microdissection testicular sperm extraction, if present, dilated tubules were retrieved, otherwise, tubules with slightly larger caliber than that of the surroundings were removed. When no dilated tubule or tubule with slightly larger caliber was found, not dilated tubules were excised. A prediction model was built with seminiferous tubules pattern and testis histology as covariates.

RESULTS

Sperm retrieval was successful in 30 out of 79 patients. The prediction model correctly classified 88.3% of cases, explained the 29.7% variability of the outcome, and significantly predicted the microdissection testicular sperm extraction outcome with a sensitivity of 67.7% and a specificity of 90.2%, Both tubules with slightly larger caliber and not dilated tubules were negatively associated with the chance of retrieving spermatozoa. Among the histological categories, only early maturation arrest was significant to the model (log(SSR) = 0.57 - 1.9SDT - 3.3NDT - 1.76EMA) (where SSR is sperm retrieval rate, SDT is tubule with slightly larger caliber, NDT is not dilated tubule, and EMA is early maturation arrest). The model had a clearly useful discrimination (area under the curve = 0.814), the estimated performance was 0.8105, and internal calibration was acceptable (p > 0.05).

DISCUSSION

Seminiferous tubules pattern and testis histology may reliably explain the salvage microdissection testicular sperm extraction outcome in all patients with non-obstructive azoospermia apart from those with early maturation arrest, where the homogeneous apparent seminiferous tubules pattern may be misleading.

CONCLUSION

The outcome of salvage microdissection testicular sperm extraction can be predicted by the same intrasurgical parameters that have been demonstrated to predict the outcome of microdissection testicular sperm extraction in naïve patients with non-obstructive azoospermia.

Differential Diagnosis of Azoospermia in Men with Infertility

The differential diagnosis between obstructive and nonobstructive azoospermia is the first step in the clinical management of azoospermic patients with infertility. It includes a detailed medical history and physical examination, semen analysis, hormonal assessment, genetic tests, and imaging studies. A testicular biopsy is reserved for the cases of doubt, mainly in patients whose history, physical examination, and endocrine analysis are inconclusive. The latter should be combined with sperm extraction for possible sperm cryopreservation. We present a detailed analysis on how to make the azoospermia differential diagnosis and discuss three clinical cases where the differential diagnosis was challenging. A coordinated effort involving reproductive urologists/andrologists, geneticists, pathologists, and embryologists will offer the best diagnostic path for men with azoospermia.

Effect of vas ligation on testicular sperm extraction results in nonobstructive azoospermic rats: Shaeer's lock-in technique

This study evaluates the efficacy of vas ligation in enhancing sperm retrieval in nonobstructive azoospermia cases, by accumulating intratesticular spermatozoa. Fifty-six mature male rats with equally sized testes were included in this study. Forty-six were in the study group, and 10 were in the control group. Bilateral testicular fine needle aspiration was performed for all, to confirm presence of spermatozoa in all testes. Nonobstructive azoospermia was induced in all 56 rats, using Dienogest (40 mg/kg) + Testosterone Undecanoate (25 mg/kg) every month for three months. Monthly aspirations confirmed nonobstructive azoospermia from all rats, within the three months treatment. This was followed by unilateral vas ligation and was performed for 46 rats of the study group, with no ligation performed in the control group. After a further period of 90 days (2 spermatogenic cycles) with the same medical treatment maintained, bilateral testicular sperm extraction was performed. Sperm retrieval was evaluated, comparing the outcome of vas-ligated testicles to the nonligated. Upon evaluation, spermatozoa were found in 14/46 of the vas-ligated testes (30.4%), compared to none of the nonligated (0/66), p = .0005. Ligation of the vas deferens in rats with nonobstructive azoospermia may enhance the results of sperm retrieval via sperm accumulation.

Quantifying Heterogeneity of Testicular Histopathology in Men with Nonobstructive Azoospermia

PURPOSE

We sought to determine if testicular histopathological heterogeneity is associated with sperm retrieval rates (SRRs) in men with nonobstructive azoospermia (NOA) who are undergoing microdissection testicular sperm extraction (mTESE).

MATERIALS AND METHODS

All patients undergoing mTESE by a single, high-volume surgeon at a tertiary infertility referral center between 2010 and 2020 were evaluated. Pathology reports from testis biopsy at the time of mTESE reported by fellowship-trained genitourinary pathologists were reviewed. Testicular heterogeneity was correlated to absolute SRRs. Logistic regression was used to determine if heterogeneity was associated with sperm retrieval.

RESULTS

A total of 918 men with mTESE were included. Of these, 391 men (43%) had 1 pathology, 388 men (42%) had 2, 108 (12%) had , and 31 (3.4%) had 4. Overall, the most common histopathology was Sertoli-cell only, followed by maturation arrest. The overall SRR was 42% with a clinical intrauterine gestation rate of 30%. Increasing histopathological variety was associated with higher SRRs (p <0.01); a SRR of 33% was observed when one histopathological subtype was present vs 94% with 4 subtypes. Furthermore, men with any foci of spermatogenesis had higher SRRs.

CONCLUSIONS

In men with NOA, increasing testicular heterogeneity is correlated with higher SRRs driven by the identification of focal areas of spermatogenesis. This is an important, although predictable, observation. While diagnostic biopsy is not routinely required, these findings emphasize the value of having histology to perhaps predict the chance of sperm retrieval for future mTESE procedures.

Use of testicular sperm in couples with SCSA-defined high sperm DNA fragmentation and failed intracytoplasmic sperm injection using ejaculated sperm

Sperm DNA fragmentation (SDF) has been linked with male infertility, and previous studies suggest that SDF can have negative influence on pregnancy outcomes with assisted reproduction. We performed a retrospective review of consecutive couples with a high SDF level that had intracytoplasmic sperm injection (ICSI) using testicular sperm (T-ICSI). We compared the T-ICSI outcomes to that of two control groups: 87 couples with failed first ICSI cycle and who had a second ICSI cycle using ejaculated sperm (Ej-ICSI), and 48 consecutive couples with high sperm chromatin structure assay (SCSA)-defined SDF (>15%) that underwent an ICSI cycle using ejaculated sperm after one or more failed ICSI cycles (Ej-ICSI-high SDF). The mean number of oocytes that were retrieved and the total number of embryos were not different among the three groups. The mean number of transferred embryos in the T-ICSI group was higher than the Ej-ICSI group but not significantly different than the Ej-ICSI-high SDF group (1.4, 1.2, and 1.3, respectively, P < 0.05). Clinical pregnancy rate in the T-ICSI group was not significantly different than the Ej-ICSI and Ej-ICSI-high SDF groups (48.6%, 48.2%, and 38.7%, respectively, P > 0.05). No significant difference was found in live birth rate when comparing T-ICSI to Ej-ICSI and Ej-ICSI-high SDF groups. The results suggest that pregnancy outcomes and live birth rates with T-ICSI are not significantly superior to Ej-ICSI in patients with an elevated SCSA-defined sperm DNA fragmentation and prior ICSI failure(s).

Does acquired obstructive azoospermia have less impact than congenital azoospermia on ICSI results? Systematic review and meta-analysis

An electronic-based search was performed with MEDLINE bases through PubMed, Cochrane through Central, and Embase until August 2020 for the purpose of evaluating the impact of the aetiology of obstructive azoospermia on ICSI cycles. In the final analysis, there were 15 cohort studies included, comparing a group of patients with acquired azoospermia and others due to congenital bilateral absence of the vas deferens submitted to ICSI. Those 15 articles within 4,480 couples were analysed, and similar fertilisation rate (65.1% vs. 65.3%; p = .38), pregnancy rate per cycle (40.0% vs. 43.1%; p = .06) and live birth rate (29.6% vs. 30.0%;p = .76) were found between groups. Comparing specifically post-vasectomy azoospermia and congenital groups, both presented a similar fertilisation rate (62.4% vs. 53.4%, respectively; OR 1.10; 95% CI, 0.79, 1.54; p = .56; I²  = 89%) and pregnancy rate per cycle (39.4% vs. 35.6%, respectively; OR 1.26; 95% CI, 0.96, 1.66; p = .09; I²  = 0%). However, a higher live birth rate was identified in the congenital group compared to vasectomy group (28.4% × 19.5%; OR 1.54; 95% CI, 1.11, 2.15; p = .01; I²  = 0%). The reasons for that are unclear and factors such as couple age and sperm DNA fragmentation should be considered.

Does mirabegron deteriorate spermatogenesis? A lesson from spinal cord injury cases

OBJECTIVES

To evaluate whether the long-term usage of mirabegron, which was reported to have potential side effects on male reproductive organs in animal studies, was harmful to spermatogenesis in human testis.

METHODS

Thirty consecutive patients with spinal cord injury (20-48 years old) who performed clean intermittent catheterization were involved in this study. Ten patients were treated with mirabegron (50 mg/d) for more than 2 years and refrained from using an antimuscarinic agent due to the side effects of constipation and dry mouth. Twenty patients were treated with neither anticholinergic agents nor mirabegron. All underwent conventional testicular sperm extraction. The sperm recovery rate and histopathologic findings of the retrieved testicular tissue were compared between both groups.

RESULTS

We found no difference in the sperm recovery rate (P = .083) between both groups. Spinal cord injury patients treated with mirabegron had better spermatogenesis than those not treated with mirabegron (P < .05).

CONCLUSIONS

From these data, we conclude that the therapeutic dose of mirabegron had no harmful effect on spermatogenesis in spinal cord injury patients of reproductive age.

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%.

Comparative Analysis of Surgically Retrieved Sperms in Cases of Obstructive and Nonobstructive Azoospermia Treated for Infertility

Background

Azoospermia is a highly evolving subject in the last few decades. In the past, use of donor sperm was the only option providing a realistic chance of conception for couples affected by azoospermia. Introduction of sperm retrieval techniques and assisted reproductive technologies, especially intracytoplasmic sperm injection (ICSI), has provided these men a chance to father their genetically own child and changed the management approach significantly.

Objective

The objective was to compare the sperm retrieval rate (SRR) and ICSI outcomes of surgically retrieved sperms in cases of obstructive and nonobstructive azoospermia (NOA) as well as to evaluate the efficacy of sperm retrieval techniques.

Materials and Methods

A total of sixty azoospermic patients were included in the study. The patients were divided between OA (16) and NOA groups (44). A retrospective outcome analysis was done on SRR and ICSI results among them.

Results

The overall SRR in patients with NOA and OA was 47.7% and 100%, respectively (P < 0.001). On subgroup analysis, higher serum follicle-stimulating hormone has shown significantly decreased sperm retrieval. The size of testes was not found to be related to sperm retrieval. Fertilization and embryo formation rate were found to be higher in OA cases in comparison to those of NOA cases. Clinical pregnancy rate showed no significant difference.

Conclusion

Various sperm retrieval techniques can provide new dimensions for successful ICSI and managing azoospermia patients. Although SRRs as well as ICSI outcomes are lower in NOA patients than patients with OA, still they are potentially fertile. A systematic approach especially in patients with NOA is an important step. Microdissection testicular sperm extraction is an attractive option for NOA patients in order to increase the chances of successful sperm retrieval.

Infertility considerations in klinefelter syndrome: From origin to management

Klinefelter syndrome (KS) is defined as the presence of one or more extra "X" chromosome in a male patient. It affects approximately 1 in 600 newborn males and the most common chromosomal abnormality, leading to male hypogonadism and infertility. There is a lack of data supporting best practices for KS patients' care. In this paper we review controversial issues in KS research ranging from mechanisms of variation in KS phenotype to abnormalities resulting in reduced sperm production to successful sperm retrieval disparities after testicular sperm extraction (TESE). Translation to live birth and offspring health is also examined. Finally, medical therapies used to optimize the hormonal status and chances of fertility in KS patients are reviewed. We will also discuss the experimental spermatogonial stem cell (SSC) treatments, which are considered the future for TESE negative patients.

The evolution of testicular sperm extraction and preservation techniques

Along with the advent of intracytoplasmic sperm injection in 1992, sperm retrieval procedures now allow the possibility of conception from male sterility. In cases of sterility due to blockages in the reproductive tract, sperm retrieval procedures are relatively straightforward and reliable. In nonobstructive azoospermia or testis failure, sperm often can be difficult to retrieve. For this reason, the field of testicular sperm retrieval has witnessed tremendous change and innovation to achieve higher sperm yields, increasing efficiency and safety, along with fewer complications. We review the history and evolution of testicular sperm retrieval since its inception. Using the findings from randomized controlled trials, basic science studies, meta-analyses, case-controlled or cohort studies, best-practice policies, and literature reviews, we outline the concepts, facts, and principles that have been elucidated over several decades of experience with sperm retrieval. We also appraise the merits and issues of the most popular sperm retrieval techniques and strategies. Finally, we define areas of future clinical and laboratory development that will further refine the field of testicular sperm retrieval.

Predictive model to estimate the chances of successful sperm retrieval by testicular sperm aspiration in patients with nonobstructive azoospermia

OBJECTIVE

To explore predictors of successful sperm retrieval (SR) and to identify potentially suitable candidates for testicular sperm aspiration (TESA), a more straightforward, less traumatic, and less costly procedure than open surgical SR methods.

DESIGN

Retrospective chart review.

SETTING

Academic tertiary medical center.

PATIENTS

A total of 297 patients with nonobstructive azoospermia.

INTERVENTIONS

All patients underwent full clinical evaluation before undergoing a staged SR procedure, starting with TESA and proceeding to microsurgical testicular sperm extraction (microTESE). Predictors of positive SR with TESA were selected using the least absolute shrinkage and selection operator (LASSO) regression analysis using k-fold cross-validation. The obtained regression coefficients were used to create a predictive model, and a receiver operating characteristic (ROC) curve was obtained to express its predictive ability. Cut-off values for each significant predictor were also identified using ROC analysis.

MAIN OUTCOME MEASURE(S)

Development of a prediction model for positive SR with TESA.

RESULTS

Overall, a positive SR was observed in 23.6% of patients undergoing TESA. Average testis size (P = .017) and serum follicle-stimulating hormone (FSH) level (P < .001) were the significant predictors of positive SR identified by LASSO regression analysis. The predictive model had an AUC of 0.742 with a sensitivity of 73.9% and specificity of 69.9%. Patients presenting with an average testis size >7.75 mL and serum FSH level <8.5 IU/L had a TESA-positive SR of 43%.

CONCLUSIONS

TESA may be a suitable alternative to microTESE in selected nonobstructive azoospermia patients presenting with an average testis size >7.75 mL and serum FSH level <8.5 IU/L.

Fertility outcomes and predictors for successful sperm retrieval and pregnancy in 327 azoospermic men with a history of cryptorchidism who underwent microdissection testicular sperm extraction

BACKGROUND

Although few studies have reported fertility outcomes, no study has reported risk factors that might predict sperm retrieval and pregnancy in azoospermic men with a history of cryptorchidism in a large series.

OBJECTIVES

To investigate fertility outcomes and predictors for successful sperm retrieval and pregnancy in azoospermic men with a history of cryptorchidism who underwent microdissection testicular sperm extraction (mTESE).

MATERIALS AND METHODS

This retrospective observational study included 327 azoospermic men with a history of cryptorchidism who underwent mTESE. Fertility outcomes including sperm retrieval, fertilization rate, number of transferred embryos, pregnancy, miscarriage, and live birth rates were recorded.

RESULTS

Sperm retrieval was observed in 172 (52.6%) of the patients. The mean fertilization, pregnancy, and live birth rates were 55.2%±20.5, 53.5%, and 44.8%, respectively. The sperm retrieval rate was significantly higher at the orchidopexy age of ≤ 9.5 years (70.8%) than the orchidopexy age of > 9.5 years (42.1%) (P = .000). Patients with total testicular volume of ≥ 13.75 mL had significantly higher sperm retrieval rate (65.2%) than the patients with total testicular volume of < 13.75 mL (45.5%) (P = .001). Patients with total testosterone level of ≥ 300.5 ng/dL had significantly higher sperm retrieval rate (65.6%) than the patients with total testosterone level of < 300.5 ng/dL (40.3%) (P = .000). Patients with follicle-stimulating hormone (FSH) level of ≤ 17.25 mIU/ml had significantly higher sperm retrieval rate (72.3%) than the patients with FSH level of > 17.25 mIU/mL (44.4%) (P = .000). Younger male and female ages, and higher fertilization rates were the parameters that might predict pregnancy.

CONCLUSIONS

Infertile azoospermic men with a history of cryptorchidism have high sperm retrieval rate with mTESE. Patients who had orchidopexy at the age of ≤ 9.5 years, and having total testicular volumes of ≥ 13.75 mL with total testosterone level of > 300.5 ng/dL and FSH level of ≤ 17.25 mIU/mL have higher success rate for sperm retrieval.

Surgically Extracted Epididymal Sperm from Men with Obstructive Azoospermia Results in Similar In Vitro Fertilization/Intracytoplasmic Sperm Injection Outcomes Compared with Normal Ejaculated Sperm

PURPOSE

Controversy exists around the use of epididymal sperm for in vitro fertilization and intracytoplasmic sperm injection for couples with obstructive azoospermia, and the ability to reliably predict fertility outcomes with surgically extracted epididymal sperm remains limited. To provide additional clinical context, we sought to compare in vitro fertilization/intracytoplasmic sperm injection outcomes of epididymal sperm from couples with obstructive azoospermia to outcomes of couples using normal, ejaculated sperm.

MATERIALS AND METHODS

We performed a case-control analysis of 40 couples who underwent office based epididymal sperm retrieval for obstructive azoospermia followed by in vitro fertilization/intracytoplasmic sperm injection compared with a control group of 38 female, age matched couples with no evidence of female factor infertility who underwent in vitro fertilization/intracytoplasmic sperm injection with normal, ejaculated sperm. Primary outcome was live birth on the initial embryo transfer.

RESULTS

Epididymal samples yielded a median total motile sperm count of 9.1 million, compared to 81 million for ejaculated sperm. On the primary embryo transfer fertilization rate (71% vs 77%, p=0.2), blastulation rate (48% vs 59%, p=0.09), clinical pregnancy rate (70% vs 58%, p=0.4), and live birth rate (58% vs 47%, p=0.4) did not differ between epididymal and ejaculated sperm groups.

CONCLUSIONS

For couples with a male partner with obstructive azoospermia epididymal sperm in vitro fertilization/intracytoplasmic sperm injection outcomes compare similarly with age matched controls undergoing in vitro fertilization/intracytoplasmic sperm injection using normal, ejaculated sperm. These results may help reproductive surgeons provide reassurance about the use of obstructed epididymal sperm as well as help guide discussions about anticipated outcomes of in vitro fertilization/intracytoplasmic sperm injection.

Role of treatment with human chorionic gonadotropin and clinical parameters on testicular sperm recovery with microdissection testicular sperm extraction and intracytoplasmic sperm injection outcomes in 184 Klinefelter syndrome patients

OBJECTIVE

To investigate whether preoperative human chorionic gonadotropin (hCG) treatment can help predict the outcomes of microdissection testicular sperm extraction (micro-TESE) and affect fertility outcomes in non-mosaic Klinefelter syndrome (KS) patients.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated fertility center.

PATIENT(S)

A total of 184 non-mosaic KS patients who underwent micro-TESE with or without preoperative hCG treatment from January 2016 to July 2019.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Sperm retrieval rate (SRR) with and without hCG treatment, logistic models analysis.

RESULT(S)

Eighty KS patients (43.5%) had successful sperm retrievals after micro-TESE. There was no statistically significant difference in the SRR between the group who received hCG treatment and the group that did not (44.0% vs. 43.3%). Logistic regression analyses demonstrated that the hCG treatment had no statistically significant effect on successful sperm retrieval. However, higher preoperative testosterone (T) levels seemed to be associated with a higher probability of successful sperm retrieval (multivariate adjusted odds ratio 1.09; 95% confidence interval [CI], 1.04-1.16). The prediction model for SRR on KS patients had an area under the curve of 67.3% (95% CI, 59.3-75.3%). In the hCG treatment group, the data indicated that the three parameters of testicular volume, pretreatment T level, and alterations of T were associated with the probability of successful sperm retrieval. Moreover, hCG therapy did not affect intracytoplasmic sperm injection (ICSI) outcomes. No differences in the pregnancy rate or live-birth rate were observed between the two groups.

CONCLUSION(S)

Therapy with hCG does not affect SRR or ICSI outcomes of non-mosaic KS patients. However, preoperative T levels, whether treated with hCG or not, can predict the chance of sperm retrieval with micro-TESE.

Towards a better testicular sperm extraction: novel sperm sorting technologies for non-motile sperm extracted by microdissection TESE

Non-obstructive azoospermia (NOA) is the most severe form of male factor infertility. It is characterized by a lack of spermatogenesis in the seminiferous tubules. Microdissection testicular sperm extraction (microTESE) has significantly improved testicular sperm retrieval rates compared to conventional techniques for NOA. Following testicular biopsy, the sperm is usually non-motile and contained within seminiferous tubules requiring extensive laboratory processing to find individual sperm sufficient for artificial reproductive technologies (ART). Current techniques include mechanical and enzymatic processing which is time-consuming and often damaging to sperm. We review novel techniques that may help improve sperm retrieval rates after microTESE including microfluidics (dielectrophoretic cell sorting, spiral channel sorting, and pinched flow fractionation), fluorescence-activated cell sorting (FACS), and magnetic-activated cell sorting (MACS).