Higher pregnancy rates using testicular sperm in men with severe oligospermia

Sperm DNA damage and its role in IVF and ICSI

While the semen analysis has traditionally been relied upon to differentiate fertile and infertile men, its utility has been questioned in the current era of assisted reproductive technologies. The desire for more sophisticated diagnostic and predictive tools has led to increased use of sperm DNA damage in the management of male infertility. Despite the availability of numerous assays to measure sperm DNA damage, our understanding of the etiology, measurement, and clinical implications of sperm DNA damage remains incomplete. While the current evidence is fraught with heterogeneity that complicates attempts at comparison and meta-analysis, there does appear to be a role for sperm DNA damage in the development and maintenance of pregnancy in the era of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). However, as noted by the American Society for Reproductive Medicine, the routine and widespread use of sperm DNA damage testing is not yet supported. Further studies are needed to standardize the measurement of sperm DNA damage and to clarify the exact role of sperm DNA damage within the myriad of other male and female factors contributing to reproductive outcomes in IVF and ICSI.

Recent advances in understanding & managing male infertility

Male infertility remains a struggle to definitively diagnose and treat with many men labelled as “idiopathic infertility” and eventually requiring assisted reproductive techniques.  Along those lines, research groups are continuing to explore current social and environmental factors, including the obesity epidemic, and their effects on male fertility potential.  Novel biomarkers of natural fertility status and azoospermia etiology have additionally seen recent attention with ACRV1 and TEX101/ECM1 assays either currently or soon to be commercially available.  Despite these advancements, however, medical treatment options have seen little progress.  Though surgical therapies have similarly seen little transformation, groups are exploring the use of testicular sperm for couples with elevated sperm DNA fragmentation and either planned or previously failed IVF/ICSI.  Concerted collaborative efforts will be needed as we move forward to better understand the challenges men face when struggling to conceive.

Use of testicular sperm for ICSI in oligozoospermic couples: how far should we go?

In 1992 and subsequently, several reports indicated that ICSI was a successful technique to achieve clinical pregnancy and live birth using spermatozoa with severely impaired characteristics. The initial optimism over the ability of ICSI to overcome significant sperm abnormalities was later tempered by the findings of more recent publications suggesting that some sperm deficits may not be as effectively treated with ICSI. In search for effective treatment for couples with severe male factor, a number of small retrospective and prospective studies have reported high pregnancy and live birth rates using testicular sperm for men with necrozoospermia, cryptozoospermia and oligozoospermia with or without elevated sperm DNA damage. Although the data suggest that there may be some benefit in performing testicular sperm retrieval (TSR)-ICSI in select groups of non-azoospermic infertile men, there are potential risks involved with TSR. Clinicians should balance these risks prior to the recommendation of TSR-ICSI on the result of a semen analysis or sperm DNA test alone. Careful evaluation and management of male factor infertility is important. The use of TSR-ICSI in the absence of specific sperm DNA defects is still experimental.

Testicular versus ejaculated spermatozoa in ICSI cycles of normozoospermic men with high sperm DNA fragmentation and previous ART failures

As a part of male assessment, conventional sperm parameters including morphologic features have been dedicated as major factors influencing fertilisation and pregnancy rates in assisted reproductive technology (ART). Genomic integrity of spermatozoa has also been found to influence fertility prognosis, and hence, sperm DNA fragmentation index (DFI) has been adopted by many centres to document this entity. Despite several suggested approaches, there is lack of universal consensus on optimising fertility outcomes in males with high sperm DFI. In this context, the results from cycles using testicular spermatozoa (TESA) obtained by aspiration were compared with those of ejaculated spermatozoa (EJ) in normozoospermic subjects with high sperm DFI and previous ART failures. Clinical (41.9% versus 20%) and ongoing pregnancy rates (38.7% versus 15%) were significantly better and miscarriages were lower in TESA group when compared to EJ group. Sperm DFI should be a part of male partner's evaluation following unsuccessful ART attempts. When high DFI is detected (>30%), ICSI using testicular spermatozoa obtained by TESA seems an effective option particularly for those with repeated ART failures in terms of clinical, ongoing pregnancies and miscarriages even though conventional sperm parameters are within normal range.

Use of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with cryptozoospermia: a meta-analysis

OBJECTIVE

To examine outcomes of intracytoplasmic sperm injection (ICSI) using testicular versus ejaculated sperm among men with cryptozoospermia.

DESIGN

Meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Men with cryptozoospermia undergoing consecutive ICSI cycles using ejaculated or testicular sperm.

INTERVENTION(S)

A systematic search was performed using PubMed (inception to August 2015). Inclusion criteria were studies comparing ICSI outcomes among men with cryptozoospermia using ejaculated and testicular sperm.

MAIN OUTCOME MEASURE(S)

Primary outcomes included ICSI fertilization or pregnancy rates (PRs). Secondary analysis included number of retrieved oocytes, maternal and paternal ages. Meta-analysis of weighted data using a random effects model was performed. Results are reported as relative risk or weighted mean differences (WMD) with 95% confidence intervals (CI).

RESULT(S)

Five cohort studies were included, encompassing 272 ICSI cycles and 4,596 injected oocytes. There were no differences in ICSI PRs (relative risk [RR] 0.53, 95% CI 0.19-1.42, I(2) = 67%) or fertilization rates (RR 0.91, 95% CI 0.78-1.06, I(2) = 73%) between testicular and ejaculated sperm groups. There was a significant trend toward increasing maternal age (WMD 1.69 years, 95% CI -2.71 to -0.66) and paternal age (WMD 2.61 years, 95% CI -4.73 to -0.48) with testicular sperm. There was no difference between numbers of oocytes retrieved (WMD 0.95, 95% CI -0.15 to 2.05). Post-hoc power analysis revealed pβ <20% for PR analysis and pβ <10% for fertilization rate analysis.

CONCLUSION(S)

The existing literature does not support a recommendation for men with cryptozoospermia to use testicular sperm in preference over ejaculated sperm for ICSI.