Are there any predictive factors for successful testicular sperm recovery in azoospermic patients?

Testicular histology may predict the successful sperm retrieval in patients with non-obstructive azoospermia undergoing conventional TESE: a diagnostic accuracy study

PURPOSE

The present study sought to determine the diagnostic accuracy of FSH level, testicular volume, and testicular histology in predicting the successful sperm retrieval (SSR) in a large cohort of patients with non-obstructive azoospermia undergoing conventional testicular sperm extraction (TESE).

METHODS

We retrospectively evaluated 356 patients with non-obstructive azoospermia between June 2004 and July 2009. Binary logistic regression was used to evaluate the diagnostic accuracy of our predicting model, identifying sperm retrieval rate as binary dependent variable. The predictive accuracy of all variables individually evaluated was quantified with area under curve (AUC) estimates derived from receiver operating characteristic (ROC) curve.

RESULTS

The mean patients' age was 36.8 years. Testicular sperm were retrieved in 158 out of 356 patients (44.3 %). Histological diagnosis of Sertoli cell only syndrome (SCO) was obtained in 216 patients (60.6 %), while 55 patients (15.4 %) had maturation arrest (MA) and 85 (23.8 %) had hypospermatogenesis (HYPO). The binary logistic regression model was statistically significant (χ ² = 96.792, p < 0.0001) and correctly classified 72.8 % of cases with 46.8 % sensitivity and 93.4 % specificity, positive predictive value (PPV) 85.06 %, negative predictive value (NPV) 68.7 %, +likelihood ratio (LR) 7.13, and -LR 0.57. Only testicular histology was significant to the model, while FSH and testicular volume were not. Sperm retrieval rate (SRR) was significantly higher in patients with HYPO compared to patients with SCO or MA (88.2 vs 30.5 and 30.9 %, respectively, p < 0.0001) CONCLUSIONS: This study demonstrates that including testicular histology in a model for predicting sperm retrieval increases its diagnostic accuracy. As histology is not available prior to TESE, this model applies only to patients with previous testicular surgery.

Effects of clinical, laboratuary and pathological features on successful sperm retrieval in non-obstructive azoospermia

OBJECTIVE

The study aims to evaluate the correlation of testicular sperm extraction (TESE) and histopathology with various features of non-obstructive azoospermia (NOA) cases who consulted to our university-based infertility clinic, and the probability of prompting couples about TESE success and to investigate the cost reduction chance through cost-beneficial aspects.

MATERIAL AND METHODS

One hundred and twenty-five patients were enrolled in this study. Age, unprotected intercourse period, age of puberty, and concomittant diseases were noted. Testicular volumes were measured. The correlations between genetic test results and serum levels of Follicle-Stimulating Hormone (FSH), Luteinizing Hormone (LH), free testosterone, prolactine were investigated.

RESULTS

The incidence of NOA among infertile men was found to be 15.1%. Median age of the cases was 33.1 years. Decrease in TESE success rate was seen in the group aged >30, and those who practiced unprotected intercourse for more than 10 years. TESE success rate was 40 percent. The required negative correlation between FSH levels, and testicular volume was not observed when the patient had additional diseases and/or genitourinary surgery. FSH and LH levels were significantly different between TESE- positive and negative groups (p=0.006, and p=0.001 respectively). Success rate in bilateral TESE group was 14.2%, and 96% of TESE- negative patients had bilateral TESE. Fifteen of 118 patients had Y chromosome microdeletions. These results were similar in both TESE- positive and negative group.

CONCLUSION

None of the parameters investigated herein predicted succesful TESE outcomes. However, in cases with increased FSH and AZFa/AZFb deletion before application of bilateral TESE, in cases of increased FSH and AZFa/AZFb deletion, detailed information should be given to these patients about low success rates and risk of disease inheritance which may reduce procedural costs. Knowing groups with poor prognosis, may help rearrangement of the appropriation of infertility in health policies.

Are there optimal numbers of oocytes, spermatozoa and embryos in assisted reproduction?

The aim of this overview is to discuss the current information about the search for the optimum yield of gametes in assisted reproduction, as one of the major pillars of IVF success. The first topic is focused on the number of male gametes and the possible impact of some genetic traits on these parameters. The number of spermatozoa did not seem to be crucial when there is no severe male factor of infertility. Genetic testing prior to using those sperm cells is very important. Different methods were applied in order to elect the "best" spermatozoa according to specific indications. The next problem discussed is the importance of the number of oocytes collected. Several studies have agreed that "15 oocytes is the perfect number," as the number of mature oocytes is more important. However, if elective single embryo transfer is performed, the optimal number of oocytes will enable a proper embryo selection. The third problem discussed concerns fertility preservation. Many educational programs promote and encourage procreation at maternal ages between 20-35 years, since assisted reproduction is unable to fully overcome the effects of female aging and fertility loss after that age. It is also strongly recommended to ensure a reasonable number of cryopreserved mature oocytes, preferably in younger ages (<35), for which an average of two stimulation cycles are likely required. For embryo cryopreservation, the "freeze all" strategy suggests the vitrification of good embryos, therefore quality is prior to number and patient recruitment for this strategy should be performed cautiously.

Clinical management of infertile men with nonobstructive azoospermia

The clinical management of men with nonobstructive azoospermia (NOA) seeking fertility has been a challenge for andrologists, urologists, and reproductive medicine specialists alike. This review presents a personal perspective on the clinical management of NOA, including the lessons learned over 15 years dealing with this male infertility condition. A five-consecutive-step algorithm is proposed to manage such patients. First, a differential diagnosis of azoospermia is made to confirm/establish that NOA is due to spermatogenic failure. Second, genetic testing is carried out not only to detect the males in whom NOA is caused by microdeletions of the long arm of the Y chromosome, but also to counsel the affected patients about their chances of having success in sperm retrieval. Third, it is determined whether any intervention prior to a surgical retrieval attempt may be used to increase sperm production. Fourth, the most effective and efficient retrieval method is selected to search for testicular sperm. Lastly, state-of-art laboratory techniques are applied in the handling of retrieved gametes and cultivating the embryos resulting from sperm injections. A coordinated multidisciplinary effort is key to offer the best possible chance of achieving a biological offspring to males with NOA.

Successful fertilization and embryo development after spermatid injection: A hope for nonobstructive azoospermic patients

Spermatids are the earliest male germ cells with haploid set of chromosomes. Spermatid injection was introduced in human assisted reproduction for the treatment of men with non-obstructive azoospermia. Spermatozoa can be recovered in half of patients with nonobstructive azoospermia. The use of spermatids for intracytoplasmic injection (ICSI) has been proposed for cases in which no spermatozoa can be retrieved. However, there are low pregnancy rates following ICSI using round spermatids from men with no elongated spermatids or spermatozoa in their testes. The in vitro culture of immature germ cells has been proposed as a means to improve this poor outcome. Oocyte activation rarely occurs when injected with a spermatid. Therefore, spermatid injection requires use of calcium ionophores for oocyte activation which is otherwise carried out by PLC zeta from mature sperms. This is the only option available for the nonobstructive azoospermic patients to have their own biological child.

Predictive factors of successful sperm retrieval on microdissection testicular sperm extraction in Japanese men

Purpose

To evaluate retrospectively the outcomes of microdissection testicular sperm extraction (micro-TESE) in men with nonobstructive azoospermia (NOA) and to identify the parameters predicting successful sperm retrieval in this cohort of patients.

Methods

After excluding patients with normal testicular volume and serum follicle-stimulating hormone (FSH) level who received conventional TESE, this study included 329 consecutive NOA patients undergoing micro-TESE at our institution. The significance of several factors, including age, testicular volume, etiology and serum levels of FSH, luteinizing hormone (LH) and serum testosterone (T), as predictors of successful sperm retrieval, was evaluated.

Results

Of the 329 men included in this series, 246 (74.8 %), 40 (12.2 %), and 43 (13.1 %) were pathologically diagnosed with Sertoli cell only, maturation arrest, and hypospermatogenesis, respectively. Spermatozoa were retrieved in 97 (29.5 %) of these 329 men by micro-TESE. Older age and non-idiopathic etiology were significantly associated with the probability of successful sperm retrieval; however, there were no significant effects of testicular volume as well as serum levels of FSH, LH, and T on sperm retrieval outcome. Furthermore, Johnsen score of the micro-TESE specimen showed a significant association with whether spermatozoa were successfully retrieved. Univariate analysis of preoperative parameters identified older age and non-idiopathic etiology as significant predictors of successful sperm retrieval, of which only etiology appeared to be independently related to successful sperm retrieval on multivariate analysis.

Conclusions

Spermatozoa are significantly less likely to be successfully retrieved by micro-TESE in men with idiopathic azoospermia.

How successful is TESE-ICSI in couples with non-obstructive azoospermia?

STUDY QUESTION

What are the chances of a couple with infertility due to non-obstructive azoospermia (NOA) having their genetically own child by testicular sperm extraction combined with ICSI (TESE-ICSI)?

SUMMARY ANSWER

Candidate TESE-ICSI patients with NOA should be counselled that, when followed-up longitudinally, only a minority (13.4%) of men embarking for TESE eventually become a biological father.

WHAT IS KNOWN ALREADY

Data available in the literature are only fragmentary because they report either on sperm retrieval rates after TESE or on the outcome of ICSI once testicular spermatozoa has been obtained, mostly in a selected subpopulation. Unfortunately, reliable data to counsel men with NOA on their chance to become a biological father are still lacking.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study performed in the Centre for Reproductive Medicine, University Hospital of Brussel, approved by the institutional review board of the hospital.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

We identified all patients with NOA, based on histology, who had their first testicular biopsy between 1994 and 2009. Patients were followed longitudinally during consecutive ICSI cycles with testicular sperm. The primary outcome measure was live birth delivery. The cumulative live birth delivery rate was calculated, based only on ICSI cycles with testicular sperm (fresh and/or frozen) available for injection. When patients delivered after transfer of supernumerary frozen embryos, this delivery was tallied up to the (unsuccessful) original fresh ICSI cycle. The sperm retrieval rate and pregnancy rate were secondary outcome measures.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 714 men with NOA, 40.5% had successful sperm retrieval at their first TESE. In total, 261 couples had 444 ICSI cycles and 48 frozen embryo transfer cycles, leading to 129 pregnancies and 96 live birth deliveries. Crude and expected cumulative delivery rates after six ICSI cycles were 37 and 78%.

LIMITATIONS AND REASON FOR CAUTION

A retrospective cohort study design was the only way to study the cumulative delivery rate after TESE-ICSI in couples with NOA. Intrinsic limitations are related to the observational study design.

WIDER IMPLICATION OF THE FINDING

TESE-ICSI is a breakthrough in the treatment of infertility due to NOA, with almost 4 out of 10 (37%) couples having ICSI obtaining a delivery. However, unselected candidate NOA patients should be counselled, before undergoing TESE, that only one out of seven men (13.4%) eventually father their genetically own child.

STUDY FUNDING AND COMPETING INTERESTS

None declared.

Salvage micro-dissection testicular sperm extraction; outcome in men with non-obstructive azoospermia with previous failed sperm retrievals

OBJECTIVE

To assess the outcome of micro-dissection testicular exploration sperm extraction (m-TESE) as a salvage treatment in men with non-obstructive azoospermia (NOA) in whom no sperm was previously found on single/multiple TESE or testicular sperm aspiration (TESA).

PATIENTS AND METHODS

In all, 58 men with NOA underwent m-TESE. All the patients had previously undergone either single/multiple TESE or TESA with no sperm found. All the patients underwent an m-TESE using a standard technique. Serum follicle-stimulating hormone (FSH), testosterone and histopathological diagnosis were examined as predictive factors for sperm recovery. All patients underwent preoperative genetic screening. One patient was found to have an azoospermic factor c (AZFc) micro-deletion and five were diagnosed with Kleinfelter's syndrome.

RESULTS

The mean (range) patient age was 39.0 (26-57) years. Spermatozoa were successfully retrieved in 27 men by m-TESE (46.5%). The mean (range) FSH level was 19.4 (1.6-58.5) IU/L. There was no correlation in age (mean age retrieved 38.1 years, not retrieved 39.7 years, P = 0.38), FSH levels (mean FSH retrieved 21.4 IU/L, not retrieved 17.7 IU/L, P = 0.3) and the ability to find sperm by m-TESE. However, there was a significant difference in testosterone levels and sperm retrieval (mean testosterone retrieved 14.99 nmol/L, not retrieved 11.39 nmol/L, P < 0.05). Patients with a diagnosis of Sertoli-cell-only (SCO) syndrome [14/35 (40%)] and maturation arrest [four of 11 (36%)] had lower sperm retrieval rates than those in the hypospermatogenesis group [nine of 12 (75.0%)] (P < 0.05). There were no significant complications after m-TESE.

CONCLUSIONS

In men with NOA who have undergone previous attempts at sperm retrieval with negative results, a salvage m-TESE offers a significant chance of finding sperm even in SCO syndrome. There does seem to be a correlation between preoperative testosterone levels and the ability to successfully find sperm.

Predictive factors of successful microdissection testicular sperm extraction in patients with presumed sertoli cell-only syndrome

BACKGROUND

To evaluate predictive factors of successful microdissection-testicular sperm extraction (MD-TESE) in patients with presumed Sertoli cell-only syndrome (SCOS).

MATERIALS AND METHODS

In this retrospective analysis, 874 men with non-obstructive azoospermia (NOA), among whom 148 individuals with diagnosis of SCOS in prior biopsy, underwent MD-TESE at Department of Andrology, Royan Institute, Tehran, Iran. The predictive values of follicle stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (T) levels, testicular volume, as well as male age for retrieving testicular sperm by MD-TESE were analyzed by multiple logistic regression analysis.

RESULTS

Testicular sperm were successfully retrieved in 23.6% men with presumed SCOS. Using receiver operating characteristic (ROC) curve analysis, it was shown that sperm retrieval rate in the group of men with FSH values >15.25% was 28.9%. This was higher than the group of men with FSH ≤15.25 (11.8%).

CONCLUSION

Sperm retrieval rate (SRR) was 23.6% in men with presumed SCOS and FSH level can be a fair predictor for SPR at MD-TESE. MD-TESE appears to be recommendable in such cases (SCOS with high FSH concentration) with reasonable results.

Intracytoplasmic sperm injection (ICSI) in extreme cases of male infertility

INTRODUCTION

Severely compromised spermatogenesis typical of men with virtual azoospermia or non-obstructive azoospermia requires an extreme search for spermatozoa. Our goal was to evaluate the usefulness of a meticulous search carried out in ejaculated or surgically retrieved specimens in achieving pre- and post-implantation embryo development.

PATIENTS AND METHODS

In a retrospective cohort study carried out in an academic institution, intracytoplasmic sperm injection (ICSI) outcomes were reviewed as a function of length of microscopic sperm search in ejaculated and surgically retrieved specimens. Couples whose male partner presented with either virtual or non-obstructive azoospermia were treated by ICSI and categorized according to the time spent in identifying and retrieving enough spermatozoa to inject all the oocyte cohort. Semen parameter, fertilization, pregnancies, deliveries, and child welfare in relation to increasing search time were analyzed and compared.

RESULT(S)

The maternal and paternal ages were comparable in both ejaculated and testicular sperm extraction (TESE) groups along with the oocytes retrieved. The fertilization rates for both ejaculated and TESE progressively decreased with increasing time (P<0.0001). Clinical pregnancies in the ejaculated cohort remained satifactory. In the TESE cohort, there was a decrease in pregnancy rate with increasing time, from 44% to 23%. In a limited number of cases, offspring health was evaluated in both semen sources and appeared reassuring.

CONCLUSION(S)

An extensive and at time exhaustive sperm quest yields kinetically and morphologically impaired spermatozoa without apparent impact on embryo developmental competence. Retrieval of spermatozoa from the seminiferous tubules provided more consistent fertilization and pregnancy outcomes than those retrieved from the ejaculate. A trend indicated that pregnancy rate decreased as search time increased in the TESE group. The utilization of the scarce and unselected spermatozoa did not obviously impair embryo development or cause post-implantation errors.

Microdissection testicular sperm extraction in men with Sertoli cell-only testicular histology

OBJECTIVE

To study the outcomes of microdissection testicular sperm extraction (microTESE) among men with pure Sertoli cell-only histology on diagnostic testicular biopsy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENT(S)

Six hundred forty patients with pure Sertoli cell-only histology on testicular biopsy who underwent microTESE by a single surgeon.

INTERVENTION(S)

MicroTESE.

MAIN OUTCOME MEASURE(S)

Sperm retrieval rates.

RESULT(S)

Overall, 44.5% of patients with Sertoli cell only had sperm retrieved with microTESE. No difference was noted in sperm retrieval rates based on testis volume (≥15 mL vs. <15 mL, 35.3% vs. 46.1%, respectively). Patients with ≥15 mL testicular volume and FSH 10-15 mU/mL had the worst prognosis, with a sperm retrieval rate of 6.7%.

CONCLUSION(S)

Patients with previous testicular biopsy demonstrating Sertoli cell-only histology can be counseled that they have a reasonable likelihood of sperm retrieval with the contemporary delivery of microTESE. Given this finding, the utility of testicular biopsy before microTESE is further questioned.

Etiology of azoospermia in a military population

PURPOSE

Male infertility is commonly seen at urology clinics and 10% to 20% of infertile males are found to be azoospermic. Azoospermia is classically categorized as nonobstructive or obstructive. This classification tailors the evaluation, diagnosis and proper treatment. We performed a retrospective study to provide an updated etiology of azoospermia in patients in the United States in a universal health care model.

MATERIALS AND METHODS

We retrospectively reviewed the records of men with azoospermia who presented to our institution between 2004 and 2012. Laboratory data were analyzed, included semen analysis, follicle-stimulating hormone, luteinizing hormone, testosterone, semen fructose and genetic studies. Patients underwent scrotal exploration as indicated for testis biopsy and sperm extraction.

RESULTS

We reviewed 139 outpatient records. Nonobstructive azoospermia was diagnosed in 99 men (71%), including 33 (34%) identified with Sertoli-cell only syndrome. Other etiologies included an idiopathic cause in 25 cases (26%), Klinefelter syndrome in 9 (9%), maturation arrest in 9 (9%), Y chromosome microdeletion in 5 (5%), cryptorchidism in 4 (4%), trauma in 4 (4%), exogenous testosterone supplementation in 4 (4%) and other genetic disorders in 6 (6%). Obstructive azoospermia was identified in 40 men (29%), of whom 16 (40%) had congenital bilateral absence of the vas deferens. Other etiologies included an idiopathic cause in 11 cases (28%), an iatrogenic condition due to a surgical cause in 5 (13%), ejaculatory duct obstruction in 3 (8%), trauma in 1 (3%), retrograde ejaculation in 1 (3%), vas deferens occlusion in 2 (5%) and unilateral absence of the vas deferens in 1 (3%).

CONCLUSIONS

This study delineates the etiology of azoospermia in men with universal access to care.

Decreased expression of SAM68 in human testes with spermatogenic defects

OBJECTIVE

To assess the expression patterns of SAM68 in the testes of azoospermic patients with normal and abnormal spermatogenesis.

DESIGN

Retrospective study and in vitro study.

SETTING

University hospital.

PATIENT(S)

Testicular biopsies of azoospermic men with normal spermatogenesis (OAZ; n=20), with maturation arrest at the spermatocyte stage (MA; n=20), and with Sertoli cell-only syndrome (SCOS; n=10).

INTERVENTION(S)

No interventions with patients. Knockdown of Sam68 was performed in the GC-2spd(ts) cell line.

MAIN OUTCOME MEASURE(S)

SAM68 expression was analyzed using quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR), Western blot, and immunohistochemistry analysis in tissues. Moreover, Sam68 was knocked down in GC-2spd(ts) cells. Cell viability was measured using the MTT assay, and the apoptosis rate was detected using flow cytometry with the Annexin V-FITC kit.

RESULT(S)

Using qRT-PCR, the expression level of testicular SAM68 mRNA in MA and SCOS patients was statistically reduced compared with in OAZ patients. In addition, using qRT-PCR, Western blot, and immunohistochemistry analyses, mRNA and protein expressions of SAM68 were absent or barely detectable in testicular tissues in 45% (9 of 20) of patients with MA and in all patients with SCOS. Furthermore, decreased expression of Sam68 suppressed germ cell proliferation and induced apoptosis in transfected GC-2spd(ts) cells.

CONCLUSION(S)

Deficient SAM68 expression was observed in the human testis with MA at the spermatocyte stage and SCOS. These results may offer new perspectives on the molecular basis of abnormal spermatogenesis.

Sperm retrieval techniques

Since the advent of intracytoplasmic sperm injection in 1992, sperm retrieval procedures have been routinely employed to treat male infertility owing to azoospermia. With obstructive azoospermia, sperm is potentially harvestable from the vas deferens, epididymis, and testicle using percutaneous and open sperm retrieval procedures that are relatively straightforward and reliable. In nonobstructive azoospermia, sperm is generally found only in the testicles and can often be difficult to retrieve. Several approaches aimed at maximizing sperm yield in this condition have been developed, but only 50% of men with nonobstructive azoospermia will have clinically usable sperm. Multibiopsy testicular sperm extraction (TESE), microdissection TESE, and fine-needle-aspiration map-guided TESE are three common methods currently employed to locate and retrieve sperm in these difficult cases. Other factors that influence the use of surgically retrieved sperm for assisted reproduction include differences in sperm DNA integrity, the expertise of the surgeon and the andrology laboratory, and the described differences in the viability of sperm from different anatomical sources after freezing and thawing.

Predictive factors of successful microdissection testicular sperm extraction

Azoospermia in men requires microsurgical reconstruction or a procedure for sperm retrieval with assisted reproduction to allow fertility. While the chance of successful retrieval of sperm in men with obstructive azoospermia approaches >90%, the chances of sperm retrieval in men with non-obstructive azoospermia (NOA) are not as high. Conventional procedures such as fine needle aspiration of the testis, testicular biopsy and testicular sperm extraction are successful in 20-45% of men with NOA. With microdissection testicular sperm extraction (micro-TESE), the chance of successful retrieval can be up to 60%. Despite this increased success, the ability to counsel patients preoperatively on their probability of successful sperm retrieval has remained challenging. A combination of variables such as age, serum FSH and inhibin B levels, testicular size, genetic analysis, history of Klinefelter syndrome, history of cryptorchidism or varicocele and histopathology on diagnostic biopsy have provided some insight into the chance of successful sperm retrieval in men with NOA. The goal of this review was to evaluate the preoperative factors that are currently available to predict the outcome for success with micro-TESE.

Sperm recovery and IVF after testicular sperm extraction (TESE): effect of male diagnosis and use of off-site surgical centers on sperm recovery and IVF

Objective

Determine whether testicular sperm extractions and pregnancy outcomes are influenced by male and female infertility diagnoses, location of surgical center and time to cryopreservation.

Patients

One hundred and thirty men undergoing testicular sperm extraction and 76 couples undergoing 123 in vitro fertilization cycles with testicular sperm.

Outcome Measures

Successful sperm recovery defined as 1–2 sperm/0.5 mL by diagnosis including obstructive azoospermia (n = 60), non-obstructive azoospermia (n = 39), cancer (n = 14), paralysis (n = 7) and other (n = 10). Obstructive azoospermia was analyzed as congenital absence of the vas deferens (n = 22), vasectomy or failed vasectomy reversal (n = 37) and “other”(n = 1). Sperm recovery was also evaluated by surgical site including infertility clinic (n = 54), hospital operating room (n = 67) and physician’s office (n = 11). Treatment cycles were evaluated for number of oocytes, fertilization, embryo quality, implantation rate and clinical/ongoing pregnancies as related to male diagnosis, female diagnosis, and use of fresh or cryopreserved testicular sperm.

Results

Testicular sperm recovery from azoospermic males with all diagnoses was high (70 to 100%) except non-obstructive azoospermia (31%) and was not influenced by distance from surgical center to laboratory. Following in vitro fertilization, rate of fertilization was significantly lower with non-obstructive azoospermia (43%, p = <0.0001) compared to other male diagnoses (66%, p = <0.0001, 59% p = 0.015). No differences were noted in clinical pregnancy rate by male diagnosis; however, the delivery rate per cycle was significantly higher with obstructive azoospermia (38% p = 0.0371) compared to diagnoses of cancer, paralysis or other (16.7%). Women diagnosed with diminished ovarian reserve had a reduced clinical pregnancy rate (7.4% p = 0.007) compared to those with other diagnoses (44%).

Conclusion

Testicular sperm extraction is a safe and effective option regardless of the etiology of the azoospermia. The type of surgical center and/or its distance from the laboratory was not related to success. Men with non-obstructive azoospermia have a lower chance of successful sperm retrieval and fertilization.

Predictive factors of successful sperm retrieval in azoospermia

INTRODUCTION

Testicular sperm extraction with intracytoplasmic sperm injection is the standard treatment for azoospermia. The objective of this study is to identify predictive factors of successful sperm retrieval.

MATERIALS AND METHODS

Between June 2003 and May 2011, we tried testicular sperm extraction (TESE) in 74 azoospermic patients in the Reproductive Medicine Unit of Son Espases Hospital (Palma de Mallorca). Serum follicle stimulating hormone (FSH) and inhibin B levels, testicular histology, genetic study, presence or not of cryptozoospermia and testicular volume were examined.

RESULTS

Spermatozoa were successfully recovered in 47.2% of the total patients, in 36% of non-obstructive azoospermic patients and in 100% of obstructive azoospermic patients. Low inhibin B and high FSH were correlated to sperm retrieval failure. The cutoff points were determined using ROC curves that were 67 pg/mL for inhibin B and 12.2 mUI/mL for FSH. Spermatozoa were not successfully retrieved in any patient with Y microdeletions in AZFa,b regions. Spermatozoa were successfully retrieved in 100% of the patients with CFTR mutations. The highest sperm retrieval rate was for hypospermatogenesis, followed by maturation arrest and Sertoli-cell-only. Spermatozoa were successfully retrieved in all cryptozoospermic patients. Although using a non-significant test, there seems to be a correlation between higher testicular volume and a higher probability of successful sperm retrieval.

CONCLUSIONS

Except for Y microdeletions in AZFa,b regions, there is no predictive factor of testicular sperm retrieval to rule out a patient for TESE. Lower inhibin B is more related to sperm retrieval failure than higher FSH. Sperm retrieval is possible for all cases of CFTR mutations but in any case of microdeletion Y in AZFa,b. The lack of germ cells is correlated with a high probability of sperm retrieval failure. The presence of cryptozoospermia is correlated with a high probability of sperm retrieval success. We do not find a statistically significant relation between testicular volume and successful sperm retrieval.

The validity of testicular aspirate cytology and DNA image-analysis of the aspirate in the assessment of infertile men

Objective

To assess the possibility of using cytological examination and DNA image-analysis of testicular fine-needle aspirates instead of open surgical biopsy in the investigation of infertile men, as testicular biopsy has long been used for investigating infertility but the interpretation of histological slides is usually subjective.

Patients and methods

Thirty-three men (aged 22–36 years) were evaluated for infertility and underwent both open biopsy and fine-needle aspiration of their testes. Subsequently, the needle aspirates were assessed histopathologically and cytologically, and by DNA image cytometry. The percentages of haploid, diploid and tetraploid cells were determined for each patient.

Results

The cases were divided into four categories: (1) Complete spermatogenesis, with a DNA pattern of 1n > 2n > 4n; (2) Maturation arrest, with a DNA pattern of 2n > 4n with no haploid cells; (3) Sertoli cell-only syndrome, with a DNA pattern of only 2n, with no haploid or tetraploid cells; (4) Hypospermatogenesis, with a variable DNA pattern, i.e. mild with 1n > 2n, moderate with 2n > 1n > 4n, and marked where the DNA pattern was 2n > 4n > 1n. From the cytological and DNA image-analysis of the aspirate a diagnosis was possible that had a strong correlation with the histological diagnosis of the same case. From image analysis we could exclude interstitial cells, Sertoli cells and sperms on the static image, and differentiate between spermatozoa and spermatids based on morphological characteristics in the cytological smear. This technique can therefore be used to quantitatively determine the percentages of various cell types within the seminiferous tubules. By coupling image ploidy analysis and cytological examination of a cytological smear, spermatogenesis can be assessed accurately.

Conclusion

Image cytometry could be used to exclude interstitial cells, Sertoli cells and sperms on the static image and so produce an accurate assessment of spermatogenesis. A combination of ploidy and cell morphology characteristics in cytological smears provides an accurate, reproducible and easily used alternative to open testicular biopsy.

The Ratio of Second to Fourth Digit Length in Azoospermic Males Undergoing Surgical Sperm Retrieval: Predictive Value for Sperm Retrieval and on Subsequent Fertilization and Pregnancy Rates in IVF/ICSI Cycles

The differentiation of the urogenital system and the appendicular skeleton in vertebrates is under the control of Homeobox (Hox) genes. It has been shown that this common control of digit and gonad differentiation has connected the pattern of digit formation to spermatogenesis and prenatal hormone concentrations in males. We wished to establish whether digit patterns, particularly the ratio between the lengths of the second and fourth digit in males (2D : 4D), was related to spermatogenesis and, more specifically, the presence of spermatozoa in testicular biopsies from azoospermic men undergoing surgical sperm retrieval. Forty-four men were recruited, of whom 16 were diagnosed with nonobstructive azoospermia and 4 with congenital bilateral absence of the vas deferens, and 24 previously fertile men were azoospermic after previous vasectomy. Our results show that men with previous fertility or of an acquired form of azoospermia had significantly lower 2D : 4D ratios than men with nonobstructive azoospermia. In nonobstructive azoospermia, there was a significantly lower 2D : 4D ratio on the left side in men who had successful retrieval than those with unsuccessful retrieval. For these men who had a successful retrieval, none had a 2D : 4D ratio more than 1 on the left side, whereas 4 of 7 men in whom sperm was not found had a 2D : 4D ratio greater than 1. On successful sperm retrieval, subsequent fertilization and clinical pregnancy rates were unaffected by 2D : 4D ratios.

Intracytoplasmic spermatid injection and in vitro maturation: fact or fiction?

Intracytoplasmic injection with testicular spermatozoa has become a routine treatment in fertility clinics. Spermatozoa can be recovered in half of patients with nonobstructive azoospermia. The use of immature germ cells for intracytoplasmic injection has been proposed for cases in which no spermatozoa can be retrieved. However, there are low pregnancy rates following intracytoplasmic injection using round spermatids from men with no elongated spermatids or spermatozoa in their testes. The in vitro culture of immature germ cells to more mature stages has been proposed as a means to improve this poor outcome. Several years after the introduction of intracytoplasmic injection with elongating and round spermatids, uncertainty remains as to whether this approach can be considered a safe treatment option. This review outlines the clinical and scientific data regarding intracytoplasmic injection using immature germ cells and in vitro matured germ cells.

Intérêt de la ponction épididymaire et de la biopsie testiculaire systématique dans la prise en charge de l’azoospermie obstructive

Introduction

Dans l’azoospermie obstructive (AO), les taux d’extraction chirurgicale de spermatozoïdes sont élevés. Cependant, en ce qui concerne les issues des ICSI (Intra cytoplasmic Sperm Injection) chirurgicales, les données de la littérature divergent. Quels sont, dans notre équipe, les taux d’extraction de spermatozoïdes après aspiration épidydimaire (MESA) et après extraction testiculaire (TESE) dans l’AO ? Les taux de grossesses, les taux de fausses couches spontanées et d’accouchements diffèrent-ils en fonction de l’origine du sperme ?

Matériels et méthodes

L’étude a rétrospectivement inclus 48 couples dont l’homme présente une azoospermie obstructive pure et ayant bénéficié d’un prélèvement chirurgical de spermatozoïdes associant systématiquement MESA et TESE. Les ICSI ont été réalisées de manière asynchrone. À chaque fois que cela était possible, la première ICSI a été réalisée avec des spermatozoïdes épididymaires.

Résultats

Pour les 48 couples, 99 ICSI ont été réalisées. Quinze couples ont réalisé 24 ICSI-TESE car l’aspiration épididymaire était négative. Onze couples ont réalisé 20 ICSI-TESE car la qualité du prélèvement épididymaire n’était pas satisfaisante (vitalité spermatique réduite le plus souvent). Vingt-deux couples ont réalisé 22 ICSI-MESA en première intention puis en cas d’échec, 11 couples ont réalisé 12 ICSI-MESA et dix couples ont réalisé 20 ICSI-TESE. Alors que les nombres d’ovocytes injectés (7,1±4,1 vs 6,9 ±3,6 P: 0,8) et d’embryons obtenus (4,5±3,0 vs 4,7±2,7; P: 0,7) ne sont pas significativement différents dans les deux groupes d’ICSI, les nombres d’embryons de top qualité (2,4±1,9 vs 3,6±2,0 P: 0,005) et d’embryons congelés (0,9±1,8 vs 1,7±1,9 P: 0,04) sont significativement supérieurs dans le groupe TESE. Le nombre de grossesse par ponction est supérieur dans le groupe TESE (58,5 % vs 26,5 %, P: 0,002).

Conclusion

L’approche de notre centre a la particularité d’associer systématiquement un prélèvement testiculaire au prélèvement épididymaire chez tout homme présentant une azoospermie obstructive alors que la plupart des autres études rapportées se limitent à l’exploration épididymaire si cette dernière est positive lors de l’examen extemporané. Alors que classiquement, on rapporte 100% de positivité lors du prélèvement épididymaire chez l’homme atteint d’une azoospermie obstructive, dans notre étude, plus de la moitié des explorations épididymaires s’est avérée inexploitable. La qualité embryonnaire et les taux de grossesses sont meilleurs avec des spermatozoïdes testiculaires. L’association de ces 2 sites de prélèvement (MESA et TESE) peut être complémentaire et utile pour le couple et l’issue de sa prise en charge en AMP sans pour autant entraîner un sur-risque pour l’homme dans les suites de la chirurgie.

Clinical characteristics and reproductive outcomes in infertile men with testicular early and late maturation arrest

OBJECTIVE

To compare the clinical characteristics and reproductive outcomes of nonobstructive azoospermic men with uniform early and late maturation arrest.

METHODS

Patients with biopsy-documented uniform maturation arrest undergoing testicular sperm retrieval and complete medical records were enrolled in the present study. Their medical history, physical examination findings, testicular volume, serum hormone parameters, genetic anomalies, sperm retrieval, and reproductive outcomes were retrospectively analyzed.

RESULTS

In a cohort of 223 nonobstructive azoospermic men, 34 men with uniform maturation arrest (21 early maturation arrest and 13 late maturation arrest) were identified. No significant differences were seen in the age distribution, testicular volume, or hormone parameters between patients with early and late maturation arrest. Only 13 patients (38.2%) had a normal serum follicle-stimulating hormone level and normal testicular volume. Patients with early maturation arrest had a greater frequency of overall genetic anomalies, and patients with late maturation arrest had a greater frequency of previous testicular insults. The sperm retrieval and impregnation rate were nonsignificantly greater in patients with late maturation arrest.

CONCLUSION

Maturation arrest has a variety of causes and presents with diverse phenotypes. Not all patients with uniform maturation arrest have a normal follicle-stimulating hormone level or testicular volume. Patients with early maturation arrest have a greater incidence of genetic anomalies and are more likely to have worse reproductive outcomes than are patients with late maturation arrest.

Testicular histopathology as a predictor of a positive sperm retrieval in men with non-obstructive azoospermia

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The management of patients with non-obstructive azoospermia (NOA) involves testicular sperm extraction (TESE or microdissection TESE) combined with intracytoplasmic sperm injection (ICSI). Sperm retrieval is successful in up to 50% of men with NOA; however, there is no single clinical finding or investigation that can accurately predict a positive outcome. Several studies have concluded that testicular biopsy is the best predictor of a successful TESE. The present study shows that the strongest predictor of the success of TESE is when tubules with mature spermatozoa (Johnsen score ≥8) are found in the histopathology specimen, irrespective of the overall state of spermatogenesis. The findings suggest that a lower limit threshold value of 2% of tubules with spermatogenesis in the histopathology specimen will result in a positive sperm retrieval. However, it is not practical to perform a diagnostic biopsy before TESE because this would mean that patients undergo two surgeries, which adds to the cost and increases the complications. The diagnostic biopsy is best coupled with an initial TESE before starting the ICSI cycle. Based on the findings of the histopathology specimen, patients may be then offered a repeat TESE if more sperm is needed on the day of ovum pick-up and ICSI. Also, if the initial TESE was negative, the biopsy result will help in the decision to offer a repeat TESE. This regimen is more cost-effective because the ICSI cycle will be started only if adequate sperm is retrieved.

OBJECTIVE

To assess whether testicular histopathology can predict the outcome of testicular sperm extraction (TESE) in men with non-obstructive azoospermia (NOA) and therefore the role of preoperative diagnostic testis biopsy.

PATIENTS AND METHODS

The study comprised a retrospective analysis of 388 patients with azoospermia who were referred from 2005 to 2010. Information collected included a clinical history and an examination including age and testicular size, serum follicle-stimulating hormone, two semen analyses and testicular histology collected at the time of surgical sperm retrieval (TESE or microdissection TESE).

RESULTS

In total, 388 patients with a mean (range) age of 37 (18-66) years were included in the present study. Based on the history, clinical and laboratory findings, 112 patients had obstructive azoospermia and 276 patients had NOA. All patients in the obstructed group had a positive sperm retrieval. The sperm retrieval rate for the NOA group was 50%. An analysis of the results showed that the best predictor of a positive sperm retrieval was when tubules with mature spermatozoa were seen at biopsy, irrespective of the overall state of spermatogenesis (P < 0.001).

CONCLUSIONS

The presence of tubules with spermatazoa on biospy is the best predictor of a positive surgical sperm retrieval in patients with NOA. The diagnostic biopsy is best coupled with an initial TESE before starting the intracytoplasmic sperm injection (ICSI) cycle. Based on the findings of the histopathology specimen, patients may be offered a repeat TESE if more sperm is needed on the day of ovum pick-up and ICSI, or a redo TESE if the initial TESE was negative.

Novel concepts in male infertility

Extraordinary advances have been achieved in the field of male infertility in the last decades. There are new concepts in sperm physiology and several modern tools for the assessment of spermatogenesis kinetics in vivo. New tests using molecular biology and DNA damage assays allow the clinician to correctly diagnose men so far classified as having idiopathic male infertility. In the field of treatment, microsurgery has increased success rates either for reconstruction of the reproductive tract or the retrieval of spermatozoa for assisted conception. Emerging evidence suggests that life-style and environmental conditions are of utmost importance in male fertility and subfertility. This review discusses several concepts that have changed over the last years, such as the duration of the spermatogenic cycle in humans, Y-chromosome infertility, the reproductive potential of non-mosaic Klinefelter syndrome men, the impact of paternal age and sperm DNA in male infertility, the role of antioxidants in the treatment of infertile men, the predictive factors and techniques for sperm retrieval in non-obstructive azoospermia, and the microsurgical treatment of clinical varicoceles. Whenever possible, levels of evidence are provided as suggested by the Oxford Center of Evidence-based Medicine.

Testicular biopsy: clinical practice and interpretation

Testicular biopsy was considered the cornerstone of male infertility diagnosis for many years in men with unexplained infertility and azoospermia. Recent guidelines for male infertility have limited the indications for a diagnostic testicular biopsy to the confirmation of obstructive azoospermia in men with normal size testes and normal reproductive hormones. Nowadays, testicular biopsies are mainly performed for sperm harvesting in men with non-obstructive azoospermia, to be used for intracytoplasmic sperm injection. Testicular biopsy is also performed in men with risk factors for testicular malignancy. In a subgroup of infertile men, there is an increased risk for carcinoma in situ of the testis, especially in men with a history of cryptorchidism and testicular malignancy and in men with testicular atrophy. Ultrasonographic abnormalities, such as testicular microlithiasis, inhomogeneous parenchyma and lesions of the testes, further increase the risk of carcinoma in situ (CIS) in these men. For an accurate histological classification, proper tissue handling, fixation, preparation of the specimen and evaluation are needed. A standardized approach to testicular biopsy is recommended. In addition, approaches to the detection of CIS of the testis testicular immunohistochemistry are mandatory. In this mini-review, we describe the current indications for testicular biopsies in the diagnosis and management of male infertility.

Human chorionic gonadotrophin treatment prior to microdissection testicular sperm extraction in non-obstructive azoospermia

BACKGROUND

Despite the improved success rate of sperm retrieval by microdissection testicular sperm extraction (micro-TESE), methods to stimulate spermatogenesis in men with non-obstructive azoospermia (NOA) remain unexplored. The aim of this study was to evaluate the effects of hCG-based hormonal stimulation in men with NOA on the success of sperm retrieval by micro-TESE.

METHODS

Forty-eight men with NOA who had negative sperm retrieval results by the micro-TESE procedure were included. A second micro-TESE was subsequently performed on these men: 20 were not treated by any hormonal therapy, and 28 subjects received daily subcutaneous injections of hCG for 4-5 months prior to the second micro-TESE. Recombinant FSH was added if endogenous gonadotrophin levels decreased during the hCG stimulation. The sperm retrieval rate at the second micro-TESE; the levels of gonadotrophins, testosterone and estradiol; and the effects of hormonal therapy on testicular histology were evaluated.

RESULTS

Among the 28 men with hCG stimulation, 15 (54%) showed decreased LH and FSH levels (0.67 ± 0.10 and 0.96 ± 0.14 mIU, mean ± SEM, respectively) due to elevated serum testosterone (9.5 ng/dl). Sperm were obtained at the second micro-TESE from six men who had received hormonal therapy (21%), whereas no sperm were retrieved from untreated men (P < 0.05). Success at the second micro-TESE was more likely if histology at the first micro-TESE showed hypospermatogenesis.

CONCLUSIONS

The Leydig cells of the testis can respond positively to exogenous hCG even under hypergonadotropic conditions. HCG-based hormonal therapy prior to a second micro-TESE attempt is effective in men with hypospermatogenesis.

Surgical recovery of sperm in non-obstructive azoospermia

The development of intracytoplasmic sperm injection (ICSI) opened a new era in the field of assisted reproduction and revolutionized the assisted reproductive technology protocols for couples with male factor infertility. Fertilisation and pregnancies can be achieved with spermatozoa recovered not only from the ejaculate but also from the seminiferous tubules. The most common methods for retrieving testicular sperm in non-obstructive azoospermia (NOA) are testicular sperm aspiration (TESA: needle/fine needle aspiration) and open testicular biopsy (testicular sperm extraction: TESE). The optimal technique for sperm extraction should be minimally invasive and avoid destruction of testicular function, without compromising the chance to retrieve adequate numbers of spermatozoa to perform ICSI. Microdissection TESE (micro-TESE), performed with an operative microscope, is widely considered to be the best method for sperm retrieval in NOA, as larger and opaque tubules, presumably with active spermatogenesis, can be directly identified, resulting in higher spermatozoa retrieval rates with minimal tissue loss and low postoperative complications. Micro-TESE, in combination with ICSI, is applicable in all cases of NOA, including Klinefelter syndrome (KS). The outcomes of surgical sperm retrieval, primarily in NOA patients with elevated serum follicle-stimulating hormone (FSH) (NOA including KS patients), are reviewed along with the phenotypic features. The predictive factors for surgical sperm retrieval and outcomes of treatment were analysed. Finally, the short- and long-term complications in micro-TESE in both 46XY males with NOA and KS patients are considered.

Clinical comparison of conventional testicular sperm extraction and microdissection techniques for non-obstructive azoospermia

Background

We compared the efficacy of microdissection testicular sperm extraction (microdissection TESE) and conventional TESE in patients with non-obstructive azoospermia (NOA) and related the positive sperm recovery to certain variables: follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, testicular volume and histology.

Methods

Sperm retrieval rates (SRR) in patients with NOA who underwent microdissection TESE (n = 65) or conventional TESE (n = 68) were compared and related to the different variables.

Results

SRR by microdissection TESE (56.9%) was significantly higher than conventional TESE (38.2%). There was a positive relation between the SRR and increased testicular volume or decreased FSH levels. No effect of Testosterone or Prolactin levels on SRR by using either technique was observed. Sperm were recovered from those with hypospermatogenesis in 84% and 92.9% by conventional and microdissection TESE, respectively (P = 0.3). In cases of maturation arrest the SRR was 27.3% and 36.4%, respectively (P = 0.6). In cases of Sertoli-cell-only syndrome (SCOS) the SRR was 6.2% and 26.9%, respectively (P = 0.03). No major operative complications occurred in any patient in either group, and no patient required post-operative hormone replacement to treat hypogonadism.

Conclusions

Microdissection TESE significantly had twice better probability of success of SRR when compared to conventional TESE. No secure pre-operative prognostic elements of sperm recovery exist for NOA patients. Microdissection TESE appears to be recommendable in cases of atrophied testicles, high FSH concentration, or when SCOS with high FSH concentration can be predicted.

Keywords

Microdissection TESE; Sperm retrieval; Non-obstructive azoospermia; Histopathology; FSH concentration; Orchidometry

Correlation between testicular sperm extraction outcomes and clinical, endocrine and testicular histology parameters in 120 azoospermic men with normal serum FSH levels

We retrospectively evaluated the clinical and hormonal profiles, sperm extraction outcomes and testicular histology parameters in 120 azoospermic men with normal serum follicle-stimulating hormone (FSH) level. Microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) were performed in 33 and 87 cases, respectively. Sperm were successfully retrieved in all the MESA procedures and in 65 of the TESE procedures. The mean serum FSH and inhibin B levels and the testicular volume differed significantly according to whether or not sperm were retrieved. The threshold serum inhibin B value for predicting successful TESE was 123.5pg/mL (sensitivity: 69.7%; specificity: 66.7%). The 13 patients with Sertoli cell only syndrome (SCOS) had a higher mean serum FSH level and a lower mean serum inhibin B level than the other phenotypes. TESE was negative for 11 of the 13 SCOS men. The mean±SD inhibin B level was significantly lower in patients with 5-10IU/L of FSH than those with 2-5IU/L of FSH (108.30±53.86 vs. 175.23±70.17pg/mL, respectively). The sperm retrieval rates were 71.42% for the group with 5-10IU/L of FSH and 87.32% for the group with 2-5IU/L of FSH. Ten of the 13 SCOS men had a FSH level between 5 and 10IU/L. The clinical pregnancy rate was significantly lower (p=0.04) in the group with 5-10IU/L (50%) of FSH than in the group with 2-5IU/L (77.5%) of FSH. In conclusion, there is no FSH value below which spermatogenesis is always found. Inhibin B assays and clinical assessments are thus of particular value in men with normal serum FSH levels.

Update on surgical sperm recovery--the European view

Surgical sperm recovery has become a well-established procedure to obtain spermatozoa for intra-cytoplasmic sperm injection (ICSI). Although a tendency exists to treat all azoospermic patients by ICSI using surgically retrieved sperm, vasovasostomy remains the gold standard for post-vasectomy azoospermia. In men with obstructive azoospermia in whom vasovasostomy is not indicated, sperm can be easily obtained by either aspiration from epididymis or testis, or a testicular biopsy. In about half of men with non-obstructive azoospermia, sperm may be obtained by testicular biopsy but unfortunately no accurate tests are currently available to predict successful recovery. In these patients, not only recovery rates are limited but also the chance to establish an ongoing pregnancy is decreased compared to men with normal spermatogenesis. When no spermatozoa are recovered after testicular sperm extraction (TESE), the use of donor sperm or adoption is indicated. Given the extremely low pregnancy rates, ICSI using round spermatids is not an option and remains unlawful in some countries.

Sperm retrieval for azoospermia and intracytoplasmic sperm injection success rates--a personal overview

It is often questioned whether sperm parameters, including whether retrieved or ejaculated, have any effect on intracytoplasmic sperm injection (ICSI) results. Do severe spermatogenic defects affect embryo quality or pregnancy rate? Further, does it matter in azoospermic patients whether the sperm source is testicular or epididymal? Our studies show there is no significant difference in results with ICSI related to any sperm count parameters either with patient's sperm or even with donor sperm. No matter how poor the sperm count, there was no difference from patients with high sperm counts nor even patients using donor sperm. There is no significant difference between results with epididymal sperm, either fresh or frozen, in comparison to results with ejaculated or donor sperm. However, both pregnancy rate and delivery rate were considerably lower with testicular sperm (testis sperm extraction) than with epididymal sperm (microsurgical epididymal sperm aspiration). This was true for overall results as well as in each category of the female partner's age. It is obvious that in all these cycles the female partner's age was the most important determinant of delivery rate, but testicular sperm always yielded lower results than epididymal sperm. These results show that it is the origin of the sperm rather than the spermatogenic defect that determines success rate with ICSI.

What to do when ICSI fails

The refinement of gamete micromanipulation techniques has made conception possible for couples with male factor infertility who otherwise would remain childless. Moreover, intracytoplasmic sperm injection (ICSI) has ensured that such refractory cases can now generate offspring as successfully as in couples that merely require in vitro insemination. However, despite the now sterling record of ICSI it does not assure a successful outcome for every patient. This can be due, for instance, to the inability of the spermatozoon to activate the oocyte, and applies obviously in cases where spermatozoa are absent from the ejaculate or testicular biopsy. In the present paper we describe in detail the reasons for such failure and review the options that may help overcome it. In particular, we outline the treatment protocol for the situation in which spermatozoa are unable to induce oocyte activation. Further, we report on the clinical outcome achieved with spermatozoa retrieved from the testis, and in cases of extreme oligozoospermia we also explore the option of replicating a single spermatozoon while gaining information on its genomic content. For the most extreme situation in which men have no identifiable germ cells, we will discuss the current status of efforts to accomplish neo-gametogenesis through embryonic stem cell differentiation.