Should diagnostic testicular sperm retrieval followed by cryopreservation for later ICSI be the procedure of choice for all patients with non-obstructive azoospermia?

The effect of condition/state of testicular spermatozoa injected to the outcome of TESE-ICSI-ET cycles

OBJECTIVE

The effect of state/condition of spermatozoa (fresh/motile, fresh/immotile, frozen/motile and frozen/immotile) to fertilization, embryo formation/development, implantation and pregnancy/delivery and abortion rates were studied.

STUDY DESIGN

The data of a total of 167 TESE-ICSI-ET cycles with fresh and cryopreserved, motile and immotile testicular spermatozoa collected with testicular biopsy from patients suffering from non-obstructive azoospermia were analyzed retrospectively. Analysis of variance (ANOVA) was used to distinguish the group effects in fertilization, embryo formation, and implantation ratio. The group effect was evaluated by using non-parametric statistics and the independent grouping variable was also the "semen state/condition". "Semen state/condition" groups were created according to fresh or frozen, and motile or non-motile (immotile) characteristics. For comparing the four groups, Kruskal-Wallis ANOVA and Median-test was applied. The analysis was carried out using Statistica for Windows (StatSoft, Inc., Chicago, USA).

RESULTS

Independently of state/condition of testicular spermatozoa injected into oocytes, no differences were found in fertilization and implantation/pregnancy rates. No difference was obtained in embryo development of oocytes injected with fresh/immotile or frozen/motile spermatozoa. However, difference was found in embryo development of oocytes injected with fresh/motile or frozen/immotile testicular spermatozoa (87% vs. 73%; P<0.04). Comparing embryo development of oocytes injected with fresh vs. frozen spermatozoa difference was also found (83% vs. 74%; P<0.01). No difference was found in the abortion rates between the groups. Differences were observed in the implantation rates, however, these differences could not be verified statistically.

CONCLUSION

The presented data show that condition of injected testicular spermatozoa has influence to embryo development and even frozen/immotile testicular spermatozoa is able to induce/support fertilization and early embryo development.

Outcome of repeated micro-surgical testicular sperm extraction in patients with non-obstructive azoospermia

AIM

To evaluate the outcome of repetitive micro-surgical testicular sperm extraction (mTESE) attempts in non-obstructive azoospermia (NOA) cases, in relation to patients' initial testicular histology results.

METHODS

A total of 68 patients with NOA in whom mTESE had been performed in previous intracytoplasmic sperm injection (ICSI) attempts were reviewed.

RESULTS

Among the 68 patients with NOA, the first mTESE yielded mature sperm for ICSI in 44 (64%) (Sp(+)), and failed in the remaining 24 (36%) (Sp(-)). Following their first trial, 24 patients decided to undergo a second mTESE. Of these 24 patients, no spermatozoa were obtained in 5 patients, and Sp(+) but no fertilization/pregnancy were achieved in 19. In these 24 cases, mTESE was successively repeated for two (n = 24), three (n = 4) and four (n = 1) times. The second attempt yielded mature sperm in 3/5 patients from the Sp- group and 16/19 patients from the Sp(+) group. At the third and fourth trials, 4/4 and 1/1 of the original Sp(+) patients were Sp(+) again, respectively. Distribution of main testicular histology included Sertoli cell-only syndrome (16%), maturation arrest (22%), hypospermatogenesis (21%) and focal spermatogenesis (41%). Overall, in repetitive mTESE, 24/29 (82%) of the attempts were finally Sp(+).

CONCLUSION

Repeated mTESE in patients with NOA is a feasible option, yielding considerably high sperm recovery rate. In patients with NOA, mTESE may safely be repeated one or more times to increase sperm retrieval rate, as well as to increase the chance of retrieving fresh spermatozoa to enable ICSI.

Microdissection testicular sperm extraction: effect of prior biopsy on success of sperm retrieval

PURPOSE

We determined the effect of prior biopsies with no sperm seen on the chance of sperm retrieval with microdissection testicular sperm extraction in men with nonobstructive azoospermia.

MATERIALS AND METHODS

A total of 311 men with NOA underwent microdissection testicular sperm extraction. Of these patients 135 underwent no prior biopsies, 159 underwent 1 or 2 diagnostic testicular biopsies per testis and 17 underwent 3 or 4. The outcome measure studied was the success of sperm retrieval with microdissection testicular sperm extraction. Serum follicle-stimulating hormone and histopathological diagnosis were examined as predictive factors for sperm recovery.

RESULTS

Spermatozoa were retrieved in 150 men by microdissection testicular sperm extraction (48%). The success of sperm retrieval in patients who underwent 3 to 4 biopsies (23%) was lower than the retrieval rate in patients who underwent no prior biopsies (56%) and 1 to 2 biopsies per testis (51%) (p = 0.04). When histopathology was considered, patients with Sertoli-cell-only diagnosis on prior diagnostic biopsy had lower retrieval rates compared to the group with no biopsies (p = 0.02). Men with maturation arrest and hypospermatogenesis had similar microdissection testicular sperm extraction sperm retrieval rates regardless of the number of prior biopsies. Spermatozoa recovery was independent of serum follicle-stimulating hormone.

CONCLUSIONS

There is no threshold of prior negative biopsies that precludes the success of sperm retrieval using microdissection testicular sperm extraction. A limited number of testicular biopsies provide limited or no prognostic value for sperm retrieval with microdissection testicular sperm extraction.

Histological evaluation of the human testis--approaches to optimizing the clinical value of the assessment: mini review

Testicular biopsy is a crucial assessment in reproductive practice with diagnostic and prognostic importance for assisted reproductive technologies (ARTs) and risk of testicular neoplasia. Endocrine and genetic tests cannot reliably distinguish obstructive azoospermia (OA) from non-obstructive azoospermia (NOA) or predict recovery of mature spermatids by testicular sperm extraction (TESE). Currently, divergent histological reporting systems and the use of imprecise terminology seriously degrade the value of the literature on TESE recovery rates and hamper evaluation of treatments and research on genotype-phenotype relationships. The rising incidence of testis cancer and carcinoma in situ (CIS), especially in infertile populations, requires that every effort be made for its early detection. We provide a systematic approach to the histological classification of spermatogenic disorders and detection of CIS in adult patients. We evaluate a large consecutive series of bilateral biopsies from infertile men and report (i) the frequency of bilateral or discordant patterns that supports the use of bilateral biopsy for comprehensive evaluation and (ii) a high prevalence of mixed patterns, particularly within the hypospermatogenesis classification, that helps account for reported success of TESE. We propose a new diagnosis code for testicular biopsies that addresses the needs of ART clinicians and allows data storage and retrieval of value in clinical practice and research.

Sperm harvesting and cryopreservation during vasectomy reversal is not cost effective

OBJECTIVE

To determine whether sperm harvesting and cryopreservation at the time of vasectomy reversal is cost-effective.

DESIGN

Model of actual costs and results at five institutions.

SETTING

Multicenter study comprising five centers, including university hospitals and private practices.

PATIENT(S)

Men undergoing vasectomy reversal.

INTERVENTION(S)

We established two models for vasectomy reversal. The first model was sperm harvesting and cryopreservation at the time of vasectomy reversal. The second model was sperm harvesting at the time of IVF only if the patient remained azoospermic after vasectomy reversal. Vasectomy reversal procedures modeled included bilateral vasovasostomy and bilateral epididymovasostomy. The costs for each procedure at the five institutions were collated and median costs determined.

MAIN OUTCOME MEASURE(S)

Median cost of procedure and calculated financial comparisons.

RESULT(S)

The median cost of testicular sperm extraction/cryopreservation performed at the time of bilateral vasovasostomy was $1,765 (range, $1,025-$2,800). The median cost of microsurgical epididymal sperm aspiration or testicular sperm extraction with cryopreservation performed at the time of epididymovasostomy was $1,209 (range, $905-$2,488). The average of the median costs for percutaneous sperm aspiration or testicular sperm aspiration for those patients with a failed vasectomy reversal was $725 (range, $400-$1,455).

CONCLUSION(S)

Sperm retrieval with cryopreservation at the time of vasectomy reversal is not a cost-effective management strategy.

How successful is repeat testicular sperm extraction in patients with azoospermia?

BACKGROUND

Little is known about the extraction rate in repeated sperm retrieval procedures in azoospermic patients. This study aimed to assess the feasibility of repeated sperm recovery in these patients.

METHODS

A total of 1066 azoospermic men had their first sperm recovery between 1 January 1995 and 31 December 2003. A total of 381 men had obstructive azoospermia (OA), 628 nonobstructive azoospermia (NOA) and 57 showed hypospermatogenesis.

RESULTS

Overall, sperm could be retrieved in all procedures in the 598 cycles performed in OA men (100%). A total of 117, 57, 24, 11, 7 and 1 men underwent, respectively, two, three, four, five, six and seven sperm retrievals; all were successful. Of the 784 procedures performed on the 628 men with NOA, sperm could be retrieved in 384 procedures (49%). During the first testicular sperm extraction (TESE) procedure, sperm could be extracted in 261 men with NOA (41.6%). A total of 103 men had a second attempt, 34 had a third attempt, 11 had a fourth attempt, 6 had a fifth attempt and 2 had a sixth attempt. In these cycles, sperm could be extracted in, respectively, 77 (74.7%), 28 (82.3%), 11 (100%), 5 (83.3%) and 2 (100%) men.

CONCLUSION

Repeated TESE ensures a high sperm recovery rate even in patients with NOA. In NOA patients, studies reporting on TESE may therefore overestimate the retrieval rate by reallocating successful patients. These data also show that when no spermatozoa can be obtained after thawing cryopreserved testicular sperm for ICSI in NOA patients, a repeat TESE procedure can be planned.

Cryopreservation of spermatozoa in alginic acid capsules

OBJECTIVE

To develop a method of freezing small amounts of spermatozoa in polymerized alginic acid drops, which can be liquified after thawing for recovery of the spermatozoa.

DESIGN

Prospective clinical study.

SETTING

Medical School, RWTH Aachen, Aachen Germany.

PATIENT(S)

None.

INTERVENTION(S)

Validation of the encapsulation method with bovine sperm; cryopreservation of human spermatozoa in alginic capsules.

MAIN OUTCOME MEASURE(S)

We optimized the cryopreservation method by testing different parameters influencing the freezing procedure, such as concentration of alginic acid, size of drops, time of polymerization, and culture media.

RESULT(S)

The final protocol was as follows: encapsulation by 7.3 mg/mL alginic acid forming 10-muL drops polymerized for 30 seconds and liquefied for 2.5 minutes in sodium citrate. Cryopreservation of human spermatozoa by this protocol resulted in a decreased motility of 18.3% compared with standard protocols but a 19.9% higher vitality of the immotile spermatozoa.

CONCLUSION(S)

No difference in viability of spermatozoa after both sperm-freezing procedures could be observed. Further investigation will be undertaken to reduce the amount of immotile but viable sperm after microencapsulation in alginic acid.

Interest of pentoxifylline in ICSI with frozen–thawed testicular spermatozoa from patients with non-obstructive azoospermia

Selection for intracytoplasmic sperm injection (ICSI) of viable frozen-thawed testicular spermatozoa obtained from patients suffering from non-obstructive azoospermia is very often long, difficult and sometimes impossible. The purpose of this study was to determine if the use of pentoxifylline (PF) could facilitate this selection in stimulating sperm motility. From January 2000 to December 2004, 108 ICSI cycles with non-obstructive azoospermia were performed. From these 108 cycles, in 64 cycles where no motile spermatozoa were observed or when the time search per spermatozoa was above 20 min, 1.5 mmol/l PF was used for 10 min, whereas the 44 other ICSI cycles were performed using spontaneously motile spermatozoa (control group). In all cases, PF either initiated the motility when no motile spermatozoa were observed, or stimulated the motility, reducing dramatically the time search per spermatozoa. The total fertilization rate was 54.2% versus 66.7% in the control group (P < 0.02). Twenty-nine pregnancies out of the 64 PF cycles (45.3% per cycle) occurred, including 20 deliveries of 23 healthy children and eight ongoing pregnancies, whereas 12 pregnancies were obtained in the control group (27.3% per cycle), including nine deliveries of 13 healthy children. In conclusion, in 100% of cycles pentoxifylline allows the selection of viable frozen-thawed testicular spermatozoa with the same outcome after ICSI as that observed with fresh ejaculated spermatozoa.

The use of the modified hypo-osmotic swelling test for the selection of immotile testicular spermatozoa in patients treated with ICSI: a randomized controlled study

BACKGROUND

Various methods for the selection of viable sperm from among immotile testicular spermatozoa for use in ICSI have been described in non-randomized studies. We have conducted a randomized controlled study to compare the use of the modified hypo-osmotic swelling (HOS) test (50% culture medium + 50% Milli-Q grade water) with that of sperm selection on the basis of their morphology alone.

METHODS

A total of 79 couples with immotile testicular spermatozoa treated with ICSI were randomly assigned into two groups. In the first group, spermatozoa used for injection were selected using the modified HOS test, while in the second group spermatozoa were selected on the basis of their morphology.

RESULTS

The fertilization rate was significantly higher in the HOS test group (43.6%) compared with the no-HOS test group (28.2%) [odds ratio (OR) 2.494; 95% confidence interval (CI) 1.606-3.872]. The pregnancy and ongoing pregnancy rates were also higher in the HOS test group (27.3% versus 20.5%) compared with the no-HOS test group (5.7% versus 2.9%) (OR 6.188, 95% CI 1.282-29.860; and OR 8.743, 95% CI 1.050-72.783, respectively).

CONCLUSIONS

The use of the modified HOS test for the selection of viable sperm from among immotile testicular spermatozoa for ICSI results in higher fertilization, pregnancy and ongoing pregnancy rates compared with morphological selection.

The choice and outcome of the fertility treatment of 38 couples in whom the male partner has a Yq microdeletion

BACKGROUND

Patients with Yq microdeletions may suffer from fertility problems. The purpose of this study was to assess the outcome of the fertility treatment of these patients.

METHODS

For 38 patients with Yq microdeletions, data were collected about medical history, karyotype, testicular histopathology and the presence of spermatozoa in the ejaculate or testicular biopsies.

RESULTS

Sixteen patients with an azoospermia factor region c (AZFc) deletion had at least one cycle with ICSI. The clinical pregnancy outcome was 22% per embryo transfer. Three babies have been born and two pregnancies are ongoing. Sex selection for female embryos in combination with ICSI in order to prevent the transmission of the fertility problems was discussed with 14 couples; eight were in favour of the selection. In addition, eight couples made the decision to use donor sperm because ICSI was impossible or objectionable and, in this group of patients, a total of nine babies were born.

CONCLUSIONS

Despite the improvement of assisted reproductive technology, ICSI could be offered only to patients with an AZFc deletion. Insemination with donor sperm is a potential alternative for other patients.

Crude cumulative delivery rate following ICSI using intentionally frozen–thawed testicular spermatozoa in 51 men with non-obstructive azoospermia

This prospective study evaluated the crude cumulative delivery rate following delayed intracytoplasmic sperm injection (ICSI) using spermatozoa recovered by testicular extraction (TESE) and intentionally frozen in men with non-obstructive azoospermia (NOA). This procedure can be termed 'cryoTESE-ICSI'. This study involved a series of 118 patients who underwent testicular biopsy for diagnosis of NOA in the period from January 1998 to December 2002. Testicular histology confirmed the diagnosis of NOA. Testicular parenchyma was obtained surgically from both testicles under general anaesthesia. Cryopreservation of spermatozoa was performed in 51 of 118 patients (43%). Ninety-nine delayed ICSI procedures were performed. Frozen-thawed suspensions were used in all cycles. Application of pentoxifylline was required to stimulate spermatozoa in 52% of cases. Fertilization, embryo transfer, and ongoing pregnancy rates were 60, 98 and 29% respectively. The crude cumulative delivery rate was 49% after two cycles and 57% after four cycles. A total of 39 healthy children were born in 29 deliveries. Thus, cryoTESE-ICSI is an effective procedure for routine use in patients with NOA. The main advantages of cryoTESE-ICSI are to (i) avoid repeated surgical biopsy, (ii) ensure the availability of spermatozoa when the ovarian stimulation cycle is begun, and (iii) allow programmed biopsy and therefore dissociate it from ICSI.