Evaluation of the azoospermic patient

Semen impairment and occurrence of SARS-CoV-2 virus in semen after recovery from COVID-19

STUDY QUESTION

How is the semen quality of sexually active men following recovery from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection?

SUMMARY ANSWER

Twenty-five percent of the men with recent SARS-Cov-2 infections and proven healing were oligo-crypto-azoospermic, despite the absence of virus RNA in semen.

WHAT IS KNOWN ALREADY

The presence of SARS-CoV-2 in human semen and its role in virus contagion and semen quality after recovery from coronavirus disease 2019 (COVID-19) is still unclear. So far, studies evaluating semen quality and the occurrence of SARS-CoV-2 in semen of infected or proven recovered men are scarce and included a limited number of participants.

STUDY DESIGN, SIZE, DURATION

A prospective cross-sectional study on 43 sexually active men who were known to have recovered from SARS-CoV2 was performed. Four biological fluid samples, namely saliva, pre-ejaculation urine, semen, and post-ejaculation urine, were tested for the SARS-CoV-2 genome. Female partners were retested if any specimen was found to be SARS-CoV-2 positive. Routine semen analysis and quantification of semen leukocytes and interleukin-8 (IL-8) levels were performed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Questionnaires including International Index of Erectile Function and Male Sexual Health Questionnaire Short Form were administered to all subjects. The occurrence of virus RNA was evaluated in all the biological fluids collected by RT-PCR. Semen parameters were evaluated according to the World Health Organization manual edition V. Semen IL-8 levels were evaluated by a two-step ELISA method.

MAIN RESULTS AND THE ROLE OF CHANCE

After recovery from COVID-19, 25% of the men studied were oligo-crypto-azoospermic. Of the 11 men with semen impairment, 8 were azoospermic and 3 were oligospermic. A total of 33 patients (76.7%) showed pathological levels of IL-8 in semen. Oligo-crypto-azoospermia was significantly related to COVID-19 severity (P < 0.001). Three patients (7%) tested positive for at least one sample (one saliva; one pre-ejaculation urine; one semen and one post-ejaculation urine), so the next day new nasopharyngeal swabs were collected. The results from these three patients and their partners were all negative for SARS-CoV-2.

LIMITATIONS, REASONS FOR CAUTION

Although crypto-azoospermia was found in a high percentage of men who had recovered from COVID-19, clearly exceeding the percentage found in the general population, the previous semen quality of these men was unknown nor is it known whether a recovery of testicular function was occurring. The low number of enrolled patients may limit the statistical power of study.

WIDER IMPLICATIONS OF THE FINDINGS

SARS-CoV-2 can be detected in saliva, urine, and semen in a small percentage of men who recovered from COVID-19. One-quarter of men who recovered from COVID-19 demonstrated oligo-crypto-azoospermia indicating that an assessment of semen quality should be recommended for men of reproductive age who are affected by COVID-19.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Weighted Correlation Gene Network Analysis Reveals New Potential Mechanisms and Biomarkers in Non-obstructive Azoospermia

Non-obstructive azoospermia (NOA) denotes a severe form of male infertility, whose etiology is still poorly understood. This is mainly due to limited knowledge on the molecular mechanisms that lead to spermatogenesis failure. In this study, we acquired microarray data from GEO DataSets and identified differentially expressed genes using the limma package in R. We identified 1,261 differentially expressed genes between non-obstructive and obstructive azoospermia. Analysis of their possible biological functions and related signaling pathways using the cluster profiler package revealed an enrichment of genes involved in germ cell development, cilium organization, and oocyte meiosis. Immune infiltration analysis indicated that macrophages were the most significant immune component of NOA, cooperating with mast cells and natural killer cells. The weighted gene coexpression network analysis algorithm generated three related functional modules, which correlated closely with clinical parameters derived from histopathological subtypes of NOA. The resulting data enabled the construction of a protein–protein interaction network of these three modules, with CDK1, CDC20, CCNB1, CCNB2, and MAD2L1 identified as hub genes. This study provides the basis for further investigation of the molecular mechanism underlying NOA, as well as indications about potential biomarkers and therapeutic targets of NOA. Finally, using tissues containing different tissue types for differential expression analysis can reflect the expression differences in different tissues to a certain extent. But this difference in expression is only related and not causal. The specific causality needs to be verified later.

Evaluating the quality of reported outcomes for microsurgical TESE in men with non-obstructive azoospermia: A methodological analysis

BACKGROUND

Publications of microsurgical testicular sperm extraction (mTESE) techniques and outcomes are heterogeneous, which may limit creation of best surgical practices.

OBJECTIVE

To study the quality and heterogeneity of published mTESE outcomes via a methodological analysis.

MATERIALS/METHODS

A systematic methodological analysis of all published literature on the use of mTESE in men with non-obstructive azoospermia from 1999 to the July 2020 was performed. PubMed and MEDLINE searches were performed using the search terms "microdissection TESE OR microsurgical TESE." Publications were evaluated on their reporting of pre-operative factors, intraoperative techniques, surgical and clinical outcomes, and adverse events.

RESULTS

Fifty-five studies met inclusion criteria. Surgical technique and sperm retrieval rates were the most reported criteria. Reporting on the presence of an embryologist intraoperatively was observed in approximately 30% of articles, while other procedural details including method of sperm quantification, quantity retrieved, and number of cryopreserved vials were observed in fewer than 10% of articles. Clinical outcomes, including pregnancy rates and live birth rates, were reported in fewer than 40% of the articles. Fetal outcomes including fetal and neonatal anomalies were rarely reported. Fetal growth restriction, preterm delivery, small or large for gestational age, and NICU admissions were never reported.

CONCLUSION

There are inconsistencies in reporting quality of mTESE outcomes, specifically a lack of information on the quantity and quality of sperm retrieved, the role of embryology intraoperatively, and clinical outcomes, such as live birth rate and fetal anomalies. These gaps may guide development of standardized reporting guidelines to better assess and compare clinical outcomes across institutions and maintain focus on couples-centric fertility outcomes in future mTESE studies.

Outcome prediction of microdissection testicular sperm extraction based on extracellular vesicles piRNAs

PURPOSE

Microdissection testicular sperm extraction (micro-TESE) could retrieve sperm from the testicles to help the non-obstructive azoospermia (NOA) patients to get their biological children, but also would cause damage to the testicles. Therefore, it is necessary to preoperatively predict the micro-TESE outcome in NOA patients. For this purpose, we aim to develop a model based on extracellular vesicles' (EVs) piRNAs (EV-piRNAs) in seminal plasma.

METHODS

To identify EV-piRNAs that were associated with spermatogenic ability, small RNA-seq was performed between the NOA group (n = 8) and normal group (n = 8). Validation of EV-piRNA expression in seminal plasma EVs and testicles tissues was used to select EV-piRNAs for the model. Candidate EV-piRNAs were further selected by LASSO regression analysis. Binary logistic regression analysis was used for the models' calculation formula. ROC analysis and Hosmer-Lemeshow test was used to assess the models' performance in the training (n = 20) and validation (n = 25) cohorts.

RESULTS

We identified 8 EV-piRNAs which were associated with spermatogenic ability. Two EV-piRNAs (pir-60351 and pir-61927) were selected by LASSO regression analysis. Finally, we developed a favorable model based on the expression of pir-61927 with good discrimination wherein the AUC was 0.82 (95% CI: 0.63~1.00, p = 0.016) in the training cohort and 0.83 (95% CI: 0.66~1.00, p = 0.005) in the validation cohort, as well as good calibration.

CONCLUSIONS

A favorable model based on the expression of pir-61927 in seminal plasma EVs was established to predict the micro-TESE outcome in NOA patients.

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.

Can preoperative parameters predict successful sperm retrieval and live birth in couples undergoing testicular sperm extraction and intracytoplasmic sperm injection for azoospermia?

Background

We aimed to determine if the success of TESE and live-birth following TESE-ICSI can be predicted from readily available preoperative parameters for couples with azoospermia. Our methodology was as follows, this was a cohort study of couples who attended the fertility service (from 2009-2019) at an NHS hospital in whom the male partner was diagnosed with azoospermia and required conventional TESE with multiple biopsies to obtain sperm. Of 414 men included, 223 had successful TESE and of those 178 have used sperm in ICSI cycle(s). Predictive models were developed using logistic regression. We assessed model performance by internally validated concordance statistics and calibration plots. Successful sperm retrieval was defined as the presence of motile sperm which survived the freeze-thaw process and live-birth defined as delivery after 34 weeks of gestation.

Results

Successful TESE was associated with higher male age and lower FSH. The TESE model discriminated well with a c statistic of 0.81 (0.77-0.85). Live-birth was associated with lower maternal age, earlier ICSI cycle, and lower testicular volume. The live-birth model also discriminated well with a c statistic of 0.70 (0.64-0.76).

Conclusions

These results support the pragmatic counselling of couples diagnosed with azoospermia about the chances of success of the TESE procedure and of biological parenthood prior to surgical intervention. The models help to discriminate between men who have a high or low chance of successful TESE and couples who have a higher chance of achieving a live-birth after successful TESE. This will allow couples to make a better assessment of the balance of risk versus benefit prior to commitment to surgical interventions.

How do we counsel men with obstructive azoospermia due to CF mutations?-a review of treatment options and outcomes

Obstructive azoospermia (OA) is a rare cause of male infertility, with Congenital Bilateral Absence of The Vas Deferens (CBAVD) being a major cause. A wealth of literature has established an irrefutable link between CFTR mutations and CBAVD, with CBAVD affecting almost all men with cystic fibrosis (CF) disease and a significant portion of men that are CFTR mutation carriers. In the past two decades, assisted reproductive technologies have made the prospect of fathering children a viable possibility in this subset of men, using a combination of sperm extraction techniques and intracystoplasmic sperm injection (ICSI). In order to assess techniques for sperm retrieval, as well as reproductive outcomes, a systemic search of the MEDLINE database was conducted for all articles pertaining to management options for CBAVD, and also all reports describing outcomes of these procedures in the CBAVD population. Both epididymal and testicular sperm extraction (TESE) are viable options for men with CBAVD, and though rigorous data are lacking, live birth rates range from 8% to 50% in most small retrospective series and subset analyses. In addition, there does not appear to be significant differences in the rate of live birth or complications and miscarriages between the various techniques, though further investigation into other factors that limit reproductive potential of men with CFTR mutations and CBAVD is warranted.

Male infertility due to testicular disorders

CONTEXT

Male infertility is defined as the inability to conceive following 1 year of regular unprotected intercourse. It is the causative factor in 50% of couples and a leading indication for assisted reproductive techniques (ART). Testicular failure is the most common cause of male infertility, yet the least studied to date.

EVIDENCE ACQUISITION

The review is an evidence-based summary of male infertility due to testicular failure with a focus on etiology, clinical assessment, and current management approaches. PubMed-searched articles and relevant clinical guidelines were reviewed in detail.

EVIDENCE SYNTHESIS/RESULTS

Spermatogenesis is under multiple levels of regulation and novel molecular diagnostic tests of sperm function (reactive oxidative species and DNA fragmentation) have since been developed, and albeit currently remain as research tools. Several genetic, environmental, and lifestyle factors provoking testicular failure have been elucidated during the last decade; nevertheless, 40% of cases are idiopathic, with novel monogenic genes linked in the etiopathogenesis. Microsurgical testicular sperm extraction (micro-TESE) and hormonal stimulation with gonadotropins, selective estrogen receptor modulators, and aromatase inhibitors are recently developed therapeutic approaches for men with the most severe form of testicular failure, nonobstructive azoospermia. However, high-quality clinical trials data is currently lacking.

CONCLUSIONS

Male infertility due to testicular failure has traditionally been viewed as unmodifiable. In the absence of effective pharmacological therapies, delivery of lifestyle advice is a potentially important treatment option. Future research efforts are needed to determine unidentified factors causative in "idiopathic" male infertility and long-term follow-up studies of babies conceived through ART.

[Prevalence of male infertility in a university hospital in Morocco]

INTRODUCTION

infertility in couples has become a public health problem in recent years. It can be related to a problem in the male, female or both. Men infertility accounts for 40% of cases. In Morocco, most studies have focused on the causes and risk factors for male infertility. The purpose of our study was to assess the prevalence of male infertility and semen parameters in infertile men or in men at high risk of developing infertility in a tertiary hospital in Rabat.

METHODS

we conducted an analysis of 482 patients referred for evaluation of infertility in the couple or as part of preoperative assessment of varicocele or testicular ectopia. Demographic data, risk factors for infertility, primary or secondary infertility were recorded for each patient. Semen parameters were assessed and interpreted according to WHO standards updated in 2010 based on studies of factors associated with their disturbance.

RESULTS

the average age of patients was 35.35±8.81 years. Primary infertility was found in 61.8% of cases. The most common risk factors for infertility were tobacco followed by varicocele and infection. Spermogram was altered in 53.1% of cases. The most common abnormality was sperm vitality issues (36.9%) followed by spermatic concentration (29.7%) and morphology (29.3%). Age was the unique factor which had a significant impact on spermogram (p=0.002). Abnormalities in mobility were detected in patients ≥31 years, sperm vitality issues in patients aged 34 years, abnormalities in morphology in patients aged 35 years and concentration in patients aged 37 years. Azoospermia was found in 16.4% of cases and was mainly associated with primary infertility. Oligo-astheno-teratozoospermia was the most common association (26.2%).

CONCLUSION

male infertility is common in our context. The major risk factor is age. Mobility is the earliest parameter achieved.

Mutational analysis of the GATA4 gene in Chinese men with nonobstructive azoospermia

As a crucial transcription factor for spermatogenesis, GATA-binding protein 4 (GATA4) plays important roles in the functioning of Sertoli and Leydig cells. Conditional knockout of GATA4 in mice results in age-dependent testicular atrophy and loss of fertility. However, whether GATA4 is associated with human azoospermia has not been reported. Herein, we analyzed the GATA4 gene by direct sequencing of samples obtained from 184 Chinese men with idiopathic nonobstructive azoospermia (NOA). We identified a missense mutation (c.191G>A, p.G64E), nine single-nucleotide polymorphisms (SNPs), and one rare variant (c.^*84C>T) in the 3´ untranslated region (UTR). Functional studies demonstrated that the p.G64E mutation did not affect transactivation ability of GATA4 for spermatogenesis-related genes (claudin-11 and steroidogenic acute regulatory protein, Star), and the 3´ UTR rare variant c.^*84C>T did not generate microRNA-binding sites to repress GATA4 expression. To our knowledge, this is thefirst report to investigate the association between GATA4 and azoospermia; our results indicate that mutations in GATA4 may not be pathogenic for NOA in Chinese men.

Investigating the Role of the microRNA-34/449 Family in Male Infertility: A Critical Analysis and Review of the Literature

There is a great body of evidence suggesting that in both humans and animal models the microRNA-34/449 (miR-34/449) family plays a crucial role for normal testicular functionality as well as for successful spermatogenesis, regulating spermatozoa maturation and functionality. This review and critical analysis aims to summarize the potential mechanisms via which miR-34/449 dysregulation could lead to male infertility. Existing data indicate that miR-34/449 family members regulate ciliogenesis in the efferent ductules epithelium. Upon miR-34/449 dysregulation, ciliogenesis in the efferent ductules is significantly impaired, leading to sperm aggregation and agglutination as well as to defective reabsorption of the seminiferous tubular fluids. These events in turn cause obstruction of the efferent ductules and thus accumulation of the tubular fluids resulting to high hydrostatic pressure into the testis. High hydrostatic pressure progressively leads to testicular dysfunction as well as to spermatogenic failure and finally to male infertility, which could range from severe oligoasthenozoospermia to azoospermia. In addition, miR-34/449 family members act as significant regulators of spermatogenesis with an essential role in controlling expression patterns of several spermatogenesis-related proteins. It is demonstrated that these microRNAs are meiotic specific microRNAs as their expression is relatively higher at the initiation of meiotic divisions during spermatogenesis. Moreover, data indicate that these molecules are essential for proper formation as well as for proper function of spermatozoa per se. MicroRNA-34/449 family seems to exert significant anti-oxidant and anti-apoptotic properties and thus contribute to testicular homeostatic regulation. Considering the clinical significance of these microRNAs, data indicate that the altered expression of the miR-34/449 family members is strongly associated with several aspects of male infertility. Most importantly, miR-34/449 levels in spermatozoa, in testicular tissues as well as in seminal plasma seem to be directly associated with severity of male infertility, indicating that these microRNAs could serve as potential sensitive biomarkers for an accurate individualized differential diagnosis, as well as for the assessment of the severity of male factor infertility. In conclusion, dysregulation of miR-34/449 family detrimentally affects male reproductive potential, impairing both testicular functionality as well as spermatogenesis. Future studies are needed to verify these conclusions.

Efficacy of the second micro-testicular sperm extraction after failed first micro-testicular sperm extraction in men with nonobstructive azoospermia

OBJECTIVE

To evaluate the efficacy of the second micro-testicular sperm extraction (TESE)in men with nonobstructive azoospermia in whom the first micro-TESE failed.

DESIGN

Retrospective.

SETTING

Private clinic.

PATIENT(S)

One hundred twenty-five men with nonobstructive azoospermia with failed previous micro-TESE. The patients were divided into 2 groups according to their surgical sperm retrieval status during the second micro-TESE. If sperm could not be found, these patients were classified as Group 1, and, if sperm was found, the patients were classified as Group 2. The 2 groups were compared for clinical parameters and pathologic findings.

INTERVENTION(S)

Micro-TESE.

MAIN OUTCOME MEASURE(S)

Surgical sperm retrieval status.

RESULT(S)

Sperm was recovered successfully in 23 of 125 (18.4%) men with the second micro-TESE. Testicular volume was significantly lower in Group 2 (8.2 ± 5.4 mL) than Group 1 (11.3 ± 5.3 mL). Seven of 14 (50%) patients with Klinefelter's Syndrome had sperm recovery with repeat micro-TESE. The sperm retrieval rate was significantly higher in the Leydig cell hyperplasia and tubular sclerosis groups than in the Sertoli cell only and maturation arrest groups (54.5%, 10.1%, and 18.6%, respectively).

CONCLUSION(S)

On the basis of our results, 18.4% of men with failed first micro-TESE had a probability of sperm retrieval with the second micro-TESE. Patients with successful sperm recovery had smaller testicular volumes than those with a failed second attempt. Severe testicular atrophy was not a contraindication for the second micro-TESE in such patients.

Hsa-miR-27a-3p overexpression in men with nonobstructive azoospermia: A case-control study

Background

The role of KDM3A and its downstream genes in male fertility has been approved in animal models. Additionally, the expression shrinkage of KDM3A is significantly correlated with human azoospermia phenotype. Aberrant expression of micro-RNAs could mislead spermatogenesis and mostly lead to diverse phenotypes of male infertility.

Objective

The aim of this study was to evaluate the expression level of hsa-miR-27a-3p in azoospermic men to reveal its possible association with infertility.

Materials and Methods

This case-control study was conducted on 30 azoospermic men, of whom, 19 had non obstructive azoospermia (NOA) and 11 obstructive azoospermia (OA) according to the pathological examinations. Comprehensive bioinformatics investigations were performed securely and hsa-miR-27a-3p was selected afterward. Reverse Transcriptase-quantitative polymerase chain reaction (RT-qPCR) method was used and statistical analysis was performed to compare the expression level of hsa-miR-27a-3p in both OA and NOA individuals.

Results

In silico analysis suggested hsa-miR-27a-3p, with its potential binding ability to target KDM3A transcripts. The expression analysis of candidate hsa-miR-27a-3p indicated its significant overexpression in NOA men.

Conclusion

The hsa-miR-27a-3p was overexpressed in NOA men compared to OA-control individuals. As a consequence, the overexpressed micro-RNA could downregulate directly KDM3A and indirectly TNP1 and PRM1. Therefore, spermatogenesis could be misled and male infertility could be developed.

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.

The Role of Hormone Stimulation in Men With Nonobstructive Azoospermia Undergoing Surgical Sperm Retrieval

Nonobstructive azoospermia, (NOA) is the most common cause of azoospermia. NOA is characterized by hypergonadotropic hypogonadism, testicular failure, and impaired spermatogenesis. The recent development of surgical sperm retrieval techniques such as microsurgical testicular sperm extraction (mTESE) has, for the first time, allowed some men with NOA to father biological children. It is common practice for endocrine stimulation therapies such as gonadotropins, selective estrogen receptor modulators (SERMs), and aromatase inhibitors to be used prior to mTESE to increase intratesticular testosterone synthesis with the aim of improving sperm retrieval rates; however, there is currently a paucity of data underpinning their safety and efficacy. We present 2 cases of men with NOA undergoing endocrine stimulation therapy and mTESE. We also discuss the current evidence and controversies associated with the use of hormonal stimulation therapy in couples affected by this severe form of male infertility.

miRNA-122-5p stimulates the proliferation and DNA synthesis and inhibits the early apoptosis of human spermatogonial stem cells by targeting CBL and competing with lncRNA CASC7

Epigenetic regulators of human spermatogonia stem cells (SSCs) remain largely unknown. We found that miRNA-122-5p was upregulated in human spermatogonia from obstructive azoospermia (OA) patients compared with non-obstructive azoospermia (NOA). MiRNA-122-5p stimulated the proliferation and DNA synthesis of human SSCs, whereas it inhibited the early apoptosis of human SSCs. CBL was predicted and identified as a direct target of miRNA-122-5p in human SSCs. CBL silencing led to an enhancement of cell proliferation and DNA synthesis and neutralized the effect of miRNA-122-5p inhibitor on the DNA synthesis of human SSCs. The decrease in the early apoptosis of human SSCs was observed after CBL knockdown. By comparing the profiles of lncRNAs between OA and NOA spermatogonia, CASC7 was significantly deficient in OA spermatogonia, and it had a direct association with miRNA-122-5p. LncRNA CASC7 competed with miRNA-122-5p, and it suppressed the inhibition of CBL. Collectively, these results implicate that miRNA-122-5p enhances the proliferation and DNA synthesis and inhibits the early apoptosis of human SSCs by targeting CBL and competing with lncRNA CASC7. Therefore, this study provides novel insights into epigenetic regulation of fate determinations of human SSCs, and it offers new targets for gene therapy of male infertility that is associated with aging.

Reconstitution of prospermatogonial specification in vitro from human induced pluripotent stem cells

Establishment of spermatogonia throughout the fetal and postnatal period is essential for production of spermatozoa and male fertility. Here, we establish a protocol for in vitro reconstitution of human prospermatogonial specification whereby human primordial germ cell (PGC)-like cells differentiated from human induced pluripotent stem cells are further induced into M-prospermatogonia-like cells and T1 prospermatogonia-like cells (T1LCs) using long-term cultured xenogeneic reconstituted testes. Single cell RNA-sequencing is used to delineate the lineage trajectory leading to T1LCs, which closely resemble human T1-prospermatogonia in vivo and exhibit gene expression related to spermatogenesis and diminished proliferation, a hallmark of quiescent T1 prospermatogonia. Notably, this system enables us to visualize the dynamic and stage-specific regulation of transposable elements during human prospermatogonial specification. Together, our findings pave the way for understanding and reconstructing human male germline development in vitro.

Spermatogonia establishment in the fetal and postnatal period is essential for spermatozoa production. Here the authors present a protocol for in vitro reconstitution of human prospermatogonial specification and perform single cell RNA-sequencing to delineate lineage trajectories.

Prevalence of CBAVD in azoospermic men carrying pathogenic CFTR mutations - Evaluated in a cohort of 639 non-vasectomized azoospermic men

BACKGROUND

Men with obstructive azoospermia (OA) due to impaired development of the genital tract often carry at least one Cystic Fibrosis Transmembrane Conductance Regulator CFTR mutation.

OBJECTIVE

To determine the frequency of Congenital Bilateral Absence of Vas deferens (CBAVD) in men with azoospermia carrying CFTR gene mutations.

MATERIALS AND METHODS

Non-vasectomized men with azoospermia referred to our andrological center were consecutively included. All men underwent palpation of the scrotal parts of the Vasa deferentia, ultrasonography of the testicles and hormone profile, and genetic analyses. Testicular biopsy was usually performed. A panel of 32 of the most important CFTR mutations was examined from genomic DNA isolated from blood lymphocytes. Either multiplex PCR analysis or a next-generation sequencing technique was performed.

RESULTS

Among the 639 men with azoospermia, 69 (10.8%) had at least one CFTR mutation. Of the 43 patients with at least one of the two CFTR mutations, ΔF508 and R117H, 19 (44.2%) showed CBAVD, 2 (4.7%) Congenital Unilateral Absence of Vas deferens (CUAVD), and 22 (51.2%) presence of the scrotal parts of the Vasa deferentia. In contrast, only 1/21 men (4.8%) with an isolated IVS8-5T variant showed CBAVD. Among the further 20 men with an isolated IVS8-5T variant, 11 had a history of cryptorchidism. Among the 570 men without CFTR mutations, CBAVD was found in only two men and CUAVD in one. FSH level was higher and testicular volume lower in men with present Vasa deferentia compared to those without (P < .001; Student's t test). Thirty-one men with either ΔF508 or R117H mutations, or both, had a testicular biopsy. Motile spermatozoa were found in 100% of 16 cases with CBAVD but in only 6 out of 15 cases with present Vasa deferentia (P < .01; Fisher's exact test).

DISCUSSION AND CONCLUSIONS

CBAVD was found in ~ 44% of men with ΔF508/R117H mutations. The data may support that CFTR mutations might affect male fertility through other mechanisms than obstruction of the genital tract. For a practical, clinical purpose analysis for only ΔF508, R117H and IVS8-5T seems sufficient until further research shows anything else.

Thoughts on the popularity of ICSI

Purpose

Intracytoplasmic sperm injection (ICSI) is the most widely utilized assisted reproductive technique (ART) worldwide. In this feature, we review the early assisted fertilization attempts that eventually led to the development of ICSI, and discuss its current utilization in cases of male and non-male factor infertility.

Methods

We researched the literature related to the development, indications, and current use of ICSI, such as sperm structural abnormalities, male genetic indications, surgically retrieved sperm, high sperm chromatin fragmentation, oocyte dysmorphism, and preimplantation genetic testing (PGT). We also describe the potential future applications of ICSI.

Results

This review summarizes the early micromanipulation techniques that led to the inception of ICSI. We also explore its current indications, including non-male factor infertility, where its use is more controversial. Finally, we consider the benefits of future advancements in reproductive biology that may incorporate ICSI, such as in vitro spermatogenesis, neogametogenesis, and heritable genome editing.

Conclusion

The versatility, consistency, and reliability of ICSI have made it the most prevalently utilized ART procedure worldwide.

Male factor infertility and risk of death: a nationwide record-linkage study

STUDY QUESTION

What is the risk of death among men with oligospermia, unspecified male factor and azoospermia in the years following fertility treatment?

SUMMARY ANSWER

No significantly elevated risk was observed among men with oligospermia and unspecified male factor, while an increased risk was found among men with azoospermia.

WHAT IS KNOWN ALREADY

Previous studies have shown associations between male factor infertility and risk of death, but these studies have relied on internal reference groups and the risk of death according to type of male infertility is not well characterized.

STUDY DESIGN, SIZE, DURATION

In this prospective record-linkage cohort study, we identified men who had undergone medically assisted reproduction (MAR) between 1994 and 2015. Data was linked to the Danish causes of death register and sociodemographic registers through personal identification numbers assigned to all Danish citizens at birth.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Men that had undergone MAR in Denmark (MAR Cohort; n = 64 563) were identified from the Danish IVF register, which includes data on whether infertility was due to male factor. For each man in the MAR cohort, five age-matched men who became fathers without fertility treatment were selected from the general population (non-MAR fathers; n = 322 108). Men that could not adequately be tracked in the Danish CPR register (n = 1259) and those that were censored prior to study entry (n = 993) were excluded, leaving a final population of 384 419 men. Risk of death was calculated by Cox regression analysis with age as an underlying timeline and adjustments for educational attainment, civil status and year of study entry. The risk of death was compared among men with and without male factor infertility identified from the IVF register (internal comparisons) as well as to the non-MAR fathers (external comparison).

MAIN RESULTS AND THE ROLE OF CHANCE

The risk of death between the MAR cohort (all men, regardless of infertility) and the non-MAR fathers was comparable [hazard ratio (HR), 1.07; 95% CI, 0.98-1.15]. When the MAR cohort was limited to infertile men, these men were at increased risk of death [HR, 1.27; 95% CI, 1.12-1.44]. However, when stratified by type of male factor infertility, men with azoospermia had the highest risk of death, which persisted when in both the internal [HR, 2.30; 95% CI, 1.54-3.41] and external comparison [HR, 3.32; 95% CI, 2.02-5.40]. No significantly elevated risk of death was observed among men with oligospermia [HR, 1.14; 95% CI, 0.87-1.50] and unspecified male factor [HR, 1.10; 95% CI, 0.75-1.61] compared with the non-MAR fathers. The same trends were observed for the internal comparison.

LIMITATIONS, REASONS FOR CAUTION

Duration of the follow-up was limited and there is limited generalizability to infertile men who do not seek fertility treatment.

WIDER IMPLICATIONS OF THE FINDINGS

Using national health registers, we found an increased risk of death among azoospermic men while no increased risk was found among men with other types of infertility. For the azoospermic men, further insight into causal pathways is needed to identify options for monitoring and prevention.

STUDY FUNDING/COMPETING INTEREST(S)

This study is part of the ReproUnion collaborative study, co-financed by the European Union, Interreg V ÖKS. C.G.'s research stay at Stanford was funded by grants from the University of Copenhagen, Kong Christian den Tiendes Fond, Torben og Alice Frimodt Fond and Julie Von Müllen Fond. M.E. is an advisor for Sandstone and Dadi. All other authors declare no conflict of interests.

TRIAL REGISTRATION NUMBER

Not relevant.

Impact on using cryopreservation of testicular or epididymal sperm upon intracytoplasmic sperm injection outcome in men with obstructive azoospermia: a systematic review and meta-analysis

PURPOSE

To determine whether there was a significant impact on using cryopreservation of testicular or epididymal sperm upon the outcomes of intracytoplasmic sperm injection (ICSI) in patients with obstructive azoospermia (OA).

METHOD

Systematic review and meta-analysis of 20 retrospective studies in databases from January 1, 1995, to June 1, 2020.

RESULT

Twenty articles were included in this study. A total of 3602 (64.1%) of 5616 oocytes injected with fresh epididymal sperm were fertilized, compared with 2366 (61.2%) of 3862 oocytes injected with cryopreserved sperm (relative risk ratio (RR) 0.96, 95% confidence interval (CI) (0.90, 1.02), P > 0.05). A total of 303 (44.1%) of 687 ICSI cycles using fresh epididymal sperm resulted in a clinical pregnancy, compared with 150 (36.6%) of 410 ICSI cycles using cryopreserved epididymal sperm (RR 0.84, 95% CI (0.72, 0.97), P < 0.05). In the testis, a total of 2147 (68.7%) of 3125 oocytes injected with fresh sperm were fertilized, compared with 1623 (63.5%) of 2557 oocytes injected with cryopreserved sperm (RR 0.97, 95% CI (0.90, 1.06), P > 0.05). A total of 151 (47.8%) of 316 ICSI cycles using fresh testicular sperm resulted in a clinical pregnancy, compared with 113 (38.2%) of 296 ICSI cycles using cryopreserved sperm (RR 0.87, 95% CI (0.72, 1.05), P > 0.05).

CONCLUSIONS

In men with OA, there was a statistical lower clinical pregnancy rate (CPR) by using frozen epididymal sperm compared with fresh epididymal sperm, but showing no difference on fertilization rate (FR). Additionally, FR and CPR were not affected by whether the retrieved testicular sperm was frozen or fresh.

Spontaneous Infertility Secondary to Testicular Sarcoidosis: A Case Report

Sarcoidosis is a multisystem disease that can affect any region of the body. Rarely, sarcoid involvement may even involve the male genitourinary tract, including the testicles. Testicular sarcoidosis causes spontaneous and severe effects on male fertility due to obstructive azoospermia. The case presented offers an insight into successful fertility treatment in a patient with obstructive testicular sarcoidosis. The patient and his partner presented to the clinic two years post successful natural conception of their first child with subsequent infertility. Within this period, the male partner was diagnosed with sarcoidosis and was on a treatment plan consisting of methotrexate and glucocorticoids. Complete azoospermia was confirmed via two separate semen analyses six weeks apart. The patient's testosterone (free and total), thyroid stimulating hormone (TSH), prolactin, follicle stimulating hormone (FSH), and luteinizing hormone (LH) were all within normal limits. With approval of pulmonology, methotrexate was discontinued for three months; however, subsequent semen analysis revealed no improvement. The patient was referred to urology, who confirmed the presence a palpable testicular nodule. Treatment of infertility was eventually achieved via testicular sperm aspiration (TESA) followed by in vitro fertilization (IVF) using intracytoplasmic sperm injection (ICSI). This treatment was successful in achieving one blastocyst and one morula, which were replaced via fresh transfer, resulting in a successful term singleton pregnancy. The possibility of obstructive azoospermia should be considered in males diagnosed with sarcoidosis who are seeking to preserve their reproductive potential.

A comprehensive assessment of predictors of fertility outcomes in men with non-obstructive azoospermia undergoing microdissection testicular sperm extraction

BACKGROUND

Microdissection testicular sperm extraction (microTESE) in men with non-obstructive azoospermia (NOA) is the procedure that results in the highest number of sperm cells retrieved for in vitro fertilization (IVF). This study presents a novel assessment of predictors of sperm retrieval as well as downstream embryology and pregnancy outcomes in cases of men with NOA undergoing microTESE.

METHODS

A retrospective chart review of 72 men who underwent microTESE for predictors of fertility outcomes including sperm retrieved at microTESE, embryology progression to embryo transfer (ET), clinical pregnancy, live birth, and surplus sperm retrieved for additional IVF/intracytoplasmic injection cycles beyond one initial cycle. Statistical models for each of these outcomes were fitted, with a p-value of < 0.05 considered significant for the parameters estimated in each model.

RESULTS

Seventy-two men underwent microTESE, and 51/72 (70.8%) had sperm retrieved. Of those, 29/43 (67.4%) reached ET. Of the couples who underwent ET, 21/29 (72.4%) achieved pregnancy and 18/29 (62.1%) resulted in live birth. Of the men with sperm retrieved, 38/51 (74.5%) had surplus sperm cryopreserved beyond the initial IVF cycle. Age, testicular volume, FSH, and testicular histopathology were assessed as predictors for sperm retrieved at microTESE, progression to ET, pregnancy, live birth, and surplus sperm. There were no preoperative predictors of sperm retrieval, clinical pregnancy, or live birth. Age predicted reaching ET, with older men having increased odds. FSH level had a negative relationship with surplus sperm retrieved. Men with hypospermatogenesis histology had higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm.

CONCLUSIONS

Men who underwent microTESE with a hypospermatogenesis histopathology had better outcomes, including higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm retrieved. Increasing male partner age increased the odds of reaching ET. No other clinical factors were predictive for the outcomes considered.

A modified single-armed microsurgical vasoepididymostomy for epididymal obstructive azoospermia: intraoperative choice and postoperative consideration

Background

To evaluate the clinical outcomes and the duration required for the sperm to return to the ejaculate after a modified single-armed 2-suture longitudinal intussusception vasoepididymostomy (SA-LIVE).

Methods

From March 2015 to December 2018, 134 patients with epididymal obstruction azoospermia underwent the modified single-armed vasoepididymostomy at Shanghai General Hospital. The outcomes and clinical findings were documented and evaluated. The mean follow-up period was 17 (range: 3–36) months.

Results

Patency was assessed by the return of sperm in the ejaculate. The overall patency rate was 55.2%, and the patency rates were 58.9, 40.7, 36.4, and 58.9% for bilateral surgery, unilateral surgery, proximal anastomosis, and distal anastomosis, respectively. The average time to achieve patency was 4.11 ± 2.74 months. In the first 6 months, 87.8% (65/74) patency patients reported sperm in the ejaculate. The overall pregnancy rate was 40.9% (29/66) at the follow-up of 3–36 months, and the natural pregnancy rate was 30.3% (20/66). The natural pregnancy rate was 32.1% post-bilateral surgery and 33.3% for the site of distal anastomosis; surprisingly, it was 0% for the site of proximal anastomosis.

Conclusion

Modified SA-LIVE is safe and may achieve favorable patency and pregnancy rates. When double-armed sutures are not accessible, single-armed may be preferable. The expected patency time was within 1 year. Moreover, because of the low natural pregnancy rate for proximal anastomosis, sperm banking is preferred to SA-LIVE.

Predictors of surgical sperm retrieval in non-obstructive azoospermia: summary of current literature

Intracytoplasmic sperm injection (ICSI), combined with surgical sperm retrieval (SR) techniques, is the sole option for patients with non-obstructive azoospermia to achieve fertility; however, with suboptimal results. Given the variability in clinical presentation, the potential role of factors that can predict the likelihood of successful testicular SR needs to be clarified. This article summarizes the current evidence concerning the variables predicting SR success in non-obstructive azoospermic patients with spermatogenic failure. For this, we used 60 articles, including 46 original papers and six meta-analyses. Clinical and laboratory factors, as well as adjuvant therapies and surgical retrieval methods, were the factors most commonly investigated. We found that Klinefelter syndrome, Y chromosome microdeletions in regions AZFa/b, and Sertoli cell-only histopathology were associated with reduced SR success. By contrast, testis volume > 12.5 ml, history of cryptorchidism, use of micro-TESE as the sperm retrieval method, and adjuvant therapy were associated with improved SR success. None of the predictors, alone or combined, provide definitive information about the chances of harvesting sperm in men with non-obstructive azoospermia, except for Y chromosome microdeletions in regions AZFa/b. In the latter, SR success is virtually nil. We conclude that SR outcomes in men with non-obstructive azoospermia are difficult to predict based on the existing variables. Although several predictors can be used for patient counseling, their clinical value is limited to either ensure SR success or discourage reproductive urologists from recommending SR to men with non-obstructive azoospermia seeking fertility. A notable exception includes the deletions involving the regions AZFa and/or AZFb of the Y chromosome; the affected patients should be counseled against undergoing SR.

Survey of Microsurgery Training Availability in US Urology Residency Programs

Purpose

The Accreditation Council of Graduate Medical Education (ACGME) establishes surgical minimum numbers of cases for urologic training. Currently there is not a requirement for microsurgery, likely from a belief that programs do not offer exposure. In an effort to evaluate the availability of microsurgery training among urology residency programs we surveyed the programs.

Materials and Methods

We obtained a list of the 138 ACGME-accredited urology residencies and contact information the American Urology Association (AUA). We contacted the residency programs by phone and e-mail. For programs that did not reply, we performed a search of the program website. We answered 3-questions to assess resident subspecialty training in microsurgery and used penile implant and artificial urinary sphincters as a comparison. Data are reported as frequencies.

Results

We obtained data from 134 programs (97.1%). A total of 104 programs (77.6%) had fellowship-trained physicians for training in microsurgery, 86.6% for penile implants, and 88.8% for artificial urinary sphincters. The percentage of fellowship-trained microsurgeons per program did not vary significantly when comparing the different sections of the AUA. The northeast and southeast sections had the lowest percentage (67% and 68%).

Conclusions

Nearly 80% of urology residency programs have a fellowship-trained microsurgeon on faculty, we therefore believe that microsurgery should be added as part of the ACGME minimums. In order to provide an equal exposure to all graduating urology residents, urology residency programs that lack microsurgery should identify potential faculty with fellowship training.

Prediction of microdissection testicular sperm extraction outcome in men with idiopathic nonobstruction azoospermia

The aim of the present study is to assess whether the preoperative clinical indicators have an impact on sperm retrieval rate (SRR) in men with idiopathic nonobstructive azoospermia (NOA).We retrospectively studied 241 consecutive men with NOA who underwent microdissection testicular sperm extraction from 2016 to 2019 in the Reproductive Medicine Center, including 154 patients diagnosed with idiopathic NOA. They were grouped according to preoperative indicators, including average testicular volume, follicle-stimulating hormone (FSH), luteinizing hormone, Testosterone (T), and pathology, respectively.The overall SRR was 20.0% (31/155). Men with testicular volume of ≤5 mL had significant higher SRR than men with testes 5 to 10 and ≥10 mL (35.6% vs 12.3%, P = .002; 35.6% vs 16.2, P = .049, respectively). The SRR in men with FSH ≥ 24.8 mIU/mL was significant higher, compared with FSH level of 12.4 to 24.8 mIU/mL (32.6% vs 15.8%, P = .033). Men with Sertoli cell-only had significantly lower SRR than other pathological type (8.1%). Men with an FSH ≥ 24.8 mIU/mL in testicular volume ≤5 mL group had a significantly higher SRR than FSH level of 12.4 to 24.8 mIU/mL in testicular volume of ≤5 to 10 mL group (44.0% vs 11.4%, P = .002). Men with a luteinizing hormone level of 8.6 to 17.2 mIU/mL in testicular volume of 5 to 10 mL group had a poor prognosis, with an SRR of only 6.5%.Severely reduced testicular volume (≤5 mL) and severely increased FSH level (≥24.8 mIU/mL) had the better sperm retrieval outcome, which can be used as independent predictors in men with idiopathic NOA. And a combination of testicular volume and the hormone seemed to be useful in further increase predictive value.

Evaluation of neoadjuvant gonadotropin administration with downregulation by testosterone prior to second time microsurgical testicular sperm extraction: A prospective case-control study

PURPOSE

The aim of this prospective study was to determine whether there is a beneficial role of combining gonadotropin administration with testosterone downregulation in non-obstructive azoospermia patients prior to a second time microsurgical testicular sperm extraction after a negative one.

METHODS

A total of 40 non-obstructive azoospermia men were recruited from a specialized IVF center from 2014 to 2016. Participants were divided equally into two groups: Group A was subjected to testosterone downregulation alone for 1 month and then combined with gonadotropin administration for 3 months prior to second time testicular sperm extraction; Group B (controls) underwent second time microsurgical testicular sperm extraction without prior hormonal therapy.

RESULTS

Mean baseline follicle-stimulating hormone levels of the controls and the cases were 26.9 ± 11.8 and 25.4 ± 8.7, respectively. One month after testosterone downregulation, follicle-stimulating hormone level of the cases was normalized and became 2.4 ± 1.2. There was no statistically significant difference between baseline follicle-stimulating hormone levels of the controls and cases (p = 0.946). Remarkably, two cases were positive after downregulation (10%) and no controls were positive at second testicular sperm extraction (0%). There was no statistically significant difference between sperm retrieval after the second microsurgical testicular sperm extraction in the controls and the cases (p = 0.072).

CONCLUSION

Patients who underwent first time testicular sperm extraction with unfavorable outcome due to different techniques may benefit from testosterone downregulation combined with neoadjuvant gonadotropin administration as it had shown positive sperms retrieval in 2 out of the 20 cases, especially those with hypergonadotropic azoospermia.

Use of mini-incision microdissection testicular sperm extraction in men with cryptozoospermia and non-obstructive azoospermia

INTRODUCTION

Microdissection testicular sperm extraction (micro-TESE) is a procedure commonly utilized to harvest spermatozoa in severe male factor infertility. We have developed a technique involving a mini tunica albuginea incision with superficial tissue dissection (mini-incision micro-TESE). The modification is designed to reduce potential tissue injury, and we studied its effectiveness to harvest spermatozoa in men with cryptozoospermia and non-obstructive azoospermia.

MATERIALS AND METHODS

We performed a retrospective analysis of 103 infertile men with NOA and cryptozoospermia who underwent a mini-incision micro-TESE between March 2015 and August 2018 at the OVO fertility clinic. We consider the mini-incision micro-TESE procedure successful when at least five spermatozoa are identified in the micro-biopsies obtained from the superficial tissue exposed by the 1-cm mini-incision. If no spermatozoa are identified through the mini-incision, we can easily extend the incision to the standard micro-TESE.

RESULTS

The mini-incision procedure allowed for successful recovery of spermatozoa (intra-operative recovery of ≥ 5 spermatozoa) in 58% of men with cryptozoospermia and 25.6% of men with NOA. Overall, a successful sperm retrieval (with conversion to conventional micro-TESE if mini-incision was not successful) was achieved in 89% of men with cryptozoospermia and 48% of men with NOA. A successful mini-incision micro-TESE was associated with a significantly lower number of biopsies than conventional micro-TESE (8.8 vs 24.2, P < .0001). Moreover, in men undergoing a redo micro-TESE after a previously successful micro-TESE, 64% (9/14) had spermatozoa found and 21% (3/14) of these men only required a mini-incision micro-TESE.

CONCLUSION

Our data suggest that mini-incision micro-TESE is a useful approach in men undergoing micro-TESE, allowing for a shorter incision and a high sperm retrieval rate in men with cryptozoospermia. Furthermore, the findings of our study offer insight into the distribution of spermatogenesis in men with cryptozoospermia and NOA.

Testicular expression of TDRD1, TDRD5, TDRD9 and TDRD12 in azoospermia

Background

Tudor domain-containing proteins (TDRDs) play a critical role in piRNA biogenesis and germ cell development. piRNAs, small regulatory RNAs, act by silencing of transposons during germline development and it has recently been shown in animal model studies that defects in TDRD genes can lead to sterility in males.

Methods

Here we evaluate gene and protein expression levels of four key TDRDs (TDRD1, TDRD5, TDRD9 and TDRD12) in testicular biopsy samples obtained from men with obstructive azoospermia (OA, n = 29), as controls, and various types of non-obstructive azoospermia containing hypospermatogenesis (HP, 28), maturation arrest (MA, n = 30), and Sertoli cell-only syndrome (SCOS, n = 32) as cases. One-way ANOVA test followed by Dunnett’s multiple comparison post-test was used to determine inter-group differences in TDRD gene expression among cases and controls.

Results

The results showed very low expression of TDRD genes in SCOS specimens. Also, the expression of TDRD1 and TDRD9 genes were lower in MA samples compared to OA samples. The expression of TDRD5 significantly reduced in SCOS, MA and HP specimens than the OA specimens. Indeed, TDRD12 exhibited a very low expression in HP specimens in comparison to OA specimens. All these results were confirmed by Western blot technique.

Conclusion

TDRDs could be very important in male infertility, which should be express in certain stages of spermatogenesis.

Variation analysis of SOX8 gene in Chinese men with non-obstructive azoospermia or oligozoospermia

Sox8, encoding a SRY-related HMG box transcription factor, is essential in Sertoli cells for germ cell differentiation via regulation of integrity of the blood-testis barrier (BTB) as well as Sertoli-germ cell adhesion. Inactivation of Sox8 gene in mice causes postnatal progressive spermatogenic failure, resulting in male infertility. This study aims to investigate whether variants of SOX8 contribute to pathogenesis of idiopathic non-obstructive azoospermia (NOA) or oligozoospermia. A case-control genetic study was conducted in which all exons and exon-intron boundaries of SOX8 gene were screened in 190 NOA and 139 oligozoospermia cases by Sanger sequencing. The detected variants were examined in 284 normospermic controls. Nine known single-nucleotide polymorphisms (SNPs) of SOX8 gene were identified, and four of them exist simultaneously in oligo/azoospermia patients. A comparison of allele/genotype frequencies of these variants showed no significant difference between oligo/azoospermia cases and controls. The results indicate that deleterious variants in SOX8 gene may not be a common cause for oligo/azoospermia in Chinese men. Considering ethnic diversity, SOX8 could not be ruled out as a candidate gene for male infertility. The role of SOX8-mediated Sertoli cell function and BTB integrity played in the pathogenesis of male infertility needs to be further explored in other populations.

Genetic Landscape of Nonobstructive Azoospermia and New Perspectives for the Clinic

Nonobstructive azoospermia (NOA) represents the most severe expression of male infertility, involving around 1% of the male population and 10% of infertile men. This condition is characterised by the inability of the testis to produce sperm cells, and it is considered to have an important genetic component. During the last two decades, different genetic anomalies, including microdeletions of the Y chromosome, karyotype defects, and missense mutations in genes involved in the reproductive function, have been described as the primary cause of NOA in many infertile men. However, these alterations only explain around 25% of azoospermic cases, with the remaining patients showing an idiopathic origin. Recent studies clearly suggest that the so-called idiopathic NOA has a complex aetiology with a polygenic inheritance, which may alter the spermatogenic process. Although we are far from a complete understanding of the molecular mechanisms underlying NOA, the use of the new technologies for genetic analysis has enabled a considerable increase in knowledge during the last years. In this review, we will provide a comprehensive and updated overview of the genetic basis of NOA, with a special focus on the possible application of the recent insights in clinical practice.

Evaluating genetic causes of azoospermia: What can we learn from a complex cellular structure and single-cell transcriptomics of the human testis?

Azoospermia is a condition defined as the absence of spermatozoa in the ejaculate, but the testicular phenotype of men with azoospermia may be very variable, ranging from full spermatogenesis, through arrested maturation of germ cells at different stages, to completely degenerated tissue with ghost tubules. Hence, information regarding the cell-type-specific expression patterns is needed to prioritise potential pathogenic variants that contribute to the pathogenesis of azoospermia. Thanks to technological advances within next-generation sequencing, it is now possible to obtain detailed cell-type-specific expression patterns in the testis by single-cell RNA sequencing. However, to interpret single-cell RNA sequencing data properly, substantial knowledge of the highly sophisticated data processing and visualisation methods is needed. Here we review the complex cellular structure of the human testis in different types of azoospermia and outline how known genetic alterations affect the pathology of the testis. We combined the currently available single-cell RNA sequencing datasets originating from the human testis into one dataset covering 62,751 testicular cells, each with a median of 2637 transcripts quantified. We show what effects the most common data-processing steps have, and how different visualisation methods can be used. Furthermore, we calculated expression patterns in pseudotime, and show how splicing rates can be used to determine the velocity of differentiation during spermatogenesis. With the combined dataset we show expression patterns and network analysis of genes known to be involved in the pathogenesis of azoospermia. Finally, we provide the combined dataset as an interactive online resource where expression of genes and different visualisation methods can be explored ( https://testis.cells.ucsc.edu/ ).

The second mutation of SYCE1 gene associated with autosomal recessive nonobstructive azoospermia

PURPOSE

It is estimated that 40-50% of infertility among human couples is due to male infertility. Azoospermia is estimated to occur in 1% of all men and to be the cause of 10-20% of male infertility. Genetic defects, including single gene effects, maybe cause of azoospermia in 20-30% of affected males. Here, we aim to identify the genetic cause of azoospermia in a man who is also affected by hereditary spastic paraplegia.

METHODS

The proband was subjected to whole-exome sequencing, followed by a comprehensive in silico analysis to identify the azoospermia causative gene.

RESULTS

A novel splice site mutation c.375-2A > G in SYCE1 that is thought to be the cause of azoospermia was identified. This variant co-segregated with azoospermia status in the family that has three additional affected males.

CONCLUSION

SYCE1 gene encodes synaptonemal complex (SC) central element 1 protein which contributes to the formation of the synaptonemal complex during meiosis. Syce1 null male and female mice have been shown to be infertile. There have only been two reports on the effects of SYCE1 mutations in humans; it was shown as the cause of primary ovarian failure (POI) in one and as the cause of nonobstructive azoospermia (NOA) in another. We suggest that the mutation 375-2A > G, which affects the acceptor splice site within intron 6 of SYCE1, is the likely cause of azoospermia and subsequent infertility in the family studied. The finding constitutes the third report of SYCE1mutations that affect infertility in humans and further supports its contribution to this condition.

Failure modes and effects analysis for testicular sperm extraction management process

Failure modes and effects analysis (FMEA) is a proactive risk evaluation to identify and reduce potential failures that may occur during a procedure within a quality management programme. One of the procedures performed in assisted reproduction technology centres is testicular sperm extraction (TESE) as treatment of azoospermic patients. To examine the risks associated with the 'TESE management' process, we applied the FMEA method, before and after implementation of corrective measures defined in a standard operative procedure (SOP). A multidisciplinary team was formed. Possible causes of failures and their potential effects were identified, and risk priority number (RPN) for each failure was calculated. The FMEA team identified 4 process activities, 19 process steps and 19 potential failure modes. The re-evaluation after the corrective measures disclosed a reduction in the number of phases with high/moderate risk (pre-SOP: n = 13; post-SOP: n = 3). Improvements in the traceability system removed 11 out of 13 (85%) steps with a low risk of occurrence. In our experience, FMEA is efficient in helping multidisciplinary groups to strengthen knowledge and awareness on routine processes, identifying critical steps and planning practical improvements for a better compliance with criteria of traceability and conformity of biological samples and patients.

Serum estradiol levels in infertile men with non-obstructive azoospermia

PURPOSE

To report the different patterns of estradiol levels in infertile men with non-obstructive azoospermia and correlate these levels with their clinical and laboratory findings.

MATERIALS AND METHODS

A retrospective study was launched, and a retrieval of data for infertile men with non-obstructive azoospermia (n = 166) and fertile controls (n = 40) was performed. The retrieved data included demographics, clinical findings, scrotal duplex, semen analysis, and hormonal assay (testosterone, follicle-stimulating hormone, luteinizing hormone, prolactin, and estradiol).

RESULTS

Our findings showed a wide spectrum of estradiol concentrations. The patients were arranged into three groups (high, normal, and low estradiol groups). The normal estradiol group was the most prevalent (71.1%). Testosterone, gonadotrophins, testicular volumes, and the number of patients with jobs in polluted workplaces showed significant differences among the study groups (p = 0.001, <0.001, <0.001, and 0.004, respectively). Age, body mass index, varicocele prevalence, prolactin, and smoking habits did not show any significant differences among the groups. Obesity was lacking in the low estradiol group, but it had significantly higher prevalence in the normal (p = 0.013) or high group (p = 0.023) compared with the controls.

CONCLUSION

Serum estradiol, in infertile men with non-obstructive azoospermia, may be present at different levels. It is recommended that estradiol be measured in infertile men with non-obstructive azoospermia when there is an alteration in testosterone concentration, obesity, a polluted workplace occupation, or before trying hormonal therapy. Extended studies are highly recommended to provide a clear clue whether alterations in estradiol concentrations in men with non-obstructive azoospermia are the cause or a consequence of the condition.

Intracytoplasmic sperm injection with fresh versus cryopreserved testicular sperm in azoospermic patients

Background

The purpose of this study is to compare the outcome of intracytoplasmic sperm injection (ICSI) using fresh sperm versus frozen-thawed sperm in both obstructed and non-obstructed azoospermias. This retrospective study included 159 ICSI cycles from 126 couples. In 91 obstructed azoospermia cases, 66 cycles were treated with fresh testicular sperm and 25 cycles were treated with frozen-thawed testicular samples. In 68 non-obstructed azoospermia cases, 32 cycles were treated with fresh testicular sperm and 36 cycles were treated with frozen-thawed testicular sperm, and the main measure and outcomes calculated are fertilization rate, clinical pregnancy, and live birth rate.

Results

In case of obstructed azoospermia, there were no statistically significant differences between fresh sperm and frozen-thawed testicular sperm used for ICSI regarding fertilization rate, clinical pregnancy rate, and live birth rate as shown (57%, 47%, 0.093 p value; 23.7%, 17.4%, 0.54 p value; and 11.9%, 8.7%, 0.68 p value, respectively). Non-obstructed azoospermia cases also show no significant differences in fertilization rate (37%, 36%, 0.91 p value), clinical pregnancy rate (20%, 14.3%, 0.58 p value), and live birth rate (4%, 3.6%, 0.93 p value).

Conclusion

Cryopreservation of testicular sperm is reliable if carried out before ovulation induction especially in cases with non-obstructive azoospermia

Deletion of Ck2β gene causes germ cell development arrest and azoospermia in male mice

Objectives

In humans, non‐obstructive azoospermia (NOA) is a major cause of male infertility. However, the aetiology of NOA is largely unknown. Previous studies reported that protein CK2β was abundantly and broadly expressed in spermatogenic cells. Here, we investigate whether protein CK2β participates in spermatogenesis.

Materials and Methods

In this study, we separated spermatogenic cells using STA‐PUT velocity sedimentation, analysed the expression pattern of protein CK2β by immunoblotting, specifically deleted Ck2β gene in early‐stage spermatogenic cells by crossing Ck2β^fl mice with Stra8‐Cre⁺ mice and validated the knockout efficiency by quantitative RT‐PCR and immunoblotting. The phenotypes of Ck2β^fl/Δ;SCre⁺ mice were studied by immunohistochemistry and immunofluorescence. The molecular mechanisms of male germ cell development arrest were elucidated by immunoblotting and TUNEL assay.

Results

Ablation of Ck2β gene triggered excessive germ cell apoptosis, germ cell development arrest, azoospermia and male infertility. Inactivation of Ck2β gene caused distinctly reduced expression of Ck2α′ gene and CK2α′ protein.

Conclusions

Ck2β is a vital gene for germ cell survival and male fertility in mice.

Parameters predicting sperm retrieval rates during microscopic testicular sperm extraction in nonobstructive azoospermia

The aim of this study was to investigate the predictive value of the parameters that might have an effect on the success of microscopic testicular sperm extraction (micro-TESE) in infertile patients with nonobstructive azoospermia (NOA). Between 2003 and 2014, 860 patients with NOA were retrospectively analysed. The effect of age, infertility duration, history of varicocelectomy, herniorrhaphy or orchiopexy, presence of solitary testis, tobacco use, previous testicular biopsy results, history of orchitis, usage of human chorionic gonadotropin in the past three months, presence of undescended or retractile testis, presence of varicocele, testicular volume, levels of serum follicle-stimulating hormone, luteinising hormone, and testosterone, presence of Klinefelter syndrome and micro-deletion of Y chromosome on sperm retrieval rates were evaluated. In 45.8% (n = 394) of the patients who underwent micro-TESE, spermatozoon was adequately obtained. Multiple logistic regression analysis demonstrated that previous successful testicular biopsy (OR = 15.346; GA = 5.45-43.16; p < .001) and higher testicular volumes significantly increase sperm retrieval rate in micro-TESE. The testicular volume cut-off as 11 ml was found to be the most significant factor. Although currently testicular biopsy result is not being used as a diagnostic method, it is significantly associated with micro-TESE result.

The Role of Sperm Centrioles in Human Reproduction - The Known and the Unknown

Each human spermatozoon contains two remodeled centrioles that it contributes to the zygote. There, the centrioles reconstitute a centrosome that assembles the sperm aster and participate in pronuclei migration and cleavage. Thus, centriole abnormalities may be a cause of male factor infertility and failure to carry pregnancy to term. However, the precise mechanisms by which sperm centrioles contribute to embryonic development in humans are still unclear, making the search for a link between centriole abnormalities and impaired male fecundity particularly difficult. Most previous investigations into the role of mammalian centrioles during fertilization have been completed in murine models; however, because mouse sperm and zygotes appear to lack centrioles, these studies provide information that is limited in its applicability to humans. Here, we review studies that examine the role of the sperm centrioles in the early embryo, with particular emphasis on humans. Available literature includes case studies and case-control studies, with a few retrospective studies and no prospective studies reported. This literature has provided some insight into the morphological characteristics of sperm centrioles in the zygote and has allowed identification of some centriole abnormalities in rare cases. Many of these studies suggest centriole involvement in early embryogenesis based on phenotypes of the embryo with only indirect evidence for centriole abnormality. Overall, these studies suggest that centriole abnormalities are present in some cases of sperm with asthenoteratozoospermia and unexplained infertility. Yet, most previously published studies have been restricted by the laborious techniques (like electron microscopy) and the limited availability of centriolar markers, resulting in small-scale studies and the lack of solid causational evidence. With recent progress in sperm centriole biology, such as the identification of the unique composition of sperm centrioles and the discovery of the atypical centriole, it is now possible to begin to fill the gaps in sperm centriole epidemiology and to identify the etiology of sperm centriole dysfunction in humans.

Non-syndromic monogenic male infertility

Infertility is a widespread clinical problem affecting 8-12% of couples worldwide. Of these, about 30% are diagnosed with idiopathic infertility since no causative factor is found. Overall 40-50% of cases are due to male reproductive defects. Numerical or structural chromosome abnormalities have long been associated with male infertility. Monogenic mutations have only recently been addressed in the pathogenesis of this condition. Mutations of specific genes involved in meiosis, mitosis or spermiohistogenesis result in spermatogenic failure, leading to the following anomalies: insufficient (oligozoospermia) or no (azoospermia) sperm production, limited progressive and/or total sperm motility (asthenozoospermia), altered sperm morphology (teratozoospermia), or combinations thereof. Androgen insensitivity, causing hormonal and sexual impairment in males with normal karyotype, also affects male fertility. The genetic causes of non-syndromic monogenic of male infertility are summarized in this article and a gene panel is proposed. (www.actabiomedica.it)

Fine-Needle Aspiration Cytology of the Testes for the Classification of Azoospermia and Its Value in the Assessment of Male Infertility

BACKGROUND

Infertility is an ever-increasing problem in today's world. It can be due to male or female causes. Azoospermia seen in 5-10% of infertile men is due to obstructive or non-obstructive causes. Traditionally, testicular biopsy is the gold standard for evaluation. Fine-needle aspiration (FNA), however, is minimally invasive, provides qualitative and quantitative information about spermatogenesis, and can aid in assisted reproductive techniques making it a novel technique for the evaluation of male infertility.

OBJECTIVE

We aimed to classify different causes of azoospermia into different patterns based upon FNA, and assess the utility of cell indices in classifying cases into different patterns.

METHOD

We conducted a prospective and a retrospective study of 42 azoospermic males, confirmed on semen analysis, over a period of 5 years. Patients were subjected to FNA of the testes. Smears were prepared, air-dried, wet-fixed, and then stained with May-Grünwald Giemsa and Papanicolaou stains, respectively. Cells were identified using predetermined morphologic criteria, and various indices were calculated followed by statistical analysis of the observations.

RESULTS

The mean age of 40 patients who satisfied the adequacy criteria was 32.75 years (range 22-48 years). Thirty-four patients had primary infertility and 6 had secondary infertility. Of these, 12 had normal spermatogenesis, 8 had hypo-spermatogenesis, 3 had early and 7 had late maturation arrest, 6 had Sertoli cell-only syndrome (SCOS), and there were different results in each testicle in 4 cases. The Sperm Index (SI) was significantly higher in all cases of normal spermatogenesis than in any of the hypo-spermatogenesis cases (p = 0.009). The Sertoli Index (SEI) in cases of hypo-spermatogenesis and maturation arrest was significantly higher than in cases of normal spermatogenesis (p < 0.001). The Sperm-Sertoli Index (SSI) also showed significant differences between cases of hypo-spermatogenesis and normal spermatogenesis (p < 0.001). These indices were useful in categorising patients with azoospermia.

CONCLUSION

FNA helps to easily and accurately identify all types of testicular cells without biopsy. SI, SEI, and SSI are powerful cell indices for assessing the extent of spermatogenesis and classifying various causes of azoospermia. Bilateral sampling and multiple aspirations give a better mapping of spermatogenesis within the testes. Testicular FNA can thus play a very important role in the evaluation of male infertility.

The management of obstructive azoospermia: a committee opinion

Infertility due to obstructive azoospermia may be treated effectively by surgical reconstruction or by retrieval of sperm from the epididymis or testis, followed by in vitro fertilization with intracytoplasmic sperm injection. This replaces the ASRM documents titled "Sperm retrieval for obstructive azoospermia" and "The management of infertility due to obstructive azoospermia," last published in 2008.

Is there a role for varicocelectomy after microdissection testicular sperm extraction? Case report and literature review

Men with non-obstructive azoospermia (NOA) are candidates for microdissection testicular sperm extraction (microTESE). In men with NOA and varicocele, varicocelectomy has been associated with the appearance of sperm in the ejaculate. We report an infertile male with NOA, a solitary left testicle and a left clinical varicocele. The patient first underwent an extensive left microTESE. No spermatozoa were seen on initial microscopic evaluation but after an extensive search, spermatozoa were identified. ICSI did not result in pregnancy. Fifteen months after the microTESE, the patient underwent a left microsurgical varicocelectomy. A semen analysis post-varicocelectomy revealed the presence of sperm.

Testicular sperm extraction in men with sertoli cell-only testicular histology - 1680 cases

Objective:

To study the outcomes of testicular sperm extraction (TESE) among men with pure Sertoli cell-only histology identified during diagnostic testicular biopsy.

Methods:

This retrospective cohort study involved 1680 cases of patients with nonobstructive azoospermia (NOA) diagnosed with pure Sertoli cell-only histology who underwent testicular biopsy with TESE in a reference center in Brazil by a single surgeon. Sperm retrieval rates (SSR) were the main outcome measure.

Results:

Overall, 14.83% of patients with Sertoli cell-only had sperm retrieved with TESE in quantity that allowed the performance of ICSI. No differences were observed in SSR based on testis volume (<15 mL vs. <15 mL) or serum FSH level.

Conclusions:

Patients with Sertoli cell-only histology can be counseled that they have some likelihood of sperm retrieval with TESE. Based on the findings, patients to be submitted to testicular biopsy for histologic analysis may be concomitantly prepared for ICSI with TESE in case sperm is available.

[Analysis of intratesticular condition in micro-dissection testicular sperm extraction era]

OBJECTIVE

To summarizes the intratesticular condition of azoospermia patients, to understand azoospermia more intuitively, and improve the ability of clinical doctors to predict the success rate of microsperm extraction in azoospermia patients.

METHODS

Azoospermia patients (excluding Klinefelter's syndrome) who underwent a micro-TESE during January 2014 and January 2018 in a single center were enrolled. The types of seminiferous tubules were summarized, and the clinical characteristics of different types of seminiferous tubules compared with the success rates of sperm extraction. In this study, 472 cases of non-obstructive azoospermia (excluding Klinefelter's syndrome) were analyzed by SPSS 21.0 software package. Relevant data were expressed by median(minimum,maximum).t-test was used to compare the difference of success rate of sperm extraction between each group and the group with the lowest rate (a type).

RESULTS

The 472 patients with non-obstructive azoospermia underwent micro-TESE. The mean age of the patients was 31 (23, 46) years, the mean testicular size was 10 (1, 20) mL, the mean FSH was 15.4 (1.21, 68.4) IU/L, the mean T was 8.34 (0.69, 30.2) nmol/L, and totally 202 patients achieved success in micro-TESE (42.7%, 202/472). According to the seminiferous tubules seen during the operation, they were divided into the following six types: Class a, seminiferous tubules developed well and uniformly; Class b, seminiferous tubules developed well, occasionally slightly thick; Class c, seminiferous tubules were generally thin; Class d, seminiferous tubules basically atrophied, occasionally well-developed seminiferous tubules; Class e, all seminiferous tubules atrophied; Class f, seminiferous tubules were infiltrated by yellow substances. The success rate of micro-TESE varied greatly among different types of the patients. A total of 78 patients with type a were 29 (24, 40) years old, FSH 11.1 (1.21, 15.8) IU/L, T 10.2 (3.29, 26.5) nmol/L), and testicular size 12 (12, 20) mL. The successful rate of sperm extraction was 6.41%; 82 patients with type b were 31 (23, 42) years old, FSH 13.8 (3.23, 19.6) IU/L, T 9.44 (3.58, 30.2) nmol/L), and testicular size 12(8,15) mL. The successful rate of sperm extraction was 74.39%; There were 162 patients in group c, aged 31 (25, 40), FSH 19.6 (9.28, 26.6) IU/L, T 8.75 (5.66, 18.6) nmol/L, and testicular size 8 (5, 12) mL. The successful rate of sperm extraction was 45.06%. There were 36 patients in group d, aged 25 (23,38) years and FSH 28.5 (19.3, 45.6) IU/L, T 6.52 (2.12, 9.83) nmol/L, and testicular size 5 (3, 8) mL, and the success rate of sperm extraction was 94.44%. 26 patients with type e were 28(23, 46) years old, FSH 31.3 (18.5, 68.4) IU/L, T 6.72 (0.69, 18.2) nmol/L, and testicular size 5 (1, 8) mL. The success rate of sperm extraction was 45.38%. 88 patients with type f were 29 (24, 38) years old, FSH 18.5 (5.23, 31.6) IU / L, T 8.32 (3.58, 16.5) nmol/L, and testicular size 12 (6, 20) mL. The success rate of sperm extraction was 28.41%.

CONCLUSION

The success rate of micro-TESE in different types of seminiferous tubules in testis can be helpful to the judgement of the surgeon during the operation.

Clinical application of cross microsurgical vasovasostomy in scrotum for atypical obstructive azoospermia

Seminal duct obstruction may result in obstructive azoospermia (OA) and severe oligoasthenoteratozoospermia (OAT) (<0.5 million/mL) (Nordhoff et al., 2015). Cases of partial OA and OAT can be treated effectively by microsurgical anastomosis (Goldstein and Kim, 2013) to obtain successful surgical reversal. However, microsurgical vasovasostomy (VV) (Dickey et al., 2015) and vasoepididymostomy (VE) (Peng et al., 2017) are not suitable for patients with atypical OA and poor epididymis conditions or unpredictable obstruction of the distal vas deferens. For those patients, cross anastomosis may be applied instead of routine VE or VV. A single-center, retrospective, comparison study was conducted, which assessed the usefulness of the cross VV (CVV) in the scrotum for indication and efficacy. A total of 77 cases with OA or OAT were included, and 20 cases implemented cross anastomosis, including unilateral CVV (UCVV) in 4 cases, unilateral VE plus CVV (UVE+CVV) in 11 cases, and unilateral VV-based CVV (UVV+CVV) in 5 cases. The other 57 cases received no cross-matching anastomosis. The patency and natural pregnancy rates in one year were 75.0% and 50.0%, respectively, in the UCVV group; 54.5% and 27.3%, respectively, in the UVE+CVV group; and 60.0% and 40.0%, respectively, in the UVV+CVV group. The CVV in the scrotum in the selected patients with OA and severe OAT could yield good results. We regard the CVV in the scrotum as an efficacious operation with a lower risk of injury in cases of atypical OA.

Sertoli cell only syndrome induced by a varicocele

A case is reported which describes the severity of testicular histological damage that can be induced by a high-grade varicocele in a male with secondary infertility. A chart review of a patient's case was performed. A 34-year-old male with a three-and-a-half-year-old son who was conceived spontaneously with timed intercourse, with a grade three left varicocele, who's semen parameters progressed to non-obstructive azoospermia (NOA). He did not regain sperm in the ejaculate three or six months post left subinguinal microsurgical varicocele repair. He underwent bilateral microdissection testicular sperm extraction (microTESE) without identification of sperm in the testicular samples. A testicular biopsy from the time of microTESE revealed a Sertoli cell only pattern. A high-grade varicocele has the potential to induce sufficient testicular damage to result in the most severe testicular histological architecture associated with non-obstructive azoospermia (NOA), Sertoli cell only syndrome (SCOS).