Evaluation of the azoospermic patient

Molecular cytogenetic characterization of a mosaic small supernumerary marker chromosome derived from chromosome Y in an azoospermic male: A case report

RATIONALE

Small supernumerary marker chromosomes (sSMCs) can be usually discovered in the patients with mental retardation, infertile couples, and prenatal fetus. We aim to characterize the sSMC and explore the correlation between with sSMC and male infertility.

PATIENT CONCERNS

A 26-year-old Chinese male was referred for infertility consultation in our center after 1 year of regular unprotected coitus and no pregnancy.

DIAGNOSIS

Cytogenetic G-banding analysis initially described a mosaic karyotype 47,X,Yqh-,+mar[28]/46,X,Yqh-[22] for the proband, while his father showed a normal karyotype. The chromosome microarray (CMA) analysis showed there existed a duplication of Yp11.32q11.221, a deletion of Yq11.222q12, a duplication of 20p11.1 for the patient. Azoospermia factor (AZF) microdeletion analysis for the patient showed that he presented a de novo AZFb+c deletion. Fluorescence in situ hybridization further confirmed the sSMC was an sSMC(Y) with SRY signal, Y centromere, and Yq deletion.

INTERVENTIONS

The patient would choose artificial reproductive technology to get his offspring according to the genetic counseling.

OUTCOMES

The sSMC in our patient was proved to be an sSMC(Y), derived from Yq deletion. The spermatogenesis failure of the proband might be due to the synthetic action of sSMC(Y) mosaicism and AZFb+c microdeletion.

LESSONS

It is nearly impossible to detect the chromosomal origin of sSMC through traditional banding techniques. The molecular cytogenetic characterization could be performed for identification of sSMC so that comprehensive genetic counseling would be offered.

Decreased expression of DNA methyltransferases in the testes of patients with non-obstructive azoospermia leads to changes in global DNA methylation levels

DNA methylation plays key roles in epigenetic regulation during mammalian spermatogenesis. DNA methyltransferases (DNMTs) function in de novo and maintenance methylation processes by adding a methyl group to the fifth carbon atom of the cytosine residues within cytosine-phosphate-guanine (CpG) and non-CpG dinucleotide sites. Azoospermia is one of the main causes of male infertility, and is classified as obstructive (OA) or non-obstructive (NOA) azoospermia based on histopathological characteristics. The molecular background of NOA is still largely unknown. DNA methylation performed by DNMTs is implicated in the transcriptional regulation of spermatogenesis-related genes. The aim of the present study was to evaluate the cellular localisation and expression levels of the DNMT1, DNMT3A and DNMT3B proteins, as well as global DNA methylation profiles in testicular biopsy samples obtained from men with various types of NOA, including hypospermatogenesis (hyposperm), round spermatid (RS) arrest, spermatocyte (SC) arrest and Sertoli cell-only (SCO) syndrome. In the testicular biopsy samples, DNMT1 expression and global DNA methylation levels decreased gradually from the hyposperm to SCO groups (P P P <0.05). Although both DNMT1 and DNMT3A were localised in the cytoplasm and nucleus of the spermatogenic cells, staining for DNMT3B was more intensive in the nucleus of spermatogenic cells. In conclusion, the findings suggest that significant changes in DNMT expression and global DNA methylation levels in spermatogenic cells may contribute to development of male infertility in the NOA groups. Further studies are needed to determine the molecular biological effects of the altered DNMT expression and DNA methylation levels on development of male infertility.

Low total motile sperm in transgender women seeking hormone therapy

PURPOSE

This study was undertaken to compare semen quality, hormonal status, and social factors in transgender women seeking fertility preservation with those of fertile cisgender men. Long-range goals are to establish standard practice measures ensuring optimum semen quality for cryopreservation and fertility preservation in transgender women.

METHODS

This is a case-control study carried out at an academic medical center. Cases are transgender women seeking fertility preservation prior to initiation of hormone therapy. Controls are cisgender men recently fathering a child. All participants completed the Depression Anxiety Stress Scales 21 survey and additional survey questions related to personal behaviors. Complete semen analysis was carried out in a clinical andrology laboratory according to WHO guidelines, 5th edition. Serum follicle stimulating hormone, estradiol, and testosterone were measured at the time of semen analysis.

RESULTS

Sperm concentration, total sperm per ejaculate, total motile sperm, volume, and normal sperm morphology were significantly lower in transgender females compared with fertile cisgender men. Other measures of semen parameters and hormone concentrations were not different between groups. Survey results indicated transgender women were more likely to have symptoms of depression, anxiety, and stress and utilize tucking and tight undergarments, compared with controls; however, both groups reported similar numbers of ejaculations per week.

CONCLUSIONS

Although semen parameters were low, cryopreservation of sperm prior to hormone therapy is a viable fertility preservation option for most transgender women. The etiology of the differences in semen parameters is not known. Enhanced education related to personal behaviors or treatment to reduce effects of stressors prior to cryopreservation may improve future fertility potential.

FSHB -211 G>T Polymorphism as Predictor for TESE Success in Patients With Unexplained Azoospermia

CONTEXT

Testicular sperm extraction (TESE) followed by assisted reproductive techniques often remains the only therapeutic option for men with azoospermia due to spermatogenic failure. Reproductive parameters, such as gonadotropin levels and testicular volume or histopathology, contribute to the prediction of sperm retrieval rate (SRR) in TESE. However, there is an eminent lack of noninvasive predictive factors for TESE outcome.

OBJECTIVE

To clarify the impact of three common genetic variants affecting FSH and its cognate receptor on testicular histopathology patterns and SRR in TESE.

DESIGN

We evaluated the association of the single-nucleotide polymorphisms (SNP) FSHB -211G>T (rs10835638), FSHR -29G>A (rs1394205), and FSHR c.2039A>G (rs6166) with testicular histopathology and SRR in patients with azoospermia.

SETTING

Tertiary referral center for andrology.

PATIENTS OR OTHER PARTICIPANTS

Men (n = 1075) with azoospermia who underwent TESE (grouped by clinical pathologies).

INTERVENTION(S)

All participants underwent TESE.

MAIN OUTCOME MEASURE(S)

Testicular histopathology, SRR, and reproductive hormone levels.

RESULTS

FSHB -211G>T was significantly associated with reduced chances of sperm retrieval in patients with unexplained azoospermia. Indicating an additional mechanism, the association of the SNP with SSR could not be solely attributed to decreased FSH levels.

CONCLUSION

A common genetic factor was significantly associated with SRR in TESE. In perspective, a calculator or score including the noninvasive parameters FSH level, testicular volume, and FSHB haplotype should be considered to estimate the chances for sperm retrieval in men with azoospermia.

Prospective analysis of factors predicting feasibility & success of longitudinal intussusception vasoepididymostomy in men with idiopathic obstructive azoospermia

Background & objectives

: Microsurgical reconstruction for idiopathic obstructive azoospermia is a challenging procedure, and selection of appropriate patients is important for successful outcomes. This prospective study was done to evaluate the ability of scrotal ultrasound measurements to predict the surgical feasibility and determine factors that could predict a patent anastomosis following vaso-epididymal anastomosis (VE) in men with idiopathic obstructive azoospermia.

Methods

: In this prospective study, men diagnosed with idiopathic obstructive azoospermia, scheduled for a longitudinal intussusception VE, underwent a scrotal ultrasound measurement of testicular and epididymal dimensions. During surgery, site and type of anastomosis, presence of sperms in the epididymal fluid and technical satisfaction with the anastomosis were recorded. All men where VE could be performed were followed up for appearance of sperms in the ejaculate. Ultrasound parameters were compared between men who had a VE versus those with negative exploration. Predictive factors were compared between men with or without a patent anastomosis.

Results

: Thirty four patients were included in the study conducted between September 2014 and August 2016 and a VE was possible in only 19 (55%) patients. Of these 19 patients, six had a patent anastomosis with one pregnancy. Preoperative ultrasound measurements could not identify patients where a VE could not be performed. Motile sperm in the epididymal fluid was the only significant predictor of a successful anastomosis.

Interpretation & conclusion

: Forty five per cent of men planned for a VE for idiopathic obstructive azoospermia could not undergo a reconstruction. Ultrasound assessment of testicular and epididymal dimensions could not predict the feasibility of performing a VE. The presence of motile sperms in the epididymal fluid was the only significant predictor of a patent VE in our study.

Genetic defects in human azoospermia

As with many other diseases, genetic testing in human azoospermia was initially restricted to karyotype analyses (leading to diagnostic chromosome rearrangement tests for Klinefelter and other syndromes). With the advent of molecular biology in the 1980s, genetic screening was broadened to analyses of Y chromosome microdeletions and the gene coding for the cystic fibrosis transmembrane conductance regulator (CFTR). Decades later, the emergence of whole-genome techniques has led to the identification of other genetic defects associated with human azoospermia. Although TEX11 and ADGRG2 defects are frequently described in men with azoospermia, most of the causal gene defects found to date are private (i.e. identified in a small number of consanguineous families).

Here, we provide an up-to-date overview of all the types of genetic defects known to be linked to human azoospermia and try to give clinical practice guidelines according to azoospermia phenotype. Along with homozygous mutations, polymorphisms and epigenetic defects are also briefly discussed. However, as these variations predispose to azoospermia, a specific review will be needed to compile data on all the particular genetic variations reported in the literature.

Effects of obesity on sperm retrieval, early embryo quality and clinical outcomes in men with nonobstructive azoospermia undergoing testicular sperm aspiration-intracytoplasmic sperm injection cycles

The objective of this study was to assess the effects of body mass index (BMI) on sperm retrieval, early embryo quality and clinical outcomes in patients with nonobstructive azoospermia (NOA) undergoing testicular sperm aspiration-intracytoplasmic sperm injection (TESA-ICSI). A total of 3,005 infertile couples were evaluated between January 2010 and June 2017, including 1585 normal-weight (BMI < 25 kg/m² ), 847 overweight (BMI 25-29.99 kg/m² ) and 573 obese (BMI ≥ 30 kg/m² ) patients. We found no significant relationship between BMI and sperm retrieval rate (22.4%, 24.3% and 25.1%, p = 0.327) or sperm motility. Among the 705 patients with NOA who underwent TESA-ICSI cycles, obese individuals had lower T levels and higher E2 levels than normal-weight and overweight individuals. However, there were no significant differences in other male hormones (follicle stimulating hormone [FSH], luteinizing hormone [LH], or prolactin [PRL]) among the groups. We also found that the sperm parameters, embryo quality and clinical outcomes of patients with NOA undergoing TESA-ICSI were not influenced by high BMI levels. In conclusion, this study demonstrated a lack of obvious effects of obesity on sperm retrieval, early embryo quality and clinical outcomes in infertile men undergoing TESA-ICSI cycles, although T and E2 levels were affected.

SLC9A3 Affects Vas Deferens Development and Associates with Taiwanese Congenital Bilateral Absence of the Vas Deferens

Background

The pathophysiology of Taiwanese congenital bilateral absence of the vas deferens (CBAVD) is different from that in Caucasians. In particular, major cystic fibrosis transmembrane conductance regulator (CFTR) mutations and cystic fibrosis are absent in the former. Instead, deficiency in solute carrier family 9 sodium/hydrogen exchanger isoform 3 (SLC9A3) may play a role by generating obstructive azoospermia and degraded epithelial structure in the reproductive tract.

Objectives

The objective of the study was to test whether SLC9A3 variants cause Taiwanese CBAVD.

Materials and Methods

Six-month-old Slc9a3 ^-/-male mice were used to evaluate the effect of long-term SLC9A3 loss on the reproductive system. A case-control cohort of 29 men with CBAVD and 32 fertile men were genotyped for SLC9A3 variants.

Results

SLC9A3 was expressed and localized in the apical border of the epithelium of human vas deferens and glandular epithelium of the seminal vesicle. SLC9A3 deficiency specifically induces atrophy of vas deferens and unfolding of seminal vesicle mucosa in mice. Loss of SLC9A3 increased the incidence of CBAVD in humans from 3.1% to 37.9% (p < 0.001). Up to 75.9% of CBAVD patients carry at least one variant in either SLC9A3 or CFTR.

Discussion

Our findings build upon previous data associated with CBAVD pathogenesis. Here, we now report for the first time an association between CBAVD and loss of SLC9A3 and propose that specific defects in the reproductive duct due to SLC9A3 variants drive CBAVD development.

Conclusion

The data implicate loss of SLC9A3 as a basis of Taiwanese CBAVD and highlight SLC9A3 function in reproduction.

Shorter leukocyte telomere length is associated with risk of nonobstructive azoospermia

OBJECTIVE

To determine the association between leukocyte telomere length and the risk of nonobstructive azoospermia (NOA).

DESIGN

The mean leukocyte telomere length (LTL) among men with NOA, obstructive azoospermia (OA), and normospermic subjects was determined by quantitative polymerase chain reaction (PCR). We used logistic regression to investigate the association between LTL and the risk of NOA after adjustment for age and body mass index (BMI). Partial correlation analysis was also used to evaluate the relationship of clinical parameters with the mean LTL among men with OA and NOA.

SETTING

Reproductive medicine center.

PATIENTS(S)

A total of 866 men, including 270 normospermic controls, 247 OA and 349 NOA patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Leukocyte telomere length.

RESULT(S)

The mean relative LTL of men with NOA was significantly shorter than that of those with OA and in normospermic controls (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.64-0.98 vs. OR 0.92, 95% CI 0.70-1.24 vs. OR 0.99, 95% CI 0.83-1.22), respectively). Subjects with shorter telomeres (lowest tertile) had a significantly higher risk of NOA than those with longer telomeres (highest tertile). Interestingly, we also found that a low relative LTL was associated with poor efficiency of spermatogenesis using the Johnsen score after testis biopsy and histopathology in azoospermic patients, after adjusting for patient age and BMI.

CONCLUSION(S)

This is the first report that short LTL is associated with NOA, shedding light on an important biological pathway involved in the etiology of this form of male factor infertility.

Analysis of factors affecting repeat microdissection testicular sperm extraction outcomes in infertile men

OBJECTIVE

There is no clear consensus on which patients and how many of microscopic testicular sperm extraction (mTESE) procedures will be successful. In this study, we aimed to evaluate the sperm retrieval rates and factors affecting these rates in men who underwent repeat mTESEs.

MATERIAL AND METHODS

A total of 346 patients who underwent mTESE for sperm retrieval were included in the study. Patients were divided into groups according to the number of mTESE operations. Patients' karyotype, follicle-stimulating hormone (FSH) and testosterone levels, varicocele presence, and testis volumes were recorded from patient files. The sperm retrieval rates were compared between groups, and predicting factors for successful sperm retrieval were evaluated.

RESULTS

Microscopic TESE was applied for the first time in 244 patients, 1-2 times in 73 patients, and 3-4 times in 29 patients. There was a significant difference between groups in preoperative FSH values and postoperative testicular histopathology (p=0.004 and p<0.001). The sperm retrieval rate in the group of patients who had not undergone previous TESE was higher than the group of patients that had undergone TESE for 1-2 times and 3-4 times (p=0.028). In addition, testicular volume, histology, karyotype, and Y-chromosome microdeletion were predicting factors for successful sperm retrieval (p=0.011, p=0.039, p=0.002, and p<0.001, respectively).

CONCLUSION

Our results confirm the necessity for repeat mTESE operations to be performed by experienced surgeons in reference centers to optimize the chance of reduced sperm retrieval rates with recurrent biopsies.

Sperm fine-needle aspiration (FNA) mapping after failed microdissection testicular sperm extraction (TESE): location and patterns of found sperm

We sought to evaluate the ability of fine-needle aspiration (FNA) mapping to find sperm and to guide sperm retrieval after failed microdissection testicular sperm extraction (micro-TESE) in nonobstructive azoospermic men. In this study of consecutive male infertility cases, interventions included testicular FNA mapping and subsequent sperm retrieval. Outcomes included the frequency and location of found sperm on FNA maps after failed micro-TESE and the salvage sperm retrieval success. Among 548 patients undergoing FNA mapping from 2010 to 2016, 82 men with previous micro-TESE procedures were identified. The mean time between micro-TESE and FNA mapping was 2.2 years. A total of 2825 (1424 on right and 1401 on left) sites were mapped. At least one site revealed mature sperm in 24 (29.3%) of 82 men with prior failed micro-TESE procedures. There was an equal likelihood of detecting sperm in either testis (6.1% right; 5.7% left; P = 0.58). Digital "heat maps" revealed differences in sperm findings within the testis with mature sperm more likely found in the testis periphery rather than centrally. Fifteen (62.5%) patients subsequently underwent sperm retrieval procedures guided by FNA maps. Sufficient sperm were retrieved in all cases, and in 10 (66.7%) of 15 cases, extra sperm were frozen for future use. In a significant proportion of failed micro-TESE procedures representing the largest study to date, sperm were detected by FNA mapping and could be reliably retrieved through FNA map-guided surgical sperm retrieval. When present, sperm were more likely to be found in the testis periphery rather than centrally with FNA mapping.

Testicular Fine-Needle Aspiration for Sperm Retrieval in Azoospermia: A Small Step toward the Technical Standardization

PURPOSE

The aim was to describe our preliminary experience performing testicular fine-needle aspiration (TEFNA) with a larger needle in infertile patients with obstructive azoospermia, and to provide a systematic literature review of the different testicular sperm aspiration techniques, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations.

MATERIALS AND METHODS

We prospectively collected data between March 2017 and June 2018. All men underwent bilateral TEFNA under analgo-sedation, using a larger disposable 18-gauge butterfly needle with 60 mL Luer-Lock syringe attached to it.

RESULTS

Thirty consecutive patients were enrolled. Median operative time was 16 minutes (interquartile range [IQR]: 12-30 minutes). No intraoperative complications occurred. Two/thirty patients (6.7%) reported postoperative adverse events: 1 patient had prolonged orchialgia, 1 patient presented scrotal hematoma. Successful sperm retrieval was found in 28/30 cases (93.3%). Median sperm concentration was 0.05 ×10⁶/mL (IQR: 0.001-0.1 ×10⁶/mL). Median total sperm motility was 10% (IQR: 0%-15%). In 20/30 men (66.7%) sperm retrieved was used for fresh intracytoplasmic sperm injection cycle, in 8/30 (26.7%) sperm cryopreservation was necessary, because on the day of sperm retrieval the female resulted not responder to ovarian stimulation. In this cases mean number of 3 (IQR: 1-4) bio system straws was cryopreserved.

CONCLUSIONS

TEFNA with 18-gauge needle proved to be a feasible, safe and effective treatment, even if future prospective studies will be addressed to clarify what type of azoospermia benefits from this procedure, and if a larger needle permits to improve Assisted Reproductive Technologies (ART) outcomes.

Microdissection testicular sperm extraction: Overall results and impact of preoperative testosterone level on sperm retrieval rate in patients with nonobstructive azoospermia

Objective:

The main objective is to review the overall result and impact of preoperative testosterone level on sperm retrieval rate (SRR) by microdissection testicular sperm extraction (micro-TESE) in patients with nonobstructive azoospermia (NOA).

Materials and Methods:

We retrospectively reviewed the files of patients who underwent micro-TESE for NOA from August 2013 to December 2014. All patients were evaluated with history, physical examination, and hormonal assessment. Patients who had previous micro-TESE, obstructive azoospermia, or who took hormone therapy were excluded from the study. Patients were classified into two groups. Group A included patients who had low testosterone (<10 nmol/L), and Group B included patients with normal testosterone (>10 nmol/L). The primary endpoint was to review the overall results of the procedure and the impact of preoperative testosterone level on sperm retrieval.

Results:

A total of 264 patients with NOA underwent micro-TESE. Group A included 133 patients with low testosterone (<10 nmol/l) with a median age of 36 ± 6.59 years, and Group B included 131 patients with normal testosterone (>10 nmol/L) with a median age of 33 ± 7.88 years (P = 0.1350). There was no significant difference in follicle-stimulating hormone (P = 0.2467), luteinizing hormone (P = 0.1078), prolactin (P = 0.5619), and testicular volume (P = 0.4052), whereas a significant difference was found in testosterone level (P = 0.0001) in both groups. Overall, sperm were successfully retrieved in 48.8% of men. SRR in Group B was significantly higher (57.25%) than that in Group A (40.60%) (P = 0.0068). SRR in patients with Sertoli-cell-only pathology was 30.35%, hypospermatogenesis was 89.74%, and maturation arrest was 32.43%.

Conclusion:

Micro-TESE is a successful and safe procedure in NOA patients with a poor prognosis. Preoperative testosterone level has a significant impact in the SRR by micro-TESE.

Evaluation of the azoospermic male: a committee opinion

The purpose of this document is to review the current methods of diagnosis and evaluation for men with azoospermia.

Novel method of histopathological analysis after testicular sperm extraction in patients with nonobstructive and obstructive azoospermia

Objective

To assess whether the “testicular pool” could be used for histological analysis and whether it gave more accurate information than the standard testicular biopsy.

Methods

Between January 2017 and March 2018, this single-center prospective study included 60 azoospermic men undergoing conventional bilateral testicular sperm extraction. Six samples were excised from each testicle and transferred to an embryologist. One additional biopsy was randomly taken from each testis for a histological analysis. After processing, the testicular pool was also sent for a histological analysis, which showed normal spermatogenesis (NS), hypospermatogenesis (HYPO), maturation arrest (MA), Sertoli cell-only syndrome (SCOS), and tubular atrophy (TA).

Results

Twenty of the 60 patients (33.3%) had obstructive azoospermia (OA), while the remaining 40 (66.6%) had nonobstructive azoospermia. Their mean age was 40.5 years. All patients with OA had previously undergone unsuccessful testicular fine-needle aspiration. Successful sperm retrieval (SSR) occurred in 93.3% of patients. Histological analysis of the testicular biopsy revealed NS in 12 patients (20%), HYPO and TA in 28 patients (46.6%), MA in eight patients (13.3%), and SCOS in 12 patients (20%). The testicular pool analysis showed NS in 12 patients (20%), HYPO and TA in 44 patients (73.3%), MA in four patients (6.6%), and SCOS in no patients. In four patients with MA (6.6% of the total sample) and 12 patients with SCOS (20% of the total sample) according to the standard testicular biopsy, the embryologist found SSR with cryopreservation. Overall, in 44 patients (73.3%), the testicular pool analysis confirmed the histological findings of the standard testicular biopsy. In the 16 cases (26.6%) with a discrepancy between the single-biopsy histological findings and SSR, the testicular pool analysis confirmed the embryological data on SSR.

Conclusion

The testicular pool proved to be easily analyzable, practical, manageable, and more accurate for predicting sperm retrieval than standard testicular biopsy.

Seminal human papillomavirus originates from the body surface and is not a frequent aetiological factor in azoospermia

Human papillomavirus (HPV) DNA has been detected in the testis tissue of 6.5% of 185 men with non‐obstructive azoospermia (NOA). Others have suggested that seminal HPV originates from contamination from the genital skin and mucosa. One hundred unselected azoospermic men and 43 normal men undergoing vasectomy were recruited. Testicular biopsies for HPV examination were collected from all the men. Additionally, the normal men undergoing vasectomy delivered a semen sample and had a swab for HPV examination taken from the genital skin before vasectomy. A piece of each Vas deferens obtained during the vasectomy was examined for the presence of HPV. Two of the primarily azoospermic men were shown to have cryptozoospermia. It was not possible to detect HPV in the testis tissue of any of the included 98 azoospermic men or the 43 proven fertile men. In the proven fertile men, HPV DNA was detected in the semen of 15 men (35%), on the genital skin of 28 men (65%), and in the Vas deferens in three cases (7%). In 13 (87%) men with HPV‐positive semen samples, HPV DNA was also detected in the skin swabs, and in 11 men (73%), identical HPV genotypes were found in the two locations.

Intraoperative assessment of tubules in predicting microdissection testicular sperm extraction outcome in men with Sertoli cell-only syndrome

Objective

This study aimed to assess the value of measuring the tubule diameter during microdissection testicular sperm extraction (micro-TESE) in predicting outcomes in patients with Sertoli cell-only syndrome (SCOS).

Methods

Fifty-six consecutive patients with SCOS were included. Patients were classified into two groups on the basis of the diameter of seminiferous tubules measured against 5/0 surgical suture (≥100 µm or <100 µm).

Results

The sperm retrieval rate (SRR) in men with a tubule diameter ≥100 µm was significantly lower than that in those with <100 µm (3.1% vs. 25.0%). The SRR from the contralateral testis in men with a tubule diameter ≥100 µm was lower than that in those with <100 µm (0% vs. 14.3%). Men with a tubule diameter ≥100 µm had a significantly larger testis and lower follicle-stimulating hormone levels than did men with <100 µm (8.1 ± 2.4 vs. 5.3±1.8 mL, 19.9 ± 9.7 vs. 25.9 ± 7.1 mIU/mL, respectively).

Conclusions

The diameter of tubules is a useful predictor for a successful SRR in men with SCOS. Intraoperative assessment of homogeneous large tubules allows some men to perform a limited (superficial) contralateral micro-TESE after no spermatozoa are initially identified.

A Search for Disorders of Sex Development among Infertile Men

A retrospective cross-sectional study was performed in a DSD clinic at a tertiary service (University Hospital) to estimate the frequency of disorders of sex development (DSD) among men who seek medical care because of infertility. The sample included 84 men >20 years of age referred from 2010-2017 due to oligozoospermia or nonobstructive azoospermia of unknown etiology. Twelve cases (14%) were diagnosed as DSD, including Klinefelter Syndrome, 46,XX testicular DSD, and mild androgen insensitivity syndrome. Y chromosome microdeletions were detected in 2 patients. Among the remaining 70 cases there were patients with chromosome abnormalities which are not included in the DSD classification as well as rare NR5A1 variants of uncertain significance and hypergonadotropic hypogonadism and microorchidism in 46,XY subjects. In conclusion, the frequency of DSD in this study was 14%, consisting mainly of sex chromosome abnormalities but also 46,XX and 46,XY DSD. However, this figure may increase as further investigations are conducted in idiopathic cases with signs of primary testicular failure, which may present partial gonadal dysgenesis.

Results of intracytoplasmic sperm injection performed with sperm retrieved by microscopic testicular sperm extraction in azoospermic patients

OBJECTIVE

The absence of any sperm in the ejaculate is called azoospermia and it is detected in 1% of males and 10-15% of those with infertility complaints. Azoospermia may be due to obstructive (OA) and non-obstructive (NOA) causes. Today, healthy pregnancies can be achieved in azoospermic patients by intracytoplasmic sperm injection (ICSI) performed using sperm retrieved from microscopic testicular sperm extraction (m-TESE). In this study, we examined the sperm retrieval rates with m-TESE in azoospermic patients, the results of ICSI in OA and NOA patients with sperm and the underlying testicular pathologies in patients without sperm.

MATERIAL AND METHODS

Patients who underwent m-TESE at IVF unit of our hospital between January 2005 and April 2017 were retrospectively reviewed. A total of 342 azoospermic patients (117 OA and 225 NOA cases) with regular follow-up were included in the study. In these cases, sperm retrieval and clinical pregnancy rates after ICSI were compared.

RESULTS

In the m-TESE procedure, motile sperm was found in all of the OA patients and in 52.4% (118/225) of the NOA patients. Clinical pregnancy rate in the OA group was 29.9% (35/117) and live birth rate was 25.6% (30/117). In the NOA group, the clinical pregnancy rate was 27.1% (32/118) and the live birth rate was 23.7% (27/118). Histopathologic evaluation was made in 107 cases in the NOA group with no testicular sperm, revealing that 59 cases with germ-cell aplasia (sertoli-cell only syndrome), 42 cases with maturation arrest, and 6 cases with hypospermatogenesis. Postoperative hematoma developed in 3 of m-TESE cases and subsided with conservative treatment.

CONCLUSION

If motile sperm is retrieved with m-TESE application in azoospermic patients, pregnancy resulting in one live birth in about 4 couples who undergo ICSI application can be achieved. In the presence of motile sperm, live birth rates are similar between OA and NOA case with very low complication rates.

Pregnancy and Neonatal Outcomes in Azoospermic Men After Intracytoplasmic Sperm Injection Using Testicular Sperm and Donor Sperm

Background

The safety of intracytoplasmic sperm injection (ICSI) with testicular sperm in azoospermic men has been a concern. We evaluated ICSI outcomes, including neonatal outcomes, in children born using testicular sperm or donor sperm.

Material/Methods

Ninety-nine males with nonobstructive azoospermia (NOA) who underwent microdissection testicular sperm extraction (micro-TESE) and 126 males with obstructive azoospermia (OA) were included in this study. Sixty-one patients with NOA used donor sperm for ICSI on the day of oocyte retrieval when no spermatozoa were identified by micro-TESE on the day before oocyte retrieval. ICSI outcomes were compared among OA, donor, and NOA groups.

Results

There was no statistical difference in terms of female partner characteristics among OA, donor, and NOA groups. The normal fertilization rate (P=0.005), high quality embryo rate (P=0.014), implantation rate (P<0.001), clinical pregnancy rate (P=0.015), live birth rate (P=0.043) were significant lower in the NOA group, compared with the donor sperm group. The normal fertilization rate was significant lower in the NOA group than the OA group (P<0.001), but the live birth rate was not significantly lower (P=0.058). The high-quality embryo rate (P=0.014) and implantation rate (P=0.009) were lower in the OA group than the donor group. No differences between groups were observed in our study regarding neonatal parameters of the infants born.

Conclusions

The fertilization and pregnancy outcomes were negatively affected by using testicular sperm from males with NOA. Once a live birth was achieved, there was no difference in neonatal outcomes.

Evaluation of Prognostic Factors and Determinants in Surgical Sperm Retrieval Procedures in Azoospermic Patients

Introduction:

Main categorisation of azospermic is in two grups: nonobstructive azoospermia (NOA) and obstructive azoospermia (OA). We had evaluation of prognostic factors and determinants in sperm retrieval procedures in azoospermic patients.

Methods:

Retrospective evaluation observed 21 selected patients with NOA and OA azoospermia, after that complete history, physical examination with ultarsound volume of testis and hormonal profile. Hormonal profile included: follicle stimulating hormone (FSH), luteinizing hormone (LH), testosteron (T) and prolactin (P) serum levels. Also karyotype and Y-deletion analysis were done and analyzed.

Results:

9 OA patients (42,9%) were undergone for TESE operation and 12 NOA patients (57,1%) for Micro-TESE operation. All TESE procedures were positive (100%). Micro-TESE in 12 selected NOA patients, 5 patients (41,6%) were positive and 7 patients (58,4%) negative. Patients testicular size, serum FSH and testosterone level showed correlation in success of sperm retrieval procedures.

Conclusion:

TESE is elected procedure for obstructive azospermia (OA). Micro-TESE is appropriate sperm retrieval procedurec for patients with non-obstructive azoospermia (NOA) and correlate with high FSH and small volume of testis.

An Evaluation of Reported Follicle-stimulating Hormone, Luteinizing Hormone, Estradiol, and Prolactin Reference Ranges in the United States

OBJECTIVE

To characterize US clinical laboratory reference range reporting and testing methods of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and prolactin.

METHODS

One hundred and seventeen US laboratories were surveyed. Outcomes measured were variation in lower and upper limits of normal male reference ranges for serum FSH, LH, estradiol, and prolactin, method of analysis and source of reference range RESULTS: The upper limit of normal reference ranges for FSH, LH, estradiol, and prolactin varied substantially across laboratories compared to the lower limits. The range of upper limits of FSH, LH, estradiol, and prolactin respectively are 7.9-20.0, 4.9-86.5, 37.7-77.0, and 7.4-25.0. Ninety-four percent of laboratories performed measurements on in-house high throughput analyzer utilizing immunoassays. Seventy percent of reported reference ranges for each hormone were based on validation studies of the analyzer's package insert values. Ten percent of laboratories derived their own reference ranges. Both the validation studies and derivations were based on a limited number of patient samples, ranging from 20 to 200.

CONCLUSION

Current reference ranges are based on small population studies of men with unknown medical histories, sexual or reproductive function. Influence of race and age has not been evaluated and could potentially be important in normal variation. The absence of standard information has yielded a spectrum of upper and lower normal values, which could delay an appropriate male infertility evaluation. Our findings highlight the need for a large population study of males with known normal sexual and reproductive function to formulate more accurate clinical reference ranges.

DNA Flow cytometric analysis of the human testicular tissues to investigate the status of spermatogenesis in azoospermic patients

A single, rapid and reproducible diagnostic test to predict the type of azoospermia and outcome of sperm retrieval is not yet available. So the feasibility of employing DNA flow cytometry for rapid investigation of the status of spermatogenesis in the patients with azoospermia was investigated. Testicular biopsies of 44 patients with azoospermia undergoing sperm-retrieval surgery and 4 controls were analyzed by flow cytometry to ascertain their testicular germ-cell patterns. The observed germ-cell pattern was further confirmed by RT-PCR analysis of the cell-specific markers and histology for some patients. The patients with Obstructive Azoospermia (OA) exhibited normal spermatogenesis similar to the control fertile patients showing the presence of diploid, double-diploid and haploid cells. The non-obstructive azoospermia (NOA) patients exhibited disrupted spermatogenesis with arrest at the pre-meiotic (only diploid cells present) or meiotic (diploid and double-diploid cells present) stages. The germ-cell pattern, as ascertained by flow cytometry, provided a clear picture of the intra-testicular spermatogenesis and the presence of spermatozoa in the patients’ testes, which was prognostic of their sperm-retrieval. DNA flow cytometry test to ascertain the testicular germ-cell pattern is simple in execution, analysis and interpretation, requires small amount of tissue and provides quantitative data about the status of spermatogenesis in patients. This test would allow comparable analysis of the status of spermatogenesis in patients across clinics and may form the basis for deciding future treatment and intervention strategies.

Spermatogenesis after Transplantation of Adipose Tissue-Derived Stem Cells in Azoospermic Guinea Pigs: A Histological and Histomorphometric Study

Background:

The purpose of this research was to determine histomorphometric changes in busulfan-induced azoospermia after transplantation of Adipose Tissue-Derived Stem Cells (AdSCs) in guinea pig. AdSCs were isolated from adipose tissue around the testes of guinea pigs and characterized for mesenchymal properties.

Materials and Methods:

Guinea pigs were allocated into three groups, including the control group without any intervention. To induce azoospermia, groups 2 and 3 received a dose of 40 mg/kg of busulfan with 21 days interval. Group 3 received 1×106 AdSCs in their seminiferous tubules of left testes, 35 days following last busulfan injection, while right testis in the group was considered for comparison as controls. Sixty days following transplantation of cell, histomorphometric and histopathologic changes of the experiments were assessed.

Results:

After AdSCs’ transplantation, normal spermatogenesis appearance was noticed compared to busulfan-induced azoospermia and AdSCs recovered spermatogenesis, and our findings can be added to the literature in treating azoospermic infertilities.

Conclusion:

The transplanted AdSCs could induce production of germinal cells using testicular seminiferous tubules and were an effective source in treating azoospermia

Heterogenicity of testicular histopathology and tubules as a predictor of successful microdissection testicular sperm extraction in men with nonobstructive azoospermia

Only a few studies evaluate the presence of spermatozoa intraoperatively. The study aimed to assess whether the heterogenicity of testicular histopathology and seminiferous tubules can predict the outcome of microdissection testicular sperm extraction (micro-TESE) in men with nonobstructive azoospermia (NOA).The study comprised a retrospective analysis of 94 patients with azoospermia who were referred from 2016 to 2017. Under optical magnification, they were classified into 2 groups based on the diameter of tubules intraoperatively, namely homogeneous tubules and heterogeneous tubules. Postoperatively, patients were divided into 2 groups of heterogeneous histopathology and homogeneous histopathology according to the 8 histopathological classification subgroups. The sperm retrieval rate was the main outcome.Testicular spermatozoa were successfully retrieved in 27 men (28%). The sperm retrieval rate in those with heterogeneous histopathology was higher than men with homogeneous histopathology (47% vs 12%; P < .001). The sperm retrieval rate of each histopathological subgroup in men who had the heterogeneous histopathology was higher, compared with the homogeneous histopathology (Sertoli cell only [SCO]: 30% vs 6%; maturation arrest [MA]: 38% vs 0%; tubular hyalinization: 42% vs 20%, respectively). Under the optical magnification, the sperm retrieval rate was significantly higher in men with heterogeneous vs homogeneous tubules (65% vs 15%, P < .001). Moreover, the sperm retrieval rate of the contralateral testicular was higher in men who had heterogeneous tubules, compared with the homogeneous tubules (25% vs 3%; P = .036).Heterogenicity of histopathology is an effective predictor in men with histopathological information available from a previous diagnostic biopsy or conventional TESE attempt preoperatively for successful sperm retrieval. Homogeneous tubules seem beneficial for some patients to perform a limited (superficial) contralateral micro-TESE after no spermatozoa were identified initially.

Reporting on longitudinal live birth rates and cumulative delivery rates are more realistic outcome measures than sperm retrieval rates in couples undergoing mTESE-ICSI

The live birth rates (LBRs) in men with non-obstructive azoospermia (NOA) undergoing microdissection TESE (mTESE) are under reported, with surgical sperm retrieval rate often used as the primary outcome measure. We analysed longitudinal and cumulative delivery rates following mTESE- intracytoplasmic sperm injection (ICSI) in NOA. Sperm was retrieved in 45% of patients undergoing mTESE. Median male and female age were 42 years (IQR 37-47) and 35 years (IQR 31-38) respectively. A total of 141 ICSI cycles and 23 frozen embryo transfers resulted in 62 pregnancies and 37 LBRs. The longitudinal LBR, crude and expected cumulative delivery rates after five cycles were 15.5%, 48.7% and 71.1%, respectively. Reassuringly, there was no significant difference in pregnancy rate (PR) (p = 0.37) or LBR (p = 0.68) using fresh or frozen sperm or embryo (p = 0.74). Sperm retrieval was significantly correlated with Johnsen score (JS) (p = 0.006) and hypospermatogenesis (HS) (p = 0.04), whilst LBR only significantly correlated with female age (p = 0.04). The longitudinal LBR for a couple embarking on mTESE for azoospermia is only 15.5%, although the cumulative delivery rates are promising. Reassuringly, the outcomes using fresh versus frozen embryos or sperm are comparable. Reporting on delivery rates from a single mTESE procedure are more objective and realistic measures of treatment success in men with NOA.

Sonography in male infertility: a look beyond the obvious

Infertility affects 15-20% of the reproductive age range population; the male factor accounts for up to 40-60% of these. With female factor infertility catching most of the limelight in research, diagnosis and treatment, the other half of the problem has not been duly addressed. Imaging has an important role to play in the evaluation of male infertility, especially to identify correctible (obstructive) causes. We review the scrotal, trans-rectal sonographic and Doppler findings in infertile men to aid in the accurate diagnosis and proper management of such patients.

Relevance of testicular histopathology on prediction of sperm retrieval rates in case of non-obstructive and obstructive azoospermia

Introduction:

The aim of our research was to establish the relevance of testicular histopathology on sperm retrieval after testicular sperm extraction in patients with non-obstructive azoospermia and in patients with obstructive azoospermia, who already underwent a previous failure testicular fine needle aspiration.

Methods:

We evaluated a total of 82 azoospermic men, underwent testicular sperm extraction, referring to the Assisted Reproductive Technology Centre of the University of Florence, Italy between January 2008 and March 2017. A general and genital physical examination, scrotal and trans-rectal ultrasound, semen analysis, hormone measurements, including follicle-stimulating hormone, luteinizing hormone and total testosterone, were collected.

Results:

Successful sperm retrieval was obtained in 36 men of total (43.9%). Successful sperm retrieval was 29.5% in non-obstructive azoospermia patients, while men with obstructive azoospermia, who, underwent a previous failure testicular fine needle aspiration, had sperm retrieval in 86% of cases. Mean luteinizing hormone was 6.55 IU/L, total testosterone 4.70 ng/mL, right testicular volume 13.7 mL and left testicular volume 13.6 mL. Mean Follicle-stimulating hormone was 13.45 IU/L in patients with negative sperm retrieval and 8.18 IU/L in men with successful sperm retrieval. According to histology, 20.7% had normal spermatogenesis, 35.3% hypospermatogenesis, 35.3% maturation arrest and 8.5% Sertoli cell-only syndrome. Successful sperm retrieval was 88.2% in patients with normal spermatogenesis, 24.1% in the maturation arrest group and 48.27% in patients with hypospermatogenesis, while negative sperm retrieval was reported in Sertoli cell-only syndrome patients. Seven cases with maturation arrest showed a successful sperm retrieval.

Conclusion:

Testicular histopathology after testicular sperm extraction offers important information on prediction of sperm retrieval and can guide the surgeon in choosing the more suitable therapeutic practice.

Next-generation sequencing for patients with non-obstructive azoospermia: implications for significant roles of monogenic/oligogenic mutations

Azoospermia affects up to 1% of adult men. Non-obstructive azoospermia is a multifactorial disorder whose molecular basis remains largely unknown. To date, mutations in several genes and multiple submicroscopic copy-number variations (CNVs) have been identified in patients with non-obstructive azoospermia. The aim of this study was to clarify the contribution of nucleotide substitutions in known causative genes and submicroscopic CNVs in the genome to the development of non-obstructive azoospermia. To this end, we conducted sequence analysis of 25 known disease-associated genes using next-generation sequencing and genome-wide copy-number analysis using array-based comparative genomic hybridization. We studied 40 Japanese patients with idiopathic non-obstructive azoospermia. Functional significance of molecular alterations was assessed by in silico analyses. As a result, we identified four putative pathogenic mutations, four rare polymorphisms possibly associated with disease risk, and four probable neutral variants in 10 patients. These sequence alterations included a heterozygous splice site mutation in SOHLH1 and a hemizygous missense substitution in TEX11, which have been reported as causes of non-obstructive azoospermia. Copy-number analysis detected five X chromosomal or autosomal CNVs of unknown clinical significance, in addition to one known pathogenic Y chromosomal microduplication. Five patients carried multiple molecular alterations. The results indicate that monogenic and oligogenic mutations, including those in SOHLH1 and TEX11, account for more than 10% of cases of idiopathic non-obstructive azoospermia. Furthermore, this study suggests possible contributions of substitutions in various genes as well as submicroscopic CNVs on the X chromosome and autosomes to non-obstructive azoospermia, which require further validation.

Isolated follicle stimulated hormone deficiency in male: case report

Background

Recent rapid advances in assisted reproductive health technologies enables couples with subfertility to conceive through various intervention. Majority of treatment modalities target the female partner. However it is important to identify and treat male factor subfertility right at the outset. We report a case of isolated follicle stimulating hormone deficiency resulting in azoospermia and primary subfertility.

Case presentation

A 28 year otherwise healthy male presented with primary subfertility with a healthy female counterpart. He was found to have non obstructive azoospermia with low seminal fluid volume. He had normal external genitalia and potency with increased libido. Further evaluation revealed an isolated deficiency of follicle stimulating hormone with elevated testosterone levels. His luteinizing hormone and prolactin levels were normal. Contrast enhanced CT scan of chest, abdomen and pelvis and MRI scan of the pituitary fossa were normal too.

Conclusion

In the era of modern reproductive technology it is important to further evaluate males with non-obstructive azoospermia to detect underlying gonadotropin deficiency.

Microdissection testicular sperm extraction in Finland - results of the first 100 patients

INTRODUCTION

Testicular microdissection sperm extraction (MD-TESE) combined with intracytoplasmic sperm injection (ICSI) has made biological fatherhood possible for many men with the most severe form of male infertility, non-obstructive azoospermia. MD-TESE was introduced in Turku in 2008, and by 2015, 100 Finnish men with non-obstructive azoospermia have been operated on.

MATERIAL AND METHODS

The average age of the men was 33 years at the time of surgery. Forty-eight had a needle biopsy previously and 56% had a testicular size <15 mL. The most common diagnoses were idiopathic (n = 65), Klinefelter syndrome (n = 15), operated cryptorchidism or torsion (n = 10), and Y chromosome microdeletion (n = 7). The pregnancy outcomes were followed.

RESULTS

The sperm recovery rate (SRR) overall was 42%: 31% for idiopathic non-obstructive azoospermia, 40% for Klinefelter syndrome, 57% for Y chromosome microdeletion AZFc, 90% for previous testicular surgery (mostly for cryptorchidism; n = 10) and 67% for previous cytotoxic treatment (n = 3). SRR with histopathologic diagnosis Sertoli-cell-only was 29%, and 44% for spermatogenic arrest. Age did not affect the outcome of the surgery. Small testicular size seemed to predict a higher SRR. A previous needle biopsy did not predict a lower SRR. Surgical complications were rare. Of couples, 32 had at least one ICSI attempt, and 22 at least one live birth, giving a cumulative live birth rate of 69%. No major pregnancy complications occurred.

CONCLUSIONS

Our SRR is comparable with international results, and the cumulative live birth rate similar to other ICSI indications in Finland. Physicians and specialists need to be made aware of new treatment options to enable biological fatherhood for men with non-obstructive azoospermia.

Superior clinical pregnancy rates after microsurgical epididymal sperm aspiration

Purpose

To assess normal fertilization, clinical pregnancy, and live birth rates after the use of microscopic epididymal sperm aspiration (MESA).

Methods

One-hundred-and-sixty azoospermic participants who underwent MESA were evaluated. The MESA was performed by using a micropuncture method with a micropipette. In cases in which motile sperm were not obtained after the MESA, conventional or micro-testicular sperm extraction (TESE) was completed.

Results

Adequate motile sperm were retrieved in 71 participants by using MESA and in 59 out of 89 participants by using TESE. Of the total number of patients, 123 underwent intracytoplasmic sperm injection. After MESA, the normal fertilization rate was 73.5% and the clinical pregnancy rate per case was 95.7%. Healthy deliveries resulted after MESA in 65 (92.9%) cases and after TESE in 38 (71.7%) cases.

Conclusion

The MESA specimen collection does not have any special requirements, such as mincing tissue disposition. The MESA also can reduce the amount of laboratory work that is needed for cryopreservation. In the authors' experience, MESA is a beneficial procedure and should be given priority over TESE.

Fertility outcomes after extended searches for ejaculated spermatozoa in men with virtual azoospermia

OBJECTIVE

To assess the fertility outcomes of extended searches for ejaculated spermatozoa in men with virtual azoospermia.

DESIGN

A retrospective cohort of 242 couples whose male partner suffered from nonobstructive azoospermia and who were treated with the use of intracytoplasmic sperm injection (ICSI).

SETTING

Not applicable.

PATIENT(S)

One hundred forty patients were referred to an extended search in the ejaculate and 102 patients were referred to microsurgical testicular sperm extraction (microTESE).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rates of sperm retrieval, fertilization, and pregnancy, take-home baby rate, and missed abortion rate were analyzed and compared.

RESULT(S)

In the ejaculated spermatozoa group, motile spermatozoa were retrieved in 91 cases (65%) and on oocyte pick-up day in 71 cases (78%), compared with 70 cases (68%) in the microTESE group, with a similar incidence of sperm retrieval between groups. No significant difference was found between groups regarding mean number of embryo transfer and fertilization and pregnancy rates. There was no significant difference between groups regarding take-home baby rate. A significantly higher first-trimester missed abortion rate was found in the ejaculated sperm group (n = 14; 52%) compared with the microTESE group (n = 3; 8.6%).

CONCLUSION(S)

Conducting an extended spermatozoa search in the ejaculate of men with virtual azoospermia can provide pregnancy rates similar to those obtained with the use of microTESE, with a higher rate of spontaneous abortions in the ejaculate group.

Prospective evaluation of scrotal ultrasound and intratesticular perfusion by color-coded duplex sonography (CCDS) in TESE patients with azoospermia

PURPOSE

The objective of this study was to assess whether CCDS might improve the outcome of testicular sperm retrieval in patients with azoospermia. Furthermore, we evaluated potential sonographic alterations of the testis before and after trifocal and Micro-TESE.

METHODS

78 patients were enrolled prospectively: 24 with obstructive azoospermia (OA) and 54 with non-obstructive azoospermia (NOA). 31 of 54 patients in the NOA group had negative surgical sperm retrieval. Testicular volume, hormonal parameters and sonographical findings were compared before and after TESE. The spermatogenetic score was determined for all retrieval sites. CCDS was performed at the upper, middle and lower segment of the testis. Ultrasound parameters and peak systolic velocity (PSV) were measured pre- and post-operatively.

RESULTS

Testicular volume and epididymal head size were significantly increased in OA patients compared to NOA patients. Ultrasound parameters were comparable between NOA patients with and without successful sperm retrieval. A higher intratesticular PSV was significantly correlated with a better spermatogenic score in the corresponding sonographic position. However, after adjustment for other clinical confounders, PSV does not show a significant influence on the spermatogenic score. Testicular volume decreased significantly in all patients post-operatively after 6 weeks (p < 0.001). Finally, the PSV significantly increased in all patients 24 h after surgery and nearly returned to baseline levels after 6 weeks (p < 0.001).

CONCLUSIONS

A higher intratesticular PSV may be helpful as a pre-operative diagnostic parameter in mapping for better sperm retrieval, but CCDS does not help to predict successful testicular sperm retrieval after adjustment for other clinical confounders.

A no-stop mutation in MAGEB4 is a possible cause of rare X-linked azoospermia and oligozoospermia in a consanguineous Turkish family

PURPOSE

The purpose of this study was to identify mutations that cause non-syndromic male infertility using whole exome sequencing of family cases.

METHODS

We recruited a consanguineous Turkish family comprising nine siblings with male triplets; two of the triplets were infertile as well as one younger infertile brother. Whole exome sequencing (WES) performed on two azoospermic brothers identified a mutation in the melanoma antigen family B4 (MAGEB4) gene which was confirmed via Sanger sequencing and then screened for on control groups and unrelated infertile subjects. The effect of the mutation on messenger RNA (mRNA) and protein levels was tested after in vitro cell transfection. Structural features of MAGEB4 were predicted throughout the conserved MAGE domain.

RESULTS

The novel single-base substitution (c.1041A>T) in the X-linked MAGEB4 gene was identified as a no-stop mutation. The mutation is predicted to add 24 amino acids to the C-terminus of MAGEB4. Our functional studies were unable to detect any effect either on mRNA stability, intracellular localization of the protein, or the ability to homodimerize/heterodimerize with other MAGE proteins. We thus hypothesize that these additional amino acids may affect the proper protein interactions with MAGEB4 partners.

CONCLUSION

The whole exome analysis of a consanguineous Turkish family revealed MAGEB4 as a possible new X-linked cause of inherited male infertility. This study provides the first clue to the physiological function of a MAGE protein.

Preclinical evaluation of a TEX101 protein ELISA test for the differential diagnosis of male infertility

BACKGROUND

TEX101 is a cell membrane protein exclusively expressed by testicular germ cells and shed into seminal plasma. We previously verified human TEX101 as a biomarker for the differential diagnosis of azoospermia, and developed a first-of-its-kind TEX101 ELISA. To demonstrate the clinical utility of TEX101, in this work we aimed at evaluating ELISA performance in a large population of fertile, subfertile, and infertile men.

METHODS

Mass spectrometry, size-exclusion chromatography, ultracentrifugation, and immunohistochemistry were used to characterize TEX101 protein as an analyte in seminal plasma. Using the optimized protocol for seminal plasma pretreatment, TEX101 was measured by ELISA in 805 seminal plasma samples.

RESULTS

We demonstrated that TEX101 was present in seminal plasma mostly in a free soluble form and that its small fraction was associated with seminal microvesicles. TEX101 median values were estimated in healthy, fertile pre-vasectomy men (5436 ng/mL, N = 64) and in patients with unexplained infertility (4967 ng/mL, N = 277), oligospermia (450 ng/mL, N = 270), and azoospermia (0.5 ng/mL, N = 137). Fertile post-vasectomy men (N = 57) and patients with Sertoli cell-only syndrome (N = 13) and obstructive azoospermia (N = 36) had undetectable levels of TEX101 (≤0.5 ng/mL). A cut-off value of 0.9 ng/mL provided 100% sensitivity at 100% specificity for distinguishing pre- and post-vasectomy men. The combination of a concentration of TEX101 > 0.9 ng/mL and epididymis-specific protein ECM1 > 2.3 μg/mL provided 81% sensitivity at 100% specificity for differentiating between non-obstructive and obstructive azoospermia, thus eliminating the majority of diagnostic testicular biopsies. In addition, a cut-off value of ≥0.6 ng/mL provided 73% sensitivity at 64% specificity for predicting sperm or spermatid retrieval in patients with non-obstructive azoospermia.

CONCLUSIONS

We demonstrated the clinical utility of TEX101 ELISA as a test to evaluate vasectomy success, to stratify azoospermia forms, and to better select patients for sperm retrieval.

Processing and selection of surgically-retrieved sperm for ICSI: a review

Although the technique of intracytoplasmic sperm injection (ICSI) has been a revolution in the alleviation of male infertility, the use of testicular sperm for ICSI was a formerly unseen breakthrough in the treatment of the azoospermic man with primary testicular failure. At the clinical level, different procedures of testicular sperm retrieval (conventional TESE, micro-TESE, FNA/TESA, MESA, PESA) are being performed, the choice is mainly based on the cause of azoospermia (obstructive versus non-obstructive) and the surgeon's skills. At the level of the IVF laboratory, mechanical procedures to harvest the sperm from the tissue may be combined with enzymatic treatment in order to increase the sperm recovery rates. A number of techniques have been developed for viable sperm selection in males with only immotile testicular sperm available. However, large, well-designed studies on the benefit and safety of one over the other technique are lacking. Despite all the available methods and combinations of laboratory procedures which have a common goal to maximize sperm recovery from testicular samples, a large proportion of NOA patients fail to father a genetically own child. Advanced technology application may improve recovery rates by detection of the testicular foci with active spermatogenesis and/or identification of the rare individual sperm in the testicular suspensions. On the other hand, in vitro spermatogenesis or sperm production from embryonic stem cells or induced pluripotent stem cells might be future options. The present review summarizes the available strategies which aim to maximize sperm recovery from surgically retrieved samples.

An easy, reproducible and cost-effective method for andrologists to improve the laboratory diagnosis of nonobstructive azoospermia: a novel microcentrifugation technique

This study describes a new method of microcentrifugation as an improved, viable, cost-effective option to the classical Cytospin apparatus to confirm azoospermia. Azoospermic semen samples were evaluated for cryptozoospermia by a centrifugation method similar to that of World Health Organization guidelines (2010; entire specimen centrifuged at 3000g for 15 min, and aliquots of the pellet examined). Then, if no sperm were detected, the pellet from that procedure was resuspended in culture medium, centrifuged (2000g for 15 min), and the entire pellet spread on a 4 X 6mm area of a slide and stained using the Christmas tree method (Nuclear-Fast solution and picric acid). The entire stained area was examined for the presence or absence of sperm. A total of 148 azoospermic samples (after standard WHO diagnosis) were included in the study and 21 samples (14.2%) were identified as sperm-positive. In all microcentrifugation slides, intact spermatozoa could be easily visualized against a clear background, with no cellular debris. This novel microcentrifugation technique is clearly a simple and effective method, with lower cost, increasing both sensitivity and specificity in confirming the absence or presence of spermatozoa in the ejaculate. It may represent a step forward of prognostic value to be introduced by andrology laboratories in the routine evaluation of patients with azoospermia in the initial semen analysis.

Single-nucleotide polymorphisms in the human RAD21L gene may be a genetic risk factor for Japanese patients with azoospermia caused by meiotic arrest and Sertoli cell-only syndrome

Genetic mechanisms are implicated in some cases of male infertility. Recently, it was demonstrated that male mice lacking the gene for RAD21L exhibited azoospermia caused by meiotic arrest. Mouse RAD21L is a functionally relevant meiotic α-kleisin that is essential for male fertility. Therefore, we hypothesized that RAD21L mutations or polymorphisms may be associated with male infertility, especially azoospermia secondary to meiotic arrest. To determine if RAD21L defects are associated with azoospermia in groups of patients with meiotic arrest, we performed direct sequencing of the RAD21L coding regions in 38 Japanese patients with meiotic arrest and in 200 normal controls. Three coding single-nucleotide polymorphisms (SNP1-SNP3) were detected in the meiotic arrest patient group. Sertoli cell-only syndrome is considered a common cause of non-obstructive azoospermia. For comparison, the RAD21L coding regions in which SNP1-SNP3 were detected were sequenced in 140 patients with Sertoli cell-only syndrome. Statistical analyses were used to compare the two groups of patients with the control group. Genotype and allele frequencies of SNP2 and SNP3 were notably higher in the two patient groups compared with the control group (Bonferroni adjusted p value <0.016). These results suggest a critical role for RAD21L in human spermatogenesis.

Advanced forensic validation for human spermatozoa identification using SPERM HY-LITER™ Express with quantitative image analysis

Identification of human semen is indispensable for the investigation of sexual assaults. Fluorescence staining methods using commercial kits, such as the series of SPERM HY-LITER™ kits, have been useful to detect human sperm via strong fluorescence. These kits have been examined from various forensic aspects. However, because of a lack of evaluation methods, these studies did not provide objective, or quantitative, descriptions of the results nor clear criteria for the decisions reached. In addition, the variety of validations was considerably limited. In this study, we conducted more advanced validations of SPERM HY-LITER™ Express using our established image analysis method. Use of this method enabled objective and specific identification of fluorescent sperm's spots and quantitative comparisons of the sperm detection performance under complex experimental conditions. For body fluid mixtures, we examined interference with the fluorescence staining from other body fluid components. Effects of sample decomposition were simulated in high humidity and high temperature conditions. Semen with quite low sperm concentrations, such as azoospermia and oligospermia samples, represented the most challenging cases in application of the kit. Finally, the tolerance of the kit against various acidic and basic environments was analyzed. The validations herein provide useful information for the practical applications of the SPERM HY-LITER™ Express kit, which were previously unobtainable. Moreover, the versatility of our image analysis method toward various complex cases was demonstrated.

Pregnancy and live birth rates after microsurgical vasoepididymostomy for azoospermic patients with epididymal obstruction

STUDY QUESTION

Can microsurgical vasoepididymostomy (MVE) be an effective treatment for azoospermic men with epididymal obstruction?

SUMMARY ANSWER

MVE is an effective treatment for epididymal obstruction, with overall patency and live birth rates of 76.3% and 34.8%, respectively.

WHAT IS KNOWN ALREADY

We showed that MVE was an effective treatment for non-vasectomized patients with epididymal obstruction and prior failed sperm retrieval for ICSI. ICSI is the preferred treatment for obstructive azoospermia in some reproductive centers. Some small studies documented that MVE could achieve high patency and pregnancy rates.

STUDY DESIGN, SIZE, DURATION

This retrospective study was designed to investigate the natural pregnancy and live birth rates after MVE and to identify possible predictors of pregnancy. From January 2011 to July 2013, 241 patients underwent MVE for epididymal obstruction in our andrology center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients underwent scrotal exploration and MVE. Semen was analyzed every 3 months postoperatively until pregnancy was achieved. Patency, pregnancy and live birth rates were evaluated. Preoperative and intraoperative data were compared between patent and non-patent groups to identify factors affecting the patency rate. Predictors of pregnancy were identified by univariate and multivariate analyses with Cox regression models.

MAIN RESULTS AND THE ROLE OF CHANCE

Data from 198 males (82.2%) were analyzed. The mean (±SD) age of males and female partners was 31.0 ± 5.8 and 28.4 ± 4.4 years, respectively. Sperm was present in the ejaculate of 151 patients (76.3%) postoperatively. Patency rates were increased for patients with bilateral anastomosis, distant anastomosis and motile sperm in epididymal fluid. Overall, 81/198 males (40.9%) reported pregnancy in partners and 73 newborns were delivered. The overall live birth rate was 34.8%. Male age (hazard ratio (HR) [95% CI] 0.407 [0.203-0.816], P = 0.011), sperm concentration (HR [95% CI] 4.988 [2.777-8.957], P < 0.001) and forward motility (HR [95% CI] 1.751 [1.042-2.945], P = 0.035) were predictors of pregnancy.

LIMITATIONS, REASONS FOR CAUTION

A randomized control trial comparing pregnancy rates, live birth rates, risks and medical costs of MVE and IVF/ICSI is needed. The sample size of females >35 years old was small, so we could not determine whether female age was a predictor of pregnancy.

WIDER IMPLICATIONS OF THE FINDINGS

MVE is an effective therapy for azoospermic patients with epididymal obstruction. Sperm concentration and forward motility may predict pregnancy after the procedure. Microsurgical reconstruction could be a first choice for epididymal obstruction.

STUDY FUNDING/COMPETING INTERESTS

No external funding was received. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Microdissection testicular sperm extraction in men with nonobstructive azoospermia: Experience of King Saud University Medical City, Riyadh, Saudi Arabia

Objectives:

Microdissection testicular sperm extraction (micro-TESE) is an optimal technique of sperm extraction for intracytoplasmic sperm injection. This study is to present our experience in micro-TESE and evaluate the relation of its sperm retrieval rate (SRR) with patients' characteristics, testicular functions, and histological parameters as well as previous sperm retrieval interventions.

Materials and Methods:

We retrospectively reviewed records of 255 patients with nonobstructive azoospermia who underwent micro-TESE between 2011 and 2014. Medical records were reviewed for the results of follicle stimulating hormone (FSH), luteinizing hormone (LH), total testosterone levels, karyotype analysis, and testicular histology pattern. Testicular volume was measured with an ultrasound scale.

Results:

The mean patients' age was 35.8 ± 7.2 years, duration of infertility 7.7 ± 4.5 years, right testicular volume 13.1 ± 5 ml, and left testicular volume 12.9 ± 5 ml. The overall SRR was 43.9%. SRR was significantly higher in testes with hypospermatogenesis histology pattern (P = 0.011). Patients' age, testicular size, serum FSH, LH, prolactin, and testosterone or failed previous sperm retrieval interventions showed no significant impact on SRR. Eleven (4.3%) patients had nonmosaic Klinefelter syndrome with a mean age of 37.8 ± 3.3 years. Sperms were retrieved in 6 (54.5%) patients. Post micro-TESE androgens significantly deteriorated with near complete recovery after 1 year.

Conclusions:

Micro-TESE has a high SRR, minimal postoperative complications, and reversible long-term androgen deficiency. Sperm retrieval depends on the most advanced pattern of testicular histology. Hypospermatogenesis pattern has the highest SRR. We demonstrated a high SRR with micro-ESE in men with Klinefelter syndrome.