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

Testicular fine needle aspiration as a diagnostic tool in non-obstructive azoospermia

AIM

To report the fine needle aspiration cytology (FNAC) of the testes used as a diagnostic tool in non-obstructive azoospermic patients.

METHODS

One hundred and twenty-five non-obstructive azoospermic male candidates to intracytoplasmic sperm injetion (ICSI) were analysed for follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone and inhibin B plasma levels. They were classified into three groups on the basis of FNAC: 1) Sertoli cell-only syndrome (SCOS) (70); 2) severe hypospermatogenesis (42); and 3) maturation arrest (13). Then, all men underwent testicular sperm extraction (TESE) for sperm recovery for ICSI.

RESULTS

Mature spermatozoa were detected by FNAC in 24 of 42 men with severe hypospermatogenesis and nine of 13 men with maturation arrest; while they were retrieved by TESE in 29 of 70 men with SCOS, 35 of 42 men with severe hypospermatogenesis (including the 24 by FNAC) and 10 of 13 men with maturation arrest (including the nine by FNAC). The sensitivity and specificity of FNAC were 44.6 % and 100 %, respectively. There was no difference on testicular volume and hormonal parameters in men with and without sperm retrieved.

CONCLUSION

These findings suggest that FNAC may be a simple and valid diagnostic parameter in non-obstructive azoospermic men and it may represent a valid positive prognostic parameter for sperm recovery at TESE.

Flow cytometry of human semen: a preliminary study of a non-invasive method for the detection of spermatogenetic defects

BACKGROUND

The pathway of spermatogenesis involves the conversion of diploid stem cells (spermatogonia) to tetraploid primary spermatocytes, followed by meiosis and two cell divisions, first forming diploid secondary spermatocytes and then haploid round spermatids. Differentiation of round spermatids results in spermatozoa containing condensed chromatin. It has long been known that semen from patients with non-obstructive azoospermia or oligospermia contains small numbers of immature germinal cells. In this article, a flow cytometric procedure is described for assessing defects in spermatogenesis by identifying the ploidy of those immature cells.

METHODS

Cells in semen samples from 44 infertile patients and 14 controls were stained with propidium iodide, which displays red fluorescence when intercalated between bases in double-stranded DNA. The resulting cell suspension was examined by quantitative flow cytometry, with excitation by laser light (488 nm) and red fluorescence recorded on a logarithmic scale to allow easy differentiation between intensities of tetraploid, diploid and haploid round spermatids, and spermatozoa containing condensed chromatin.

RESULTS

The flow cytometric method differentiated between cases of 'Sertoli cell-only' syndrome (complete absence of tetraploid and haploid cells) and cases where spermatogenesis was blocked in meiosis or in spermiogenesis. Flow cytometric histograms from semen samples from normozoospermic, oligozoospermic and azoospermic patients fell into patterns that correlated well with the results obtained from testis histology findings.

CONCLUSIONS

The method described may serve as a simple, non-invasive and reliable assay to help clinicians counsel patients with severe male infertility before referring them for testicular surgery to locate spermatozoa for ICSI.

Seminal haploid cell detection by flow cytometry in non-obstructive azoospermia: a good predictive parameter for testicular sperm extraction

BACKGROUND

Testicular sperm extraction (TESE) associated with ICSI gives patients suffering from non-obstructive azoospermia (NOA) the possibility of becoming a father. The success rate of TESE based on sperm recovery is approximately 50%, and the commonly used non-invasive parameters are not predictive enough. Only the invasive testis biopsy has a good prognostic value. The aim of this study was to evaluate the prognostic value of the detection of seminal haploid cells by flow cytometry (FCM) in order to avoid unnecessary testicular biopsy.

METHODS

For 37 NOA patients undergoing testicular biopsy, we measured testis size, serum FSH and inhibin B levels and carried out seminal cytology, seminal FCM analysis and histological examination.

RESULTS

Sperm were found in 18 biopsies. These results were correlated with cytology, FCM analysis and the histological examination. FCM was more sensitive than cytology (100 versus 59%) but less specific (67 versus 83.5%) whereas the histological observation of complete spermatogenesis appeared to be less sensitive (50%) but more specific (100%).

CONCLUSION

Detection of seminal haploid cells by FCM appears to be an interesting non-invasive technique which can predict TESE results and improve the management of NOA patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of age, follicle stimulating hormone and Johnsen's score on successful sperm retrieval by microdissection testicular sperm extraction

Background:  The spermatozoa retrieval rate achieved by microdissection testicular sperm extraction (TESE) for patients with non-obstructive azoospermia is still approximately 50%, despite technical advances. Predicting a successful outcome is important to avoid unnecessary surgery. A study was conducted to determine a method for calculating the predicted probability of successful microdissection TESE. Methods:  Testicular spermatozoa were retrieved in 41 of 100 patients by microdissection TESE. Ten clinical factors were examined in the search for an optimal logistic model for predicting a good outcome. Once the best delimiting value was established, sensitivity and specificity were calculated. Results:  Patient age, serum follicle stimulating hormone (FSH) concentration and Johnsen's score (JS) were shown to be influential factors by multivariate logistic analysis. The mathematical model for predicting the probability of a successful outcome was as follows: P = (1 + exp[0.144 × patient age - 0.059 × serum FSH concentration - 1.310 × JS])^-1. When a predictive probability of 49.7% was selected as the best cut-off value, sensitivity and specificity were 78.0% and 76.3%, respectively. Conclusion:  This present model is very useful for predicting successful microdissection TESE. In addition, we suggest that a younger patient age would increase the probability of success with this procedure. (Reprod Med Biol 2005; 4: 53-57).

Messenger RNA transcripts of the meiotic regulator BOULE in the testis of azoospermic men and their application in predicting the success of sperm retrieval

BACKGROUND

Testicular sperm retrieval can lead to paternity for azoospermic patients with spermatogenic failure. The human BOULE gene, a meiotic regulator of germ cells, is a gene whose altered expression may be associated with sterility. We determined the levels of BOULE transcripts in the testes of azoospermic patients, and evaluated the relationship between BOULE transcript levels and patients' testicular phenotypes, clinical parameters and sperm retrieval results.

METHODS AND RESULTS

BOULE transcript levels in the testes of 41 azoospermic patients were examined by quantitative competitive-reverse transcription-polymerase chain reaction. A significant decrease in BOULE transcript levels was detected in patients with spermatogenic failure, and BOULE transcript levels progressively decreased with increasing severity of testicular failure. BOULE transcript levels did not correlate with the serum hormone parameters measured. Significantly higher BOULE transcript levels were detected in 19 patients with successful sperm retrieval than in 12 patients with failed sperm retrieval. When using a cut-off value of 0.5 for BOULE transcript ratio to predict the success of sperm retrieval, both the sensitivity and specificity value were 100%.

CONCLUSIONS

We suggest the BOULE transcript plays an important role in human spermatogenesis and that the levels may predict the presence of testicular sperm in patients with spermatogenic failure.

Search and identification of spermatozoa and spermatids in the ejaculate of non-obstructive azoospermic patients

OBJECTIVE

To search and to identify spermatozoa and spermatids, present in the ejaculate of non-obstructive azoospermic patients.

MATERIALS AND METHODS

27 patients, aged between 18 and 48 years, with initial diagnosis compatible with non-obstructive azoospermia, underwent up to 3 seminal samples, with assessment of macroscopic and microscopic parameters differentiated for each sample. In the first sample, 5 microL of semen were analyzed in a Horwell chamber in order to assess the presence or absence of spermatozoa. The procedure was repeated with 2 other aliquots. In the absence of spermatozoa, the entire sample was transferred to a conic tube and following centrifugation the sediment was freshly analyzed. The second seminal sample was collected only when no spermatozoa were found in the first sample and the research was performed in the same way. In cases where spermatozoa were not seen, the sample was centrifuged and the obtained sediment was stained by the panoptic method and observed under common light microscopy (1250X). The third seminal sample was collected only in cases when patients had not shown spermatozoa in the first and second seminal samples.

RESULTS

4/27 (14.8%) patients presented spermatozoa in the first seminal sample and 6/23 (26.1%), in the second seminal sample. No spermatozoa were seen in the third sample, however, 11/17 (64.7%) presented spermatids.

CONCLUSION

In clinical situations where the initial diagnosis is non-obstructive azoospermia, one single routine seminal analysis is not enough to confirm this diagnosis and the analysis of the centrifuged sediment can have relevant clinical consequences. Among patients considered non-obstructive azoospermic, when duly assessed, 37% presented spermatozoa and 64.7%, spermatids.

Monoclonal Antibodies against Sperm Intra-acrosomal Antigens as Markers for Male Infertility Diagnostics and Estimation of Spermatogenesis

PROBLEM

To determine the ability of monoclonal antibodies (MoAbs) against acrosomal antigens to detect physiology and pathology of human spermatozoa and to detect spermatids in ejaculates of infertile male with azoospermia.

METHOD OF STUDY

Sperm antigens detected with prepared MoAbs were partially characterized by biochemical and immunocytochemical methods. The acrosomal status of spermatozoa was compared in men with normal and pathological spermiograms and in sperm before and after induced acrosome reaction (AR). Ejaculates from patients were tested for the presence of spermatids.

RESULTS

MoAbs specifically bind to intra-acrosomal sperm antigens with quantitative difference between ejaculates with normal and pathological spermiograms. These antigens are released from the acrosome after induced AR. MoAbs labeled acrosomal proteins in round and elongated spermatids in the ejaculates of patients with azoospermia.

CONCLUSION

MoAbs against intra-acrosomal sperm antigens are useful for human sperm diagnosis and prediction of spermatogenesis. The spermatids can be utilized in assisted reproduction.

Tissue perfusion essential for spermatogenesis and outcome of testicular sperm extraction (TESE) for assisted reproduction

PURPOSE

In order to determine if there are areas of major and minor perfusion in a single testicle and if the quality of sperm is correlated with quantity of perfusion we collected testicle tissue for TESE in accordance to the local testicle tissue perfusion.

METHODS

A patient undergoing TESE underwent testicular perfusion mapping using contrast enhanced ultrasound. The exposed tissue was scanned with a Laser Doppler scanner and perfusion rates were determined measuring tissue perfusion units (TPUs). Tissue was biopsied and sperm were selected and prepared for assisted reproduction.

RESULTS

The total amount of isolated sperm correlated highly with the intensity of tissue perfusion showing high number of sperm in areas with high TPUs.

CONCLUSIONS

This is the first demonstration that sperm quality and quantity is depending on tissue perfusion within the testicle. To further improve infertility treatment we propose that random biopsies could be replaced by perfusion-dependent collection of testicular tissue.

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

PURPOSE

Microsurgical techniques in testicular sperm extraction can improve sperm retrieval in patients with nonobstructive azoospermia (NOA). However, spermatozoa retrieval rates have still been reported to be around 50% for patients with NOA. Thus, a reliable prediction method for successful outcome is needed to avoid unnecessary surgery. In this retrospective study we determined the diagnostic and predictive values of noninvasive parameters used in the treatment of patients with NOA.

MATERIALS AND METHODS

We analyzed 9 preoperative factors including patient age, testicular volume and endocrinological data of 100 patients with NOA using multivariate logistic modeling. Testicular spermatozoa were retrieved successfully in 41 of the 100 patients (41%).

RESULTS

We found that the concentrations of follicle-stimulating hormone (FSH), total testosterone (TT) and inhibin B were considered the most influential preoperative factors. We developed a formula to calculate the probability of successful outcome, P = [1 + exp(5.201 - 0.048 x FSH - 0.449 x TT - 0.021 x inhibin B)](-1). Association of predicted probabilities and observed responses was 0.77. A predicted probability of more than 15.7% was found to be the best cutoff. Sensitivity was 71.0% and specificity was 71.4% as determined by receiver operating characteristic analysis.

CONCLUSIONS

We concluded that our formula should be useful for doctors considering microdissection testicular sperm extraction for patients with NOA because our equation uses noninvasive parameters without a preoperative testicular biopsy, which is a relatively invasive examination.

Diagnostic and Prognostic Value of Testicular Fine Needle Aspiration in Non-Obstructive Azoospermia

Modern techniques of assisted reproduction may be useful also in non obstructive azoospermic men using sperm extracted from the testis (TESE). However, no clinical or hormonal parameter has reliable prognostic value in predicting the presence of testicular sperm. We report here our experience with fine needle aspiration cytology (FNAC) of the testes used as a diagnostic tool in non obstructive azoospermic patients looking at its possible role as prognostic parameter for the presence of testicular sperm at TESE.

Methods

One hundred and twenty-five non obstructive azoospermic men candidates to ICSI were analysed for FSH, LH, testosterone, and inhibin B plasma levels, and classified in three groups on the basis of FNAC: Sertoli cell-only syndrome (70), severe hypospermatogenesis (42), and maturation arrest (13). After that, all men underwent TESE for sperm recovery for ICSI.

Results

FNAC detected sperm in 24 of 42 men with severe hypospermatogenesis and 9 of 13 men with maturation arrest. TESE retrieved sperm in all such patients, as well as in additional 29 of 70 men with Sertoli cell-only syndrome, additional 11 cases of severe hypospermatogenesis (35 of 42 in total) and 1 additional case of maturation arrest (10 of 13 in total). Testicular volume and hormonal parameters were not different in men with and without sperm retrieved.

Conclusion

These findings suggest that FNAC may be a simple and valid diagnostic parameter in non obstructive azoospermic men, and it may represent a valid positive prognostic parameter for sperm recovery at TESE.

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

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

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

BACKGROUND

This was a retrospective study to determine if diagnostic testicular biopsy followed by cryopreservation should be the procedure of choice for all patients with testicular failure.

METHODS

The first part of the study analysed 97 ICSI cycles scheduled with frozen-thawed testicular sperm for 69 non-obstructive azoospermia (NOA) patients. The second part focused on a subgroup of 32 patients who underwent 42 ICSI cycles with frozen and 44 cycles with fresh testicular sperm. Sperm characteristics, fertilization, embryo quality, pregnancy and implantation rates were evaluated.

RESULTS

Part I: The average time needed to find sperm was 113 min per cycle and 17 min per individual sperm. Fertilization rate, embryo transfer rate, ongoing pregnancy and implantation rates were 58.4%, 83%, 20.8% and 11.3%, respectively. Part II: The search time per sperm was higher (P=0.016) in frozen (18 min) than in fresh suspensions (13 min). A higher embryo transfer rate was observed in fresh cycles than in frozen cycles (93.2% vs 76.2%, P=0.028). Fertilization, ongoing pregnancy and implantation rates were comparable for the two groups.

CONCLUSIONS

Even in a programme with low-restrictive criteria for patient allocation and for sperm cryopreservation, diagnostic testicular biopsy followed by cryopreservation can be the procedure of choice for patients with testicular failure.

Fine-needle aspiration cytology of the testis: can it be a single diagnostic modality in azoospermia?

PURPOSE

The aim of this study was to determine whether fine-needle aspiration cytology (FNAC) of testis alone is sufficient to diagnose testicular function and whether follicle-stimulating hormone (FSH) estimation can be safely eliminated from the evaluation protocol of the azoospermic subject.

MATERIALS AND METHODS

We studied 46 adult azoospermic males who were infertile for more than 2 years following marriage. Hormonal profile was done in all. Later all 46 patients were subjected to bilateral FNAC of the testes. The cytological findings were correlated with histological findings.

RESULTS

We found 95.65% agreement between FNAC and testicular biopsy. Though serum FSH estimation was done in all patients in this series, in none of the cases did it affect overall management.

CONCLUSION

FNAC is a quick, safe and minimally invasive modality. Following a well-performed semen analysis in an azoospermic subject, it appears that FNAC may be the only investigation needed. It provides a reliable diagnosis in patients with either obstructive or non-obstructive azoospermia. Routine estimation of FSH can be omitted from the investigative protocol in these patients.

Use of surgical sperm retrieval in azoospermic men: A meta-analysis

OBJECTIVE

To compare the outcome of intracytoplasmic sperm injection (ICSI) cycles [1] using epididymal and testicular sperm in patients with obstructive azoospermia (OA); [2] using surgically retrieved sperm in patients with OA and nonobstructive azoospermia (NOA); and [3] using fresh and frozen-thawed sperm.

DESIGN

Meta-analysis of published data.

SETTING

Assisted conception unit.

PATIENT(S)

Ten reports (734 cycles: 677 transfers) were identified as suitable to assess source of sperm; 9 reports (1,103 cycles: 998 transfers) to assess etiology; and 17 reports (1,476 cycles: 1,377 transfers) to assess the effect of cryopreservation.

INTERVENTION(S)

Surgical sperm retrieval/ICSI.

MAIN OUTCOME MEASURE(S)

Fertilization rate (FR), implantation rate (IR), clinical pregnancy rate (CPR), and ongoing pregnancy rate (OPR) per embryo transfer.

RESULT(S)

Meta-analysis demonstrated no significant difference in any outcome measure between the use of epididymal or testicular sperm in men with OA. Meta-analysis showed a significantly improved FR (relative risk [RR] 1.18; 95% confidence interval [CI]: 1.13-1.23) and CPR (RR 1.36; 95% CI: 1.10-1.69) in men with OA as compared to NOA with a nonsignificant increase in OPR. There was no difference in either IR or miscarriage rate between the two groups. Comparing fresh with frozen-thawed epididymal sperm there was no difference in FR or IR, a significantly higher CPR (RR 1.20; 95% CI: 1.0-1.42), and no difference in OPR. No difference in fertilization or pregnancy outcome was noted when the testicular cycles were analyzed separately, but IR was significantly impaired using frozen-thawed sperm (RR 1.75; 95% CI: 1.10-2.80).

CONCLUSION(S)

Meta-analysis of published data confirms that etiology of azoospermia and cryopreservation of surgically retrieved sperm impacts on ICSI outcome, and allows us to make several recommendations for clinical practice. Origin of sperm, in men with similar etiology, does not affect outcome.

Klinefelter's syndrome

Klinefelter's syndrome is the most common genetic cause of human male infertility, but many cases remain undiagnosed because of substantial variation in clinical presentation and insufficient professional awareness of the syndrome itself. Early recognition and hormonal treatment of the disorder can substantially improve quality of life and prevent serious consequences. Testosterone replacement corrects symptoms of androgen deficiency but has no positive effect on infertility. However, nowadays patients with Klinefelter's syndrome, including the non-mosaic type, need no longer be considered irrevocably infertile, because intracytoplasmic sperm injection offers an opportunity for procreation even when there are no spermatozoa in the ejaculate. In a substantial number of azoospermic patients, spermatozoa can be extracted from testicular biopsy samples, and pregnancies and livebirths have been achieved. The frequency of sex chromosomal hyperploidy and autosomal aneuploidies is higher in spermatozoa from patients with Klinefelter's syndrome than in those from normal men. Thus, chromosomal errors might in some cases be transmitted to the offspring of men with this syndrome. The genetic implications of the fertilisation procedures, including pretransfer or prenatal genetic assessment, must be explained to patients and their partners.

Role of testicular tissue telomerase assay for the prediction of the presence of testicular spermatozoa in azoospermic men with varicoceles, pre- and post-varicocelectomy

We evaluated the reproductive potential of frozen/thawed testicular spermatozoa of azoospermic men with left varicocele. The role of testicular tissue telomerase assay (TTA) in the prediction of the presence of testicular spermatozoa pre- and post-varicocelectomy was investigated, as well. Therapeutic testicular biopsy and TTA were performed in 82 nonobstructed azoospermic (NOA) men with varicoceles. Testicular spermatozoa were found in 33 men and processed for cryopreservation. Oocytes were later recovered from the spouses of the latter azoospermic men with varicoceles and injected with frozen/thawed testicular spermatozoa. Among the 49 men who were negative for testicular spermatozoa, 22 men underwent subsequently subinguinal microsurgical varicocelectomy. A total of 198 mature oocytes were successfully injected and 101 were normally fertilized and subsequently cleaved. Transfer of these 101 embryos in 26 women resulted in nine full-term pregnancies. Thirteen healthy babies were delivered. A cut-off value of TTA of 39 TPG U microg(-1) protein had an overall diagnostic accuracy equal to 90.2% to predict the presence of testicular spermatozoa pre-varicocelectomy. Within the group of men who were negative for testicular spermatozoa a cut-off value of TTA equal to 28 TPG U microg(-1) protein (pre-varicocelectomy) had a 84.2 % diagnostic accuracy to recognize the men who would become positive for either ejaculated or testicular spermatozoa post-varicocelectomy. Testicular spermatozoa can be found in 40% of NOA men with left varicocele. Ooplasmic injections with frozen/thawed testicular spermatozoa have a role in the therapeutic management of non-obstructive azoospermia associated with varicocele. Pre-varicocelectomy, a TTA cut-off value equal to 39 TPG U microg(-1) protein has a 90.2% diagnostic accuracy to indicate the men positive/negative for testicular spermatozoa. In addition, pre-varicocelectomy, a cut-off value equal to 28 TPG U microg(-1) protein has a 84.2% diagnostic accuracy to identify those men with varicoceles without testicular spermatozoa, who will become positive/negative for spermatozoa (either ejaculated or testicular) post-varicocelectomy.

Expression profiles of the DAZ gene family in human testis with and without spermatogenic failure

OBJECTIVE

To determine the expression profiles of the DAZ gene family in men with and without spermatogenic failure.

DESIGN

Prospective case study.

SETTING

University-based reproductive clinics and genetics laboratory.

PATIENT(S)

Thirty-four infertile men presenting with azoospermia.

INTERVENTION(S)

The mRNA transcript concentrations of the DAZ family genes (BOULE, DAZL, DAZ) and the housekeeping GAPDH gene in the testes of azoospermic men were examined by quantitative competitive-reverse transcription-polymerase chain reaction (QC-RT-PCR). The steady-state concentrations of mRNA encoding for each gene in each testicular sample were normalized by the amounts of GAPDH.

MAIN OUTCOME MEASURE(S)

Transcript ratios (gene/GAPDH) of BOULE, DAZL, and DAZ.

RESULT(S)

The transcript ratios for BOULE, DAZL, and DAZ were significantly decreased in tissues with spermatogenic failure (hypospermatogenesis, maturation arrest, and Sertoli cell-only). However, the ratios of BOULE/DAZL and DAZ/DAZL did not reveal any significant difference in all tissues. Three patients with DAZ deletion possess lower transcripts of BOULE and DAZL.

CONCLUSION(S)

All members of the DAZ gene family play important roles in human spermatogenesis. Decreased concentrations of DAZ family members in men with spermatogenic failure may be due to the secondary effect of germ cell loss, and transcriptional control of BOULE, DAZL, and DAZ are not altered in the various degrees of spermatogenic failure. Although the sample size is limited, no compensatory increase of DAZL or BOULE transcription was found in men with DAZ deletion.

Synchronous sperm retrieval and sperm washing in an intracytoplasmic sperm injection cycle in an azoospermic man who was positive for human immunodeficiency virus

OBJECTIVE

To present the first reported case of synchronous sperm retrieval followed by sperm washing before an intracytoplasmic sperm injection (ICSI) cycle in an HIV-positive azoospermic man.

DESIGN

Case report.

SETTING

Assisted reproduction center.

PATIENT(S)

A 40-year-old HIV-positive man with obstructive azoospermia due to vasal aplasia.

INTERVENTION(S)

Synchronous sperm retrieval, sperm washing, nucleic acid-based sequence amplification testing, and intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

Successful sperm retrieval sufficient for sperm washing and fertilization.

RESULT(S)

Sufficient quantity of spermatozoa for washing was obtained at epididymal aspiration. After the wash, HIV ribonucleic acid (RNA) was undetectable with nucleic acid-based sequence amplification testing, enabling injection of oocytes collected after routine gonadotropin superovulation. Of seven oocytes collected from the 39-year-old woman partner, six were injected and five fertilized (83%). Three embryos were transferred on day 2. The pregnancy test was negative on this occasion.

CONCLUSION(S)

This case demonstrates that sperm washing can be applied in cases of sperm retrieval where sperm volume and density is low, allowing the treatment of azoospermic HIV-positive men.

Transcriptional levels of four Y chromosome-linked AZF genes in azoospermic men and their association with successful sperm retrieval

OBJECTIVES

To investigate the transcriptional levels of four azoospermia factor genes in the testis of azoospermic men and to investigate the association between transcriptional levels and the results of sperm retrieval.

METHODS

Thirty-eight azoospermic men with normal karyotype and without Y chromosome gene deletions were enrolled. The amounts of USP9Y (ubiquitin specific protease 9, Y chromosome), DBY (dead box on the Y), RBMY1 (RNA-binding motif on the Y, 1), and DAZ (deleted in azoospermia) transcripts were examined by quantitative competitive-reverse transcriptase-polymerase chain reaction. The steady-state concentrations of mRNA encoding for each gene in each testicular sample were normalized by the amounts of a housekeeping gene (glyceraldehyde phosphate dehydrogenase [GAPDH]). Differences in the transcript ratios (gene transcript/GAPDH transcript) among patients with different testicular histologic findings (normal spermatogenesis, hypospermatogenesis, maturation arrest, Sertoli cell-only syndrome) were analyzed. For each gene, the association between the transcript ratios and the results of sperm retrieval was evaluated.

RESULTS

No statistically significant difference was found in the transcript ratios of USP9Y and DBY among the four histologic patient groups (P = 0.33 and P = 0.21, respectively). In contrast, statistically significant decreases were found in the transcript ratios of RBMY1 and DAZ in patients with spermatogenic failure (P = 0.0002 and P = 0.002, respectively). The transcript ratios of USP9Y and DBY were not associated with the results of sperm retrieval, and the transcript ratios of RBMY1 and DAZ revealed a positive association with successful sperm retrieval.

CONCLUSIONS

The decreased transcriptional levels of RBMY1 and DAZ in patients with spermatogenic failure may reflect the generalized loss of germ cells. The transcriptional levels of RBMY1 and DAZ may have the potential of becoming useful parameters in the prediction of successful sperm retrieval.

Percutaneous epididymal sperm aspiration: a diagnostic tool for the prediction of complete spermatogenesis

The classification of azoospermia into obstructive or non-obstructive is largely based on medical history, physical examination and biochemical markers in serum and semen. However, the most accurate parameter for diagnosis is the testicular histology. The predictive value of the percutaneous epididymal sperm aspiration (PESA), FSH, LH, testosterone, inhibin-B and testicular volume was investigated for their accuracy to predict a complete spermatogenesis (Johnsen score > or =8) in order to replace the testicular histology. The specificity and sensitivity of FSH, inhibin-B, LH, testosterone, testicular volume, and the presence of sperm in a PESA procedure was evaluated in 147 azoospermic males attending the centre for infertility diagnosis. A positive PESA outcome presented the highest sensitivity and specificity to predict a Johnsen score > or =8 (93 and 94% respectively) compared with FSH (90 and 19%), inhibin-B (88 and 57%) and testicular volume (95 and 45%). Differences in clinical presentation were observed between patients with positive sperm retrieval with PESA, depending on the aetiology of obstruction. In conclusion, the presence of spermatozoa in the epididymis (PESA+) correlates with a Johnsen score > or =8 and is the most accurate parameter to predict complete spermatogenesis compared with clinical or biochemical parameters. Between obstructive azoospermic patients, the clinical parameters observed varied according to the aetiology.

Predictive factors for motile sperm recovery using testicular biopsy in nonobstructive azoospermic patients

OBJECTIVE

The objective of the present study was to assess the predictive value of hormone values, histological analysis for the finding of motile spermatozoa on testicular biopsy in nonobstructive azoospermia.

METHODS

This cross-sectional study assessed serum follicle-stimulating hormone (FSH), luteinizing hormone, prolactin and total testosterone values in 50 patients undergoing testicular biopsy prior to ICSI. P < 0.05 was considered significant.

RESULTS

Recovery was successful in 28 cases, and motile spermatozoa were retrieved in 7. Significant differences were detected between presence of motile spermatozoa and absence of spermatozoa in terms of FSH values (P = 0.003, one-way ANOVA). The other variables did not present statistical differences. A receiver operating characteristic curve showed that FSH levels below 17.00 IU/L were predictive of motile spermatozoa recovery.

CONCLUSIONS

FSH values can serve as a predictive factor for the recovery of motile spermatozoa using biopsy in azoospermic patients. On the other hand, histological analysis and other hormone values were not helpful in the prediction of motile sperm.

Sperm retrieval in infertile males: comparison between testicular sperm extraction and testicular sperm aspiration techniques

Improvements in using retrieved testicular spermatozoa in infertile males to achieve fertilization and pregnancy has enabled patients with clinical azoospermia and non-obstructive testicular failure to father children. In this review article, we compare the relative yields of the two major techniques for sperm retrieval in males with non-obstructive azoospermia; TESE (Testicular Sperm Extraction) and TESA (Testicular Sperm Aspiration). We also discuss the role of follicle-stimulating hormone (FSH), testicular volume, serum levels of inhibin B, testicular doppler flow pattern, chromosome Yq deletions, and presence of spermatids in azoospermic ejaculates as predictors of presence or absence of spermatozoa in biopsied testicular tissues. In conclusion, although most studies favor the more invasive TESE in terms of sperm retrieval success rate, the degree of certainty in this regard remains unsatisfactory, and future studies need to address the issues of standard error and differential misclassification attributable to needle gauge size in patients undergoing TESA.

Protein phosphatase 1cgamma is required in germ cells in murine testis

The protein phosphatase 1cgamma (PP1cgamma) gene is required for spermatogenesis. Males homozygous for a null mutation are sterile, and display both germ cell and Sertoli cell defects. As these two cell types are physically and functionally intimately connected in the testis, the question arises as to whether the primary site of PP1cgamma action is in Sertoli cells, germ cells, or both. We generated chimeric males by embryo aggregation to test whether wild type Sertoli cells are capable of rescuing mutant germ cells. To distinguish between the desired XY-XY chimeras and uninformative XX-XY chimeras, we designed an adaptation of the single nucleotide primer extension (SNuPE) assay. None of the XY-XY chimeras sired pups derived from mutant germ cells, indicating that the protein is required in germ cells for production of functional sperm. Analysis of a chimeric testis revealed intermediate phenotypes when compared with PP1cgamma-/- testes, suggestive of cell nonautonomous effects. We conclude that PP1cgamma is required in a cell autonomous fashion in germ cells. There may be an additional cell nonautonomous role played by this gene in testes, possibly mediated by defective signaling between germ cells and Sertoli cells.

Male infertility

Infertility affects 13-18% of couples and growing evidence from clinical and epidemiological studies suggests an increasing incidence of male reproductive problems. The pathogenesis of male infertility can be reflected by defective spermatogenesis due to pituitary disorders, testicular cancer, germ cell aplasia, varicocele and environmental factors or to defective sperm transport due to congenital abnormalities or immunological and neurogenic factors. Recent studies suggest an increased incidence of genetic disorders related to male infertility which may affect different levels, interfering with germ cell generation and maturation or leading to the production of non-functional spermatozoa. The identification of genetic causes of male infertility raises the issue of the transmission of defects to the offspring, a situation that is becoming more important given the increasing use of intracytoplasmic sperm injection (ICSI), a procedure in which the natural selection of the spermatozoa is by-passed. Fertilization can occur in vitro using ejaculated, epididymal or testicular spermatozoa, either fresh or frozen-thawed, providing opportunities hitherto not possible for men to be genetic fathers.

Postoperative pain, complications, and satisfaction rates in patients who undergo surgical sperm retrieval

OBJECTIVE

To determine patients' experiences with surgical sperm retrieval and its common complications.

DESIGN

A questionnaire based survey using visual analogue scales (VAS) and closed questions to analyze complication, pain, and satisfaction rates.

SETTING

Tertiary care university hospital.

PATIENT(S)

One hundred consecutive males undergoing surgical sperm retrieval by percutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

We surveyed for pain perception complication rates and satisfaction scores.

RESULT(S)

Of the 85 patients who replied, 21 underwent retrieval for nonobstructive causes, 37 following failed reversal of vasectomy, and 27 for other obstructive causes. Retrieval was successful in 100% of obstructive causes and in 61% for nonobstructive azoospermia. Epididymal retrieval was successful in 23 patients, 30 patients underwent TESE after failed PESA, and 23 had TESE only. There were significant increases in pain perception scores and reported complications with TESE over PESA (31 vs. 16; and 21 out of 63 vs. 2 out of 22, respectively), but no difference in satisfaction rate. The cause of azoospermia did not affect pain perception or satisfaction in TESE. Complication rates were increased in larger testes (3 out of 22 vs. 24 out of 63). Unsuccessful sperm retrieval did not significantly affect patients' pain perception or satisfaction. Surgical sperm retrieval was rated as significantly less painful than both vasectomy and reversal (21% vs. 42% vs. 57%, respectively) and was associated with significantly fewer days absent from work (3.0 vs. 8.5).

CONCLUSION(S)

Surgical sperm retrieval by PESA or TESE is a safe procedure with only minor complications that is tolerated well by patients.

Correlation between fluorescence in situ hybridization and testicular biopsy for the prediction of spermatogenesis in 37 patients with nonobstructive azoospermia

OBJECTIVES

We applied interphase fluorescence in situ hybridization (FISH) to testis sections to examine the evidence of spermatogenesis in patients with nonobstructive azoospermia. This technique was evaluated and compared with conventional testicular histopathologic findings for the possibility of additional clinical applications.

METHODS

Thirty-seven consecutive patients with nonobstructive azoospermia were carefully evaluated clinically. Testes were biopsied for both sperm extraction and histopathologic examination. FISH staining was performed with a CEP 18 SpectrumAqua/CEP X SpectrumGreen/CEP Y SpectrumOrange probe.

RESULTS

Eight of 11 cases (sensitivity 73%) that were found to have spermatids on the histopathologic slides also were proven to produce haploid cells by FISH staining. On the other hand, 21 of the 26 cases (specificity 81%) for which no spermatids could be found on the histopathologic slides also had only diploid cells by FISH staining. On the basis of the good correlation between the FISH staining and conventional histopathologic findings, we could confirm the diagnosis of spermatogenesis using both methods.

CONCLUSIONS

FISH staining of testicular sections allows more reliable prediction of spermatogenesis and provides benefits for a patient's decision regarding fertility counseling.

Serum levels of inhibin B and follicle-stimulating hormone may predict successful sperm retrieval in men with azoospermia who are undergoing testicular sperm extraction

To evaluate the predictive power for sperm retrieval in testicular sperm extraction of inhibin B and FSH levels in the peripheral blood in association with the testicular histology. Clinical study. Departments of andrology and urology at a university hospital.Fifty-two patients with azoospermia. Determination of serum levels of FSH and inhibin B in men with azoospermia. Testicular incision and histological investigation as well as testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection were performed. Comparison of hormone levels with different histological features of seminiferous tubules (normospermatogenesis, hypospermatogenesis, and Sertoli cell-only syndrome) and TESE outcome.With respect to the histological proof of spermatozoa, the sensitivity of the FSH levels >10 mU/mL was 82%, and of inhibin B levels, <79 pg/mL, 78%; the specificity was 80% for both hormone levels. With respect to the successful sperm extraction in the TESE procedure, the sensitivity of the FSH levels was 58% and the specificity was 50%; and the sensitivity of inhibin B levels was 52.5% and the specificity was 60%. Inhibin B and FSH levels are correlated with spermatogenetic activity. The combination of the two parameters is currently the best predictor for the presence of sperm, which may be found in TESE. However, the prediction is not absolutely reliable: TESE can be also successful when both hormone levels are outside the threshold levels.

Conventional multiple or microdissection testicular sperm extraction: a comparative study

BACKGROUND

Testicular sperm extraction (TESE) with ICSI is becoming the first-line treatment for non-obstructive azoospermia (NOA). Recently, the sperm retrieval rate (SRR) by microdissection TESE was reported to be higher than by conventional TESE. However, a comprehensive comparison between multiple and microdissection TESE patients including histological findings has not been reported.

METHODS

Patients with NOA who underwent microdissection TESE (n = 56) or multiple TESE (n = 37) were compared. Pre-operative characteristics were similar between groups. In addition, microscopic findings during microdissection TESE also were investigated.

RESULTS

Operative time was significantly longer for microdissection TESE than for multiple TESE. Histological examination suggested that spermatogenesis was relatively more impaired in the microdissection TESE group than in the multiple TESE group. Despite this, SRR by microdissection TESE (42.9%) appeared higher than by conventional TESE (35.1%) although this observation failed to reach statistical significance. Seventeen of 26 patients (65.4%) with heterogeneous tubule were successful for sperm retrieval. No severe operative complications occurred in any patient in either group, and no patient required post-operative hormone replacement to treat hypogonadism.

CONCLUSIONS

Microsurgical technique is safe and may improve SRR for TESE in a variety of patients with NOA, especially patients with heterogeneous testicular tubules.

The future of reproductive cellular engineering in male infertility

Understanding of the pathophysiology of defective spermatogenesis, spermatozoa, and germ cell function must be advanced so that appropriate rational treatment, such as gene therapy, can be developed. Despite the dramatic advances in ART, one ultimate goal must be to develop treatment so that the couple can conceive naturally. Because such treatment will not be possible in all cases, a complementary step will be the ability to induce the production of haploid, functionally competent germ cells that can be used for ART. The achievement of these goals will be based on advances in many other disciplines. Whatever the future holds, it promises to be exciting.

The diagnosis and treatment of the azoospermic patient in the age of intracytoplasmic sperm injection

Microsurgical reconstruction remains the treatment of choice for men with reconstructable obstructive azoospermia. Sperm retrieval techniques performed with ICSI are highly effective for men in whom reconstruction is not feasible. In men with nonobstructive azoospermia, the optimization of spermatogenesis with hormonal therapy and, when appropriate, microsurgical varicocelectomy can result in the appearance of adequate sperm in the ejaculate for ICSI. In men with persistent nonobstructive azoospermia, TESE with ICSI has provided encouraging results. Caution must be used when this ART is applied in couples in whom genetic aberrations are detected given certain inheritance of these anomalies, as the genetic consequences of this procedure have not been thoroughly elucidated. Just as the possibility of ICSI was thought to be inconceivable several decades ago, the advent of future sentinel discoveries will present the possibility for realization of achievements that now seem incredulous.

Serum levels of inhibin B in men and their relationship with gonadal hormones, testicular volume, testicular biopsy results and sperm parameters

Currently, serum inhibin B levels, indicating testicular function due directly to its testicular origin, has been used increasingly in assisted reproductive units. Our aim in this prospective study was to evaluate the biological significance of inhibin B in gonadal dysfunctional males and the usefulness of inhibin B for the detection of male reproductive dysfunction. We included 52 oligoazoospermic and 20 normospermic men in this study. In our study serum inhibin B levels had statistically significant negative correlation with serum FSH and LH levels (P < 0.001, r: 0.781) and statistically moderate positive correlation with oestradiol levels (P < 0.005, r: 0.292). Inhibin B levels had significantly positive correlation with sperm count (P < 1.005, r: 0.851) and with testicular volume (P < 0.001, r: 0.466). Consequently, serum inhibin B level determination is a useful and non-invasive method for the evaluation of male gonadal dysfunction, taking into account its correlation with history, clinical examination, hormonal parameters, testicular volume, spermiogram and testicular biopsy.

Comparison of the ICSI outcome of ejaculated sperm with normal, abnormal parameters and testicular sperm

OBJECTIVE(S)

To compare fertilization rates, quality of embryos, pregnancy rates (PRs) and outcome of pregnancies in intracytoplasmic sperm injection (ICSI) using sperm from ejaculates of normal and abnormal semen and testicular sperm of non-obstructive azoospermia.

STUDY DESIGN

Four hundred fifty-four patients who underwent 454 ICSI cycles were evaluated retrospectively. Patients were divided into three groups according to the quality and source of sperm. Patients in group 1 underwent 133 cycles of ICSI using ejaculated normal semen, group 2 underwent 235 cycles using ejaculated abnormal semen, and group 3 underwent 86 cycles using testicular sperm.

RESULTS

The parameters were compared among the groups with respect to cycles induced by long (n = 160) and short (n = 294) protocol. In group 3, the fertilization and PRs were significantly lower than in all other groups (51.3 and 10.6% in the long protocol cycles, 53.3 and 5.1% in the short protocol cycles, respectively). There was no significant difference in the outcome of pregnancies in respect to abortion rates between different groups.

CONCLUSION(S)

The fertilizing ability of sperm in ICSI is highest with ejaculated sperm and lowest with sperm extracted by testicular biopsy. Also, the clinical PRs are significantly lower in ICSI with sperm from testicular biopsy. However, the outcomes of pregnancies are not affected by using surgically retrieved sperm from ejaculated semen.

Use of a highly sensitive quantitative telomerase assay in intracytoplasmic sperm injection programmes for the treatment of 47,XXY non-mosaic Klinefelter men

We evaluated the role of the sensitive quantitative telomerase assay (SQTA) in the management of men with non-mosaic Klinefelter's syndrome (KS). Diagnostic testicular biopsy (DTB) was performed in 24 men with KS. A part of the DTB was stained and the remaining fragment was processed for the SQTA. After 3-18 months, a therapeutic testicular biopsy (TTB) was performed in the same testicle and the recovered specimens were processed to identify spermatozoa. Men with a SQTA outcome equal to 0.00 Units microg-1 protein (n = 7) demonstrated therapeutic testicular biopsy material that was negative for spermatogenic cells. In five men with a SQTA outcome of 8.11-38.03 Units microg-1, the most advanced germ cell was the spermatogonium/primary spermatocyte. In the remaining 12 men, the most advanced spermatogenic cell in the TTB was the spermatozoon. In these men, the SQTA outcome was equal to 25.76-92.68 Units microg-1 protein. Using 39.00 Units microg-1 protein as a cut-off value, the accuracy of the SQTA in identifying men positive for spermatozoa was 91.6%. It appears that the SQTA has a role for identifying non-mosaic KS men who have testicular spermatozoa.

Five years experiences with microinjection of testicular spermatozoa into oocytes in Hungary

The aim of the study was to summarize our five years experience (1996-2000) of testicular spermatozoa for intracytoplasmic sperm injection in Hungary. The influence of sperm count, maternal age, number of transferred embryos, and application of assisted hatching on outcome was investigated. Testicular spermatozoa were retrieved by microsurgical testicular sperm extraction. Samples were classified depending on the number of spermatozoa. Indication for testicular sperm extraction in conjunction with intracytoplasmic sperm injection was severe azoospermia or azoospermia combined with tubal origin infertility. Ovarian stimulation was carried out using an ultrashort protocol with GnRH agonist and gonadotrophin. Intracytoplasmic sperm injection was performed without PVP. Embryos were cultured for 48 or 72 h before embryo transfer. Indications for assisted hatching included elevated maternal age, increased zona thickness or at least two previous unsuccessful IVF cycles. Testicular spermatozoa were successfully retrieved in 218 out of 273 cases. Extreme low sperm count was found more frequently in cases of nonobstructive azoospermia. No significant differences were observed in fertilization rate (61.1% vs. 51.7%) or clinical pregnancy rate (29.0% vs. 26.7%) between patients with obstructive or nonobstructive azoospermia. Maternal age, number of transferred embryos and application of assisted hatching had a significant effect on outcome. A total of 55 clinical pregnancies were achieved, including 14 sets of twins, three sets of triplets and two sets of quadruplets. It is concluded that testicular sperm extraction is an efficient way of obtaining testicular spermatozoa, allowing not only successful fertilization by ICSI, but also freezing of testicular spermatozoa for use in subsequent cycles.

Predictive value of testicular histology in secretory azoospermic subgroups and clinical outcome after microinjection of fresh and frozen-thawed sperm and spermatids

BACKGROUND

A retrospective study was carried out on 159 treatment cycles in 148 secretory azoospermic patients to determine whether histopathological secretory azoospermic subgroups were predictive for gamete retrieval, and to evaluate outcome of microinjection using fresh or frozen-thawed testicular sperm and spermatids.

METHODS

Sperm and spermatids were recovered by open testicular biopsy and microinjected into oocytes. Fertilization and pregnancy rates were assessed.

RESULTS

In hypoplasia, 97.7% of the 44 patients had late spermatids/sperm recovered. In maturation-arrest (MA; 47 patients), 31.9% had complete MA, and 68.1% incomplete MA due to a focus of early (36.2%) or late (31.9%) spermiogenesis. Gamete retrieval was achieved in 53.3, 41.2 and 93.3% of the cases respectively. In Sertoli cell-only syndrome (SCOS; 57 patients), 61.4% were complete SCOS, whereas incomplete SCOS cases showed one focus of MA (5.3%), or of early (29.8%) and late (3.5%) spermiogenesis. Only 29.8% of the patients had a successful gamete retrieval, 2.9% in complete and 77.3% in incomplete SCOS cases. In total, there were 87 ICSI, 39 elongated spermatid injection (ELSI) and 33 round spermatid injection (ROSI) treatment cycles, with mean values of fertilization rate of 71.4, 53.6 and 17%, and clinical pregnancy rates of 31.7, 26.3 and 0% respectively.

CONCLUSIONS

Histopathological subgroups were positively correlated with successful gamete retrieval. No major outcome differences were observed between testicular sperm and elongated spermatids, either fresh or frozen-thawed. However, injection of intact round-spermatids showed very low rates of fertilization and no pregnancies.

[Role of the urologist in the management of infertile men at the time of sperm intracytoplasmic injection]

Although intracytoplasmic sperm injection (ICSI) revolutionized treatment and prognosis of male infertility, checkup (case history, clinical and paraclinical examinations) practiced by urologist in infertile man keeps all its place. Varicocele, congenital or acquired seminal duct obstruction, urogenital tract infection, or ejaculation disorder must be sought, because these affections remain accessible to treatment.

Successful pregnancy and delivery after testicular sperm extraction despite an undetectable concentration of serum inhibin B in a patient with nonobstructive azoospermia

OBJECTIVE

To describe a successful pregnancy and delivery after testicular sperm extraction (TESE) despite an undetectable concentration of serum inhibin B in a man with nonobstructive azoospermia.

DESIGN

Case report.

SETTING

Obstetrics and gynecology and reproductive biology departments.

PATIENT(S)

A 31-year-old woman and a 32-year-old man with nonobstructive azoospermia and an undetectable inhibin B serum level.

INTERVENTION(S)

TESE, testicular spermatozoa cryopreservation, intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Pregnancy and delivery.

RESULT(S)

Successful pregnancy and delivery of a normal healthy child following a third ICSI cycle with frozen-thawed spermatozoa extracted from the testis.

CONCLUSION(S)

This case report shows that there is no minimal level of inhibin B below which TESE is always unsuccessful. The delivery of a normal healthy baby is strong evidence to perform TESE in these circumstances.

Surgical sperm retrieval: a review of current practice

Although pregnancies were achieved after surgical sperm retrieval and in vitro fertilization 8 years before the introduction of intracytoplasmic sperm injection (ICSI), it is the development of ICSI that has led to the rapid expansion of surgical procedures to obtain sperm from azoospermic males for use in assisted conception cycles. The natural desire for couples to achieve a pregnancy using their own gametes and a national shortage of donor sperm have driven the demand for an expansion of this service. Males who have previously been considered unable to father their own genetic child can now be offered treatment, which, in most cases, will lead to the recovery of sperm for use in treatment. This article considers the development of the techniques available to clinicians and provides an overview of the many treatments (and their acronyms) to assist clinicians unfamiliar with the practicalities of surgical sperm retrieval. In reviewing the current published studies, we also offer some guidelines as to the optimization of the potential future provisions of surgical sperm retrieval treatments for azoospermic males, either secondary to obstruction (particularly after vasectomy) or from non-obstructive causes.